Perceptions of sexual risk behaviours and substance abuse among adolescents in South Africa: a qualitative investigation

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A qualitative exploration of alcohol, gender, stigma, and sexual assault in Moshi, Tanzania

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi. In-depth interviews were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach. Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use encouraged for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men. Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context while treatment for men should be cognizant of the social pressures to drink. Strategies to address and/or mitigate these factors should be incorporated in subsequent care and interventions.

"When a man drinks alcohol it's cool but when a woman drinks she is a hoe": A Qualitative Exploration of Alcohol, Gender, Stigma, and Sexual Assault in Moshi, Tanzania

Background

Alcohol's ever-increasing global use poses a distinct threat to human well-being, with intake and associated burdens rising especially quickly in low- and middle-income countries like Tanzania. Prior research has shown alcohol use and related consequences differ by gender in Moshi, Tanzania, with important implications for both clinical care and future alcohol-reduction interventions. This study builds upon this knowledge by providing a deeper understanding of how gender differences affect alcohol-related stigma and sexual assault among Emergency Department (ED) and Reproductive Health Center (RHC) patients at Kilimanjaro Christian Medical Center (KCMC) in Moshi.

Methods

In-depth interviews (IDIs) were conducted among ED and RHC KCMC patients (n = 19) selected for participation via purposive sampling. A mix of inductive and deductive coding schemes was used to identify themes and subthemes. All data were analyzed through a grounded theory approach.

Results

Gender roles that linked men with financial responsibilities and women with child caretaking led to different expectations on alcohol intake, with alcohol use normalized for men but vilified for women. Women who drank, for example, were deemed poor mothers and undesirable spouses. Patients likewise emphasized that both alcohol-related stigma and sexual violence disproportionately impacted women, the latter fueled through alcohol use, with serious and lasting acts of discrimination and isolation from community members seen among women alcohol users but not for men.

Conclusion

Women alcohol users in Moshi are subject to severe social consequences, facing disproportionate stigma and sexual violence as compared to men. Alcohol-related treatment for women should be mindful of the disproportionate burdens present in this context and incorporate strategies to address and/or mitigate these harms in subsequent care and interventions.

Drug Use and High-risk Sexual Behavior among School-Going Adolescents in Nigeria

BACKGROUND: Sexual risk behavior and drug abuse among adolescents and youths remained perpetual topical issues of focus in most developmental programs related to developing countries, especially in Nigeria, where the school-going adolescents constitute more than half of the youths. The high level of teenage pregnancy and sexual violence such as abuses and other harmful trajectories including STIs and HIV is increasingly reported than the pre-2000s. AIM: This study focuses on underscoring the variation in risky sexual behavior among school-going users and non-users of drugs. It also analyzed the predisposing factors of drug use among school-going adolescents in Nigeria. METHODS: In combination with problem behavior theory, the research draws data (n = 11,799) from the 2012 National HIV and AIDS and Reproductive Health Survey (NARHS Plus II) collated by the Federal Ministry of Health in Nigeria with support from the Department for International Development and United States Agency for International Development, to underscore the self-reported sexual risk behavior among students who are users and non-users of drugs. RESULTS: The result revealed that 32.5% (male) and 33.4% (female) use drugs. More than half of the respondents reported that they have engaged in sexual intercourse, 27.3% (male) and 31.8% (female) have had ≥2 lifetime sexual partners. There is higher odds ratio (OR) of risky sexual behavior among students that have ever used drugs or taken alcohol (OR = 2.2, 95% CI [1.8–2.8]) for male and (OR = 2.1, 95% CI [0.83–2.03]) for female. CONCLUSION: The study concludes that continued exposure of school-going youths to drugs or alcohol may pose serious challenge of risky sexual behavior and also severe threat to initiatives on zero new HIV infections or zero new AIDS death in Nigeria. The authors recommend that campaign to discourage drug or alcohol use should be intensified and introduced to all schools.

The adaptation of an evidence-based brief intervention for substance-using adolescents and their caregivers

Objective: Adolescent substance use is prevalent and associated with additional risk behaviours. Research shows that evidence-based brief interventions with adolescents and their main caregiver may mitigate the progression of substance use. Method: We used the ADAPT-ITT framework to develop a needs-based, culturally-sensitive intervention. Five focus groups with adolescents (n = 30), three focus groups with separate main caregivers of adolescents who use substances (n = 21), key informant interviews and an expert meeting, were conducted. Results: Adolescents described the need to decrease risk behaviours, while adolescents and caregivers requested additional support. The core components of the original intervention were retained, with some additions. The newly adapted RAD-PAL intervention was viewed as acceptable. Conclusion: Despite apparent acceptability, we need to test feasibility and efficacy in a trial.

With a little help from my friends? A longitudinal look at the role of peers versus friends on adolescent alcohol use

INTRODUCTION

Alcohol is the most commonly used substance by South African adolescents. Social norms play a key role in alcohol use, although distinctions are not always made between descriptive and injunctive norms and peer proximity. Additionally, little research identifies factors attenuating social norms, peer proximity, and alcohol use, such as one's ability to resist peer influence.

METHODS

The current study investigates the relationship between adolescent alcohol use in 9th Grade and descriptive peer and injunctive friend norms in 8th grade, the moderating role of resistance to peer influence, and sex differences. Data were from South African students (N = 3592; M_age = 14) participating in the HealthWise South Africa implementation quality trial.

RESULTS

Path model results indicated injunctive friend norms, but not peer norms, influenced alcohol use. Resistance to peer influence did not moderate relationships and group comparisons found no sex differences.

CONCLUSION

Findings suggest social proximity shapes influences of alcohol use. Despite a differing cultural context, findings were consistent with those from the United States, indicating social proximity is relevant cross-culturally.

Perceptions of key participants about Botswana adolescents' risks of unplanned pregnancy, sexually transmitted diseases, and HIV: Qualitative findings

AIM

The qualitative research findings are reported on the perceptions of key participants in Botswana about adolescent sexuality problems and the feasibility (with suggestions) of an adolescent prevention intervention.

METHODS

Twenty adult key participants who were selected through purposive sampling from schools and youth centers responded to open-ended questions during face-to-face individual in-depth interviews that were conducted between December, 2011 and January, 2012 in Gaborone, Botswana.

RESULTS

The data were analyzed by using an inductive content analysis. Five major themes and 12 subthemes emerged from the interviews. The key participants discussed situations that exposed adolescents to HIV, sexually transmitted infections, and pregnancy. They also discussed unsafe sexual practices, the consequences of unprotected sex, poor parent-adolescent communication on sexuality, and the need for a sexuality education program.

CONCLUSION

Policy changes are needed to improve collaboration between adolescents, parents, teachers, and youth officers in order to address adolescent sexuality problems. Further research is needed to explore the ways in which to improve sexuality communication between these groups. The results of the study provide valuable information on the sexuality risks that expose adolescents to HIV, pregnancy, and sexually transmitted infections and the strategies for the prevention of these risks, thus informing targeted interventions for risk reduction for adolescents.

Validation of a substance and alcohol use assessment instrument among orphans and vulnerable children in Zambia using Audio Computer Assisted Self-Interviewing (ACASI)

BACKGROUND

Substance and alcohol misuse is a global problem that increases the risk of HIV infection. This is a concern among orphans and vulnerable children (OVC) in sub-Saharan Africa who may have elevated substance use rates. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) is a reliable and valid instrument of substance use among adults in primary care high-income settings. This study examined psychometric properties of the ASSIST among OVC in Zambia using Audio Computer Assisted Self-Interviewing (ACASI).

METHODS

Baseline data from an ongoing randomized trial of interventions to reduce HIV risk behaviors were analyzed. The analysis included 502 OVC ages 13-17 living in low-income, high-density neighborhoods in Lusaka, Zambia. Internal consistency of the ASSIST was assessed and discriminant validity was measured using items from the Youth Self Report as criterion variables.

RESULTS

Internal reliability was strong with a Cronbach's alpha of ≥0.80 for each of the specific substance scales and total substance involvement. For all substances except tobacco and sedatives, discriminant validity was demonstrated in distinguishing between low risk use and moderate use. Sensitivity and specificity analysis indicated adequate area under the curve across substance types (AUC range: 0.68-0.80). Discrimination between moderate and high risk was demonstrated for alcohol and total substance involvement.

CONCLUSIONS

ASSIST administered via ACASI is a reliable instrument and an appropriate tool for distinguishing between low and hazardous substance use among adolescent OVC populations in sub-Saharan Africa. Additional examination is warranted to determine its ability to measure gradations of severity within hazardous use.

Reliability of the GAIN-SS, CRAFTT and PESQ screening instruments for substance use among South African adolescents

Introduction

Screening for adolescent substance use can assist with the early identification of substance-related problems and guide the provision of appropriate services. As such, psychometrically sound screening tools are needed. The aim of this study was to compare the reliability of the CRAFFT, Global Appraisal of Individual Needs-Short Screener (GAIN-SS) substance use subscale and Personal Experience Screening Questionnaire (PESQ) among adolescents from disadvantaged communities in Cape Town, South Africa.

Methods

Adolescents aged 12–19 years (n = 231) completed the three screeners at two points in time.

Results

Findings show that all three of the screeners had adequate internal consistency (Cronbach α ≥ 0.8). Test-retest reliability was similar for all three screeners, with intraclass correlation coefficient values slightly higher for the PESQ (0.82, 95% CI: 0.77–0.86) than for the GAIN-SS substance use subscale (0.79, 95% CI: 0.73–0.84) and CRAFFT (0.76; 95% CI: 0.66–0.83). Kappa values indicated that the GAIN-SS substance use subscale and CRAFFT had moderate levels of agreement, while the PESQ had substantial levels of agreement for identifying those who had moderate or higher substance use risks at Time 1 and Time 2.

Conclusion

The findings indicate that all of these short screeners seem to have acceptable reliability when used in this population. All of the three screeners are appropriately reliable when used with adolescents from disadvantaged communities in Cape Town, but the PESQ performed slightly better. Future studies should also include the assessment of validity of these screeners in this context.

Trajectories of adolescent substance use development and the influence of healthy leisure: A growth mixture modeling approach

Considerable heterogeneity exists in adolescent substance use development. To most effectively prevent use, distinct trajectories of use must be identified as well as differential associations with predictors of use, such as leisure experience. The current study used a person-centered approach to identify distinct substance use trajectories and how leisure is associated with trajectory classes. Data came from a larger efficacy trial of 2.249 South African high school students who reported substance use at any time across 8 waves. Growth mixture modeling was used to identify developmental trajectories of substance use and the influence of healthy leisure. Results identified three increasing and one stable substance use trajectory and subjective healthy leisure served to protect against use. This study is the first of its kind to focus on a sample of South African adolescents and serves to develop a richer understanding of substance use development and the role of healthy leisure.

Correlates of sexual activity versus non-activity of incoming first-year students at a South African university

In order to contribute to the design of more effective programmes to curb the spread of HIV at tertiary institutions, this study compares the profile of students who are sexually active versus those who are not yet sexually active when entering university. The study was conducted among three cohorts of first-year university students at the University of the Western Cape from 2007 to 2009. A range of correlates of sexual activity versus non-activity were explored using logistic regression analysis. The predicted probabilities of the logit link function depict marked differences between genders and racial groups. Males were more likely than females to be sexually active when entering university and the Black racial group was more likely than other racial groups to be sexually active. Risk-taking behaviours such as smoking, alcohol and drug use were shown to increase the likelihood of being sexually active when entering university, as did indicators of depression and suicidal ideation. The results indicate that religion plays an important role in influencing sexual behaviour, highlighting the important potential role that religious organisations can play in addressing HIV risk at tertiary institutions.

Inkwari: an emerging high-risk place potentiating hiv spread among young adults in a hyper-endemic South African setting

Young adults in South Africa are at the epicenter of the HIV epidemic. The prevalence of HIV among young people in the province of KwaZulu-Natal (KZN) is particularly high. This study characterizes inkwari (Zulu word for raves or weekend-long parties) in eThekwini District, KZN and explored how these place-based dynamics shape the risk environment for the young adult attendees. In 2011, 13 qualitative interviews were conducted with men and women between 18 and 30 years-old who reported unprotected sex with at least one casual partner in the prior 3 months and attended an inkwari in the same time period. Interviews were analyzed using qualitative content analysis. Nine key informant interviews helped to triangulate these data. Five women and eight men were interviewed and the mean age was 25 years (SD 3.24). Ten reported meeting a sexual partner at an inkwari. Inkwari were characterized as sexualized settings with limited adult supervision. Participants attended inkwari to socialize with peers, use drugs and alcohol, and meet sexual partners. Sexual and physical violence also occurred at inkwari. Given the convergence of social, sexual, and substance-using networks at inkwari, further inquiry is needed to determine how this place may potentiate HIV transmission risk in an endemic setting.

Predictors of sexual risk behaviour among adolescents from welfare institutions in Malaysia: a cross sectional study

BACKGROUND

In welfare institutions, it is essential to address the health-related needs of adolescent populations who often engage in sexual activities. This study examines the association between individual and interpersonal factors concerning sexual risk behaviour (SRB) among adolescents in welfare institutions in Malaysia.

METHODS

Data were derived from a cross-sectional study of 1082 adolescents in 22 welfare institutions located across Peninsular Malaysia in 2009. Using supervised self-administered questionnaires, adolescents were asked to assess their self-esteem and to complete questions on pubertal onset, substance use, family structure, family connectedness, parental monitoring, and peer pressure. SRB was measured through scoring of five items: sexual initiation, age of sexual debut, number of sexual partners, condom use, and sex with high-risk partners. Multivariate logistic regression analysis was used to examine the various predictors of sexual risk behaviour.

RESULTS

The study showed that 55.1% (95%CI = 52.0-58.2) of the total sample was observed to practice sexual risk behaviours. Smoking was the strongest predictor of SRB among male adolescents (OR = 10.3, 95%CI = 1.25-83.9). Among females, high family connectedness (OR = 3.13, 95%CI = 1.64-5.95) seemed to predict the behaviour.

CONCLUSION

There were clear gender differences in predicting SRB. Thus, a gender-specific sexual and reproductive health intervention for institutionalised adolescents is recommended.

Sexual risk reduction interventions for HIV prevention among South African youth: a meta-analytic review

OBJECTIVES

To examine the efficacy of sexual risk reduction interventions among South African youth.

METHODS

Electronic databases were searched to identify studies published between 2007 and early 2013. Studies were eligible if they (1) targeted youth age 9-26, (2) evaluated sexual risk reduction interventions and (3) reported at least one behavioral outcome. Independent raters coded study characteristics, and intervention content. Weighted mean effect sizes were calculated; positive effect sizes indicated less sexual risk behavior and incident STIs.

RESULTS

Ten studies (k = 11; N = 22,788; 54% female; 79% Black-African) were included. Compared to controls, interventions were successful at delaying sexual intercourse and, among sexually active youth, at increasing condom use. A single study found reductions in the incidence of herpes simplex virus-2, but not HIV.

CONCLUSIONS

Implementing behavioral interventions to delay sexual debut and improve condom use can help to reduce the transmission of HIV among South African youth.

Adolescents' beliefs about forced sex in KwaZulu-Natal, South Africa

Gender-based violence has serious consequences for the psychological, physical, and sexual well-being of both men and women. Various gender roles, attitudes, and practices in South Africa create an environment that fosters submission and silence in females and hegemony and coercion in males. One of the expressions of this power inequity is a high prevalence of forced sex, which in its turn is associated with higher risk of HIV infection. This study therefore assessed potential gender differences in beliefs about forced sex and in prevalence of reported forced sex among high school students (N = 764) in KwaZulu-Natal. Results showed that significantly more boys were sexually active (26 %) than girls (12 %) and that boys experienced earlier sexual debut by over a year. Boys also held a more positive view about forced sex than girls since they associated it more often with signs of love, as an appropriate way to satisfy sexual urges, and as acceptable if the girl was financially dependent on the boy. The perception that peers and friends considered forced sex to be an effective way to punish a female partner was also more common among boys. On the other hand, boys were less knowledgeable about the health and legal consequences of forced sex, but no significant differences were found for other sociocognitive items, such as self-efficacy and behavioral intention items. Consequently, health education programs are needed to inform both boys and girls about the risks of forced sex, to convince boys and their friends about its inappropriateness and girls to empower themselves to avoid forced sex.

The Dynamic Association between Healthy Leisure and Substance Use in South African Adolescents: A State and Trait Perspective

South Africa has an increasing adolescent substance use problem, lack of leisure opportunities and resources, and high adolescent discretionary time. How aspects of leisure relate to adolescent substance use is not well understood. Little research has been conducted on the leisure behaviors and experiences of South African adolescents, if and how those behaviors are associated with substance use, and ecological influences on those associations. By applying multi-level models to longitudinal data obtained from youth living in high-risk contexts, this research examines the association between state and trait healthy leisure and adolescent substance use and how perceived parental over-control moderates those associations. Results indicate healthy leisure protects against substance use at state and trait levels, provides empirical support that risk behavior can be addressed through leisure-based interventions, and emphasizes the importance of both short- and long-term processes when considering the context-dependent nature of adolescents' leisure experiences.

Substance use and sexual risk among at-risk adolescents in Juiz de Fora, Minas Gerais State, Brazil

We examined the difference in prevalence of substance use and sexual risk behaviors among at-risk youth participants in programs offered by community-based organizations in Juiz de Fora, Minas Gerais State, Brazil, by gender and organization type (governmental vs. non-governmental). 388 adolescents were recruited from 25 intervention-based organizations servicing at-risk youth between the ages of 12 and 17 in Juiz de Fora. Participants completed a 15-item survey assessing substance use and sexual risk behaviors, along with socio-demographic predictors of these behaviors. Males were more likely to report drug and alcohol use associated with homelessness and abandonment. Females were more likely to report sexual risk taking associated with neighborhood crime. Participants from non-governmental organizations were less likely to engage in all measured risk behaviors. The present analysis points to the need to understand how Brazil’s Child and Adolescent Act is being applied and the implications this has for intervention and the promotion of positive health outcomes for young people.

HIV risk and prevention among men who have sex with men (MSM) in peri-urban townships in Cape Town, South Africa

Current guidelines on HIV prevention for MSM emphasise the need for 'combination prevention' based on context-specific understandings of HIV risk. MSM in South Africa are a population with a high risk of HIV infection, however there is little research available on the drivers of this risk. In the context of a focus on combination prevention, this paper argues that effective HIV prevention for MSM in South Africa requires an understanding of the factors at multiple 'distances' from individuals that contribute to HIV risk. Based on qualitative research with MSM in Cape Town, South Africa, we situate HIV risk using a socio-ecological framework and identify factors at distal, proximal, and personal, levels that contribute to MSM's high risk of HIV infection. By understanding the interactions and linkages between risk environments and the risk situations in which HIV is transmitted, HIV prevention programmes will be more effectively able to address the multiple drivers of HIV risk in this population.

HIV and chemoprophylaxis, the importance of considering social structures alongside biomedical and behavioral intervention

This manuscript draws connections between chemoprophylaxis and the biomedical model of disease that emphasizes individual behavior. We argue that chemoprophylactic HIV interventions have limited utility at the population-level, and that structural interventions need to be prioritized. We use the recent CAPRISA 004 and iPrEx trials to (a) critique the utility of these trials from a public health perspective by highlighting the difference between efficacy and effectiveness, (b) apply an alternative theory of health behavior as a way to reorient the field toward the discussion of the need to employ structural interventions, and (c) examine two aspects of HIV prevention efforts - funding structures and iatrogenic effects of biomedical approaches - as a means of overcoming obstacles to more widespread adoption of structural interventions.

Gender, peer and partner influences on adolescent HIV risk in rural South Africa

BACKGROUND AND METHODS

In preparation for a school-based intervention in KwaZulu-Natal, South Africa, a cross-sectional survey of potential HIV risk factors in youth aged 14-17 (n=983) was conducted.

RESULTS

Boys were significantly more likely than girls to report lifetime sexual activity (37.7% v. 13.8%, P<0.01). Among boys and girls, 46.1% reported condom use at last sex. Discussion of condom use with a partner was the strongest predictor of condom use (boys, odds ratio (OR)=7.39; girls, OR=5.58, P<0.0001). Age was independently associated with sexual activity for boys (OR=1.49, P<0.0001) and girls (OR=1.74, P=0.02). For boys, perceptions of male peer behaviour were associated with both ever having participated in sexual activity (OR=1.48, P<0.01) and condom use at last sex (OR=1.79, P<0.01). Girls who equated condom use with having numerous partners were more likely to use them. Among boys, results challenged some expected gender beliefs: support for girls' initiative in relationship formation and refusal of sex were significant predictors of sexual activity. Among girls, higher pregnancy risk perception (OR=1.32, P=0.02) and knowledge (OR=4.85, P=0.055) were associated with sexual activity.

CONCLUSIONS

Creating more gender equitable norms can reduce HIV risk behaviours. HIV prevention interventions should build on existing gender equitable beliefs, and work to promote others, including sexual communication and negotiation skills, and modelling of positive peer norms.

Costing human rights and community support interventions as a part of universal access to HIV treatment and care in a Southern African setting

Expanding access to antiretroviral therapy (ART) has both individual health benefits and potential to decrease HIV incidence. Ensuring access to HIV services is a significant human rights issue and successful programmes require adequate human rights protections and community support. However, the cost of specific human rights and community support interventions for equitable, sustainable and non-discriminatory access to ART are not well described. Human rights and community support interventions were identified using the literature and through consultations with experts. Specific costs were then determined for these health sector interventions. Population and epidemic data were provided through the Statistics South Africa 2009 national mid-year estimates. Costs of scale up of HIV prevention and treatment were taken from recently published estimates. Interventions addressed access to services, minimising stigma and discrimination against people living with HIV, confidentiality, informed consent and counselling quality. Integrated HIV programme interventions included training for counsellors, ‘Know Your Rights’ information desks, outreach campaigns for most at risk populations, and adherence support. Complementary measures included post-service interviews, human rights abuse monitoring, transportation costs, legal assistance, and funding for human rights and community support organisations. Other essential non-health sector interventions were identified but not included in the costing framework. The annual costs for the human rights and community support interventions are United States (US) $63.8 million (US $1.22 per capita), representing 1.5% of total health sector HIV programme costs. Respect for human rights and community engagement can be understood both as an obligation of expanded ART programmes and as a critically important factor in their success. Basic rights-based and community support interventions constitute only a small percentage of overall programmes costs. ART programs should consider measuring the cost and impact of human rights and community support interventions as key aspects of successful programme expansion.

Rapid assessment response (RAR) study: drug use and health risk - Pretoria, South Africa

BACKGROUND

Within a ten year period South Africa has developed a substantial illicit drug market. Data on HIV risk among drug using populations clearly indicate high levels of HIV risk behaviour due to the sharing of injecting equipment and/or drug-related unprotected sex. While there is international evidence on and experience with adequate responses, limited responses addressing drug use and drug-use-related HIV and other health risks are witnessed in South Africa. This study aimed to explore the emerging problem of drug-related HIV transmission and to stimulate the development of adequate health services for the drug users, by linking international expertise and local research.

METHODS

A Rapid Assessment and Response (RAR) methodology was adopted for the study. For individual and focus group interviews a semi-structured questionnaire was utilised that addressed key issues. Interviews were conducted with a total of 84 key informant (KI) participants, 63 drug user KI participants (49 males, 14 females) and 21 KI service providers (8 male, 13 female).

RESULTS AND DISCUSSION

Adverse living conditions and poor education levels were cited as making access to treatment harder, especially for those living in disadvantaged areas. Heroin was found to be the substance most available and used in a problematic way within the Pretoria area. Participants were not fully aware of the concrete health risks involved in drug use, and the vague ideas held appear not to allow for concrete measures to protect themselves. Knowledge with regards to substance related HIV/AIDS transmission is not yet widespread, with some information sources disseminating incorrect or unspecific information.

CONCLUSIONS

The implementation of pragmatic harm-reduction and other evidence-based public health care policies that are designed to reduce the harmful consequences associated with substance use and HIV/AIDS should be considered. HIV testing and treatment services also need to be made available in places accessed by drug users.

Changing trends and the impact of alcohol on the HIV/AIDS epidemic in South Africa: review

The association between increased HIV infection and alcohol use has been extensively studied and is established. South Africa is among one of the sub-Saharan African countries with the highest prevalence and number of people living with HIV/AIDS in the world. Although recent evidence suggests that the epidemic has stabilised, infection rates remain unacceptably high. Alcohol use is on the increase, particularly in the groups most susceptible to HIV infection, namely women and young adults, and informs poor choices with respect to safer sexual practices. This paper reviews the association between alcohol and HIV. More specifically, however, it aims to explore the potential socio-politico-biological and cultural explanations as to the factors that intersect to drive these two epidemic diseases: alcoholism and HIV/AIDS in South Africa. Understanding some of the underlying factors will provide a framework to implement public health measures to curb HIV.

Preventing HIV infection in women: a global health imperative

Women account for approximately one-half of all human immunodeficiency virus (HIV) infections worldwide. Sexual transmission is the dominant mode of HIV transmission to women, and there is a concomitant associated epidemic of transmission to infants. The majority of HIV infections in women are in sub-Saharan Africa, with a disproportionate burden in young women <25 years of age. Acquisition and prevention of HIV infection in women is complex and influenced by biological, behavioral, and structural factors. Efforts to reduce the incidence of HIV infection among women in sub-Saharan African could play a substantial role in altering global trajectories of HIV infection. Increasing access to sexual and reproductive health services, addressing gender-based violence and social instability, reducing poverty and the need to engage in sex for survival, and encouraging greater male responsibility are critical short-to-medium-term interventions. Efforts to find a microbicide and HIV vaccine need to be matched with efforts to deepen understanding of acquisition of HIV in the female genital tract to inform development of targeted molecules for prevention of HIV infection.

Nicotine dependence and problem behaviors among urban South African adolescents

Tobacco use and its concomitant, nicotine dependence, are increasing in African countries and other parts of the developing world. However, little research has assessed nicotine dependence in South Africa or other parts of the African continent. Previous research has found that adolescent problem behaviors, including tobacco use, tend to cluster. This study examined the relationship between nicotine dependence and adolescent problem behaviors in an ethnically diverse sample of urban South African adolescents. A community sample (N = 731) consisting of "Black," "White," "Coloured," and "Indian" youths aged 12-17 years was drawn from the Johannesburg metropolitan area. Structured interviews were administered by trained interviewers. Nicotine dependence was assessed by the Fagerström Test of Nicotine Dependence. Logistic regression analyses showed that higher levels of nicotine dependence significantly predicted elevated levels of violent behavior, deviant behavior, marijuana and other illegal drug use, binge drinking, early sexual intercourse, multiple sexual partners, and inconsistent condom use, despite control on the adolescents' demographic characteristics, peer smoking, conflict with parents, peer deviance, and the availability of legal and illegal substances. These relationships were robust across ethnicity and gender. The findings indicate the need for policy makers and prevention and intervention programs in South Africa to consider adolescent nicotine dependence in conjunction with comorbid problem behaviors, including other substance use, sexual risk behaviors, and deviant behaviors.

Rapid assessment of HIV risk behavior in drug using sex workers in three cities in South Africa

A rapid assessment was undertaken with drug using commercial sex workers (CSWs) to investigate practices putting them at risk for contracting HIV. It included key informant (KI) (N = 67) and focus group (N = 10) interviews in locations with a high prevalence of drug use in Cape Town, Durban and Pretoria, South Africa. HIV testing of KIs was conducted. Cocaine, Ecstasy, heroin and methaqualone are used by CSWs prior to, during and after sex. Drugs enhance the sexual experience and prolong sex sessions. Interviews revealed inconsistent condom use among CSWs together with other risky sexual practices such as needle sharing. Among CSWs who agreed to HIV testing, 34% tested positive. Barriers to accessing drug treatment and HIV treatment and preventive services were identified. Interventions recognizing the role of drug abuse in HIV transmission should be prioritized, and issues of access to services, stigma and power relations must be considered.

HIV-risk behavior among injecting or non-injecting drug users in Cape Town, Pretoria, and Durban, South Africa

The rapid assessment aimed to describe drug use and sexual practices that place injection and noninjection drug users (IDUs/NIDUs) at risk for HIV in South Africa. The sample comprised 85 key-informant (KI) and focus-group (FG) interviewees in or serving locations with high levels of drug use in Cape Town, Durban, and Pretoria. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. The findings indicated that commonly used drugs had differing effects on sexual and drug-use practices. Risky injecting behaviors among IDUs were common, and most interviewees engaged in sex when on drugs, some without condoms. These behaviors were also influenced by trust in intimate relationships. Injection drug users seemed more knowledgeable about HIV transmission than NIDUs, and 20% of IDUs who agreed to HIV screening tested positive. Views about drug- and HIV-intervention services, accessibility, and their efficacy were mixed. The findings suggest greater synergy is needed between drug- and HIV-intervention sectors and that consideration should be given to making various risk-reduction strategies more accessible. The study's limitations have been noted.

Community influences on young people's sexual behavior in 3 African countries

OBJECTIVES

I examined the role of community-level factors in the reporting of risky sexual behaviors among young people aged 15 to 24 years in 3 African countries with varying HIV prevalence rates.

METHODS

I analyzed demographic and health survey data from Burkina Faso, Ghana, and Zambia during the period 2001 through 2003 to identify individual, household, and community factors associated with reports of risky sexual behaviors.

RESULTS

The mechanisms through which the community environment shaped sexual behaviors varied among young men and young women. Community demographic profiles were not associated with reports of risky sexual behavior among young women but were influential in shaping the behavior of young men. Prevailing economic conditions and the behaviors and attitudes of adults in the community were strong influences on young people's sexual behaviors.

CONCLUSIONS

These results provide strong support for a focus on community-level influences as an intervention point for behavioral change. Such interventions, however, should recognize specific cultural settings and the different pathways through which the community can shape the sexual behaviors of young men and women.

Rapid assessment of drug use and sexual HIV risk patterns among vulnerable drug-using populations in Cape Town, Durban and Pretoria, South Africa

This exploratory study examines the links between drug use and high-risk sexual practices and HIV in vulnerable drug-using populations in South Africa, including commercial sex workers (CSWs), men who have sex with men (MSM), injecting drug users (IDUs) and non-injecting drug users who are not CSWs or MSM (NIDUs). A rapid assessment ethnographic study was undertaken using observation, mapping, key informant interviews and focus groups in known 'hotspots' for drug use and sexual risk in Cape Town, Durban and Pretoria. Key informant (KI) and focus group interviews involved drug users and service providers. Purposeful snowball sampling and street intercepts were used to recruit drug users. Outcome measures included drug-related sexual HIV risk behaviour, and risk behaviour related to injection drug use, as well as issues related to service use. HIV testing of drug-using KIs was conducted using the SmartCheck Rapid HIV-1 Antibody Test. Non-injection drug use (mainly cannabis, methaqualone, crack cocaine and crystal methamphetamine) and injection drug use (mainly heroin) was occurring in these cities. Drug users report selling sex for money to buy drugs, and CSWs used drugs before, during and after sex. Most (70%) of the drug-using KIs offered HIV testing accepted and 28% were positive, with rates highest among CSWs and MSM. IDUs reported engaging in needle sharing and needle disposal practices that put them and others at risk for contracting HIV. There was a widespread lack of awareness about where to access HIV treatment and preventive services, and numerous barriers to accessing appropriate HIV and drug-intervention services were reported. Multiple risk behaviours of vulnerable populations and lack of access to HIV prevention services could accelerate the diffusion of HIV. Targeted interventions could play an important role in limiting the spread of HIV in and through these under-reached and vulnerable populations.

Alcohol and sexual risk behavior among men who have sex with men in South african township communities

There are few studies of HIV risk behavior among men who have sex with men (MSM) in sub-Saharan Africa. We conducted a behavioral survey of MSM in peri-urban "township" communities in Gauteng province, South Africa. Between October 2004 and March 2005, 199 MSM completed an interviewer administered pen-and-paper standardized questionnaire. The sample was 94% black, 83% identified as gay, and 12% as bisexual. Among those reporting sex with other men in the prior six months (n = 147), 59% reported unprotected anal intercourse (UAI). Increased risk of UAI was associated with both regular drinking (adjusted odds ratio (OR) 4.1, 95% confidence interval (CI) 1.4, 12.6) regular drinking to intoxication (OR 2.6, 95% CI 1.0, 6.8), and reporting symptoms of rectal trauma resulting from anal intercourse (AI; OR 4.3, 95% CI 1.8, 10.4). Decreased risk of UAI was associated with the exclusive use of lubricants that are latex-compatible for AI (OR 0.3, 95% CI 0.1, 0.7). Township MSM in South Africa are at high risk of HIV infection. Targeted sexual health and risk reduction interventions that address the link between alcohol use and HIV risk are urgently needed.

Sexual behavior and reproductive health among HIV-infected patients in urban and rural South Africa

BACKGROUND

With the rollout of antiretroviral therapy in South Africa and its potential to prolong the lives of HIV-infected individuals, understanding the sexual behavior of HIV-positive people is essential to curbing secondary HIV transmission.

METHODS

We surveyed 3,819 HIV-positive patients during their first visit to an urban wellness clinic and a rural wellness clinic.

RESULTS

Urban residents were more likely than rural residents to have current regular sex partners (75.1% vs. 46.0%; chi2 odds ratio [OR] = 3.531; P < 0.001), to have any current sexual partners (75.3% vs. 51.2%; chi2 OR = 2.908; P < 0.001), and to report consistent condom use with regular partners (78.4% vs. 48.3%; chi2 OR = 3.886; P < 0.001) and with casual partners (68.6% vs. 48.3%; chi2 OR = 2.337; P < 0.001). In multivariate analysis, independent predictors of consistent condom use with regular partners included across gender, urban residence, and higher education levels; for women, disclosure and younger age; and for men only, no history of alcohol consumption. Male and female participants with a casual sexual partner were less likely to use a condom consistently with regular partners. Additionally, urban residence and a CD4 count greater than 200 cells/mm as well as (for women only) a higher household income and a history of alcohol consumption were predictors of having a regular sexual partner.

CONCLUSIONS

HIV prevention programs in South Africa that emphasize the importance of condom use and disclosure and are tailored to the needs of their attending populations are critical given the potential for HIV-infected individuals to resume risky sexual behavior with improving health.

Rapid assessment of drug-related HIV risk among men who have sex with men in three South African cities

The current assessment was undertaken to examine the link between drug use and sexual risk behavior among men who have sex with men (MSM) in locations known to have high prevalence rates of drug use and sexual risk behavior in Cape Town, Durban and Pretoria, South Africa. Street intercepts and purposive snowball sampling were used to recruit drug-using MSM. A rapid assessment was undertaken which included observation, mapping, key informant interviews and focus group interviews with MSM. Drug using key informants were tested for HIV. The use of drugs like crack cocaine, cannabis and methamphetamine to specifically facilitate sexual encounters was evident. Drugs led to inconsistent condom use and other high-risk sexual activities despite HIV risk knowledge being high. Many injecting drug-using MSM shared needles and reused equipment. Among MSM who agreed to HIV testing, one-third tested positive. Views about drug and HIV treatment and preventive services and their efficacy were mixed. Various barriers to accessing services were highlighted including homosexual stigmatization and availability of drugs in treatment facilities. Recommendations include addressing the gap between HIV-risk knowledge and practice, extending VCT services for MSM, increasing the visibility of drug abuse services within communities, addressing concerns about drug availability in treatment centers as well as reintegration issues and the need for after-care services, reducing stigmatization in drug and HIV services for MSM and finally, strengthening the link between drug treatment services and HIV prevention by integrating HIV/drug-related risks into HIV prevention efforts and HIV risks into drug use prevention efforts.

Use of the male condom by heterosexual adolescents and young people: literature review

AIM

This paper is a report of a literature review to explore issues influencing condom use in heterosexual adolescents and young people.

BACKGROUND

Sexually transmitted infections (STIs) are a major international health issue and adolescents and young people are particularly vulnerable. Efforts to address the rapid spread of STIs have largely focused on promoting the use of condoms as a protective 'safer sex' measure. However, use of the male condom is still inconsistent and the incidence of STIs continues to increase.

METHOD

A search of the literature using EBSCO Host databases was undertaken in 2006, with a focus on women, young people, condoms and STIs. Papers published in English from 1992 to 2006 were sought. Only research papers are included in this review.

RESULTS

Factors impeding decisions to use protection by young people include lack of knowledge about prevalence of STIs, ambiguity around contraception and safer sex practices, and the difficulty faced by young women in particular in negotiating safer sex. The notion of romantic love confounds the assessment of risk and can render young people, particularly young women, ineffective in negotiating safer sex practices.

CONCLUSION

Adolescents and young adults are particularly vulnerable in relation to STIs. There is a need to ensure that accurate messages are delivered about safer sex and contraception to this very vulnerable group. Furthermore, it is important to recognize that romantic love comprises strong emotions that have a role in decision-making and options for reducing personal-health risk during sexual activity.

HIV/AIDS prevention through peer education and support in secondary schools in South Africa

The implementation and evaluation of a peer education and support programme in secondary schools to prevent and reduce high-risk sexual behaviour amongst adolescents is discussed.The aims of the programme were to provide accurate information about HIV/AIDS, discuss and reconsider peer group norms, and establish support for learners. In the programme that was implemented in 13 secondary schools in Tshwane, South Africa, peer educators were identified, trained and supported to implement the programme in their schools with the assistance of a teacher and postgraduate students as facilitators. Peer educators organised HIV awareness activities, facilitated class discussions on risk behaviour and gender relationships, and supported learners in solving personal problems. Process evaluation included weekly reports and focus group discussions with peer educators and teachers. A quasiexperimental design involving an experimental and control group, as well as pre- and post-assessments, was used to evaluate the impact of the programme on psychological well-being, personal control, school climate and reported high-risk behaviour of learners aged between 13 and 20 years.The results showed that the percentage of learners in the experimental group who were sexually experienced remained unchanged over the time period of 18 months. In contrast, a significantly increased percentage of learners in the control group were sexually experienced after the same time period.The control group also perceived more of their friends to be sexually experienced. No differences were reported in condom use in either of the groups.The findings of this study suggest that peer education can contribute to a delayed onset of sexual activity, and can therefore contribute to the prevention of HIV/AIDS amongst adolescents.