Food Insufficiency is Associated with High Risk Sexual Behavior among Women in Botswana and Swaziland

Slideshow Transcript

1. Slide 1: Food Insufficiency is Associated with High Risk Sexual Behavior among Women in Botswana and Swaziland PLoS Medicine. October 2007; 4(10); e-260 Presented by: Nthabiseng Phaladze, PhD and Sheri Weiser, MD, MPH October 22, 2007 Authors: Sheri Weiser, Karen Leiter, David Bangsberg, Lisa Butler, Fiona Percy, Zakhe Hlanze, Nthabiseng Phaladze, Vincent Iacopino and Michele Heisler Funded by: Physicians for Human Rights and NIH
2. Slide 2: HIV and Food Insufficiency • Botswana and Swaziland have highest HIV prevalence in the world • Food insufficiency leading cause of morbidity and mortality in southern Africa, linked to HIV pandemic • Both food insufficiency and HIV transmission risk affected by gender inequalities • Growing recognition that food insufficiency may impact HIV transmission
3. Slide 3: Food Insufficiency and HIV Transmission Risk • Food insufficiency postulated to increase sexual-risk taking • Malnutrition weakens immune system and compromises mucosal integrity • Little data on the independent effect of food insufficiency on sexual risk-taking
4. Slide 4: Aims for Population-based Study in Botswana/Swaziland 1. Assess association between food insufficiency and risky sexual behaviors 2. Determine whether gender modifies associations 3. Evaluate extent to which associations are mediated by SES (income, education)
5. Slide 5: Methods • Cross-sectional population-based study in 5 districts of Botswana and all 4 districts in Swaziland • Stratified 2-stage probability design • Inclusion criteria: – 18 to 49 years old – fluent in Setswana/Siswati or English – resident of Botswana/Swaziland
6. Slide 6: Methods cont. • Primary independent variable: – Food insufficiency (inadequate food to eat over previous 12 months) • Primary outcomes: – Unprotected sex with a non-monogamous partner – Selling or paying for sex using money or resources – Intergenerational sex (>=10 years age difference) – Lack of control in sexual relationships
7. Slide 7: Analysis • Multivariate logistic regression, stratified by gender • Standard errors were adjusted to account for effects of clustering by country* • Covariates – Demographics (including income and education) – HIV Knowledge (based on UNAIDS measure)** – Problem Drinking (>7 drinks/week for women, 14 drinks/week for men) *Using the Huber/White heteroscedastic estimator of the variance/covariance **UNAIDS HIV/AIDS Prevention Indicator Survey; May 2000
8. Slide 8: Sample • Conducted between November 2004 and May 2005 • 2,309 individuals randomly selected (Botswana 1433, Swaziland 876) • 2,049 included, 89% response rate (Swaziland 91%, Botswana 88%)
9. Slide 9: Participant Characteristics Women Men (n=1050) (n=999) Food insufficiency 32%* 22%* Education >=HS 47%* 52%* Rural residence 32% 38% Problem drinking 17%* 30%* Unprotected sex 8%* 11%* Exchanging sex 5%* 1%* Paying for sex 2%* 10%* Intergenerational sex 17% 15% Lack of control in sex 26%* 2%* * Denotes statistically significant differences between men and women
10. Slide 10: Adjusted Correlates of Unprotected Sex with Non-monogamous Partner* Women Men AOR (95% CI) AOR (95% CI) Food insufficiency 1.7 (1.3-2.4) 1.1 (1.1-1.2) Education >= HS 0.7 (0.6-0.9) 0.9 (0.6-1.4) Income >= Median 1.2 (0.6-2.4) 0.8 (0.7-0.8) Married (compared with single) 1.1 (0.8-1.6) 0.8 (0.4-1.6) Rural residence 0.5 (0.4-0.5) 1.1 (0.3-3.7) Correct HIV knowledge 0.6 (0.5-0.6) 1.0 (0.8-1.2) Problem drinking 4.4 (1.7-11.0) 2.1 (1.4-3.2) *Model also controlled for age and living with sexual partner
11. Slide 11: Adjusted Correlates of Sex Exchange* Women Men (Exchanging sex) (Paying for sex) AOR (95% CI) AOR (95% CI) Food insufficiency 1.8 (1.7-1.9) 1.1 (0.5-2.3) Education >= HS 0.7 (0.4-1.5) 1.1 (0.8-1.6) Income >= Median 0.9 (0.5-1.6) 1.9 (1.6-2.4) Married (compared with single) 0.8 (0.6-1.0) 0.2 (0.1-0.6) Rural residence 1.7 (1.0-3.1) 1.1 (0.6-2.2) Correct HIV knowledge 0.7 (0.6-0.8) 1.5 (0.3-6.6) Problem drinking 12.5 (8.5-18.3) 3.2 (1.9-5.5) *Model also controlled for age and living with sexual partner
12. Slide 12: Adjusted Correlates of Intergenerational Sex* Women Men AOR (95% CI) AOR (95% CI) Food insufficiency 1.5 (1.1-2.1) 1.3 (0.6-2.7) Education >= HS 0.8 (0.5-1.3) 0.8 (0.4-1.8) Income >= Median 0.9 (0.7-1.2) 1.1 (0.4-3.1) Married (compared with single) 1.1 (0.5-2.1) 0.3 (0.1-1.3) Rural residence 1.2 (0.8-1.7) 1.1 (0.7-1.3) Correct HIV knowledge 1.3 (0.9-1.8) 1.4 (1.0-2.1) Problem drinking 2.1 (1.6-2.8) 1.0 (0.5-2.1) *Model also controlled for age and living with sexual partner
13. Slide 13: Adjusted Correlates of Lack of Control in Sexual Relations for Women* AOR 95% CI Food insufficiency 1.7 1.2 - 2.3 Education >= HS 0.4 0.4 - 0.4 Income >= Median 0.9 0.8 - 1.1 Married (compared with single) 2.3 2.0 - 2.5 Rural residence 1.2 0.8 - 1.7 Correct HIV knowledge 1.4 1.1 - 1.7 Problem drinking 1.3 0.9 - 2.0 *Model also controlled for age and living with sexual partner
14. Slide 14: Limitations • Social desirability bias • Cross-sectional design limits ability to infer causality • SES measured by income and education only • Food insufficiency measure possibly insensitive
15. Slide 15: Conclusions • High prevalence of food insufficiency (22% men, 32% women) • Strong and consistent relationship between food insufficiency and multiple high risk sexual behaviors among women • Relationship between food insufficiency and risky sex for women not mediated by income and education
16. Slide 16: Implications • Protecting and promoting right to food may decrease vulnerability to HIV • Integration of food assistance and HIV prevention programs may help reduce HIV transmission risk
17. Slide 17: Acknowledgements • Affiliations – Physicians for Human Rights – University of California, San Francisco – University of Botswana – Women and Law, Swaziland – University of Michigan, School of Medicine • Funding sources – Physicians for Human Rights – NIMH • Acknowledgements: – Dr. Sheila Tlou, Dr. William Wolfe, David Tuller, Dr. Ibou Thior, Dr. Diane Havlir Dr. Vijai Dwivedi, Dr. Wayne Steward, Dr. Banu Kahn, Dr. Edward Frongillo, Dr. Steven Morin, Dr. Susan Kegeles, Dr. Willi MacFarland, David Ngele, Dr. Diana Dickinson, Choice Ginindza, Sibongile Maseko, Dr. Donald De Korte, Leonard Rubenstein.