Association between severe drought and HIV prevention and care behaviors in Lesotho: A population-based survey 2016–2017

Background A previous analysis of the impact of drought in Africa on HIV demonstrated an 11% greater prevalence in HIV-endemic rural areas attributable to local rainfall shocks. The Lesotho Population-Based HIV Impact Assessment (LePHIA) was conducted after the severe drought of 2014–2016, allowing for reevaluation of this relationship in a setting of expanded antiretroviral coverage. Methods and findings LePHIA selected a nationally representative sample between November 2016 and May 2017. All adults aged 15–59 years in randomly selected households were invited to complete an interview and HIV testing, with one woman per household eligible to answer questions on their experience of sexual violence. Deviations in rainfall for May 2014–June 2016 were estimated using precipitation data from Climate Hazards Group InfraRed Precipitation with Station Data (CHIRPS), with drought defined as <15% of the average rainfall from 1981 to 2016. The association between drought and risk behaviors as well as HIV-related outcomes was assessed using logistic regression, incorporating complex survey weights. Analyses were stratified by age, sex, and geography (urban versus rural). All of Lesotho suffered from reduced rainfall, with regions receiving 1%–36% of their historical rainfall. Of the 12,887 interviewed participants, 93.5% (12,052) lived in areas that experienced drought, with the majority in rural areas (7,281 versus 4,771 in urban areas). Of the 835 adults living in areas without drought, 520 were in rural areas and 315 in urban. Among females 15–19 years old, living in a rural drought area was associated with early sexual debut (odds ratio [OR] 3.11, 95% confidence interval [CI] 1.43–6.74, p = 0.004), and higher HIV prevalence (OR 2.77, 95% CI 1.19–6.47, p = 0.02). It was also associated with lower educational attainment in rural females ages 15–24 years (OR 0.44, 95% CI 0.25–0.78, p = 0.005). Multivariable analysis adjusting for household wealth and sexual behavior showed that experiencing drought increased the odds of HIV infection among females 15–24 years old (adjusted OR [aOR] 1.80, 95% CI 0.96–3.39, p = 0.07), although this was not statistically significant. Migration was associated with 2-fold higher odds of HIV infection in young people (aOR 2.06, 95% CI 1.25–3.40, p = 0.006). The study was limited by the extensiveness of the drought and the small number of participants in the comparison group. Conclusions Drought in Lesotho was associated with higher HIV prevalence in girls 15–19 years old in rural areas and with lower educational attainment and riskier sexual behavior in rural females 15–24 years old. Policy-makers may consider adopting potential mechanisms to mitigate the impact of income shock from natural disasters on populations vulnerable to HIV transmission

In Sickness and Wealth:Three Essays on Health Human Capital and HIV in sub-Sahran Africa

This dissertation concerns itself with the effects of education and wealth on health in Africa. The first two chapters focus on the impact of adult education levels on the HIV epidemic in four sub-Saharan countries. The last chapter turns to children's health and examines whether the urban advantage in health persists despite rapid urbanization in South Africa. Chapter one employs longitudinal HIV data from Mali, Tanzania, Kenya and Zambia to examine whether the positive relationship between educational attainment and HIV prevalence is changing. I find evidence that the relationship between HIV and education has begun to reverse. Although it remains positive at the regional level, its much weaker for the youngest cohort. Furthermore, I find no association between HIV and education at the individual level among the youngest cohort. Secondarily, I test two explanations for change- erosion of educational infrastructure and adoption of protective knowledge among the educated. I find evidence consistent with the hypothesis that education is becoming protective as the epidemic matures; regions with higher average adult education at baseline experience larger drops in HIV prevalence. Chapter two builds on these findings by examining whether the behavioral response to HIV is stronger among the more educated. I find a robust positive association between education and condom use, HIV testing, and age at marriage, with evidence that younger cohorts may be reducing age at marriage. I also find that more educated individuals are increasing their rates of HIV testing and reducing age of marriage more than the less educated. Finally, I use anthropometric scores from two national surveys from South Africa to examine changes in urban and rural children's health over 15 years. I find that the urban health advantage disappears despite urban children retaining advantages in average household wealth. I then explore several common explanations for this pattern, including the growth of particularly vulnerable urban populations or deepening urban poverty. I find no evidence of deteriorated circumstances for the urban poor, although urban-rural migrants have begun to show a health disadvantage. I find that the differential gains are likely due to improvements made by very poor rural households

Eat, drink, man, woman: gender, income share and household expenditure in South Africa

This study examines how gendered household bargaining occurs in non-nuclear family households. We employ two South African data sets and use linear regression and household fixed effects to investigate the relationship between women's income shares and household expenditures. In married couple households, when women garner larger shares of income, spending on food is higher and spending on alcohol is lower. However, the relationship between women's income shares and expenditures attenuates with additional adults in the household. We find that in households with multiple adults, men and women bargain in gender groups to realize gendered preferences for expenditures. Future work should consider household members outside of the married dyad when modeling bargaining processes

Who is taking up voluntary medical male circumcision? Early evidence from Tanzania

We examined the impacts of nationwide voluntary medical male circumcision efforts in Tanzania. Using Demographic and Health Surveys (DHS) data, we found that circumcision rates increased from 37 to 47% in regions targeted by the programme. Those who took up medical male circumcision were younger, more educated, wealthier and more likely to use condoms. Efforts going forward should focus on stimulating circumcision demand among more vulnerable men

Who is taking up voluntary medical male circumcision? Early evidence from Tanzania

We examined the impacts of nationwide voluntary medical male circumcision efforts in Tanzania. Using Demographic and Health Surveys (DHS) data, we found that circumcision rates increased from 37 to 47% in regions targeted by the programme. Those who took up medical male circumcision were younger, more educated, wealthier and more likely to use condoms. Efforts going forward should focus on stimulating circumcision demand among more vulnerable men

A systematic tale of two differing reviews: evaluating the evidence on public and private sector quality of primary care in low and middle income countries

Abstract Systematic reviews are powerful tools for summarizing vast amounts of data in controversial areas; but their utility is limited by methodological choices and assumptions. Two systematic reviews of literature on the quality of private sector primary care in low and middle income countries (LMIC), published in the same journal within a year, reached conflicting conclusions. The difference in findings reflects different review methodologies, but more importantly, a weak underlying body of literature. A detailed examination of the literature cited in both reviews shows that only one of the underlying studies met the gold standard for methodological robustness. Given the current policy momentum on universal health coverage and primary health care reform across the globe, there is an urgent need for high quality empirical evidence on the quality of private versus public sector primary health care in LMIC

The wealth gradient and the effect of COVID-19 restrictions on income loss, food insecurity and health care access in four sub-Saharan African geographies.

IntroductionWhile there has been considerable analysis of the health and economic effects of COVID-19 in the Global North, representative data on the distribution and depth of social and economic impacts in Africa has been more limited.MethodsWe analyze household data collected prior to the COVID-19 pandemic and during the first wave of COVID in four African countries. We evaluate the short-term changes to household economic status and assess women's access to health care during the first wave of COVID-19 in nationally representative samples of women aged 15-49 in Kenya and Burkina Faso, and in sub-nationally representative samples of women aged 15-49 in Kinshasa, Democratic Republic of Congo and Lagos, Nigeria. We examine prevalence and distribution of household income loss, food insecurity, and access to health care during the COVID-19 lockdowns across residence and pre-pandemic wealth categories. We then regress pre-pandemic individual and household sociodemographic characteristics on the three outcomes.ResultsIn three out of four samples, over 90% of women reported partial or complete loss of household income since the beginning of the coronavirus restrictions. Prevalence of food insecurity ranged from 17.0% (95% CI 13.6-20.9) to 39.8% (95% CI 36.0-43.7), and the majority of women in food insecure households reported increases in food insecurity during the COVID-19 restriction period. In contrast, we did not find significant barriers to accessing health care during COVID restrictions. Between 78·3% and 94·0% of women who needed health care were able successfully access it. When we examined pre-pandemic sociodemographic correlates of the outcomes, we found that the income shock of COVID-19 was substantial and distributed similarly across wealth groups, but food insecurity was concentrated among poorer households. Contrary to a-priori expectations, we find little evidence of women experiencing barriers to health care, but there is significant need for food support

Differential discontinuation by covert use status in Kenya

Objectives: Qualitative research suggests that covert users may be more likely to discontinue contraception due to the logistics of discretion and fear of disclosure. This study sought to quantify whether covert users are more likely to discontinue contraception than overt users. Study design: We used a national longitudinal survey from Kenya conducted from November 2019/February 2020 to November 2020/April 2021 to test whether the time to discontinuation between covert and overt users still in need of contraception differed using survival analyses over a period of 5 years since method initiation. Results: Multivariate Cox regression results showed there was an interaction with time and covert use on the risk of discontinuation; for every additional month of use, there was an increased risk of discontinuation of covert users compared to overt users (3% increased hazard, p = 0.02). At 1 and 2 years, there were no differences in the hazard of discontinuation (adjusted hazard ratio [aHR]1 year 0.95, 95% CI 0.54–1.65 and aHR2 years 1.37, 95% CI 0.85–2.21), yet at 3, 4, and 5 years, the hazard of discontinuation was higher for covert compared to overt users (aHR3 years 1.99, 95% 1.11–3.56; aHR4 years 2.89, 95% CI 2.0–6.40; aHR5 years 4.18, 95% CI 1.45–12.0). Conclusions: These results suggest efforts are needed to support covert users in managing their contraceptive use and for improving contraceptive counseling surrounding covert use. Our findings shed light on the increasing challenge covert users face after approximately the first 2 years of use; covert users require additional follow-up in both research and care provision. Implications: Covert users are at a higher risk of discontinuation of contraception while still trying to avoid pregnancy, particularly after the first 2 years of use. Family planning providers and programs must protect access to and maintain the privacy of reproductive services to this population, focusing on follow-up care provision and counseling

Gendered health, economic, social and safety impact of COVID-19 on adolescents and young adults in Nairobi, Kenya

Background Infectious disease outbreaks like COVID-19 and their mitigation measures can exacerbate underlying gender disparities, particularly among adolescents and young adults in densely populated urban settings. Methods An existing cohort of youth ages 16–26 in Nairobi, Kenya completed a phone-based survey in August-October 2020 (n = 1217), supplemented by virtual focus group discussions and interviews with youth and stakeholders, to examine economic, health, social, and safety experiences during COVID-19, and gender disparities therein. Results COVID-19 risk perception was high with a gender differential favoring young women (95.5% vs. 84.2%; p<0.001); youth described mixed concern and challenges to prevention. During COVID-19, gender symmetry was observed in constrained access to contraception among contraceptive users (40.4% men; 34.6% women) and depressive symptoms (21.8% men; 24.3% women). Gender disparities rendered young women disproportionately unable to meet basic economic needs (adjusted odds ratio [aOR] = 1.21; p<0.05) and in need of healthcare during the pandemic (aOR = 1.59; p<0.001). At a bivariate level, women had lower full decisional control to leave the house (40.0% vs. 53.2%) and less consistent access to safe, private internet (26.1% vs. 40.2%), while men disproportionately experienced police interactions (60.1%, 55.2% of which included extortion). Gender-specific concerns for women included menstrual hygiene access challenges (52.0%), increased reliance on transactional partnerships, and gender-based violence, with 17.3% reporting past-year partner violence and 3.0% non-partner sexual violence. Qualitative results contextualize the mental health impact of economic disruption and isolation, and, among young women, privacy constraints. Implications Youth and young adults face gendered impacts of COVID-19, reflecting both underlying disparities and the pandemic’s economic and social shock. Economic, health and technology-based supports must ensure equitable access for young women. Gender-responsive recovery efforts are necessary and must address the unique needs of youth