Can family-centered programing mitigate HIV risk factors among orphaned and vulnerable adolescents? Results from a pilot study in South Africa

Let's Talk is a structured, family-centered adolescent HIV prevention program developed for use in South Africa using key components adapted from programs successfully implemented in the US and South Africa. It is designed to address individual HIV transmission risk factors common among orphaned and vulnerable adolescents, including elevated risk for poor psychological health and sexual risk behavior. These efforts are accentuated through parallel programing to support caregivers’ mental health and parenting skills. Twelve Let's Talk groups, each serving approximately 10 families, were piloted by two local community-based organizations in Gauteng and Kwa-Zulu Natal provinces, South Africa. Face-to-face interviews were conducted among participating caregivers and adolescents at baseline and three months post-intervention to explore the potential effects of the program on intermediate outcomes that may support HIV preventive behavior. Specifically, generalized estimation equations were used to estimate average change on HIV prevention knowledge and self-efficacy, caregiver and adolescent mental health, and family dynamics. Among the 105 adolescents and their 95 caregivers who participated in Let's Talk and completed both surveys, statistically significant improvements were found for adolescents’ HIV and condom use knowledge as well as condom negotiation self-efficacy, but not sexual refusal self-efficacy. Both caregivers and adolescents demonstrated significantly better mental health at post-test. Adolescent/caregiver connection and communication about healthy sexuality also improved. These preliminary results highlight the potential of HIV prevention interventions that engage caregivers alongside the vulnerable adolescents in their care to mitigate adolescent HIV risk factors. A more rigorous evaluation is warranted to substantiate these effects and identify their impact on adolescents’ risk behavior and HIV incidence.     

Long-Term Correlates of Childhood Abuse among Adults with Severe Mental Illness: Adult Victimization, Substance Abuse, and HIV Sexual Risk Behavior

The prevalence of childhood sexual and physical abuse among persons with severe mental illness (SMI) is disproportionately high. Adults with SMI also engage in high rates of HIV risk behaviors. This study examined the association between childhood abuse and adult victimization, substance abuse, and lifetime HIV sexual risk in a sample of 152 adults with SMI receiving community mental health services. Structured interviews assessed psychiatric, psychosocial, and behavioral risk factors. Seventy percent reported childhood physical and/or sexual abuse, and 32% reported both types of abuse. Participants with childhood abuse were more likely to report adult victimization and greater HIV risk. A structural equation model found that childhood abuse was directly and indirectly associated with HIV risk through drug abuse and adult vicitimization. Integrated treatment approaches that address interpersonal violence and substance abuse may be necessary for HIV risk reduction in this population.     

"We're going to have to cut loose some of our personal beliefs": barriers and opportunities in providing HIV prevention to African American men who have sex with men and women

In the United States, there is an urgent need to provide HIV prevention services to African American men who have sex with men and women (MSMW) but who do not identify as gay or homosexual. Engaging these men in HIV prevention has historically been challenging. This study used qualitative methodology to explore the beliefs and experiences from community-based service providers (n = 21) and from African American MSMW (n = 21) regarding the provision of HIV prevention education and counseling to these men. Data analysis revealed that (a) African American MSMW who do not identify as gay can challenge service providers' assumptions about sexual behavior and sexual identity; (b) service providers' attitudes toward these men can be affected by ambivalent or negative beliefs that pervade the general community; (c) African American MSMW need safe and nonjudgmental spaces that offer HIV risk reduction, but they also might experience anxiety about disclosing same-sex behaviors to counselors. Findings highlighted the complexities related to culture, masculinity, and sexuality as determinants of HIV risk in African American MSMW, and findings also revealed tensions between these factors that may affect the quality of HIV prevention services. Service providers may need additional training to provide appropriate and non-judgmental HIV prevention counseling and education.     

Sexual Networks and HIV Risk of People with Severe Mental Illness in Institutional and Community-Based Care

This study examines the sexual networks and HIV risk of clients with severe mental illness in treatment in institutional and community care settings. Data were gathered through structured interviews with 401 clients at three community mental health centers and two state psychiatric hospitals. Results indicate that community clients are more likely than hospital patients to be currently sexually active and to engage in high-risk sexual behavior whereas hospitalized patients tend to have more transient sexual relationships with partners who also have a mental illness. These findings suggest that mental health treatment settings may be shaping the HIV epidemic among psychiatric patients because of the impact they have on the structure of clients’ sexual networks.     

"I understand just a little…" Perspectives of HIV/AIDS service providers in South Africa of providing mental health care for people living with HIV/AIDS

Research conducted in South Africa and other parts of the world has revealed that people living with HIV/AIDS (PLWHA) are more at risk of developing a mental disorder than the general population. It makes sense to explore means of integrating HIV/AIDS and mental health care thereby facilitating access of PLWHA to prompt mental health care. We conducted qualitative interviews with 22 HIV/AIDS service providers of three occupational categories (10 nurses, six adherence counsellors and six patient advocates) at three primary health care clinics in the Western Cape, South Africa. We explored the issues of knowledge and practice in mental health care as well as the role of nurses and lay health workers in providing mental health care to PLWHA thereby attempting to integrate mental health and HIV/AIDS care. Although the majority of participants were in favour of mental health screening for PLWHA, they lacked confidence to conduct the screening themselves. Most participants displayed poor knowledge of mental disorders and reported that they referred to colleagues or to an external mental health service if they suspected a possible mental disorder in a patient. Integration of mental health and HIV/AIDS care has potential benefit to the public HIV/AIDS care system. Mental health training should be provided to HIV/AIDS service providers in this regard.     

Correlates of HIV infection among patients with mental illness in Brazil

People living with mental illness are at increased risk for HIV. There are scarce data on correlates and prevalence of HIV infection, and none with a nationally representative sample. We report on correlates of HIV infection from a cross-sectional national sample of adults receiving care in 26 publicly funded mental health treatment settings throughout Brazil. Weighted prevalence rate ratios were obtained using multiple log-binomial regression modeling. History of homelessness, ever having an STD, early age of first sexual intercourse before 18 years old, having suffered sexual violence, previous HIV testing, self-perception of high risk of HIV infection and not knowing one's risk were statistically associated with HIV infection. Our study found an elevated HIV seroprevalence and correlates of infection were not found to include psychiatric diagnoses or hospitalizations but instead reflected marginalized living circumstances and HIV testing history. These adverse life circumstances (history of homelessness, having suffered sexual violence, reporting a sexually transmitted disease, and early sexual debut) may not be unique to people living with mental illness but nonetheless the mental health care system can serve as an important point of entry for HIV prevention in this population.     

Gender attitudes, sexual power, HIV risk: a model for understanding HIV risk behavior of South African men

The Gender Attitudes-Power-Risk (GAPR) model of HIV risk behavior was tested using survey data collected from among 309 men who were attending STI services in a primary health care clinic in Cape Town, South Africa. Results showed that negative attitudes towards women were significantly positively associated with a high level of HIV risk behavior, and that endorsement of traditional male roles was negatively associated with HIV risk behavior. Endorsement of traditional male gender roles was also inversely related to relationship control but positively to a high degree of decision-making dominance in one's relationship. Sexual relationship power did not significantly mediate the relationships between gender attitudes and HIV risk behavior. A better understanding of gender roles and ideologies in combination with one's power in sexual relationships as they relate to HIV risk behavior among men could better inform future HIV prevention interventions.     

Mental Health Treatment to Reduce HIV Transmission Risk Behavior: A Positive Prevention Model

Secondary HIV prevention, or “positive prevention,” is concerned with reducing HIV transmission risk behavior and optimizing the health and quality of life of people living with HIV/AIDS (PLWHA). The association between mental health and HIV transmission risk (i.e., sexual risk and poor medication adherence) is well established, although most of this evidence is observational. Further, a number of efficacious mental health treatments are available for PLWHA yet few positive prevention interventions integrate mental health treatment. We propose that mental health treatment, including behavioral and pharmacologic interventions, can lead to reductions in HIV transmission risk behavior and should be a core component of secondary HIV prevention. We present a conceptual model and recommendations to guide future research on the effect of mental health treatment on HIV transmission risk behavior among PLWHA.     

HIV risk among female sex workers in Miami: the impact of violent victimization and untreated mental illness

Street-based female sex workers constitute a vulnerable population for HIV, as they are often enmeshed in chronic patterns of substance use, sexual risk, homelessness, and violent victimization. This study examined the specific contributions of victimization history and abuse-related traumagenic factors to mental health functioning and sexual risk behaviors, while considering the impact of environmental risk factors as well. Using targeted sampling strategies, we enrolled 562 Miami-based female sex workers into an intervention trial testing the relative effectiveness of two alternative case management conditions in establishing linkages with health services and reducing risk for HIV. Lifetime prevalence of abuse was extremely elevated at 88%. Nearly half reported abuse before the age of 18, while 34% reported violent encounters with "dates" or clients in the past 90 days. Serious mental illness (SMI) was quite common, with 74% reporting severe symptoms of depression, anxiety, or traumatic stress. For those with histories of abuse, SMI appeared to mediate the association between abuse-related trauma and unprotected sex behaviors. Mental health treatment would appear to be an important component of effective HIV prevention among this vulnerable group, and should form part of a compendium of services offered to female sex workers.     

Sexual and reproductive health perceptions and practices as revealed in the sexual history narratives of South African men living in a time of HIV/AIDS

Abstract

The frequent positioning of men's sexual risk-taking as driving the HIV/AIDS epidemic in South Africa has triggered interest in men's sexual and reproductive health (SRH) perceptions, attitudes, and practices. Much research, however, presents men as a homogenous group, and focuses on the quantifiable aspects of male sexual behaviors, providing an inadequate basis for understanding men's SRH needs and addressing the gendered aspects of HIV prevention. This study used sexual history narratives to yield more nuanced and contextualized understandings of male sexuality as it relates to SRH. Fifty sexual life history individual interviews and 10 focus-group discussions (FGDs) with men, as well as 25 sexual life history interviews with women, were conducted with participants purposively sampled from three age categories: (18–24, 25–55, and 55+ years), a wide range of cultural and racial backgrounds, and in urban and rural sites across 5 provinces in South Africa. Interviews and FGDs elicited stories of participant's early knowledge of sex and sexual experimentation and then explored sexual relationships and experiences in adulthood—including engagement with HIV risks and SRH management. The data were analyzed using a thematic approach. Many male participants conformed to dominant norms of masculinity associated with a high risk of sexually transmitted infections including HIV, such as having regular unprotected sex, reluctance to test for HIV, and poor SRH-seeking behaviors. Yet, the narrative accounts reveal instances of men taking steps to protect their own SRH and that of their partners, and the complex ways in which hegemonic gender norms influence men and women's SRH. Ultimately, the study points to the value of sexual biographies for gaining a deeper understanding of male sexuality, and the social structures, meanings, and experiences that underlie it. Such insights are critical to more effectively engaging men in HIV prevention efforts.     

Community attitudes towards sexual activity and childbearing by HIV-positive people in South Africa

While the ability to lead a healthy sexual life and to choose whether and when to have children are well-established features of reproductive health and human rights, issues surrounding sexual activity and childbearing among HIV-infected women and men have received little attention in sub-Saharan Africa. We conducted a semi-structured, cross-sectional survey at 26 primary health care clinics in South Africa to investigate community attitudes towards sexual activity and reproduction by HIV-infected individuals. Of the 843 women interviewed, slightly less than half (43%, n = 361) thought that people living with HIV/AIDS should remain sexually active if they choose, while 13% (n = 113) said they thought that people living with HIV/AIDS should have children if they wished to do so. In multivariate analysis, negative attitudes towards both sexuality and childbearing were persistently associated with not knowing someone infected with HIV (p = 0.001 and 0.043, respectively). These findings suggest that the sexual and reproductive health rights of HIV-infected women and men may be an important target as part of efforts to reduce HIV/AIDS-related stigma. Health policies and services are required to reinforce the reproductive rights of HIV-infected individuals in South Africa and other countries in sub-Saharan Africa where HIV is most prevalent.     

Sexual Negotiations in Relation to Political Mobilization: The Prevention of HIV in a Comparative Context

Based on ethnographic research in different sites of the global economy, in New York City, Puerto Rico, and South Africa, this paper examines the ways in which women, confronted with the spread of HIV/AIDS, describe their sexual negotiations with men. In each situation, women are found to adopt different strategies for prevention in relation to their level and forms of political mobilization. The research documents the dual role of the U.S. media both in providing information for populations around the world and in perpetuating misconceptions and cultural stereotypes about the spread of HIV/AIDS and women's sexuality. Overall, the comparative data overturns stereotypes of cultural invariability with respect to women's sexuality and demonstrates women's willingness to modify their sexual behavior to reduce the threat of infection from HIV.     

"There's evidence that this really works and anything that works is good": views on the introduction of medical male circumcision for HIV prevention in South Africa

Three clinical trials have demonstrated the partial efficacy (40-60%) of surgically conducted medical male circumcision (MMC) in preventing HIV transmission to circumcised men. This research formed part of a larger study exploring the importance of integration of sexual and reproductive health with HIV services. The objective was to elicit key informant views on the introduction of MMC for HIV prevention in South Africa. Twenty-one key informants representing the South African Health Department, local and international NGOs and universities, were asked, via semi-structured interviews about their views on introducing MMC as an HIV prevention strategy in South Africa. Interviews were transcribed and all discussions on MMC were coded for analysis using NVivo 8. The majority of the key informants were knowledgeable about MMC for HIV prevention and felt that making MMC available in South Africa was a good idea, with some recommending immediate introduction. Others felt that MMC should be introduced with caution. Various factors were recommended for consideration, including culture, the impact of circumcision on women, possible increase in sexual risk behaviour from behavioural disinhibition and that MMC may become another vertical health service programme. Most felt that MMC should be undertaken in neonates, however, acknowledged concerns about cultural responses to this. Recommendations on the implementation of MMC ranged from integrating services at primary health care level, to provision by private medical practitioners. In conclusion, MMC is viewed as a key HIV prevention strategy. However, there are numerous factors which could hinder introduction and uptake in South Africa and in the region. It is important to explore and understand these factors and for these to be aligned in the national MMC policy.     

Mental health of carers of children affected by HIV attending community-based programmes in South Africa and Malawi

There is strong evidence that both adults and children infected with and affected by HIV have high levels of mental health burden. Yet there have been few studies investigating carer mental health outcomes in the context of HIV in Malawi and South Africa. The objective of this study was to assess the mental health of carers of children affected by HIV as a part of the Child Community Care study, which aims to generate evidence on the effectiveness of community-based organisation (CBO) services to improve child outcomes. In a cross-sectional study, we interviewed 952 carers of children (aged 4–13 years) attending 28 randomly selected CBOs funded by 11 major donors in South Africa and Malawi. Psychological morbidity was measured using the Shona Symptom Questionnaire and suicidal ideation was measured using an item from the Patient Health Questionnaire. Carers were asked about care-seeking for emotional problems. Overall, 28% of carers scored above the clinical cut-off for current psychological morbidity and 12.2% reported suicidal ideation. We used logistic regression models to test factors associated with poor outcomes. Household unemployment, living with a sick family member and perceived lack of support from the community were associated with both psychological morbidity and suicidal ideation in carers. Reported child food insecurity was also associated with psychological morbidity. In addition, carers living in South Africa were more likely to present with psychological morbidity and suicidal ideation than carers in Malawi. Rates of help-seeking for mental health problems were low. Carers of children affected by HIV are at risk for mental health problems as a result of HIV, socio-economic, care-giving and community factors. We call for increased recognition of the potential role of CBOs in providing mental health care and support for families as a means to improve equity in mental health care. Specifically, we highlight the need for increased training and supervision of staff at CBOs for children affected by HIV, and the inclusion of CBOs in broader efforts to improve population mental health outcomes.     

What is the relevance of mental health to HIV/AIDS care and treatment programs in developing countries? A systematic review

The expansion of AIDS treatment initiatives in resource-poor settings provides an opportunity for integrating mental health care into these programs. This systematic review of the literature on HIV and mental illness in developing countries examines the mental health risk factors for HIV, mental health consequences of HIV, psychosocial interventions of relevance for HIV-infected and affected populations, and highlights the relevance of these data for HIV care and treatment programs. We reviewed seven studies that measured the prevalence of HIV infection among clinic and hospital-based populations of people with mental illness or assessed sexual risk behavior in these populations; 30 studies that described the mental health consequences of HIV infection; and two reports of psychosocial interventions. The review demonstrates the need for methodologically sound studies of mental health throughout the course of HIV, including factors that support good mental health, and interventions that employ identified variables (e.g. coping, family support) for efficacy in reducing symptoms of mental illness. Promising intervention findings should encourage investigators to begin to study the implementation of these interventions in HIV service settings.     

Men Who Have Sex with Transgender Women: Challenges to Category-based HIV Prevention

Although transgender women are acknowledged as a priority population for HIV prevention, there is little knowledge on men who have sex with transgender women (MSTGWs). MSTGWs challenge conventional sexual orientation categories in public health and HIV prevention research, and warrant increased attention from the public health community. This paper used qualitative techniques to analyze how MSTGWs describe their sexual orientation identities, and to explore the correspondence between men’s identities and sexual behaviors with transgender women. We conducted in-depth semi-structured individual interviews with 46 MSTGWs in San Francisco. We observed a diversity in the ways participants identified and explained their sexual orientation, and found no consistent patterns between how men described their sexual orientation identity versus their sexual behavior and attraction to transgender women. Findings from this qualitative study question the utility of category-based approaches to HIV prevention with MSTGWs and offer insights into developing HIV interventions for these men.     

Family, cultural and gender role aspects in the context of HIV risk among African American women of unidentified HIV status: an exploratory qualitative study

This was an exploratory, qualitative study of contextual cultural and social realities of the sexual interactions of a representative sample of African American women of unidentified HIV status. The study expanded our understanding of family and gender role variables by exploring influences of family of origin and idealistic perceptions of roles on sexual relationships. Data was collected on 51 African American women who were recruited through probability sampling. Between 39% and 70% of study participants reported at least one of the following HIV risk factors: low condom use, substance use during sex, partner's incarceration and history of abuse. Nonetheless, all women in our study perceived their chances of HIV infection to be almost non-existent, despite a fairly good knowledge of HIV/AIDS modes of transmission including that anyone could become HIV infected, knowing somebody with HIV/AIDS and acknowledgment, among some, of their partner's infidelity and risk behaviors. Our analysis revealed that parental communications about sexuality in relationships focused largely on trust (being mistrustful of men) and women's control of their sexual impulses. Trust was also emphasized (desired) by women in the discussions of gender roles. Women reported a strong reliance on God and made frequent references to the role of the church in HIV prevention. Our findings offer suggestions for HIV prevention for the general population of African American women. HIV-prevention messages that consider their views of relationships, gender roles, sexual abuse history and the role of the church are suggested.     

Perception of risk of HIV infection in marital and cohabiting partnerships

The purpose of this paper is to understand how married and cohabiting men and women define risk and to identify the factors that influence risk perceptions in a setting with a high prevalence of HIV infection. A combination of qualitative and quantitative methods was used during a cross-sectional survey conducted among 248 men and 289 women in KwaZulu-Natal, South Africa. Forty in-depth interviews were conducted with sexually-active men and women in the same population. The majority of men and women perceived themselves at risk of HIV infection. Women were more likely than men to report a higher risk of HIV infection. Nearly 46% of women and 28% of men perceived themselves at medium or high risk of HIV infection. The qualitative and quantitative data show that perception of risk of HIV infection was influenced both by a person's own sexual behaviour and a partner's sexual behaviour. Men were significantly more likely to perceive themselves at risk because of their own risky sexual behaviour (P < 0.01). In general, few women reported engaging in risky sexual behaviour. However, women were more likely to report that their partners had other sexual partners. Thus, women were significantly more likely to perceive themselves at risk because of their partner's sexual behaviour (P < 0.05). Also, rural women were significantly more likely than urban women to perceive a high risk of HIV infection (P < 0.05). Prevention programmes have an important role to play in creating awareness of the risk of HIV, especially among men. The belief that they are not at risk of HIV infection may result in their failure to adopt self-protective behaviour.     

The VUKA family program: Piloting a family-based psychosocial intervention to promote health and mental health among HIV infected early adolescents in South Africa

An increasing number of adolescents born with HIV in South Africa are on antiretroviral treatment and have to confront complex issues related to coping with a chronic, stigmatizing and transmittable illness. Very few evidence-based mental health and health promotion programs for this population exist in South Africa. This study builds on a previous collaboratively designed and developmentally timed family-based intervention for early adolescents (CHAMP). The study uses community-based participatory approach as part of formative research to evaluate a pilot randomized control trial at two hospitals. The paper reports on the development, feasibility, and acceptability of the VUKA family-based program and its short-term impact on a range of psychosocial variables for HIV + preadolescents and their caregivers. A 10-session intervention of approximately 3-month duration was delivered to 65 preadolescents aged 10–13 years and their families. VUKA participants were noted to improve on all dimensions, including mental health, youth behavior, HIV treatment knowledge, stigma, communication, and adherence to medication. VUKA shows promise as a family-based mental and HIV prevention program for HIV + preadolescents and which could be delivered by trained lay staff.