SISTA South Africa: The adaptation of an efficacious HIV prevention trial conducted with African-American women for isiXhosa-speaking South African women

Although new HIV treatments continue to offer hope for individuals living with HIV, behavioural interventions shown to reduce HIV risk behaviour remain one of the most powerful tools in curbing the HIV epidemic. Unfortunately, the development of evidencebased HIV interventions is a resource-intensive process that has not progressed as quickly as the epidemiology of the disease. As the epidemic continues to evolve, there is a need to expedite the development of evidence-based HIV interventions for populations that are often disproportionately impacted by HIV/AIDS. One mechanism of accelerating the development process is to adapt evidence-based HIV interventions for vulnerable populations. The aim of this paper was to describe the adaptation process of a HIV intervention for African-American women for black South African Xhosa women. For African-American women the intervention was effective in increasing consistent condom use, sexual self-control, sexual communication, sexual assertiveness and partner adoption of norms supporting consistent condom use.     

Development and initial validation of a brief screener for focused HIV prevention efforts

Objectives

The public health response to the spread of HIV relies on behavioural changes, especially reductions in sexual and drug‐use‐related transmission risk behaviours (TRBs). While understanding the factors that dispose people towards risky behaviours is important scientifically, it can be difficult to distil the many predictors of sexual risk behaviours into a useful clinical tool for focused prevention efforts. Our goal was to evaluate the extent to which known predictors of sexual TRBs (self‐efficacy, treatment optimism, engagement with medical care, awareness of risky behaviours, substance use, and relevant behavioural and socio‐demographic characteristics) combined with additional attitude‐related assessments to identify those who had engaged in recent sexual TRBs and may therefore be at risk of additional TRBs.

Methods

In this study, we analysed data on beliefs and behaviours related to sex, substance use, HIV prevention and other relevant factors for 280 patients at a publicly funded HIV/AIDS clinic in Seattle. All participants completed a baseline audio computer‐assisted self interview (ACASI) as part of a larger trial focused on reducing TRBs.

Results

Our multivariate model yielded three screening questions that could prove effective in identifying HIV‐positive patients in need of focused prevention resources.

Conclusions

The resulting screener holds promise as a brief and easily deployed tool that can be used by providers regardless of access to ACASI technology. Additional validation is needed and longitudinal evaluation is currently in progress.

     

Gendered socioeconomic conditions and HIV risk behaviours among young people in South Africa

Recent evidence suggests that the burden of new HIV infections in sub-Saharan Africa is concentrated among young people, especially females. Even in a country such as South Africa where knowledge among young people of how to protect oneself from infection is rather high, such information may not always be usable in daily situations of economic and social disadvantage that characterise many of their lives. Despite this possibility, there are surprisingly few definitive studies that examine the effects of socioeconomic status on HIV risk and prevention behaviours among youth in South Africa.

Using household survey data collected in 2001, this study investigates how socioeconomic disadvantage has influenced the sexual behaviour and experiences of 4 000 young women and men aged 14–24 years in KwaZulu-Natal province — an area characterised by high HIV prevalence and high rates of poverty and inequality. Socioeconomic disadvantage, measured here as low relative household wealth, is found to be associated with a variety of unsafe sexual behaviours and experiences, particularly for females. Among young women low wealth is associated with earlier sexual debut, having had multiple sexual partners in the year before the survey, and lower chances of condom use at last sex. It is also associated with increased chances that first female sexual experience is non-consensual and with higher odds of females having traded sex and having experienced physically forced sex. For females and males, low wealth reduces the chances of discussing safe-sex practices with the most recent sexual partner. Without sufficient attention, during the design and placement of HIV prevention programmes, to the gendered economic and social conditions in which individuals live — conditions that can make people more or less vulnerable to behaviours and experiences that may lead to infection — the potential effectiveness of the global response to HIV/AIDS is sacrificed.     

HIV testing of construction workers in the Western Cape,South Africa

With an infection rate estimated at 14%, the South African construction industry is one of the economic sectors most adversely affected by the HIV/AIDS pandemic. Construction workers are considered a high-risk group. The provision and uptake of voluntary counselling and testing (VCT) is critical to reducing transmission rates. This study examined the testing behaviour of site-based construction workers in terms of demographic and lifestyle risk behaviour characteristics to help inform better strategies for work-based interventions by construction firms. A total of 512 workers drawn from six firms operating on 18 construction sites in the Western Cape province participated in the study. Twenty-seven per cent of the participants reported never having been tested for HIV. Results indicate that females (aOR = 4.45, 95% CI, 1.25–15.82), older workers (aOR = 1.40, 95% CI, 1.08–1.81), permanent workers (aOR = 1.67, 95% CI, 1.11–2.50) and workers whom had previously used a condom (aOR = 1.93, 95% CI, 1.02–3.65) were significantly more likely to have been tested. Ethnicity was not significantly related to prior testing. Identification of these subgroups within the industry has implications for the development of targeted work-based intervention programmes to promote greater HIV testing among construction workers in South Africa.     

Dilemmas and tensions facing a faith-based organisation promoting HIVprevention among young people in South Africa

Faith-based organisations (FBOs) are receiving growing attention for their roles in addressing HIV and AIDS in southern Africa. These roles, however, are not without philosophical challenges. Yet, to date, most references to the successes or limitations of FBOs have remained the domain of theoretical and, often, ideological debate. In this context, discussions about the roles of faith and FBOs in responding to HIV and AIDS often evoke extreme positions—either advocating for or critiquing their involvement. In place of this there is a need for empirical evidence and analyses that shed light on both the challenges and opportunities of faith-based HIV-prevention programming. This article presents a critical sociological analysis of the complexities confronting one FBO in its effort to deliver an abstinence-focused HIV-prevention programme to school-going adolescents in a poor peri-urban area of South Africa. As one aspect of a larger mixed-methods evaluation, this analysis is based on 11 focus group discussions, variously held with parents, teachers, learners and programme facilitators, in an effort to determine how and why the participants perceived the programme to work. We present and analyse four sources of tension appearing within the data which relate to the programme's faith-based orientation: a) enthusiasm for sexual abstinence despite awareness of the structural constraints; b) a dichotomous framing of behaviours (i.e. good versus bad); c) mixed messages about condoms; and d) administering faith-based programming within secular public schools. Through this analysis we aim to identify opportunities and challenges for faith-based HIV-prevention efforts more broadly. We argue that any assessment of faith-based HIV-prevention programming ought to respect and reflect its complexity as well as the complexity of the context within which it operates.     

Cardiovascular disease and prevention among people living with HIV in South Florida

Antiretroviral therapy (ART) has improved survival of patients living with HIV (PLWH); however, this has been accompanied by an increase in cardiovascular disease (CVD). Although preventative measures for CVD among the general population are well described, information is limited about CVD prevention among PLWH. The goal of this study was to characterize the prevalence of CVD in our population and to assess the use of primary and secondary prevention.We performed a retrospective review of PLWH receiving primary care at a large academic center in Miami, Florida. We characterized the prevalence of CVD, CVD risk, and the use of aspirin and statins for primary and secondary CVD prevention.A total of 985 charts were reviewed (45% women, 55% men). Average age was 52.2 years. Average CD4 count was 568 cells/microL. 92.9% were receiving ART, and 71% were virologically suppressed. The median 10-year ASCVD risk was 7.3%. The prevalence of CVD was 10.4% (N = 102). The odds of having CVD was lower in patients on ART (OR 0.47, 95% CI: 0.25–0.90, P = .02). The use of medications for primary and secondary prevention of CVD based on current guidelines was low: 15% and 37% for aspirin respectively, and 25% and 44% for statins.CVD risk and rates of CVD are high among PLWH and receiving ART could protect against CVD. However, the use of medications for primary and secondary prevention is low. Increased awareness of CVD risk-reduction strategies is needed among providers of PLWH to decrease the burden of CVD.     

Male circumcision for HIV prevention: female risk compensatory behaviour in South Africa

South Africa promotes male circumcision (MC) as an HIV prevention method and implemented a national plan to scale-up MC in the country from 2012 to 2016. Literature has suggested that female risk compensatory behaviours (RCBs) are occurring in countries where these programmes have been implemented. Behaviours such as decreased condom use, concurrent sexual partners and sexual activity during the circumcision wound-healing period have the potential to jeopardise the campaigns’ objectives. Literature has shown that directly providing women with MC information results in correct knowledge however, previous studies have not directly sought women’s views and ideas on engagement with the information. This study aims to identify and explore female RCBs in relation to MC campaigns in South Africa, and to identify interventions that would result in greater female involvement in the campaigns. Snowball sampling was used to conduct twelve qualitative vignette-facilitated semi-structured interviews with women residing in a municipal housing estate in Durban, Kwa-Zulu Natal, South Africa. Interviews were audio-recorded, verbatim transcribed and analysed using framework analysis. MC knowledge and understanding varied, with some participants mistaking MC as direct HIV protection for females. Despite a lack in knowledge, the majority of women did not report signs of RCBs. Even with a lack of evidence of RCBs, misinterpretation of the MC protective effect has the potential to lead to RCBs; a concept acknowledged in the literature. Several women expressed that MC campaigns are directed to males only and expressed a keenness to be more involved. Suggested interventions include couple counselling and female information sessions in community clinics. Exploring women’s attitude towards involvement in MC campaigns fills in a research knowledge gap that is important to international health, as women have a vital role to play in reducing the transmission of HIV.     

Opportunities for technology-based HIV prevention programming among high school students in Cape Town,South Africa

One in three new cases of HIV in South Africa is among adolescents. Given that adolescents are particularly affected, scalable, and cost-effective prevention programs are urgently needed. This study aims to identify opportunities to integrate technology into youth HIV prevention efforts. In 2012, 1107 8th–11th graders completed a paper-and-pencil survey. Respondents were enrolled in one of three public high schools in Langa, a lower income community in Cape Town, South Africa. Eighty-nine percent of respondents have used text messaging (SMS) and 86% have gone online. If an HIV prevention program was offered online, 66% of youth would be somewhat or extremely likely to access it; slightly fewer (55%) felt the same about SMS-based programming. In comparison, 85% said they would be somewhat or extremely likely to access a school-based HIV prevention program. Interest in Internet- (60%) and SMS-based (54%) HIV prevention programming was similar for youth who had a self-appraised risk of HIV compared to youth who appraised their risk to be lower, as it was for youth who were tired of hearing messages about HIV prevention. Technology use is common – even among high school students who live in lower income communities. At the same time, these data reveal that it is not uncommon for youth to be tired of hearing messages about HIV prevention, and many of the typical topics key to HIV prevention have low interest levels among youth. HIV prevention researchers need to be mindful of the extent of existing programming that youth are exposed to. Technology-based programming may be especially amenable to meeting these requirements because of its novelty especially in developing countries, and because interactive functionality can be easily integrated into the program design. Given the preference for school- and Internet-based programming, it seems that a hybrid approach is likely feasible and acceptable.     

Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention

Objectives

Sexually transmitted infections (STIs) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STIs in a community sample of 490 HIV‐positive men and women.

Methods

Assessments were performed using confidential computerized interviews in a community research setting.

Results

Fourteen per cent of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a 6‐month period. Individuals with a new STI had significantly more sexual partners in that time period, including non‐HIV‐positive partners. Participants who had contracted an STI were significantly more likely to have detectable viral loads and were less likely to know their viral load than participants who did not contract an STI. Multivariate analysis showed that believing an undetectable viral load leads to lower infectiousness was associated with contracting a new STI.

Conclusions

Individuals who believed that having an undetectable viral load reduces HIV transmission risks were more likely to be infectious because of STI coinfection. Programmes that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STIs among people living with HIV/AIDS.     

HIV testing is associated with increased knowledge and reductions in sexual risk behaviours among men in Cape Town,South Africa

HIV testing benefits those who test positive, allowing them to receive treatment, but the benefits for those who test negative remain controversial. We evaluated the impact of testing on HIV knowledge and sexual risk among men in South Africa. Men were recruited from townships outside Cape Town and completed a survey that assessed testing history, knowledge, and sexual behaviours. Among the 820 participants, 516 (63%) reported being tested (82% tested negative, 6% tested positive, and 12% unknown). Compared to those who had never been tested for HIV, men who tested for HIV were more knowledgeable about HIV transmission, but did not differ on sexual risk behaviour. Knowledge moderated the effect of testing on sexual risk such that men reported fewer sexual partners (incidence rate ratio (IRR) = 0.91, 95% CI = 0.84, 0.98) and fewer unprotected anal sex events (IRR = 0.81, 95% CI = 0.66, 1.00) if they had been tested for HIV and were knowledgeable about HIV transmission. For men testing HIV-negative, knowledge predicted fewer sexual risk behaviours. Previous HIV testing is associated with enhanced knowledge, which moderates sexual risk behaviour among South African men living in Cape Town. Results suggest that HIV testing may increase knowledge and lead to reductions in sexual risk even when results are negative.     

Understanding of the risk of HIV infection among the elderly in Ga-Rankuwa,South Africa

Abstract

The literature pertaining to the elderly shows that HIV infection among this population is on the increase, suggesting that the elderly population engages in activities risky for HIV infection. Reports on such behaviour include frequent sexual relations with much younger people and having multiple partners. A study was carried out in Ga-Rankuwa, a black township in Gauteng Province, South Africa to explore and describe the understanding of these elderly people regarding their risks of HIV infection and AIDS. Using a qualitative, exploratory design, three focus-group interviews were conducted with 32 women aged over 50 years. Findings revealed that older persons have knowledge about transmission of HIV infection and AIDS. However, a few had misconceptions as to how HIV infection is transmitted, as they believed that poor nutrition and sharing facilities play a role. Knowledge of mechanisms of protecting themselves against infection, such as use of a condom during coitus and wearing gloves when caring for infected family members, was also evident. The elderly indicated that they would prefer an older person, who they could identify with, to educate them more about HIV infection and AIDS. Although majority of participants had knowledge of how HIV is transmitted, and issues that put them at risk of transmission, a few the older persons had misconceptions about how HIV is transmitted due to lack of knowledge, as they believed that poor nutrition and sharing facilities can transmit infection. The lack of knowledge underscores the importance of addressing sexual risk with older people. It was very clear that more needs to be done in terms of education campaigns to dispel the myths of HIV infection and to empower the elderly.     

Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drugusing populations in Cape Town,Durban and Pretoria,South Africa

This exploratory study examines the links between drug use and high-risk sexual practices and HIV in vulnerable drug-using populations in South Africa, including commercial sex workers (CSWs), men who have sex with men (MSM), injecting drug users (IDUs) and non-injecting drug users who are not CSWs or MSM (NIDUs). A rapid assessment ethnographic study was undertaken using observation, mapping, key informant interviews and focus groups in known ‘hotspots’ for drug use and sexual risk in Cape Town, Durban and Pretoria. Key informant (KI) and focus group interviews involved drug users and service providers. Purposeful snowball sampling and street intercepts were used to recruit drug users. Outcome measures included drug-related sexual HIV risk behaviour, and risk behaviour related to injection drug use, as well as issues related to service use. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. Non-injection drug use (mainly cannabis, methaqualone, crack cocaine and crystal methamphetamine) and injection drug use (mainly heroin) was occurring in these cities. Drug users report selling sex for money to buy drugs, and CSWs used drugs before, during and after sex. Most (70%) of the drug-using KIs offered HIV testing accepted and 28% were positive, with rates highest among CSWs and MSM. IDUs reported engaging in needle sharing and needle disposal practices that put them and others at risk for contracting HIV. There was a widespread lack of awareness about where to access HIV treatment and preventive services, and numerous barriers to accessing appropriate HIV and drug-intervention services were reported. Multiple risk behaviours of vulnerable populations and lack of access to HIV prevention services could accelerate the diffusion of HIV. Targeted interventions could play an important role in limiting the spread of HIV in and through these under-reached and vulnerable populations.     

Discordance of voluntary HIV testing with HIV sexual risk-taking and self-perceived HIV infection risk among social media-using black,Hispanic, and white young-men-who-have-sex-with-men (YMSM)

Discordance between self-perceived HIV risk and actual risk-taking may impede efforts to promote HIV testing among young adult men-who-have-sex-with-men (YMSM) in the United States (US). Understanding the extent of, and reasons for, the discordance of HIV risk self-perception, HIV risk-taking and voluntary HIV testing among black, Hispanic and white YMSM could aid in the development of interventions to increase HIV testing among this higher HIV risk population. HIV-uninfected 18–24-year-old black, Hispanic, and white YMSM were recruited from across the US through multiple social media websites. Participants were queried about their voluntary HIV testing history, perception of currently having an undiagnosed HIV infection, and condomless anal intercourse (CAI) history. We assessed the association between previous CAI and self-perceived possibility of currently having an HIV infection by HIV testing status using Cochran-Mantel-Haenszel testing. Of 2275 black, Hispanic and white social media-using 18–24 year-old YMSM, 21% had never been tested for HIV voluntarily, 87% ever had CAI with another man, 77% believed that it was perhaps possible (as opposed to not possible at all) they currently could have an undiagnosed HIV infection, and 3% who reported CAI with casual or exchange partners, but had not been tested for HIV, self-perceived having no possibility of being HIV infected. Of 471 YMSM who had not been HIV tested, 57% reported CAI with casual or exchange partners, yet self-perceived having no possibility of being HIV infected. Per the Cochran-Mantel-Haenszel test results, among those reporting HIV risk behaviors, the self-perception of possibly being HIV-infected was not greater among those who had never been tested for HIV, as compared to those who had been tested. Future interventions should emphasize promoting self-realization of HIV risk and translating that into seeking and accepting voluntary HIV testing among this higher HIV risk population.     

HIV protective strategies among college students in Durban,South Africa

There is growing concern about the high level of HIV infection among young people in South Africa. The aim of the study is to examine the HIV protective strategies used by college students with specific emphasis on variations by race group. The data for the study come from a self-administrated survey that was conducted with 3 000 college students in Durban in order to understand the strategies they use to protect themselves against the risk of HIV infection. Overall, students perceived a far greater risk of pregnancy than HIV infection. The results show that abstinence is the most common protective factor among Indian and White students. Among African students, there is great concern about HIV but abstinence is less common. Among sexually active men and women, the majority report having more than one sexual partner (with the exception of Indian females). Female students among all groups were more likely than male students to report that they were faithful to their partners. In Africans the contrast is stark: 25% for women versus 6% for men. Condoms are the most commonly used method by students but are not used in every sexual encounter. Consistent condom use was highest among Indian males (46%) and lowest among White females (13.7%). More effort needs to be directed at promoting correct and consistent condom use in order to avoid the negative consequences associated with unprotected sexual intercourse including unwanted pregnancy and HIV/AIDS.     

Risk factors for HIV-AIDS among youth in Cape Town, South Africa

South Africa is in the midst of a devastating HIV-AIDS epidemic and most new HIV infections occur among young adults and adolescents. The current study examined risk behaviors and HIV risk factors among young people living in a Black South African township. Using community-based outreach methods of street intercept and facility-based surveying, 113 men and 115 women age 25 and younger responded to an anonymous survey. Results showed that men (68%) and women (56%) reported HIV-related high risk sexual behaviors. Although knowledge about HIV transmission was generally high, there was evidence that misconceptions about AIDS persist, particularly myths related to HIV transmission. For young men, HIV risk factors were associated with fewer years of education, lower levels of AIDS-related knowledge, condom attitudes, and Dagga (marijuana) use. Among young women, HIV risk factors were associated with beliefs that condoms get in the way of sex and rates of unprotected vaginal intercourse. Despite adequate general AIDS knowledge and risk sensitization, South African youth demonstrated high rates of sexual practices that place them at risk for HIV infection. There is an urgent need for behavioral interventions targeted to young South Africans living in the most economically disadvantaged areas.     

UnPrEPed for HIV prevention services: Hesitancy among US primary care providers

Provision of HIV prevention services by primary care (PCP) healthcare providers is critical to reduce the number of new HIV infections. We examined the performance of HIV risk assessments and provision of HIV prevention services by PCPs. In our cohort, less than one-half of respondents asked about sex and drug use all or most of the time, and among those that did not routinely ask about sex and drug use only 66% and 59%, respectively, would ask given more time. Less than a quarter of respondents noted that HIV prevention services were part of their clinical practice. These findings demonstrate gaps in the provision of HIV prevention services by a key population of healthcare providers.     

Sexual risk during initial months in US among Latina young adults

Latina young adults are disproportionately at risk for sexually transmitted infections (e.g., HIV). However, little is known about social and cultural factors contributing to sexual health disparities among young adult Latina recent immigrants. The present study examined social and cultural factors contributing to sexual risk behaviors among 530 Latina women (ages 18–23) who immigrated to Miami-Dade County, Florida, approximately 12 months before assessment. At the cultural/macrosystemic level, participants who reported more sexual risk behaviors tended to (a) be less acculturated; (b) use less positive religious coping; (c) endorse to a greater extent the marianismo belief that Latinas should be the pillar of the family; and (d) endorse less of the marianismo belief that Latinas should be virtuous and chaste (i.e., abstain from premarital sex). As for individual-level factors, participants who reported more sexual risk behaviors also indicated (e) older age, (f) being married/partnered, (g) being employed, (h) living in the US longer, and (i) drinking more alcohol. Findings indicate areas for HIV/STI prevention for this underserved population.     

Stigma,discrimination and the implications for people living with HIV/AIDS in South Africa

Stigma and discrimination play significant roles in the development and maintenance of the HIV epidemic. It is well documented that people living with HIV and AIDS experience stigma and discrimination on an ongoing basis. This impact goes beyond individuals infected with HIV to reach broadly into society, both disrupting the functioning of communities and complicating prevention and treatment of HIV. This paper reviews the available scientific literature on HIV/AIDS and stigma in South Africa, as well as press reports on the same subject over a period of 3 years. Analysis of this material indicates that stigma drives HIV out of the public sight, so reducing the pressure for behaviour change. Stigma also introduces a desire not to know one's own status, thus delaying testing and accessing treatment. At an individual level stigma undermines the person's identity and capacity to cope with the disease. Fear of discrimination limits the possibility of disclosure even to potential important sources of support such as family and friends. Finally, stigma impacts on behaviour change as it limits the possibility of using certain safer sexual practices. Behaviour such as wanting to use condoms could be seen as a marker of HIV, leading to rejection and stigma. All interventions need to address stigma as part of their focus. However, the difficulty of the task should not be underestimated, as has been shown by the persistence of discrimination based on factors such as race, gender and sexual orientation.