Exploring HIV status as a mediator in the relationship of psychological distress with socio-demographic and health related factors in South Africa: findings from the 2012 nationally representative population-based household survey

BACKGROUND

Psychological distress as measured by mental disorders like depression and anxiety is more prevalent in people living with HIV (PLHIV) than in the general population. However, the relationship between mental disorders and HIV is complex and bidirectional. Improved understanding of the relationship between mental disorders and HIV is important for designing interventions for this group. This paper explores the interrelationships of psychological distress with HIV and associated socio-demographic and health-related factors.

METHODS

This secondary data analysis used the 2012 South African population-based household survey on HIV collected using a cross-sectional multi-stage stratified cluster sampling design. Generalized structural equation modelling (G-SEM) path analysis was used to explore the direct and indirect relationships of socio-demographic, health and HIV-related factors with psychological distress as measured by Kessler 10 scale using HIV status as a moderator variable.

RESULTS

A total of 20,083 participants were included in the study, 21.7% reported psychological distress, of whom (32.6%) were HIV positive. In the final path model with HIV status as a moderator, psychological distress was significantly more likely among age group 25-49 years (AOR: 1.4 [95% CI 1.3-1.6]), age 50 years and older, (AOR: 1.4 [95% CI 1.2-1.6]), females (AOR: 1.6 [95% CI 1.4-1.8]), high risk drinkers (AOR: 1.9 [1.6-2.2]) hazardous drinkers (AOR: 4.4 [95% CI 3.1-6.3]), ever tested for HIV (AOR: 1.2 [95% CI 1.1-1.3]). Psychological distress was significantly less likely among the married [AOR: 0.8 (0.7-0.9)], other race groups [AOR: 0.5 (0.5-0.6)], those with secondary level education (AOR: 0.9 [95% CI 0.8-0.9]), and tertiary level education (AOR: 0.7 [95% CI 0.6-0.9]), those from rural informal [AOR: 0.8 (0.7-0.9)], and rural formal [AOR: 0.8 (0.7-0.9)] areas and those who rated their health as excellent/good [AOR: 0.4 (0.4-0.5)].

CONCLUSION

The findings highlight the importance of designing tailored interventions targeted at psychological distress among PLHIV especially the elderly, females, those with no education and / or low education attainment and those residing in informal urban areas.

The HIV Epidemic in South Africa: Key Findings from 2017 National Population-Based Survey

South Africa has the largest number of people living with HIV worldwide. South Africa has implemented five population-based HIV prevalence surveys since 2002 aimed at understanding the dynamics and the trends of the epidemic. This paper presents key findings from the fifth HIV prevalence, incidence, and behaviour survey conducted in 2017 following policy, programme, and epidemic change since the prior survey was conducted in 2012. A cross-sectional population-based household survey collected behavioural and biomedical data on all members of the eligible households. A total of 39,132 respondents from 11,776 households were eligible to participate, of whom 93.6% agreed to be interviewed, and 61.1% provided blood specimens. The provided blood specimens were used to determine HIV status, HIV incidence, viral load, exposure to antiretroviral treatment, and HIV drug resistance. Overall HIV incidence among persons aged 2 years and above was 0.48% which translates to an estimated 231,000 new infections in 2017. HIV prevalence was 14.0% translating to 7.9 million people living with HIV. Antiretroviral (ARV) exposure was 62.3%, with the lowest exposure among those aged 15 to 24 years (39.9%) with 10% lower ARV coverage among males compared to females. Viral suppression among those on treatment was high (87.3%), whilst HIV population viral load suppression was much lower (62.3%). In terms of risk behaviours, 13.6% of youth reported having had an early sexual debut (first sex before the age of 15 years), with more males reporting having done so (19.5%) than females (7.6%). Age-disparate relationships, defined as having a sexual partner 5+ years different from oneself,) among adolescents were more common among females (35.8%) than males (1.5%). Self-reported multiple sexual partnerships (MSPs), defined as having more than one sexual partner in the previous 12 months, were more commonly reported by males (25.5%) than females (9.0%). Condom use at last sexual encounter was highest among males than females. Three quarters (75.2%) of people reported they had ever been tested for HIV, with more females (79.3%) having had done so than males (70.9%). Two-thirds of respondents (66.8%) self-reported having tested for HIV in the past 12 months. Finally, 61.6% of males in the survey self-reported as having been circumcised, with circumcision being more common among youth aged 15–24 years (70.2%), Black Africans (68.9%), and those living in both rural informal (tribal) areas (65%) and urban areas (61.9%). Slightly more (51.2%) male circumcisions were reported to have occurred in a medical setting than in traditional settings (44.8%), with more young males aged 15–24 (62.6%) and men aged 25–49 (51.5%) reporting to have done so compared to most men aged 50 and older (57.1%) who reported that they had undergone circumcision in a traditional setting. The results of this survey show that strides have been made in controlling the HIV epidemic, especially in the reduction of HIV incidence, HIV testing, and treatment. Although condom use at last sex act remains unchanged, there continue to be some challenges with the lack of significant behaviour change as people, especially youth, continue to engage in risky behaviour and delay treatment initiation. Therefore, there is a need to develop or scale up targeted intervention programmes to increase HIV testing further and put more people living with HIV on treatment as well as prevent risky behaviours that put young people at risk of HIV infection.

Factors associated with external HIV-related stigma and psychological distress among people living with HIV in South Africa

BACKGROUND

HIV-related stigma and psychological distress among people living with HIV (PLHIV) pose a public health challenge in most African countries. This study aims to investigate the association between HIV-related stigmatizing attitudes and psychological distress amongst PLHIV in South Africa using the 2012 nationally representative population-based household survey.

METHODS

The data used in the analysis were collected using a multi-stage stratified cluster sampling design. Bivariate and multivariate logistic regression models were used to identify factors associated with stigma among PLHIV with psychological distress. A total of 2521 HIV positive individuals that responded to the question on psychological distress, 34.3% had psychological distress and 37.9% experienced high levels of HIV related stigmatizing attitudes. Stigmatizing attitudes among PLHIV with psychological distress were significantly less likely among those with secondary level education [aOR = 0.67 (95% CI: 0.44-1.01), p = 0.050], those with correct knowledge about HIV and rejection of myths about HIV [aOR = 0.58 (95% CI: 0.38-0.89), p = 0.013], and those who ever tested for HIV [aOR = 0.65 (95% CI: 0.42-1.01), p = 0.054].

CONCLUSION

The findings suggest a need to reinvigorate stigma-reduction interventions in the national HIV response with emphasis on HIV awareness and education campaigns. In addition, HIV testing services should be reinforced through communication strategies targeted against HIV stigmatization, discrimination and fear. There is also a need to continuously engage PLHIV in programs through counselling and support interventions for acceptance of HIV positive status and to help them cope with HIV-related stigma.

Factors associated with age-disparate sexual partnerships among males and females in South Africa: a multinomial analysis of the 2012 national population-based household survey data

BACKGROUND

In South Africa, age-disparate to sexual relationships where the age difference between partners is 5 years or greater is an important contributor to the spread of HIV. However, little is known about the predictors of age-disparate sexual relationships. This study investigates factors associated with age-disparate sexual relationships among males and females in South Africa.

METHODS

This analysis used the 2012 nationally representative population-based household survey conducted using multi-stage stratified cluster sampling design. Multivariate multinomial stepwise logistic regression models were used to determine factors associated with age-disparate sexual relationships.

RESULTS

Of 15,717 participants, who responded to the question on age-disparate sexual relationships, 62% males versus 58.5% females had partners within 5 years older or younger, 34.7% of males versus 2.7% of females had partners at least 5 years younger and 3.3% of males versus 38.8% of females had partners at least 5 years older. Among both males and females predictors of age-disparate sexual relationships were education, employment, socioeconomic status, locality type, age at sexual debut, condom use at last sexual act and HIV status while race was also an additional predictor for among females. Including unprotected sex and risk of HIV infection among adolescent girls and young women with sexual partners 5 years older their age.

CONCLUSIONS

This study suggest that there is a need for reprioritizing the combination of behavioural and structural interventions to address risky sexual behaviours, unprotected sex, poverty, limited education and gender inequitable norms related to age-disparate sexual relationships and HIV.

Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey

Background

Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90–90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90–90–90 targets for the country stratified by a variety of key factors.

Methods

To evaluate progress towards achievement of the 90–90–90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90).

Results

Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one’s positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15–24 years old, 25–49 years old and 50–64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25–49 years old, 82.9% of those aged 50–64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90–90–90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%.

Conclusions

South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15–24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90–90–90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.

Culture Matters in Communicating the Global Response to COVID-19

Current communication messages in the COVID-19 pandemic tend to focus more on individual risks than community risks resulting from existing inequities. Culture is central to an effective community-engaged public health communication to reduce collective risks. In this commentary, we discuss the importance of culture in unpacking messages that may be the same globally (physical/social distancing) yet different across cultures and communities (individualist versus collectivist). Structural inequity continues to fuel the disproportionate impact of COVID-19 on black and brown communities nationally and globally. PEN-3 offers a cultural framework for a community-engaged global communication response to COVID-19.

Trends and determinants of ever having tested for HIV among youth and adults in South Africa from 2005-2017: Results from four repeated cross-sectional nationally representative household-based HIV prevalence, incidence, and behaviour surveys

BACKGROUND

HIV testing contributes to the prevention and control of the HIV epidemic in the general population. South Africa has made strides to improve HIV testing towards reaching the first of the UNAIDS 90-90-90 targets by 2020. However, to date no nationally representative analysis has examined temporal trends and factors associated with HIV testing among youth and adults in the country.

AIM

This study aimed to examine the trends and associations with ever having tested for HIV among youth and adults aged 15 years and older in South Africa using the 2005, 2008, 2012 and 2017 nationally representative population-based household surveys.

METHODS

The analysis of the data collected used multi-stage stratified cluster randomised cross-sectional design. P-trend chi-squared test was used to identify any significant changes over the four study periods. Bivariate and multivariate logistic regression analysis was conducted to determine factors associated with HIV testing in each of the survey periods.

RESULTS

Ever having tested for HIV increased substantially from 2005 (30.6%, n = 16 112), 2008 (50.4%, n = 13 084), 2012 (65.5%, n = 26 381), to 2017 (75.2%, n = 23 190). Those aged 50 years and older were significantly less likely to ever have tested for HIV than those aged 25-49 years. Those residing in rural areas were significantly less likely to have tested for HIV as compared to people from urban areas. There was a change in HIV testing among race groups with Whites, Coloureds and Indian/Asians testing more in 2005 and 2008 and Black Africans in 2017. Marriage, education and employment were significantly associated with increased likelihood of ever testing for HIV. Those who provided a blood specimen for laboratory HIV testing in the survey rounds and were found to have tested positive were more likely to have ever tested for HIV previously.

CONCLUSION

The results show that overall there has been an increase in ever having an HIV test in the South African population over time. The findings also suggest that for South Africa to close the testing gap and reach the first of the UNAIDS 90-90-90 targets by 2020, targeted programmes aimed at increasing access and utilization of HIV testing in young people, males, those not married, the less educated, unemployed and those residing in rural areas of South Africa should be prioritised.

Trauma and mental health in South Africa: Overview

Provides an introduction to this special edition of Psychological Trauma. The papers included in this special section focus on aspects of trauma and the effects of trauma in a cultural context that pertains to the way of life in South Africa. These articles highlight the complexities of the effects of trauma and call for tailored interventions to address the lasting effects on health and mental health. (PsycINFO Database Record

Determinants of HIV infection among adolescent girls and young women aged 15-24 years in South Africa: a 2012 population-based national household survey

BACKGROUND

South Africa is making tremendous progress in the fight against HIV, however, adolescent girls and young women aged 15-24 years (AGYW) remain at higher risk of new HIV infections. This paper investigates socio-demographic and behavioural determinants of HIV infection among AGYW in South Africa.

METHODS

A secondary data analysis was undertaken based on the 2012 population-based nationally representative multi-stage stratified cluster random household sample. Multivariate stepwise backward and forward regression modelling was used to determine factors independently associated with HIV prevalence.

RESULTS

Out of 3092 interviewed and tested AGYW 11.4% were HIV positive. Overall HIV prevalence was significantly higher among young women (17.4%) compared to adolescent girls (5.6%). In the AGYW model increased risk of HIV infection was associated with being young women aged 20-24 years (OR = 2.30, p = 0.006), and condom use at last sex (OR = 1.91, p = 0.010), and decreased likelihood was associated with other race groups (OR = 0.06, p < 0.001), sexual partner within 5 years of age (OR = 0.53, p = 0.012), tertiary level education (OR = 0.11, p = 0.002), low risk alcohol use (OR = 0.19, p = 0.022) and having one sexual partner (OR = 0.43, p = 0.028). In the adolescent girls model decreased risk of HIV infection was associated with other race groups (OR = 0.01, p < 0.001), being married (OR = 0.07), p = 0.016], and living in less poor household (OR = 0.08, p = 0.002). In the young women's models increased risk of HIV infection was associated with condom use at last sex (OR = 2.09, p = 0.013), and decreased likelihood was associated with other race groups (OR = 0.17, p < 0.001), one sexual partner (OR = 0.6, p = 0.014), low risk alcohol use (OR = 0.17, p < 0.001), having a sexual partner within 5 years of age (OR = 0.29, p = 0.022), and having tertiary education (OR = 0.29, p = 0.022).

CONCLUSION

These findings support the need to design combination prevention interventions which simultaneously address socio-economic drivers of the HIV epidemic, promote education, equity and access to schooling, and target age-disparate partnerships, inconsistent condom use and risky alcohol consumption.

Antiretroviral Treatment and Sexual Risk Behavior in South Africa

The sexual behavior of individuals living with HIV determines the onward transmission of HIV. With the understanding that antiretroviral therapy (ART) prevents transmission of HIV, the sexual behaviors of the individuals not on ART with unsuppressed viral loads becomes of the greatest importance in elucidating transmission. We assessed the association between being on ART and sexual risk behavior among those living with HIV in a nationally representative population-based cross-sectional survey of households in South Africa that was conducted in 2012. Of 2237 adults (aged 15-49) who tested HIV-seropositive, 667 (29.8 %) had detectable antiretroviral drugs in their blood specimens. Among males, 77.7 % of those on ART reported having had sex in the past year contrasted with 88.4 % of those not on ART (p = 0.001); among females, 72.2 % of those on ART reported having had sex in the past year while 80.3 % of those not on ART did (p < 0.001). For males and females, the odds of reporting consistent condom use and condom use at last sex were statistically significantly higher for individuals on ART compared to those not on ART (males: consistent condom use aOR 2.8, 95 % CI 1.6-4.9, condom use at last sex aOR 2.6, 95 % CI 1.5-4.6; females: consistent condom use aOR 2.3, 95 % CI 1.7-3.1, condom use at last sex aOR 2.3, 95 % CI 1.7-3.1), while there were no statistically significant differences in odds of reporting multiple sexual partners in the past year. In this nationally representative population-based survey of South African adults, we found evidence of less risky sexual risk behavior among people living with HIV on ART compared to those not on ART.

Predictors of knowledge about tuberculosis: results from SANHANES I, a national, cross-sectional household survey in South Africa

BACKGROUND

South Africa is one of the 22 high tuberculosis burden countries that contribute 80% of the global tuberculosis cases. Tuberculosis is infectious and due to its rapid and easy transmission route poses a threat to population health. Considering the importance of social and psychological factors in influencing health outcomes, appraising knowledge and awareness of tuberculosis, remain vital for effective tuberculosis control. The main aim of this study was to investigate the factors that predict knowledge about tuberculosis among 18-64 year old adults in South Africa.

METHODS

A cross-sectional survey method was used. Multi-stage disproportionate, stratified cluster sampling was used to select households within enumeration areas stratified by province and locality type. Based on the Human Sciences Research Council 2007 master sample, 500 Enumerator Areas representative of the socio-demographic profile of South Africa were identified and a random sample of 20 households was randomly selected from each Enumerator Area, yielding an overall sample of 10,000 households. The tuberculosis module contained in the South African National Health And Nutrition Examination Survey I was the only module that examined the social determinants of an infectious disease. This module was questionnaire-based with no biomarkers obtained to screen for the presence of tuberculosis disease among the participants. Data was collected by administering a researcher developed individual level questionnaire. Simple and multiple linear regression was used to determine the independent variables associated with tuberculosis knowledge.

RESULTS

Half the sample (52.6%) was female and the majority of the respondents were black African (76.5%). More than two thirds (68.0%) resided in urban areas, 56.9% did not complete high school and half were not in formal employment. Significant predictors of tuberculosis knowledge were race, sex, completion of high school, being in employment, having a diagnosis of the disease in ones' life-time and learning about tuberculosis from television, brochures, health workers, and teachers.

CONCLUSIONS

To reduce the burden of tuberculosis in South Africa, media campaigns targeting both rural and urban communities should include conveying accurate information about the disease. Policy makers should also address structural barriers that vulnerable communities face.

Perceived social context of AIDS in a Black township in Cape Town

AIDS is only one of several life threatening social problems facing people living in poverty. HIV/AIDS prevention messages and prevention programmes should be framed within the context of relevant social problems. The current study examined public perceptions of AIDS as a relative social problem and AIDS-related socio-political beliefs among South African men and women living in a Black township of Cape Town. Participants (224 men and 276 women) completed surveys that assessed perceptions of HIV/AIDS relative to nine other social problems: lack of housing, transportation, poor sanitation, sufficient food, unemployment, discrimination, poor education, violence and crime. Participants also responded to six items assessing socio-political views of AIDS. Results showed that AIDS was perceived as a serious social problem in the township, but was perceived as less serious than crime and not different from violence and unemployment. Principal components factor analyses showed that AIDS was associated with multiple social problems and that AIDS was most closely associated with crime and violence, representing social problems that directly cause death. Although AIDS perceptions were similar to those expressed by the South African government, there was evidence for some mistrust about both what the government was doing and what it was saying about AIDS. HIV prevention messages in South Africa should be tailored to fit the perceived social context of AIDS.

Prevalence and acceptability of male circumcision in South Africa

BACKGROUND

The objectives of the current national study were to determine the rates of self-reported circumcision among South African men and, more importantly, evaluate the acceptability of male circumcision in South Africa by uncircumcised adult men and all adult women.

MATERIALS AND METHODS

The study based on a population-based survey included a nationally representative subgroup of 6654 men aged 15 years and older who where included in the analysis on male circumcision prevalence, and a subgroup of 6796 women aged 15 to 49 years who were included in the analysis on male circumcision acceptance.

RESULTS

An overall prevalence of self-reported male circumcision of 42.8% was found. Among the Black African population group the prevalence of male circumcision was 48.2%, 32.1% were traditionally and 13.4% were medically circumcised. Among males not circumcised 45.7% of 15-24 years olds indicated that they would consider being circumcised compared to 28.3% among 25-49 years olds. In multivariate analysis among non-circumcised men Black African and Coloured population groups and having heard of the HIV protective effect of male circumcision were significant predictors for male circumcision acceptability, and among women with a non-circumcised sexual partner, Black African and Coloured population groups and higher education were predictors for male circumcision acceptability.

CONCLUSION

The study found high rates and high acceptability of male circumcision. Findings associated with the acceptability of male circumcision can be used to increase awareness of the benefits of male circumcision for HIV prevention.

Identifying community risk factors for HIV among South African adolescents with mental health problems: a qualitative study of parental perceptions

High risk sexual behaviour, alcohol and drug use, and mental health problems combine to yield high levels of HIV-risk behaviour among adolescents with mental health problems. In South Africa, little research has been conducted on parental perspectives of HIV-risk among this population. We conducted a series of focus group discussions with 28 mothers of adolescents receiving services at two mental health clinics in South Africa to identify, from their perspectives, the key community problems facing their children. Participants indicated that HIV remained a serious threat to their adolescent children's well-being, in addition to substance abuse, early sexual debut, and teenage pregnancy. These social problems were mentioned as external to their household dynamics, and thus seemingly beyond the purview of the parent-adolescent relationship. These data have implications for the design of family-based interventions to ameliorate the factors associated with HIV-risk among youth receiving mental health services.

From research to practice: lay adherence counsellors' fidelity to an evidence-based intervention for promoting adherence to antiretroviral treatment in the Western cape, South Africa

In the Western Cape, lay counsellors are tasked with supporting antiretroviral (ARV) adherence in public healthcare clinics. Thirty-nine counsellors in 21 Cape Town clinics were trained in Options for Health (Options), an evidence-based intervention based on motivational interviewing (MI). We evaluated counsellors' ability to deliver Options for addressing poor adherence following 5 days training. Audio-recordings of counselling sessions collected following training were transcribed and translated into English. Thirty-five transcripts of sessions conducted by 35 counsellors were analysed for fidelity to the Options protocol, and using the Motivational Interviewing Treatment and Integrity (MITI) code. Counsellors struggled with some of the strategies associated with MI, such as assessing readiness-to-change and facilitating change talk. Overall, counsellors failed to achieve proficiency in the approach of MI according to the MITI. Counsellors were able to negotiate realistic plans for addressing patients' barriers to adherence. Further efforts aimed at strengthening the ARV adherence counselling programme are needed.

Lay counselors' ability to deliver counseling for behavior change

OBJECTIVE

Options for Health is an evidence-based sexual risk reduction intervention based on motivational interviewing (MI). Thirty-nine antiretroviral adherence lay counselors were trained to deliver Options for Health to help their patients to optimize their antiretroviral treatment adherence. An evaluation of counselors' ability to deliver the intervention after 35 hr of training revealed that counselors struggled with elements of the 8-step Options protocol and failed to achieve proficiency in MI. The current study aimed to determine the impact of refresher training and supervision on counselors' proficiency in the intervention.

METHOD

Audio-recordings of counseling sessions were collected for 22 of 39 counselors after 18 hr of refresher training and supervision had been delivered over a 12-month period. Recordings were transcribed, translated, and analyzed for fidelity to the Options protocol and the MI approach. Analysis was conducted using the Motivational Interviewing Treatment Integrity Tool and an instrument developed by the researchers. Results were compared to findings from an evaluation of counselors' performance immediately following the initial 35-hr training.

RESULTS

Counselors improved their delivery of some intervention steps, but not others; their use of micro-counseling skills and therapeutic approach improved to such an extent that they closely approximated the MI approach.

CONCLUSIONS

This study contributes evidence for the positive impact of ongoing training and supervision on lay health worker practice. Although counselors did not achieve complete proficiency in the Options protocol, refresher training and supervision improved counselors' basic counseling communication skills and therapeutic approach, enabling them to deliver better quality counseling for behavior change.

A study of descriptive data for orphans and non-orphans on key criteria of economic vulnerability in two municipalities in South Africa

BACKGROUND

It is generally assumed that orphan status increases the risk to children of a range of negative outcomes. In South Africa, death of parents due to HIV-related illness is contributing to a rapid increase in the prevalence of orphans. This paper presents descriptive data from two South African communities, namely Kopanong, in the Free State and Kanana in the North West province, characterising the differences between orphans (double, maternal and paternal) and non-orphans on key criteria of social vulnerability.

OBJECTIVES

The objective was to obtain a better understanding of how different types of orphans and non-orphans may differ in these key areas as a crucial starting point for addressing the devastating consequences the AIDS epidemic has on these children's lives. While the study focuses on two specific areas these will provide insight into the general situation of orphans in South Africa.

METHODS

A cross-sectional census survey was conducted in the two communities of Kopanong, comprising n=5254 households and Kanana, comprising n=12,984 households.

RESULTS

In Kopanong, 8.2% of children had lost both parents, 19.1% had lost their father and 6.5% their mother only, whilst in Kanana the results were 6.5%, 28.1% and 3.7% respectively. Loss of both parents appeared to have a consistent impact on material need, including access to food, clothing and essential services, whilst loss of a single parent seems to have a more variable impact. At present, there are very few child headed households, but this constitutes a risk in the longer term.

CONCLUSIONS

Orphans appear to be more vulnerable in terms of material need. Children assessed in this study as being most in need were not accessing adequately many services directed at them. There is a need to extend understanding and measurement of emotional need and abuse.

"It's important to take your medication everyday okay?" An evaluation of counselling by lay counsellors for ARV adherence support in the Western Cape, South Africa

There is growing interest in standard care programmes for antiretroviral (ARV) adherence support. In South Africa, individual counselling following ARV initiation is a main strategy for supporting adherence in the public sector. Egan's client-centred "Skilled Helper" counselling model is the predominant model used in HIV counselling in this context. This study evaluated counselling delivered by lay ARV adherence counsellors in Cape Town in terms of adherence to Egan's model. Thirty-eight transcripts of counselling sessions with non-adherent patients were analysed based on the methods of content analysis. These sessions were conducted by 30 counsellors. Generally counsellors' practice adhered neither to Egan's model nor a client-centred approach. Inconsistent with evidence-based approaches to counselling for ARV adherence support, counsellors mainly used information-giving and advice as strategies for addressing clients' non-adherence. Recommendations for improving practice are made. The question as to how appropriate strategies from developed countries are for this setting is also raised.

Behaviour change counselling for ARV adherence support within primary health care facilities in the Western Cape, South Africa

Health care systems have been described as ideal settings for behaviour change counselling interventions. There is little research evaluating the feasibility of implementing such interventions in routine practice in primary care facilities. We implemented an intervention called Options for Health within routine adherence counselling practice in 20 antiretroviral facilities in Cape Town, South Africa. Lay counsellors were trained to use Options to help clients to optimise ARV adherence and reduce sexual risk behaviour. Counsellors delivered the intervention to 9% of eligible patients over 12 months. Interviews with counsellors revealed barriers to implementation including a lack of counselling space, time pressure and patient resistance to counselling. Counsellors felt that Options was not appropriate for use with all patients and adherence problems, and used parts of the intervention as it suited their needs. Findings revealed weaknesses in the current adherence counselling system that have implications for the feasibility of behaviour change counselling within this context.

Research capacity building: a US-South African partnership

Research capacity building engenders assets that allow communities (and, in this case, student fellows) to respond adequately to health issues and problems that are contextual, cultural and historical in nature. In this paper, we present a US-South African partnership that led to research training for 30 postgraduate students at two South African universities. We begin by exploring the nature of research capacity building in a partnership research project designed to promote HIV and AIDS-related stigma reduction. We examine methodological issues and their relevance to training of postgraduate students in South Africa. We conclude with recommendations for a successful model of partnership for building capacity of health researchers in Africa with the goal of developing research that informs policies and helps to bridge the health inequity gap globally.

HIV risk reduction intervention among traditionally circumcised young men in South Africa: a cluster randomized control trial

The aim of this study was to test a 180-minute group HIV risk-reduction counseling intervention trial with men undergoing traditional circumcision in South Africa to reduce behavioral disinhibition (false security) as a result of the procedure. A cluster randomized controlled trial design was employed using a sample of 160 men, 80 in the experimental group and 80 in the control group. Comparisons between baseline and 3-month follow-up assessments on key behavioral outcomes were completed. We found that behavioral intentions, risk-reduction skills, and male role norms did not change in the experimental compared to the control condition. However, HIV-related stigma beliefs were significantly reduced in both conditions over time. These findings show that one small-group HIV risk-reduction intervention did not reduce sexual risk behaviors in recently traditionally circumcised men at high risk for behavioral disinhibition.

Lay counsellor-based risk reduction intervention with HIV positive diagnosed patients at public HIV counselling and testing sites in Mpumalanga, South Africa

OBJECTIVE

To evaluate the feasibility, fidelity, and effect of a human immunodeficiency virus (HIV) risk reduction intervention delivered to HIV-infected patients by lay counsellors during routine HIV counselling and testing (HCT) public service in Mpumalanga, South Africa.

METHODS

A total of 488 HIV-infected patients, aged 18 years and older, receiving HCT service at clinics in Mpumalanga, received an "Options for Health" intervention delivered by clinic lay counsellors. Intervention lay counsellors implemented a brief risk reduction intervention at on average 2.3 sessions to help patients reduce their unprotected sexual behaviour. Questionnaires were administered at baseline and 4 months following the intervention to assess HIV risk behaviour in previous 3 months.

RESULTS

A significant increase in AIDS knowledge, behavioural intentions and risk reduction efficacy among participants at follow-up was found. Participants at 4-month follow-up reported a significant reduction of multiple partners, unprotected sex, alcohol or drug use in a sexual context, and transactional sex. In addition, sexual abstinence increased and alcohol use decreased, in the past 3 months.

CONCLUSIONS

A lay counsellor-delivered HIV prevention intervention targeting HIV-infected patients seems to be feasible to implement with fidelity in the South African HCT setting and promising at reducing risk behaviour.

Stigma, Culture, and HIV and AIDS in the Western Cape, South Africa: An Application of the PEN-3 Cultural Model for Community-Based Research

HIV- and AIDS-related stigma has been reported to be a major factor contributing to the spread of HIV. In this study, the authors explore the meaning of stigma and its impact on HIV and AIDS in South African families and health care centers. They conducted focus group and key informant interviews among African and Colored populations in Khayelitsha, Gugulethu, and Mitchell's Plain in the Western Cape province. The audio-recorded interviews were transcribed and coded using NVivo. Using the PEN-3 cultural model, the authors analyzed results showing that participants' shared experiences ranged from positive/nonstigmatizing, to existential/unique to the contexts, to negative/stigmatizing. Families and health care centers were found to have both positive nonstigmatizing values and negative stigmatizing characteristics in addressing HIV/AIDS-related stigma. The authors conclude that a culture-centered analysis, relative to identity, is central to understanding the nature and contexts of HIV/AIDS-related stigma in South Africa.

Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa

The links between gender roles, gender-based violence and HIV/AIDS risk are complex and culturally specific. In this qualitative study we investigated how women and men in two black communities in the Western Cape, South Africa, constructed their gender identities and roles, how they understood gender-based violence, and what they believed about the links between gender relations and HIV risk. First we conducted 16 key informant interviews with members of relevant stakeholder organisations. Then we held eight focus group discussions with community members in single-sex groups. Key findings included the perception that although traditional gender roles were still very much in evidence, shifts in power between men and women were occurring. Also, gender-based violence was regarded as a major problem throughout communities, and was seen to be fuelled by unemployment, poverty and alcohol abuse. HIV/AIDS was regarded as particularly a problem of African communities, with strong themes of stigma, discrimination, and especially 'othering' evident. Developing effective HIV/AIDS interventions in these communities will require tackling the overlapping as well as divergent constructions of gender, gender violence and HIV which emerged in the study.

New approaches, new activities and new outcomes in international conferences on HIV/AIDS in Africa — Report of the 3rd African Conference on the Social Aspects of HIV/AIDS, Dakar, 10 – 14 October 2005

Africa's HIV/AIDS situation remains cause for concern. The impact of HIV is considerable and threatens the survival and development of African societies. Although much has been attempted, the results still leave much to be desired. AIDS is an epidemic that needs to be addressed with much creativity and spirit of initiative. It is against this background that the 3rd African conference on the social aspects of HIV/AIDS brought innovations in the way international conferences are designed, activities implemented and results obtained. The innovations concerned the approach to international conferences and take into account reconceptualising HIV/AIDS so as to encourage holistic approaches and better visibility of vulnerable groups. The activities of the conference were organised in such a way as to get people living with HIV/AIDS (PLWHA), grassroots communities and marginalised groups to play a focal role. The conference offered an opportunity for developing cultural activities that would translate the African cultural concepts that had been identified as important in the HIV situation and response analysis. Interaction at the conference created an opportunity to analyse the various dimensions of the political, cultural and economic determinants. The conference offered food for thought around response construction while singling out the themes of urgency and acceleration of response, synergy construction, and coordination and conception of political responses.

HIV/AIDS and 'othering' in South Africa: the blame goes on

In order to explore the relevance of social concepts such as stigma and denial to the transmission of HIV, this qualitative study sought to examine cultural and racial contexts of behaviour relevant to the risk of HIV infection among South Africans. A cultural model was used to analyse transcripts from 39 focus group discussions and 28 key informant interviews. Results reveal how cultural and racial positionings mediate perceptions of the groups considered to be responsible and thus vulnerable to HIV infection and AIDS. An othering of blame for HIV and AIDS is central to these positionings, with blame being refracted through the multiple prisms of race, culture, homophobia and xenophobia. The study's findings raise important questions concerning social life in South Africa and the limitation of approaches that do not take into account critical contextual factors in the prevention of HIV and care for persons living with AIDS.

HIV prevalence in three predominantly Muslim residential areas in the Cape Town metropole

OBJECTIVE

To report on the results of a random and representative household survey of HIV prevalence in 3 predominantly Muslim areas in the Cape Town metropole.

METHOD

A cross-sectional representative community household survey was conducted in 3 residential areas. Aerial photographs were used in the selection of a random sample of 548 households, with the objective of obtaining an oral fluid sample and behavioural data from 2 inhabitants per household. Phase 1 of the study involved preparing the communities and notifying the household residents of the study. In phase 2, trained nurses collected oral fluid specimens for HIV testing and administered a confidential and anonymous behavioural questionnaire to household inhabitants aged 15 years and older.

RESULTS

A total of 717 people completed a behavioural interview and 512 were tested for HIV, yielding response rates of 65% and 47% respectively. The specimens of 503 respondents were correctly matched with behavioural data; 352 of these respondents indicated that they were Muslim. Of these oral fluid specimens 9 were reactive and 341 were non-reactive. We therefore calculated HIV prevalence among Muslims living in the three areas at 2.56% (95% confidence interval (CI): 1.18 - 4.80%). None of the individuals who tested HIV-positive had been previously tested for HIV. There were no HIV infections in the remainder of the sample.

CONCLUSION

The results indicate that HIV prevalence among Muslims living in the 3 targeted residential areas of the Cape Town metropole, while not trivial, is significantly lower than the national prevalence for South Africa. These results imply the need for ongoing prevention and education programmes specifically targeting Muslim youth and adults and support and assistance for Muslims infected with and affected by HIV.

Traditional beliefs about the cause of AIDS and AIDS-related stigma in South Africa

AIDS-related stigmas are pervasive in some segments of South African society and stigmas can impede efforts to promote voluntary counselling and testing and other HIV-AIDS prevention efforts. The current study examined associations among the belief that AIDS is caused by spirits and supernatural forces, AIDS-related knowledge and AIDS-related stigmas. A street intercept survey with 487 men and women living in a Black township in Cape Town, South Africa showed that 11% (n=54) believed that AIDS is caused by spirits and supernatural forces, 21% (n=105) were unsure if AIDS is caused by spirits and the supernatural, and 68% (n=355) did not believe that AIDS is caused by spirits and supernatural forces. Multiple logistic regression analyses controlling for participant age, gender, years of education and survey venue showed that people who believed HIV-AIDS is caused by spirits and the supernatural demonstrated significantly more misinformation about AIDS and were significantly more likely to endorse repulsion and social sanction stigmatizing beliefs against people living with HIV-AIDS. However, nearly all associations between beliefs that AIDS is caused by spirits and AIDS stigmas were non-significant when logistic regressions were repeated with AIDS-related knowledge included as a control variable. This finding suggests that relationships between traditional beliefs about the cause of HIV-AIDS and AIDS stigmas are mediated by AIDS-related knowledge. AIDS education efforts are urgently needed to reach people who hold traditional beliefs about AIDS to remedy AIDS stigmas.

Evaluation of the Quality of Care for Sexually Transmitted Infections in Primary Health Care Centres in South Africa

Sexually transmitted infections (STIs) are one of the most common illnesses among adolescents and adults in developing countries. While research from other countries indicates that a lack of financial, infra-structural and human resources are central determinants of the quality of care for STIs, South African studies suggest that there are also problems in health workers' interactions with STI patients. This study investigates the quality of care for STIs at 24 primary health care (PHC) centres in four provinces of South Africa (SA). Semi-structured interviews were conducted with STI patients and health providers. In addition, in-depth interviews were conducted with a sample of STI patients, and focus group discussions were held with diverse community groupings. Simulated patients also completed questionnaires on the care they received at the centres. Frequencies were computed on close-ended questions in order to describe patterns and trends in the data. Cross-tabulations were calculated to check for gender, provincial and urban-rural differences. Composite scores were also generated for the purpose of comparing quality of care across the different participating groups. Finally, the depth interviews and focus groups were analysed thematically. The results show that PHC centres in SA are relatively well-resourced. However, problems were found in the actual encounter between health workers and STI patients, which severely undermines the quality and effectiveness of treatment. It is strongly recommended that attention be given to health providers, in particular through the provision of further training and support in relation to effective STI management.

The social construction of sexually transmitted infections (STIs) in South African communities

Since the medical link between sexually transmitted infections (STIs) and HIV/AIDS was established, there has been an increased focus on the spread of STIs in South Africa. The aim of this study was to provide an in-depth picture of the dynamics involved in sexuality and the spread of STIs and HIV/AIDS. The authors present the findings of a focus group study, which was a part of a larger, national project addressing the broad question of health-care seeking behavior for STIs. A discourse analysis carried out on 10 focus groups reveals complex and rich narratives on the way in which STIs are constructed in South African communities. The dominant discourses focused on the continuing stigmatization of STIs, causal explanations, and prevention strategies. The analysis raises important recommendations for both educational interventions and health services toward the challenge of halting the spread of STIs and HIV/AIDS.