Population mobility associated with higher risk sexual behaviour in eastern African communities participating in a Universal Testing and Treatment trial

Abstract

IntroductionThere are significant knowledge gaps concerning complex forms of mobility emergent in sub‐Saharan Africa, their relationship to sexual behaviours, HIV transmission, and how sex modifies these associations. This study, within an ongoing test‐and‐treat trial (SEARCH, NCT01864603), sought to measure effects of diverse metrics of mobility on behaviours, with attention to gender.MethodsCross‐sectional data were collected in 2016 from 1919 adults in 12 communities in Kenya and Uganda, to examine mobility (labour/non‐labour‐related travel), migration (changes of residence over geopolitical boundaries) and their associations with sexual behaviours (concurrent/higher risk partnerships), by region and sex. Multilevel mixed‐effects logistic regression models, stratified by sex and adjusted for clustering by community, were fitted to examine associations of mobility with higher‐risk behaviours, in past 2 years/past 6 months, controlling for key covariates.ResultsThe population was 45.8% male and 52.4% female, with mean age 38.7 (median 37, IQR: 17); 11.2% had migrated in the past 2 years. Migration varied by region (14.4% in Kenya, 11.5% in southwestern and 1.7% in eastern and Uganda) and sex (13.6% of men and 9.2% of women). Ten per cent reported labour‐related travel and 45.9% non‐labour‐related travel in past 6 months—and varied by region and sex: labour‐related mobility was more common in men (18.5%) than women (2.9%); non‐labour‐related mobility was more common in women (57.1%) than men (32.6%). In 2015 to 2016, 24.6% of men and 6.6% of women had concurrent sexual partnerships; in past 6 months, 21.6% of men and 5.4% of women had concurrent partnerships. Concurrency in 2015 to 2016 was more strongly associated with migration in women [aRR = 2.0, 95% CI(1.1 to 3.7)] than men [aRR = 1.5, 95% CI(1.0 to 2.2)]. Concurrency in past 6 months was more strongly associated with labour‐related mobility in women [aRR = 2.9, 95% CI(1.0 to 8.0)] than men [aRR = 1.8, 95% CI(1.2 to 2.5)], but with non‐labour‐related mobility in men [aRR = 2.2, 95% CI(1.5 to 3.4)].ConclusionsIn rural eastern Africa, both longer‐distance/permanent, and localized/shorter‐term forms of mobility are associated with higher‐risk behaviours, and are highly gendered: the HIV risks associated with mobility are more pronounced for women. Gender‐specific interventions among mobile populations are needed to combat HIV in the region.

Effect of ART scale-up and female migration intensity on risk of HIV acquisition: results from a population-based cohort in KwaZulu-Natal, South Africa

“…For example, individuals who migrate or migrate frequently are less likely to engage with the local health-care system where they can access preventative HIV services [16, 17]. Increased levels of migration may also weaken the spousal bond through long absences away from home [9, 18–20], leading to greater opportunities for casual and transactional sexual contact. Despite an abundance of studies on migration and HIV acquisition risk [20, 21], most have focused on male migration [15, 17], with a few notable exceptions [22, 23].…”

“…Increased levels of migration may also weaken the spousal bond through long absences away from home [9, 18–20], leading to greater opportunities for casual and transactional sexual contact. Despite an abundance of studies on migration and HIV acquisition risk [20, 21], most have focused on male migration [15, 17], with a few notable exceptions [22, 23]. Furthermore, there is lack of empirical evidence on whether the frequency of migration will attenuate the preventative benefits of ART, which is highly relevant in the era of universal access to HIV test and treat services.…”

Treatment as Prevention: Concepts and Challenges for Reducing HIV Incidence

“…This classic dilemma of the control group benefiting from their participation in the study, resembling the intervention group, and leading to bias towards the null and reduction in planned statistical power, is a hazard of multi-year prevention clinical trials. 38,39 Another potential explanation is that the new infections in the intervention group may have arisen from individuals never exposed to the full intervention, including mobile populations (who also tend to be younger), 40 youth, individuals during the early stages of new infection and with a high level of infectiousness, and/or a subset of individuals with unsuppressed viral loads, thought to be particularly salient for communities in Kenya. 41 Newly infected individuals may not yet have had an opportunity to be diagnosed, may have tested negative on an antibody test (despite having been recently infected), and/or may be those involved with higher numbers of concurrently partnerships.…”

One step ahead: timing and sexual networks in population mobility and HIV prevention and care

“…Circular migration, where migrants leave home to work (or for other reasons) but frequently return home before leaving again, is also common, especially in South Africa . Sexual risk behaviour of circular migrants vary over time as well: before migrating, while away and after returning home .…”