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1.  Applying the Dynamic Social Systems Model to HIV prevention in a rural African context: The Maasai and the esoto dance 
This study applied the Dynamic Social Systems Model (DSSM) to the issue of HIV risk among the Maasai tribe of Tanzania, using data from a cross-sectional, cluster survey among 370 randomly selected participants from Ngorongoro and Siha Districts. A culturally-appropriate survey instrument was developed to explore traditions reportedly coadunate with sexual partnership, including “wife-sharing”, fertility rituals, and various traditional dances. One dance, esoto, accounted for over two-thirds of participants’ lifetime sexual partners (n=10.5). The DSSM, combining structural and systems theories, was applied to systematize complex multilevel factors regarding esoto practice. Participants reported multifaceted beliefs regarding esoto; a majority viewed the dance as exciting and essential, yet most men feared social stigma and three-quarters of women had experienced physical punishment for non-attendance. In multivariate logistic regression, esoto attendance was predicted by female gender (AOR 4.67, 95% CI: 1.6, 13.2), higher positive beliefs regarding esoto (AOR 2.84, 95% CI: 1.9, 4.2) and Maasai lifecycle events (AOR 0.06, 95% CI: 0.01, 0.47). The DSSM proved useful for characterizing esoto and for revealing feedback loops that maintain esoto, thus indicating avenues for future interventions.
PMCID: PMC3830632  PMID: 23372030
2.  The role of intent in serosorting behaviors among MSM sexual partnerships 
Journal of acquired immune deficiency syndromes (1999)  2013;64(3):10.1097/QAI.0b013e3182a0e880.
Serosorting is increasingly assessed in studies of MSM. Most research studies have measured serosorting by combining reported unprotected anal intercourse (UAI) and the occurrence of participant and partner same HIV status (seroconcordance). The CDC definition of serosorting also incorporates intent to be in such a partnership, although few studies incorporate both intent and behavior into their measures.
Using data from a national, online survey of 3,519 US MSM, we assessed the role of intention in seroconcordant partnerships, as measured by participant rating of the importance of shared serostatus when selecting a sex partner.
For HIV+ men, 30% of partnerships were seroconcordant; of these, 48% reported intent to be in such a partnership (intentional seroconcordance). For HIV− men, 64% of partnerships were seroconcordant; of these, 80% reported intentional seroconcordance. Intentional seroconcordance was associated with UAI for HIV+ partnerships (OR 1.9; CI: 1.3, 2.9), but not significant for HIV− partnerships (OR 1.1; CI: 0.99, 1.3). In separate models where intent was not considered, seroconcordance was associated with UAI for HIV+ partnerships (odds ratio (OR) 3.2; 95% confidence interval (CI): 2.2, 4.6) and for HIV− partnerships (OR 1.2; CI: 1.0, 1.3; p = 0.03).
Regardless of intentionality, seroconcordance was strongly associated with UAI for HIV+ men and weakly associated with UAI for HIV− men. Intentional seroconcordance was not associated with UAI more strongly than was seroconcordance in absence of consideration of intent. Intentionality may not be a critical element of the relationship between seroconcordance and UAI.
PMCID: PMC3839244  PMID: 23846562
HIV prevention; MSM; serosorting; measurement
3.  Sibanye Methods for Prevention Packages Program Project Protocol: Pilot Study of HIV Prevention Interventions for Men Who Have Sex With Men in South Africa 
JMIR Research Protocols  2014;3(4):e55.
Human immunodeficiency virus (HIV) prevention intervention programs and related research for men who have sex with men (MSM) in the southern African region remain limited, despite the emergence of a severe epidemic among this group. With a lack of understanding of their social and sexual lives and HIV risks, and with MSM being a hidden and stigmatized group in the region, optimized HIV prevention packages for southern African MSM are an urgent public health and research priority.
The objective of the Sibanye Health Project is to develop and evaluate a combination package of biomedical, behavioral, and community-level HIV prevention interventions and services for MSM in South Africa.
The project consists of three phases: (1) a comprehensive literature review and summary of current HIV prevention interventions (Phase I), (2) agent-based mathematical modeling of HIV transmission in southern African MSM (Phase II), and (3) formative and stigma-related qualitative research, community engagement, training on providing health care to MSM, and the pilot study (Phase III). The pilot study is a prospective one-year study of 200 men in Cape Town and Port Elizabeth, South Africa. The study will assess a package of HIV prevention services, including condom and condom-compatible lubricant choices, risk-reduction counseling, couples HIV testing and counseling, pre-exposure prophylaxis (PrEP) for eligible men, and non-occupational post-exposure prophylaxis for men with a high risk exposure. The pilot study will begin in October 2014.
Preliminary results from all components but the pilot study are available. We developed a literature review database with meta-data extracted from 3800 documents from 67 countries. Modeling results indicate that regular HIV testing and promotion of condom use can significantly impact new HIV infections among South African MSM, even in the context of high coverage of early treatment of HIV-positive men and high coverage of PrEP for at-risk HIV-negative men. Formative qualitative research consisted of 79 in-depth interviews, and six focus group discussions in Cape Town and Port Elizabeth. Analysis of these data has informed pilot study protocol development and has been documented in peer-reviewed manuscripts. Qualitative work regarding stigma faced by South African MSM resulted in finalized scales for use in the pilot study questionnaire. A total of 37 health care providers completed training designed to facilitate clinically and culturally competent care for MSM in the Eastern Cape.
The design of a future, larger study of the HIV prevention package will be conducted at the end of the pilot study, powered to detect efficacy of the prevention package. Data from the updated mathematical model, results of the pilot study, acceptability data, and advancements in HIV prevention sciences will be considered in developing the final proposed package and study design.
Trial Registration NCT02043015; (Archived by WebCite at
PMCID: PMC4210958  PMID: 25325296
HIV; prevention & control; South Africa; Truvada
4.  Condoms “contain worms” and “cause HIV” in Tanzania: Negative Condom Beliefs Scale development and implications for HIV prevention 
Social science & medicine (1982)  2012;75(9):1685-1691.
Condom promotion remains a key component of HIV prevention programs, complimenting recent successes in biomedical HIV prevention. Although condom use has increased in much of East Africa, it remains substantially below optimal levels. Negative rumors about condoms have been documented in East Africa, yet the prevalence and effects of belief in the negative rumors have not been explored. This study evaluated levels of belief in negative rumors about condoms, developed a Negative Condom Beliefs Scale, and assessed its accuracy in predicting willingness to use condoms. A cross-sectional, cluster survey (n=370) was conducted representing adults in two rural districts in Northern Tanzania in 2008. Item agreement ranged from 35–53% for the following rumors regarding condoms: causing cancer, having holes, containing HIV, having worms, and the worms causing HIV. Items loaded on a single latent factor and had high internal consistency and convergent validity. In a multivariate model, negative condom score (AOR=0.67, 95% CI=0.6, 0.8) was the strongest single predictor of willingness to use condoms, followed by greater perceived anonymity in acquiring condoms (AOR=4.36, 95% CI=2.2, 8.6) and higher condom self-efficacy (AOR=4.24, 95% CI=2.0, 8.9). Our findings indicate high levels of subscription to negative beliefs about condoms, with two out of three respondents affirming belief in at least one negative condom rumor. This study highlights the relation between condom rumor beliefs and willingness to use condoms, and indicates avenues for future research and means for improving the design of HIV prevention programs.
PMCID: PMC3432708  PMID: 22877934
HIV; prevention; condoms; Africa; Tanzania; behavioral research; survey research
5.  Acceptability of Medical Male Circumcision and Improved Instrument Sanitation Among a Traditionally Circumcising Group in East Africa 
AIDS and behavior  2012;16(7):1846-1852.
By removing the foreskin, medical male circumcision (MMC) reduces female to male heterosexual HIV transmission by approximately 60 %. Traditional circumcision has higher rates of complications than MMC, and reports indicate unsanitized instruments are sometimes shared across groups of circumcision initiates. A geographically stratified, cluster survey of acceptability of MMC and improved instrument sanitation was conducted among 368 eligible Maasai participants in two Northern Districts of Tanzania. Most respondents had been circumcised in groups, with 56 % circumcised with a shared knife rinsed in water between initiates and 16 % circumcised with a knife not cleaned between initiates. Contrasting practice, 88 % preferred use of medical supplies for their sons’ circumcisions. Willingness to provide MMC to sons was 28 %; however, provided the contingency of traditional leadership support for MMC, this rose to 84 %. Future interventions to address circumcision safety, including traditional circumciser training and expansion of access to MMC, are discussed.
PMCID: PMC3465712  PMID: 22797931
Male circumcision; Risk reduction; Acceptability; HIV prevention; Africa
6.  Barriers to cervical cancer screening in Mulanje, Malawi: a qualitative study 
In Malawi, cervical cancer is the most prevalent form of cancer among women, with an 80% mortality rate. The Mulanje Mission Hospital has offered free cervical cancer screening for eight years; however, patients primarily seek medical help for gynecologic complaints after the disease is inoperable.
We investigated how women in rural Malawi make health-seeking decisions regarding cervical cancer screening using qualitative research methods. The study was conducted between May and August of 2009 in Mulanje, Malawi.
This study found that the primary cue to action for cervical cancer screening was symptoms of cervical cancer. Major barriers to seeking preventative screening included low knowledge levels, low perceived susceptibility and low perceived benefits from the service. Study participants did not view cervical cancer screening as critical health care. Interviews suggested that use of the service could increase if women are recruited while visiting the hospital for a different service.
This study recommends that health care providers and health educators target aspects of perceived susceptibility among their patients, including knowledge levels and personal risk assessment. We believe that continued support and advertisement of cervical cancer screening programs along with innovative recruitment strategies will increase usage density and decrease unnecessary deaths from cervical cancer in Malawi.
PMCID: PMC3063659  PMID: 21448296
cervical cancer; interviews; health care; Mulanje Mission Hospital

Results 1-6 (6)