Determinants of gender disparities in scaling up the first 90 towards the UNAIDS 90-90-90 targets in South Africa: findings from the 2017 household-based national cross-sectional survey

BACKGROUND

The first 90 of UNAIDS 90-90-90 targets to have 90% of the people living with HIV know their status is an important entry point to the HIV treatment cascade and care continuum, but evidence shows that there is a large gap between males and females in this regard. It is therefore important to understand barriers and facilitators of achieving the first 90 target. This study examined determinants of the first 90 target among females and males in order to inform strategies aimed at improving the HIV cascade in South Africa.

METHODS

The data used in the analysis were obtained from a 2017 household-based cross-sectional nationally representative survey conducted using a multi-stage stratified cluster random sampling design. A series of hierarchical multiple logistic regression models were fitted to identify the determinants of the first 90 target by gender.

RESULTS

Overall, 84.8% of HIV-positive individuals aged 15 years and older were aware of their HIV status. Females were significantly more aware of their HIV status compared to males (88.7% vs 78.2%, p < 0.001). Both females aged 25 to 49 years [aOR = 3.20 (95% CI 1.35-7.57), p = 0.008], and 50 years and older [aOR = 3.19 (95% CI 1.04-9.76), p = 0.042] and males aged 25 to 49 years [aOR = 3.00 (95% CI 1.13-7.97), p = 0.028], and 50 years and older [aOR = 7.25 (95% CI 2.07-25.36), p = 0.002] were significantly more likely to know their HIV status compared to those aged 15 to 19 years. Males with tertiary education level were significantly more likely to be aware of their HIV positive status [aOR = 75.24 (95% CI 9.07-624.26), p < 0.001] compared to those with no education or with primary level education. Females with secondary [aOR = 3.28 (95% CI 1.20-8.99), p = 0.021] and matric [aOR = 4.35 (95% CI 1.54-12.37), p = 0.006] educational levels were significantly more likely to be aware of their HIV positive status, compared to those with no education or with primary level education.

CONCLUSION

Significant progress has been made with regards to reaching the UNAIDS first 90 target. In this context achieving the first 90 target is feasible but there is a need for additional interventions to reach the males especially youth including those with no education or low levels of education.

HIV risk perception and behavior among medically and traditionally circumcised males in South Africa

BACKGROUND

In South Africa, voluntary medical male circumcision (VMMC) has recently been implemented as a strategy for reducing the risk of heterosexual HIV acquisition among men. However, there is some concern that VMMC may lead to low risk perception and more risky sexual behavior. This study investigated HIV risk perception and risk behaviors among men who have undergone either VMMC or traditional male circumcision (TMC) compared to those that had not been circumcised.

METHODS

Data collected from the 2012 South African national population-based household survey for males aged 15 years and older were analyzed using bivariate and multivariate multinomial logistic regression, and relative risk ratios (RRRs) with 95 % confidence interval (CI) were used to assess factors associated with each type of circumcision relative no circumcision.

RESULTS

Of the 11,086 males that indicated that they were circumcised or not, 19.5 % (95 % CI: 17.9-21.4) were medically circumcised, 27.2 % (95 % CI: 24.7-29.8) were traditionally circumcised and 53.3 % (95 % CI: 50.9-55.6) were not circumcised. In the final multivariate models, relative to uncircumcised males, males who reported VMMC were significantly more likely to have had more than two sexual partners (RRR = 1.67, p = 0.009), and males who reported TMC were significantly less likely to be low risk alcohol users (RRR = 0.72, p < 0.001).

CONCLUSION

There is a need to strengthen and improve the quality of the counselling component of VMMC with the focus on education about the real and present risk for HIV infection associated with multiple sexual partners and alcohol abuse following circumcision.

Intimate partner violence as a factor associated with risky sexual behaviours and alcohol misuse amongst men in South Africa

Globally intimate partner violence (IPV) is a public health problem that can be perpetrated by both males and females, although males are more likely to inflict severe IPV-related injuries on their female partners. In low- and middle-income countries like South Africa, few studies have conducted research to determine whether IPV perpetration by men may be a risk factor for engaging in other risk behaviours. The aim of this study is to determine whether IPV perpetration by men is a risk factor for engaging in other risk behaviours with a particular focus on risky sexual behaviours and alcohol misuse. The data for this study were drawn from a multilevel intervention study, which addressed the nexus of alcohol abuse and HIV prevention among men in South Africa. Men were screened and recruited from informal drinking places within 12 communities situated in one of the oldest, predominantly Xhosa-speaking African townships in Cape Town. Univariate and multivariate logistic regression models were used to analyse the associations between IVP and potential explanatory variables. Of the 975 men included in the survey, 39.9% reported to have been involved in Intimate Partner Violence. IPV perpetration was significantly more likely among men who reported having a child [OR 1.51 (1.07-2.14) p = .019], having a casual sexual partner [OR 1.51 (1.11-2.05) p = .008], and those with possible alcohol dependence [OR 3.46 (1.17-10.20) p = .024]. IPV was significantly less likely among men with matric educational qualification than those with no education [OR 0.30 (95% CI: 0.09-1.02) p = .053] and among those who reported using a condom at last sex [OR 0.69 (0.50-0.97) p = .034]. We therefore recommend that interventions aimed at reducing IPV need to address risky sexual and drinking behaviours amongst men simultaneously, while also focusing on intimate relationship power dynamics and gendered norms amongst couples.

Heterosexual anal intercourse among community and clinical settings in Cape Town, South Africa

BACKGROUND

Anal intercourse is an efficient mode of HIV transmission and may play a role in the heterosexual HIV epidemics of southern Africa. However, little information is available on the anal sex practices of heterosexual individuals in South Africa.

PURPOSE

To examine the occurrence of anal intercourse in samples drawn from community and clinic settings.

METHODS

Anonymous surveys collected from convenience samples of 2593 men and 1818 women in two townships and one large city sexually transmitted infection (STI) clinic in Cape Town. Measures included demographics, HIV risk history, substance use and 3-month retrospective sexual behaviour.

RESULTS

A total of 14% (n = 360) men and 10% (n = 172) women reported engaging in anal intercourse in the past 3 months. Men used condoms during 67% and women 50% of anal intercourse occasions. Anal intercourse was associated with younger age, being unmarried, having a history of STI, exchanging sex, using substances, having been tested for HIV and testing HIV positive.

CONCLUSIONS

Anal intercourse is reported relatively less frequently than unprotected vaginal intercourse among heterosexual individuals. The low prevalence of anal intercourse among heterosexual individuals may be offset by its greater efficiency for transmitting HIV. Anal sex should be discussed in heterosexual HIV prevention programming.

Stigma and discrimination experiences of HIV-positive men who have sex with men in Cape Town, South Africa

Since the primary mode of HIV transmission in sub-Saharan Africa is heterosexual, research focusing on the sexual behaviour of men who have sex with men (MSM) is scant. Currently it is unknown how many people living with HIV in South Africa are MSM and there is even less known about the stigmatisation and discrimination of HIV-positive MSM. The current study examined the stigma and discrimination experiences of MSM living with HIV/AIDS in South Africa. Anonymous venue-based surveys were collected from 92 HIV-positive MSM and 330 HIV-positive men who only reported sex with women (MSW). Internalised stigma was high among all HIV-positive men who took part in the survey, with 56% of men reporting that they concealed their HIV status from others. HIV-positive MSM reported experiencing greater social isolation and discrimination resulting from being HIV-positive, including loss of housing or employment due to their HIV status, however these differences were not significant. Mental health interventions, as well as structural changes for protection against discrimination, are needed for HIV-positive South African MSM.

The evaluation of immediate behavioural outcomes of the syndromic case management approach for the treatment of patients with sexually transmitted infections at PHC centres in South Africa: knowledge, attitudes, beliefs and sexual behaviour

This study aimed to determine the immediate behavioural outcomes of the WHO syndromic case management model for STIs in the public health sector in South Africa, on the levels of knowledge, attitudes and beliefs, and behavioural practices (KABPs) concerning STIs. An outcomes evaluation was conducted using KABP methodology. Exit interviews were conducted with 126 STI and non-STI patients at 24 primary health care (PHC) centres in four provinces. Both groups were found to have equally high levels of knowledge about STIs and their attitudes towards and beliefs about STIs were mostly practical and slightly negative, with only promiscuity both stereotyped and stigmatised. However, both groups were found to engage in risky sexual behavioural practices although they also indicated very strong intentions to use condoms in future. Overall, no significant differences were found between the two groups on any of the variables investigated. The implications of these findings for the control and prevention of both classic STIs and HIV/AIDS in South Africa are discussed.

Sexual assault, sexual risks and gender attitudes in a community sample of South African men

Sexual assault against women and HIV infection are both prevalent and related social problems in South Africa. The current study examined hostile attitudes toward women, acceptance of violence against women and masculine ideological beliefs in relation to sexual assault history among men in a Cape Town township in South African. Men (n=435) completed anonymous surveys of sexual assault history, HIV risk history and gender-based attitudes. More than one in five men in this community sample reported that they had either threatened to use force or used force to gain sexual access to a woman in their lifetime. Men with a history of sexual assault were at significantly higher risk for HIV transmission than their non-sexually assaultive counterparts. Men with a history of sexual assault were also more likely to endorse hostile attitudes toward women and were more likely to accept violence against women, although these attitudes and beliefs were prevalent and pervasive across men with and without histories of sexual assault. These findings extend previous research to show that men who have a history of sexual assault also exhibit elevated risks for HIV infection and transmission. Interventions are needed to address hostile attitudes toward women, sexual assault and sexual risks for HIV among South African men.

Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa

BACKGROUND

The HIV epidemic continues to amplify in southern Africa and there is a growing need for HIV prevention interventions among people who have tested HIV positive.

METHODS

Anonymous surveys were completed by 413 HIV-positive men and 641 HIV-positive women sampled from HIV/AIDS services; 73% were <35 years old, 70% Black African, 70% unemployed, 75% unmarried, and 50% taking antiretroviral treatment.

RESULTS

Among the 903 (85%) participants who were currently sexually active, 378 (42%) had sex with a person to whom they had not disclosed their HIV status in the previous 3 months. Participants who had not disclosed their HIV status to their sex partners were considerably more likely to have multiple partners, HIV-negative partners, partners of unknown HIV status and unprotected intercourse with non-concordant sex partners. Not disclosing their HIV status to partners was also associated with having lost a job or a place to stay because of being HIV positive and feeling less able to disclose to partners.

CONCLUSIONS

HIV-related stigma and discrimination are associated with not disclosing HIV status to sex partners, and non-disclosure is closely associated with HIV transmission risk behaviours. Interventions are needed in South Africa to reduce the AIDS stigma and discrimination and to assist people with HIV to make effective decisions on disclosure.

Development of an HIV risk reduction counselling intervention for use in South African sexually transmitted infection clinics

South Africa urgently needs HIV prevention interventions that can be disseminated for use in clinical and community settings. A brief theory-based HIV risk reduction counselling intervention originally developed in the USA has recently been adapted for use in a South African sexually transmitted infection clinic. The 60-minute risk reduction counselling intervention was grounded in the Information-Motivation-Behavioural Skills (IMB) model of HIV preventive behaviour change, adapted through a series of interdisciplinary collaborative workshops. This paper reports the process of developing and culturally adapting the brief risk reduction counselling intervention. The processes used for adapting the HIV risk reduction counselling for South Africa provides a potential model for conducting technology transfer activities with other HIV prevention interventions. Several lessons learned from this process may help guide future efforts to transfer HIV prevention technologies.

Sexual assault history and risks for sexually transmitted infections among women in an African township in Cape Town, South Africa

Sexual violence is associated with women's risks for HIV infection. The current study investigated factors related to risks for sexually transmitted infections (STIs), including HIV, among South African women with a history of sexual assault. An anonymous street intercept survey of women (N = 272) living in an African township in the Western Cape, South Africa assessed demographic characteristics, history of sexual assault, HIV risk behaviours, substance use and non-sexual relationship abuse. Surveys were completed by 90% of women approached. Forty-four per cent (N = 119) of women reported a history of sexual assault. Multiple logistic regressions, controlling for participant age, education, marital status and survey venue, showed that women who had been sexually assaulted were significantly more likely to have shared injection drug equipment, exchanged sex to meet survival needs, and used alcohol compared to women who had not been sexually assaulted. Women with a history of sexual assault were also significantly more likely to have multiple male sex partners, greater rates of unprotected vaginal intercourse, lower rates of condom protected anal intercourse, more sexual contacts involving blood, more STIs and genital ulcers. Finally, women who had been sexually assaulted were more likely to have been non-sexually abused by relationship partners and were more likely to fear asking partners to use condoms. There is a close connection between sexual assault and women's risks for STIs and HIV. Structural and behavioural interventions are needed to simultaneously reduce the prevalence of sexual assault against women and prevent the transmission of HIV.

Behavioural responses of South African youth to the HIV/AIDS epidemic: a nationwide survey

South Africa is reported to have the largest number of people living with HIV/AIDS in the world. The present study investigated the behavioural responses of South African youth to the HIV/AIDS epidemic. A multi-stage stratified cluster sample of 2,430 youths aged 15-24 was selected, 46.9% of them males and 53.1% females. Nurses administered questionnaires to consenting youths, measuring behavioural risks and also took an oral fluid specimen for HIV antibody testing. It was found that the median age of sexual debut for both sexes was 16.5 years; most of the youths were sexually experienced with no variation by sex; sexual experience was highest among Africans living in informal urban areas; partner turnover was low and multiple partners were more common among African males living in urban informal settings; sexual frequency among sexually active youth was relatively low; secondary abstinence during the past 12 months was 24%; condom use at last sexual intercourse was high, at 52.8% for males and 47.6% for females, especially among Africans living in urban informal settings; and the majority of youths (74%) indicated that they had discussed HIV prevention with their partners during the past 12 months. These results suggest that South African youth are heeding the message to abstain, be faithful and use a condom; messages that are at the core of South Africa's HIV/AIDS prevention programme.

Marital status and risk of HIV infection in South Africa

OBJECTIVE

Available evidence on the relationship between marital status and HIV is contradictory. The objective of this study was to determine HIV prevalence among married people and to identify potential risk factors for HIV infection related to marital status in South Africa.

METHODS

A multistage probability sample involving 6 090 male and female respondents, aged 15 years or older was selected. The sample was representative of the South African population by age, race, province and type of living area, e.g. urban formal, urban informal, etc. Oral fluid specimens were collected to determine HIV status. A detailed questionnaire eliciting information on socio-demographic, sex behaviour and biomedical factors was administered through face-to-face interviews from May to September 2002.

RESULTS

HIV prevalence among married people was 10.5% compared with 15.7% among unmarried people (p-value < 0.001). The risk of HIV infection did not differ significantly between married and unmarried people (odds ratio (OR) = 0.85, 95% confidence interval (CI): 0.71 - 1.02) when age, sex, socio-economic status, race, type of locality, and diagnosis of a sexually transmitted infection (STI) were included in the logistical regression model. However, the risk of HIV infection remained significantly high among unmarried compared with married people when only sex behaviour factors were controlled for in the model (OR 0.55; 95% CI: 0.47 - 0.66).

CONCLUSIONS

The relationship between marital status and HIV is complex. The risk depends on various demographic factors and sex behaviour practices. Increased prevention strategies that take socio-cultural context into account are needed for married people.

HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa

OBJECTIVES

A cornerstone of HIV prevention in South Africa is voluntary HIV antibody counselling and testing (VCT), but only one in five South Africans aware of VCT have been tested. This study examined the relation between HIV testing history, attitudes towards testing, and AIDS stigmas.

METHODS

Men (n = 224) and women (n = 276) living in a black township in Cape Town completed venue intercept surveys; 98% were black, 74% age 35 or younger.

RESULTS

47% of participants had been tested for HIV. Risks for exposure to HIV were high and comparable among people tested and not tested. Comparisons on attitudes toward VCT, controlling for demographics and survey venue, showed that individuals who had not been tested for HIV and those tested but who did not know their results held significantly more negative testing attitudes than individuals who were tested, particularly people who knew their test results. Compared to people who had been tested, individuals who were not tested for HIV demonstrated significantly greater AIDS related stigmas; ascribing greater shame, guilt, and social disapproval to people living with HIV. Knowing test results among those tested was not related to stigmatising beliefs.

CONCLUSIONS

Efforts to promote VCT in South Africa require education about the benefits of testing and, perhaps more important, reductions in stigmatising attitudes towards people living with AIDS. Structural and social marketing interventions that aim to reduce AIDS stigmas will probably decrease resistance to seeking VCT.

Effects of anterior basolateral amygdala lesions on taste aversions produced by high and low oral doses of LiCl and lactose in the rat

Adult male hooded rats (n = 12) with bilateral electrolytic lesions centered on the anterior basolateral amygdala (BLA) were given training using procedures meant to produce two different types of conditioned taste aversions (CTAs) to test whether the disruptive effects of such lesions on this form of learning were dependent upon the dosages of the illness-inducing agents used as unconditioned stimuli (UCSs). The CTAs were produced by either LiCl-induced toxicosis or lactose malabsorption. Comparison with sham-operated control subjects (n = 8) indicated that the disruptive effects of the lesions were inversely related to the dosage level of LiCl but not lactose: whilst the lesions disrupted CTAs produced by a low i.p. dose of LiCl and by a low, but not a high, oral dose of LiCl, they did not alter CTA learning produced by either high or low oral doses of lactose. These results were interpreted as providing further evidence that BLA mediates only certain types of CTA learning.

Effects of basolateral amygdala lesions on taste aversions produced by lactose and lithium chloride in the rat

In Experiment 1, intact rats were given either lactose or sucrose solutions. Although on first exposure they readily consumed lactose, its ingestion produced a conditioned taste avoidance which was partly extinguished by repeated sucrose exposure after lactose conditioning. In Experiment 2, rats with large bilateral electrolytic lesions of the basolateral amygdala and those with either sham or no operations were given two pairings of saline with LiCl injections (upper gastrointestinal tract discomfort) and in a separate condition access to high levels of lactose (lower gastrointestinal tract discomfort). Conditioned taste avoidances were measured both by two-bottle tests and by video recordings of the rats' orofacial and somatic responses. The lesions attenuated LiCl-induced taste aversion but not lactose-induced taste avoidance, results demonstrating that taste avoidance can occur without the basolateral amygdala. The results suggested that aversions based on distaste can be distinguished from avoidances based on danger, not only in terms of orofacial responses but also in terms of their neuroanatomical substrate.

Effects of basolateral amygdala lesions on taste aversions produced by lactose and lithium chloride in the rat

In Experiment 1, intact rats were given either lactose or sucrose solutions. Although on first exposure they readily consumed lactose, its ingestion produced a conditioned taste avoidance which was partly extinguished by repeated sucrose exposure after lactose conditioning. In Experiment 2, rats with large bilateral electrolytic lesions of the basolateral amygdala and those with either sham or no operations were given two pairings of saline with LiCl injections (upper gastrointestinal tract discomfort) and in a separate condition access to high levels of lactose (lower gastrointestinal tract discomfort). Conditioned taste avoidances were measured both by two-bottle tests and by video recordings of the rats' orofacial and somatic responses. The lesions attenuated LiCl-induced taste aversion but not lactose-induced taste avoidance, results demonstrating that taste avoidance can occur without the basolateral amygdala. The results suggested that aversions based on distaste can be distinguished from avoidances based on danger, not only in terms of orofacial responses but also in terms of their neuroanatomical substrate.

Can rats learn to associate a flavour with the delayed delivery of food?

Associations between a specific flavour and access to food were studied using a discrimination procedure devised by Holman (1975). This involved giving rats one flavour (e.g. cinnamon) of saccharin solution on some days, and following this by delivery of food, and a second flavour (e.g. wintergreen) on other days which was never followed by food. Experiment 1 used glucose delivered after a 30-min delay and a slight increase in preference for the paired flavour was detected. Using a 20-min delay Experiment 2 varied the kind of food used; some evidence for discrimination learning was again found in the glucose group, but there was no evidence that rats could associate a flavour with starch solution or solid chow over this delay. To check that the general procedure was a sensitive one, in Experiment 3 one flavour was added to glucose i.e. without delay, and this produced large shifts in a subsequent preference test. Overall the results threw doubt on claims that rats as readily form flavour-calorie associations over delays as they do flavour-toxicosis associations.