Suchergebnisse

AbstractIntroductionTo maximize impact and minimize costs, antiretroviral pre‐exposure prophylaxis (PrEP) interventions should be offered to those at highest risk for HIV infection. The risk score derived from the VOICE trial is one tool currently being utilized to determine eligibility in adolescent PrEP trials in sub‐Saharan Africa. This study is aimed at evaluating the utility of the risk score in predicting HIV incidence among a cohort of adolescent girls in rural South Africa.MethodsWe utilized data from HIV Prevention Trials Network (HPTN) 068, a phase III randomized controlled trial conducted in rural Mpumalanga province, South Africa. School‐attending young women aged 13 to 20 years were enrolled into the trial from 2011 to 2012 and followed for up to three years. A risk score based on individual‐level risk factors measured at enrolment was calculated for HPTN 068 participants who completed a one‐year follow‐up visit and were HIV seronegative at enrolment. Possible scores ranged from 0 to 10. A proportional hazards model was then used to determine if risk score at enrolment was predictive of incident HIV infection at follow‐up and an area under the curve analysis was used to examine the predictive ability of the score.Results and DiscussionThe risk score had limited variability in the HPTN 068 sample. Scores ≥5 identified 85% of incident infections from 94% of the sample, compared to the VOICE sample in which scores ≥5 identified 91% of incident infections from only 64% of participants. The risk score did not predict HIV incidence after one year of follow‐up (hazard ratio = 1.029; 95% confidence interval (CI): 0.704, 1.503, p = .884) and showed poor predictive ability (area under the curve = 0.55; 95% CI: 0.44, 0.65). Certain individual risk factors that comprise the risk score may be context specific or not relevant for adolescent populations. Additional factors should be considered when assessing risk for the purposes of determining PrEP eligibility.ConclusionsThe VOICE risk score demonstrated low utility to predict HIV incidence in the HPTN 068 sample. Findings highlight the need for an age and developmentally appropriate tool for assessing risk for HIV infection among adolescents. Use of the VOICE risk score for determining PrEP eligibility in younger populations should be carefully considered.

For this study we conducted in-depth interviews with 29 youth living with HIV (YLWH) and key informant interviews with 8 HIV care/support providers. We describe terms used to portray people living with HIV (PLWH) in Kinshasa, Democratic Republic of the Congo. Labels commonly used, mostly derogatory, described PLWH as walking corpses, dangers to others, or people deserving to die before others get infected. Blame and other accusations were directed at PLWH through anchoring or objectification. Being labeled sometimes made these youth suffer in silence, afraid to disclose their status, or avoid performing actions in public, preferring to let others do them. YLWH need psychosocial support to mitigate the harmful effects of these labels and strengthen their coping skills, whereas community, institutional, and national efforts are needed for stigma reduction.

AbstractIn sub‐Saharan Africa, adolescent girls and young women (AGYW) have high levels of unmet need for contraception, particularly those who are unmarried or nulliparous. Conversations with partners, peers, and family members influence AGYW contraceptive decision‐making yet little is known about conversation content and impact or how they vary by relationship status and parity. This paper draws on qualitative data from 60 AGYW (aged 15–24) participating in a sexual and reproductive health study in Malawi to examine contraceptive conversation patterns among participants and their social ties. AGYW's relationship status and parity influenced whether they talked about contraceptives, who they talked to about contraceptives, and the type of contraceptives that were endorsed during conversations. Unmarried and nulliparous AGYW were less likely to discuss contraceptives with all social ties and when conversations occurred, norms and misinformation regarding nonbarrier methods were reinforced, and condoms were largely prescribed. Conversations with intimate partners often provided permission for contraceptive use while conversations with peers and older women in the family provided information on contraceptive methods. Our results highlight the unique roles that social ties play in AGYW contraceptive decision‐making and suggest that existing contraceptive conversation patterns might exclude unmarried, nulliparous AGYW from accurate and comprehensive contraceptive information and options.

The prevalence of intimate partner violence (IPV) is alarmingly high among South African adolescent girls and young women (AGYW). Limited data exist exploring how IPV prevalence and its risk factors differ by age. Study data were from the baseline visit of HPTN 068, a randomized controlled trial (RCT) conducted from 2011 to 2015 in Mpumalanga, South Africa. A cohort of 2,533 AGYW, aged 13 years to 20 years, answered survey questions on demographics and behaviors, including their experiences of physical and sexual violence ever and in the past 12 months. We calculated the prevalence of IPV and related risk factors, as well as prevalence ratios with 95% confidence intervals, stratified by age. Nearly one quarter (19.5%, 95% CI = [18.0, 21.2]) of AGYW experienced any IPV ever (physical or sexual) by a partner. The prevalence of any IPV ever among AGYW aged 13 years to 14 years, 15 years to 16 years, and 17 years to 20 years was 10.8%, 17.7%, and 32.1%, respectively. Key variables significantly associated with any IPV ever across all age groups included borrowing money from someone outside the home in the past 12 months, ever having had vaginal sex, ever having had anal sex, and consuming any alcohol. Few statistically significant associations were unique to specific age groups. The history of IPV among the youngest AGYW is a critical finding and should be a focus of prevention efforts.

AbstractIntroductionEvidence has shown that the experience of violence by a partner has important influences on women's risk of HIV acquisition. Using a randomized experiment in northeast South Africa, we found that a conditional cash transfer (CCT) targeted to poor girls in high school reduced the risk of physical intimate partner violence (IPV) in the past 12 months by 34%. The purpose of this analysis is to understand the pathways through which the CCT affects IPV.MethodsHPTN 068 was a phase 3, randomized controlled trial in rural Mpumalanga province, South Africa. Eligible young women (aged 13–20) and their parents or guardians were randomly assigned (1:1) to either receive a monthly cash transfer conditional on monthly high school attendance or no cash transfer. Between 2011 and 2015, participants (N = 2,448) were interviewed at baseline, then at annual follow‐up visits at 12, 24 and 36 months. The total effect of the CCT on IPV was estimated using a GEE log‐binomial regression model. We then estimated controlled direct effects to examine mediation of direct effects through intermediate pathways. Mediators include sexual partnership measures, the sexual relationship power scale, and household consumption measures.ResultsWe found evidence that the CCT works in part through delaying sexual debut or reducing the number of sexual partners. The intervention interacts with these mediators leading to larger reductions in IPV risk compared to the total effect of the CCT on any physical IPV [RR 0.66, CI(95%):0.59–0.74]. The largest reductions are seen when we estimate the controlled direct effect under no sexual debut [RR 0.57, CI(95%):0.48–0.65] or under no sexual partner in the last 12 months [RR 0.53, CI(95%):0.46–0.60].ConclusionsResults indicate that a CCT for high school girls has protective effects on their experience of IPV and that the effect is due in part to girls choosing not to engage in sexual partnerships, thereby reducing the opportunity for IPV. As a lower exposure to IPV and safer sexual behaviours also protect against HIV acquisition, this study adds to the growing body of evidence on how cash transfers may reduce young women's HIV risk.

AbstractIntroductionCross‐sectional methods can be used to estimate HIV incidence for surveillance and prevention studies. We evaluated assays and multi‐assay algorithms (MAAs) for incidence estimation in subtype C settings.MethodsWe analysed samples from individuals with subtype C infection with known duration of infection (2442 samples from 278 adults; 0.1 to 9.9 years after seroconversion). MAAs included 1‐4 of the following assays: Limiting Antigen Avidity assay (LAg‐Avidity), BioRad‐Avidity assay, CD4 cell count and viral load (VL). We evaluated 23,400 MAAs with different assays and assay cutoffs. We identified the MAA with the largest mean window period, where the upper 95% confidence interval (CI) of the shadow was <1 year. This MAA was compared to the LAg‐Avidity and BioRad‐Avidity assays alone, a widely used LAg algorithm (LAg‐Avidity <1.5 OD‐n + VL >1000 copies/mL), and two MAAs previously optimized for subtype B settings. We compared these cross‐sectional incidence estimates to observed incidence in an independent longitudinal cohort.ResultsThe optimal MAA was LAg‐Avidity <2.8 OD‐n + BioRad‐Avidity <95% + VL >400 copies/mL. This MAA had a mean window period of 248 days (95% CI: 218, 284), a shadow of 306 days (95% CI: 255, 359), and provided the most accurate and precise incidence estimate for the independent cohort. The widely used LAg algorithm had a shorter mean window period (142 days, 95% CI: 118, 167), a longer shadow (410 days, 95% CI; 318, 491), and a less accurate and precise incidence estimate for the independent cohort.ConclusionsAn optimal MAA was identified for cross‐sectional HIV incidence in subtype C settings. The performance of this MAA is superior to a testing algorithm currently used for global HIV surveillance.

Background: One in four South African women will experience intimate partner violence (IPV) in their lifetime, potentially increasing their biological stress. In South Africa, limited IPV and stress research has utilized multiple timepoints or examined modifying factors. Cash transfers (CTs) are associated with reduced IPV and stress and may be an intervention target. Aims: We used data-driven methods to identify longitudinal IPV trajectory groups among South African adolescent girls and young women (AGYW), estimate each group's association with stress, and assess modification by a CT. Methods: A total of 2,183 South African AGYW ages 13 to 24 years from the HIV Prevention Trials Network 068 study were randomized to a CT or control group. Physical IPV was measured five times (2011–2017), and stress was captured once (2018–2019). Stress measures included the Cohen Stress Scale and stress biomarkers (C-reactive protein (CRP), cytomegalovirus (CMV), herpes simplex virus type-1 (HSV-1)). Group-based trajectory modeling identified IPV trajectories; ordinal logistic regression estimated the association between trajectory group and stress. Results: A two-group quadratic trajectory model was identified (higher trajectory group = 26.7% of AGYW; lower trajectory group = 73.3%). In both groups, the probability of IPV increased from ages 13 to 17 years before declining in early adulthood. However, the higher group's probability peaked later and declined gradually. The higher trajectory group was associated with an increased odds of elevated CRP (OR: 1.41, 95% CI [1.11, 1.80]), but not with other stress measures. The CT modified the relationship with CMV: a positive association was observed among the usual care arm (OR: 1.59, 95% CI [1.11, 2.28]) but not the CT arm (OR: 0.85, 95% CI [0.61, 1.19]). Conclusions: Sustained IPV risk during adolescence was associated with elevated CRP in young adulthood. The relationship between IPV and elevated CMV was attenuated among those receiving a CT, suggesting that CTs could possibly reduce biological stress due to IPV.

BackgroundHIV testing rates in many hyper-endemic areas are lower than needed to curtail the HIV epidemic. New HIV testing strategies are needed to overcome barriers to traditional clinic based testing; HIV self-testing is one modality that offers promise in reaching individuals who experience barriers to clinic-based testing.MethodsWe conducted a randomized control trial among young women ages 18-26 living in rural Mpumalanga, South Africa where they were randomized in a 1:1 allocation to either the: (1) HIV Counseling and Testing (HCT) arm: an invitation to test at one of the 9 local government clinics where free HCT is provided and is standard of care (SOC), or (2) choice arm: choice of either a clinic-based HCT invitation or oral HIV Self-Testing (HIVST) kits. Depending on the arm, participants were also provided either: (1) 4 HCT invitations to provide to peers/partners for HIV testing at one of the 9 local clinics, or (2) 4 HIV self-test kits to provide to peers/partners (thus 5 total HIVST kits or HCT invitations). Young women were asked to return 3 months and 9 months after enrollment to assess testing uptake and invitation or kit distribution to peers and partners and experiences with testing. Peers and partners who were reported by index participants to have received kits/invitations during follow-up visits were also invited to attend a study visit to assess their testing experiences. The trial is registered at clinical trials.gov NCT03162965.Findings287 young women were enrolled and randomized, with 146 randomized to the HCT arm and 141 to the choice (HCT or HIVST) arm. Of those randomized to the choice arm, over 95% (n=135) chose the HIV self-testing kit and only 6 individuals chose HCT. At the 3-month follow-up visit, 92% of index participants in the choice arm reported having tested for HIV compared to 43% of participants in the HCT arm, resulting in a significant risk difference of 49% (95% CI 40%, 58%). By 9 months, this difference decreased to a risk difference of 25% (95% CI 17%, 33%) between ...

BackgroundHIV testing rates in many hyper-endemic areas are lower than needed to curtail the HIV epidemic. New HIV testing strategies are needed to overcome barriers to traditional clinic based testing; HIV self-testing is one modality that offers promise in reaching individuals who experience barriers to clinic-based testing.MethodsWe conducted a randomized control trial among young women ages 18-26 living in rural Mpumalanga, South Africa where they were randomized in a 1:1 allocation to either the: (1) HIV Counseling and Testing (HCT) arm: an invitation to test at one of the 9 local government clinics where free HCT is provided and is standard of care (SOC), or (2) choice arm: choice of either a clinic-based HCT invitation or oral HIV Self-Testing (HIVST) kits. Depending on the arm, participants were also provided either: (1) 4 HCT invitations to provide to peers/partners for HIV testing at one of the 9 local clinics, or (2) 4 HIV self-test kits to provide to peers/partners (thus 5 total HIVST kits or HCT invitations). Young women were asked to return 3 months and 9 months after enrollment to assess testing uptake and invitation or kit distribution to peers and partners and experiences with testing. Peers and partners who were reported by index participants to have received kits/invitations during follow-up visits were also invited to attend a study visit to assess their testing experiences. The trial is registered at clinical trials.gov NCT03162965.Findings287 young women were enrolled and randomized, with 146 randomized to the HCT arm and 141 to the choice (HCT or HIVST) arm. Of those randomized to the choice arm, over 95% (n=135) chose the HIV self-testing kit and only 6 individuals chose HCT. At the 3-month follow-up visit, 92% of index participants in the choice arm reported having tested for HIV compared to 43% of participants in the HCT arm, resulting in a significant risk difference of 49% (95% CI 40%, 58%). By 9 months, this difference decreased to a risk difference of 25% (95% CI 17%, 33%) between arms (96% in the choice arm and 72% in the HCT arm). Participants in the choice arm were also more likely to invite peers and partners to test compared to the HCT arm (94% vs. 76% or an average of 4.97 vs 2.79 tests). Few male partners were invited to test by index participants; however, index participants in the choice arm were more likely to have their male partners test than index participants in the HCT arm (RR 2.99, 95% CI 1.45, 6.16).InterpretationWhen given a choice between clinic-based HIV testing and HIV oral self-testing, the overwhelming majority of young women chose HIVST. In addition, those offered a choice of HIV testing modality were much more likely to test, distribute test kits to peers and partners, and to have peers and partners who reported testing compared to the HCT arm. Self-testing offers an important opportunity to significantly increase testing rates among young women and their peers and partners compared to clinic-based HCT. Other strategies to reach men with testing are needed.FundingUS National Institutes of Health.

BACKGROUND: HIV testing rates in many hyper-endemic areas are lower than needed to curtail the HIV epidemic. New HIV testing strategies are needed to overcome barriers to traditional clinic based testing; HIV self-testing is one modality that offers promise in reaching individuals who experience barriers to clinic-based testing. METHODS: We conducted a randomized control trial among young women ages 18-26 living in rural Mpumalanga, South Africa where they were randomized in a 1:1 allocation to either the: (1) HIV Counseling and Testing (HCT) arm: an invitation to test at one of the 9 local government clinics where free HCT is provided and is standard of care (SOC), or (2) choice arm: choice of either a clinic-based HCT invitation or oral HIV Self-Testing (HIVST) kits. Depending on the arm, participants were also provided either: (1) 4 HCT invitations to provide to peers/partners for HIV testing at one of the 9 local clinics, or (2) 4 HIV self-test kits to provide to peers/partners (thus 5 total HIVST kits or HCT invitations). Young women were asked to return 3 months and 9 months after enrollment to assess testing uptake and invitation or kit distribution to peers and partners and experiences with testing. Peers and partners who were reported by index participants to have received kits/invitations during follow-up visits were also invited to attend a study visit to assess their testing experiences. The trial is registered at clinical trials.gov NCT03162965. FINDINGS: 287 young women were enrolled and randomized, with 146 randomized to the HCT arm and 141 to the choice (HCT or HIVST) arm. Of those randomized to the choice arm, over 95% (n=135) chose the HIV self-testing kit and only 6 individuals chose HCT. At the 3-month follow-up visit, 92% of index participants in the choice arm reported having tested for HIV compared to 43% of participants in the HCT arm, resulting in a significant risk difference of 49% (95% CI 40%, 58%). By 9 months, this difference decreased to a risk difference of 25% (95% CI 17%, 33%) ...

AbstractIntroductionCommunity mobilization (CM) is increasingly recognized as critical to generating changes in social norms and behaviours needed to achieve reductions in HIV. We conducted a CM intervention to modify negative gender norms, particularly among men, in order to reduce associated HIV risk.MethodsTwenty two villages in the Agincourt Health and Socio‐Demographic Surveillance Site in rural Mpumalanga, South Africa were randomized to either a theory‐based, gender transformative, CM intervention or no intervention. Two cross‐sectional, population‐based surveys were conducted in 2012 (pre‐intervention, n = 600 women; n = 581 men) and 2014 (post‐intervention, n = 600 women; n = 575 men) among adults ages 18 to 35 years. We used an intent‐to‐treat (ITT) approach using survey regression cluster‐adjusted standard errors to determine the intervention effect by trial arm on gender norms, measured using the Gender Equitable Mens Scale (GEMS), and secondary behavioural outcomes.ResultsAmong men, there was a significant 2.7 point increase (Beta Coefficient 95% CI: 0.62, 4.78, p = 0.01) in GEMS between those in intervention compared to control communities. We did not observe a significant difference in GEMS scores for women by trial arm. Among men and women in intervention communities, we did not observe significant differences in perpetration of intimate partner violence (IPV), condom use at last sex or hazardous drinking compared to control communities. The number of sex partners in the past 12 months (AOR 0.29, 95% CI 0.11 to 0.77) were significantly lower in women in intervention communities compared to control communities and IPV victimization was lower among women in intervention communities, but the reduction was not statistically significant (AOR 0.53, 95% CI 0.24 to 1.16).ConclusionCommunity mobilization can reduce negative gender norms among men and has the potential to create environments that are more supportive of preventing IPV and reducing HIV risk behaviour. Nevertheless, we did not observe that changes in attitudes towards gender norms resulted in desired changes in risk behaviours suggesting that more time may be necessary to change behaviour or that the intervention may need to address behaviours more directly.Clinical Trials numberClinicalTrials.gov NCT02129530.

AbstractIntroductionPrevalence of HIV among young women in South Africa remains extremely high. Adolescent peer groups have been found to be an important influence on a range of health behaviours. The characteristics of young women's friendships might influence their sexual health and HIV risk via connections to sexual partners, norms around sexual initiation and condom use, or provision of social support. We investigated associations between young women's friendships and their Herpes Simplex Virus Type 2 (HSV‐2) and HIV infection status in rural South Africa.MethodsOur study is a cross‐sectional, egocentric network analysis. In 2011 to 2012, we tested 13‐ to 20‐year‐old young women for HIV and HSV‐2, and collected descriptions of five friendships for each. We generated summary measures describing friend socio‐demographic characteristics and the number of friends perceived to have had sex. We used logistic regression to analyse associations between friend characteristics and participant HIV and HSV‐2 infection, excluding likely perinatal HIV infections.ResultsThere were 2326 participants included in the study sample, among whom HIV and HSV‐2 prevalence were 3.3% and 4.6% respectively. Adjusted for participant and friend socio‐demographic characteristics, each additional friend at least one year older than the participant was associated with raised odds of HIV (odds ratio (OR) = 1.37, 95% CI 1.03 to 1.82) and HSV‐2 (adjusted OR=1.41, 95% CI 1.18 to 1.69). Each additional friend perceived to have ever had sex also raised the odds of HIV (OR = 1.29, 95% CI 1.03 to 1.63) and HSV‐2 (OR=1.18, 95% CI 1.03 to 1.35).DiscussionWe found good evidence that a greater number of older friends and friends perceived to have had sex were associated with increased risk for HSV‐2 and HIV infection among young women.ConclusionsThe characteristics of young women's friendships could contribute to their risk of HIV infection. The extent to which policies or programmes influence age‐mixing and young women's normative environments should be considered.

IntroductionYoung adolescent women in sub‐Saharan Africa are three to four times more likely to be HIV‐positive than boys or men. One of the relationship dynamics that is likely to be associated with young women's increased vulnerability to HIV is transactional sex. There are a range of HIV‐related risk behaviours that may drive this vulnerability. However, to date, limited epidemiological data exist on the role of transactional sex in increasing HIV acquisition, especially among young women in sub‐Saharan Africa. Our paper presents data on the prevalence of self‐reported engagement in transactional sex and explores whether transactional sex is associated with increased risk of HIV infection among a cohort of young, rural, sexually active South African women. We also explore whether this relationship is mediated through certain HIV‐related risk behaviours.MethodsWe analyzed baseline data from a phase III trial of conditional cash transfers for HIV prevention of 693 sexually active, school‐going young women aged 13–20 years in rural South Africa. We examined the association between young women's engagement in transactional sex and HIV infection. Transactional sex is defined as a non‐commercial, non‐marital sexual relationship whereby sex is exchanged for money and/or gifts. We explored whether this relationship is mediated by certain HIV‐related risk behaviours. We used logistic and multinomial regression and report unadjusted and adjusted odds ratios with 95% CI.ResultsOverall, 14% (n=97) of sexually active young women reported engaging in transactional sex. Engagement in transactional sex was associated with an increased risk of being HIV‐positive (aOR: 2.5, CI: 95% 1.19–5.25, p=0.01). The effect size of this association remained nearly unchanged when adjusted for certain other dimensions of HIV risk that might help explain the underlying pathways for this relationship.ConclusionsThis study provides quantitative support demonstrating that transactional sex is associated with HIV infection in young women. Even though the specific variables tested do not mediate the relationship, a potential explanation for this association may be that the men with whom young women are having sex belong to networks of sexually connected individuals who are at a "high risk" for HIV infection. The results highlight the importance of structural intervention approaches that can alter the context of young women's HIV risk.