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We explored the prevalence and predictors of transactional sex with casual partners and main girlfriends among 1288 men aged 15-26 from 70 villages in the rural Eastern Cape province of South Africa. Data were collected through face-to-face interviews with young men enroling in the Stepping Stones HIV prevention trial. A total of 17.7% of participants reported giving material resources or money to casual sex partners and 6.6% received resources from a casual partner. Transactionally motivated relationships with main girlfriends were more balanced between giving (14.9%) and getting (14.3%). We constructed multivariable models to identify the predictors for giving and for getting material resources in casual and in main relationships. Each model resulted in remarkably similar predictors. All four types of exchange were associated with higher socio-economic status, more adverse childhood experiences, more lifetime sexual partners, and alcohol use. Men who were more resistant to peer pressure to have sex were less likely to report transactional sex with casual partners, and men who reported more equitable gender attitudes were less likely to report main partnerships underpinned by exchange. The most consistent predictors of all four types of transaction were perpetration of intimate partner violence and rape against women other than a main partner. The strong and consistent association between perpetration of gender-based violence and both giving and getting material goods from female partners suggests that transactional sex in both main and casual relationships should be viewed within a broader continuum of men's exercise of gendered power and control. HIV prevention interventions need to explicitly address transactional sex in the context of ideas about masculinity, which place a high emphasis on heterosexual success with, and control of, women.
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PMID:Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: prevalence, predictors, and associations with gender-based violence. 1756 Jul 2

In South Africa, both HIV and gender-based violence are highly prevalent. Gender inequalities give men considerable relational power over young women, particularly in circumstances of poverty and where sex is materially rewarded. Young women are often described as victims of men, but this inadequately explains women's observed sexual agency. This paper takes a different approach. We use qualitative interviews and ethnographic observation among 16 young women from the rural Eastern Cape to explore ways young women construct their femininities and exercise agency. The data were collected as part of an evaluation of Stepping Stones, which is a participatory behavioural intervention for HIV prevention that seeks to be gender transformative. Agency was most notable in particular stages of the dating 'game', especially relationship initiation. Constructions of desirable men differed but generally reflected a wish to avoid violence, and a search for mutual respect, sexual pleasure, romance, modernity, status and money. Agency was constrained once relationships were consented to, as men expected to control their partners, using violent and non-violent methods. Women knew this and many accepted this treatment, although often expressing ambivalence. Many of the women expressed highly acquiescent femininities, with power surrendered to men, as a 'choice' that made their lives in cultural terms more meaningful. In marked contrast to this was a 'modern' femininity, centred around a desire to be 'free'. A visible third position, notably emerging after the Stepping Stones intervention, rested not on a feminist challenge to patriarchy, but on an accommodation with men's power whilst seeking to negotiate greater respect and non-violence within relations with men. These multiple and dynamic femininities open up possibilities for change. They demonstrate the need to engage with women, both as victims of patriarchy and active supporters of the gender order. The multiplicity of women's hopes and desires and circumstances of emotional and relational fulfillment provides potential for interventions with women that acknowledge existing gender inequalities, validate women's agency, reduce violence and prevent HIV.
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PMID:Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices. 2169 74

There is a lack of data on the prevalence of emotional abuse in youth. The aim of this study was thus to estimate the prevalence of emotional abuse in intimate partnerships among young women in rural South Africa and to measure the association between lifetime experience of emotional abuse (with and without the combined experience of physical and/or sexual abuse) and adverse health outcomes. Between 2002 and 2003, young women from 70 villages were recruited to participate in the cluster randomized controlled trial of an HIV behavioral intervention, Stepping Stones. Data was obtained through the administration of a questionnaire at baseline. Of the 1,293 women who had ever been partnered, 189 (14.6%) had experienced only emotional abuse in their lifetimes. Three hundred sixty-six women (28.3%) experienced emotional abuse with physical and/or sexual abuse in their lifetimes, and one hundred forty-four women (11.1%) experienced physical and/or sexual abuse without emotional abuse. Hazardous drinking was associated with the experience of physical and/or sexual abuse, with (OR 6.0, 95% CI [1.0, 36.6]) and without emotional abuse (OR 5.8, 95% CI [1.1, 29.4]). Illicit drug use (OR 5.6, 95% CI [2.4, 12.6]), having depressive symptoms (OR 2.9, 95% CI [1.2, 4.2]), having psychological distress (OR 1.9, 95% CI [1.4, 2.6]), and suicidality (OR 79.0, 95% CI [17.3, 359.6]) was associated with the experience of emotional abuse with physical and/or sexual abuse. Suicidality was also strongly associated with having experienced emotional abuse alone (OR 79.5, 95% CI [16.7, 377.4]). This study showed that emotionally abused young women had a greater risk of suicidality than those experiencing no abuse and that the combined experience of emotional with physical and/or sexual abuse was strongly associated with poor mental health outcomes.
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PMID:Adverse mental health outcomes associated with emotional abuse in young rural South African women: a cross-sectional study. 2198 16

This paper seeks to refocus debates on structural interventions away from 'assessing' their effectiveness towards understanding processes around how such interventions are implemented. Implementation Science is focused on understanding potential challenges of translating interventions from highly controlled conditions into 'real life' settings. Using the case study of Stepping Stones and Creating Futures a structural and behavioural intervention to reduce intimate partner violence and HIV risk behaviours amongst young women and men in urban informal settlements, we explore the challenges of implementing such an approach. We move beyond simply describing challenges of implementing, to understand how these challenges had an impact on the safe social space the intervention seeks to create as its underlying theory of change. We identify four major challenges of implementation: taxi fares, food provided during the intervention, young people's ongoing need to work and journals provided during the intervention. We suggest that, in different ways, these factors all impinged on the emergence of a safe social space. Understanding the challenges of implementing the intervention is critical for reflecting on scaling up interventions. Central to this is the need to work with participants to help them negotiate the challenges of participating in interventions.
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PMID:Jobs, food, taxis and journals: complexities of implementing Stepping Stones and Creating Futures in urban informal settlements in South Africa. 2517 33

Community-based behavioural interventions aimed at reducing risky sexual behaviour have yet to be shown to be effective in the developing world. Stepping Stones is a participatory STI/HIV prevention workshop programme based on empowerment techniques, which has been adapted to an infertility prevention framework for The Gambia. This paper describes a preliminary evaluation in two villages where the intervention was carried out compared to two control villages. Methods used include: participatory evaluation; 84 in-depth interviews; seven focus group discussions; a knowledge, attitudes and practice questionnaire administered to a random sample of 25% of the adult population at three time points; and monitoring of condom supply. The structure of the evaluation is based on the themes derived from the qualitative data. The infertility prevention approach made it possible to overcome resistance to discussing the topics of sexual and reproductive health. An atmosphere of trust was created and men were persuaded to participate in the programme as they felt that their own needs were being addressed. Participants enjoyed the programme and found the content relevant. Knowledge of the modes of transmission of HIV and sexually transmitted infections and levels of risk awareness increased. The value of condoms in particular situations was recognised: for sex before marriage, within marriage (when the woman is breastfeeding) and with non-marital partners. Women reported that they would insist on condom use outside marriage and even ask their husbands to use condoms for non-marital sex. Condom monitoring data suggested that condom uptake had increased. It was reported that there was significant increase in dialogue within marriage with the consequence that there were fewer disagreements and incidents of domestic violence. Diffusion of the messages of Stepping Stones appeared to have taken place with non-participants including children. The evaluation techniques used can now be refined in order to generate further evidence on a larger scale and over a longer period.
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PMID:'Before we were sleeping, now we are awake': Preliminary evaluation of the Stepping Stones sexual health programme in The Gambia. 2587 8

Participatory approaches to behaviour change dominate HIV- and intimate partner violence prevention interventions. Research has identified multiple challenges in the delivery of these. In this article, we focus on how facilitators conceptualize successful facilitation and how these understandings may undermine dialogue and critical consciousness, through a case study of facilitators engaged in the delivery of Stepping Stones and Creating Futures and ten focus-group discussions held with facilitators. All facilitators continually emphasized the importance of discussion and active engagement by participants. However, other understandings of successful facilitation also emerged, including group management--particularly securing high levels of attendance; ensuring answers provided by participants were 'right'; being active facilitators; and achieving behaviour change. These in various ways potentially undermined dialogue and the emergence of critical thinking. We locate these different understandings of success as located in the wider context of conceptualizations of autonomy and structure; historical experiences of work and education; and the ongoing tension between the requirements of rigorous research and those of participatory interventions. We suggest a new approach to training and support for facilitators is required if participatory interventions are to be delivered at scale, as they must be.
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PMID:'Eh! I felt I was sabotaged!': facilitators' understandings of success in a participatory HIV and IPV prevention intervention in urban South Africa. 2659 Feb 46

Ending intimate partner violence (IPV) and reducing gender inequalities are recognised as critical to "'ending AIDS" by 2030. Amongst women, experiencing IPV has been shown to increase HIV acquisition, reduce women's ability to use HIV prevention strategies and reduce adherence to antiretroviral therapy (ART). In Southern and Eastern Africa there has recently been a significant push to strengthen programming around this through broad funding and programming streams. However, while gender inequality underpins IPV and HIV acquisition, in different contexts a variety of other factors intersect to shape this vulnerability. Using reflections focused on young women living in urban informal settlements and the Stepping Stones and Creating Futures intervention, this paper illustrates the need to understand the specific drivers of HIV and IPV in any given context and the need for interventions to prevent this. Any intervention needs to include three key components: 1) resonate with the lived realities of women they target; 2) tackle multiple factors shaping women's vulnerability to IPV and HIV simultaneously; and 3) consider how best to work with men and boys to achieve improved outcomes for women. Such an approach, it is argued, resonating with the "slow research" movement, will yield better outcomes for interventions, but will also require a fundamental rethinking of how interventions to prevent IPV and HIV amongst women are conceptualised, with a greater emphasis on understanding the ways in which gender resonates in each context and how interventions can operate.
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PMID:Tackling gender inequalities and intimate partner violence in the response to HIV: moving towards effective interventions in Southern and Eastern Africa. 2739 43

Childhood traumas, in the form of physical, sexual, and emotional abuse and neglect, are globally widespread and highly prevalent, and associated with a range of subsequent poor health outcomes. This study sought to understand the relationship between physical, sexual and emotional childhood abuse and subsequent HIV-risk behaviours amongst young people (18-30) living in urban informal settlements in Durban, South Africa. Data came from self-completed questionnaires amongst 680 women and 677 men comprising the baseline of the Stepping Stones and Creating Futures intervention trial. Men and women were analysed separately. Logistic regression models assessed the relationship between six HIV-risk behaviours and four measures of trauma: the form of trauma, the severity of each trauma, the range of traumas, and overall severity of childhood trauma. Childhood traumas were incredibly prevalent in this population. All childhood traumas were associated with a range of HIV-risk behaviours. This was for the ever/never trauma, as well as the severity of each type of trauma, the range of trauma, and overall severity of childhood trauma. Despite the wider harsh contexts of urban informal settlements, childhood traumas still play a significant role in shaping subsequent HIV-risk behaviours amongst young people. Interventions to reduce childhood traumas for populations in informal settlements need to be developed. In addition, trauma focused therapies need to be considered as part of wider HIV-prevention interventions for young adults.
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PMID:Childhood traumas as a risk factor for HIV-risk behaviours amongst young women and men living in urban informal settlements in South Africa: A cross-sectional study. 2962 12

Despite being highly vulnerable to acquiring HIV, no effective evidence-based interventions (EBI) exist for street-connected young people (SCY) in low- and middle-income countries (LMICs). Therefore, this paper describes the research process of adapting an existing EBI in Eldoret, Kenya using a modified ADAPT-ITT model with a young key population. From May to August 2018 we adapted the combined Stepping Stones and Creating Futures interventions. We used community-based participatory methods, focus group discussions, and working groups with four Peer Facilitators and 24 SCY aged 16-24 years. At the inception of this project, a matched-savings programme was integrated into the intervention to further address structural drivers of HIV. Numerous adaptations came forth through the participatory process. Engaging SCY in the adaptation process ensured the programme was responsive to their needs, relevant to the street context, and respected their right to participate in the research process.
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PMID:Adapting an evidence-based gender, livelihoods, and HIV prevention intervention with street-connected young people in Eldoret, Kenya. 3116 89

Participatory interventions with men and boys to transform masculinities are increasingly common to improve health and reduce intimate partner violence and HIV-related risk. Yet, despite this, there has been little consideration of how facilitators' own masculinities shape interventions. In this analysis of Stepping Stones and Creating Futures, a gender-transformative programme delivered to young men (aged 18-30 years) in urban informal settlements in Durban, South Africa we explore how facilitators' masculinities were employed to engender change in the masculinities of participants. We argue facilitators had to negotiate two tasks existing in some tension, the first, overt and the main aim of the programme: namely, challenging elements of the youthful masculinity at play in the lives of participants, such as exerting violent power over women. A second task was more covert: namely, establishing facilitators' credibility 'as men' in order to do this work with participants. Through strategies including clothes, mobile phones, jokes and storytelling, facilitators demonstrated to participants their 'successful' masculinity and could then engage with participants around emotions, non-violence and consistent condom use. This enabled facilitators and participants to undergo a limited processes of change, without 'compromising' their sense of masculinity, and without fundamentally challenging men's patriarchal privilege.
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PMID:Constructing, reproducing and challenging masculinities in a participatory intervention in urban informal settlements in South Africa. 3120 94


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