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1.  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.
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.
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.
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.
PMCID: PMC3477958  PMID: 22994247
2.  Sexual Risk Reduction Interventions for HIV Prevention among South African Youth: A Meta-Analytic Review 
Current HIV research  2013;11(7):549-558.
To examine the efficacy of sexual risk reduction interventions among South African youth.
Electronic databases were searched to identify studies published between 2007 and early 2013. Studies were eligible if they (1) targeted youth age 9–26, (2) evaluated sexual risk reduction interventions and (3) reported at least one behavioral outcome. Independent raters coded study characteristics, and intervention content. Weighted mean effect sizes were calculated; positive effect sizes indicated less sexual risk behavior and incident STIs.
Ten studies (k = 11, N = 22,788; 54% female; 79% Black-African) were included. Compared to controls, interventions were successful at delaying sexual intercourse and, among sexually active youth, at increasing condom use. A single study found reductions in the incidence of herpes simplex virus-2, but not HIV.
Implementing behavioral interventions to delay sexual debut and improve condom use can help to reduce the transmission of HIV among South African youth.
PMCID: PMC4059352  PMID: 24476351
HIV; intervention; meta-analysis; sex; South Africa; youth
3.  Behavioral Changes Associated with Testing HIV Positive among Sexually Transmitted Infections Clinic Patients, Cape Town South Africa 
American journal of public health  2010;100(4):714-719.
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.
PMCID: PMC2836331  PMID: 20167895
4.  A pandemic of the poor: social disadvantage and the U.S. HIV epidemic 
The American psychologist  2013;68(4):197-209.
The U.S. HIV epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this paper, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions including environmental resources, constraints, access to care, and psychosocial influences are examined in relation to HIV disease trajectories. Greater attention to contextual factors and co-morbidities is needed to reduce the health disparities in HIV infection.
PMCID: PMC3700367  PMID: 23688088
5.  Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana 
Sexually Transmitted Infections  2007;83(5):371-375.
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.
PMCID: PMC2659030  PMID: 17475684
HIV/AIDS prevention; multiple concurrent sex partners; HIV positive sex risks; positive prevention
6.  Co-Occurring Psychosocial Problems and HIV Risk Among Women Attending Drinking Venues in a South African Township: A Syndemic Approach 
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.
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.
560 women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors.
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.
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.
PMCID: PMC3578969  PMID: 23054944
HIV risk; sexual risk behavior; syndemics; mental health; abuse; alcohol
7.  Behavioral Aspects of Male Circumcision for the Prevention of HIV Infection 
Current HIV/AIDS reports  2009;6(4):187-193.
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.
PMCID: PMC3557929  PMID: 19849961
8.  Drinking before and after pregnancy recognition among South African women: the moderating role of traumatic experiences 
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.
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.
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.
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.
PMCID: PMC3975846  PMID: 24593175
South Africa; Pregnancy; Fetal alcohol spectrum disorder; Drinking; Trauma; Childhood abuse; Intimate partner violence
9.  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.
PMCID: PMC3567216  PMID: 23160840
female sex work; HIV; risk environments; social factors; structural interventions; HIV prevention
10.  Intentional Non-Adherence to Medications among HIV Positive Alcohol Drinkers: Prospective Study of Interactive Toxicity Beliefs 
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.
To examine prospective relationships of factors contributing to intentional medication non-adherence when drinking.
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.
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.
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.
PMCID: PMC3579979  PMID: 23065532
medication adherence; alcohol use; HIV treatment beliefs
11.  Brief Behavioral Self-Regulation Counseling for HIV Treatment Adherence Delivered by Cell Phone: An Initial Test of Concept Trial 
AIDS Patient Care and STDs  2011;25(5):303-310.
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.
PMCID: PMC3085946  PMID: 21457056
12.  Food Insufficiency, Substance Use, and Sexual Risks for HIV/AIDS in Informal Drinking Establishments, Cape Town, South Africa 
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.
PMCID: PMC3531356  PMID: 22669645
HIV prevention; South Africa; Food insufficiency; Alcohol risks
13.  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.
PMCID: PMC3646073  PMID: 22526526
gender-based violence; intimate partner violence; alcohol; sexual risk; HIV risk
14.  Recent Advances (2011-2012) in Technology-Delivered Interventions for People Living with HIV 
Current HIV/AIDS reports  2012;9(4):326-334.
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.
PMCID: PMC3492505  PMID: 22922945
HIV/AIDS; HIV management; technology; technology intervention; technology-based intervention; secondary prevention; systematic review; sexual risk reduction; people living with HIV (PLWH)
15.  Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention 
HIV medicine  2010;11(8):502-509.
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.
PMCID: PMC2937207  PMID: 20201976
HIV/AIDS prevention; HIV/AIDS treatment; Sexually Transmitted Infections
16.  Adherence to Antiretroviral Therapy and HIV Transmission Risks: Implications for Test-and-Treat Approaches to HIV Prevention 
AIDS Patient Care and STDs  2010;24(5):271-277.
HIV transmission may be prevented by effectively suppressing viral replication with antiretroviral therapy (ART). However, adherence is essential to the success of ART, including for reducing HIV transmission risk behaviors. This study examined the association of nonadherence versus adherence with HIV transmission risks. Men (n = 226) living with HIV/AIDS and receiving ART completed confidential computerized interviews and telephone-based unannounced pill counts for ART adherence monitoring. Data were collected between January 2008 and June 2009. Results showed that nonadherence to ART was associated with greater number of sex partners and engaging in unprotected and protected anal intercourse. These associations were not moderated by substance use. The belief that having an undetectable viral load leads to lower infectiousness was associated with greater number of partners, including nonpositive partners, and less condom use. Men who had an undetectable viral load and believed that having an undetectable viral load reduces their infectiousness, were significantly more likely to have contracted a recent STI. Programs aimed at testing and treating people living with HIV/AIDS for prevention require attention to adherence and sexual behaviors.
PMCID: PMC2875951  PMID: 20438373
17.  HIV transmission risk behaviours among HIV seropositive sexually transmitted infection clinic patients in Cape Town, South Africa 
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.
PMCID: PMC2860715  PMID: 19726591
HIV/AIDS; HIV infectiousness; positive prevention; sexually transmitted infections.
18.  HIV Super-infection Beliefs and Sexual Practices of People Living with HIV/AIDS 
Sexual health  2010;7(4):420-424.
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.
PMCID: PMC3058929  PMID: 21062581
19.  “There is no Proof that HIV Causes AIDS”: AIDS Denialism Beliefs among People Living with HIV/AIDS 
Journal of behavioral medicine  2010;33(6):432-440.
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.
PMCID: PMC3015095  PMID: 20571892
20.  Community Norms for HIV Risk Behaviors among Men in a South African Township 
Journal of behavioral medicine  2010;34(1):32-40.
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.
PMCID: PMC3015007  PMID: 20680673
21.  Stress and Poverty Predictors of Treatment Adherence among People with Low-Literacy Living with HIV/AIDS 
Psychosomatic medicine  2010;72(8):810-816.
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.
PMCID: PMC3016469  PMID: 20716711
HIV/AIDS; Stress; Poverty; Food security; HIV treatment adherence
22.  Heterosexual Anal Intercourse among Community and Clinical Settings in Cape Town, South Africa 
Sexually transmitted infections  2009;85(6):411-415.
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.
PMCID: PMC3017216  PMID: 19429569
HIV; AIDS; risk behavior. anal intercourse; disease prevention
23.  Integrated Gender-Based Violence and HIV Risk Reduction Intervention for South African Men: Results of a Quasi-Experimental Field Trial 
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.
PMCID: PMC3015088  PMID: 19353267
24.  The Association between Health Literacy and HIV Treatment Adherence: Further Evidence from Objectively Measured Medication Adherence 
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.
PMCID: PMC3015090  PMID: 19056866
25.  Multiple-Recent Sexual Partnerships and Alcohol Use among Sexually Transmitted Infection Clinic Patients, Cape Town South Africa 
Sexually transmitted diseases  2011;38(1):18-23.
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.
PMCID: PMC3015092  PMID: 20625349
HIV/AIDS; South Africa; sexual concurrency; multiple partners; alcohol use

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