Dear Editor,

Screening for syphilis during pregnancy in Nigeria: a practice that must continue We read with interest the report from Osogbo in Nigeria (1). In our opinion and experience, we agree that this practice should not only continue but be improved upon. In a similar study on pregnant women done in Lagos, Nigeria (2), the incidence of positive syphilis test was about 3%. Serology for other possible sexually transmitted infections was done and reported as shown in Table1. While the antenatal patients in Osogbo made a captive audience, the report did not mention tracing and screening the male partners of the women positive for syphilis. Contact tracing of sexual partners is an important part of controlling the spread of sexually transmitted infections. This is not an easy exercise but it is essential. The prevalence of hepatitis B and HIV infections is high in sub-Saharan Africa. We suggest that following counselling and with patient consent, it is prudent to screen antenatal patients for these infections. Early detection and appropriate treatment will decrease maternal-fetal transmission of these infections.

References

1. Taiwo S.S, Adesiji O.O, Adekanle D.A. Screening for syphilis during pregnancy in Nigeria: a practice that must continue. Sex. Transm. Infect. 2007; 83: 357-358.

2. Opaneye A, Fabanwo A, Ashton V, Dada O. A. Seroprevalence of HIV and hepatitis B virus markers in Ikeja, Nigeria. Sexual Health Matters 2006; (7): 65-67. www.sexualhealthmatters.com

Abayomi Opaneye
Consultant in GU/HIV Medicine
Department of Genitourinary Medicine,
James Cook University Hospital,
Middlesbrough, England. TS4 3BW.

Adetokunbo Fabamwo
Senior Lecturer
Honorary Consultant Obstetrician and Gynaecologist,
Lagos State University College of Medicine/ Teaching
Hospital,
Ikeja,
Lagos, Nigeria.

Conflicts of interest: None.

Dear Editor,

Violence against women is a global problem, and rates in Southeast Asia is high enough.Patriarchy culture take a part for this condition. The culture is also contribute to the situation. Gender inequality is especially visible in developing countries. Women and girls often have less information and access to services, especially in rural areas. Girls make their sexual debut early, either through early marriage or sexual abuse. In most cases their partners are typically much older men. Physical and sexual violence within marriage are also common, and women have little room to negotiate the use of condoms or to refuse sex to an unfaithful partner. Culture is not immutable, but change has to come from within a society,because people feel the need for it.Mobilization of local resources and indigenous knowledge, as well as the promotion of women's creativity and productivity, can be vital tools in the prevention and control of HIV/AIDS amongst women. There is a strong need of media support, NGO, and government.

Dear Editor

I noticed an error in the editorial "Effective HIV prevention requires gender-transformative work with men" by Kristin L. Dunkle and Rachel Jewkes. The list should indicate that the first article referenced, "How men’s power over women fuels the HIV epidemic" by G.R. Gupta, is from the 324th, not the 321st, volume (issue 7331). At this time, your web site's Crossref link links to a review of a movie, 28 Days. In addition to the confusion this may (and has) cause readers, it also detracts from the referenced author's citation record.

Sincerely,

Amanda Feist

Dear Editor,

In the June 2007 issue of Sexually Transmitted Infections, Dunkle and Jewkes make a much needed case for increased attention to the role of gender-based violence (GBV) in fueling the HIV pandemic. In their editorial, Dunkle and Jewkes assert that "social ideals of asculinity," including, inter alia, heterosexual success with women in the context of an entrenched gender hierarchy and the ability to control women, is an underlying cause of the observed association between violence perpetration and sexual risk taking among men. Referring to an article published in the same issue of Sexually Transmitted Infections regarding gender-based violence and STI risk in Bangladesh, they find mounting evidence for national generalizability across a range of cultural settings "supporting the link between perpetration of GBV and STI/HIV risk". Lastly, they recommend replicating gender transformative interventions with men, such as the Stepping Stones program, in order to address the underlying causes of gendered HIV risk, namely repressive gender norms and socioeconomic inequality that serve to disempower women vis-á-vis men. Their commentary is welcome, especially in a policy climate that is increasingly turning towards biomedical and non-gender transformative solutions to HIV, such as male circumcision to stem the tide of a continually mounting epidemic.

While agreeing with the spirit of their editorial, I question the logic that they use to derive their recommendations and propose an alternative method for analyzing the relationship among social ideals of masculinity, gender-based violence and HIV/STI transmission using an ecologic and comparative framework to explain population-level variations in GBV and HIV risk.

Dunkle and Jewkes accurately point to the growing body of evidence that demonstrates unequivocally that women who experience GBV and gender inequitable attitudes are at greater risk of HIV at the individual level. However, despite this association at the individual level, at the ecologic level it does not necessarily hold that countries or regions with high rates of GBV/gender inequality experience heightened rates of HIV/STIs. For instance, although the WHO multi-country study on GBV has found that Bangladesh has among the highest rates of GBV of the countries studied¹ (findings reinforced in the Silverman et al study), Bangladesh as of 2005 has a negligible national HIV prevalence rate of <0.1% (see table 1). Evidence suggests that Muslim societies, though often endorsing highly repressive gender norms, have extremely low rates of HIV/STIs.² In fact, it may be the repressive sexual culture of these countries/regions that is protective against HIV, limiting opportunities for marital infidelity and sexual liberty.

Likewise, the WHO multi-country study found Ethiopia’s and Peru’s prevalence of intimate partner violence to be the highest of the ten countries under study respectively; yet, adult HIV prevalence was estimated at 4.4% in Ethiopia in 2003 and 0.6% in Peru as of 2005. Countries with higher national HIV prevalence rates, including Namibia (19.6% in 2005) and Tanzania (6.5% in 2005), exhibited relatively lower rates of GBV (see table 1). Further, whereas HIV prevalence rates tend to be higher in urban areas,³ according to the WHO multi-country study results, GBV is more common in rural (provincial) settings while urban residence appears to have a protective effect. In essence, Dunkle and Jewkes’ comment commits the atomistic fallacy, or incorrectly generalizing an individual-level association to the group level.⁴ In order to assess the contribution of GBV to HIV at the ecologic level, studies must move from thinking about the replication of findings in different settings to a comparative, population-level framework. The disciplines of sociology, political science and economics routinely use cross-national data to test hypotheses about variations in social phenomena across countries.⁵ In his classic piece “Sick Individuals and Sick Populations”, epidemiologist Geoffrey Rose (1985) reminds us that the question,“‘Why do individuals have hypertension?’ is a quite different question from ‘why do some populations have much hypertension, whilst in others it is rare?’”.⁶ In order to address this second question, Rose argues that “what distinguishes the two groups is nothing to do with the characteristics of individuals, it is rather a shift of the whole distribution- a mass influence acting on the population as a whole.” In public health, cross-national comparisons can shed light on a host of important public health questions, including those related to GBV and HIV. To reframe Rose’s question, ‘Why are individuals who experience GBV more likely to contract HIV?’ is a very different question from ‘Why do some countries experience higher rates of GBV and how does this affect population rates of HIV infection?’

In the case of HIV, it remains somewhat of a mystery how individual HIV risk factors link up to population risk. Ultimately, due to the limited number of transmission routes, some variation in behavior between populations, coupled with a tipping point and possible biomedical transmissible cofactors must be responsible for the heightened rate of HIV in certain populations. More evidence is needed to explain under what conditions gender inequitable beliefs and behaviors link up with population-level GBV and HIV risk.

Furthermore, interventions aimed at transforming a group level characteristic, such as repressive gender norms, should focus on interventions that address the ecologic or structural level.⁷ There is intuitively a contradiction inherent in using individual-level interventions to induce broad, socially transformative gender equality. Social change does not proceed one individual at a time, but rather when, in Rose’s words, there is a “mass influence causing a shift in the whole distribution”. In order to understand what that mass influence is, and to intervene at the population level, one must know what constitute the population-level risk factors. More research must be conducted on why HIV prevalence rates vary so greatly within and between countries despite similar risk factors, such as high rates of GBV. Differences in collection and reporting of national HIV sero-prevalence estimates previously hampered comparative research of cross-national HIV prevalence. However, new data sources, notably Demographic and Health Surveys (DHS) with linked HIV testing results are an extraordinarily rich, new data source that has not yet been fully exploited to address questions regarding the social-structural and population-level determinants of HIV infection and GBV. Further, comparable national probability samples such as those utilized in the DHS allow for national estimates of GBV that can facilitate cross-national and intra-national comparisons of ecologic-level risk factors.

This comment is in solidarity with Dunkle and Jewkes’ contention that “broad socially transformative programs that promote gender equality and discourage perpetration of gender-based violence and are needed to combat the global HIV pandemic”. It is clear in countries with highly generalized HIV epidemics that reducing gender inequality and sexually empowering women are crucial to stem the spread of HIV. However, the modes by which to generate social transformation must stem from an understanding of the macro-level causes of differing social phenomena across populations. Dunkle and Jewkes point to microbicides as a gender-sensitive technology, but one that fails to address the “underlying social constructions of gender”. To this I would add male circumcision, an anti-HIV intervention increasingly gaining in prominence, which also fails to transform the broader constructions of gender in society and arguably has the potential to actually reinforce entrenched gender norms and male power. In keeping with recent literature, GBV should be addressed as a public health problem and human rights concern in its own right⁸ and not solely in relation to its instrumental association with reducing HIV and STI prevalence. Public health interventions that reinforce gender inequality and gendered power relations should be eschewed in favor of gender transformative interventions that proceed at the population level.

References

1. World Health Organization. Summary Report, WHO multi-country study on women’s health and domestic violence against women: initial results on prevalence, health outcomes and women’s responses, 2005. Retrieved June 25, 2007, from http://www.who.int/gender/violence/who_multicountry_study/en/index.html. See also, Garcia-Moreno C, Jansen H, Ellsberg M. Prevalence of intimate partner violence: findings from the WHO multi-country study on women’s health and domestic violence, Lancet 2006; 368:1260-1269

2. Gray PB. HIV and Islam: is HIV prevalence lower among Muslims? Soc Sci Med 2004;58:1751–1756.

3. Shelton JD, Cassell MM, Adetunji J. Is poverty or wealth at the root of HIV? Lancet 2005; 366(9491): 1057.

4. Leyland AH, Groenewegen PP. Multilevel modeling and public health policy, Scandinavian Journal of Public Health 2003; 31(4):267-274.

5. e.g., Dogan M, Pelassy D. How to compare nations: strategies in comparative politics. New Jersey: Chatham House Publishers, 1984.

6. Rose G. Sick individuals and sick populations, Int J Epidemiol 2001;30:427-432.

7. Blankenship KM, Friedman SR, Dworkin S, et al. Structural Interventions: Concepts, Challenges and Opportunities for Research, Journal of Urban Health 2006;83(1):59-72.

8. Brundtland GH. Violence, health, and human rights: toward a shared agenda for prevention, Health and Human Rights: An International Journal 2003;6(2): 11-13.