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 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
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
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
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.
We surveyed 2,120 men and women attending drinking establishments in a township located in the Western Cape of South Africa.
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.
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.
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.
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.
This qualitative study explores alcohol-serving venues as sites of risk or protection from violence against women (VAW) in one South African community. In 2010, we conducted in-depth interviews with 31 female patrons, 13 male patrons and 11 venue staff, and conducted structured observations in six alcohol venues. VAW was a common experience and venues contributed to risk through aggression, negative attitudes towards women, risks leaving the venues, and owners tolerating VAW. Concurrently, venues offered potential to avoid VAW through perceived safety and owner protection. Results highlight the influence of the venue environment and importance of addressing the setting of alcohol consumption.
South Africa; Qualitative; Violence against women; Gender-based violence; Alcohol; Venues; Gender
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.
Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention.
Participants (N=738) were surveyed in six alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms, predicted unprotected sexual intercourse. Men and women were analyzed separately.
Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women.
Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance use problems may aid in reducing HIV infection. Sexual assault prevention and treatment following sexual assault may strengthen HIV prevention efforts.
HIV/AIDS; HIV prevention; Mental health; Alcohol; South Africa
Brief and low-burden HIV risk reduction counseling interventions are needed for populations at greatest risk for HIV infection.
This randomized controlled trial tested a brief theory-based counseling intervention delivered entirely over the telephone for men who engage in unprotected intercourse with men.
Participants received either risk reduction counseling that included information, motivational enhancement and behavior skills building, or brief HIV education counseling. A total of 319 participants completed follow-up assessments over a 10-month period. Descriptive and random effects mixed models are used to evaluate findings.
Results demonstrate that a brief telephone intervention can reach and engage high-risk men in risk reduction counseling. Nearly one third of participants identified as men of color; the median age was 33 years. Participants in both counseling conditions increased their motivation and behavioral skills to practice safer sex and reduced their number of sex partners and frequencies of engaging in unprotected anal sex over the study observation period. However, there were few differences between intervention conditions.
The effects of repeated measurement reactivity and brief interpersonal consciousness raising may account for the lack of differences between counseling conditions and the decrease in risk for all participants over time.
Affordable and effective antiretroviral therapy (ART) adherence interventions are needed for many patients to promote positive treatment outcomes and prevent viral resistance. We conducted a two-arm randomized trial (n = 40 men and women receiving and less than 95% adherent to ART) to test a single office session followed by four biweekly cell phone counseling sessions that were grounded in behavioral self-management model of medication adherence using data from phone-based unannounced pill counts to provide feedback-guided adherence strategies. The control condition received usual care and matched office and cell phone/pill count contacts. Participants were baseline assessed and followed with biweekly unannounced pill counts and 4-month from baseline computerized interviews (39/40 retained). Results showed that the self-regulation counseling delivered by cell phone demonstrated significant improvements in adherence compared to the control condition; adherence improved from 87% of pills taken at baseline to 94% adherence 4 months after baseline, p < 0.01. The observed effect sizes ranged from moderate (d = 0.45) to large (d = 0.80). Gains in adherence were paralleled with increased self-efficacy (p < 0.05) and use of behavioral strategies for ART adherence (p < 0.05). We conclude that the outcomes from this test of concept trial warrant further research on cell phone-delivered self-regulation counseling in a larger and more rigorous trial.
Use of dietary supplements is common among people living with HIV/AIDS. Because dietary supplements are used in the context of other health behaviors, they may have direct and indirect health benefits. However, supplements may also be associated with vulnerability to medical misinformation and unfounded health claims. We examined use of dietary supplements among people living with HIV/AIDS (PLWH) and the association between use of dietary supplements and believing medical misinformation.
A convenience sample of 268 men and 76 women living with HIV was recruited from AIDS services and clinics in Atlanta, GA. Participants completed measures of demographic and health characteristics, dietary supplement use, beliefs about dietary supplements, internet use, and an internet evaluation task designed to assess vulnerability to medical misinformation.
One out of four PLWH currently used at least one dietary supplement product excluding vitamins. Dietary supplement use was associated with higher education and greater use of the internet for health-related information. Dietary supplement users also endorsed greater believability and trust in unfounded claims for HIV cures.
Dietary supplement use is common among PLWH and is associated with a broad array of health information seeking behaviors. Interventions are needed to reduce the vulnerability of PLWH, particularly dietary supplement users, to medical misinformation propagated on the internet.
HIV treatment; medical misinformation; treatment beliefs; dietary supplements