Changing attitudes and beliefs towards a woman’s right to protect against HIV risk in Malawi

Female empowerment and positive attitudes towards women’s rights in sexual relationships have been found to be key elements of successful behaviour-based HIV prevention programmes. However, HIV prevention programmes that do not specifically engage with gender issues may also affect attitudes and beliefs towards women’s rights within sexual relationships. Using data from the Malawi Longitudinal Study of Families and Health we compare measures of female empowerment and changing gender norms between intervention participants and non-participants. Results suggest that female intervention participants were more likely than non-participants to believe that: (1) women have more rights within sexual relationships in general and (2) women have the right to protect themselves against HIV risk (indicating possible increases in female self-efficacy in making HIV prevention decisions). Male intervention participants showed no substantial positive change in attitudes towards women’s rights. These results highlight an important positive effect of HIV prevention programmes on women’s attitudes towards their own rights.     

Using mystery clients to assess condom negotiation in Malawi: some ethical concerns

To halt the HIV/AIDS epidemic in Malawi, donors supported the government in promoting safer sex among women who solicit sex with men in and around bars. In 1996, a qualitative study explored the changing dynamics of concurrent sexual partnerships, using a variety of researchers and methods. Although most international ethical research codes prescribe the informed consent of research subjects, the present author, as principal investigator for that study, included the mystery-client method, which omits informants' consent. Five trained, pilot-tested, and closely supervised male researchers contacted 101 bar girls and "freelancing" women in trading and urban centers to assess the women's ability to negotiate condom use. The men posed as clients but were instructed not to have sex with their informants. This approach provided important contextualized information to improve HIV transmission-prevention programs, yet it raises ethical concerns. This article is intended to contribute to the dialogue and debate on ethical research involving mystery clients and to encourage other researchers to share their ethical dilemmas and show how they have addressed them.     

Expanding the boundaries of previously obtained informed consent in research: Views from participants in the Personalised Risk-based Mammascreening study

Introduction

Understanding participants' concerns and information needs regarding broadened consent is crucial to ensure transparency and participant autonomy. Our study qualitatively examined these issues in women participating in the Personalized RISk-based MAmmascreening study (PRISMA). The original PRISMA informed consent was project-specific (i.e., breast cancer research), limiting the scope of secondary research. We explored participants' needs for broadened consent to preserve informed decision-making while maximising the potential re-use of data.

Methods

Focus groups (FGs) were performed following a semistructured discussion guide. Two independent researchers analysed the data thematically using an inductive approach.

Findings

Twenty-three asymptomatic women and 13 women diagnosed with breast cancer were randomly divided into six FGs. Four superordinate themes were identified: (1) Normalization, (2) Attitude towards the pharmaceutical industry, (3) Privacy and (4) Knowledge. Our participants viewed data sharing as an important conduit for advancing medical science. Perceived integrity was more often attributed to noncommercial than commercial parties, with a marked mistrust towards the pharmaceutical industry. Most requested information needs related to data protection. Participants' ideal consent process would confer a range of options; for example, they would be able to choose with whom data can be shared, whether data will be de-identified or anonymous, the expiration date of their consent and how, if requested, general and personal study results would be disclosed.

Conclusion

Our participants expressed clear information needs and a strong desire to be actively engaged in future data sharing decisions. Given that many researchers collaborate with commercial parties, building public confidence in these institutions would be beneficial. Illustrative examples addressing privacy concerns and clarifying difficult terms would aid consent decision-making. Although our participants displayed great altruism in sharing their data and accepted that broad consent would ultimately facilitate future research, broad consent did not reflect their ideal situation. Dynamic consent may be an option but warrants further feasibility research.

Patient and Public Contribution

Women were recruited from the general breast cancer screening population. Their perceptions and information needs, as reported in this study, will not only inform broadened consent for PRISMA but ideally guide other consent templates and decisions regarding consent processes.     

Prenatal HIV testing in Ontario: knowledge,attitudes and practices of prenatal care providers in a province with low testing rates

OBJECTIVE: To describe the knowledge, attitudes and practices of prenatal care providers in relation to prenatal HIV testing. METHODS: A stratified random sample of 784 family physicians, 200 obstetricians and 103 midwives providing prenatal care in 3 health planning regions in Ontario received a questionnaire. RESULTS: Response was 622/1087 (57%). Almost half of participants (43%) were not aware of Ontario's prenatal HIV testing policy. Eighty-five percent of participants reported that they offered or ordered HIV testing for all pregnant women. Sixty-six percent agreed that women should have a choice about whether to test or not, and midwives were more supportive of having an informed consent process than were physicians. CONCLUSION: Knowledge about the risks and benefits of prenatal HIV testing needs to be improved, and standards for informed consent should be re-evaluated to achieve the most ethical process with the least complexity.     

Children's attitudes toward people with AIDS in Puerto Rico: exploring stigma through drawings and stories

AIDS stigma refers to prejudice and discrimination directed at people or groups perceived to have HIV/AIDS (Herek, 1999). Although AIDS stigma has been found in adolescent and adult populations, few researchers have explored it among children. Misconceptions about people with AIDS (PWA) might lead to negative attitudes toward PWA and obstruct HIV prevention efforts. The authors assessed 110 Puerto Rican children's attitudes toward PWA using drawings (n=65) and stories (n=45). Although participants held stigmatizing attitudes toward PWA across both methods, the approaches captured different beliefs and attitudes. Drawings depicted PWA as physically deteriorated and performing socially condemned behaviors, whereas stories describing PWA highlighted children's fear of contagion and death. Stigma toward PWA was more pronounced than toward other illnesses (e.g., cancer). The study highlights the importance of assessing children's attitudes through creative data collection procedures.     

HIV prevention risks for Black women in Canada

The future availability of HIV vaccines can increase options available to Canadian Black women for risk reduction. However, current conceptual frameworks do not adequately address barriers to HIV prevention for this population, and may be inadequate to address challenges with vaccines. This study explored knowledge and attitudes regarding HIV vaccines and associated prevention methods to inform appropriate conceptual frameworks for their dissemination to Canadian Black women. We completed four 90-min focus groups with women (n=26) of African or Caribbean origins, and six interviews with key informants providing health and social services in the Black communities of Toronto. The participants suggested that there were significant risks associated with seeking prevention information and attempting to reduce exposure to HIV infection. They described individual, familial, community and institutional domains of risk and predicted the same spectrum of risk for HIV vaccines. Participants advocated for education, empowerment and institutional change to create a supportive environment for vaccines and other HIV prevention methods. They further indicated that preparation for vaccine dissemination will need to prioritize building trust between women of the Black communities and institutions in the research, health and government sectors.     

Selectively willing and conditionally able: HIV vaccine trial participation among women at "high risk" of HIV infection

Efficacy studies of investigational HIV vaccines require enrollment of individuals at ‘high risk’ for HIV. This paper examines participation in HIV vaccine trials among women at ‘high risk’ for HIV acquisition. In-depth interviews were conducted with 17 African-American women who use crack cocaine and/or exchange sex for money/drugs to elicit attitudes toward medical research and motivators and deterrents to HIV vaccine trial participation. Interviews were digitally recorded and transcribed; data were coded and compiled into themes. Most women expressed favorable attitudes toward medical research in general. Motivators for trial participation included compensation; personal benefits including information, social services, and the possibility that the trial vaccine could prevent HIV; and altruism. Deterrents included: dislike of needles; distrust; concern about future consequences of participating. In addition, contingencies, care-giving responsibilities, and convenience issues constituted barriers which could impede participation. Respondents described varied, complex perspectives, and individual cases illustrate how these themes played out as women contemplated trial participation. Understanding factors which influence vaccine research participation among women at ‘high risk’ can aid sites to tailor recruitment procedures to local contexts. Concerns about future reactions can be addressed through sustained community education. Convenience barriers can be ameliorated by providing rides to study visits when necessary, and/or conducting study visits in accessible neighborhood locations. Women in this sample thought carefully about enrolling in HIV vaccine trials given the structural constraints within which they lived. Further research is needed regarding structural factors which influence personal agency and individuals’ thinking about research participation.     

Views of US researchers about informed consent in international collaborative research

Informed consent poses challenges in all settings. Challenges may be particularly great in international collaborative research, where cultural perspectives may differ, and where education levels and language may be barriers to participant understanding. We conducted a written survey and focus groups with US health researchers doing research in developing countries, asking about informed consent and other ethical issues in their research. We present here both qualitative and quantitative data relevant to informed consent. Qualitative data revealed that researchers' experiences and beliefs about informed consent fell into three paradigms: regulatory, community, and individual. The regulatory paradigm refers to researchers' views and practices relating to informed consent requirements of institutional review boards and other oversight bodies. The community paradigm refers to researchers' approach to the content and methodology of informed consent in the context of long-term relationships between research teams and study communities. Researchers emphasized the importance of these relationships for creating and maintaining communication fundamental to the informed consent process. Finally, the individual paradigm refers to researchers' views about individual participants' understanding and decision-making process regarding research. Researchers described community-level influences on participants' decision-making, but stressed the need for individual comprehension and voluntary participation. While these paradigms are distinct, they also are intertwined. Quantitative data supported the existence of these three paradigms in respondents' characterization of informed consent. Researchers frequently stated that legal language on the consent forms was meaningless (52%). Forty-four percent of researchers had consulted with community leaders, and 23% believed the consent process focuses too much on the individual, rather than on family or community. Most researchers (82%) reported that the consent process was an important means of educating participants about the study. Fifty-four percent of researchers believed participants did not understand placebos. Further research is needed to understand how culture and relationships affect research participation, and to provide information and dialogue among researchers, oversight bodies and community representatives about appropriate ways to approach informed consent in international research.     

FACTORS THAT CONTRIBUTE TO WOMEN DECLINING ANTENATAL HIV TESTING

In this study we aimed to identify factors that contribute to women’s decisions to decline an HIV test during their pregnancy in an antenatal clinic setting in Metropolitan London. Voluntary HIV testing (“opt-in”) is recommended by the British Department of Health in areas of higher HIV prevalence. We developed a questionnaire that focused on attitudes toward testing, knowledge of transmission routes, a self-assessment of HIV risk, and reasons for declining the HIV test. All women attending the 16-week antenatal booking appointment were offered an HIV test. Of these 560 women, 124 (23%) had an HIV test and the 436 (77%) who declined the test were asked to complete a questionnaire that explored their reasons for declining. We based our findings on the 393 completed returned questionnaires. The major finding was that women declined testing because they did not think they had been at risk for HIV. However, they based this belief on patchy HIV knowledge. The women were making an important decision during their pregnancy on the basis of poor information. The antenatal setting may not be the most appropriate environment in which to give HIV information, however, this task must be performed also in other health environments.     

Attitudes toward online HIV/sexually-transmitted infection prevention programs and Internet user profiles among men who have sex with men

Objectives

To describe the attitudes of men who have sex with men (MSM) toward online HIV/sexually-transmitted infection (STI) prevention programs and to identify and characterize user profiles with regard to their attitudes toward online prevention programs.

Method

A survey in gay venues or via the internet was completed by 2,044 participants from Madrid, Barcelona, Bilbao and San Sebastián (Spain). The survey explored socio-demographic variables, sexual behavior and other risk behaviors associated with HIV infection, as well as attitudes toward online prevention programs. The statistical analysis included factor analysis and non-hierarchical cluster analysis.

Results

Most MSM had positive attitudes towards online HIV/STI prevention programs. Factor analysis revealed two factors: online prevention aimed at interaction and online prevention aimed at information. Based on these factors, three user profiles were identified: users oriented toward informative and interactive online prevention (53.5%), users oriented toward interactive online prevention (25.9%) and users were not oriented toward online prevention (20.7%). On characterizing these profiles, we observed a significant presence of men who were not interested in online prevention among those with a lower educational level, bisexual men and HIV-positive men. Conversely, those most receptive to online prevention were men self-identified as gay, those with a bachelors degree, those who had been tested for HIV and those who were HIV-negative.

Conclusion

The internet can facilitate sexual health promotion among MSM. Characterization of user profiles offers the possibility of segmenting prevention programs and of combining online and offline strategies.     

戒毒所和妇教所收容人员对艾滋病检测咨询的态度及其影响因素

目的了解戒毒所和妇教所收容人员艾滋病检测咨询经历、态度及影响因素。方法在戒毒所和妇教所分别调查了185名吸毒者和159名暗娼,内容包括人口学信息、性行为、吸毒史、艾滋病检测相关知识及态度等,分析两组人群对所内进行艾滋病检测咨询态度的影响因素。结果所有收容人员在入所时都做过HIV检测,但只有26.2%的人表示自己做过检测,其中81.1%知道检测结果。分别有83.1%的吸毒者和84.6%的暗娼愿意在戒毒所和妇教所咨询艾滋病知识;有80.9%的吸毒者和78.9%的暗娼愿意在戒毒所和妇教所做艾滋病检测。结论戒毒所和妇教所收容人员在入所时已做HIV检测,但多数没有被告知。收容人员对所内开展艾滋病检测咨询表示接受。戒毒所和妇教所应注意改善检测服务,加强检测结果告知。     

AIDS high-risk and precautionary behaviour in young african adults: A Zimbabwean perspective

Increases in condom use among hetero-sexual active individuals are crucial to containing the spread of AIDS. A random sample of respondents (N =2,201) completed measures of sexual behaviour, HIV-related risk reduction, attitudes toward condom use and their experiences with deception when dating covering the previous two months and psychological measures theoreticaily pertinent to AIDS risk. Thirty-five percent of the sample reported engaping in unprotected anal intercourse, the abysmal high risk behaviour most strongly associated with transmission of human immunodeficiency virus (HIV) infection. In addition, these data confirm the findings of previous research that majority of women had been lied to by a dating partner. However, it was also noted that sexually experienced men often told a lie in order to have sex and were more dishonest in dating. While women demonstrated greater anxiety/worry and concerns about all STDS, including HIV, because they know they are more vulnerable. These data support the views that personality and psychological adjustment are important predictors of risk reduction for HIV infection in sexually active young adults. HIV education and innovative prevention programmes need to focus more on culturally relevant interventions to achieve safer sex practices and on grassroot social processes that will sustain behaviour changes and consistently support risk reduction maintenance toward safer sex.     

Impact of peer group education on HIV prevention among women in Botswana

A peer group HIV prevention intervention based on social-cognitive learning theory, gender inequality, and the primary health care model for community-based health promotion was developed for more than 300 urban employed women in Botswana. All women volunteered to participate in the intervention. To control for self-selection, matched workplaces were assigned to the intervention group or to the delayed control group. Compared with women in the delayed control group, women in the intervention group had significantly higher postintervention levels of knowledge of HIV transmission, sexually transmitted diseases (STDs), and HIV prevention behaviors; positive condom attitudes and confidence in condom use; personal safer sex behaviors; and positive attitudes toward persons living with HIV/AIDS and community HIV/AIDS-related activities. The peer group leaders have sustained the program for more than 5 years after the end of research funding. Peer groups are a low-cost and sustainable intervention that can change HIV prevention knowledge, attitudes, and behaviors for ordinary urban employed women in sub-Saharan Africa.     

‘Hold on’ (Bambelela)! Lyrical interpretations of participation in an HIV prevention clinical trial

Abstract

During a five-day workshop, former clinical trial participants and local musicians wrote the lyrics and recorded a song about an HIV prevention trial. Born of concerns about misconceptions regarding experimental drug trials, the aim was to engender engagement with medical researchers and open dialogue about the risks and benefits of trial participation. Composing lyrics that highlighted their credibility as communicators of medical scientific knowledge and their selfless sacrifice to stem the transmission of HIV, women performed their social positioning and cultural authority in contrast to men as well as other women not part of the trial. While involvement in HIV prevention initiatives often attracts stigma, scorn and criticism, the song’s lyrics highlighted women’s new-found identities as heroines searching for a solution to the spread of HIV, challenging these stereotypes. Methodologically, the paper describes a novel approach that uses artistic expression for public engagement with biomedical research.     

Ugandan Men's Attitudes Toward Their Partner's Participation in Antenatal HIV Testing

Several authors have shown that women's uptake of antenatal HIV testing is influenced by fear of their partners’ reactions. We conducted a qualitative study with 40 Ugandan men to examine their attitudes toward their partners' participation in antenatal HIV testing. Most men believed women should consult their husbands prior to HIV testing to avoid negative consequences and facilitate disclosure. When women tested during routine antenatal care, however, the need to obtain permission was considered less important. These findings lend support to the practice of routine antenatal HIV testing as an acceptable way for women to test independently of their partners.     

Gay Male Couples’ Attitudes Toward Using Couples-Based Voluntary HIV Counseling and Testing

Many men who have sex with men acquire HIV from their primary male partners while in a relationship. Studies with gay couples have demonstrated that relationship characteristics and testing behaviors are important to examine for HIV prevention. Recently, couples-based voluntary HIV counseling and testing (CVCT) has become available to male couples throughout the U.S. However, HIV-negative couples’ attitudes toward using CVCT and how their relationship characteristics may affect their use of CVCT remain largely unknown. This information is particularly relevant for organizations that offer CVCT. To assess couples’ attitudes, and associated factors toward using CVCT, a cross-sectional study design was used with a novel Internet-based recruitment method to collect dyadic data from a national sample of 275 HIV-negative gay couples. Multivariate multilevel modeling was used to identify factors associated with differences between and within couples about their attitudes towards using CVCT. Findings revealed that couples were “somewhat” to “very likely” to use CVCT. More positive attitudes toward using CVCT were associated with couples who had higher levels of relationship satisfaction and commitment toward their sexual agreement and among those who had at least one partner having had sex outside of the relationship. Less positive attitude toward using CVCT was associated with couples who had higher levels of trust toward their partners being dependable. Differences within couples, including age between partners, whether sex had occurred outside of the relationship, and value toward a sexual agreement also affected their attitudes toward using CVCT. Providing additional testing methods may help HIV-negative gay couples better manage their HIV risk.     

Perinatal HIV transmission and children affected by HIV / AIDS: concepts and issues

The International Community of Women Living with HIV/AIDS (ICW) is the only international network run for and by women living with HIV infection and AIDS. This network of women educates, supports, and advocates for each other on local, national, and global levels. HIV-positive women often report feeling that everyone has an opinion upon how they should behave, especially with regard to pregnancy. Doctors and other health care workers often have moral and discriminating attitudes toward such women which often interfere with the standard of health care and information HIV-positive women receive in order to make informed choices. ICW is planning to explore the experiences of HIV-positive women with regard to their sexual and reproductive rights. Many women have experienced rejection, fear, and ignorance because of their HIV serostatus. Women should therefore not be singled out for HIV testing when they face such risks and violence. The counseling of couples and testing with joint consent could reduce women's vulnerability. Finally, there may be many reasons why a woman does not tell her children that she is HIV-positive. However, without being open about illness, it is very difficult to plan for the future.     

Sexual Consent Behaviors in Same-Sex Relationships

Consent is a key issue in defining sexual coercion yet few researchers have analyzed sexual consent attitudes and behaviors and, to date, there has been no published research examining sexual consent within same-sex relationships. The main objective of this study was to identify which behaviors people use to ask for and to indicate sexual consent to their same-sex partner(s). A Same-Sex Sexual Consent Scale was developed to measure both initiating and responding consent behaviors in same-sex relationships. Data were collected using an on-line survey from 257 participants (127 men, 130 women). The participants reported using nonverbal behaviors significantly more frequently than verbal behaviors to indicate consent. Exploratory factor analysis for the Initiating and Responding subscales resulted in four factors for each subscale. The four factors for the Initiating Subscale were nonverbal behaviors involving touch, no resistance behaviors, verbal behaviors, and nonverbal behaviors without touch. The factors for the Responding Subscale were no resistance behaviors, verbal behaviors, nonverbal behaviors, and undressing behaviors. There were no significant differences in the initiating behaviors used by men who have sex with men (MSM) and women who have sex with women (WSW); however, when responding to initiating behavior, MSM reported using significantly more nonverbal signals than did WSW. The scale that was developed in this study should be useful for other researchers who wish to study the topic of sexual consent.