HIV prevalence in Botswana is among the highest in the world and sexual networking patterns represent an important dimension to understanding the spread of HIV/AIDS.
To examine risk behaviour associated with recent multiple sexual partnerships among people living with HIV/AIDS in Botswana.
Confidential brief interviews were administered to 209 HIV positive men and 291 HIV positive women recruited conveniently from HIV/AIDS support groups and antiretroviral clinics. Measures included demographics, duration of HIV diagnosis, sexual partnerships, condom use, and HIV status disclosure.
The response rate was 63% and 309 (62%) participants were currently sexually active, of whom 247 (80%) reported only one sex partner in the previous 3 months and 62 (20%) reported two or more partners during that time. Condom use exceeded 80% across partner types and regardless of multiple partnerships. Steady sex partners of participants with multiple partnerships were significantly less likely to be protected by condoms than steady partners of individuals with only one sex partner. Individuals with multiple sex partners were also significantly less likely to have disclosed their HIV status.
Multiple sexual partnerships, many of which are probably concurrent, are not uncommon among sexually active people living with HIV in Botswana. HIV prevention is needed for all individuals who are at risk and assistance should be provided to HIV infected people who continue to practise unprotected sex with uninfected partners or partners of unknown HIV status.
HIV/AIDS prevention; multiple concurrent sex partners; HIV positive sex risks; positive prevention
Male circumcision (MC) can prevent female to male HIV transmission and has the potential to significantly alter HIV epidemics. The ultimate impact of MC on HIV prevention will be determined, in part, by behavioral factors. In order to fully realize the protective benefits of MC, factors related to acceptability and sexual risk must be considered. Research shows that acceptability of MC among uncircumcised men is high and suggests that free and safe circumcision may be taken up in high-HIV prevalence places. Perceptions of adverse effects of MC may however limit uptake. Furthermore, considerable risk reduction counseling provided by MC trials limits our ability to understand the impact MC may have on behavior. There is also no evidence that MC protects women with HIV positive partners or that it offers protection during anal intercourse. Research is urgently needed to better understand and manage the behavioral implications of MC for HIV prevention.
HIV/AIDS is concentrated in impoverished communities. Two critical aspects of poverty are food insufficiency and substance abuse, and both are associated with sexual risks for HIV/AIDS in southern Africa. The current study is the first to examine both hunger and substance use in relation to sexual risks for HIV infection in South African alcohol serving establishments. Anonymous venue-based intercept surveys were completed by men (n = 388) and women (n = 407) patrons of six informal drinking places (e.g., shebeens) in Cape Town, South Africa. Food insufficiency and its more extreme form hunger were common in the sample, with 24 % of men and 53 % of women experiencing hunger in the previous 4 months. Multiple regression analyses showed that quantity of alcohol use was related to higher rates of unprotected sex for men and women. Trading sex to meet survival needs was related to food insufficiency and methamphetamine use among men but not women. Food insufficiency and substance use may both contribute to HIV risks in South African shebeens. However, the influence of hunger and substance use on sexual risks varies for men and women. Interventions to reduce HIV transmission risks may be bolstered by reducing both food insufficiency and substance use.
HIV prevention; South Africa; Food insufficiency; Alcohol risks
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.
gender-based violence; intimate partner violence; alcohol; sexual risk; HIV risk
Technology is rapidly advancing and becoming a cost effective option for intervention delivery particularly for isolated and hard to reach populations, such as people living with HIV/AIDS. A systematic review was conducted to identify recent technology based interventions for people living with HIV. The review yielded 12 studies that were grouped by the health behavior that it addressed and then the type of technology utilized. The majority of studies reviewed focused on medication adherence and used several different technologies to deliver the intervention including SMS/text messaging, cell phones and computers. This review identified several gaps in the literature particularly the lack of technology-based interventions focusing on engagement and retention to care as well as sexual risk reduction. Suggestions for future research based on these findings are provided.
HIV/AIDS; HIV management; technology; technology intervention; technology-based intervention; secondary prevention; systematic review; sexual risk reduction; people living with HIV (PLWH)
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.
To estimate the efficacy of single-session, behavioral interventions for STI prevention.
MEDLINE (PubMed), PsycINFO, CINAHL, ERIC, Proquest, all international sub-databases in the WHO's Global Health Library were searched through May 2011.
Data from 29 single-session interventions (20 studies; N = 52,465) with an STI outcome were coded and analyzed.
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.
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.
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.
South Africa; gender-based violence; HIV; HIV risk; sexual risk; alcohol use; mental health; mediation; women
Sexually transmitted infections (STI) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STI in a community sample of 490 HIV positive men and women.
Confidential computerized interviews were collected in a community research setting.
14% of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a six month period. Individuals with a new STI had significantly more sex 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.
Individuals who believe having an undetectable viral load reduces HIV transmission risks were more likely infectious because of STI co-infection. Programs that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STI among people living with HIV/AIDS.
HIV/AIDS prevention; HIV/AIDS treatment; Sexually Transmitted Infections
Background: South Africa has one of the fastest growing HIV epidemics in the world and new infections may often result from people who have tested HIV positive. This study examined the sexual practices and risk behaviours of men and women living with HIV/AIDS being treated for a co-occurring sexually transmitted infection (STI). Methods: A sample of men and women receiving services at three South African STI clinics completed a computer administered behavioural assessment. Results: Among the 218 HIV positive STI clinic patients, 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sex partners in the previous month. A multivariate logistic regression indicated that unprotected sex with uninfected or unknown HIV status partners was independently associated with older age, female gender, alcohol use, and other drug use, and drug use in sexual contexts. Conclusions: People living with HIV/AIDS who contract co-occurring STI are at significant risk for transmitting HIV to uninfected partners. Positive prevention interventions are urgently needed for South Africa.
HIV/AIDS; HIV infectiousness; positive prevention; sexually transmitted infections.
People living with HIV can be reinfected with a new viral strain resulting in potential treatment resistant recombinant virus known as HIV super-infection. Individual’s beliefs about the risks for HIV super-infection may have significant effects on the sexual behaviors of people living with HIV/AIDS.
To examine HIV super-infection beliefs and sexual behaviors among people living with HIV/AIDS.
Three hundred and twenty men, 137 women, and 33 transgender persons completed confidential surveys in a community research setting.
A majority of participants were aware of HIV super-infection and most believed it was harmful to their health. Hierarchical multiple regressions predicting protected anal/vaginal intercourse with same HIV status (seroconcordant) partners showed that older age and less alcohol use were associated with greater protected sex. In addition, HIV super-infection beliefs predicted protected sexual behavior over and above participant age and alcohol use.
Beliefs about HIV super-infection exert significant influence on sexual behaviors of people living with HIV/AIDS and should be targeted in HIV prevention messages for HIV infected persons.
AIDS denialists offer false hope to people living with HIV/AIDS by claiming that HIV is harmless and that AIDS can be cured with natural remedies. The current study examined the prevalence of AIDS denialism beliefs and their association to health-related outcomes among people living with HIV/AIDS. Confidential surveys and unannounced pill counts were collected from a predominantly middle aged and African American convenience sample of 266 men and 77 women living with HIV/AIDS. One in five participants stated that there is no proof that HIV causes AIDS and that HIV treatments do more harm than good. AIDS denialism beliefs were more often endorsed by people who more frequently used the internet after controlling for confounds. Believing that there is a debate among scientists about whether HIV causes AIDS was related to refusing HIV treatments and poorer health outcomes. AIDS denialism beliefs may be common among people living with HIV/AIDS and such beliefs are associated with poor health outcomes.
We investigated alcohol-related sexual risk behavior from the perspective of social norms theory. Adults (N = 895, 62% men) residing in a South African township completed street-intercept surveys that assessed risk and protective behaviors (e.g., multiple partners, drinking before sex, meeting sex partners in shebeens, condom use) and corresponding norms. Men consistently overestimated the actual frequency of risky behaviors, as reported by the sample, and underestimated the frequency of condom use. Relative to actual attitudes, men believed that other men were more approving of risk behavior and less approving of condom use. Both behavioral and attitudinal norms predicted the respondents' self-reported risk behavior. These findings indicate that correcting inaccurate norms in HIV-risk reduction efforts is worthwhile.
Southern Africa's catastrophic HIV epidemic is exacerbated by co-occurring sexually transmitted infections (STI). Understanding HIV transmission risks of STI patients who test HIV positive may inform prevention interventions.
To examine behavioral risks and behavior changes associated with testing HIV positive among STI patients.
A cohort study of 29 STI patients who tested HIV positive during one year of observation and 77 patients who persistently tested HIV negative. Computerized behavioral interviews were collected at baseline and one year later, and STI clinic charts were abstracted over the same one year period.
STI patients who reported genital bleeding during sex at the baseline were significantly more likely to test HIV positive. Reductions in number of sex partners and rates of unprotected intercourse occurred for all STI clinic patients regardless of whether they tested HIV positive.
We observed 5% of HIV negative STI clinic patients subsequently testing HIV positive over one year. Behavioral risk reduction interventions are urgently needed for men and women STI clinic patients.
Emotional distress is among the more common factors associated with HIV treatment adherence. Typical barriers to adherence may be overshadowed by poverty experiences in the most disadvantaged populations of people living with HIV/AIDS, such as people with lower-literacy skills.
This study examined the association of social, health and poverty-related stressors in relation to antiretroviral treatment (ART) adherence in a sample of people with low-literacy living with HIV/AIDS in the southeastern US.
One hundred eighty-eight men and women living with HIV/AIDS who demonstrated poor health literacy completed measures of social and health-related stress, indicators of extreme poverty as well as other factors associated with non-adherence. HIV treatment adherence was monitored prospectively using unannounced pill counts.
Two thirds of the sample demonstrated adherence below 85% of pills taken. Multivariable analyses showed that food insufficiency and hunger predicted ART non-adherence over and above depression, internalized stigma, substance use and HIV-related social stressors.
Interventions for HIV treatment non-adherence with the most socially disadvantaged persons in developed countries should be re-conceptualized to directly address poverty, especially food insufficiency and hunger, as both a moral and public health imperative.
HIV/AIDS; Stress; Poverty; Food security; HIV treatment adherence
Anal intercourse is an efficient mode of HIV transmission and may play a role in heterosexual HIV epidemics of southern Africa. However, little information is available on the anal sex practices of heterosexuals in South Africa.
To examine the occurrence of anal intercourse in samples drawn from community and clinic settings.
Anonymous surveys collected from convenience samples of 2593 men and 1818 women in two townships and one large city STI clinic in Cape Town. Measures included demographics, HIV risk history, substance use, and three month retrospective sexual behavior.
A total of 14% (n = 360) men and 10% (n = 172) women reported engaging in anal intercourse in the past three months. Men used condoms during 67% and women 50% of anal intercourse occasions. Anal intercourse was associated with younger age, being unmarried, having a history of STIs, exchanging sex, using substances, having been tested for HIV, and testing HIV positive.
Anal intercourse is reported relatively less frequently than unprotected vaginal intercourse among heterosexuals. The low prevalence of anal intercourse among heterosexuals may be offset by its greater efficiency for transmitting HIV. Anal sex should be discussed in heterosexual HIV prevention programming.
HIV; AIDS; risk behavior. anal intercourse; disease prevention
South Africa is in the midst of one of the world’s most devastating HIV/AIDS epidemics and there is a well documented association between violence against women and HIV transmission. Interventions that target men and integrate HIV prevention with gender-based violence prevention may demonstrate synergistic effects. A quasi-experimental field intervention trial was conducted with two communities randomly assigned to receive either: (a) a five session integrated intervention designed to simultaneously reduce gender-based violence (GBV) and HIV risk behaviors (N=242) or (b) a single 3-hour alcohol and HIV risk reduction session (N=233). Men were followed for 1, 3, and 6-months post intervention with 90% retention. Results indicated that the GBV/HIV intervention reduced negative attitudes toward women in the short term and reduced violence against women in longer term. Men in the GBV/HIV intervention also increased their talking with sex partners about condoms and were more likely to have been tested for HIV at the follow-ups. There were few differences between conditions on any HIV transmission risk reduction behavioral outcomes. Further research is needed to examine the potential synergistic effects of alcohol use, gender violence, and HIV prevention interventions.
People with lower health literacy are vulnerable to health problems. Studies that have examined the association between literacy and medication adherence have relied on self-reported adherence, which is subject to memory errors, perhaps even more so in people with poor literacy.
To examine the association between health literacy and objectively assessed HIV treatment adherence.
Men and women (N = 145) receiving antiretroviral therapies completed a test of health literacy and measures of common adherence markers. Medication adherence was monitored by unannounced pill counts.
Median adherence was 71%; Participants with lower health literacy also demonstrated poorer adherence compared to individuals with higher literacy. Hierarchical regression showed literacy predicted adherence over and above all other factors. Sensitivity tests showed the same results for 80% and 90% adherence.
The association between literacy and adherence appears robust and was confirmed using an objective measure of medication adherence.
Multiple recent sex partners promote the rapid spread of sexually transmitted infections (STI), including HIV. Alcohol use is also closely associated with HIV transmission risks but alcohol use has not been investigated as a factor contributing to multiple recent sex partners in southern Africa.
To examine the combined risks of multiple recent sex partners and alcohol use among people seeking treatment for an identified STI in Cape Town South Africa.
Men (n = 529) and women (n = 210) receiving STI clinic services completed anonymous surveys of sexual behaviors and substance use over a two-month retrospective period. Sexual risk was defined by frequencies of unprotected intercourse and drinking alcohol before sexual intercourse.
A total of 264 (31%) participants reported two or more sex partners in the previous two months; 87% of these partnerships occurred within one month of each other. Substantially greater multiple recent partners, including a greater fraction of sexual relationships estimated concurrent were observed among men than women. Alcohol use was common in the sample and drinking in sexual contexts was associated with multiple partners. Moderator analyses failed to show alcohol use played a significant role in sexual exposure risks stemming from multiple recent partners.
Multiple recent partners and drinking appear independently related to unprotected sex and both multiple partners and alcohol use should be targeted in HIV risk reduction interventions.
HIV/AIDS; South Africa; sexual concurrency; multiple partners; alcohol use
Evidence based interventions are often disseminated in public health education with little known about their operational fidelity. This study examined the delivery of intervention components (operational fidelity) of a widely disseminated HIV prevention program designed for people living with HIV/AIDS named Healthy Relationships. Two hundred and ninety nine agencies that had been trained in the intervention by the Centers for Disease Control and Prevention were contacted and 122 (41%) completed confidential interviews. Among the 93 agencies that implemented the program, 39 (40%) adapted at least one core element activity and 21 (23%) dropped an activity. Most adaptations were intended to improve the community fit of the intervention. Agencies believed that funders demand that they implement the intervention with fidelity. Models of technology transfer that emphasize behavior change processes rather than specific curriculum content may advance prevention program dissemination.
Evidence-based interventions; HIV prevention; Operations research
Beliefs that HIV treatments reduce HIV transmission risks are related to increases in sexual risk behaviors, particularly unprotected anal intercourse among men who have sex with men (MSM). Changes in unprotected anal intercourse and prevention-related treatment beliefs were recently reported for surveys of mostly white gay men collected in 1997 and 2005. The current study extends this previous research by replicating the observed changes in behaviors and beliefs in anonymous community surveys collected in 2006. Results indicated clear and consistent increases in beliefs that HIV treatments reduce HIV transmission risks and increases in unprotected anal intercourse. These changes were observed for both HIV positive and non-HIV positive men. African American men endorsed the belief that HIV treatments protect against HIV transmission to a greater degree than White men. Results show that HIV prevention messages need to be updated to educate MSM about the realities of HIV viral concentrations and HIV transmission risks.
Despite growing numbers of people living with HIV (PLWH), the landscape of related services is shrinking. This study investigated health and social service needs of men (N = 489) and women (N = 165) living with HIV in Atlanta, GA. Participants completed confidential measures asking about the health and social services they needed and accessed. Results showed an array of health and social service needs among PLWH; failure to access services was prevalent. Hunger was among the most common basic needs, reported by greater than 60% of men and women. For men, unmet service needs were associated with fewer years since testing positive for HIV, higher CD4+ T cell values, experiencing more stressors and depression, and greater quantity of alcohol use. For women, failure to access services was associated with experiencing depression and not receiving HIV medications. Providing basic services to PLWH remains a public health priority and moral imperative.
access to services; HIV services; service needs
This research evaluated a motivation-based HIV-risk-reduction intervention for economically disadvantaged urban women. Participants completed a survey that assessed HIV-related knowledge, risk perceptions, behavioral intentions, sexual communication, substance use, and risk behavior. A total of 102 at-risk women (76% African-American) were randomly assigned to either the risk-reduction intervention or to a waiting list. Women were reassessed at three and twelve weeks. Results indicated that treated women increased their knowledge and risk awareness, strengthened their intentions to adopt safer sexual practices, communicated their intentions with partners, reduced substance use proximal to sexual activities, and engaged in fewer acts of unprotected vaginal intercourse. These effects were observed immediately and most were maintained at follow-up.
Previous research has documented the practice of transactional sex in sub-Saharan Africa and its association with gender-based violence, gender inequalities and HIV risk. At the same time, it has been suggested that women may use transactional sex to obtain a greater sense of control over their lives and their sexualities, and to garner access to resources. The aim of this study was to better understand the practice of exchanging alcohol for sex in alcohol-serving venues in a township in Cape Town, South Africa. Data were collected between June 2009 and October 2010. Six venues were included and observations were conducted in each for four one-week periods over the course of a year. In-depth qualitative interviews included 31 women and 13 men whom interviewers had observed as regular venue customers. Follow-up interviews were conducted with 24 respondents to explore emerging themes. Interviews were recorded and transcribed. Using a grounded theory approach, Atlas.ti was used to code transcripts, field notes, and analytical memos written about each document. Results revealed that alcohol was commonly used as a currency of sexual exchange in this setting, and both women and men understood that accepting alcohol from a man implied consent for sexual favors. Women reported a sense of agency in participating in the transactional sex dynamic, especially when they were able to manipulate it to meet their own ends without fulfilling the men’s sexual expectations. At the same time, data revealed that the norm of transactional sex reinforced the undervaluing and commoditization of women. As identified elsewhere, transactional sex put both women and men at greater risk of HIV through multiple partners and inconsistent use of condoms, and the possibility of rape. Interventions are needed to address sexual risk behaviors and substance use within this context to prevent new HIV infections.
South Africa; Transactional sex; Alcohol; Sexual behavior; HIV; Gender
Diabetes education for ethnic minorities should address variations in values underlying motivations, preferences, and behaviors of individuals within an ethnic group. This paper describes the development and implementation of a culturally tailored diabetes intervention for Puerto Rican Americans that can be delivered by a health care paraprofessional and implemented in routine clinical care. We describe a formative process, including interviews with providers, focus groups with patients and a series of multidisciplinary collaborative workshops used to inform intervention content. We highlight the intervention components and link them to a well-validated health behavior change model. Finally, we present support for the intervention’s clinical effects, feasibility, and acceptability and conclude with implications and recommendations for practice. Lessons learned from this process should guide future educational efforts in routine clinical care.
Culturally tailored; diabetes; behavior change; primary care; Puerto Rican
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.
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.
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.
Endorsement of AIDS-related stigma was negatively associated with HIV lifetime testing. In addition, stigma endorsement was associated with higher HIV transmission risks.
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.
HIV/AIDS-related stigma; HIV testing; HIV risk behavior; alcohol; substance use