Men and women living with HIV with access to ARVs are living longer, healthier lives that can and often do include bearing children. Children occupy a key space in men and women's personal and social lives and often play a fundamental role in maintaining these relationships, irrespective of illness concerns. Couples living with HIV need to balance prevention needs and ill health while trying to maintain healthy relationships. Health care providers serving the reproductive needs of HIV-affected couples need to consider the social and relational factors shaping reproductive decisions and associated periconception risk behaviors. This paper based on qualitative research at three hospital sites in eThekwini District, South Africa, investigates the childbearing intentions and needs of people living with HIV (PLHIV), attitudes and experiences of healthcare providers serving the reproductive needs of PLHIV, and client and provider views and knowledge of safer conception. This research revealed personal, social, and relationship dynamics shape the reproductive decisions of PLHIV and "unplanned" pregnancies are not always unintended. Additionally, conception desires are not driven by the number of living children, rather clients are motivated by whether or not they have had any children with their current partner/spouse. Providers should consider the relationship status of clients in discussions about childbearing desires and intentions. Although many providers recognize the complex social realities shaping NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript their clients' reproductive decisions, they have outdated information on serving their reproductive needs. Appropriate training to enable providers to better understand the relationship and social realities surrounding their clients' childbearing intentions is required and should be used as a platform for couples to work together with providers towards safer conception. The adoption of a more participatory approach should be employed to equalize client-provider power dynamics and ensure clients are more involved in decision-making about reproduction and conception.

Background Medical male circumcision (MMC) reduces the risk of HIV acquisition for men in heterosexual encounters by 50–60%. However, there is no evidence that a circumcised man with HIV poses any less risk of infecting his female partner than an uncircumcised man. There may be an additional risk of HIV transmission to female partners during the 6-week healing period and if condoms are used less often after circumcision. The aim was to explore young women’s perspectives on MMC, with a view to developing clear messages about the limitations of MMC in reducing women’s HIV risk. Methods We explored women’s perspectives on MMC in KwaZulu-Natal, South Africa, with a sample of 30 female tertiary students via four focus groups (two for women only; two mixed gender). Results In all groups, women communicated a thorough understanding of the partial efficacy of MMC, but believed that others would not understand this concept. Participants noted that MMC affords no direct benefit to women. Most thought that MMC would increase females’ risk of contracting HIV, that circumcised men may engage in risky behaviours and that men would increase their number of sexual partners after circumcision. Participants believed that condom use would decrease after MMC and speculated that men would have sex during the healing period, which could further compromise women’s sexual health. Conclusion The concerns expressed by women regarding MMC highlight the need for including women in the dialogue about MMC and for clarifying the impact of MMC on HIV risk for women.

ObjectiveThis study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending.MethodsData for this study were collected as a part of the situational analysis for the “Diagonal Interventions to Fast Forward Enhanced Reproductive Health” (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income.ResultsThe results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03–7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were “receiving [money] from partner or household members” (69 %) and “using own savings or regular income” (44 %), respectively.ConclusionHighly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.

Background Medical male circumcision has been shown to reduce HIV transmission to an uninfected male partner. In South Africa, medical male circumcision programs were rolled-out in 2010. Objectives Prior to roll-out, we explored healthcare providers’ knowledge, attitudes and practices about medical male circumcision and their understandings of partial efficacy for HIV prevention. Design We conducted qualitative research, using in-depth interviews. Setting Participants were from three rural and three urban primary healthcare clinics, randomly selected in eThekwini District, KwaZulu-Natal. Participants 25 healthcare providers (including nurse managers, nurses and counselors) were purposively selected from the clinics. Methods In-depth interviews were recorded, transcribed and translated. Independent researchers reviewed the transcripts and developed a codebook based on emergent themes, using thematic analysis. NVivo 8 was used to facilitate data management, coding and analysis. Results Although most providers had heard that medical male circumcision can reduce risk of HIV acquisition in men, most did not have accurate scientific understandings of this. Some providers had misperceptions about the limited/partial protection medical male circumcision offers. Many had concerns that their communities would misunderstand it, causing increased risky sexual behavior. Conclusions These data provide a baseline of providers’ understandings of medical male circumcision prior to roll-out, and can be used to compare current data and ensure accurate messaging to clients. Healthcare provider messaging should build client understandings of the meaning of partially efficacious technologies.

phone diaries to capture contextual features of STI/HIV-risk that could impact disease acquisition among female sex workers (FSW). Methods Women engaging in transactional sex in the prior 90 days were recruited utilising incentivized snowball sampling. Participants completed STI testing and baseline/exit surveys. Over 4-weeks, they completed twice-daily electronic diaries assessing event-level sexual behaviour, condom use, and drug use. Weekly inperson interviews used open-ended questions to explore geographical characteristics of sexual encounter locations as well as acceptability of event-level monitoring. Results 25/26 participants (median age 43.5 years) completed the 4-week study. At baseline, 27% tested positive for a STI. Participants completed 84.5% of 1,518 expected surveys and 95% of 106 expected interviews. Patterns of diary compliance were stable over time. Partnered sexual activity was captured in 21.4% of diaries. At the participant-level, most reported giving oral sex (84.7%) or vaginal sex (96.1%); fewer (19.2%) reported engaging in anal sex. Among women reporting partnered sexual behaviour with any partner type (i.e., new/regular customers, romantic partners), using condoms was reported 39.2%, 45.5% and 83.3% of the time for giving oral sex, vaginal sex, and anal sex respectively. At the event-level, the frequency of giving oral sex, vaginal sex or anal sex did not significantly change over time. Conclusions It is feasible to engage and retain FSW in a technologically-advanced study to characterise risk contexts of sexual events. Adherence to study protocol was high indicating event-level monitoring using cell phone based diaries is acceptable. These data can be utilised to improve our understanding of the individual, relational and environmental factors that influence STI/HIV acquisition among FSW. An EnvironmEntAl And PoliticAl Economic Zigong Center for Disease Control and Prevention, Zigong, ChinaBackground In Sichuan province, the criminalised status of female sex work, coupled with the mobility of female sex workers (FSWs), poses major challenges to gathering information about the organisation of the sex trade. Objectives This study has 2 main objectives: (1) To document the environmental risk factors in sex work venues; (2) To describe the sex trade industry in relation to political economic factors, including broader economic transformations. Methods We trained 3 FSWs to conduct participant observation and ethnographic field note writing, including "thick descriptions" (the pealing back of multiple layers of meaning during observations of social scenes). These observations were conducted in 9 sex work venues representing previously mapped FSW venues. Findings were contextualised with secondary historical sources. Findings Participant observation revealed that FSWs were independent when choosing where they worked and when they shifted to another work site. However, gender power inequalities between sex workers and their clients were also described. These power relationships are tied to s...