Does a history of sexual and physical childhood abuse contribute to HIV infection risk in adulthood? A study among post-natal women in Harare, Zimbabwe.

BACKGROUND: Sexual and physical abuse in childhood creates a great health burden including on mental and reproductive health. A possible link between child abuse and HIV infection has increasingly attracted attention. This paper investigated whether a history of child physical and sexual abuse is associated with HIV infection among adult women. METHODS: A cross sectional survey was conducted among 2042 postnatal women (mean age = 26y) attending six public primary health care clinics in Harare, Zimbabwe within 6 weeks post-delivery. Clinic records were reviewed for mother's antenatal HIV status. Participants were interviewed about childhood abuse including physical or sexual abuse before 15 years of age, forced first sex before 16, HIV risk factors such as age difference at first sex before age 16. Multivariate analyses assessed the associations between mother's HIV status and child physical and sexual abuse while controlling for confounding variables. RESULTS: More than one in four (26.6%) reported abuse before the age of 15: 14.6% physical abuse and 9.1% sexual abuse,14.3% reported forced first sex and 9.0% first sex before 16 with someone 5+ years older. Fifteen percent of women tested HIV positive during the recent antenatal care visit. In multivariate analysis, childhood physical abuse (aOR 3.30 95%CI 1.58-6.90), sexual abuse (3.18 95%CI: 1.64-6.19), forced first sex (aOR 1.42, 95%CI: 1.00-2.02), and 5+ years age difference with first sex partner (aOR 1.66 95%CI 1.09-2.53) were independently associated with HIV infection. CONCLUSION: This study highlights that child physical and/or sexual abuse may increase risk for HIV acquisition. Further research is needed to assess the pathways to HIV acquisition from childhood to adulthood. Prevention of child abuse must form part of the HIV prevention agenda in Sub-Saharan Africa.

"Girls need to behave like girls you know": the complexities of applying a gender justice goal within sexuality education in South African schools.

Sexuality education, as a component within the Life Orientation (LO) programme in South African schools, is intended to provide young people with knowledge and skills to make informed choices about their sexuality, their own health and that of others. Key to the programme are outcomes relating to power, power relations and gender. In this paper, we apply a critical gender lens to explore the ways in which the teaching of sexuality education engages with larger goals of gender justice. The paper draws from a number of ethnographic studies conducted at 12 South African schools. We focus here on the data collected from focus group discussions with learners, and semi-structured interviews with individual learners, principals and Life Orientation (LO) teachers. The paper highlights the complexities of having gender justice as a central goal of LO sexuality education. Teaching sexuality education is reported to contradict dominant community values and norms. Although some principals and school authorities support gender equity and problematize hegemonic masculinities, learners experience sexuality education as upholding normative gender roles and male power, rather than challenging it. Teachers rely heavily on cautionary messages that put more responsibility for reproductive health on female learners, and use didactic, authoritative pedagogical techniques, which do not acknowledge young people's experience nor facilitate their sexual agency. These complexities need to be foregrounded and worked with systematically if the goal of gender justice within LO is to be realised.

Resisting the binarism of victim and agent: Critical reflections on 20 years of scholarship on young women and heterosexual practices in South African contexts.

The last 20 years have seen a proliferation of research, spurred by the imperatives of the HIV epidemic and reportedly high rates of gender-based violence, on heterosexual practices in the South African context. Research has focused on how poverty, age and gender within specific cultural contexts shape sexual agency and provide a context for unequal, coercive and violent practices for young women. This paper takes stock of what we currently 'know' about heterosex and critically reflects on the political and ideological effects of such research, specifically in the light of young women's agency. A primary concern is that efforts to address gender inequality and the normative gender practices that shape inequitable heterosexual practices may have functioned to reproduce the very discourses that underpin such inequalities. The paper 'troubles' the victim-agency binarism as it has been played out in South African research on heterosex, raising concerns about how the research may reproduce gendered, classed and raced othering practices and discourses and bolstered regulatory and disciplinary responses to young women's sexualities. The paper argues for critical, feminist self-reflexivity that should extend to re-thinking methodologies entrenched in frameworks of authority and surveillance.

Masculinity, sexuality and vulnerability in 'working' with young men in South African contexts: 'you feel like a fool and an idiot a loser'.

South Africa has seen a rapid increase in scholarship and programmatic interventions focusing on gender and sexuality, and more recently on boys, men and masculinities. In this paper, we argue that a deterministic discourse on men's sexuality and masculinity in general is inherent in many current understandings of adolescent male sexuality, which tend to assume that young women are vulnerable and powerless and young men are sexually powerful and inevitably also the perpetrators of sexual violence. Framed within a feminist, social constructionist the oretical perspective, the current research looked at how the masculinity and sexuality of South African young men is constructed, challenged or maintained. Focus groups were conducted with young men between the ages of 15 and 20 years from five different schools in two regions of South Africa, the Western and Eastern Cape. Data were analysed using Gilligan's listening guide method. Findings suggest that participants in this study have internalised the notion of themselves as dangerous, but were also exploring other possible ways of being male and being sexual, demonstrating more complex experiences of manhood. We argue for the importance of documenting and highlighting the precariousness, vulnerability and uncertainty of young men in scholarly and programmatic work on masculinities.

Intimate partner violence after disclosure of HIV test results among pregnant women in Harare, Zimbabwe.

BACKGROUND: HIV status disclosure is a central strategy in HIV prevention and treatment but in high prevalence settings women test disproportionately and most often during pregnancy. This study reports intimate partner violence (IPV) following disclosure of HIV test results by pregnant women. METHODS: In this cross sectional study we interviewed 1951 postnatal women who tested positive and negative for HIV about IPV experiences following HIV test disclosure, using an adapted WHO questionnaire. Multivariate regression models assessed factors associated with IPV after disclosure and controlled for factors such as previous IPV and other known behavioural factors associated with IPV. RESULTS: Over 93% (1817) disclosed the HIV results to their partners (96.5% HIV- vs. 89.3% HIV+, p<0.0001). Overall HIV prevalence was 15.3%, (95%CI:13.7-16.9), 35.2% among non-disclosers and 14.3% among disclosers. Overall 32.8% reported IPV (40.5% HIV+; 31.5% HIV- women, p = 0.004). HIV status was associated with IPV (partially adjusted 1.43: (95%CI:1.00-2.05 as well as reporting negative reactions by male partners immediately after disclosure (adjusted OR 5.83, 95%CI:4.31-7.80). Factors associated with IPV were gender inequity, past IPV, risky sexual behaviours and living with relatives. IPV after HIV disclosure in pregnancy is high but lower than and is strongly related with IPV before pregnancy (adjusted OR 6.18, 95%CI: 3.84-9.93). CONCLUSION: The study demonstrates the interconnectedness of IPV, HIV status and its disclosure with IPV which was a common experience post disclosure of both an HIV positive and HIV negative result. Health services must give attention to the gendered nature and consequences of HIV disclosure such as enskilling women on how to determine and respond to the risks associated with disclosure. Efforts to involve men in antenatal care must also be strengthened.

Policy commitments vs. lived realities of young pregnant women and mothers in school, Western Cape, South Africa.

Reproductive rights in South Africa continue to be undermined for young women who fall pregnant and become mothers while still at school. Before 1994, exclusionary practices were common and the majority of those who fell pregnant failed to resume their education. With the adoption of new policies in 2007, young pregnant women and mothers are supposed to be supported to complete school successfully. Notwithstanding these new policies, there are incongruities between policy implementation and young women's lived experience in school. This paper explores the experiences of pregnancy and parenting among a group of 15 young women who fell pregnant and became mothers while attending three high schools in Khayelitsha township, a working-class community in the Western Cape of South Africa. Qualitative, in-depth interviews, conducted between 2007 and 2008, highlighted two key areas of concern: continuing exclusionary practices on the part of schools, based on conservative interpretations of policy, and negative and moralistic responses from teachers and peers. Such practices resulted in secrecy and shame about being pregnant, affecting the young women's emotional and physical well-being and their decisions whether to remain in school during pregnancy and return after having the baby. Further attention is required to ensure appropriate implementation of policies aimed at supporting pregnant and parenting young women to complete their education successfully.

Intimate partner violence during pregnancy in Zimbabwe: a cross-sectional study of prevalence, predictors and associations with HIV.

OBJECTIVE: To describe the occurrence, dynamics and predictors of intimate partner violence (IPV) during pregnancy, including links with HIV, in urban Zimbabwe. METHODS: A cross-sectional survey of 2042 post-natal women aged 15-49 years was conducted in six public primary healthcare clinics in low-income urban Zimbabwe. An adapted WHO questionnaire was used to measure IPV. Multivariate logistic regression was used to assess factors associated with IPV and severe (six or more episodes) IPV during pregnancy. RESULTS: 63.1% of respondents reported physical, emotional and/or sexual IPV during pregnancy: 46.2% reported physical and/or sexual violence, 38.9% sexual violence, 15.9% physical violence and 10% reported severe violence during pregnancy. Physical violence was less common during pregnancy than during the last 12 months before pregnancy (15.9% [95% CI 14.3-17.5] vs. 21.3% [95% confidence interval 19.5-23.1]). Reported rates of emotional (40.3% [95% CI 38.1-42.3] vs. 44.0% [95% CI 41.8-46.1]) and sexual violence (35.6% [95% CI 33.5-37.7] vs. 38.9% [95% CI 36.8-41.0]) were high during and before pregnancy. Associated factors were having a younger male partner, gender inequities, past abuse, problem drinking, partner control of woman's reproductive health and risky sexual practices. HIV status was not associated with either IPV or severe IPV, but reporting a partner with a known HIV status was associated with a lower likelihood of severe abuse. CONCLUSION: The rates of IPV during pregnancy in Zimbabwe are among the highest ever reported globally. Primary prevention of violence during childhood through adolescence is urgently needed. Antenatal care may provide an opportunity for secondary prevention but this requires further work. The relationship between IPV and HIV is complex in contexts where both are endemic.

Taxi 'sugar daddies' and taxi queens: male taxi driver attitudes regarding transactional relationships in the Western Cape, South Africa.

Media reports are emerging on the phenomenon of young girls who travel with older mini-bus taxi drivers, and who are thought to have sex with the drivers in exchange for gifts and money. The extent to which such relationships might facilitate unsafe sexual practices and increased risks for both the men and the young women, often referred to as taxi queens, remains an important question in the light of the current challenges of HIV/AIDS in sub-Saharan Africa. However, very little research has been undertaken on this issue, especially regarding the perceptions and experiences of taxi drivers. Thus this paper aims to provide some preliminary findings on taxi drivers' attitudes and beliefs about taxi queens and their relationships with taxi drivers. A 22-item questionnaire was administered to 223 male taxi drivers in two regions in the Western Cape Province, South Africa. Taxi drivers in this study largely saw the relationship between taxi drivers and the young girls who ride with them as providing status for both the girls and drivers, and there seemed to be recognition of the transactional nature of the relationship between taxi drivers and taxi queens. The stigmatisation of young girls who ride with taxi drivers was evident. Drivers had knowledge and awareness of the risks of unsafe sex and supported condom use, although there appeared to be some uncertainty and confusion about the likelihood of HIV infection between drivers and girls. While taxi drivers recognised the role of alcohol in relationships with young girls, they seemed to deny that the abuse of drugs was common. The study highlights a number of key areas that need to be explored with men in the taxi industry, in order to address risk behaviours for both taxi drivers and the girls who ride with them.

"That pregnancy can bring noise into the family": exploring intimate partner sexual violence during pregnancy in the context of HIV in Zimbabwe.

BACKGROUND: Globally, studies report a high prevalence of intimate partner sexual violence (IPSV) and an association with HIV infection. Despite the criminalisation of IPSV and deliberate sexual HIV infection in Zimbabwe, IPSV remains common. This study explored women's and health workers' perspectives and experiences of sexuality and sexual violence in pregnancy, including in relation to HIV testing. METHODS: This qualitative study was part of a larger study of the dynamics of intimate partner violence and HIV in pregnancy in Zimbabwe. Key informant interviews were conducted with health workers and focus group discussions were held with 64 pregnant or nursing mothers attending antenatal and postnatal care clinics in low-income neighbourhoods of Harare, covering the major thematic areas of validated sexual violence research instruments. Thematic content analysis of audio-recorded and transcribed data was conducted. RESULTS: While women reported some positive experiences of sex in pregnancy, most participants commonly experienced coercive sexual practices. They reported that men failed to understand, or refused to accept, pregnancy and its associated emotional changes, and often forced painful and degrading sexual acts on them, usually while the men were under the influence of alcohol or illicit drugs. Men often refused or delayed HIV testing, and participants reported accounts of HIV-positive men not disclosing their status to their partners and deliberately infecting or attempting to infect them. Women's passive acceptance of sexual violence was influenced by advice they received from other females to subordinate to their partners and to not deprive men of their conjugal sexual rights. CONCLUSIONS: Cultural and societal factors, unequal gender norms and practices, women's economic vulnerability, and men's failure to understand pregnancy and emotional changes, influence men to perpetrate IPSV, leading to high risk of HIV infection.

Narratives of transactional sex on a university campus.

Given the imperatives of HIV and gender equality, South African researchers have foregrounded transactional sex as a common practice that contributes to unsafe and inequitable sexual practices. This paper presents findings from a qualitative study with a group of students at a South African university, drawing on narratives that speak to the dynamics of reportedly widespread transactional sex on campus. Since many of these relationships are inscribed within unequal power dynamics across the urban-rural and local-'foreigner' divides, and across differences of wealth, age and status that intersect with gender in multiple, complex ways, it is argued that these may be exacerbating unsafe and coercive sexual practices among this group of young people. The paper further argues for a critical, reflexive position on transactional sex, pointing to the way in which participants articulate a binaristic response to transactional relationships that simultaneously serves to reproduce a silencing of a discourse on female sexual desires, alongside a simplistic and deterministic picture of masculinity underpinned by the male sexual drive discourse.

AIDS fatigue and university students' talk about HIV risk.

Drawing on a qualitative study that included 20 focus group discussions with male and female students at an urban-based university in South Africa, this article reports on perceptions, attitudes and reported behaviour with respect to HIV and AIDS and safer sex in the campus setting, with an aim to better understand how young people are responding to the challenges of HIV and AIDS in contemporary South Africa. The findings demonstrate the gap between reported HIV-prevention knowledge and safer-sex practices among a group of young and educated South Africans. Although the participants reported that students were knowledgeable about HIV and had easy access to condoms on campus, a range of factors mediated their capacity to apply this knowledge to safer-sex practices. Besides the usual set of complex social-cultural dynamics, including normative gender roles and power inequalities between men and women, socioeconomic challenges, and differences in age and status between sexual partners, the findings reveal substantial denial, stigma and HIV/AIDS 'fatigue.' The findings point to the importance of seeking creative ways to impart HIV-prevention and safer-sex messages that are not explicitly referent to HIV but link rather with broader issues concerning relationships, lifestyle and identity, and hence are responsive to the particular cultural context of university campuses.

South African teachers' responses to teenage pregnancy and teenage mothers in schools.

South African law forbids excluding pregnant teenagers from school and permits young parents to continue with their schooling. However, the existence of progressive policy and law does not by itself ensure that pregnant teenagers and young parents remain in school or experience as little disruption to their studies as possible. Two of the factors influencing the experiences that pregnant girls and young parents have are the attitudes and practices of teachers. We explore how teachers in diverse South African secondary schools respond to young women's pregnancy and parenting. Teachers' responses are situated within a complex set of meanings invoking sexuality (and sexual censure), gender, class and race. We argue that many teachers view teenage pregnancy and parenting as social problems - a domain of sexual shame with negative effects and disruptive to the academic life of the school (including teachers and other learners). Teachers do not monolithically subscribe to such negativity and, in the context of changing policy and gender equality, there are glimmers of hope. Without much support, training or any formal school-based support, many teachers show care and concern for pregnant women and young parents, providing some hope for better experiences of schooling.

Gender attitudes, sexual power, HIV risk: a model for understanding HIV risk behavior of South African men.

The Gender Attitudes-Power-Risk (GAPR) model of HIV risk behavior was tested using survey data collected from among 309 men who were attending STI services in a primary health care clinic in Cape Town, South Africa. Results showed that negative attitudes towards women were significantly positively associated with a high level of HIV risk behavior, and that endorsement of traditional male roles was negatively associated with HIV risk behavior. Endorsement of traditional male gender roles was also inversely related to relationship control but positively to a high degree of decision-making dominance in one's relationship. Sexual relationship power did not significantly mediate the relationships between gender attitudes and HIV risk behavior. A better understanding of gender roles and ideologies in combination with one's power in sexual relationships as they relate to HIV risk behavior among men could better inform future HIV prevention interventions.

The social construction of sexually transmitted infections (STIs) in South African communities.

Since the medical link between sexually transmitted infections (STIs) and HIV/AIDS was established, there has been an increased focus on the spread of STIs in South Africa. The aim of this study was to provide an in-depth picture of the dynamics involved in sexuality and the spread of STIs and HIV/AIDS. The authors present the findings of a focus group study, which was a part of a larger, national project addressing the broad question of health-care seeking behavior for STIs. A discourse analysis carried out on 10 focus groups reveals complex and rich narratives on the way in which STIs are constructed in South African communities. The dominant discourses focused on the continuing stigmatization of STIs, causal explanations, and prevention strategies. The analysis raises important recommendations for both educational interventions and health services toward the challenge of halting the spread of STIs and HIV/AIDS.