Exploring the Relationship Between Stigma, Stigma Challenges, and Disclosure Among Slum-Dwelling Survivors of Intimate Partner Violence in Kenya.

This article uses survey data from 131 women living in urban slums in Kenya to explore associations between stigma, stigma challenges, empowerment, and disclosure of intimate partner violence (IPV). A total of 81.7% of women reported informal or formal disclosure of IPV. A bystander offering help and experiencing stigma were associated with significant increases in the odds of informal and formal disclosure. There were also significant positive associations between participating in financial decision-making, membership in survivor support groups, and formal disclosure. Results suggest that interpersonal, community, and structural challenges to stigma interfere with stigma as a barrier to disclosure.

Perceived Neighborhood Quality and HIV-related Stigma among African Diasporic Youth; Results from the African, Caribbean, and Black Youth (ACBY) Study.

Socio-environmental factors such as neighborhood quality are increasingly recognized drivers of HIV disparities. Additionally, HIV- related stigma heightens HIV vulnerability among youth in the African Diaspora. However, little research examines the intersection of neighborhood quality and HIV- related stigma. This study uses survey data (N=495) from African, Caribbean, and Black youth in a midsized city in Ontario, Canada to address this research deficit. Analysis of variance and multivariate ordinary least squares regressions were conducted to determine differences in HIV- related stigma by neighborhood quality, experiences of discrimination, HIV- knowledge, and demographic factors. Residents in more socially disordered neighborhoods (p<.05), males (p<.0001), African- Muslim youth (p<.01), and individuals with lower HIV- knowledge (p<.0001) endorsed stigmatizing beliefs more often. Addressing neighborhood disadvantage may have implications for HIV- related stigma. More research should be conducted to understand the impact of socio- environmental disadvantage and HIV- related stigma.

Effects Of HIV stigma reduction interventions in diasporic communities: insights from the CHAMP study.

Racialized diasporic communities in Canada experience disproportionate burden of HIV infection. Their increased vulnerabilities are associated with interlocking challenges, including barriers in accessing resources, migration and settlement stress, and systemic exclusion. Further, people living with HIV (PLHIV) in these diasporic communities face stigma and discrimination in both mainstream Canadian society as well as their own ethno-racial communities. HIV stigma negatively impacts all aspects of HIV care, from testing to disclosure to treatment and ongoing care. In response to these challenges, a Toronto based community organization developed and implemented the CHAMP project to engage people living with HIV/AIDS (PLHIV) and leaders from different service sectors from the African/Caribbean, Asian and Latino communities to explore challenges and strategies to reduce HIV stigma and build community resilience. The study engaged 66 PLHIV and ethno-racial leaders from faith, media and social justice sectors in two stigma-reduction training programs: Acceptance Commitment Therapy Training (ACT) and Social Justice Capacity Building (SJCB). Data collection included pre-and post- intervention surveys, focus groups and monthly activity logs. Participants were followed for a year and data on changes in the participants' attitudes and behaviors as well as their actual engagement in HIV prevention, PLHIV support and stigma reduction activities were collected. CHAMP results showed that the interventions were effective in reducing HIV stigma and increasing participants' readiness to take action towards positive social change. Participants' activity logs over a period of 9 months after completing the training showed they had engaged in 1090 championship activities to advocate for HIV related health equity and social justice issues affecting racialized and newcomer PLHIV and communities.

Modeling Beliefs, Attitudes, and Intentions of Condom Use Among Secondary School Students in Kenya.

As in other parts of sub-Saharan Africa, youth in Kenya report low rates of condom use. Although several studies have explored reasons for the low condom use among Kenyan youth, not many have established linkages between lack of use and normative beliefs and attitudes around condoms. Using the Theory of Planned Behavior (TPB), this article examined whether beliefs and attitudes around condoms influenced intentions and actual condom use. Data for the study were restricted to 1453 sexually active youth during the last school break. Path analysis was used to examine the relationship between the TPB constructs and condom use among Kenyan youth. Results indicated a direct relationship between attitudes and condom use for male respondents and an indirect relationship between these two variables for females. Both males and females who expressed greater intentions to use condoms were significantly more likely to report they used condoms consistently. Also, male and female youth with higher perceived behavioral control were significantly more likely to have used condoms consistently. Males with friends who used condoms were significantly more likely to use condoms consistently. The findings suggest the importance of examining young people's attitudes toward condoms-in particular, those deeply rooted in misconceptions that serve to discourage safer sexual behaviors.

Sexual Networking and Partner Characteristics Among Single, African, Caribbean, and Black Youth in Windsor, Ontario.

The disproportionate HIV burden shared by African, Caribbean, and Black (ACB) populations in Canada has not been explained by unique sexual behaviors in this population. This study investigates partner selection and sexual networking as potential contributors to HIV vulnerability. The study examines variations in the characteristics of sexual partners and sexual networking across groups based on differences in ethno-religious identity, gender, and length of Canadian residency among single, 16- to 27-year old, heterosexual-identified, ACB individuals living in Windsor, Ontario, Canada. Respondent-driven sampling maximized the representativeness of the sample of 250 (45 % male; 55 % female) youth with penile-vaginal intercourse experience who completed surveys. Logistic regression and analysis of variance compared groups with respect to number of lifetime partners, concurrency of sexual relationships, non-relational and age disparate partnering, and intra-ethnic sexual networking. For vulnerability associated with number of partners, concurrency and non-relational sex, women, newcomers to Canada, and African-Muslim participants were at lower vulnerability for HIV infection than their comparator groups. For vulnerability associated with sexual networking within a group with higher HIV prevalence, women and newcomers to Canada were at higher vulnerability to HIV infection than their comparator groups. There were insufficient data on age disparate partnering to support analysis. These results point to the importance of considering characteristics of partners and sexual networking both in further research and in developing policies and programs to curtail the spread of HIV and other sexually transmitted infections.

Challenging HIV vulnerability discourse: the case of professional and entrepreneurial women in Dar Es Salaam, Tanzania.

A poverty-HIV narrative has dominated many HIV prevention strategies in Africa despite epidemiological data showing higher prevalence of infection among educated and wealthier women in several African countries. This paper examines the perspectives of professional and entrepreneurial women on HIV risk and vulnerability based on their knowledge and lived experiences, comparing this to the HIV discourse evident in five strategic documents that shape intervention in Tanzania. The purpose is to uncover the confluence and dissonance between the discourses of government and those of professional women themselves. Qualitative research methods included critical discourse analysis of five strategic documents and thematic analysis of 37 in-depth interviews with women. The findings challenge fixed representations of women and notions of vulnerability embedded in the poverty-HIV discourse. Women described using their sexuality and sexual agency as a means to elevate their position in ways that made them vulnerable to sexual harassment and coercion. This is explored through two intersecting themes: non-marital sexual exchanges to gain an education or employment, and marriage. The intersecting social positions and constructions of female sexuality and agency expressed by the women in this study provide insights into other avenues and forms of HIV vulnerability.

HIV-related stigma among African, Caribbean, and Black youth in Windsor, Ontario.

HIV-related stigma has been shown to undermine prevention, care, treatment, and the well-being of people living with HIV. A disproportion burden of HIV infection, as well as elevated levels of HIV-related stigma, is evidenced in sub-Saharan African (SSA) and African-diasporic populations. This study explores factors that influence HIV-related stigma among 16- to 25-year-old youth residing in a Canadian city who identify as African, Caribbean, or Black. Stigma, as rooted in cultural norms and beliefs and related social institutions, combined with insights from research on stigma in SSA and African-diasporic populations, guided the development of a path analytic structural equation model predicting levels of HIV-related stigmatizing attitudes. The model was tested using survey responses of 510 youth to estimate the direct and indirect influences of ethno-religious identity, religious service attendance, time in Canada, HIV/AIDS knowledge, HIV-testing history, sexual health service contact, and gender on HIV-related stigma. Statistically significant negative associations were found between levels of stigma and knowledge and HIV-testing history. Ethno-religious identity and gender had both direct and indirect effects on stigma. African-Muslim participants had higher levels of stigma, lower knowledge, and were less likely to have been tested for HIV infection than other ethno-religious groups. Male participants had higher levels of stigma and lower knowledge than women. Time in Canada had only indirect effects on stigma, with participants in Canada for longer periods having higher knowledge and less likely to have been tested than more recent arrivals. While the strength of the effect of knowledge on stigmatizing attitudes in this research is consistent with other research on stigma and evaluations of stigma-reduction programs, the path analytic results provide additional information about how knowledge and HIV-testing function as mediators of non-modifiable characteristics such as gender, ethnicity, religion, and time in a country.

Qualitative Exploration of Sexual Experiences Among Adults on the Autism Spectrum: Implications for Sex Education.

CONTEXT: The increasing prevalence of autism since the 1990s has led to growing demand for sex education that meets the needs of persons on the autism spectrum. Yet there is a dearth of research documenting the firsthand experiences and perspectives of autistic individuals. METHODS: A thematic analysis was conducted of in-depth, Internet-facilitated interviews with 24 adults on the autism spectrum who were recruited from Internet community spaces between November 2012 and May 2013. Inclusion criteria were self-identification as a person on the autism spectrum, being a U.S. resident, being aged 18 or older, and having the ability to communicate orally or through writing. RESULTS: Participants were aged 18-61 and were living in the community at the time of interview, most with limited extrafamilial support. They were less likely than the general population to be heterosexual or gender-conforming and were more likely to have experienced romantic or sexual debut after age 18. Participants' most common concerns were courtship difficulties and sensory dysregulation in the context of partnered sexuality. These concerns were exacerbated by inadequate and inappropriate sex education experiences. Participants addressed challenges by using sensory barriers (e.g., latex gloves); planning when and how to have sex; negotiating alternatives to sexual scripts predicated on nondisabled experience; and practicing explicit and intentional communication. CONCLUSIONS: Individuals on the autism spectrum would benefit from sex education that normalizes differences (e.g., in identities and experiences of sexuality), is offered throughout young adulthood, addresses disability-relevant sensory and communication needs, and includes practicing neurotypical sociosexual norms.

Assessing young people's perceptions of HIV risks in Nyanza, Kenya: are school and community level factors relevant?

The majority of cognitive models used in HIV prevention identify risk perception as essential, and the first step towards safer sexual behaviors. Yet, previous studies have rarely examined risk perceptions as an outcome variable, and the few that have, limited their analysis to individual-level determinants. Conspicuously missing in the literature is how school/community level factors affect risk perceptions among school-going youth. Using data collected from primary school youth in Nyanza, Kenya and employing hierarchical linear modeling, this study examines how both individual and community level factors shape individuals' perceived risks of contracting HIV. Results indicate that measures captured at both individual and school/community levels were significantly associated with risk perception. At the individual level, and for boys, high risk perception was associated with higher knowledge about HIV, rejection of myths surrounding HIV transmission, higher condom use self-efficacy and having engaged in risky sexual behaviors. For girls, it was pressure from others to engage in sexual activity, having engaged in risky sexual behaviors and knowing someone infected with HIV that resulted in increased risk perceptions. Beyond individual level variables, some school/community level factors are significantly associated with risk perception. For instance, boys and girls in communities with higher estimates of AIDS deaths reported higher risk perceptions. Boys in communities where AIDS was acknowledged as the cause of death at funerals were less likely to report high risk perceptions. The findings suggest that interventions targeting HIV prevention among young people in Nyanza, Kenya could benefit immensely from an understanding of how schools and communities affect risk perceptions and behavioral change.

Individual- and community-level influences on the timing of sexual debut among youth in Nyanza, Kenya.

CONTEXT: Delaying sexual debut is an important HIV prevention strategy, yet few studies have examined associations between both community- and individual-level characteristics and sexual debut among youth in Sub-Saharan Africa. METHODS: Cross-sectional survey data collected from 8,183 youth aged 11-17 in 160 schools in Nyanza, Kenya, were used to examine the relationships between individual and community measures and the timing of sexual debut. Multilevel discrete-time hazard models were used to identify bivariate and multivariate associations. RESULTS: At the individual level, youth were more likely to have initiated sex (or had done so at an earlier age) if they had felt pressure to engage in sex from a greater number of sources (odds ratios, 1.3-1.8); perceived that they had a small or (among females) moderate chance, rather than no chance, of contracting HIV (1.2-1.3); or endorsed a greater number of HIV transmission myths (1.1 for both sexes). In addition, males with higher abstinence selfefficacy had a reduced risk of sexual debut (0.95). At the community level, males and females had a reduced risk of sexual debut if they lived in a community where AIDS deaths were publicly acknowledged (0.6-0.8) or the Primary School Action for Better Health program had been implemented (0.8-0.95); risk was also reduced among young men who lived in communities where HIV was discussed at a greater number of parent-teacher association meetings (0.9) or where abstinence was the primary AIDS prevention message conveyed to youth (0.9). CONCLUSION: Community-level variables are frequently associated with sexual debut and should be included in future research.

Individual- and school-level correlates of HIV testing among secondary school students in Kenya.

The policy framework guiding Kenya's response to the AIDS epidemic identifies voluntary counseling and testing as crucial to risk reduction and HIV-preventive activities. Yet in Kenya, as in most sub-Saharan countries, voluntary testing rates are low, especially among young people. Using hierarchical linear models, we identify both individual- and teacher/school-level factors that affect voluntary HIV testing among secondary school students in Kenya. Results indicate that adolescents are more likely to test for HIV serostatus when they are knowledgeable about testing, have been involved in HIV/AIDS activities in primary school, have been provided with HIV information in secondary school, perceive themselves as at high risk of contracting HIV or know of someone infected with or who has died from HIV/AIDS, and have ever engaged in sexual intercourse. Barriers include fear of going to testing centers and being perceived as HIV-positive. Teacher/school-level characteristics are relevant for explaining rates of HIV testing, especially among girls. To encourage testing, policymakers should attend to teacher/school-level factors as well as individual characteristics of students.

Breast cancer risk in relation to occupations with exposure to carcinogens and endocrine disruptors: a Canadian case-control study.

BACKGROUND: Endocrine disrupting chemicals and carcinogens, some of which may not yet have been classified as such, are present in many occupational environments and could increase breast cancer risk. Prior research has identified associations with breast cancer and work in agricultural and industrial settings. The purpose of this study was to further characterize possible links between breast cancer risk and occupation, particularly in farming and manufacturing, as well as to examine the impacts of early agricultural exposures, and exposure effects that are specific to the endocrine receptor status of tumours. METHODS: 1005 breast cancer cases referred by a regional cancer center and 1146 randomly-selected community controls provided detailed data including occupational and reproductive histories. All reported jobs were industry- and occupation-coded for the construction of cumulative exposure metrics representing likely exposure to carcinogens and endocrine disruptors. In a frequency-matched case-control design, exposure effects were estimated using conditional logistic regression. RESULTS: Across all sectors, women in jobs with potentially high exposures to carcinogens and endocrine disruptors had elevated breast cancer risk (OR = 1.42; 95% CI, 1.18-1.73, for 10 years exposure duration). Specific sectors with elevated risk included: agriculture (OR = 1.36; 95% CI, 1.01-1.82); bars-gambling (OR = 2.28; 95% CI, 0.94-5.53); automotive plastics manufacturing (OR = 2.68; 95% CI, 1.47-4.88), food canning (OR = 2.35; 95% CI, 1.00-5.53), and metalworking (OR = 1.73; 95% CI, 1.02-2.92). Estrogen receptor status of tumors with elevated risk differed by occupational grouping. Premenopausal breast cancer risk was highest for automotive plastics (OR = 4.76; 95% CI, 1.58-14.4) and food canning (OR = 5.70; 95% CI, 1.03-31.5). CONCLUSIONS: These observations support hypotheses linking breast cancer risk and exposures likely to include carcinogens and endocrine disruptors, and demonstrate the value of detailed work histories in environmental and occupational epidemiology.

HIV prevention for rural youth in Nigeria: background overview.

The negative impact of the HIV/AIDS epidemic has been a major challenge to sub-Saharan Africa. Although the rate of new HIV infections in sub-continent has decreased, the total number of people living with HIV continues to rise. Most of the people infected with HIV/AIDS in sub-Saharan Africa are within the age bracket of 15 to 35 years. It has been estimated that about 80% of the infected group are aged 20-29 years. It is against the background of the challenges posed by HIV/AIDS to young people that the Canadian-Nigerian partnership Action Research on HIV Prevention for Rural Youth was conceived. This paper provides the background to the outcomes reported in this special edition of this journal by reviewing the HIV/AIDS situation in sub-Saharan Africa and the nature of the associated response; discussing the rationale for the Action Research which focuses on Nigeria; and outlining the key components of the research.

Bridging theory and practice in HIV prevention for rural youth, Nigeria.

Thirty years into combating the spread of HIV through behaviour change interventions experience has grown in the application of multiple approaches from one-for-one counseling and small group workshops, information sessions, and activities to large-scale rallies and mass media campaigns with reducing the spread of HIV. These approaches have been variously guided by best field practice and theoretical frameworks developed to understand health-related behaviours and behaviour change. This article reviews the dominant theoretical approaches used to develop behaviour change interventions and strategies and presents the theoretical frameworks guiding the multi-level strategy to reduce youth vulnerability in Edo State, Nigeria known as HIV Prevention for Rural Youth (HP4RY). HP4RY is set within the multi-level Ecological Framework and specifically uses Sexual Scripting Theory and the AIDS Competent Community theoretical framework to guide an Action Research project that uses research to enhance the Family Life and HIV Education (FLHE) programme delivered in Junior Secondary Schools and a Community Mobilization programme led by members of the National Youth Service Corps. The benefits to using these theories and their fit with contemporary thinking in the field of HIV prevention through behaviour change are reviewed here.

What does a decolonizing/decentralizing methodology in examining sexual lives entail?

This paper is based on an international study, HIV Prevention for Rural Youth (HP4RY) 2008-2012, designed to examine the state of, and teach about, sexual health and HIV/AIDS in Edo State, Nigeria. The paper focuses on the mixed methods used in this study, paying attention to the meaning of collaboration and participation in research in a cross-continental setting. Additionally, the paper considers the complexities of engaging in decolonizing and respectful methodological approaches in these settings. Drawing on specifics from the mixed methods and details from the relevant literature, this paper demonstrates the continued need for cross-continental decolonization and decentralized engagements, specifically when dealing with sensitive topics like sexuality and HIV/AIDS. .

The use of National Youth Service Corp members to build AIDS competent communities in rural Edo State Nigeria.

This paper focuses on the community component of a larger action research project on HIV Prevention for Rural Youth (HP4RY), funded by the Global Health Research Initiative (Canada). It began with ethnographic research in 10 communities selected using geographic representative sampling and random assignment to one of three research arms. Using the AIDS Competent Community (ACC) model developed by Catherine Campbell, the ethnographic research identified factors in six domains that contributed to youth vulnerability to HIV infection. This was followed by recruitment, training and deployment of three overlapping cohorts of young adults (n = 40) serving in Nigeria's National Youth Service Corp (NYSC), to mobilize youth and adults in the communities to increase communities' AIDS competence over a nearly 2 year period. Monthly reports of these Corpers, observations of a Field Coordinator, and community feedback supported the conclusion that communities moved towards greater AIDS competence and reduction in youth vulnerability to HIV infection.

Evaluation of school- and community-based HIV prevention interventions with junior secondary school students in Edo State, Nigeria.

This study examined the impact of two interventions delivered in rural communities and schools in Edo State, Nigeria designed to decrease youth vulnerability to HIV infection. The Ministry of Education approved Family Life and HIV Education (FLHE) programme delivered in Junior Secondary Schools and a community-based initiative to raise AIDS Competency of rural communities were evaluated using a clustered randomized control trial and mixed qualitative-quantitative methods. Ten schools were assigned to each of three research arms: FLHE programme only, FLHE and community programme, and control. Results demonstrated positive effects on rejection of myths, attitudes related to abstinence and use of condoms, and sexual activity. Confidence in these results is supported by both levels of statistical significance and consistency in patterns of results across different levels of schooling. Results support expansion of delivery of the FLHE programme and development of community-based initiatives as effective methods of reducing youth vulnerability to HIV infection.

Meeting the challenges of North-South collaboration: the case of HIV prevention for rural youth, Edo State, Nigeria.

Despite the significant contributions of the various North-South research partnerships during the past five decades to enhancing research capacity in the South, they have faced a number of challenges associated with the various partnerships. There have been limited attempts to critically examine the successes and challenges associated with these partnerships. Based on the experiences of implementing the 'HIV Prevention for Rural Youth' programme by a Canadian-Nigerian partnership during a four year period, this paper outlines the successes achieved and the challenges faced. The paper reviews the context of contemporary North-South research collaboration which provided the framework for the implementation of the HIV Prevention for Rural Youth. It then examines the benefits which the implementation of the programme have stimulated as well as the various challenges which confronted the partnership and how they were handled. The implications of the project's implementation experiences for future North-South collaborative research programmes are highlighted.

Condoms in sub-Saharan Africa.

Sub-Saharan Africa (SSA) is the region with the world's highest rates of HIV and other sexually transmissible infections (STIs), yet numerous studies show that condom use is generally rare. This suggests a need for a better understanding of how condoms fit within sexual practices and relationships in SSA. This paper seeks to address this need by reviewing research published between the late 1980s and 2011 on use and factors influencing use of male condoms in SSA. What is evident from this research is that condom use involves complex social and interpersonal dynamics, with structural and cultural conditions exerting an influence through framing social cognitions and setting boundaries on autonomy that make the apparently irrational choice of eschewing condoms a rational decision. The influences of poverty; relationships with parents, peers and partners; limited, insufficient or absent information especially in rural areas and among men who have sex with men; gender and sexual norms, and the dynamics of gendered power; and beliefs and attitudes about HIV, condoms and sexuality all have been shown to work against condom use for a large proportion of Africa's people. However, promising results are shown in trends towards increased condom use among single women in numerous countries, increasing acceptance and use of condoms among some university students, successes in producing potentially sustainable condom use resulting from select interventions, and resistance to succumbing to the dominant gender-power dynamics and structural-cultural impediments that women in groups have mobilised.

Superstition, witchcraft and HIV prevention in sub-Saharan Africa: the case of Ghana.

Belief in superstition and witchcraft is central to many African conceptions of illness, disease causation and etiology. While a number of anthropological studies have alluded to a theoretical link between such beliefs and HIV prevention in particular, there is limited empirical assessment of the association. Using data from the 2008 Ghana Demographic and Health Survey and applying random-effects logit models, we investigate whether the belief that AIDS can spread through witchcraft associates with the sexual decision making of never-married men and women. The results show that men who believed AIDS can spread through witchcraft and other supernatural means were less likely to have used condoms at last sexual intercourse, controlling for other socioeconomic and cultural variables. Women with similar beliefs were more likely to have experienced sexual intercourse but less likely to have used condoms at last sex. For women, however, the relationship between such superstitious beliefs and condom use was somewhat attenuated after controlling for ethnicity and region of residence. From a policy perspective, the findings suggest that local beliefs regarding AIDS causation must be considered in designing HIV/AIDS programmes and interventions.