Does knowing someone with AIDS affect condom use? An analysis from South Africa

Knowledge, attitudes and practices of young adults towards HIV prevention: an analysis of baseline data from a community-based HIV prevention intervention study in two high HIV burden districts, South Africa

BACKGROUND

With an HIV incidence of 1.00 skewed against women (1.51), adolescents in South Africa are at high HIV risk. This paper assesses young adults' (18-24 years) knowledge, attitudes and practices regarding HIV prevention in Nkangala and OR Tambo districts.

METHODS

A cross-sectional household survey was conducted in two districts in 2017/8. Participants completed computer-assisted self-interviews on HIV knowledge, attitudes, behaviour practices, use of social media and condom use at last sex (proxy for high-risk sex). HIV knowledge was assessed using the South African-adapted UNAIDS scale. Descriptive analyses were conducted and logistic regression models were built to assess factors associated with being knowledgeable of HIV and condom use at last sex.

RESULTS

One thousand nine hundred fifty-five participants were interviewed (90% response rate). Less than half (44.7%) had correct knowledge of HIV prevention and 73% used a condom at last sex. Social media use predicted high HIV knowledge as higher odds were observed among participants using the print media (aOR1.87; 1.34-2.60), WhatsApp (aOR1.55; 1.26-1.90), radio/television (aOR2.75; 1.15-6.55) although social networking sites' use protected against knowledge acquisition (aOR0.53; 0.34-0.82). Females (aOR0.75; 0.58-0.97) and participants reporting sexual risk were less likely to have HIV knowledge as negative associations were found for having multiple sexual partners in the last 3 months (aOR0.63;0.48-0.82) and ever having sex (aOR0.37;0.23-0.61). Participants who abused drugs (aOR1.40; 1.05-1.88) and had attitudes accepting people living with HIV (aOR2.05; 1.14-3.69) had higher odds of having HIV knowledge. Females (aOR0.70; 0.54-0.91), students (aOR0.52; 0.40-0.66) and participants who abused drugs (aOR0.58; 0.43-0.77) were less likely to report condom use at last sex.

CONCLUSIONS

There is a correlation between media use and HIV knowledge, non-condom use and HIV knowledge, and high-risk sexual behaviours and less HIV knowledge. An aggressive community media campaign utilising locally available, preferred and accessible media platforms among young adults is required for behaviour change.

Explaining HIV Risk Multiplexity: A Social Network Analysis

Risk multiplexity (i.e., overlap in drug-use, needle exchange and sexual relations) is a known risk factor for HIV. However, little is known about predictors of multiplexity. This study uses egocentric data from the Colorado Springs study to examine how individual, behavioral and social network factors influence engagement in multiplex risk behavior. Analyses revealed that compared to Whites, Hispanics were significantly more likely to engage in risk multiplexity and Blacks less so. Respondents who were similar to each other (e.g., in terms of race) had significantly higher odds of being in risk multiplex relationships, and respondents' risk perceptions and network size were significantly associated with engaging in multiplex risk behaviors. Findings from interaction analysis showed the effect of knowing someone with HIV on the odds of multiplexity depends partly on whether respondents' know their HIV status. Findings suggest that demographics, HIV behaviors and network factors impact engagement in multiplex risk behaviors, highlighting the need for multi-level interventions aimed at reducing HIV risk behavior.

Correlates of HIV Testing Experience among Migrant Workers from Myanmar Residing in Thailand: A Secondary Data Analysis

BACKGROUND

Thailand continues to attract an increasing number of migrant workers (MW) from neighboring countries including mainly Myanmar, Cambodia, and Laos; however, little is known about the extent to which MWs from these countries have access to HIV prevention, treatment, and care services. We used data from the baseline survey of the Prevention of HIV/AIDS among MWs in Thailand (PHAMIT-2) project to document the prevalence of, and factors associated with, HIV testing among MWs from Myanmar, the largest group of MWs in Thailand.

METHODS AND FINDINGS

The baseline survey of PHAMIT-2 was conducted in 2010 among MWs from Myanmar, Cambodia, and Laos in 10 purposely-selected provinces of Thailand. Of the 1,034 participants who qualified for the analysis to identify correlates of HIV testing, only 5.3% reported ever having been tested for HIV. Factors associated with HIV testing included having a secondary or higher education level (AOR, 2.58; CI, 1.36-4.90; P = 0.004), being female (AOR, 1.96; CI, 1.05-3.66; P = 0.033), knowing someone who died of AIDS (AOR, 1.81; CI, 1.00-3.27; P = 0.048), working in the fishery sector (AOR, 2.51; CI, 1.28-4.92; P = 0.007), and not having a work permit (AOR, 3.71; CI, 1.36-10.13; P = 0.010).

CONCLUSION

Our study, in addition to revealing significantly low HIV testing among MWs from Myanmar, identifies important barriers to HIV testing which could be addressed through interventions that promote migrants' culturally-sensitive and friendly service, for example by facilitating flow of information about places for HIV testing, availability of language assistance, and ensuring confidentiality of HIV testing.

Individual and contextual socioeconomic determinants of knowledge of the ABC approach of preventing the sexual transmission of HIV in Nigeria: a multilevel analysis

BACKGROUND

Nigeria has the highest number of people living with HIV/AIDS in the world after India and South Africa. HIV/AIDS places a considerable burden on society's resources, and its prevention is a cost-beneficial solution to address these consequences. To the best of our knowledge, there has been no multilevel study performed to date that examined the separate and independent associations of individual and community socioeconomic status (SES) with HIV prevention knowledge in Nigeria.

METHODS

Multilevel linear regression models were applied to the 2008 Nigeria Demographic and Health Survey on 48871 respondents (Level 1) nested within 886 communities (Level 2) from 37 districts (Level 3).

RESULTS

Approximately one-fifth (20%) of respondents were not aware of any of the Abstinence, Being faithful and Condom use (ABC) approach of preventing the sexual transmission of HIV. However, the likelihood of being aware of the ABC approach of preventing the sexual transmission of HIV increased with older age, male gender, greater education attainment, a higher wealth index, living in an urban area and being from least socioeconomically disadvantaged communities. There were significant community and district variations in respondents' knowledge of the ABC approach of preventing the sexual transmission of HIV.

CONCLUSION

The present study provides evidence that both individual- and community-level SES factors are important predictors of knowledge of the ABC approach of preventing the sexual transmission of HIV in Nigeria. The findings underscore the need to implement public health prevention strategies not only at the individual level, but also at the community level.

Inconsistent Condom Use among Iranian Male Drug Injectors

OBJECTIVES

The aim of this study was to determine the prevalence and associated factors of inconsistent condom use among Iranian male injecting drug users (IDUs).

MATERIALS AND METHODS

Data came from the national Iranian behavioral survey of drug dependence, which sampled 7743 individuals with drug dependence, from medical centers, prisons, and streets in 29 provinces in Iran, in 2007. This study included all individuals who were male, IDUs, and were sexually active (n = 1131). The main outcome was inconsistent condom use which was assessed using a single item. A logistic regression was used to determine the association between socio-economic data, drug use data, and high risk injection behaviors with inconsistent condom use.

RESULT

83.3% of sexually active IDUs (n = 965) reported inconsistent condom use. Based on the logistic regression, likelihood of inconsistent condom use was higher among those with a history of syringe sharing [Odds Ratio (OR); 1.63, 95% Confidence Interval (CI); 1.13-2.34], but lower among those with higher education levels (OR; 0.34, 95% CI; 0.14-0.82), those who mostly inject at home (OR; 0.09, 95% CI; 0.02-0.47), and those with a history of treatment (OR; 0.54, 95% CI; 0.31-0.94).

CONCLUSION

Because of the link between unsafe sex and risky injecting behaviors among Iranian IDUs, combined programs targeting both sexual and injection behavior may be more appropriate than programs that target sexual or injection behavior. The efficacy of combined programs should be, however, compared with traditional programs that only target sexual or injection behavior of IDUs.

The impact of education on sexual behavior in sub-Saharan Africa: a review of the evidence

Many studies have attempted to determine the relationship between education and HIV status. However, a complete and causal understanding of this relationship requires analysis of its mediating pathways, focusing on sexual behaviors. We developed a series of hypotheses based on the differential effect of educational attainment on three sexual behaviors. We tested our predictions in a systematic literature review including 65 articles reporting associations between three specific sexual behaviors -- sexual initiation, number of partners, and condom use -- and educational attainment or school enrollment in sub-Saharan Africa. The patterns of associations varied by behavior. The findings for condom use were particularly convergent; none of the 44 studies using educational attainment as a predictor reviewed found that more educated people were significantly less likely to use condoms. Findings for sexual initiation and number of partners were more complex. The contrast between findings for condom use on the one hand and sexual initiation and number of partners on the other supports predictions based on our theoretical framework.

Condom use within marriage: an assessment of changes in South Africa and Uganda

The aim of the study is to measure trends in condom use in marital and cohabiting relationships in South Africa and Uganda. The data for the study come from two cross sectional surveys conducted in 1998 and 2008 among adult men and women and their partners in KwaZulu-Natal, South Africa and the Jinja district, Uganda. The findings suggest that consistent condom use has risen substantially in both countries. The percentage reporting consistent condom use in the South African sample of husbands increased from 2.5% in 1998 to 12% in 2008 and from 5.5 to 12.5% among wives. In Uganda, the corresponding trends are 1.1-8.3% for husbands and 4-8.6% for wives. In both countries, condom use was considerably higher among the minority of couples where one or both partners were thought to be HIV positive. Increasingly, in both countries condoms are also used for contraceptive purposes. Condoms play a role in preventing HIV infection but the challenge is for prevention programs to broaden their focus toward meeting the needs of married and cohabiting couples.

The Experience of Sexual Risk Communication in African American Families Living With HIV

Mother-daughter communication plays an influential role in adolescent development. The impact of maternal HIV infection on family communication is not clear. This study explores how living with HIV impacts sexual risk communication between mothers and daughters and whether maternal HIV status influences adolescent choices about engagement in HIV risk behaviors. Data were collected from 12 African American women and 10 of their adolescent daughters through focus groups. Both mothers and daughters shared information about issues that promoted and inhibited communication and engagement in risk behaviors. Findings show that HIV status served as a mechanism for behavioral change related to communication and risk engagement behaviors. Therefore, HIV-infected mothers should be supported in communicating values and expectations to their daughters.

Factors influencing condom use among women in Ghana: an HIV/AIDS perspective

Although in Ghana information on HIV infection and prevention, both in terms of quality and quantity, has increased considerably within the past few years, available literature indicates that behaviour change is yet to correspond with the amount of information and education provided. The objective of this study is to examine factors that influence condom use among women in Ghana in the context of HIV/AIDS prevalence. Data for this study are from the 2003 Ghana Demographic and Health Surveys (GDHS) and the study population (N=5 691) was analysed using logistic regression with the Health Belief Model (HBM) as an explanatory tool. The outcome variable for this study is condom use during last sexual intercourse. The HBM identifies perception of HIV/AIDS risks, awareness of its seriousness, knowledge about prevention, and confidence in condom use as predictors of safe sexual activity. Results show that the proportion of women reporting use of condoms remains tremendously low, in both the rural and urban areas. In the urban areas, only 15% of women reported having sex with condom during their last intercourse, whereas in the rural areas the proportion is even lower (10%). However, multivariate analyses based on the HBM components show that speaking with a partner about how to avoid AIDS (Odds Ratio = 1.63) and perceived benefits of using condoms (Odds Ratio = 1.54) are notable factors that predict condom use. Overall, the study points out that with the exception of perceived severity, the HBM can be applied to understand condom use among the study population. It will be important to emphasise all components of the HBM and empower women with condom negotiation skills.

An assessment of sex work in Swaziland: barriers to and opportunities for HIV prevention among sex workers

The HIV situation in virtually all southern African countries is a generalised epidemic. Despite the fact that almost all adult age and social groups have high HIV prevalence estimates, sex workers are disproportionally affected, with prevalence estimates higher than the general population. In a qualitative study of 61 male and female sex workers in Swaziland, we found that while poverty drove many into sex work, others reported motivations of pleasure or "sensation seeking", and freedoms from the burden of marriage as perceived benefits of sex work. We also found that penile-vaginal sex was not universal in male-female sexual encounters; and motivation by sex workers for non-condom use included intention to earn more money from unprotected sex, desire for sexual pleasure, and not having time to use condoms. Many sex workers expressed doubts over an alternative lifestyle, even if that change afforded them money to meet their daily necessities. The findings from this study suggest that treating sex workers as a homogenous group that is driven into, or maintain sex work only because of poverty may be problematic, and could hamper HIV-relevant interventions aimed at reducing their vulnerability to sexually transmitted infections.

Socio-Demographic Determinants of Condom Use Among Sexually Active Young Adults in Rural KwaZulu-Natal, South Africa

AIM

To investigate patterns, levels and socio-demographic determinants of condom use and consistency of use among young adults aged 15-24 years.

BACKGROUND

Condoms are known to prevent HIV infection. However, HIV prevalence and incidence remain high.

METHODS

This study was conducted in the Africa Centre Demographic Surveillance Area (ACDSA) in rural KwaZulu-Natal. Analysis focused on resident young adults aged 15-24 years in 2005. In univariable and multivariable analyses, determinants of condom use and consistency of use among 15-24 year olds were estimated using data collected in 2005. 'Ever' condom use was defined as the proportion who reported having used a condom; consistent use among those ever using as "always" using condoms with most recent partner in the last year.

RESULTS

3,914 participants aged 15-24 years reported ever having sex, of whom 52% reported condom use. Adjusting for age, sex, number of partners, residence of partner, partner age difference, type of partner and socio-economic status (SES), having an older partner decreased likelihood (aOR=0.69, p<0.01), while belonging to a household in a higher SES increased likelihood of ever using condoms (aOR=1.82, p<0.01). Being female (aOR=0.61 p<0.01) and having a regular partner (aOR=0.65 p<0.01) were independently associated with low consistent condom use.

CONCLUSIONS

In this rural South African setting, condom use remains low, especially among females and with an older partner, situations commonly associated with increased HIV acquisition. Targeted supportive interventions to increase condom use need to be developed if HIV prevention programmes are to be successful.

Growing Old in the Era of a High Prevalence of HIV/AIDS: The Impact of AIDS on Older Men and Women in KwaZulu-Natal, South Africa

Despite the important consequences that HIV/AIDS is likely to have for older people in South Africa, little empirical work has focused directly on this issue. However, emerging evidence suggests that older people are increasingly affected by the AIDS pandemic. In many households, older people often assume responsibility for the care of those who are sick and/ or dying and for children orphaned by AIDS. This study uses qualitative and quantitative methods to provide insights into the multiple impacts of the HIV/AIDS pandemic on the lives of older men and women. The results show that some older men and women feel at risk of HIV infection because of their caregiving activities. Almost 17% of respondents report that they have ever cared for someone with HIV/AIDS, with the percentage somewhat higher in rural areas. The study found that the impact of HIV/AIDS is substantial and is compounded greatly by gender dynamics in the household.

Knowing kids dying of HIV: a traumatic event for AIDS orphans

Data from 755 AIDS orphans living in a rural area of China with high rates of HIV infection were used to examine the association between a child's trauma symptoms and knowing a peer with HIV infection or one who had died of HIV. Trauma symptoms were measured by the Traumatic Symptoms Checklist for Children-Chinese Version (TSCC-CV). About 47% of participants reported they knew a child with HIV or one who had died of HIV. More orphans living in family-based care reported such knowledge, and trauma symptoms were significantly higher in children who reported such knowledge. Multivariate analysis showed that such knowledge was significantly associated with traumatic symptoms, controlling for gender, age, family socioeconomic status, orphan status (double vs. single), and care arrangement (family-based vs. institutional care). The results underscored the importance of psychosocial support and counseling to orphans in communities with high levels of HIV-related mortality.

Association between knowing someone who died of AIDS and behavior change among South African youth

In South Africa, the rising AIDS related mortality has increased the publicity of the HIV/AIDS epidemic and may have an impact on behavior change. We examined the association between knowing someone who has died of AIDS and self-reported behavior change, condom use at last intercourse, number of partners in the prior 12 months, and attitudes towards HIV, among South African youth aged 15-24. We found that over 40% of youth reported knowing someone who died of AIDS, most commonly a neighbor. Using multivariable logistic regression, we found that high school-educated youth who knew someone who died of AIDS were significantly more likely to report having changed their behavior as a result of HIV (OR 2.01, 95% CI: 1.32;3.06). We found no association between knowing someone who died of AIDS and other HIV prevention-related behaviors. While youth tended to have increased odds of perceiving HIV to be serious, they did not consistently perceive their risk of contracting HIV to be higher when they knew someone who died of AIDS. Our results suggest that part of the key to impacting behavior change in youth may lie in better understanding what factors increase youth's perceived risk of contracting HIV which will help us better target our interventions. If youth are impacted by personal knowledge of an AIDS death, to the point that they change their behaviors, we must continue to encourage discourse about HIV/AIDS with the hope that persons dying from AIDS will feel more comfortable disclosing their diagnosis to youth they know and others.

Young adult Ecstasy users and multiple sexual partners: understanding the factors underlying this HIV risk practice

The purposes of this study are to (1) examine the extent to which young adult Ecstasy users recently reported having had multiple sex partners and (2) identify the factors predictive of engaging in this behavior. Potential predictors included demographic characteristics, background and experiences measures, childhood maltreatment experiences, substance use variables, and measures assessing psychological/psychosocial functioning. This research is based on a sample of 283 young adult recurrent users of the drug, Ecstasy. Study participants were recruited in Atlanta, Georgia between August 2002 and August 2004 using a targeted sampling and ethnographic mapping approach. Interviews took approximately two hours to complete. Nearly one-third of the study participants had more than one sex partner during the preceding month, and sexual protection rates tended to be low. Multivariate logistic regression analysis revealed seven predictors associated with an increased likelihood of having multiple sex partners: (1) being nonwhite, (2) knowing someone who was HIV-positive, (3) younger age of first sexual experience, (4) using Ecstasy for its touch-enhancing qualities, (5) higher self-esteem, (6) handling disagreements more dysfunctionally, and (7) not being involved in a romantic relationship. The HIV prevention- and intervention-related implications of these findings are discussed.

The culture of condoms: culturally grounded variables and their association with attitudes to condoms

OBJECTIVE

To examine attitudes toward condoms and their association with culturally grounded beliefs among young South African adults.

METHODS

A questionnaire survey undertaken in three different locations (urban, rural, and mixed), including 1100 participants, and implementing both a cross-validational and a bootstrap multivariate design. Outcome measures were intention to use a condom at next sex and condom salience (i.e., confidence in the protective value of condoms). Culturally grounded predictors included traditional beliefs about illness, beliefs in ancestral protection, endorsement of AIDS myths, and mortality salience (CONTACT).

RESULTS

Participants exhibited strong endorsement of indigenous beliefs about illness and ancestral protection, and moderate endorsement of AIDS myths. Participants who viewed condoms as important for HIV prevention were more likely to show strong endorsement of both beliefs in ancestral protection and traditional beliefs about illness. Participants who strongly endorsed AIDS myths viewed condoms as less important and also had lower intention to use scores. Finally, participants who knew HIV positive people, and/or people who had died of HIV-related illnesses, had higher condom salience and higher intention to use scores.

CONCLUSIONS

Results challenge the assumption that culturally grounded variables are inherently adversarial in their relationship to biomedical models of HIV prevention, and offer insights into how traditional beliefs and cultural constructions of HIV/AIDS might be used more effectively in HIV education programs.

Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa

OBJECTIVE

To assess the evidence that the association between educational attainment and risk of HIV infection is changing over time in sub-Saharan Africa.

DESIGN AND METHODS

Systematic review of published peer-reviewed articles. Articles were identified that reported original data comparing individually measured educational attainment and HIV status among at least 300 individuals representative of the general population of countries or regions of sub-Saharan Africa. Statistical analyses were required to adjust for potential confounders but not over-adjust for variables on the causal pathway.

RESULTS

Approximately 4000 abstracts and 1200 full papers were reviewed. Thirty-six articles were included in the study, containing data on 72 discrete populations from 11 countries between 1987 and 2003, representing over 200,000 individuals. Studies on data collected prior to 1996 generally found either no association or the highest risk of HIV infection among the most educated. Studies conducted from 1996 onwards were more likely to find a lower risk of HIV infection among the most educated. Where data over time were available, HIV prevalence fell more consistently among highly educated groups than among less educated groups, in whom HIV prevalence sometimes rose while overall population prevalence was falling. In several populations, associations suggesting greater HIV risk in the more educated at earlier time points were replaced by weaker associations later.

DISCUSSION

HIV infections appear to be shifting towards higher prevalence among the least educated in sub-Saharan Africa, reversing previous patterns. Policy responses that ensure HIV-prevention measures reach all strata of society and increase education levels are urgently needed.

Explaining the increase in condom use among South African young females

Since 1998 South Africa has experienced stability in HIV prevalence among its 15 to 19 year olds, and to a lesser extent among its 20 to 24 year olds. While a few studies point to behavioural change, mainly an increase in condom use, none has established the reasons. This article explores the influence of various information sources about AIDS upon the use of condoms among rural and urban South African young females, using the South Africa Demographic Health Survey of 1998 (1998 SADHS), while controlling for various socioeconomic and cultural parameters. The results show that condom use among urban residents was positively correlated with mass media exposure, television as a source of information about AIDS, and the number of mass media sources from which the respondent received information about AIDS. Condom use among rural residents was associated with the number of sources of information about AIDS, exposure to mass media, and the language and education of the respondent. Among urban residents condom use was almost twice as high as among rural residents. The results from the article indicate that three elements influenced the increase in condom use among females: the threat of AIDS, mass media, and receptiveness to condom use. The receptiveness was culturally dependent.

Women in Chinsapo, Malawi: vulnerability and risk to HIV/AIDS

Malawi, a very poor country located in southern Africa, is no exception to the growing trend and severity in HIV prevalence. By the end of 2003 there were 900 000 adults and children in Malawi living with HIV/AIDS. Adult prevalence was estimated to be 15%, which is higher than the 7.1% average rate for sub-Saharan Africa. In order to understand the spread of HIV/AIDS it is imperative to address the economic, social, cultural, and political issues that impact on women's contraction and spread of the virus. We do so in this paper by critically examining the gendered context of HIV/AIDS with reference to Malawi. The theoretical framework for this research focuses on poverty, gender relations, regional migration patterns, and global economic changes which place women in highly vulnerable situations. The study was conducted in a low-income area in Lilongwe, the capital city of Malawi. In 2003 and 2004, 60 randomly selected women who lived in a low socioeconomic residential area completed a structured interview on issues concerning individual economic situations, marriage history, fertility, family planning and social networks, gender, sexual partnerships, and HIV/AIDS. Focus group interviews were also conducted with an additional 20 women. The results of our study indicate that the rising epidemic among women in Malawi is firstly driven by poverty which limits their options. Secondly, gender inequality and asymmetrical sexual relations are basic to spreading HIV/AIDS among women. Thirdly, in spite of their awareness through media and health care professionals, women are unable to protect themselves, which further increases their vulnerability.

The acceptability of male circumcision as an HIV intervention among a rural Zulu population, Kwazulu-Natal, South Africa

Epidemiological and biological studies provide compelling evidence for the protective effect of male circumcision against the acquisition of HIV. Three randomized controlled trials are currently underway to assess the impact of male circumcision as an HIV intervention in traditionally non-circumcising areas with high levels of heterosexually-transmitted infection. This study explores the acceptability of male circumcision among the rural Zulu around Hlabisa and Mtubatuba, KwaZulu-Natal, South Africa. A cross-sectional convenience sample of 100 men and 44 women was surveyed, and two male focus groups held, to ascertain circumcision preferences within the population. Four in-depth interviews with service providers assessed the feasibility of promoting male circumcision. Fifty-one per cent of uncircumcised men and 68% of women favoured male circumcision of themselves or their partners; while 50% of men and 73% of women would circumcise their sons. For men, the main predictors of circumcision preference pertained to beliefs surrounding sexual pain and pleasure; for women, knowledge about the relationship between male circumcision status and STI acquisition was the key indicator for circumcision preference. Among both sexes the main barrier to circumcision was fear of pain and death. The greatest logistical barrier was that circumcision can presently only be carried out by trained hospital doctors.

When is public disclosure of HIV seropositivity acceptable?

HIV/AIDS is a major public health problem in Africa. Stigmatization, discrimination and lack of appropriate health care are among the commonest challenges that HIV infected persons and their families face. It has been suggested that among the tools available in the fight against stigmatization and discrimination is public disclosure of a person's HIV seropositive status. While public disclosure of HIV status has a place in the fight against HIV and AIDS, especially by resulting in behavioural change among people who know of an HIV infected person, we argue that such disclosure also has potential attendant harms. The posthumous disclosure of HIV status is particularly problematic. Public disclosure should be accompanied by appropriate individual counselling and preparation of the community to deal with the situation, and should have regard for cultural sensitivity after consideration of the risks and benefits to individuals, families and the community. Health practitioners should keep in mind that their main duty is to the best interest of the patient, the family and the community, in that order.