Food Insufficiency is Associated with High Risk Sexual Behavior among Women in Southern Africa

1. Food Insufficiency is Associated with High Risk Sexual Behavior among Women in Southern Africa Sheri Weiser, MD, MPH August 16, 2006

2. HIV and Food Insufficiency Botswana and Swaziland have highest HIV prevalence in the world Food insufficiency also leading cause of morbidity and mortality in southern Africa and is linked to HIV pandemic Growing recognition that food insufficiency may impact HIV transmission -Botswana and Swaziland have the highest HIV prevalence in the world with 24% of adults in Botswana and 33% of adults in Swaziland infected. -Food insufficiency is another leading cause of morbidity and mortality in sub-Saharan Africa, and is thought to be inextricably linked to the HIV pandemic. -There has been a growing recognition by International Health Organizations and NGOs that food insufficiency can increase HIV transmission risk behaviors, and susceptibility to HIV once exposed. -Botswana and Swaziland have the highest HIV prevalence in the world with 24% of adults in Botswana and 33% of adults in Swaziland infected. -Food insufficiency is another leading cause of morbidity and mortality in sub-Saharan Africa, and is thought to be inextricably linked to the HIV pandemic. -There has been a growing recognition by International Health Organizations and NGOs that food insufficiency can increase HIV transmission risk behaviors, and susceptibility to HIV once exposed.

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 There are several postulated mechanisms for how food insufficiency can increase HIV transmission: -First of all, food insufficiency is thought to increase sexual-risk taking, particularly among women. For example, women may engage in sex exchange and intergenerational sex to procure food for themselves and their children. In addition, women�s dependence on their partners for food and other resources may make it difficult for them to insist on condom use. -In addition, lack of food and malnutrition weaken the immune system and can compromise mucosal integrity, leading to increased vulnerability to HIV when exposed. -No studies that we know of have specifically assessed and quantified the effect of food insufficiency on sexual-risk taking, and there is no data on this from population-based studies.There are several postulated mechanisms for how food insufficiency can increase HIV transmission: -First of all, food insufficiency is thought to increase sexual-risk taking, particularly among women. For example, women may engage in sex exchange and intergenerational sex to procure food for themselves and their children. In addition, women�s dependence on their partners for food and other resources may make it difficult for them to insist on condom use. -In addition, lack of food and malnutrition weaken the immune system and can compromise mucosal integrity, leading to increased vulnerability to HIV when exposed. -No studies that we know of have specifically assessed and quantified the effect of food insufficiency on sexual-risk taking, and there is no data on this from population-based studies.

4. Study Aims Assess association between food insufficiency and risky sexual behaviors Determine whether gender modifies associations Evaluate extent to which associations are mediated by SES (income, education) We therefore had the following study aims. To assess the association between food insufficiency and a number of risky sexual behaviors and practices including unprotected sex, sex exchange, intergenerational sex, and lack of control in sexual relationships. 2) To determine whether gender modifies these associations 3) And finally to evaluate the extent to which associations between food insufficiency and risky sex are mediated by measures of socioeconomic status such as income and education. We therefore had the following study aims. To assess the association between food insufficiency and a number of risky sexual behaviors and practices including unprotected sex, sex exchange, intergenerational sex, and lack of control in sexual relationships. 2) To determine whether gender modifies these associations 3) And finally to evaluate the extent to which associations between food insufficiency and risky sex are mediated by measures of socioeconomic status such as income and education.

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 We conducted a cross-sectional, population based study in the 5 districts of Botswana with the highest number of HIV-infected individuals, and all 4 districts of Swaziland -We used a stratified 2-stage probability design -First 89 enumeration areas were selected in Botswana and 54 enumeration areas were selected in Swaziland with a probability proportional to size. -Then, within each enumeration area, our field researchers systematically selected households -Finally, field researchers used random number tables to select one adult within each household that met study criteria -Participants were included in the study if they were between the ages of 18-49, if they were fluent in English or either Setswana or Siswati, and if they were legal residents of the country where the interview took place We conducted a cross-sectional, population based study in the 5 districts of Botswana with the highest number of HIV-infected individuals, and all 4 districts of Swaziland -We used a stratified 2-stage probability design -First 89 enumeration areas were selected in Botswana and 54 enumeration areas were selected in Swaziland with a probability proportional to size. -Then, within each enumeration area, our field researchers systematically selected households -Finally, field researchers used random number tables to select one adult within each household that met study criteria -Participants were included in the study if they were between the ages of 18-49, if they were fluent in English or either Setswana or Siswati, and if they were legal residents of the country where the interview took place

6. Methods 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 for money or resources Intergenerational sex (>=10 years age difference) Lack of control in sexual relationships -The primary independent variable was food insufficiency; this was defined as reporting that they did not having enough food to eat over the previous 12 months. This question was adapted from previous validated measures of food insufficiency. We had 4 primary outcomes: -unprotected sex with a non-monogamous partner -selling or paying for sex for money or resources over the previous 12 months -Intergenerational sexual relations over the previous 12 months which was defined as having at least a 10 year age difference with their partners -And lack of control in sexual relationships, meaning that the participant�s partner usually or always made decisions regarding sex. -The primary independent variable was food insufficiency; this was defined as reporting that they did not having enough food to eat over the previous 12 months. This question was adapted from previous validated measures of food insufficiency. We had 4 primary outcomes: -unprotected sex with a non-monogamous partner -selling or paying for sex for money or resources over the previous 12 months -Intergenerational sexual relations over the previous 12 months which was defined as having at least a 10 year age difference with their partners -And lack of control in sexual relationships, meaning that the participant�s partner usually or always made decisions regarding sex.

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) - We used multivariate logistic regression, stratified by gender, to assess the association between food insufficiency and risky sexual behaviors. -We adjusted the standard errors to account for the effects of clustering by country. -We controlled for demographics (including age, income, education, marital status, and rural versus urban residence), and HIV knowledge. We also controlled for problem drinking which is well-recognized as an important cause of sexual-risk taking in sub-Saharan Africa and elsewhere. - We used multivariate logistic regression, stratified by gender, to assess the association between food insufficiency and risky sexual behaviors. -We adjusted the standard errors to account for the effects of clustering by country. -We controlled for demographics (including age, income, education, marital status, and rural versus urban residence), and HIV knowledge. We also controlled for problem drinking which is well-recognized as an important cause of sexual-risk taking in sub-Saharan Africa and elsewhere.

8. Sample Conducted between November 2004 and May 2005 2,309 individuals randomly selected (Botswana 1433, Swaziland 876) 2, 051 included, 89% response rate (Swaziland 91%, Botswana 88%) Our study was conducted between November of 2004 and May of 2005 In total, 2, 309 individuals were randomly selected in both countries, and 2, 051 or 89% of respondents completed the survey Our study was conducted between November of 2004 and May of 2005 In total, 2, 309 individuals were randomly selected in both countries, and 2, 051 or 89% of respondents completed the survey

9. Participant Characteristics We stratified study characteristics by gender, women are shown in this table on the left, men are in the right Approximately half of participants were women and had completed high school. Notably, 32% of women, and 22% of men reported food insufficiency 17% of women, and 30% of men were classified as problem drinkers -5% of women reported exchanging sex for money or resources. -10% of men reporting paying for sex with money or resources -Approximately 15% of both men and women reported intergenerational sexual relationships -Very few men, and one quarter of women reported lack of control in their sexual relationships -Because there were such strong differences between men and women, the remaining analyses are also stratified by gender We stratified study characteristics by gender, women are shown in this table on the left, men are in the right Approximately half of participants were women and had completed high school. Notably, 32% of women, and 22% of men reported food insufficiency 17% of women, and 30% of men were classified as problem drinkers -5% of women reported exchanging sex for money or resources. -10% of men reporting paying for sex with money or resources -Approximately 15% of both men and women reported intergenerational sexual relationships -Very few men, and one quarter of women reported lack of control in their sexual relationships -Because there were such strong differences between men and women, the remaining analyses are also stratified by gender

10. Adjusted Correlates of Unprotected Sex with Non-monogamous Partner* This table shows adjusted correlates of unprotected sex with a non-monogamous partner. -Women who were food insufficient had a 70% higher odds of unprotected sex when controlling for all covariates. On the other hand, men who were food insufficient had only a 10% higher odds of reporting unprotected sex. -Higher education, rural residence, and having correct HIV knowledge were protective factors and were associated with lower odds of unprotected sex for women only. -Higher income was associated with a lower odds of unprotected sex for men only. -As has been reported in the literature, women and men who were problem drinkers also had significantly higher odds of unprotected sex. This table shows adjusted correlates of unprotected sex with a non-monogamous partner. -Women who were food insufficient had a 70% higher odds of unprotected sex when controlling for all covariates. On the other hand, men who were food insufficient had only a 10% higher odds of reporting unprotected sex. -Higher education, rural residence, and having correct HIV knowledge were protective factors and were associated with lower odds of unprotected sex for women only. -Higher income was associated with a lower odds of unprotected sex for men only. -As has been reported in the literature, women and men who were problem drinkers also had significantly higher odds of unprotected sex.

11. Adjusted Correlates of Sex Exchange* We also looked at correlates of sex exchange. You�ll note that for women this means selling sex for money or resources and for men this means paying for sex with money or resources. -Among women, food insufficiency was associated with 80% higher odds of sex exchange. In contrast, there was no association between food insufficiency and sex exchange for men. -Income was not associated with sex exchange among women, and men with higher income had higher odds of paying for sex. -Being married was protective for both men and women, and correct HIV knowledge was again protective for women only. -Individuals with problem drinking had much higher odds of sex exchange, and this was particularly notable for women. We also looked at correlates of sex exchange. You�ll note that for women this means selling sex for money or resources and for men this means paying for sex with money or resources. -Among women, food insufficiency was associated with 80% higher odds of sex exchange. In contrast, there was no association between food insufficiency and sex exchange for men. -Income was not associated with sex exchange among women, and men with higher income had higher odds of paying for sex. -Being married was protective for both men and women, and correct HIV knowledge was again protective for women only. -Individuals with problem drinking had much higher odds of sex exchange, and this was particularly notable for women.

12. Adjusted Correlates of Intergenerational Sex* We also looked at whether food insufficiency was associated with having intergenerational sexual relations for both women and men. -Again, food insufficiency was significantly associated with having reported intergenerational sex for women but not men. -Problem drinking was also significantly associated with intergenerational sex for women only. -Income and education were not associated with intergenerational sex for either gender. We also looked at whether food insufficiency was associated with having intergenerational sexual relations for both women and men. -Again, food insufficiency was significantly associated with having reported intergenerational sex for women but not men. -Problem drinking was also significantly associated with intergenerational sex for women only. -Income and education were not associated with intergenerational sex for either gender.

13. Adjusted Correlates of Lack of Control in Sexual Relations for Women* Finally, we looked at correlates of lack of control in sexual relations for women only, since so few men reported this outcome. -Food insufficiency was associated with 70% higher odds of lack of sexual control, even after controlling for education and income. -Women with higher education had lower odds of reporting lack of sexual control, and income was not associated with lack of sexual control. -(All results trended in the same direction for separate analyses stratified by country, although will not be able to show data here). Finally, we looked at correlates of lack of control in sexual relations for women only, since so few men reported this outcome. -Food insufficiency was associated with 70% higher odds of lack of sexual control, even after controlling for education and income. -Women with higher education had lower odds of reporting lack of sexual control, and income was not associated with lack of sexual control. -(All results trended in the same direction for separate analyses stratified by country, although will not be able to show data here).

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 There were several important limitations to our study. -First social desirability bias may have led to underreporting of risky sexual behaviors -Second, the cross-sectional study design limits our ability to infer causality -Third, SES was measured by income and education only, rather than by a more comprehensive measure -and finally, our food insufficiency measure may have been insensitive in that we only asked a single validated question rather than using a more extensive scale. There were several important limitations to our study. -First social desirability bias may have led to underreporting of risky sexual behaviors -Second, the cross-sectional study design limits our ability to infer causality -Third, SES was measured by income and education only, rather than by a more comprehensive measure -and finally, our food insufficiency measure may have been insensitive in that we only asked a single validated question rather than using a more extensive scale.

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 -This is the first study we know of to assess and quantify the relationship between food insufficiency and risky sexual practices in sub-Saharan Africa -We found a high prevalence of food insufficiency in Botswana and Swaziland, particularly among women. -There was a strong and consistent relationship between food insufficiency and a number of high-risk sexual behaviors and experiences among women. -Importantly, the relationship between food insufficiency and risky sex for women did not appear to be mediated by measures of SES such as income and education. This suggests that while food insufficiency is certainly influenced by income, it is likely a distinct entity with different causes and consequences. This may be because some individuals with very limited income are able to grow food on their own, or that some family members are preferentially fed over others. -This is the first study we know of to assess and quantify the relationship between food insufficiency and risky sexual practices in sub-Saharan Africa -We found a high prevalence of food insufficiency in Botswana and Swaziland, particularly among women. -There was a strong and consistent relationship between food insufficiency and a number of high-risk sexual behaviors and experiences among women. -Importantly, the relationship between food insufficiency and risky sex for women did not appear to be mediated by measures of SES such as income and education. This suggests that while food insufficiency is certainly influenced by income, it is likely a distinct entity with different causes and consequences. This may be because some individuals with very limited income are able to grow food on their own, or that some family members are preferentially fed over others.

16. Implications Protecting and promoting right to food may decrease vulnerability to HIV Targeted food assistance programs should be strongly considered to decrease HIV transmission risk for women in sub-Saharan Africa -Our findings suggest that protecting and promoting access to food, which is an essential human right, may decrease vulnerability to HIV, especially among women. -Interventions that use targeted food assistance could help address some of the gender and economic disparities that drive unsafe sexual behaviors, and should be strongly considered to reduce HIV transmission risk for women in sub-Saharan Africa. -Our findings suggest that protecting and promoting access to food, which is an essential human right, may decrease vulnerability to HIV, especially among women. -Interventions that use targeted food assistance could help address some of the gender and economic disparities that drive unsafe sexual behaviors, and should be strongly considered to reduce HIV transmission risk for women in sub-Saharan Africa.

17. Acknowledgements Affiliations Physicians for Human Rights University of Botswana Women and Law, Swaziland University of California, San Francisco University of Michigan, School of Medicine Funding sources Physicians for Human Rights NIMH Acknowledgements: Dr.�Ibou�Thior, Dr.�Vijai�Dwivedi, Dr.�Wayne�Steward, Dr.�William�Wolfe, David�Tuller, Dr.�Banu�Kahn, Chen�Reis,�JD, Dr.�Lynn�Amowitz, Dr.�Steven�Morin, David�Ngele, Dr.�Diana�Dickinson, Dr.�Ernest�Darkoh, Choice Ginindza, Sibongile Maseko, Minnehy�Mukoma, Leonard�Rubenstein. This study was funded by Physicians for Human Rights and by the National Institute of Mental Health. This study was funded by Physicians for Human Rights and by the National Institute of Mental Health.