Creating HIV risk profiles for men in South Africa: a latent class approach using cross-sectional survey data

Latent class analysis of barriers to HIV testing services and associations with sexual behaviour and HIV status among adolescents and young adults in Nigeria

INTRODUCTION

Adolescents and young adults (AYA) face multiple barriers to accessing healthcare services, which can interact, creating complex needs that often impact health behaviours, leading to increased vulnerability to HIV. We aimed to identify distinct AYA subgroups based on patterns of barriers to HIV testing services and assess the association between these barrier patterns and sexual behaviour, socio-demographics, and HIV status.

METHODS

Data were from Nigeria's AIDS Indicator and Impact Survey (NAIIS, 2018) and included 18,612 sexually active AYA aged 15-24 years who had never been tested for HIV and reported barriers to accessing HIV testing services. A Latent class analysis (LCA) model was built from 12 self-reported barrier types to identify distinct subgroups of AYA based on barrier patterns. Latent class regressions (LCR) were conducted to compare the socio-demographics, sexual behaviour, and HIV status across identified AYA subgroups. Sex behaviour characteristics include intergenerational sex, transactional sex, multiple sex partners, condom use, and knowledge of partner's HIV status.

RESULTS

Our LCA model identified four distinct AYA subgroups termed 'low-risk perception' (n = 7,361; 39.5%), 'consent and proximity' (n = 5,163; 27.74%), 'testing site' (n = 4,996; 26.84%), and 'cost and logistics' (n = 1,092; 5.87%). Compared to adolescents and young adults (AYA) in the low-risk perception class, those in the consent and proximity class were more likely to report engaging in intergenerational sex (aOR 1.17, 95% CI 1.02-1.35), transactional sex (aOR 1.50, 95% CI 1.23-1.84), and have multiple sex partners (aOR 1.75, 95% CI 1.39-2.20), while being less likely to report condom use (aOR 0.79, 95% CI 0.63-0.99). AYA in the testing site class were more likely to report intergenerational sex (aOR 1.21, 95% CI 1.04-1.39) and transactional sex (aOR 1.53, 95% CI 1.26-1.85). AYA in the cost and logistics class were more likely to engage in transactional sex (aOR 2.12, 95% CI 1.58-2.84) and less likely to report condom use (aOR 0.58, 95% CI 0.34-0.98). There was no significant relationship between barrier subgroup membership and HIV status. However, being female, aged 15-24 years, married or cohabiting, residing in the Southsouth zone, and of Christian religion increased the likelihood of being HIV infected.

CONCLUSIONS

Patterns of barriers to HIV testing are linked with differences in sexual behaviour and sociodemographic profiles among AYA, with the latter driving differences in HIV status. Findings can improve combination healthcare packages aimed at simultaneously addressing multiple barriers and determinants of vulnerability to HIV among AYA.

An agent-based model of binge drinking, inequitable gender norms and their contribution to HIV transmission, with application to South Africa

BACKGROUND

Binge drinking, inequitable gender norms and sexual risk behaviour are closely interlinked. This study aims to model the potential effect of alcohol counselling interventions (in men and women) and gender-transformative interventions (in men) as strategies to reduce HIV transmission.

METHODS

We developed an agent-based model of HIV and other sexually transmitted infections, allowing for effects of binge drinking on sexual risk behaviour, and effects of inequitable gender norms (in men) on sexual risk behaviour and binge drinking. The model was applied to South Africa and was calibrated using data from randomized controlled trials of alcohol counselling interventions (n = 9) and gender-transformative interventions (n = 4) in sub-Saharan Africa. The model was also calibrated to South African data on alcohol consumption and acceptance of inequitable gender norms. Binge drinking was defined as five or more drinks on a single day, in the last month.

RESULTS

Binge drinking is estimated to be highly prevalent in South Africa (54% in men and 35% in women, in 2021), and over the 2000-2021 period 54% (95% CI: 34-74%) of new HIV infections occurred in binge drinkers. Binge drinking accounted for 6.8% of new HIV infections (0.0-32.1%) over the same period, which was mediated mainly by an effect of binge drinking in women on engaging in casual sex. Inequitable gender norms accounted for 17.5% of incident HIV infections (0.0-68.3%), which was mediated mainly by an effect of inequitable gender norms on male partner concurrency. A multi-session alcohol counselling intervention that reaches all binge drinkers would reduce HIV incidence by 1.2% (0.0-2.5%) over a 5-year period, while a community-based gender-transformative intervention would reduce incidence by 3.2% (0.8-7.2%) or by 7.3% (0.6-21.2%) if there was no waning of intervention impact.

CONCLUSIONS

Although binge drinking and inequitable gender norms contribute substantially to HIV transmission in South Africa, recently-trialled alcohol counselling and gender-transformative interventions are likely to have only modest effects on HIV incidence. Further innovation in developing locally-relevant interventions to address binge drinking and inequitable gender norms is needed.

Creating Reproductive Health Behavioral Profiles for Women of Reproductive Age in Niger Using Cross-Sectional Survey Data: A Latent Class Analysis

Objectives: To identify health behavioral profiles for women of reproductive age in Niger. Methods: We interviewed married women of reproductive age in Niger in April 2021 (N = 2,709). Latent class analysis based on sociodemographic and behavioral determinants was used to identify classes of women related to use of antenatal care, facility delivery, and modern family planning (FP) use. Results: We found similar classes between the use of antenatal care and facility-based delivery classes with the first class composed of less educated and poor women with weaker behavioral determinants while the second class was more educated and had stronger behavioral determinants. In the facility-based delivery class was the presence of a third class that was poor and uneducated with low levels of knowledge and social norms, but in contrast had much higher levels of positive attitudes, self-efficacy, and partner communication than the first class. A fourth class of younger, more educated women with strong behavioral determinants emerged related to FP. Conclusion: The application of empirical subgrouping analysis permits an informed approach to targeted interventions and resource allocation for optimizing maternal and reproductive health.

Food insecurity and the risk of HIV acquisition: findings from population-based surveys in six sub-Saharan African countries (2016-2017)

OBJECTIVE

To assess the potential bidirectional relationship between food insecurity and HIV infection in sub-Saharan Africa.

DESIGN

Nationally representative HIV impact assessment household-based surveys.

SETTING

Zambia, Eswatini, Lesotho, Uganda and Tanzania and Namibia.

PARTICIPANTS

112 955 survey participants aged 15-59 years with HIV and recency test results.

MEASURES

Recent HIV infection (within 6 months) classified using the HIV-1 limited antigen avidity assay, in participants with an unsuppressed viral load (>1000 copies/mL) and no detectable antiretrovirals; severe food insecurity (SFI) defined as having no food in the house ≥three times in the past month.

RESULTS

Overall, 10.3% of participants lived in households reporting SFI. SFI was most common in urban, woman-headed households, and in people with chronic HIV infection. Among women, SFI was associated with a twofold increase in risk of recent HIV infection (adjusted relative risk (aRR) 2.08, 95% CI 1.09 to 3.97). SFI was also associated with transactional sex (aRR 1.28, 95% CI 1.17 to 1.41), a history of forced sex (aRR 1.36, 95% CI 1.11 to 1.66) and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02 to 1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15-24 years (aRR 1.23, 95% CI 1.03 to 1.46). Recent receipt of food support was protective against HIV acquisition (aRR 0.36, 95% CI 0.14 to 0.88).

CONCLUSION

SFI increased risk for HIV acquisition in women by twofold. Heightened food insecurity during climactic extremes could imperil HIV epidemic control, and food support to women with SFI during these events could reduce HIV transmission.

Unawareness of HIV Infection Among Men Aged 15-59 Years in 13 Sub-Saharan African Countries: Findings From the Population-Based HIV Impact Assessments, 2015-2019

BACKGROUND

Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries.

METHODS

Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV.

RESULTS

A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity.

CONCLUSION

Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.

What's in a Name? A Mixed Method Study on How Young Women Who Sell Sex Characterize Male Partners and Their Use of Condoms

INTRODUCTION

Young women who sell sex (YWSS) are at disproportionate risk of HIV. Reducing YWSS' vulnerability requires engaging their male sexual partners. To achieve this, we need to understand the characteristics and dynamics of their sexual partnerships to inform effective interventions.

METHODS

We conducted a mixed-methods study to compare YWSS' qualitative descriptions of male partners with categories reported in a behavioral survey. Data were drawn from enrollment into an evaluation of the DREAMS initiative in Zimbabwe in 2017. As part of a respondent-driven sampling survey, we recruited 40 seed participants from 2 intervention and 4 comparison sites. We conducted semistructured interviews with 19 "seeds," followed by a behavioral survey with 2387 YWSS. We interpreted quantitative and qualitative data together to understand how YWSS perceived male sexual partners, assess how well survey variables related to narrative descriptions, and describe patterns of risk behavior within partnerships.

RESULTS

Qualitative data suggest survey categories "husband" and "client" reflect YWSS' perceptions but "regular partner/boyfriend" and "casual partner" do not. In interviews, use of the term "boyfriend" was common, describing diverse relationships with mixed emotional and financial benefits. More than 85% of male partners provided money to YWSS, but women were less likely to report condomless sex with clients than regular partners (11% vs 37%) and more likely to report condomless sex with partners who ever forced them to have sex (37% vs 21%).

CONCLUSIONS

Reducing HIV risk among YWSS requires prevention messages and tools that recognize diverse and changing vulnerability within and between sexual relationships with different male partners.

Malaria risk factors in northern Namibia: The importance of occupation, age and mobility in characterizing high-risk populations

In areas of low and unstable transmission, malaria cases occur in populations with lower access to malaria services and interventions, and in groups with specific malaria risk exposures often away from the household. In support of the Namibian National Vector Borne Disease Program's drive to better target interventions based upon risk, we implemented a health facility-based case control study aimed to identify risk factors for symptomatic malaria in Zambezi Region, northern Namibia. A total of 770 febrile individuals reporting to 6 health facilities and testing positive by rapid diagnostic test (RDT) between February 2015 and April 2016 were recruited as cases; 641 febrile individuals testing negative by RDT at the same health facilities through June 2016 were recruited as controls. Data on socio-demographics, housing construction, overnight travel, use of malaria prevention and outdoor behaviors at night were collected through interview and recorded on a tablet-based questionnaire. Remotely-sensed environmental data were extracted for geo-located village residence locations. Multivariable logistic regression was conducted to identify risk factors and latent class analyses (LCA) used to identify and characterize high-risk subgroups. The majority of participants (87% of cases and 69% of controls) were recruited during the 2016 transmission season, an outbreak year in Southern Africa. After adjustment, cases were more likely to be cattle herders (Adjusted Odds Ratio (aOR): 4.46 95%CI 1.05-18.96), members of the police or other security personnel (aOR: 4.60 95%CI: 1.16-18.16), and pensioners/unemployed persons (aOR: 2.25 95%CI 1.24-4.08), compared to agricultural workers (most common category). Children (aOR 2.28 95%CI 1.13-4.59) and self-identified students were at higher risk of malaria (aOR: 4.32 95%CI 2.31-8.10). Other actionable risk factors for malaria included housing and behavioral characteristics, including traditional home construction and sleeping in an open structure (versus modern structure: aOR: 2.01 95%CI 1.45-2.79 and aOR: 4.76 95%CI: 2.14-10.57); cross border travel in the prior 30 days (aOR: 10.55 95%CI 2.94-37.84); and outdoor agricultural work at night (aOR: 2.09 95%CI 1.12-3.87). Malaria preventive activities were all protective and included personal use of an insecticide treated net (ITN) (aOR: 0.61 95%CI 0.42-0.87), adequate household ITN coverage (aOR: 0.63 95%CI 0.42-0.94), and household indoor residual spraying (IRS) in the past year (versus never sprayed: (aOR: 0.63 95%CI 0.44-0.90). A number of environmental factors were associated with increased risk of malaria, including lower temperatures, higher rainfall and increased vegetation for the 30 days prior to diagnosis and residing more than 5 minutes from a health facility. LCA identified six classes of cases, with class membership strongly correlated with occupation, age and select behavioral risk factors. Use of ITNs and IRS coverage was similarly low across classes. For malaria elimination these high-risk groups will need targeted and tailored intervention strategies, for example, by implementing alternative delivery methods of interventions through schools and worksites, as well as the use of specific interventions that address outdoor transmission.

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria

INTRODUCTION

Substantial disparities in care outcomes exist between different subgroups of adolescents and youths living with HIV (AYLHIV). Understanding variation in individual and health facility characteristics could be key to identifying targets for interventions to reduce these disparities. We modelled variation in AYLHIV retention in care and viral suppression, and quantified the extent to which individual and facility characteristics account for observed variations.

METHODS

We included 1170 young adolescents (10-14 years), 3206 older adolescents (15-19 years) and 9151 young adults (20-24 years) who were initiated on antiretroviral therapy (ART) between January 2015 and December 2017 across 124 healthcare facilities in Nigeria. For each age group, we used multilevel modelling to partition observed variation of main outcomes (retention in care and viral suppression at 12 months after ART initiation) by individual (level one) and health facility (level two) characteristics. We used multiple group analysis to compare the effects of individual and facility characteristics across age groups.

RESULTS

Facility characteristics explained most of the observed variance in retention in care in all the age groups, with smaller contributions from individual-level characteristics (14%-22.22% vs 0%-3.84%). For viral suppression, facility characteristics accounted for a higher proportion of variance in young adolescents (15.79%), but not in older adolescents (0%) and young adults (3.45%). Males were more likely to not be retained in care (adjusted OR (aOR)=1.28; p<0.001 young adults) and less likely to achieve viral suppression (aOR=0.69; p<0.05 older adolescent). Increasing facility-level viral load testing reduced the likelihood of non-retention in care, while baseline regimen TDF/3TC/EFV or NVP increased the likelihood of viral suppression.

CONCLUSIONS

Differences in characteristics of healthcare facilities accounted for observed disparities in retention in care and, to a lesser extent, disparities in viral suppression. An optimal combination of individual and health services approaches is, therefore, necessary to reduce disparities in the health and well-being of AYLHIV.

Individual- and Facility-Level Factors Associated with Facility Testing among Men in Malawi: Findings from a Representative Community Survey

(1) Background: Men frequent outpatient departments (OPD) but are underrepresented in HIV testing services throughout sub-Saharan Africa. (2) Methods: We conducted a secondary analysis on data from a community-based survey with men in rural Malawi to assess factors associated with HIV testing, and being offered testing, during men's OPD visits. We include OPD visits made by men in-need of testing as our unit of observation. Multilevel mixed-effects logistic regression models were conducted. (3) Results: 782 men were eligible for these analyses, with 1575 OPD visits included (median two visits per man; IQR 1-3). 17% of OPD visits resulted in HIV testing. Being offered testing (aOR 42.45; 95% CI 15.13-119.10) and satisfaction with services received (aOR 3.27; 95% CI 1.28-8.33) were significantly associated with HIV testing. 14% of OPD visits resulted in being offered HIV testing. Being married/steady relationship (aOR 2.53; 95% CI 1.08-5.91) and having a sexual partner living with HIV (aOR 8.22; 95% CI 1.67-40.49) were significantly associated with being offered testing. (4) Conclusion: Being offered HIV testing was the strongest factor associated with testing uptake, while HIV status of sexual partner had the strongest association with being offered testing. Implementation of provider-initiated-testing should be prioritized for male OPD visits.

"A loving man has a very huge responsibility": A mixed methods study of Malawian men's knowledge and beliefs about cervical cancer

BACKGROUND

In Malawi, numerous barriers may prevent women from accessing cervical cancer screening services - including social factors such as male partner involvement. We conducted surveys that included open- and closed-ended questions with married Malawian men to evaluate their knowledge and beliefs about cervical cancer.

METHODS

HIV-positive adult (≥18 years) men (married or in a stable relationship) were recruited from an antiretroviral therapy clinic in Lilongwe, Malawi. Men were asked a series of survey questions to assess their knowledge about cervical cancer, experience with cervical cancer, their female partner's screening history, and their beliefs about gender norms and household decision-making. Following the survey, participants responded to a set of open-ended interview questions about cervical cancer screening, and men's role in prevention.

RESULTS

One hundred-twenty men were enrolled with average age 44 years and 55% having completed secondary school or higher education. Despite only moderate knowledge about cervical cancer and screening (average assessment score of 62% correct), all men expressed support of cervical cancer screening, and most (86%) believed they should be involved in their female partner's decision to be screened. Over half (61%) of men said their female partner had previously been screened for cervical cancer, and this was positively correlated with the male respondent having more progressive gender norms around sexual practices. Some men expressed concerns about the screening process, namely the propriety of vaginal exams when performed by male clinicians, and whether the procedure was painful.

CONCLUSIONS

Male partners in Malawi want to be involved in decisions about cervical cancer screening, but have limited knowledge about screening, and hold rigid beliefs about gender norms that may affect their support for screening. Messaging campaigns addressing men's concerns may be instrumental in improving women's adoption of cervical cancer screening services in Malawi and similar settings.