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1.  Psycho-social factors related to willingness to use pre-exposure prophylaxis for HIV prevention among Black men who have sex with men attending a community event 
Sexual health  2014;11(3):244-251.
OBJECTIVES
In the US, Black men who have sex with men (BMSM) are disproportionately affected by HIV/AIDS. Pre-exposure prophylaxis (PrEP) holds tremendous promise for curbing the HIV/AIDS epidemic among these men. However, many psycho-social components must be addressed in order to effectively implement this prevention tool among BMSM.
METHODS
We assessed PrEP knowledge and use, health care access experiences, race-based medical mistrust, sexual partners and behaviors, and drug and alcohol use among 699 men attending a community event in the southeastern US. We used generalized linear modeling to assess factors associated with their willingness to use PrEP.
RESULTS
Three hundred ninety-eight men reported being BMSM and HIV negative status. Among these men, 60% reported being willing to use PrEP. Lack of being comfortable with talking to a health care provider about having sex with men, not having discussed having sex with a man with a health care provider, race-based medical mistrust, and alcohol consumption and substance use were all identified as barriers to willingness to use PrEP. Sexual risk taking, including number of sex partners and STI diagnosis, was not associated with willingness to use PrEP.
CONCLUSIONS
Findings from the current paper demonstrate the importance of acknowledging the role of various psycho-social factors in the uptake of PrEP. It is imperative that we prioritize research into better understanding these barriers as the failure to do so will impede the tremendous potential of this prevention technology.
doi:10.1071/SH14022
PMCID: PMC4331017  PMID: 25001553
PrEP; BMSM; medical mistrust; substance use
2.  Setting the Bar High or Setting Up to Fail? Interpretations and Implications of Project EXPLORE (HPTN 015) 
AIDS and behavior  2014;18(4):625-633.
Controlled studies show that HIV risk reduction counseling significantly increases condom use, reduces unprotected sex and prevents sexually transmitted infections. Nevertheless, without evidence of reducing HIV incidence, these interventions are generally discarded. One trial, the EXPLORE study, was designed to test whether 10 sessions of risk reduction counseling could impact HIV incidence among men who have sex with men in six US cities. Based on epidemiologic models to define effective HIV vaccines, a 35% reduction in HIV incidence was set a priori as the benchmark of success in this behavioral intervention trial. Results demonstrated a significant effect of the intervention, with more than a 35% reduction in HIV incidence observed during the initial 12 to 18 months following counseling. Over an unprecedented 48-month follow-up, however, the effect of counseling on HIV incidence declined to 18%. The current review examined how the scientific literature has thus far judged the outcomes of the EXPLORE study as well as the policy implications of these judgments. We identified 127 articles that cited The EXPLORE Study since its publication. Among articles that discuss the HIV incidence outcomes, 20% judged the intervention effective and 80% judged the intervention ineffective. The overwhelmingly negative interpretation of the EXPLORE study outcomes is reflected in public policies and prevention planning. We conclude that using a vaccine standard to define success led to a broad discrediting of the benefits of behavioral counseling and, ultimately, adversely impacted policies critical to the field of HIV prevention.
doi:10.1007/s10461-013-0603-0
PMCID: PMC4299583  PMID: 23989823
3.  Beliefs about Fetal Alcohol Spectrum Disorder Among Men and Women at Alcohol Serving Establishments in South Africa 
BACKGROUND
South Africa has one of the highest rates of fetal alcohol spectrum disorder (FASD) in the world; however, little is known about what men and women, who attend alcohol serving establishments, believe about alcohol use during pregnancy and how these beliefs may be related to alcohol use.
OBJECTIVES
To understand FASD beliefs and related behaviors among men and women attending alcohol-serving establishments.
METHODS
We surveyed 1,047 men (n=565) and women (n=482) -including pregnant women and men with pregnant partners- attending alcohol serving establishments in a township located in Cape Town, South Africa. RESULTS: Among both pregnant (n=53) and non-pregnant (n=429) women, 54% reported drinking alcohol at least 2–4 times per month, and 57% reported having at least 3–4 alcohol drinks during a typical drinking session. Pregnant women were less likely to believe that they should not drink alcohol and that alcohol can harm a fetus when compared to non-pregnant women. Similar findings were observed between men with pregnant partners compared to men without pregnant partners. Among women, beliefs about how much alcohol pregnant women can safely drink were associated with self-reported alcohol use.
CONCLUSIONS
Efforts to address FASD need to focus on understanding how men and women perceive alcohol use during pregnancy and situational factors that contribute to alcohol consumption among pregnant women attending alcohol serving establishments. Structural and individual-level interventions targeting women at alcohol serving establishments should be prioritized to mitigate alcohol use during pregnancy.
doi:10.3109/00952990.2013.830621
PMCID: PMC4286322  PMID: 24588417
5.  Viral Suppression and Antiretroviral Medication Adherence Among Alcohol Using HIV Positive Adults 
Background
Substance use is a known predictor of poor adherence to antiretroviral therapies (ART) in people living with HIV/AIDS. Less studied is the association between substance use and treatment outcomes, namely suppression of HIV replication.
Methods
Adults living with HIV (N=183) who reported alcohol use in the previous week and receiving ART were observed over a 12-month period. Participants completed computer interviews, monthly-unannounced pill counts to monitor ART adherence, and daily cell-phone delivered interactive-text assessments for alcohol use. HIV viral load was collected at baseline and 12-month follow-up from medical records. Analyses compared participants who had undetectable HIV viral loads at baseline and follow-up (sustained viral suppression) to those with unsustained viral suppression. Analyses also compared participants who were adherent to their medications (> 85% pills taken) over the year of observation to those who were non-adherent.
Results
Fifty- two percent of participants had unsustained viral suppression; 47% were ART non-adherent. Overall results failed to demonstrate alcohol use as a correlate of sustained viral suppression or treatment adherence. However, alcohol use was associated with non-adherence among participants who did not have sustained viral suppression; non-adherence in unsustained viral suppression patients was related to drinking on fewer days of assessment, missing medications when drinking, and drinking socially.
Conclusions
Poor HIV treatment outcomes and non-adherence were prevalent among adults treated for HIV infection who drink alcohol. Drinking in relation to missed medications and drinking in social settings are targets for interventions among alcohol drinkers at greatest risk for poor treatment outcomes.
doi:10.1007/s12529-013-9353-7
PMCID: PMC4283596  PMID: 24085706
6.  Assumed Infectiousness, Treatment Adherence and Sexual Behaviors: Applying the Swiss Statement on Infectiousness to HIV Positive Alcohol Drinkers 
HIV medicine  2012;14(5):263-272.
Background
The success of antiretroviral therapy (ART) for treating HIV infection is now being turned toward HIV prevention. The Swiss Federal Commission for HIV/AIDS has declared that HIV positive persons who are treated with ART, have an undetectable viral load, and are free of co-occurring sexually transmitted infections (STI) should be considered non-infectious for sexual transmission of HIV. This study examined the implications of these assumptions in a sample of HIV positive individuals who drink alcohol.
Methods
People living with HIV/AIDS (N = 228) were recruited through community sampling and completed confidential computerized interviews, monthly unannounced pill counts for ART adherence, and HIV viral load obtained from medical records.
Results
One hundred eighty five HIV positive drinkers were currently receiving ART and 43 were untreated. Among those receiving ART, one in three were not viral suppressed and one in five had recently been diagnosed with an STI. Adherence was generally suboptimal, including among those assumed less infectious. As many as one in four participants reported engaging in unprotected intercourse with an HIV uninfected partner in the past 4-months. There were few associations between assumed infectiousness and sexual practices.
Conclusions
Less than half of people who drink alcohol and take ART met the Swiss criteria for non-infectiousness. Poor adherence and prevalent STI threaten the long-term potential of using ART for prevention. In the absence of behavioral interventions, the realities of substance use and other barriers place doubt on the use of ART as prevention among alcohol drinkers.
doi:10.1111/j.1468-1293.2012.01062.x
PMCID: PMC4283807  PMID: 23107801
7.  Randomized Clinical Trial of HIV Treatment Adherence Counseling Interventions for People Living with HIV and Limited Health Literacy 
Background
Limited health literacy is a known barrier to medication adherence among people living with HIV. Adherence improvement interventions are urgently needed for this vulnerable population.
Purpose
This study tested the efficacy of a pictograph-guided adherence skills building counseling intervention for limited literacy adults living with HIV.
Methods
Men and women living with HIV and receiving antiretroviral therapy (ART, N=446) who scored below 90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to one of three adherence-counseling conditions: (a) pictograph-guided adherence counseling, (b) standard adherence counseling, or (c) general health improvement counseling. Participants were followed for 9-months post-intervention with unannounced pill count adherence and blood plasma viral load as primary endpoints.
Results
Preliminary analyses demonstrated the integrity of the trial and more than 90% of participants were retained. Generalized estimating equations showed significant interactions between counseling conditions and levels of participant health literacy across outcomes. Participants with marginal health literacy in the pictograph-guided and standard-counseling conditions demonstrated greater adherence and undetectable HIV viral loads compared to general health counseling. In contrast and contrary to hypotheses, participants with lower health literacy skills in the general health improvement counseling demonstrated greater adherence compared to the two adherence counseling conditions.
Conclusions
Patients with marginal literacy skills benefit from adherence counseling regardless of pictographic tailoring and patients with lower literacy skills may require more intensive or provider directed interventions.
doi:10.1097/QAI.0b013e318286ce49
PMCID: PMC4279917  PMID: 23337369
HIV Treatment; Adherence Intervention; Health Literacy
8.  Alcohol and Adherence to Antiretroviral Medications: Interactive Toxicity Beliefs among People Living with HIV 
When taken without interruption, antiretroviral therapies (ART) effectively treat HIV infection. Alcohol is a well-known direct and indirect influence on ART adherence. Believing that drinking is harmful while taking ART (interactive toxicity beliefs) is also associated with poor adherence. The current study included 333 people living with HIV who were taking ART and actively using alcohol. Participants were recruited from health care providers and social services in a major southern U.S. city. Results showed that 52% of persons found non-adherent to ART stated that they stopped taking their medications when they were drinking. Multivariate analyses showed that interrupting treatment when drinking was related to current non-adherence, over and above several common correlates of non-adherence including frequency of alcohol use itself. These results confirm and extend past research, indicating an urgent need for medication adherence interventions designed for people living with HIV who drink.
doi:10.1016/j.jana.2011.11.005
PMCID: PMC4271641  PMID: 22421097
alcohol; antiretroviral therapy; beliefs; HIV treatment adherence
9.  Men Who Report Recent Male and Female Sex Partners in Cape Town, South Africa: An Understudied and Underserved Population 
Archives of sexual behavior  2013;42(7):1299-1308.
The HIV/AIDS epidemic in South Africa has largely focused on the needs of heterosexual men and women. However, little is known about the sexual risk histories of men who have sex with both men and women (MSMW). Furthermore, we know very little about the psychosocial health needs or of the possibility of a syndemic (numerous interrelated epidemics) among MSMW. We surveyed 1,203 men attending drinking establishments in a township located in Cape Town, South Africa. We compared the behaviors and experiences of MSMW to men reporting only having sex with women (MSW). Twelve percent of the sample reported having sex with both men and women in the past four months. MSMW were twice as likely as MSW to report being HIV positive (10.5% vs. 4.6%). MSW were more likely to be married than MSMW but reported similar numbers of female sex partners. MSMW were more likely to report a history of childhood sexual abuse, recent experienced and perpetrated physical and sexual partner violence, both receiving and giving sex for money, drugs, or shelter, and a recent STI. These factors were found to be interrelated among MSW but not MSMW. Although MSMW demonstrate considerable risk taking and report higher rates of HIV infection than MSW, their needs are largely unmet and underemphasized. Findings suggest the need to better understand factors contributing to sexual risk taking among MSMW. HIV prevention interventions should consider psychosocial health problems unique to MSMW residing in South African townships.
doi:10.1007/s10508-013-0077-1
PMCID: PMC3760968  PMID: 23519592
MSMW; syndemic; South Africa; HIV; AIDS; sexual orientation
10.  Collective efficacy and HIV prevention in South African townships 
Journal of community health  2013;38(5):885-893.
South African townships have high HIV prevalence and a strong need for collective action to change normative sexual risk behaviors. This study investigated the relationship between perceptions of individuals about collective efficacy in the community’s ability to prevent HIV and their personal HIV risk behaviors. Men (n=1581) and women (n=718) completed anonymous surveys within four Black African Townships in Cape Town, South Africa from June 2008 to December 2010. Measures included demographics, alcohol use, attitudinal and behavioral norms, sexual health communications, and sexual risk behaviors. In multivariate logistic regressions, men were more likely to endorse collective efficacy if they were married, drank less often in alcohol serving establishments, believed that fewer men approve of HIV risk behaviors, talk more with others about HIV/AIDS, and had more sex partners in the past month. Women were more likely to endorse collective efficacy if they drank alcohol less often, talked more with others about HIV/AIDS, had more sex partners in the past month, but reported fewer unprotected sex acts in the past month. Community level interventions that strengthen collective efficacy beliefs will have to consider both protective and risk behaviors associated with believing that the community is ready and capable of preventing HIV.
doi:10.1007/s10900-013-9694-9
PMCID: PMC3769453  PMID: 23660646
HIV/AIDS; Collective efficacy; Social Norms; South Africa
11.  Longitudinal cohort study of depression, post-traumatic stress, and alcohol use in South African women who attend alcohol serving venues 
BMC Psychiatry  2014;14(1):224.
Background
In South Africa, alcohol use poses a public health burden. Hazardous alcohol use often co-occurs with psychological distress (e.g., depression and post-traumatic stress). However, the majority of the research establishing the relationship between alcohol use and psychological distress has been cross-sectional, so the nature of co-occurring changes in psychological distress and alcohol use over time is not well characterized. The objective of this study is to examine the longitudinal relationship between psychological distress and alcohol use among South African women who attend alcohol serving venues.
Methods
Four waves of data were collected over the course of a year from 560 women in a Cape Town township who attended drinking venues. At each assessment wave, participants reported depressive symptoms, post-traumatic stress symptoms, and alcohol use. Multilevel growth models were used to: 1) assess the patterns of alcohol use; 2) examine how depressive symptoms uniquely, post-traumatic stress symptoms uniquely, and depressive and post-traumatic stress symptoms together were associated with alcohol use; and 3) characterize the within person and between person associations of depressive symptoms and post-traumatic stress symptoms with alcohol use.
Results
Women reported high levels of alcohol use throughout the study period, which declined slightly over time. Post-traumatic stress symptoms were highly correlated with depressive symptoms. Modeled separately, both within person and between person depressive and post-traumatic stress symptoms were uniquely associated with alcohol use. When modeled together, significant between person effects indicated that women who typically have more post-traumatic stress symptoms, when controlling for depressive symptoms, are at risk for increased alcohol use; however, women with more depressive symptoms, controlling for post-traumatic stress symptoms, do not have differential risk for alcohol use. Significant within person effects indicated an interaction between depressive and post-traumatic stress symptoms; women reported more alcohol use than usual at times when they had higher post-traumatic stress symptoms, and this increase in alcohol use was further exacerbated for women who also had higher depressive symptoms than usual.
Conclusions
These findings suggest that interventions targeting post-traumatic stress, especially when post-traumatic stress is comorbid with depression, may reduce alcohol use among South African women who drink.
doi:10.1186/s12888-014-0224-9
PMCID: PMC4149269  PMID: 25095874
Alcohol use; Depressive symptoms; PTSD symptoms; South Africa; Women
12.  A reanalysis of a behavioral intervention to prevent incident HIV infections: Including indirect effects in modeling outcomes of Project EXPLORE 
AIDS care  2012;25(7):805-811.
Background
Project EXPLORE -- a large-scale, behavioral intervention tested among men who have sex with men (MSM) at-risk for HIV infection --was generally deemed as ineffective in reducing HIV incidence. Using novel and more precise data analytic techniques we reanalyzed Project EXPLORE by including both direct and indirect paths of intervention effects.
Methods
Data from 4,296 HIV negative MSM who participated in Project EXPLORE, which included ten sessions of behavioral risk reduction counseling completed from 1999-2005, were included in the analysis. We reanalyzed the data to include parameters that estimate the overtime effects of the intervention on unprotected anal sex and the over-time effects of the intervention on HIV status mediated by unprotected anal sex simultaneously in a single model.
Results
We found the indirect effect of intervention on HIV infection through unprotected anal sex to be statistically significant up through 12 months post-intervention, OR=.83, 95% CI=.72-.95. Furthermore, the intervention significantly reduced unprotected anal sex up through 18 months post-intervention, OR=.79, 95% CI=.63-.99.
Discussion
Our results reveal effects not tested in the original model that offer new insight into the effectiveness of a behavioral intervention for reducing HIV incidence. Project EXPLORE demonstrated that when tested against an evidence-based, effective control condition can result in reductions in rates of HIV acquisition at one year follow-up. Findings highlight the critical role of addressing behavioral risk reduction counseling in HIV prevention.
doi:10.1080/09540121.2012.748870
PMCID: PMC3761806  PMID: 23245226
13.  Co-Occurring Psychosocial Problems and HIV Risk Among Women Attending Drinking Venues in a South African Township: A Syndemic Approach 
Background
In South Africa, women comprise the majority of HIV infections. Syndemics, or co-occurring epidemics and risk factors, have been applied to understanding HIV risk among marginalized groups.
Purpose
To apply the syndemic framework to examine psychosocial problems that co-occur among women attending drinking venues in South Africa, and to test how the co-occurrence of these problems may exacerbate risk for HIV infection.
Method
560 women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors.
Results
Bivariate associations among the syndemic factors showed a high degree of co-occurrence and regression analyses showed an additive effect of psychosocial problems on HIV risk behaviors.
Conclusions
These results demonstrate the utility of a syndemic framework to understand co-occurring psychosocial problems among women in South Africa. HIV prevention interventions should consider the compounding effects of psychosocial problems among women.
doi:10.1007/s12160-012-9420-3
PMCID: PMC3578969  PMID: 23054944
HIV risk; sexual risk behavior; syndemics; mental health; abuse; alcohol
14.  Drinking before and after pregnancy recognition among South African women: the moderating role of traumatic experiences 
Background
South Africa has one of the world’s highest rates of fetal alcohol spectrum disorder (FASD) and interpersonal trauma. These co-occurring public health problems raise the need to understand alcohol consumption among trauma-exposed pregnant women in this setting. Since a known predictor of drinking during pregnancy is drinking behavior before pregnancy, this study explored the relationship between women’s drinking levels before and after pregnancy recognition, and whether traumatic experiences – childhood abuse or recent intimate partner violence (IPV) – moderated this relationship.
Methods
Women with incident pregnancies (N = 66) were identified from a longitudinal cohort of 560 female drinkers in a township of Cape Town, South Africa. Participants were included if they reported no pregnancy at one assessment and then reported pregnancy four months later at the next assessment. Alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT), and traumatic experiences of childhood abuse and recent IPV were also assessed. Hierarchical linear regressions controlling for race and age examined childhood abuse and recent IPV as moderators of the effect of pre-pregnancy recognition drinking on post-pregnancy recognition AUDIT scores.
Results
Following pregnancy recognition, 73% of women reported drinking at hazardous levels (AUDIT ≥ 8). Sixty-four percent reported early and/or recent exposure to trauma. While drinking levels before pregnancy significantly predicted drinking levels after pregnancy recognition, t(64) = 3.50, p < .01, this relationship was moderated by experiences of childhood abuse, B = -.577, t(60) = -2.58, p = .01, and recent IPV, B = -.477, t(60) = -2.16, p = .04. Pregnant women without traumatic experiences reported drinking at levels consistent with levels before pregnancy recognition. However, women with traumatic experiences tended to report elevated AUDIT scores following pregnancy recognition, even if low-risk drinkers previously.
Conclusion
This study explored how female drinkers in South Africa may differentially modulate their drinking patterns upon pregnancy recognition, depending on trauma history. Our results suggest that women with traumatic experiences are more likely to exhibit risky alcohol consumption when they become pregnant, regardless of prior risk. These findings illuminate the relevance of trauma-informed efforts to reduce FASD in South Africa.
doi:10.1186/1471-2393-14-97
PMCID: PMC3975846  PMID: 24593175
South Africa; Pregnancy; Fetal alcohol spectrum disorder; Drinking; Trauma; Childhood abuse; Intimate partner violence
15.  HIV/STI risk among venue-based female sex workers across the globe: A look back and the way forward 
Current HIV/AIDS reports  2013;10(1):65-78.
Female sex workers (FSWs) continue to represent a high-risk population in need of targeted HIV prevention interventions. Targeting environmental risk factors should result in more sustainable behavior change than individual-level interventions alone. There are many types of FSWs who operate in and through a variety of micro- (e.g., brothels) and macro-level (e.g., being sex-trafficked) contexts. Efforts to characterize FSWs and inform HIV prevention programs have often relied on sex work typologies or categorizations of FSWs by venue or type. We conducted a systematic search and qualitatively reviewed 37 published studies on venue-based FSWs to examine the appropriateness of sex work typologies, and the extent to which this research has systematically examined characteristics of different risk environments. We extracted information on study characteristics like venue comparisons, HIV/STI prevalence, and sampling strategies. We found mixed results with regards to the reliability of typologies in predicting HIV/STI infection; relying solely on categorization of FSWs by venue or type did not predict seroprevalence in a consistent manner. Only 65% of the studies that allowed for venue comparisons on HIV/STI prevalence provided data on venue characteristics. The factors that were assessed were largely individual-level FSW factors (e.g. demographics, number of clients per day), rather than social and structural characteristics of the risk environment. We outline a strategy for future research on venue-based FSWs that ultimately aims to inform structural-level HIV interventions for FSWs.
doi:10.1007/s11904-012-0142-8
PMCID: PMC3567216  PMID: 23160840
female sex work; HIV; risk environments; social factors; structural interventions; HIV prevention
16.  Intersecting Epidemics Among Pregnant Women: Alcohol Use, Interpersonal Violence, and HIV Infection in South Africa 
Current HIV/AIDS reports  2013;10(1):103-110.
A critical factor for understanding negative health outcomes is acknowledging the synergistic quality that clusters of health problems create. An important step in addressing clusters of health problems involves gaining an awareness of the contextual factors that connect them. This paper considers the intersection of three mutually reinforcing health problems: alcohol use, interpersonal violence (IPV), and HIV infection among pregnant women residing in South Africa. We explore how SAVA (substance abuse, violence and AIDS)- a syndemics related theory- underscores the dire need to intervene in various areas of psycho-social health and general well-being. Based on World Health Organization data, we highlight the remarkably high rates of alcohol use, IPV, and HIV infection among South African women compared to women residing in other countries around the world. We conclude by highlighting the need for improved recognition of the intersection of these epidemics and for improved surveillance of the prevalence of alcohol use among pregnant women. Finally, based on the literature reviewed, we provide recommendations for future interventions.
doi:10.1007/s11904-012-0145-5
PMCID: PMC3572769  PMID: 23233038
17.  Intentional Non-Adherence to Medications among HIV Positive Alcohol Drinkers: Prospective Study of Interactive Toxicity Beliefs 
ABSTRACT
BACKGROUND
Antiretroviral therapy (ART) adherence is key to successful treatment of HIV infection and alcohol is a known barrier to adherence. Beyond intoxication, ART adherence is impacted by beliefs that mixing alcohol and medications is toxic.
PURPOSE
To examine prospective relationships of factors contributing to intentional medication non-adherence when drinking.
METHODS
People who both receive ART and drink alcohol (N = 178) were enrolled in a 12-month prospective cohort study that monitored beliefs about the hazards of mixing ART with alcohol (interactive toxicity beliefs), alcohol consumption using electronic daily diaries, ART adherence assessed by both unannounced pill counts and self-report, and chart-abstracted HIV viral load.
RESULTS
Participants who reported skipping or stopping their ART when drinking (N = 90, 51 %) demonstrated significantly poorer ART adherence, were less likely to be viral suppressed, and more likely to have CD4 counts under 200/cc3. Day-level analyses showed that participants who endorsed interactive toxicity beliefs were significantly more likely to miss medications on drinking days.
CONCLUSIONS
Confirming earlier cross-sectional studies, the current findings from a prospective cohort show that a substantial number of people intentionally skip or stop their medications when drinking. Interventions are needed to correct alcohol-related interactive toxicity misinformation and promote adherence among alcohol drinkers.
doi:10.1007/s11606-012-2231-1
PMCID: PMC3579979  PMID: 23065532
medication adherence; alcohol use; HIV treatment beliefs
18.  Gender-based Violence, Alcohol use, and Sexual Risk Among Female Patrons of Drinking Venues in Cape Town, South Africa 
Journal of behavioral medicine  2012;36(3):295-304.
Gender-based violence is a well-recognized risk factor for HIV infection among women. Alcohol use is associated with both gender-based violence and sexual risk behavior, but has not been examined as a correlate of both in a context of both high HIV risk and hazardous drinking. The purpose of this paper is to examine the association between recent abuse by a sex partner with alcohol and sexual risk behavior among female patrons of alcohol serving venues in South Africa. Specifically, the aim of this study is to determine whether sexual risk behaviors are associated with gender-based violence after controlling for levels of alcohol use. We surveyed 1,388 women attending informal drinking establishments in Cape Town, South Africa to assess recent history of gender-based violence, drinking, and sexual risk behaviors. Gender-based violence was associated with both drinking and sexual risk behaviors after controlling for demographics among the women. A hierarchical logistic regression analysis showed that after controlling for alcohol use sexual risk behavior remained significantly associated with gender-based violence, particularly with meeting a new sex partner at the bar, recent STI diagnosis, and engaging in transactional sex, but not protected intercourse or number of partners. In South Africa where heavy drinking is prevalent women may be at particular risk of physical abuse from intimate partners as well as higher sexual risk. Interventions that aim to reduce gender-based violence and sexual risk behaviors must directly work to reduce drinking behavior.
doi:10.1007/s10865-012-9423-3
PMCID: PMC3646073  PMID: 22526526
gender-based violence; intimate partner violence; alcohol; sexual risk; HIV risk
19.  Systematic Review and Meta-Analysis of Single-Session Behavioral Interventions to Prevent Sexually Transmitted Infections: Implications for Bundling Multiple STI/HIV Prevention Packages 
American journal of public health  2012;102(11):e34-e44.
Context
Evidence based, single-session, behavioral interventions that can be used in public health settings are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STI). Brief interventions are particularly promising given the relatively low burden they place on financially limited service providers.
Objective
To estimate the efficacy of single-session, behavioral interventions for STI prevention.
Data Sources
MEDLINE (PubMed), PsycINFO, CINAHL, ERIC, Proquest, all international sub-databases in the WHO's Global Health Library were searched through May 2011.
Study Selection
Data from 29 single-session interventions (20 studies; N = 52,465) with an STI outcome were coded and analyzed.
Findings
The odds of participants being infected with an STI in the intervention group were reduced by 35% (OR = .65, 95% CI=.55–.77) relative to control group participants. Interventions were compared to active controls and follow-up periods averaged 58 weeks. As such, single-session interventions lead to considerable benefit in terms of disease prevention and create minimal burden for both the patient and the provider.
Conclusions
Single-session interventions were most often implemented during routine health care services by clinic staff. Use of these procedures make these interventions a reasonable option for currently existing health care infrastructure. Brief and effective STI prevention interventions are a valuable tool for disease prevention and can be readily adapted to bolster the benefits of partially effective biomedical STI/HIV prevention technologies.
doi:10.2105/AJPH.2012.300968
PMCID: PMC3477958  PMID: 22994247
20.  Gender-based Violence and HIV Sexual Risk Behavior: Alcohol Use and Mental Health Problems as Mediators among Women in Drinking Venues, Cape Town 
Social science & medicine (1982)  2012;75(8):1417-1425.
Gender-based violence is a key determinant of HIV infection among women in South Africa as elsewhere. However, research has not examined potential mediating processes to explain the link between experiencing abuse and engaging in HIV sexual risk behavior. Previous studies suggest that alcohol use and mental health problems may explain how gender-based violence predicts sexual risk. In a prospective study, we examined whether lifetime history of gender-based violence indirectly affects future sexual risk behavior through alcohol use, depression and post-traumatic stress disorder (PTSD) in a high-risk socio-environmental context. We recruited a cohort of 560 women from alcohol drinking venues in a Cape Town, South African township. Participants completed computerized interviews at baseline and 4 months later. We tested prospective mediating associations between gender-based violence, alcohol use, depression, PTSD, and sexual risk behavior. There was a significant indirect effect of gender-based violence on sexual risk behavior through alcohol use, but not mental health problems. Women who were physically and sexually abused drank more, which in turn predicted more unprotected sex. We did not find a mediated relationship between alcohol use and sexual risk behavior through the experience of recent abuse or mental health problems. Alcohol use explains the link between gender-based violence and sexual risk behavior among women attending drinking venues in Cape Town, South Africa. Efforts to reduce HIV risk in South Africa by addressing gender-based violence must also address alcohol use.
doi:10.1016/j.socscimed.2012.06.020
PMCID: PMC3425436  PMID: 22832324
South Africa; gender-based violence; HIV; HIV risk; sexual risk; alcohol use; mental health; mediation; women
21.  The relationship between pornography use and sexual behaviors among at-risk HIV negative men who have sex with men 
Sexual health  2012;9(2):166-170.
Objectives
Although pornography is widely available and frequently used among many adults in the US, little is known about the relationship between pornography and risk factors for HIV transmission among men who have sex with men.
Methods
Baseline assessments from a behavioral intervention trial for at-risk men who have sex with men were conducted in Atlanta, GA in 2009. Univariate and multivariate generalized linear models were used to assess the relationships between known risk factors for HIV infection, time spent viewing pornography, and sex behaviors.
Results
One hundred forty nine men reporting HIV-negative status and two or more unprotected anal sex partners in the past six months were enrolled in an intervention trial and completed survey assessments. Time spent viewing pornography was significantly associated with having more male sexual partners (B=.45, SE=.04, p<.001) and unprotected insertive anal sex acts (B=.28, SE=.04, p<.001). Moreover, increased substance use (drug use, B=.61, SE=.14, p<.001; alcohol use, B=.03, SE=.01, p<.01) and decreased perception of risk for HIV infection (B=-.09, SE=.04, p<.05) were found to be significantly associated with greater time spent viewing pornography.
Conclusions
This exploratory study is novel in that it sheds light on the associations between viewing pornography and sexual risk taking for HIV infection. Future studies in this area should focus on understanding how the content of pornography, in particular the viewing of unprotected and protected sex acts, may affect sexual risk taking behavior.
doi:10.1071/SH10092
PMCID: PMC3560402  PMID: 22498161
22.  AIDS-related Stigma, HIV Testing, and Transmission Risk Among Patrons of Informal Drinking Places in Cape Town, South Africa 
Background
AIDS-related stigma as a barrier to HIV testing has not been examined within the context of high at-risk environments such as drinking venues. Of particular importance is whether AIDS-related stigma is associated with HIV transmission risks among people who have never been tested for HIV.
Purpose
We examined: 1) AIDS-related stigma as a barrier to testing, controlling for other potential barriers, and 2) whether stigma is associated with HIV risks among HIV-untested individuals.
Methods
We surveyed 2,572 individuals attending informal drinking establishments in Cape Town, South Africa to assess HIV testing status, AIDS-related stigma endorsement, and HIV transmission sexual risk behavior.
Results
Endorsement of AIDS-related stigma was negatively associated with HIV lifetime testing. In addition, stigma endorsement was associated with higher HIV transmission risks.
Conclusions
AIDS-related stigma must be addressed in HIV prevention campaigns across South Africa. Anti-stigma messages should be integrated with risk reduction counseling and testing.
doi:10.1007/s12160-012-9346-9
PMCID: PMC3565536  PMID: 22367752
HIV/AIDS-related stigma; HIV testing; HIV risk behavior; alcohol; substance use
23.  Pregnancy, Alcohol Intake, and Intimate Partner Violence among Men and Women Attending Drinking Establishments in a Cape Town, South Africa Township 
Journal of Community Health  2012;37(1):208-216.
Background
The highest rates of fetal alcohol syndrome worldwide can be found in South Africa. Particularly in impoverished townships in the Western Cape, pregnant women live in environments where alcohol intake during pregnancy has become normalized and interpersonal violence (IPV) is reported at high rates. For the current study we sought to examine how pregnancy, for both men and women, is related to alcohol use behaviors and IPV.
Methods
We surveyed 2,120 men and women attending drinking establishments in a township located in the Western Cape of South Africa.
Results
Among women 13% reported being pregnant, and among men 12.2% reported their partner pregnant. For pregnant women, 61% reported attending the bar that evening to drink alcohol and 26% reported both alcohol use and currently experiencing IPV. Daily or almost daily binge drinking was reported twice as often among pregnant women than non-pregnant women (8.4% vs. 4.2%). Men with pregnant partners reported the highest rates of hitting sex partners, forcing a partner to have sex, and being forced to have sex. High rates of alcohol frequency, consumption, binge drinking, and problematic drinking were reported across the entire sample. In general, experiencing and perpetrating IPV were associated with alcohol use among all participants except for men with pregnant partners.
Conclusions
Alcohol use among pregnant women attending shebeens is alarmingly high. Moreover, alcohol use appears to be an important factor in understanding the relationship between IPV and pregnancy. Intensive, targeted, and effective interventions for both men and women are urgently needed to address high rates of drinking alcohol among pregnant women who attend drinking establishments.
doi:10.1007/s10900-011-9438-7
PMCID: PMC3286872  PMID: 21744297
24.  Changes in Transmission Risk Behaviors Across Stages of HIV Disease among People Living with HIV/AIDS 
Advances in HIV treatment and opportunistic illness prophylaxis have significantly extended the life expectancy of people living with HIV/AIDS. Increased HIV/AIDS longevity is also marked by changes in HIV transmission risk behaviors. Here we review the literature on HIV transmission risk behaviors as they change in relation to stages of HIV disease among persons who are infected with HIV/AIDS. Studies confirm that the time period immediately preceding testing HIV positive is characterized by high risk behaviors indicating the potential for rapid spread of HIV during acute infection. For many people, reductions in risk behavior are seen immediately following HIV diagnosis. However, these changes in risk taking are not universal and great variability exists in terms of how HIV diagnosis influences risk behaviors. Chronic periods of asymptomatic HIV infection are generally associated with some degree of reverting to high risk behaviors. Also, a CD4 count below 200 cells/mm3 resulting in a formal diagnosis of AIDS, is associated with decreased sexual and drug-related risk behaviors. HIV risk reduction interventions that target men and women living with HIV/AIDS therefore require tailoring to stages of HIV disease. Additional research on risk behaviors of long term HIV positive persons is needed.
doi:10.1016/j.jana.2008.10.005
PMCID: PMC3560412  PMID: 19118770
25.  Condom Negotiation, HIV Testing, and HIV Risks among Women from Alcohol Serving Venues in Cape Town, South Africa 
PLoS ONE  2012;7(10):e45631.
Background
Women in South Africa are at particularly high-risk for HIV infection and are dependent on their male partners' use of condoms for sexual risk reduction. However, many women are afraid to discuss condoms with male partners, placing them at higher risk of HIV infection.
Purpose
To examine the association between fear of condom negotiation with HIV testing and transmission risk behaviors, including alcohol use and sexual risks among South African women.
Method
Women (N = 1333) residing in a primarily Xhosa-speaking African township in Cape Town and attending informal alcohol-serving venues (shebeens) completed anonymous surveys. Logistic regression was used to test the hypothesis that fear of condom negotiation would be associated with increased risk for HIV.
Results
Compared to women who did not fear condom negotiation, those who did were significantly less likely to have been tested for HIV, were more likely to have experienced relationship abuse, and to report more alcohol use and more unprotected sex.
Conclusions
For women in South Africa, fear of condom negotiation is related to higher risk of HIV. HIV prevention efforts, including targeted HIV counseling and testing, must directly address gender issues.
doi:10.1371/journal.pone.0045631
PMCID: PMC3462794  PMID: 23056211

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