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Hartmann M, Lanham M, Palanee-Phillips T, Mathebula F, Tolley EE, Peacock D, Pascoe L, Zissette S, Roberts ST, Wagner D, Wilson E, Ayub A, Wilcher R, Montgomery ET. Generating CHARISMA: Development of an Intervention to Help Women Build Agency and Safety in Their Relationships While Using PrEP for HIV Prevention. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2019; 31:433-451. [PMID: 31550193 PMCID: PMC7082989 DOI: 10.1521/aeap.2019.31.5.433] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article describes the development of the Community Health clinic model for Agency in Relationships and Safer Microbicide Adherence intervention (CHARISMA), an intervention designed to address the ways in which gender norms and power differentials within relationships affect women's ability to safely and consistently use HIV pre-exposure prophylaxis (PrEP). CHARISMA development involved three main activities: (1) a literature review to identify appropriate evidence-based relationship dynamic scales and interventions; (2) the analysis of primary and secondary data collected from completed PrEP studies, surveys and cognitive interviews with PrEP-experienced and naïve women, and in-depth interviews with former vaginal ring trial participants and male partners; and (3) the conduct of workshops to test and refine key intervention activities prior to pilot testing. These steps are described along with the final clinic and community-based intervention, which was tested for feasibility, acceptability, and preliminary effectiveness in Johannesburg, South Africa.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health Imperative, RTI International, San Francisco, California
| | | | | | | | | | - Dean Peacock
- Sonke Gender Justice, Johannesburg, South Africa
| | - Laura Pascoe
- Sonke Gender Justice, Johannesburg, South Africa
| | | | - Sarah T Roberts
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Danielle Wagner
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Ellen Wilson
- Women's Global Health Imperative, RTI International, San Francisco, California
| | - Asha Ayub
- Women's Global Health Imperative, RTI International, San Francisco, California
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Tan RKJ, Wong CS. Mobilizing civil society for the HIV treatment cascade: a global analysis on democracy and its association with people living with HIV who know their status. J Int AIDS Soc 2019; 22:e25374. [PMID: 31379133 PMCID: PMC6680091 DOI: 10.1002/jia2.25374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 07/21/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Civil society organizations (CSOs) play an essential role in the global HIV/AIDS response. Past studies have described the beneficial role of CSOs in meeting the United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 target, but have not explored how political conditions, which influence the ability of CSOs to organize, have an impact on the cascade. This study explores the relationship between measures of democracy and its association with diagnosis rates among people living with HIV (PLHIV). METHODS This study analyses 2016 data derived from the Economist Intelligence Unit's Democracy Index (EIUDI), UNAIDS country estimates for PLHIV and PLHIV who knew their status in 2016, World Bank's 2016 data on nominal gross domestic product (GDP) per capita and country population, HIV Justice Network's 2016 data on HIV criminalization, and country-level estimates for PLHIV, PLHIV who know their status, and expenditure on HIV prevention from other independent sources. An estimated HIV prevalence variable was constructed by dividing the estimated PLHIV population with the total population of a country. Analyses were limited to countries with available data on PLHIV who know their status (n = 111). RESULTS Of the 111 countries in the analytic sample, the mean democracy index score was 5.93 (of the 10), median estimated HIV prevalence was 0.20% (IQR 0.10-0.65), median GDP per capita (in thousands, US dollar) was 4.88 (IQR 2.11-13.79), and mean PLHIV who know their status is 67.12%. Preliminary analysis on the five component measures of the EIUDI revealed multicollinearity, and thus the composite democracy index score was used as the measure for democracy. Multivariate linear regression analyses revealed that democracy index scores (β = 2.10, SE = 1.02, p = 0.04) and GDP per capita (in thousands; β = 0.34. SE = 0.11, p < 0.01) were positively associated with diagnosis rates among PLHIV, controlling for country-level expenditure on HIV prevention, HIV criminalization laws and estimated HIV prevalence. CONCLUSIONS Results indicate that higher levels of democracy were positively associated with rates of diagnosis among PLHIV. Further analyses following wider implementation of universal testing and treatment is warranted, as well as the need for further research on the mechanisms through which political cultures specifically influence rates of diagnosis among PLHIV.
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Affiliation(s)
- Rayner KJ Tan
- Saw Swee Hock School of Public HealthNational University of SingaporeSingapore
| | - Chen Seong Wong
- National Centre for Infectious DiseasesSingapore
- Department of MedicineYong Loo Lin School of MedicineNational University of SingaporeSingapore
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Strategies for engaging men in HIV services. Lancet HIV 2019; 6:e191-e200. [PMID: 30777726 DOI: 10.1016/s2352-3018(19)30032-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/20/2018] [Accepted: 12/20/2018] [Indexed: 12/14/2022]
Abstract
The importance of men in the global HIV response is increasingly recognised. In most settings, men are less engaged in HIV services and have worse health outcomes than women. The multiple gender, social, economic, political, and institutional factors behind these patterns are well documented. More recently, researchers have been reporting evidence on strategies aimed at improving the engagement of men in HIV services. Several promising approaches exist, including community-based outreach programmes, gender-transformative interventions to shift gender norms and practices, and the development of more responsive, male-friendly health services. Challenges remain, however, in terms of cost and sustainability, intersecting inequalities like race and class, and the difficulty of changing community-level gender norms. Future research should focus on developing theory-informed interventions and evaluations, on improving the understanding of specific subpopulations of men, and on broadening the evidence base beyond the few countries that produce most research in this field.
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Leddy AM, Lippman SA, Neilands TB, Twine R, Ahern J, Gómez-Olivé FX, DeLong SM, MacPhail C, Kahn K, Pettifor AE. Community collective efficacy is associated with reduced physical intimate partner violence (IPV) incidence in the rural province of Mpumalanga, South Africa: findings from HPTN 068. J Epidemiol Community Health 2018; 73:176-181. [PMID: 30455373 DOI: 10.1136/jech-2018-211357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/25/2018] [Accepted: 10/27/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Intimate partner violence (IPV) is a human rights violation and is associated with a variety of adverse physical and mental health outcomes. Collective efficacy, defined as mutual trust among community members and willingness to intervene on the behalf of the common good, has been associated with reduced neighbourhood violence. Limited research has explored whether community collective efficacy is associated with reduced incidence of IPV. This is of particular interest among adolescent girls and young women (AGYW) in sub-Saharan Africa, where the burden of HIV is greatest and IPV is common. METHODS We collected longitudinal data among 2533 AGYW (ages 13-20) enrolled in the HPTN 068 cohort in Mpumalanga province, South Africa between 2011 and 2016. We included participants from 26 villages where community surveys were collected during the HPTN 068 study. Collective efficacy was measured at the village level via two population-based cross-sectional surveys in 2012 and 2014. Multivariable Poisson generalised estimating equation regression models estimated the relative risk ratio (RR) between village collective efficacy scores and subsequent physical IPV 12 month incidence, adjusting for village-level clustering and covariates. RESULTS Thirty-eight per cent of the cohort (n=950) reported at least one episode of recent physical IPV during follow-up. For every SD higher level of collective efficacy, there was a 6% lower level of physical IPV incidence (adjusted RR: 0.94; 95% CI 0.89 to 0.98) among AGYW after adjusting for covariates. CONCLUSIONS Community-level interventions that foster the development of collective efficacy may reduce IPV among AGYW.
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Affiliation(s)
- Anna M Leddy
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA
| | - Sheri A Lippman
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA.,MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Torsten B Neilands
- Department of Medicine, Division of Prevention Science, Center for AIDS Prevention Studies, University of California, San Francisco, California, USA
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Ahern
- Division of Epidemiology and Biostatistics, School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Stephanie M DeLong
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Catherine MacPhail
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia.,Wits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Audrey E Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Lippman SA, Leddy AM, Neilands TB, Ahern J, MacPhail C, Wagner RG, Peacock D, Twine R, Goin DE, Gómez‐Olivé FX, Selin A, Tollman SM, Kahn K, Pettifor A. Village community mobilization is associated with reduced HIV incidence in young South African women participating in the HPTN 068 study cohort. J Int AIDS Soc 2018; 21 Suppl 7:e25182. [PMID: 30334377 PMCID: PMC6192897 DOI: 10.1002/jia2.25182] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/20/2018] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Adolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a 'critical enabler' for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW. METHODS We examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates. RESULTS There were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role. CONCLUSIONS These results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.
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Affiliation(s)
- Sheri A Lippman
- Center for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Anna M Leddy
- Center for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Torsten B Neilands
- Center for AIDS Prevention StudiesUniversity of CaliforniaSan FranciscoCAUSA
| | - Jennifer Ahern
- Division of EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Catherine MacPhail
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- School of Health and SocietyUniversity of WollongongWollongongNSWAustralia
- Wits Reproductive Health and HIV Research InstituteUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ryan G Wagner
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Epidemiology and Global HealthDepartment of Public Health and Clinical MedicineUmeå Centre for Global Health ResearchUmeå UniversityUmeåSweden
| | - Dean Peacock
- Sonke Gender JusticeCape TownSouth Africa
- School of Public HealthUniversity of Cape TownCape TownSouth Africa
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Dana E Goin
- Division of EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - F Xavier Gómez‐Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Amanda Selin
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Epidemiology and Global HealthDepartment of Public Health and Clinical MedicineUmeå Centre for Global Health ResearchUmeå UniversityUmeåSweden
- INDEPTH NetworkAccraGhana
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Division of Epidemiology and Global HealthDepartment of Public Health and Clinical MedicineUmeå Centre for Global Health ResearchUmeå UniversityUmeåSweden
| | - Audrey Pettifor
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
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56
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Pettifor A, Lippman SA, Gottert A, Suchindran CM, Selin A, Peacock D, Maman S, Rebombo D, Twine R, Gómez‐Olivé FX, Tollman S, Kahn K, MacPhail C. Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa. J Int AIDS Soc 2018; 21:e25134. [PMID: 29972287 PMCID: PMC6058206 DOI: 10.1002/jia2.25134] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 05/09/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Community mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk. METHODS Twenty two villages in the Agincourt Health and Socio-Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory-based, gender transformative, CM intervention or no intervention. Two cross-sectional, population-based surveys were conducted in 2012 (pre-intervention, n = 600 women; n = 581 men) and 2014 (post-intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent-to-treat (ITT) approach using survey regression cluster-adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes. RESULTS Among men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16). CONCLUSION Community mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly. CLINICAL TRIALS NUMBER ClinicalTrials.gov NCT02129530.
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Affiliation(s)
- Audrey Pettifor
- Department of EpidemiologyUniversity of North Carolina Gillings School of Global Public HealthChapel HillNCUSA
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Center for AIDS Prevention Studies (CAPS)Department of MedicineUniversity of California at San FranciscoSan FranciscoCAUSA
| | - Ann Gottert
- Population CouncilHIV and AIDS programWashingtonDCUSA
| | - Chirayath M Suchindran
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
- Department of BiostatisticsUniversity of North Carolina Gillings School of Global Public HealthChapel HillNCUSA
| | - Amanda Selin
- Carolina Population CenterUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Dean Peacock
- Sonke Gender JusticeCape TownSouth Africa
- School of Public HealthDivision of Social and Behavioural ScienceUniversity of Cape TownCape TownSouth Africa
| | - Suzanne Maman
- Department of Health BehaviorUniversity of North Carolina Gillings School of Global Public HealthChapel HillNC
| | | | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Francesc Xavier Gómez‐Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Epidemiology and Global Health UnitDepartment of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Epidemiology and Global Health UnitDepartment of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Catherine MacPhail
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt)School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- School of HealthUniversity of New EnglandArmidaleNSWAustralia
- Wits RHIUniversity of the WitwatersrandJohannesburgSouth Africa
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