Effectiveness of Community Dialogue in Changing Gender and Sexual Norms for HIV Prevention: Evaluation of the Tchova Tchova Program in Mozambique

Structural HIV prevention interventions have gained prominence as ways to address underlying social and cultural factors that fuel the HIV epidemic. Identifying theories that explain how structural interventions are expected to change such factors can substantially increase their success. The Tchova Tchova community dialogue program, a theory-based intervention implemented in 2009–2010 in the provinces of Zambezia and Sofala, Mozambique, aimed to change gender and sexual norms for HIV prevention. Through facilitated sessions, the program sparked critical thinking and open dialogue among participants. This article measures the program’s effectiveness based on a sample of 462 participants and 453 nonparticipants. The results show that the program was successful in producing changes in three of the underlying structural factors of HIV: gender attitudes, gender roles, and HIV stigma. The program was also successful in changing other factors associated with HIV infection, including HIV prevention knowledge, discussion of HIV between sex partners, and having multiple sex partners.     

Obstacles to condom use among secondary school students in Maputo city,Mozambique

This study explores how urban youth in Mozambique perceive their sexual behaviour and identifies the factors that hinder them from having safer sex in the context of HIV/AIDS, with special emphasis on the condom use. Data was collected form high school students in Maputo, Mozambique. Using a combination of focus group discussions, interviews and informal conversations, it was possible to identify that one major obstacle to the use of condoms was young people's belief that they did not have to use condoms in steady relationships built on love and trust. Trust and love provide a sense of immunity to infection. Such a perception is reinforced, it is argued, by previous HIV/AIDS campaigns in Mozambique that have advocated the use of condoms only with ‘occasional sexual partners'. Students' understandings of pleasure, lack of accurate information, lack of sex education at home and at school, and gender inequalities further contribute to making condom use a difficult issue. There should be a change in focus in condom campaigns. Efforts should also be made to encourage young people to ‘emotionally invest’ in their health by using condoms.     

My first time: initiation into injecting drug use in Manipur and Nagaland, north-east India

Background  

The north-east Indian states of Manipur and Nagaland are two of the six high HIV prevalence states in the country, and the main route of HIV transmission is injecting drug use. Understanding the pathways to injecting drug use can facilitate early intervention with HIV prevention programs. While several studies of initiation into injecting drug use have been conducted in developed countries, little is known about the situation in developing country settings. The aim of this study was to increase understanding of the contextual factors associated with initiation into injecting drug use in north-east India, and the influence of these factors on subsequent initiation of others.     

Obstacles to condom use among secondary school students in Maputo city, Mozambique

This study explores how urban youth in Mozambique perceive their sexual behaviour and identifies the factors that hinder them from having safer sex in the context of HIV/AIDS, with special emphasis on the condom use. Data was collected form high school students in Maputo, Mozambique. Using a combination of focus group discussions, interviews and informal conversations, it was possible to identify that one major obstacle to the use of condoms was young people's belief that they did not have to use condoms in steady relationships built on love and trust. Trust and love provide a sense of immunity to infection. Such a perception is reinforced, it is argued, by previous HIV/AIDS campaigns in Mozambique that have advocated the use of condoms only with 'occasional sexual partners'. Students' understandings of pleasure, lack of accurate information, lack of sex education at home and at school, and gender inequalities further contribute to making condom use a difficult issue. There should be a change in focus in condom campaigns. Efforts should also be made to encourage young people to 'emotionally invest' in their health by using condoms.     

Immigration and HIV/AIDS in the New York Metropolitan Area

Because the HIV pandemic undergoes continual change in its locations and affected populations, it is crucial to study HIV risk behaviors among mobile and immigrant groups within and across borders. The impact of cross-cultural migrations and the importance of studying that impact in terms of demographic characteristics as well as cultural and environmental factors has not received adequate attention in public health research. This collaborative analysis utilizes data from three studies of immigrant groups in New York to describe and compare these factors that provide the context for risk and prevention of HIVAIDS and other health challenges. Data discussed were obtained utilizing multi-method approaches to identify and describe HIV risks among both new and more established immigrant populations within the urban settings of North America, with NYC as a central focus. Demographic and epidemiological data situate the analysis within the larger contexts of US migration and the HIV/AIDS epidemic in NYC. The authors identify risk and protective factors embedded to varying degrees in immigrants' multiple cultures and sub-cultures. The three populations studied include: 1) new Hispanic immigrants from the Dominican Republic, Mexico and Central America; 2) West Indian (Caribbean) immigrants from Jamaica, Trinidad/Tobago and other anglophone Caribbean nations; and 3) South Asian immigrants from India (Indian Americans). The paper seeks differences and commonalities, focusing on the social, attitudinal and behavioral factors that contribute to increased HIV/AIDS vulnerability among these populations. The data presented also identify some of the attitudes and behaviors of individuals and groups, as well as other facilitators and obstacles to transmission for immigrants as they adapt to new environments. Topics addressed include factors affecting HIV/AIDS vulnerability of immigrant groups, goals and expectations, health and mental heath issues, gender role change, sexual risk, alcohol and other drug use, perception of HIV/AIDS risk and implications for prevention.     

AIDS related knowledge, attitudes, and professional preparation among social work students in India

Three-hundred and eighty-five social work students enrolled in 11 colleges in India were surveyed. Overall, the students demonstrated a moderate degree of knowledge about HIV/AIDS. However, they were generally unconcerned about the contagion. Three-fourths admitted to their lack of competence to deal with HIV+ patients. Regression analyses identified the positive effect of AIDS knowledge in combination with variables 'actual contact with AIDS patients' and 'sense of competence' on attitude toward PHWA. The paper discusses a curriculum strategy aimed at gender sensitive content and recommends behavior change as the best approach to reverse the tide of the contagion.     

Providers' views concerning family planning service delivery to HIV-positive women in Mozambique

This study explores challenges and obstacles in providing effective family planning services to HIV-positive women as described by staff of maternal and child health (MCH) clinics. It draws upon data from a survey of service providers carried out from late 2008 to early 2009 in 52 MCH clinics in southern Mozambique, some with and some without HIV services. In all clinics, surveyed providers reported that practical, financial, and social barriers made it difficult for HIV-positive clients to follow protocols to prevent mother-to-child transmission of the virus. Likewise, staff were skeptical of their seropositive clients' ability to adhere to recommendations to cease childbearing and to use condoms consistently. Providers' recommendations to HIV-positive clients and their assessment of barriers to adherence did not depend on availability of HIV services. Although integration of HIV and reproductive health services is advancing in Mozambique, service providers do not feel that they can influence the behaviors of HIV-positive women effectively.     

Potential of dual-use policies to meet family planning and HIV prevention needs: a case study of Zimbabwe and Mozambique

BACKGROUND AND METHODOLOGY: The fight against the HIV epidemic in many high-prevalence countries is a struggle to motivate culturally relevant risk reduction in general populations that have been educated to associate HIV risk with commercial sex, injection drug use and other stigmatised behaviours. Common concurrent partnerships, which facilitate transmission of HIV in many high-prevalence countries, are only beginning to receive the attention they deserve. This has made the promotion of dual-use methods, such as condoms, for individuals who require both HIV protection and contraception very difficult. Recent research on concurrent partnerships and the implications for high HIV risk in sexually networked but sexually modest general populations is forcing another assessment of the response to HIV. In the light of the epidemic, it is important to better understand which policies will better meet HIV prevention and family planning (FP) needs. This article explores the potential of dual-use policies by examining Zimbabwe and Mozambique. RESULTS: Zimbabwe, with a vertically driven, stronger FP programme predating the HIV epidemic, has not yet seen an increase in condom use to the level desired by their moderately strong HIV prevention programme - one that has adopted a primarily single-use condom policy. Mozambique, however, continues to have a much weaker FP programme, but is witnessing a significant increase in condom use driven by their strong HIV programme - one that is further integrated with FP content. DISCUSSION: Integration of HIV and FP programmes has the potential to meet the need for HIV and pregnancy prevention more efficiently. By themselves, these programmes are unable to meet the need for condoms. The poorest of the poor are feeling the brunt of this inadequacy. Countries such as Zimbabwe and Mozambique have the potential to tremendously improve their efforts in increasing condom use. We suggest that thoughtful and detailed integration of HIV and FP programmes will work synergistically to reach common goals. Until a more promising method besides condoms is commercially available for protection against unintended pregnancy and sexually transmitted infections such as HIV, effective strategies must include dual-use policies as well as counselling on all available contraceptive methods so that women can maximise the benefits of mixing methods.     

Structure and agency in long-distance truck drivers’ lived experiences of condom use for HIV prevention

Condom promotion has emerged as a mainstay of targeted HIV prevention interventions in India, with its emphasis on individual behaviour change and personal responsibility. However, such approaches often do not account for marginalised populations’ structural vulnerability to HIV, arising from social, economic and political factors in the lived environment. In this paper, I use a critical health communication framework to analyse how structure and agency interact in influencing condom use among long-distance truck drivers in India. Drawing on an abductive discourse analysis of condom-use discourses among truckers and peer educators in two Indian cities, findings reveal that while truckers understand the biomedical logic of condoms as barriers, they also express anxiety about condom breakage and experience structural barriers to condom use. The paper concludes by calling for greater attention to structural vulnerabilities in future HIV prevention efforts with truck drivers.     

Willingness to use short-term oral pre-exposure prophylaxis (PrEP) by migrant miners and female partners of migrant miners in Mozambique

Abstract

Migrant miners from Mozambique who work in South Africa and their partners are at substantial risk for HIV infection. We conducted a cross-sectional study to assess the willingness of migrant miners and female partners of miners to take short-term pre-exposure prophylaxis (PrEP) for prevention of HIV acquisition. The study was conducted in Gaza Province, Mozambique, between September and October 2015. A total of 131 male miners and female partners of male miners completed a questionnaire. Subsequently, 48 in-depth interviews among male miners and female partners of miners and 3 focus-group discussions (6 participants each) among female partners of miners were conducted. Quantitative data were tabulated using Stata. A structured coding scheme was developed and qualitative data were analysed using Atlas.ti. Most participants (94%) were willing to take PrEP for short-term use. Facilitating factors for willingness to use PrEP were concerns about partner’s sexual behaviour, desire for pregnancy and one’s own sexual behaviour. The main barriers to PrEP use were concerns regarding side-effects, perceived difficulty adhering to daily pill taking and concern about partner/family disapproval. Overall, participants saw potential barriers for PrEP as minor obstacles that could be overcome. The male partner’s influence on PrEP use was significant.     

Secondary HIV prevention among Kothi‐identified MSM in Chennai,India

This study explored experiences and contexts of HIV risk and prevention among HIV‐positive kothi‐identified men in Chennai, India. In‐depth, semi‐structured interviews were conducted with 10 HIV‐positive men and three service providers, recruited using purposive sampling. Interviews were audio‐taped, transcribed in Tamil and translated into English. Data were analysed using a narrative thematic approach and constant comparative method. Misconceptions about HIV transmission; cultural taboos around discussing sexual behaviour and HIV; stigma related to same‐sex behaviour; harassment; and the criminalization of consensual sex between men present formidable challenges to HIV prevention. Frank and open discussion about male‐to‐male sexual behaviour and living with HIV, which may support health and HIV prevention, may be dangerous in the context of pervasive risks due to stigmatization, violence and criminalization. Instead, culturally appropriate, multi‐level interventions developed in collaboration with community stakeholders are needed to support HIV prevention among kothi‐identified men in South India.     

Now or Never: Perceived HIV Status and Fertility Intentions in Rural Mozambique

As the HIV epidemic evolves, researchers are devoting increased attention to the infection's effect on various life‐course activities, including marriage and reproduction. The impact of HIV on decisions about childbearing is particularly important, given the role that vertical transmission plays in the persistence of the epidemic. Previous studies on HIV and fertility intentions have yielded inconsistent results. This article expands on prior research by taking into account preferred timing of childbearing. Using data from a population‐based survey in rural Mozambique, we show that higher perceived risk of HIV is associated with greater likelihood of both wanting to speed up childbearing and wanting to stop having children. The “now or never” approach to childbearing is shown to be consistent with the widely held belief that HIV infection is incompatible with childbearing in the long term.     

Managing uncertainty around HIV/AIDS in an urban setting: private medical providers and their patients in Pune, India

Changing epidemiological patterns and the advent of new rapid diagnostic technologies and therapies have created considerable uncertainty for providers working in HIV. In India, the demand for HIV care is increasingly being met by private practitioners (PPs), yet little is known about how they deal with the challenges of managing HIV patients. To explore HIV management practices in the private medical sector, a survey was conducted with 215PPs in Pune, India, followed by in-depth interviews focusing on the social context of practice among a sub-set of 27PPs. Drawing primarily on interview data, this paper illustrates a number of uncertainties that underlie the reported actions of providers in a competitive medical market. PPs perceive HIV as a 'new' and challenging disease for which they lack adequate knowledge and skills. Combined with the perceived high cost and complexity of antiretroviral treatment, preconceptions about HIV patients' social, financial and mental capacity lead to highly individualistic management practices. While these fall short of clinical 'best practice' guidelines, they reflect adaptive responses to the wider uncertainties surrounding HIV care in urban India. By highlighting contextual issues in PPs' management of HIV patients, the paper suggests the need to explicitly acknowledge the social, moral and economic bases of uncertainty beyond the clinical setting.     

The hidden dimension: sexuality and responding to the threat of HIV/AIDS in South Sulawesi, Indonesia

Particular Asian countries (notably India, Thailand and Burma) are now estimated to have substantial numbers of HIV positive cases. The critical interacting factors which shape the HIV/AIDS epidemic in specific settings are the sexual and injecting drug using cultures and the governmental and societal responses to the threat of AIDS. This paper explores these factors in South (S.) Sulawesi in Eastern Indonesia. The paper presents recent quantitative and qualitative research findings on sexual culture, AIDS awareness and public health response in relation to the distinctive features of S. Sulawesi's geographical and socio-cultural setting. The paper concludes by discussing the major factors impeding and facilitating HIV/AIDS policy and programme implementation in S. Sulawesi.     

‘I saw it as a second chance’: A qualitative exploration of experiences of treatment failure and regimen change among people living with HIV on second- and third-line antiretroviral therapy in Kenya,Malawi and Mozambique

Increasing numbers of people living with HIV (PLHIV) in sub-Saharan Africa are experiencing failure of first-line antiretroviral therapy and transitioning onto second-line regimens. However, there is a dearth of research on their treatment experiences. We conducted in-depth interviews with 43 PLHIV on second- or third-line antiretroviral therapy and 15 HIV health workers in Kenya, Malawi and Mozambique to explore patients’ and health workers’ perspectives on these transitions. Interviews were audio-recorded, transcribed and translated into English. Data were coded inductively and analysed thematically. In all settings, experiences of treatment failure and associated episodes of ill-health disrupted daily social and economic activities, and recalled earlier fears of dying from HIV. Transitioning onto more effective regimens often represented a second (or third) chance to (re-)engage with HIV care, with patients prioritising their health over other aspects of their lives. However, many patients struggled to maintain these transformations, particularly when faced with persistent social challenges to pill-taking, alongside the burden of more complex regimens and an inability to mobilise sufficient resources to accommodate change. Efforts to identify treatment failure and support regimen change must account for these patients’ unique illness and treatment histories, and interventions should incorporate tailored counselling and social and economic support.     

Milking the cow: Young women's construction of identity and risk in age-disparate transactional sexual relationships in Maputo,Mozambique

Abstract

Sexual relationships between young women and older men involving economic transactions have been offered as a likely explanation for gender differences in HIV prevalence in many parts of sub-Saharan Africa. This study employed peer ethnography to explore young women's construction of social identity and risk within age-disparate transactional sexual relationships in Maputo, Mozambique. Peer ethnography, a rapid approach derived from the anthropological method and based upon training members of the target group to carry out in-depth qualitative interviews with their peers, was adopted in order to gather ethnographic data within a short timeframe to produce actionable results for the design of a communications intervention. The study highlights young women's perception of agency and power in these relationships. Through a strategy of extracting financial and material resources from men based on the power of their sexuality, young women construct a positive identity and esteem linked to perceptions of modernity and consumption and their ability to access consumer goods. Current behaviour change HIV prevention messages have little meaning in relation to young women's perceived goals, in a context in which structural conditions offer few opportunities and limited hope for a secure economic future.     

Editorial

Worldwide, more than 8500 people are newly infected with HIV each day and there are 21 million cumulative HIV/AIDS cases worldwide, 90% in developing countries. HIV infection and AIDS are firmly entrenched and spreading in India. World Health Organization projections suggest that India may have the highest number of HIV-positive cases by 2000. The double challenge is therefore presented of preventing personal infection and caring for others who are infected. While AIDS research is making some progress, it is clear that the war against HIV/AIDS will be long. Global efforts to prevent the spread of HIV infection are beginning to show positive results, with evidence of the slowing down of the HIV infection rate and the stabilization of the spread reported from some areas. Coordination, commitment, and social policy together with alternative people-oriented and socioculturally appropriate strategies must be brought to bear against the epidemic in India. The country's HIV/AIDS surveillance and blood banking systems also must be improved. Finally, efforts must be taken to ensure that all people have access to care.     

Dhandha, dharma and disease: traditional sex work and HIV/AIDS in rural India

This paper discusses the results of two ethnographic studies with female sex workers in rural areas of Karnataka and Rajasthan, India. In particular, we focus on women whose socio-economic status, and religious and occupational practices, are part of sex work systems that have historical precedents such that they can be termed "traditional" sex workers. The approach taken in the ethnographic work was informed by current critical approaches in medical anthropology and public health. The paper argues that in the context of an expanding HIV/AIDS epidemic in rural areas of India, understanding the historical and structural factors that operate to perpetuate female sex work as a culturally "sanctioned" occupation is critical if interventions intended to reduce the risk of HIV transmission are to succeed. We conclude that interventions designed to empower women collectively in these communities that are consistent with cultural traditions are needed to lead to healthier sexual behaviours and reduced risk of HIV/AIDS infection.