Is HIV index testing and partner notification safe for adolescent girls and young women in low- and middle-income countries?

INTRODUCTION: While HIV index testing and partner notification (PN) services have the potential to reach adolescent girls and young women (AGYW) aged 15 to 24 and their sexual partners in need of HIV testing services, the potential social harms have not yet been studied. This commentary highlights the risks of this approach, including intimate partner violence (IPV), stigma and discrimination, and outlines an urgent research agenda to fully understand the potential harms of PN for AGYW, calling for the development of mitigation strategies. DISCUSSION: A substantial evidence base exists demonstrating the feasibility, acceptability and effectiveness of index testing and partner notification for adults aged 18 years and older in low- and middle-income countries (LMICs), particularly for men, and for adults who are married/cohabiting and referring a current sexual partner. AGYW who are most vulnerable to HIV infection in LMICs do not reflect these demographics. Instead, they are often in age-disparate partnerships, have limited negotiating power within relationships, experience high rates of violence and face economic challenges that necessitate transactional sex. PN services may be particularly difficult for adolescent girls under 18 who face restrictions on their decision making and are at increased risk of rape. Adolescent girls may also face coercion to notify partners due to unequal power dynamics in the provider-adolescent client relationship, as well as judgemental attitudes towards adolescent sexual activity among providers. CONCLUSIONS: As index testing and PN with AGYW is already being rolled out in some LMICs, research is urgently needed to assess its feasibility and acceptability. Implementation science studies should assess the availability, accessibility, acceptability and quality of HIV PN services for AGYW. Qualitative studies and routine monitoring with age-disaggregated data are critical to capture potential social harms, PN preferences and support needs for AGYW aged 15 to 17, 18 to 20 and 21 to 24. To mitigate potential harms, PN methods should prioritize confidentiality and avoidance of adverse outcomes. Healthcare providers should be trained to conduct routine enquiry for IPV and provide first-line support. Support services for AGYW living with HIV and survivors of violence should be implemented alongside HIV PN.

Associations between mental distress, poly-victimisation, and gender attitudes among adolescent girls in Cambodia and Haiti: an analysis of Violence Against Children surveys.

This study aims to explore the effects of poly-victimisation (defined as the experience of multiple different forms of violence, including physical, emotional, and/or sexual) and gender attitudes on mental distress and suicidal ideation among adolescent girls, using cross-sectional nationally representative household survey data from Cambodia and Haiti. Data used were from 555 and 675 adolescent girls aged 13 to 19 from the 2013 Cambodia and 2012 Haiti Violence Against Children Surveys, respectively. Weighted bivariate and multivariate logistic regression analyses were used to assess the relationship between poly-victimisation and gender attitudes with severe mental distress and suicidal ideation, controlling for a range of factors. The results suggest that poly-victimisation is associated with severe mental distress and suicidal ideation among adolescent girls in both countries. Gender attitudes can serve as either a risk or protective factor. For example, in Haiti, respondents who agreed that women should tolerate violence to keep their family together were more likely to experience mental distress, but less likely to have had suicidal thoughts. The study's findings illustrate the need for further research on how gender norms and attitudes as well as experiences of multiple different forms of violence impact adolescent mental health.

Positive Youth Development Programs in Low- and Middle-Income Countries: A Conceptual Framework and Systematic Review of Efficacy.

PURPOSE: Positive youth development (PYD) has served as a framework for youth programs in high-income countries since the 1990s and has demonstrated broad behavioral health and developmental benefits. PYD programs build skills, assets, and competencies; foster youth agency; build healthy relationships; strengthen the environment; and transform systems to prepare youth for successful adulthood. The goal of this article was to systematically review the impact of PYD programs in low- and middle-income countries (LMICs). METHODS: Targeted searches of knowledge repository Web sites and keyword searches of Scopus and PubMed identified over 21,500 articles and over 3,700 evaluation reports published between 1990 and mid-2016. Ninety-four PYD programs with evaluations in LMICs were identified, of which 35 had at least one experimental or rigorous quasi-experimental evaluation. RESULTS: Sixty percent of the 35 programs with rigorous evaluations demonstrated positive effects on behaviors, including substance use and risky sexual activity, and/or more distal developmental outcomes, such as employment and health indicators. CONCLUSIONS: There is promising evidence that PYD programs can be effective in LMICs; however, more rigorous examination with long-term follow-up is required to establish if these programs offer benefits similar to those seen in higher income countries.

Barriers to Intrauterine Device Uptake in a Rural Setting in Ghana.

Long-acting reversible contraception is an underutilized method in low-resource areas. Our study aims to: (a) assess knowledge and attitudes around contraception; (b) identify barriers to intrauterine device (IUD) uptake; and (c) develop interventions to address this gap in contraceptive care. We conducted focus group discussions with pregnant, postpartum, and reproductive-aged women, males, and health care workers in rural Ghana. Lack of IUD-specific knowledge, provider discomfort with insertion, and incomplete contraceptive counseling contribute to lack of IUD use. Participant- and provider-related barriers contribute to poor uptake of IUDs within the community. Targeted interventions are necessary to improve IUD use.

Recommendations for scale-up of community-based misoprostol distribution programs.

Community-based distribution of misoprostol for prevention of postpartum hemorrhage (PPH) in resource-poor settings has been shown to be safe and effective. However, global recommendations for prenatal distribution and monitoring within a community setting are not yet available. In order to successfully translate misoprostol and PPH research into policy and practice, several critical points must be considered. A focus on engaging the community, emphasizing the safe nature of community-based misoprostol distribution, supply chain management, effective distribution, coverage, and monitoring plans are essential elements to community-based misoprostol program introduction, expansion, or scale-up.

A community-based continuum of care model for the prevention of postpartum hemorrhage in rural Ghana.

OBJECTIVE: To report on Phase 1 of an operations research study designed to reduce postpartum hemorrhage (PPH)-related morbidity and mortality in rural Ghana. METHODS: Phase 1 of the study-which included a needs assessment, community sensitization, implementation of blood collection drapes, training of service providers, and baseline data collection-comprised preliminary work to prepare for misoprostol distribution in Phase 2. Seventy-four primary healthcare providers were trained on safe-motherhood practices, use of blood collection drapes, and data collection. Baseline data were collected from 275 women regarding home deliveries, who attended the deliveries, incidence of PPH, and use of blood collection drapes. RESULTS: Blood collection drapes were used at 67.6% of deliveries, increasing to 88.5% over the final 6months of Phase 1. Community health extension workers (CHEWs) were present at 57.1% of all deliveries but attendance increased to 86.9% during the last 6months of Phase 1. Overall, 96.0% of deliveries resulted in healthy outcomes for the mother; 4.0% of births had complications. CONCLUSION: The preliminary work conducted in Phase 1 of the study was crucial in guiding misoprostol distribution in Phase 2. However, challenges existed, including inadequate community sensitization, low home-birth attendance by CHEWs, and data collection problems.

Integrating women's human rights into global health research: an action framework.

This article uses Scale of Change theory as a framework to guide global health researchers to synergistically target women's health outcomes in the context of improving their right to freedom, equity, and equality of opportunities. We hypothesize that health researchers can do so through six action strategies. These strategies include (1) becoming fully informed of women's human rights directives to integrate them into research, (2) mainstreaming gender in the research, (3) using the expertise of grass roots women's organizations in the setting, (4) showcasing women's equity and equality in the organizational infrastructure, (5) disseminating research findings to policymakers in the study locale to influence health priorities, and (6) publicizing the social conditions that are linked to women's diseases. We explore conceptual and logistical dilemmas in transforming a study using these principles and also provide a case study of obstetric fistula reduction in Nigeria to illustrate how these strategies can be operationalized. Our intent is to offer a feasible approach to health researchers who, conceptually, may link women's health to social and cultural conditions but are looking for practical implementation strategies to examine a women's health issue through the lens of their human rights.

Navigating the challenges of global reproductive health research.

Reproductive health research in low-resource settings poses unique and complex challenges that must be addressed to ensure that global research is conducted with strict adherence to ethical principles, offers direct benefit to the research subjects, and has the potential for adoption of positive findings to the target population. This article addresses challenges to conducting reproductive health research in low-resource settings in the following areas: (1) establishment and maintenance of global collaboration, (2) community partnerships, (3) ethical issues, including informed consent and the role of incentives, (4) staff training and development, (5) data collection and management, and (6) infrastructure and logistics. Particular attention to these challenges is important to ensure that research is culturally appropriate and methodologically sound and enhances the adoption of health-promoting behaviors. Rigorous evaluation of interventions in low-resource settings may be a cost-effective and time-efficient way to identify interventions for large-scale program replication to improve women's health.

Beyond the "birds and the bees": gender differences in sex-related communication among urban African-American adolescents.

The current study examined gender differences in communication about sex-related topics in a community sample of urban, African-American mothers and adolescents living in impoverished neighborhoods with high HIV rates. One hundred and sixty-two mother-adolescent dyads completed self-report measures of sex-related communication. Youth also reported on their sexual risk. We identified the range of sexual-based topics that adolescents discussed with their mothers, fathers, friends, and at school. The relationship between the frequency of sexual communication and sexual risk was examined. We also investigated congruency between adolescent and mother report about whether sexual-based discussions occurred. Consistent with prior research, girls talked to their mothers, fathers, friends, and at school about sex-related topics more than boys. Findings indicated that mothers not only communicated more frequently about sexual issues with their daughters than sons but that parental messages for girls were more protective. Greater sexual communication with mother was significantly associated with decreased HIV risk in the past 90 days and increased protection from HIV. Inconsistencies between mother and adolescent reports about sexual communication were marginally associated with decreased protection from HIV. Findings reveal the protective effect of sexual communication and the general lack of congruence between mother and adolescent reports of sexual communication.

Increasing parent involvement in youth HIV prevention: a randomized Caribbean study.

This article presents preliminary findings of a randomized HIV prevention study in Trinidad and Tobago in the Caribbean. The study centers on a family HIV workshop aimed at strengthening parenting skills that are empirically linked to reducing adolescent HIV exposure and other sexual risks. These skills include parental monitoring; educating youth about HIV, sex, and other sexually transmitted infections (STI's); and discussing cultural and interpersonal pressures to have sex. Participants include 180 primary caregivers and their 12-14-year-old adolescents randomized to either the Trinidad and Tobago family HIV Workshop (N = 92) or a general workshop (N = 88). Intervention and control group participants completed pretest and posttest measures on parenting and HIV risk outcomes. Compared to controls, intervention parents reported improvements in HIV knowledge (d = .79); attitudes toward AIDS (d = .42); general communication with adolescents (d = .94); conversations with adolescents about sex (d = .95); conversations about sexual risks and values (d = .43); monitoring of adolescents (d = .34); conflicts with adolescents (d = .30); and intensity of daily parenting hassles (d = .35). Intervention and control parents did not differ in behavioral control, use of positive parenting techniques, and expansion of support networks. Implications for addressing rising HIV risks among young people in Trinidad and Tobago and the Caribbean are discussed.

Parental monitoring as a moderator of the effect of family sexual communication on sexual risk behavior among adolescents in psychiatric care.

Authors examined if parental monitoring moderated effects of family sexual communication on sexual risk behavior among adolescents in psychiatric care. Seven hundred and eighteen parents reported upon quality of family discussions about sex-related topics and degree to which they monitor teen behavior. Adolescents reported the frequency of their own safe sex practices. Parental monitoring moderated the family communication quality-sexual risk behavior relationship among African American families. African American parents who perceived themselves as capable of open family sexual communication and frequent monitoring had adolescents who reported decreased sexual risk behavior. The moderator model was not supported among Caucasian and Hispanic families and findings did not depend upon gender. For African Americans, findings support the influential role of family processes in development of teen sexual risk behavior and suggest, for parents of teens receiving mental health services, learning communication and monitoring skills may be critical to their adolescent's sexual health.