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Partner notification has emerged as an important strategy in the fight against acquired immunodeficiency syndrome (AIDS), and states have now adopted a plethora of laws that encourage or mandate notification, often without the patient's consent. As human immunodeficiency virus (HIV) infection continues to spread among women, the future development of AIDS control strategies and public health laws must be shaped by concern for the safety and autonomy of patients who face a risk of domestic violence. Three distinct recommendations flow from this premise. First, all HIV-infected women should be assessed for the risk of domestic violence and offered appropriate interventions. Second, where a risk of abuse is indicated, partners should never be notified without the patient's consent. State laws that presently permit involuntary notification should be repealed or amended. Third, laws that punish a patient's refusal to notify partners should also be modified or repealed.
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PMID:The risk of domestic violence and women with HIV infection: implications for partner notification, public policy, and the law. 748 75

The salience of couple communication to the prevention of human immunodeficiency virus (HIV) was demonstrated in a study of 876 Rwandan women with one steady sexual partner in the preceding year. These women were part of a longitudinal study of the natural history of HIV infection involving 1458 mothers recruited from prenatal and pediatric clinics at a Kigali Hospital in 1988. At study entry, 234 (27%) of the 876 monogamous women were HIV-positive; 45 additional women had seroconverted by the time of the two-year follow-up. Among the 855 sexually active subjects, only 196 (23%) were using condoms. Condom use was substantially higher among HIV-positive women (39%) than their HIV-negative counterparts (17%). In addition, condom use was significantly more likely if the woman had discussed condoms with her partner or if the male partner had agreed to an HIV test. Seronegative women with untested or HIV-negative partners were the least likely to discuss or use condoms. Notable was a pattern of male control of sexual decision making and female responsibility for condom provision, coercive sex, and domestic violence. 33% of women had been forced to have sex with their partner against their will and 21% had been beaten; these rates were even higher among HIV-positive women or HIV-negative women with infected partners. Given the disproportionate power of men in sexual relations in many African societies, efforts to strengthen women's condom negotiation skills may be counterproductive. Recommended, instead, are interventions that increase male involvement in HIV testing and counseling.
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PMID:Couple communication, sexual coercion and HIV risk reduction in Kigali, Rwanda. 757 30

Few programs exist that offer a range of human immunodeficiency virus (HIV) services to multiple populations (i.e., substance abusers, individuals on probation, sex workers and their clients, court-mandated perpetrators of domestic violence) in multiple settings (i.e., courts, methadone maintenance clinics, residential and outpatient substance abuse treatment programs). The purpose of this article is to describe a model mobile HIV program, highlighting its flexibility in providing services to clients who infrequently present to traditional clinic-based testing sites. This mobile HIV program was developed to provide on-site HIV testing and counseling, education, and linkages to primary care services. The implementation of the program begins with training of agency staff, who then provide preliminary orientation with clients regarding HIV testing. Approximately 3 weeks later, the mobile program staff (HIV nurse specialist and HIV counselors) provide standardized group pretest counseling and education. Clients who decide to be tested meet with mobile program staff for individualized risk assessment and specimen collection. Two weeks later, clients meet with mobile program staff to obtain results and receive posttest counseling; risk reduction strategies are reemphasized at that time. Unique to this program is the provision of referrals for a wide range of primary care services for both seropositive and seronegative clients. Since 1994, the mobile program has been implemented at six sites, and over 1100 clients have been served. Two major outcomes from the program have been observed: 1. With adequate preparation and psychological support, 40% of hard-to-reach populations will elect to be HIV tested. 2. Through social networks of program participants, HIV-positive individuals not previously engaged in care have been referred to a comprehensive HIV primary care program.
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PMID:A mobile HIV education and testing program: bringing services to hard-to-reach populations. 1136 65

Access to care by low-income persons and residents of rural and poor inner-city areas is a persistent problem, yet physicians tend to be maldistributed relative to need. The objectives were to describe preferences of resident physicians to locate in underserved areas and to assess their preparedness to provide service to low-income populations. A national survey was made of residents completing their training in eight specialties at 162 US academic health center hospitals in 1998, with 2,626 residents responding. (Of 4,832 sampled, 813 had invalid addresses or were no longer in the residency program. Among the valid sample of 4,019, the response rate was 65%.) The percentage of residents ranking public hospitals, rural areas, and poor inner-city areas as desirable employment locations and the percentage feeling prepared to provide specified services associated with indigent populations were ascertained. Logistic regressions were used to calculate adjusted percentages, controlling for sex, race/ethnicity, international medical graduate (IMG) status, plans to subspecialize, ownership of hospital, specialty, and exposure to underserved patients during residency. Only one third of residents rated public hospitals as desirable settings, although there were large variations by specialty. Desirability was not associated with having trained in a public hospital or having greater exposure to underserved populations. Only about one quarter of respondents ranked rural (26%) or poor inner-city (25%) areas as desirable. Men (29%, P <.01) and noncitizen IMGs (43%, P <.01) were more likely than others to prefer rural settings. Residents who were more likely to rate poor inner-city settings as desirable included women (28%, P =.03), noncitizen IMGs (35%, P =.01), and especially underrepresented minorities (52%, P <.01). Whereas about 90% or more of residents felt prepared to treat common clinical conditions, only 67% of residents in four primary care specialties felt prepared to counsel patients about domestic violence or to care for human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) or substance abuse patients (all 67%). Women were more likely than men to feel prepared to counsel patients about domestic violence (70% vs. 63%, P =.002) and depression (83% vs. 75%, P <.01). Underrepresented minority residents were more likely than other residents to feel prepared to counsel patients about domestic violence (P <.01) and compliance with care (P =.04). Residents with greater exposure to underserved groups were more prepared to counsel patients about domestic violence (P =.01), substance abuse (P =.01), and to treat patients with HIV/AIDS (P =.01) or with substance abuse problems (P <.01). This study demonstrates the need to expose graduate trainees to underserved populations and suggests a continuing role of minorities, women, and noncitizen physicians in caring for low-income populations.
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PMID:Residents' preferences and preparation for caring for underserved populations. 1156 55

Appropriate preconception health care improves pregnancy outcomes. When started at least one month before conception, folic acid supplements can prevent neural tube defects. Targeted genetic screening and counseling should be offered on the basis of age, ethnic background, or family history. Before conception, women should be screened for human immunodeficiency virus and syphilis infection and begin treatment to prevent the transmission of disease to the fetus. Immunizations against hepatitis B, rubella, and varicella should be completed, if needed. Women should be counseled on ways to prevent infection with toxoplasmosis, cytomegalovirus, and parvovirus B19. Environmental toxins such as cigarette smoke, alcohol, and street drugs, and chemicals such as solvents and pesticides should be avoided. In women with diabetes, it is important to optimize disease control through intensive management before pregnancy. Medications for hypertension, epilepsy, thromboembolism, depression, and anxiety should be reviewed and changed, if necessary, before the patient becomes pregnant. Counseling about exercise, obesity, nutritional deficiencies, and the overuse of vitamins A and D is beneficial. Physicians may also choose to discuss occupational and financial issues related to pregnancy and to screen patients for domestic violence.
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PMID:Preconception health care. 1261 25

An overview of health and social issues is presented here regarding Native Hawaiian transgenders. Perhaps due to relatively greater tolerance of gender diversity among Polynesian cultures, approximately 70% of all male-to-female transgenders in Hawai'i are Native Hawaiian. However, the overall climate is one of discrimination and harassment such that transgenders--who tend to be under-educated, under-employed, and medically underserved--may be the most severely impacted of all Native Hawaiians. Lei Anuenue, human immunodeficiency virus (HIV) prevention program for Native Hawaiians, has provided a variety of services for transgenders, including outreach, educational workshops, support groups, HIV testing, and case management. All services are provided by peer leaders who are employed by the program. Data for this article are based on case management, including client self-disclosures and reports of peer staff who knew details of clients' lives having shared with them both generic experiences and specific activities. Information from 100 transgender clients and their case managers indicated that the transgender health profile is far more serious than that of mainstream Native Hawaiians. For example, 74% smoke, 31% use illegal drugs (excluding marijuana), more than 50% have been involved in street or domestic violence, and few individuals over age 50 have been found during three years of outreach. To some extent, employment options limit transgenders to prostitution, drug dealing, and minimum-wage jobs. In addition, a lifestyle of multiple sex partners and lack of opportunities for stable relationships place transgenders at much greater risk for HIV, sexually transmitted diseases (STD), and other infectious and non-infectious diseases as compared to the mainstream Native Hawaiian community. Clients in this study were from O'ahu, primarily from downtown Honolulu, Chinatown, and Wai'anae. Future studies should compare the results of this sample to transgenders from the neighbor islands (especially in rural Hawaiian areas), as well as utilize a structured prospective longitudinal approach.
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PMID:Eo na Mahu o Hawai'i: the extraordinary health needs of Hawai'i's Mahu. 1218 May 12

By the year 2000, it is projected that more than 13 million women will be infected with human immunodeficiency virus (HIV) and 4 million will have died from acquired immunodeficiency syndrome (AIDS). By the end of the century, HIV transmission rates for women are expected to exceed those for men--a major shift from 1985, when the male/female ratio was 10:1. AIDS overlaps the most pressing issues for the international women's movement: domestic violence, trafficking of girls and young women, reproductive health, educational and economic opportunities, and equality under the law. Issues of gender-based power and control have been central to the escalating HIV rates among women. Limited access to economic resources and fear of violence force many women to yield control over sexual relations to men. Without a preventive method they can control, even monogamous married women are at risk of acquiring HIV from their husbands. Universal behavior change strategies such as consistent condom use bypass the issue of who controls the decision to practice safe sex. Needed are AIDS prevention strategies based in the concept of empowerment that help women to gain control over their economic, social, and sexual lives. Such programs would include economic opportunity to reduce women's dependence, social and political advancement to raise women's status, and female-controlled HIV preventive methods. As approaches designed by and for women become a part of standard AIDS programming, women will at last have a face and voice in the struggle against AIDS.
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PMID:Let their voices be heard: empowering women in the fight against AIDS. 1234 62

In Kenya, as in many other developing countries, women who lack the rights to control their own bodies, choose their own partners, or own and inherit property are vulnerable to human immunodeficiency virus (HIV) infection. The International Federation of Women Lawyers (FIDA-K) and other women's organizations in Kenya are pushing for legal reforms to reduce women's dependence on men. FIDA-K has worked with law enforcement agencies to protect women who report domestic violence and lobbied policymakers to make domestic violence and marital rape offenses punishable by law. Pressure to end the cultural practice of wife inheritance is growing in regions of Kenya where HIV prevalence is especially high. Also under scrutiny are laws that return a man's property to his own family when he dies, forcing many women widowed by acquired immunodeficiency syndrome (AIDS) to turn to commercial sex work to support themselves and their children. In addition, FIDA-K is working to educate law enforcement agencies to understand female genital mutilation as a prosecutable offense. The Platform for Action adopted at the United Nations Fourth World Conference on Women calls for all governments to review and amend laws and enact legislation against sociocultural practices that contribute to women's susceptibility to HIV infection.
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PMID:HIV prevention and women's rights: working for one means working for both. 1234 63

Although domestic violence is an increasing public health concern in developing countries, evidence from representative, community-based studies is limited. In a survey of 5109 women of reproductive age in the Rakai District of Uganda, 30% of women had experienced physical threats or physical abuse from their current partner--20% during the year before the survey. Three of five women who reported recent physical threats or abuse reported three or more specific acts of violence during the preceding year, and just under a half reported injuries as a result. Analysis of risk factors highlights the pivotal roles of the male partner's alcohol consumption and his perceived human immunodeficiency virus (HIV) risk in increasing the risk of male against female domestic violence. Most respondents--70% of men and 90% of women--viewed beating of the wife or female partner as justifiable in some circumstances, posing a central challenge to preventing violence in such settings.
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PMID:Domestic violence in rural Uganda: evidence from a community-based study. 1264 Apr 77

Domestic violence and human immunodeficiency virus (HIV) infection are problems of great public health worldwide, especially sub-Saharan Africa and much of the developing countries. This is due to their far reaching social, economic and public health consequences. The two problems have gender inequality and gender power imbalances as the driving force behind the "epidemics". HIV infection is mainly acquired through heterosexual relations, which themselves are greatly influenced by socio-cultural factors, underlying which are gender power imbalances. Unfortunately gender relations, and gender issues in general, have not been given much emphasis in the medical perspective, especially in efforts for prevention and control of HIV infection. There is thus a need to mainstream gender relations in reproductive health. This article aims at emphasizing the intersection between domestic violence, gender inequality and HIV infection.
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PMID:Gender inequality and domestic violence: implications for human immunodeficiency virus (HIV) prevention. 1512 95


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