"Because he has bought for her, he wants to sleep with her": alcohol as a currency for sexual exchange in South African drinking venues

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.

Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings

Food insufficiency is associated with medication non-adherence among people living with HIV/AIDS. The current study examines the relationship between hunger and medication adherence in a US urban and peri-urban sample of people living with HIV/AIDS. Men (N=133) and women (N=46) living with HIV/AIDS were recruited using snowball sampling and small media in Atlanta, Georgia. Participants completed computerized behavioral interviews that included measures of demographics, food insufficiency, social support, depression, and substance use, and provided blood specimens to determine HIV viral load. Participants also completed monthly unannounced pill counts to prospectively monitor medication adherence over 8 months. Results indicated that 45% of participants were less than 85% adherent to their medications and that food insufficiency was related to non-adherence; nearly half of non-adherent participants reported recent hunger. Geocoding of participant residences showed that 40% lived more than 5 miles from the city center. Multivariable logistic regression controlling for demographics and common factors associated with adherence showed that the interaction between distance from downtown and experiencing hunger significantly predicted non-adherence over and above all other factors. Medication adherence interventions should address access to food, particularly for people living outside of urban centers.

The Achilles' Heel of HIV Treatment for Prevention: History of Sexually Transmitted Coinfections among People Living with HIV/AIDS Receiving Antiretroviral Therapies

BACKGROUND

Antiretroviral therapies (ARTs) offer promising new avenues for HIV prevention. Unfortunately, people infected with HIV who have co-occurring sexually transmitted infections (STIs) are more infectious than suggested by the amount of virus in their peripheral blood. We examined the history of sexually transmitted coinfections in people living with HIV.

METHODS

People living with HIV/AIDS completed confidential computerized interviews that assessed history of STI, sexual behaviors, and STI knowledge.

RESULTS

Among 414 men and 156 women currently receiving ART, 53% had been diagnosed with at least 1 STI since testing HIV positive; 24% women, 19% men, and 11% transgender persons had been diagnosed with an STI in the past year. History of STI was associated with younger age, greater STI knowledge, substance use, and ART nonadherence.

CONCLUSIONS

Aggressive strategies for detecting and treating STI in people receiving ART will be necessary to achieve protective benefits.

The influence of male circumcision for HIV prevention on sexual behaviour among traditionally circumcised men in Cape Town, South Africa

We examined the relationship between HIV prevention beliefs related to male circumcision and sexual behaviour/sexually transmitted infection (STI) acquisition among traditionally circumcised men in Cape Town, South Africa. HIV-negative men (n = 304), circumcised for cultural/religious reasons, attending a health clinic in Cape Town, South Africa, completed cross-sectional surveys. Generalized linear models were used to analyse the relationships between unprotected vaginal sex acts, number of female sexual partners, STI diagnoses and male circumcision-related beliefs and risk perceptions. Men who were aware that circumcision offers protection against HIV (relative risk [RR] = 1.19, 95% confidence interval [CI] = 1.06-1.32, P < 0.01), endorsed risk compensation related to male circumcision (RR = 1.15, 95% CI = 1.11-1.12, P < 0.01) and perceived lower risk of HIV infection when circumcised (RR = 1.08, 95% CI = 1.04-1.12, P < 0.01) were more likely to report unprotected vaginal sex acts. Similar patterns were also identified when predicting number of female sexual partners. Men who were more likely to endorse risk compensation related to male circumcision were also more likely to be diagnosed with a chronic STI (odds ratio [OR] = 1.64, 95% CI = 1.06-2.53, P < 0.05). Our findings suggest that we must not overlook the effects of beliefs towards male circumcision for HIV prevention among men traditionally circumcised; doing so may undermine current efforts to reduce HIV transmission through male circumcision.

Heterosexual anal intercourse and HIV infection risks in the context of alcohol serving venues, Cape Town, South Africa

Background

The most efficient sexual behavior for HIV transmission is unprotected receptive anal intercourse. However, it is unclear what role heterosexual unprotected anal sex is playing in the world's worst HIV epidemics of southern Africa. The objective is to examine the prevalence of heterosexual unprotected anal intercourse among men and women who drink at informal alcohol serving establishments (shebeens) in South Africa.

Methods

Cross-sectional surveys were collected from a convenience sample of 5037 patrons of 10 shebeens in a peri-urban township of Cape Town, South Africa. Analyses concentrated on establishing the rates of unprotected anal intercourse practiced by men and women as well as the factors associated with practicing anal intercourse.

Results

We found that 15% of men and 11% of women reported anal intercourse in the previous month, with 8% of men and 7% of women practicing any unprotected anal intercourse. Multiple logistic regression showed that younger age, having primary and casual sex partners, and meeting sex partners at shebeens were independently associated with engaging in anal intercourse. Mathematical modeling showed that individual risks are significantly impacted by anal intercourse but probably not to the degree needed to drive a generalized HIV epidemic.

Conclusions

Anal intercourse likely plays a significant role in HIV infections among a small minority of South Africans who patronize alcohol serving establishments. Heterosexual anal intercourse, the most risky sexual behavior for HIV transmission, should not be ignored in HIV prevention for South African heterosexuals. However, this relatively infrequent behavior should not become the focus of prevention efforts.

Development and Implementation of a Culturally Tailored Diabetes Intervention in Primary Care

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.

Randomized clinical trial of brief risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa

OBJECTIVES

We examined the effects of a brief counseling intervention designed to reduce HIV risk behaviors and sexually transmitted infections (STIs) among patients receiving STI services in Cape Town, South Africa.

METHODS

After randomization to either a 60-minute risk reduction counseling session or a 20-minute HIV-STI educational session, patients completed computerized sexual behavior assessments. More than 85% of the participants were retained at the 12-month follow-up.

RESULTS

There were 24% fewer incident STIs and significant reductions in unprotected vaginal and anal intercourse among participants who received risk reduction counseling relative to members of the control condition. Moderator analyses showed shorter lived outcomes for heavy alcohol drinkers than for lighter drinkers. The results were not moderated by gender.

CONCLUSIONS

Brief single-session HIV prevention counseling delivered to STI clinic patients has the potential to reduce HIV infections. Counseling should be enhanced for heavier drinkers, and sustained outcomes will require relapse prevention techniques. Disseminating effective, brief, and feasible behavioral interventions to those at highest risk for HIV infection should remain a public health priority.

Brief behavioral self-regulation counseling for HIV treatment adherence delivered by cell phone: an initial test of concept trial

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.

Falling through the cracks: unmet health service needs among people living with HIV in Atlanta, Georgia

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 a moral imperative.

Monthly unannounced pill counts for monitoring HIV treatment adherence: tests for self-monitoring and reactivity effects

BACKGROUND

Unannounced home-based pill counts conducted in person or on the telephone are reliable and valid for monitoring medication adherence. However, expecting to have one's pills counted, organizing medications for pill counts, and increased attention from the person conducting the pill counts may have reactive effects and inadvertently improve adherence. The current study determined whether monthly unannounced pill counts conducted by telephone influence adherence over time.

METHODS

Two prospective cohorts, one drawn from a social support condition in a behavioral intervention trial (n=186) and the other an observational study (n=187), were followed for 12 months and 8 months, respectively. Medication adherence was monitored using monthly unannounced pill counts conducted by telephone. In addition, blood plasma viral load was collected at the final pill count for the observational cohort.

RESULTS

Analyses did not indicate increases in medication adherence over time for antiretroviral or psychiatric medications among men, women, people with detectable and undetectable viral loads, and various medication regimens.

CONCLUSIONS

Unannounced pill counts conducted by telephone do not demonstrate reactivity effects and remain a viable, unobtrusive, objective method of monitoring medication adherence.

HIV super-infection beliefs and sexual practices of people living with HIV/AIDS

BACKGROUND

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 behaviours of people living with HIV/AIDS. HIV super-infection beliefs and sexual behaviours among people living with HIV/AIDS were examined in the present study.

METHODS

Three hundred and twenty men, 137 women, and 33 transgender persons completed confidential surveys in a community research setting.

RESULTS

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 behaviour over and above participant age and alcohol use.

CONCLUSIONS

Beliefs about HIV super-infection exert significant influence on sexual behaviours of people living with HIV/AIDS and should be targeted in HIV prevention messages for HIV infected persons.

Prevalence of sexually transmitted co-infections in people living with HIV/AIDS: systematic review with implications for using HIV treatments for prevention

Sexually transmitted co-infections increase HIV infectiousness through local inflammatory processes. The prevalence of STI among people living with HIV/AIDS has implications for containing the spread of HIV in general and the effectiveness of HIV treatments for prevention in particular. Here we report a systematic review of STI co-infections in people living with HIV/AIDS. We focus on STI contracted after becoming HIV infected. Electronic database and manual searches located 37 clinical and epidemiological studies of STI that increase HIV infectiousness. Studies of adults living with HIV/AIDS from developed and developing countries reported STI rates for 46 different samples (33 samples had clinical/laboratory confirmed STI). The overall mean point-prevalence for confirmed STI was 16.3% (SD=16.4), and median 12.4% STI prevalence in people living with HIV/AIDS. The most common STI studied were Syphilis with median 9.5% prevalence, Gonorrhea 9.5%, Chlamydia 5%, and Trichamoniasis 18.8% prevalence. STI prevalence was greatest at the time of HIV diagnosis, reflecting the role of STI in HIV transmission. Prevalence of STI among individuals receiving HIV treatment was not appreciably different from untreated persons. The prevalence of STI in people infected with HIV suggests that STI co-infections could undermine efforts to use HIV treatments for prevention by increasing genital secretion infectiousness.

Integrated behavioral intervention to improve HIV/AIDS treatment adherence and reduce HIV transmission

OBJECTIVES

We conducted a randomized clinical trial to test an integrated behavioral intervention designed to enhance using HIV treatment as prevention by improving medication adherence, reducing risks for other sexually transmitted infections, and minimizing risk compensation beliefs.

METHODS

Individuals living with HIV/AIDS (n = 436) participated in a randomized clinical trial testing an intensive behavioral intervention aimed at reducing HIV transmission risks compared with an attention control condition. We used unannounced pill counts to monitor antiretroviral therapy adherence and computerized interviews to measure risk behaviors.

RESULTS

The integrated transmission risk reduction intervention demonstrated increased antiretroviral therapy adherence and less unprotected intercourse with nonseroconcordant partners at 3- and 6-month follow-ups as well as fewer new sexually transmitted infections diagnosed over the 9-month follow-up period (adjusted odds ratio = 3.0; P < .05; 95% confidence interval = 1.01, 9.04). The integrated intervention also reduced behavioral risk compensation beliefs.

CONCLUSIONS

A theory-based integrated behavioral intervention can improve HIV treatment adherence and reduce HIV transmission risks. HIV treatment as prevention should be bundled with behavioral interventions to maximize effectiveness.

HIV misconceptions associated with condom use among black South Africans: an exploratory study

In South Africa, approximately 20% of 15-49-year-olds are infected with HIV. Among black South Africans, high levels of HIV/AIDS misconceptions (e.g. HIV is manufactured by whites to reduce the black African population; AIDS is caused by supernatural forces or witchcraft) may be barriers to HIV prevention. We conducted a cross-sectional study of 150 young, black adults (aged 18-26; 56% males) visiting a public clinic for sexually transmitted infections, to investigate whether HIV/AIDS misconceptions were related to low condom use in main partner relationships. We assessed agreement with HIV/AIDS misconceptions relating to the supernatural (e.g. witchcraft as a cause of HIV) and to genocide (e.g. the withholding of a cure). In multivariate models, agreement that 'Witchcraft plays a role in HIV transmission' was significantly related to less positive attitudes about condoms, less belief in condom effectiveness for HIV prevention, and lower intentions to use condoms among men. The belief that 'Vitamins and fresh fruits and vegetables can cure AIDS' was associated with lower intentions among men to use condoms. Women who endorsed the belief linking HIV to witchcraft had a higher likelihood of unprotected sex with a main partner, whereas women who endorsed the belief that a cure for AIDS was being withheld had a lower likelihood of having had unprotected sex. Knowledge about distinct types of HIV/AIDS misconceptions and their correlates can help in the design of culturally appropriate HIV-prevention messages that address such beliefs.

Impact of HIV testing on sexual health communication in South Africa

OBJECTIVES

The South African government recently launched a national campaign to test 15 million South Africans for HIV by 2011. Little is known about how receipt of HIV testing might influence interpersonal communication. To explore these questions, the authors examined the effects of prior HIV testing on sexual health communication among South Africans.

METHODS

Adults (N=1284; 98% black, 36% women, mean age 31) residing in a South African township completed street-intercept surveys.

RESULTS

Of the 1284 participants, 811 (63%) had been tested for HIV. Among those who had been tested, 77% tested negative, 12% tested positive, and 11% did not know their test result or refused to answer. Compared with those who had not been tested, participants who had been tested for HIV were more likely to communicate with community members about (a) HIV/AIDS, (b) getting tested for HIV, and (c) using condoms. Testing positive for HIV was associated with communication with sexual partners about condom use. Among participants who had been tested for HIV, exploratory analyses revealed that those who had engaged in sexual health communication with community members or sexual partners reported more condom-protected sex than those who had not engaged in sexual health communication.

CONCLUSIONS

HIV testing is associated with sexual health communication among South African community members and sexual partners. Offering HIV testing to all South Africans may increase communication and lead to reductions in sexual risk.

"There is no proof that HIV causes AIDS": AIDS denialism beliefs among people living with HIV/AIDS

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 convenience sample of 266 men and 77 women living with HIV/AIDS that was predominantly middle-aged and African American. 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.

A brief culturally tailored intervention for Puerto Ricans with type 2 diabetes

The information-motivation-behavioral skills (IMB) model of health behavior change informed the design of a brief, culturally tailored diabetes self-care intervention for Puerto Ricans with type 2 diabetes. Participants (n = 118) were recruited from an outpatient, primary care clinic at an urban hospital in the northeast United States. ANCOVA models evaluated intervention effects on food label reading, diet adherence, physical activity, and glycemic control (HbA1c). At follow-up, the intervention group was reading food labels and adhering to diet recommendations significantly more than the control group. Although the mean HbA1c values decreased in both groups (

INTERVENTION

0.48% vs.

CONTROL

0.27% absolute decrease), only the intervention group showed a significant improvement from baseline to follow-up (p < .008), corroborating improvements in diabetes self-care behaviors. Findings support the use of the IMB model to culturally tailor diabetes interventions and to enhance patients' knowledge, motivation, and behavior skills needed for self-care.

Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for female military personnel

Anecdotal evidence suggests that the HIV/AIDS prevalence rates in several African armed forces are high, with gender inequality rendering female military personnel more vulnerable to the disease. The objective of this study was to replicate a successful videotape-based HIV prevention intervention among Nigerian female military personnel in an effort to establish the cross-cultural stability, feasibility and cost-effectiveness of this approach in resource-limited countries. Enlisted women (N346) were recruited from two cantonments in Southwestern Nigeria and randomly assigned to either (a) a 5-session video-based, small group, cognitive-behavioral, HIV prevention intervention, or (b) a 5-session, video-based, contact-matched, HIV education control condition. Participants provided self-report of their HIV/AIDS-related knowledge and sexual behaviors at baseline, 3 and 6 months after completing the intervention. The results indicate that the motivational skills-building intervention did not improve participants' knowledge of HIV/AIDS any better than did the HIV education control condition at each assessment period, but it significantly increased condom use among women in this group by 53.6% at 3-month follow-up. HIV preventive behaviors among women in the motivational skills-building intervention group improved significantly, being 2 and 3 times more, compared to women in the HIV education control group at 3-month and 6-month follow-up assessments. The intervention also significantly improved behavioral intentions of participants as well as reduced alcohol use before sex by 25%, after 3 months; and number of sexual partners by 12% after 6 months. Women in the intervention group were five times more likely than women in HIV education control group to suggest that their new male partners use condom. These findings indicate that a videotape-based, HIV prevention intervention is a feasible and effective approach to HIV prevention among female military personnel from sub-Saharan Africa.

Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/AIDS

OBJECTIVE

To examine the association of social, health, and poverty-related stressors in relation to antiretroviral therapy adherence in a sample of people with low-literacy living with HIV/AIDS in the southeastern United States. 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.

METHODS

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 nonadherence. HIV treatment adherence was monitored prospectively, using unannounced pill counts.

RESULTS

Two-thirds of the sample demonstrated adherence <85% of pills taken. Multivariable analyses showed that food insufficiency and hunger predicted antiretroviral therapy nonadherence over and above depression, internalized stigma, substance use, and HIV-related social stressors.

CONCLUSIONS

Interventions for HIV treatment nonadherence with the most socially disadvantaged persons in developed countries should be reconceptualized to directly address poverty, especially food insufficiency and hunger, as both a moral and public health imperative.

Health and treatment implications of food insufficiency among people living with HIV/AIDS, Atlanta, Georgia

HIV/AIDS is concentrated among the inner-city poor and poverty may directly interfere with HIV treatment. This study examined food insufficiency in relation to HIV-related health and treatment. A sample of 344 men and women living with HIV/AIDS in Atlanta, Georgia completed measures of food security, health, and HIV disease progression and treatment. HIV treatment adherence was monitored using unannounced pill counts. Results showed that half of people living with HIV/AIDS in this study lacked sufficient food, and food insufficiency was associated with multiple indicators of poor health, including higher HIV viral loads, lower CD4 cell counts, and poorer treatment adherence. Adjusted analyses showed that food insufficiency predicted HIV treatment non-adherence over and above years of education, employment status, income, housing, depression, social support, and non-alcohol substance use. Hunger and food insecurity are prevalent among people living with HIV/AIDS, and food insufficiency is closely related to multiple HIV-related health indicators, particularly medication adherence. Interventions that provide consistent and sustained meals to people living with HIV/AIDS are urgently needed.

Adherence to antiretroviral therapy and HIV transmission risks: implications for test-and-treat approaches to HIV prevention

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.

A simple single-item rating scale to measure medication adherence: further evidence for convergent validity

BACKGROUND

Self-report measures of medication adherence are inexpensive and minimally intrusive. However, the validity of self-reported adherence is compromised by recall errors for missed doses and socially desirable responding.

METHOD

Examined the convergent validity of 2 self-report adherence measures administered by computerized interview: (a) recall of missed doses and (b) a single-item visual analogue rating scale (VAS). Adherence was also monitored using unannounced phone-based pill counts that served as an objective benchmark.

RESULTS

The VAS obtained adherence estimates that paralleled unannounced pill counts (UPCs). In contrast, self-reported recall (SR-recall) of missed medications consistently overestimated adherence. Correlations with participant characteristics also suggested that the computer-administered VAS was less influenced by response biases than SR-recall of missed medication doses.

CONCLUSIONS

A single-item VAS offers an inexpensive and valid method of assessing medication adherence that may be useful in clinical as well as research settings.

SafeTalk, a multicomponent, motivational interviewing-based, safer sex counseling program for people living with HIV/AIDS: a qualitative assessment of patients' views

With the continued transmission of HIV each year, novel approaches to HIV prevention are needed. Since 2003, the U.S. HIV prevention focus has shifted from primarily targeting HIV-negative at-risk persons to including safer sex programs for people already infected with HIV. At least 20-30% of people infected with HIV engage in risky sexual practices. Based on these data, policymakers have recommended that interventionists develop strategies to help HIV-infected people reduce their risky sexual behaviors. In the past, the few safer sex interventions that targeted HIV-infected people met with limited success because they basically adapted strategies previously used with HIV-uninfected individuals. In addition, often these adaptations did not address issues of serostatus disclosure, HIV stigma, or motivation to protect others from HIV. We had previously tested, in a demonstration project named the Start Talking About Risks (STAR) Program, a monthly three-session motivational interviewing (MI)-based intervention to help people living with HIV practice safer sex. In this study, we refined that program by enhancing its frequency and intensity and adding written and audio components to support the counseling. We theorized that an intervention such as MI, which is tailored to each individual's circumstances more than standardized prevention messages, would be more successful when supplemented with other components. We qualitatively assessed participants' perceptions, reactions, and preferences to the refined prevention with positives counseling program we called SafeTalk and learned that participants found the SafeTalk MI counseling and educational materials appealing, understandable, and relevant to their lives.

Condom failure among men receiving sexually transmissible infection clinic services, Cape Town, South Africa

BACKGROUND

Condoms offer the most realistic and available protection against sexually transmissible infections (STIs), including HIV infection. The protective benefits of condoms are, however, compromised by breaks and tears. The objective of the present study was to examine condom failure and associated behavioural risk factors among men at high-risk for HIV transmission in South Africa.

METHODS

Men (n = 431) receiving STI treatment services at a public clinic completed computer assisted interviews and STI clinic chart abstraction over a 1-year observation period.

RESULTS

One in three male STI clinic patients reported a history of condom failure. Condom failure was associated with sexual exchange, alcohol and other drug use, and higher rates of unprotected vaginal intercourse. Men with a history of condom failure were significantly more likely to have an STI diagnosis 1 month before the baseline interview and were significantly more likely to be diagnosed with an STI over the subsequent year.

CONCLUSION

Condom failures are common among STI clinic patients and pose a threat for increased HIV transmission risks.

A strategy for selecting sexual partners believed to pose little/no risks for HIV: serosorting and its implications for HIV transmission

A common HIV/AIDS risk reduction strategy among men who have sex with men (MSM) is to limit their unprotected sex partners to those who are of the same HIV status, a practice referred to as serosorting. Decisions to serosort for HIV risk reduction are based on personal impressions and beliefs, and there is limited guidance offered on this community derived strategy from public health services. This paper reviews research on serosorting for HIV risk reduction and offers an evidence-based approach to serosorting guidance. Following a comprehensive electronic and manual literature search, we reviewed 51 studies relating to the implications of serosorting. Studies showed that HIV negative MSM who select partners based on HIV status are inadvertently placing themselves at risk for HIV. Infrequent HIV testing, lack of HIV status disclosure, co-occurring sexually transmitted infections, and acute HIV infection impede the potential protective benefits of serosorting. Public health messages should continue to encourage reductions in numbers of sexual partners and increases in condom use. Risk reduction messages should also highlight the limitations of relying on one's own and partner's HIV status in making sexual risk decisions.

Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention

OBJECTIVES

Sexually transmitted infections (STIs) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STIs in a community sample of 490 HIV-positive men and women.

METHODS

Assessments were performed using confidential computerized interviews in a community research setting.

RESULTS

Fourteen per cent of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a 6-month period. Individuals with a new STI had significantly more sexual 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.

CONCLUSIONS

Individuals who believed that having an undetectable viral load reduces HIV transmission risks were more likely to be infectious because of STI coinfection. Programmes that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STIs among people living with HIV/AIDS.

Behavioral changes associated with testing HIV-positive among sexually transmitted infection clinic patients in Cape Town, South Africa

OBJECTIVES

We sought to examine behavioral risks and behavior changes associated with testing HIV-positive among sexually transmitted infection (STI) patients, in order to inform HIV- and STI-prevention interventions.

METHODS

We performed a cohort study of 29 STI patients who seroconverted from HIV-negative to HIV-positive during 1 year of observation and 77 STI patients who persistently tested HIV-negative. Computerized behavioral interviews were collected at baseline and at 1 year, and STI clinic charts were abstracted over the same 1-year period.

RESULTS

The STI patients who reported genital bleeding during sexual activity at baseline were significantly more likely to test HIV-positive. Reductions in number of sexual partners and rates of unprotected intercourse occurred for all STI clinic patients regardless of whether they tested HIV-positive.

CONCLUSIONS

Although risk reductions occurred, 5% of HIV-negative STI clinic patients subsequently tested HIV-positive over 1 year. Behavioral risk-reduction interventions are urgently needed for male and female STI clinic patients.

Behavioral aspects of male circumcision for the prevention of HIV infection

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 places with high HIV prevalence. 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.

Sexual partner selection and HIV risk reduction among Black and White men who have sex with men

OBJECTIVES

We examined differences in sexual partner selection between Black and White men who have sex with men (MSM) to better understand how HIV status of participants' sexual partners and related psychosocial measures influence risk taking among these men.

METHODS

We collected cross-sectional surveys from self-reported HIV-negative Black MSM and White MSM attending a gay pride festival in Atlanta, Georgia.

RESULTS

HIV-negative White MSM were more likely than were HIV-negative Black MSM to report having unprotected anal intercourse with HIV-negative men, and HIV-negative Black MSM were more likely than were HIV-negative White MSM to report having unprotected anal intercourse with HIV status unknown partners. Furthermore, White MSM were more likely to endorse serosorting (limiting unprotected partners to those who have the same HIV status) beliefs and favorable HIV disclosure beliefs than were Black MSM.

CONCLUSIONS

White MSM appear to use sexual partner-related risk reduction strategies to reduce the likelihood of HIV infection more than do Black MSM. Partner selection strategies have serious limitations; however, they may explain in part the disproportionate number of HIV infections among Black MSM.

Social and structural HIV prevention in alcohol-serving establishments: review of international interventions across populations

Alcohol use is associated with risks for sexually transmitted infections (STIs), including HIV/AIDS. People meet new sex partners at bars and other places where alcohol is served, and drinking venues facilitate STI transmission through sexual relationships within closely knit sexual networks. This paper reviews HIV prevention interventions conducted in bars, taverns, and informal drinking venues. Interventions designed to reduce HIV risk by altering the social interactions within drinking environments have demonstrated mixed results. Specifically, venue-based social influence models have reduced community-level risk in U.S. gay bars, but these effects have not generalized to gay bars elsewhere or to other populations. Few interventions have sought to alter the structural and physical environments of drinking places for HIV prevention. Uncontrolled program evaluations have reported promising approaches to bar-based structural interventions with gay men and female sex workers. Finally, a small number of studies have examined multilevel approaches that simultaneously intervene at both social and structural levels with encouraging results. Multilevel interventions that take environmental factors into account are needed to guide future HIV prevention efforts delivered within alcohol-serving establishments.

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.

Monitoring medication adherence by unannounced pill counts conducted by telephone: reliability and criterion-related validity

BACKGROUND

Although demonstrated valid for monitoring medication adherence, unannounced pill counts conducted in patients' homes are costly and logistically challenging. Telephone-based unannounced pill counts offer a promising adaptation that resolves most of the limitations of home-based pill counting.

PURPOSE

We tested the reliability and criterion-related validity of a telephone-based unannounced pill count assessment of antiretroviral adherence.

METHOD

HIV-positive men and women (N = 89) in Atlanta, Georgia, completed a telephone-based unannounced pill count and provided contemporaneous blood specimens to obtain viral loads; 68 participants also received an immediate second pill count conducted during an unannounced home visit.

RESULTS

A high degree of concordance was observed between the number of pills counted on the telephone and in the home (intraclass correlation [ICC] = .981, p < .001) and percent of pills taken (ICC = .987, p < .001). Adherence obtained by the telephone count and home count reached 92% agreement (Kappa coefficient = .94). Adherence determined by telephone-based pill counts also corresponded with patient viral load, providing evidence for criterion-related validity.

CONCLUSION

Unannounced telephone-based pill counts offer a feasible objective method for monitoring medication adherence.

Prevalence and clinical implications of interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapies among people living with HIV/AIDS

Alcohol use is a barrier to medication adherence. Beyond the cognitive effects of intoxication, people living with HIV/AIDS who believe that alcohol should not be mixed with their medications may temporarily stop taking medications when drinking. To examine the effects of alcohol-treatment beliefs on HIV treatment adherence. People living with HIV/AIDS who were receiving treatment (n = 145) were recruited from community and clinical services during the period between January 2006 and May 2008 to complete measures of substance use and alcohol-antiretroviral (ARV) interactive toxicity beliefs (e.g., alcohol breaks down HIV medications so they will not work). Medication adherence was monitored using unannounced telephone-based pill counts. Forty percent of participants were currently using alcohol and nearly one in four drinkers reported stopping their medications when drinking. Beliefs that mixing alcohol and medications is toxic were common among drinkers and nondrinkers, with most beliefs endorsed more frequently by non-drinkers. Hierarchical regression analysis showed that stopping ARVs when drinking was associated with treatment nonadherence over and above quantity/frequency of alcohol use and problem drinking. Beliefs that alcohol and ARVs should not be mixed and that treatments should be interrupted when drinking are common among people living with HIV/AIDS. Clinicians should educate patients about the necessity of continuing to take ARV medications without interruption even if they are drinking alcohol.

Heterosexual anal intercourse among community and clinical settings in Cape Town, South Africa

BACKGROUND

Anal intercourse is an efficient mode of HIV transmission and may play a role in the heterosexual HIV epidemics of southern Africa. However, little information is available on the anal sex practices of heterosexual individuals in South Africa.

PURPOSE

To examine the occurrence of anal intercourse in samples drawn from community and clinic settings.

METHODS

Anonymous surveys collected from convenience samples of 2593 men and 1818 women in two townships and one large city sexually transmitted infection (STI) clinic in Cape Town. Measures included demographics, HIV risk history, substance use and 3-month retrospective sexual behaviour.

RESULTS

A total of 14% (n = 360) men and 10% (n = 172) women reported engaging in anal intercourse in the past 3 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 STI, exchanging sex, using substances, having been tested for HIV and testing HIV positive.

CONCLUSIONS

Anal intercourse is reported relatively less frequently than unprotected vaginal intercourse among heterosexual individuals. The low prevalence of anal intercourse among heterosexual individuals may be offset by its greater efficiency for transmitting HIV. Anal sex should be discussed in heterosexual HIV prevention programming.

HIV transmission risk among HIV seroconcordant and serodiscordant couples: dyadic processes of partner selection

Selecting sex partners of the same HIV status or serosorting is a sexual risk reduction strategy used by many men who have sex with men. However, the effectiveness of serosorting for protection against HIV is potentially limited. We sought to examine how men perceive the protective benefits of factors related to serosorting including beliefs about engaging in serosorting, sexual communication, and perceptions of risk for HIV. Participants were 94 HIV negative seroconcordant (same HIV status) couples, 20 HIV serodiscordant (discrepant HIV status) couples, and 13 HIV positive seroconcordant (same HIV status) couples recruited from a large gay pride festival in the southeastern US. To account for nonindependence found in the couple-level data, we used multilevel modeling which includes dyad in the analysis. Findings demonstrated that participants in seroconcordant relationships were more likely to believe that serosorting reduces concerns for condom use. HIV negative participants in seroconcordant relationships viewed themselves at relatively low risk for HIV transmission even though monogamy within relationships and HIV testing were infrequent. Dyadic analyses demonstrated that partners have a substantial effect on an individual's beliefs and number of unprotected sex partners. We conclude that relationship partners are an important source of influence and, thus, intervening with partners is necessary to reduce HIV transmission risks.

On holiday: a risk behavior profile for men who have vacationed at gay resorts

Sexual risk behavior is higher when people vacation as compared to when they are at home. The current study uses survey data to compare sexual risk behavior of gay men who vacation at gay resorts to those who do not. Independent predictors of vacationing at gay resorts included income level, relationship status, ever having attended a circuit party, and HIV serostatus. For men who visit resorts to meet sex partners, independent predictors included relationship status, ever having attended a circuit party, HIV serostatus, number of male sex partners in the past six months, and number of anal insertive male partners using a condom. These results show a need for the development of structural interventions in the gay resort and hotel setting.

Stigma and discrimination experiences of HIV-positive men who have sex with men in Cape Town, South Africa

Since the primary mode of HIV transmission in sub-Saharan Africa is heterosexual, research focusing on the sexual behaviour of men who have sex with men (MSM) is scant. Currently it is unknown how many people living with HIV in South Africa are MSM and there is even less known about the stigmatisation and discrimination of HIV-positive MSM. The current study examined the stigma and discrimination experiences of MSM living with HIV/AIDS in South Africa. Anonymous venue-based surveys were collected from 92 HIV-positive MSM and 330 HIV-positive men who only reported sex with women (MSW). Internalised stigma was high among all HIV-positive men who took part in the survey, with 56% of men reporting that they concealed their HIV status from others. HIV-positive MSM reported experiencing greater social isolation and discrimination resulting from being HIV-positive, including loss of housing or employment due to their HIV status, however these differences were not significant. Mental health interventions, as well as structural changes for protection against discrimination, are needed for HIV-positive South African MSM.

Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence

BACKGROUND

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.

PURPOSE

To examine the association between health literacy and objectively assessed HIV treatment adherence.

METHODS

Men and women (N = 145) receiving antiretroviral therapy completed a test of health literacy and measures of common adherence markers. Medication adherence was monitored by unannounced pill counts.

RESULTS

Median adherence was 71%; participants with lower-health literacy also demonstrated poorer adherence compared to participants 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.

CONCLUSIONS

The association between literacy and adherence appears robust and was confirmed using an objective measure of medication adherence.

Potential markers of female condom use among inner city African-American women

Despite the availability of the female condoms and theoretically based interventions to promote its use, studies have indicated a low level of acceptability of their use among women in most populations. We aimed to determine female condom use prevalence and the potential markers among African-American women. In an intervention trial to test the efficacy of the Information-Motivation-Behavioral Skills model in increasing condom use, we utilized the baseline data of 280 subjects and examined the potential predictors of female condom use. Chi square statistic and unconditional logistic regression were used to test for group independence among users and non-users of the female condom and to assess the potential markers of female condom use respectively. After adjustment for relevant covariates associated independently with female condom use, the significant potential markers for female condom use were age, multiple sexual relationships, knowledge of female condom, and educational status. Women having multiple sexual relationships compared with a monogamous relationship were five times more likely to use the female condom, while women with high school education were three times more likely to use the female condom; prevalence odds ratio, POR=5.32, 95% CI=1.79-15.83 and POR=3.01, 95% CI=1.01-8.93. Women who were not knowledgeable of the female condom, compared to those who were, were 81% less likely to use the female condom, POR=0.19, 95% CI=0.08-0.45. Among African-American women in this sample, knowledge of female condom use, age, educational status, and multiple sexual relationships were significant markers of female condom use. This study is therefore suggestive of the need to educate African-American women on female condom use, given the obstacles in male condom negotiation, especially among the socio-economically challenged.

Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa

BACKGROUND

HIV is devastating southern Africa and alcohol use is closely related to HIV transmission risks.

PURPOSE

The current study tested the efficacy of a brief single-session HIV-alcohol risk-reduction intervention for men and women who drink at informal alcohol serving establishments (i.e., shebeens) in South Africa.

METHODS

A randomized community field trial recruited men (N = 117) and women (N = 236) through outreach and chain referrals. Participants received either: (a) 3-h theory-based behavioral HIV-alcohol risk-reduction intervention that focused on skills training for sexual negotiation and condom use or (b) 1-h HIV-alcohol information/education control group. Participants were followed up for 3 and 6 months post-intervention with 89% retention.

RESULTS

The risk-reduction intervention demonstrated significantly less unprotected intercourse, alcohol use before sex, numbers of sex partners, partners met at drinking establishments and greater condom use relative to the control group. However, intervention effects were moderated by alcohol use; lighter drinkers demonstrated significantly more intervention gains than heavier drinkers in the risk-reduction condition. Intervention effects occurred at 3 months follow-up and dissipated by 6 months.

CONCLUSIONS

A brief HIV risk-reduction intervention reduced sexual-risk behaviors among drinkers in South Africa. However, intervention effects were weakest for those who drink heaviest. Our results provide a basis for establishing HIV prevention in alcohol serving establishments in South Africa. Research is needed to identify multi-level intervention models that can reduce risks among heavier drinkers and sustain behavior changes over time.

Motivation to reduce HIV risk behaviors in the context of the Information, Motivation and Behavioral Skills (IMB) model of HIV prevention

The Information-Motivation-Behavioral Skills (IMB) model of health behavior was tested in a sample of 391 men who have sex with men at high-risk for HIV transmission. Prospective analyses of IMB predictors of unprotected anal intercourse (UAI) confirmed a good fit. Self-rated motivation was a significant predictor of UAI, as were behavioral skills. However, the lack of information and motivational constructs that predicted behavior suggests that the IMB model is limited as a theory and has its greatest utility as a framework for guiding HIV risk reduction interventions for men who have sex with men at high-risk for HIV infection.

Stress management interventions for HIV+ adults: a meta-analysis of randomized controlled trials, 1989 to 2006

OBJECTIVE

Numerous studies document that stress accelerates disease processes in a variety of diseases including HIV. As a result, investigators have developed and evaluated interventions to reduce stress as a means to improve health among persons living with HIV. Therefore, the current meta-analysis examines the impact of stress-management interventions at improving psychological, immunological, hormonal, and other behavioral health outcomes among HIV+ adults.

DESIGN

This meta-analytic review integrated the results of 35 randomized controlled trials examining the efficacy of 46 separate stress management interventions for HIV+ adults (N=3,077).

MAIN OUTCOME MEASURES

Effect sizes were calculated for stress processes (coping and social support), psychological/psychosocial (anxiety, depression, distress, and quality of life), immunological (CD4+ counts and viral load), hormonal (cortisol, dehydroepiandrosterone sulfate [DHEA-S], cortisol/DHEA-S ratio, and testosterone) and other behavioral health outcomes (fatigue).

RESULTS

Compared to controls, stress-management interventions reduce anxiety, depression, distress, and fatigue and improve quality of life (d+s=0.16 to 0.38). Stress-management interventions do not appear to improve CD4+ counts, viral load, or hormonal outcomes compared with controls.

CONCLUSION

Overall, stress-management interventions for HIV+ adults significantly improve mental health and quality of life but do not alter immunological or hormonal processes. The absence of immunological or hormonal benefits may reflect the studies' limited assessment period (measured typically within 1-week postintervention), participants' advanced stage of HIV (HIV+ status known for an average of 5 years), and/or sample characteristics (predominately male and White participants). Future research might test these hypotheses and refine our understanding of stress processes and their amelioration.

Co-occurrence of treatment nonadherence and continued HIV transmission risk behaviors: implications for positive prevention interventions

Effective treatment regimens for HIV infection demand very high levels of adherence and people infected with HIV are expected to adhere to safer sex and drug use practices throughout their lives. Treatment nonadherence overlaps with continued unsafe sexual practices for some people living with HIV/AIDS. The co-occurrence of nonadherence and HIV transmission risk behavior poses particular risk for the spread of drug-resistant variants of HIV. There are common correlates of both nonadherence and risk behavior, particularly substance use and depression. Interventions designed to address treatment nonadherence and those designed to reduce risk behavior also share common elements, particularly self-efficacy enhancement and behavioral skills training. The common correlates and shared intervention elements suggest that integrated intervention approaches that simultaneously address adherence and risk reduction may be feasible. Research is currently testing interventions that simultaneously increase HIV treatment adherence and reduce behaviors that risk HIV transmission.

Repeat HIV testing and HIV transmission risk behaviors among sexually transmitted infection clinic patients

HIV testing and counseling expends considerable HIV prevention resources and offers great opportunities for HIV risk reduction. Individuals who are at risk for HIV and have not been HIV tested are the focus of current targeted testing campaigns and yet persons who are repeatedly tested for HIV often continue engaging in high-risk practices. This study examined HIV testing, risk behaviors, and other medical diagnostic testing practices of men (N = 231) and women (N = 86) attending an inner-city sexually transmitted infections (STI) clinic. Results showed that 75 (23%) participants had not yet been tested for HIV, 45 (14%) had been tested once, and 197 (63%) had been tested two or more times. Patients that had not been tested and those who were repeatedly tested were similar in their risk behaviors; both demonstrated significantly greater risks for HIV than persons tested just once, although repeat testers were more likely to have had a past STI. HIV testing history was minimally associated with other medical testing and health protective practices, such as testicular self-examination, mammography, and having had PAP tests. Results support targeting high-risk untested persons for HIV testing and suggest an urgent need for interventions to reduce risk behaviors among STI clinic patients who repeatedly test for HIV.

Gender, Power and Resistance to Change among Two Communities in the Western Cape, South Africa

This study investigates how women and men in the Western Cape, South Africa, construct their gender identities and roles. As part of the development of an HIV prevention intervention for men, key informant interviews and focus group discussions were conducted. Several themes regarding the construction of gender were identified. First, participants reported that traditional gender relations of male dominance and female subservience were still in evidence, along with traditional gender roles that mandated a division of labour between the household and paid workforce. Second, participants reported a shift in gender roles and relations in the direction of increased power for women. Last, hostile resistance to changes in gender power relations was evident in the discussions. Redefining masculinity and femininity and shifting gender relations in the direction of `power with' instead of `power over' is perhaps a necessary prelude to lasting social change and curbing the HIV epidemic in South Africa.