HIV infection in the South African construction industry

HIV epidemiologic trends among occupational groups in Rakai, Uganda: A population-based longitudinal study, 1999-2016

Certain occupations have been associated with heightened risk of HIV acquisition and spread in sub-Saharan Africa, including female bar and restaurant work and male transportation work. However, data on changes in population prevalence of HIV infection and HIV incidence within occupations following mass scale-up of African HIV treatment and prevention programs is very limited. We evaluated prospective data collected between 1999 and 2016 from the Rakai Community Cohort Study, a longitudinal population-based study of 15- to 49-year-old persons in Uganda. Adjusted prevalence risk ratios for overall, treated, and untreated, prevalent HIV infection, and incidence rate ratios for HIV incidence with 95% confidence intervals were estimated using Poisson regression to assess changes in HIV outcomes by occupation. Analyses were stratified by gender. There were 33,866 participants, including 19,113 (56%) women. Overall, HIV seroprevalence declined in most occupational subgroups among men, but increased or remained mostly stable among women. In contrast, prevalence of untreated HIV substantially declined between 1999 and 2016 in most occupations, irrespective of gender, including by 70% among men (12.3 to 4.2%; adjPRR = 0.30; 95%CI:0.23-0.41) and by 78% among women (14.7 to 4.0%; adjPRR = 0.22; 95%CI:0.18-0.27) working in agriculture, the most common self-reported primary occupation. Exceptions included men working in transportation. HIV incidence similarly declined in most occupations, but there were no reductions in incidence among female bar and restaurant workers, women working in local crafts, or men working in transportation. In summary, untreated HIV infection and HIV incidence have declined within most occupational groups in Uganda. However, women working in bars/restaurants and local crafts and men working in transportation continue to have a relatively high burden of untreated HIV and HIV incidence, and as such, should be considered priority populations for HIV programming.

Determinants of HIV testing behaviour among male South African construction workers

The global trend of poorer outcomes across the HIV treatment cascade for men has drawn attention to the importance of engaging men in prevention and treatment services. The South African construction industry is one of the economic sectors most adversely affected by HIV/AIDS. Previous research on HIV testing behaviour among workers in the industry has revealed that male workers are less likely to be tested than female workers. Given this gender differential, this study employed a field-administered survey to gather data from 450 site-based, male construction workers in Western Cape, South Africa. An integrated model comprising demographic, cognitive, and behavioural factors was then hypothesised to explain HIV testing behaviour. Bivariate analysis and structural equation modelling were then used to test the model. Findings indicate that HIV knowledge, having previously had an STI, and possessing a positive attitude towards HIV testing are terminal predictors of testing behaviour. As a strategy for positively influencing testing behaviour, employers should ensure that effective communication about HIV testing is established with workers across all levels of education and ethnic groups. Interventions relating to risky sexual behaviour need particular attention, and where possible HIV testing should be coupled with general STI screening.

Test@work: evaluation of workplace HIV testing for construction workers using the RE-AIM framework

BACKGROUND

Community testing for HIV can reach previously untested populations but is rarely offered in workplaces. Targeting the construction sector could reach workers from high risk populations.

METHODS

The RE-AIM framework was used to evaluate Test@Work, a workplace HIV testing intervention for construction workers implemented at 21 events (10 companies) in the UK. Test@Work had three components: 1) an online health toolkit to inform managers about health screening and HIV testing; 2) general health checks; and 3) opt-in HIV consultation and testing. Quantitative data were collected using registration and exit questionnaires with workers (n = 426) and pre/post-event questionnaires with managers (n = 15), with qualitative analysis of free text responses.

RESULTS

Reach 426 individuals had health checks. Participants were broadly representative of the UK construction workforce, but with a higher proportion of permanent workers. Most workers reported being in good health but also believed their work had an adverse impact on their health. Effectiveness: 97% of health check participants opted to have a consultation about sexual health (n = 413) and 82% had an HIV test (n = 348), of whom 78% had not previously been tested. All HIV tests were non-reactive. HIV testing at work was considered acceptable by most participants. Participants reported learning new things about their health (74%), said they would make changes as a result (70%) and felt confident of success (median score 8/10). Adoption: Recruitment of companies was challenging and time consuming. Seven of the participating companies were very large, employing over 1000 workers, which is atypical of construction generally.

IMPLEMENTATION

All events were completed as planned and were considered successful by all parties. Maintenance: All managers would arrange further events if they were offered them. Six managers incorporated sexual health awareness into their health programmes, but this was not possible for many as health agendas were set centrally by their organisations.

CONCLUSIONS

Opt-in HIV testing, when embedded within a general health check, has high uptake and acceptability in the UK construction sector, and reaches individuals at risk for HIV who may not otherwise attend for testing. Cost-effectiveness of this approach is yet to be determined.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04292002 .

Accessing Voluntary HIV Testing in the Construction Industry: A Qualitative Analysis of Employee Interviews from the Test@Work Study

HIV, globally, remains a significant public health issue and community HIV testing can help to identify those with HIV at an early stage of disease. The workplace offers a prime location for provision of opt-in HIV testing as part of wider health promotion initiatives. The construction industry offers a key opportunity for HIV testing provision in a generally male-dominated group exhibiting some risky behaviors related to HIV. The intervention was an optional one-off individual health check with tailored health advice and signposting, offered to the construction workforce in health check events delivered as part of a large-scale multi-site research program called Test@Work. The events were undertaken at 10 participating organizations (21 events across 16 different sites), none had previously offered sexual health awareness or HIV testing to their workforce. Participants were invited to participate in a semi-structured interview following general health checks which included HIV testing. Out of 426 employees attending the health check events, 338 (79.3%) consented to interview on exit. Accessing HIV testing at work was valued because it was convenient, quick, and compatible with work demands. Interviewees identified HIV risks for construction including drug use, high numbers of sexual partners and job-related exposures, e.g., to used needles. Health seeking in construction was limited by stigma and low support, with particular barriers for non-permanent workers. The organization of the construction industry is complex with multiple organizations of different sizes having responsibility for varying numbers of employees. A disparity between organizational policies and employment circumstances is evident, and this generates significant health inequalities. To combat this, we recommend that organizations in the construction sector offer their employees awareness-raising around health behaviors and health protection in packages, such as toolbox talks. We recommend these be accompanied by annual health checks, including sexual health awareness and opt-in workplace HIV testing. This approach is highly acceptable to the workforce in the industry and removes barriers to access to healthcare.