The Ethics of Stigma in Medical Male Circumcision Initiatives Involving Adolescents in Sub-Saharan Africa.

Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. Voluntary medical male circumcision (VMMC) programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity. Ongoing global efforts to circumcise adolescent and adult males to reduce their risk of acquiring HIV constitute the largest public health prevention initiative, using surgical means, in human history. VMMC programs in Africa have significantly altered social norms related to male circumcision among previously non-circumcising groups and groups that have practiced traditional (non-medical) circumcision. One consequence of this change is the stigmatization of males who, for whatever reason, remain uncircumcised. This paper discusses the ethics of stigma with regard to uncircumcised adolescent males in global VMMC programs, particularly in certain recruitment, demand creation and social norm interventions. Grounded in our own experiences gained while conducting HIV-related ethics research with adolescents in Kenya, we argue that use of explicit or implicit stigma to increase the number of VMMC volunteers is unethical from a public health ethics perspective, particularly in campaigns that leverage social norms of masculinity.

Ethics of pursuing targets in public health: the case of voluntary medical male circumcision for HIV-prevention programs in Kenya.

The use of targets to direct public health programmes, particularly in global initiatives, has become widely accepted and commonplace. This paper is an ethical analysis of the utilisation of targets in global public health using our fieldwork on and experiences with voluntary medical male circumcision (VMMC) initiatives in Kenya. Among the many countries involved in VMMC for HIV prevention, Kenya is considered a success story, its programmes having medically circumcised nearly 2 million men since 2007. We describe ethically problematic practices in Kenyan VMMC programmes revealed by our fieldwork, how the problems are related to the pursuit of targets and discuss possible approaches to their management. Although the establishment and pursuit of targets in public health can have many benefits, assessments of target-driven programmes tend to focus on quantifiable outcomes rather than the processes by which the outcomes are obtained. However, in order to speak more robustly about programmatic 'success', and to maintain community trust, it is vital to ethically evaluate how a public health initiative is actually implemented in the pursuit of its targets.

Voluntary medical male circumcision for HIV prevention among adolescents in Kenya: Unintended consequences of pursuing service-delivery targets.

INTRODUCTION: Voluntary medical male circumcision (VMMC) provides significant reductions in the risk of female-to-male HIV transmission. Since 2007, VMMC has been a key component of the United States President's Emergency Plan for AIDS Relief's (PEPFAR) strategy to mitigate the HIV epidemic in countries with high HIV prevalence and low circumcision rates. To ensure intended effects, PEPFAR sets ambitious annual circumcision targets and provides funding to implementation partners to deliver local VMMC services. In Kenya to date, 1.9 million males have been circumcised; in 2017, 60% of circumcisions were among 10-14-year-olds. We conducted a qualitative field study to learn more about VMMC program implementation in Kenya. METHODS AND RESULTS: The study setting was a region in Kenya with high HIV prevalence and low male circumcision rates. From March 2017 through April 2018, we carried out in-depth interviews with 29 VMMC stakeholders, including "mobilizers", HIV counselors, clinical providers, schoolteachers, and policy professionals. Additionally, we undertook observation sessions at 14 VMMC clinics while services were provided and observed mobilization activities at 13 community venues including, two schools, four public marketplaces, two fishing villages, and five inland villages. Analysis of interview transcripts and observation field notes revealed multiple unintended consequences linked to the pursuit of targets. Ebbs and flows in the availability of school-age youths together with the drive to meet targets may result in increased burdens on clinics, long waits for care, potentially misleading mobilization practices, and deviations from the standard of care. CONCLUSION: Our findings indicate shortcomings in the quality of procedures in VMMC programs in a low-resource setting, and more importantly, that the pursuit of ambitious public health targets may lead to compromised service delivery and protocol adherence. There is a need to develop improved or alternative systems to balance the goal of increasing service uptake with the responsible conduct of VMMC.

Consent Challenges and Psychosocial Distress in the Scale-up of Voluntary Medical Male Circumcision Among Adolescents in Western Kenya.

In priority sub-Saharan African countries, on the ground observations suggest that the success of voluntary medical male circumcision (VMMC) programs should not be based solely on numbers of males circumcised. We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15-19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. Careful monitoring of male adolescents' well-being is needed in large-scale VMMC programs. There is also urgent need for research to identify effective strategies to address gaps in the delivery of VMMC services.

"If the mother does not know, there is no way she can tell the adolescent to go for drugs": Challenges in promoting health and preventing transmission among pregnant and parenting Kenyan adolescents living with HIV.

Adolescents living with HIV (ALHIV) who are pregnant, or parenting, are an important but understudied group. This study explores the challenges in promoting the health of these adolescents and preventing onward transmission. We used existing semi-structured interview data from a 2014 study conducted among Kenyan ALHIV (ages 15-19), their family members, and local health staff to examine adolescent HIV-testing, disclosure, and treatment engagement, focusing on participants who were pregnant, had given birth, or had fathered a child. A total of 28 participant interviews were analyzed, including those conducted with nine ALHIV, four family members, and 15 HIV providers. Four adolescent participants were not in care at the time of their interview. Our analysis also included a transcript from a stakeholder meeting involving HIV providers and associated administrators, held to disseminate and garner feedback on, preliminary findings from the original study. Based on our analysis, adolescents frequently reported being alone during testing, experiencing fear and denial on receiving their results, and delaying disclosure to family and linkage to treatment. They also mentioned a lack of contraceptive counseling, with some reporting multiple pregnancies. Providers voiced misgivings and uncertainty about disclosing HIV diagnoses to minor adolescents without a family member present and reported severe shortages of personnel and resources to adequately serve ALHIV in rural clinics. These findings highlight gaps in services that limit adolescent engagement in HIV treatment prior to sexual debut and conceiving a child, and in PMTCT during and after pregnancy. Greater research attention is needed to address ALHIV reproductive health needs, improve linkage to HIV treatment, and prevent onward sexual transmission. Empirical ethics studies of current adolescent disclosure policies are also warranted to examine cultural and developmental appropriateness, and effectiveness in fostering support and engagement in HIV services.

"I think the parent should be there because no one was born alone": Kenyan adolescents' perspectives on parental involvement in HIV research.

Despite a pressing need for adolescent HIV research in sub-Saharan Africa, ethical guidance for conducting research among minor adolescents is lacking. One ethical issue is the degree to which parents should be involved in the research process. The existing discourse is predominantly speculative and focuses on negative consequences of parental involvement. We use empirical data to describe the perspectives of Kenyan adolescents on parental involvement in consent and disclosure of HIV test results within a research study context. We conducted two rounds of focus group discussions with 40 adolescents in western Kenya to ask about minor adolescent participation in HIV research. We analysed data using codes and matrices. Kenyan adolescents were largely in favour of parental involvement during the research process. Half felt adolescent minors should solicit parental consent to participate, and nearly all said parents should learn the HIV test results of adolescent minors in order to provide necessary support. From their perspective, involvement of parents in research extends beyond obtaining their consent to providing essential support for youth, regardless of HIV status, both during and beyond the research study. Ethical guidelines that prioritise adolescent autonomy in research must consider reasons to involve parents considered important by adolescents themselves, particularly in low-resource settings.

An adapted instrument to assess informed consent comprehension among youth and parents in rural western Kenya: a validation study.

OBJECTIVE: To adapt and validate a questionnaire originally developed in a research setting for assessment of comprehension of consent information in a different cultural and linguistic research setting. DESIGN: The adaptation process involved development and customisation of a questionnaire for each of the three study groups, modelled closely on the previously validated questionnaire. The three adapted draft questionnaires were further reviewed by two bioethicists and the developer of the original questionnaire for face and content validity. The revised questionnaire was subsequently programmed into an audio computerised format, with translations and back translations in three widely spoken languages by the study participants: Luo, Swahili and English. SETTING: The questionnaire was validated among adolescents, their parents and young adults living in Siaya County, a rural region of western Kenya. PARTICIPANTS: Twenty-five-item adapted questionnaires consisting of close-ended, multiple-choice and open-ended questions were administered to 235 participants consisting of 107 adolescents, 92 parents and 36 young adults. Test-retest was conducted 2-4 weeks after first questionnaire administration among 74 adolescents, young adults and parents. OUTCOME MEASURE: Primary outcome measures included ceiling/floor analysis to identify questions with extremes in responses and item-level correlation to determine the test-retest relationships. Given the data format, tetrachoric correlations were conducted for dichotomous items and polychoric correlations for ordinal items. The qualitative validation assessment included face and content validity evaluation of the adapted instrument by technical experts. RESULTS: Ceiling/floor analysis showed eight question items for which >80% of one or more groups responded correctly, while for nine questions, including all seven open-ended questions,<20% responded correctly. Majority of the question items had moderate to strong test-retest correlation estimates indicating temporal stability. CONCLUSIONS: Our study demonstrates that cross-cultural adaptation and validation of an informed consent comprehension questionnaire is feasible. However, further research is needed to develop a tool which can estimate a quantifiable threshold of comprehension thereby serving as an objective indicator of the need for interventions to improve comprehension.

Experiences along the HIV care continuum: perspectives of Kenyan adolescents and caregivers.

To be effective, HIV programmes should be responsive to the unique needs of diverse groups of infected adolescents. We highlight a range of adolescent perspectives on HIV services, including those who acquired HIV perinatally or sexually and those who were either in care, had dropped out of care, or had never enrolled in care. We conducted semi-structured interviews with 29 adolescents (aged 15-19) and 14 caregivers in western Kenya. Data were analysed using a descriptive analytical approach. Adolescents who were successfully linked had a supportive adult present during diagnosis; tested during hospitalisation or treatment for a recurrent or severe illness; and initiated treatment soon after diagnosis. Barriers to retention included side effects from HIV drugs, pill burden, and limited access to clean water and nutritious food. Support in family, school, and health facility environments was key for diagnosis, linkage, and retention. We make recommendations that may improve adolescent engagement in HIV services.

The Significance of Benefit Perceptions for the Ethics of HIV Research Involving Adolescents in Kenya.

Assessment of benefits is traditionally regarded as crucial to the ethical evaluation of research involving human participants. We conducted focus group discussions (FGDs) with health and other professionals engaged with adolescents, caregivers/parents, and adolescents in Siaya County, Kenya, to solicit opinions about appropriate ways of conducting HIV research with adolescents. Our data revealed that many focus group participants have a profoundly positive conception of participation in health research, including studies conferring seemingly few benefits. In this article, we identify and analyze five different but interrelated types of benefits as perceived by Kenyan adolescent and adult stakeholders in HIV research, and discuss their ethical significance. Our findings suggest that future empirical and conceptual research should concentrate on factors that may trigger researcher obligations to improve benefit perceptions among research participants.

Evaluation of Herpes Simplex Virus Type 2 Serological Tests for Use With Dried Blood Spots in Kenya.

We evaluated 2 assays to detect antibodies to herpes simplex virus type 2 in dried blood spots prepared from blood specimens submitted to a reference laboratory in Kenya. Dried blood spots did not perform well with the Kalon herpes simplex virus type 2 assay. Focus HerpeSelect 2 was 98.8% sensitive and 98.9% specific with dried blood spots.

'I thought if I marry the prophet I would not die': The significance of religious affiliation on marriage, HIV testing, and reproductive health practices among young married women in Zimbabwe.

This study examines the association between religious affiliation and reasons for marriage, perceived church attitudes, and reproductive health-seeking behaviors, including HIV testing, among young women in eastern rural Zimbabwe. The sample comprised women (N = 35) who had married by 2012 while participating in a larger randomized controlled trial (RCT) to test the effects of school support on HIV-related risk. The RCT sample was identified in 2007 as all female sixth graders in 25 rural eastern Zimbabwe primary schools whose parents, one or both, had died (N = 328). In our previous RCT analyses, we found that participants who affiliated with an Apostolic church were more than four times more likely to marry than those from non-Apostolic churches and that control group participants were twice as likely to marry as those in the intervention group. Other studies had found that marriage greatly increased the odds of HIV infection among adolescent women. Given the link between Apostolic affiliation and marriage, we conducted semi-structured interviews to explore type of marriage, reasons for marrying, church affiliation and attitudes, family planning, HIV testing, schooling, and family life. We were interested in differences, as perceived by our sample of young married women congregants, among Apostolic sects and other denominations in their attitudes about marriage and health-seeking behaviors. We were also interested in the influence of church affiliation on intervention participants' decision to marry, since they had comprehensive school support and education is highly valued in Zimbabwe, but costly and often out of financial reach. Interviews were conducted from October 2012 through November 2013; data were analyzed using a general inductive approach. We found that pressure or perceived deception for coitus or marriage was reported only by intervention participants affiliated with Apostolic denominations. Other reasons for marriage were similar between Apostolic and non-Apostolic adherents, as well as intervention and control conditions. All participants believed HIV testing was important, but while all non-Apostolic denominations encouraged HIV testing and clinic/hospital care, there was considerable heterogeneity in attitudes among Apostolics, with ultraconservative denominations most likely to proscribe non-religious health care. We conclude that some, but not all, Apostolic-affiliated women are afforded discretion in their health-seeking behaviors. Since HIV screening and treatment depend on access to clinic/hospital care, continued public health efforts to engage Apostolic leaders is needed, along with monitoring of progress in access and outcomes.

Disclosure of HSV-2 serological test results in the context of an adolescent HIV prevention trial in Kenya.

OBJECTIVES: Herpes simplex virus type 2 (HSV-2) biomarkers are often used in adolescent sub-Saharan HIV prevention studies, but evaluations of test performance and disclosure outcomes are rare in the published literature. Therefore, we investigated the proportion of ELISA-positive and indeterminate samples confirmed by western blot (WB), the psychosocial response to disclosure and whether reports of sexual behaviour and HSV-2 symptoms are consistent with WB confirmatory results among adolescent orphans in Kenya. METHODS: In 2011, 837 Kenyan orphan youth in grades 7 and 8 enrolled in an HIV prevention clinical trial with HSV-2 biomarker outcomes. We used a modified algorithm for the Kalon HSV-2 ELISA to improve specificity; positive and indeterminate results were WB tested. We developed culturally sensitive protocols for disclosing positive results, and documented psychosocial responses, reports of sexual contact and HSV-2 symptoms. RESULTS: 28 adolescents (3.3%) were identified as HSV-2 seropositive, six as indeterminate. Of these, 22 positive and all indeterminates were WB tested; 20 and 5, respectively, were confirmed positive. Most youth reported moderate brief stress after disclosure; 22% reported longer and more severe distress. Boys were more likely to be in the latter category. Self-reported virginity was highly inconsistent with WB-confirmed positives. CONCLUSIONS: The higher than manufacturer's cut-off for Kalon ELISA modestly reduced the rate of false-positive test results, but also increased false negatives. Investigators should consider the risk:benefit ratio in deciding whether or not to disclose HSV-2 results to adolescent participants under specific field conditions. TRIAL REGISTRATION NUMBER: NCT01501864.

Use of HIV and HSV-2 biomarkers in sub-saharan adolescent prevention research: a comparison of two approaches.

Self-report of sexual behavior among adolescents is notoriously inconsistent, yet such measures are commonly used as outcomes for human immunodeficiency virus (HIV) prevention intervention trials. There has been a growing interest in the use of HIV and other sexually transmitted disease biomarkers as more valid measures of intervention impact in high HIV prevalence areas, particularly in sub-Saharan Africa. We examine the challenges, benefits, and feasibility of including HIV and herpes simplex virus type 2 (HSV-2) biomarker data, with details about different data collection and disclosure methods from two adolescent prevention trials in Kenya and Zimbabwe. In Kenya, whole blood samples were collected using venipuncture; adult guardians were present during biomarker procedures and test results were disclosed to participants and their guardians. In contrast, in Zimbabwe, samples were collected using finger pricks for dried blood spots (DBS); guardians were not present during biomarker procedures, and results were not disclosed to participants and/or their guardians. In both countries, prevalence in the study samples was low. Although the standard of care for testing for HIV and other sexually transmitted infections includes disclosure in the presence of a guardian for adolescents under age 18, we conclude that more research about the risks and benefits of disclosure to adolescents in the context of a clinical trial is needed. Notably, current serological diagnosis for HSV-2 has a low positive predictive value when prevalence is low, resulting in an unacceptable proportion of false positives and serious concerns about disclosing test results to adolescents within a trial. We also conclude that the DBS approach is more convenient and efficient than venipuncture for field research, although both approaches are feasible. Manufacturer validation studies using DBS for HSV-2, however, are needed for widespread use.

A multilevel analysis of the effect of Malawi's Social Cash Transfer Pilot Scheme on school-age children's health.

OBJECTIVE: The primary goal was to examine whether Malawi Social Cash Transfer Pilot Scheme, initially implemented in a rural district in central Malawi, improved health outcomes for children aged 6-17. Secondary goals were to examine the effects of individual child- (orphan status and gender) and household-level factors (number of working-age adults and sick adults) on health outcomes. Another secondary goal was to examine whether orphan status modified the cash transfer effect on health outcomes. METHODS: This multilevel study used panel data collected in 2007-08 from a randomized controlled evaluation study of phase one of the programme. The analyses included 1197 children aged 6-17 in 486 households. The four outcomes of interest were: illness in the past month, illness that stopped normal activities in the past month, missing school due to illness or injury in the past month and health care use for worst illness in the past year. FINDINGS: Approximately two-thirds of children in cash transfer eligible households were orphans. Compared with children in non-beneficiary households, those in beneficiary households had a 37% lower odds of child illness (P<0.05), 42% lower odds of illness that stopped normal activities (P<0.01) and substantially higher odds of utilizing health services for a serious illness (odds ratio=10.98; P<0.01). An increase in the household number of working-age adults was associated with 34% lower odds of child illness (P<0.01). An increase in the household number of sick adults increased the odds of child illness by 97% (P<0.01) and serious illness by 49% (P<0.01). No statistically significant differences were observed by orphan status and child's gender. Consistent differential programme effects by orphan status were not observed. CONCLUSION: Unconditional cash transfer programmes to poor households have the potential to improve health outcomes for all vulnerable children aged 6-17.

Consistent condom use among men with non-marital partners in four sub-Saharan African countries.

Data from the Demographic and Health Surveys for Namibia, Swaziland, and Zambia and the AIDS Indicator Survey from Tanzania were used to examine the influence of marital status and number of partners on consistent condom use among men with casual sexual partnerships in four generalized HIV epidemic settings. We restrict the sample to the 26% (Zambia), 29% (Tanzania), 35% (Swaziland), and 42% (Namibia) of men, who, in the last 12 months before the survey, had any non-marital/non-cohabiting (i.e., casual) sexual partners. We use "condom always used with any partner in the last 12 months" as a dichotomous-dependent measure of consistent condom use. Analyses were stratified by country. Of men with casual partners, 41% (Zambia) to 70% (Namibia) used a condom every time with at least one partner. The majority of men were unmarried/non-cohabiting with one casual partner in the last year. In Swaziland and Zambia, multivariate results suggest that unmarried/non-cohabiting men with one casual partner had significantly lower odds than married/cohabiting men with casual partners to use condoms consistently (odds ratio [OR]=0.56, p=0.01 and OR=0.41, p<0.001, respectively.). In Namibia, unmarried/non-cohabiting men with two or more casual partners had significantly greater odds than married/cohabiting men with casual partners to use condoms consistently (OR=2.80, p<0.01). With some exceptions by country, higher education, religious group, wealth, having no children, knowing HIV results, having an STI, having one lifetime partner, and positive condom knowledge and beliefs also were significantly associated with using a condom every time with any partner. We conclude that consistent condom use remains an elusive goal even among men with casual sexual relationships. Condom use messages should be refined and targeted to men based on their number and types of relationships and combined with other messages to decrease concurrent relationships.

Preventing HIV by providing support for orphan girls to stay in school: does religion matter?

OBJECTIVE: The paper examines the influence of religion on attitudes, behaviors, and HIV infection among rural adolescent women in Zimbabwe. DESIGN: We analyzed data from a 2007 to 2010 randomized controlled trial in rural eastern Zimbabwe testing whether school support can prevent HIV risk behaviors and related attitudes among rural adolescent orphan girls; supplementary data from the 2006 Zimbabwe Demographic and Health Survey (ZDHS) were also analyzed. The present study design is largely cross-sectional, using the most recent available survey data from the clinical trial to examine the association between religious affiliation and religiosity on school dropout, marriage, and related attitudes, controlling for intervention condition, age and orphan type. The ZDHS data examined the effect of religious denomination on marriage and HIV status among young rural women, controlling for age. RESULTS: Apostolic Church affiliation greatly increased the likelihood of early marriage compared to reference Methodist Church affiliation (odds ratio = 4.5). Greater religiosity independently reduced the likelihood of school dropout, increased gender equity attitudes and disagreement with early sex, and marginally reduced early marriage. Young rural Apostolic women in the ZDHS were nearly four times as likely to marry as teenagers compared to Protestants, and marriage doubled the likelihood of HIV infection. CONCLUSIONS: Findings contradict an earlier seminal study that Apostolics are relatively protected from HIV compared to other Christian denominations. Young Apostolic women are at increased risk of HIV infection through early marriage. The Apostolic Church is a large and growing denomination in sub-Saharan Africa and many Apostolic sects discourage medical testing and treatment in favor of faith healing. Since this can increase the risk of undiagnosed HIV infection for young married women and their infants in high prevalence areas, further study is urgently needed to confirm this emerging public health problem, particularly among orphan girls. Although empirical evidence suggests that keeping orphan girls in school can reduce HIV risk factors, further study of the religious context and the implications for prevention are needed.

The measurement of condom use in four countries in East and southern Africa.

Measurement of condom use is important to assess progress in increasing use. Since 2003, the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys (AIS) have included new measures of self-reported condom use. We use data from Namibia, Swaziland, Tanzania, and Zambia to compare measures of condom use accounting for type of sexual partner. Condom use at last sex ranged from 20% in Tanzania to 57% in Namibia for men, and from 12% in Tanzania to 41% in Namibia for women. Reported condom use was lower in response to questions about condom use every time with last partner (from 13 to 47% for men and from 8 to 33% for women). Condom use was highest among people with two or more partners in the last year and lowest with marital partners. Overall, the prevalence of condom use was low, and there was wide variability across the various measures, countries, sexes, and types of partner. Promotion of condom use in all partnerships, but especially in non-marital relationships and among individuals with multiple partners, remains a critical strategy. New condom use questions in the DHS and AIS expand options for measuring and studying condom use.

Correlates of male condom use skills among high-risk women in South Africa.

This exploratory study examined the performance of 295 South African women--who recently traded sex for goods or had unprotected sex--on a male condom use mastery index. Bivariate and multivariate logistic regression analyses were conducted to determine whether age, marital status, highest education obtained, male condom use at first penetrative sex, receiving prior demonstration of male condom use, recent sexually transmitted infection symptoms, and recently trading sex were significantly associated with index scores. Adjusted odds ratios indicated that age and sexually transmitted infection symptoms were negatively associated with condom skills; women who were older and had a higher number of recent sexually transmitted infection symptoms were more likely to have lower scores. Furthermore, participants executed, on average, approximately one third of condom use steps correctly. These findings suggest a need for increased behavioral skills training for women engaging in sexual risk behaviors because many lack the skills required to use a male condom properly.

Health services utilization among South African women living with HIV and reporting sexual and substance-use risk behaviors.

HIV health services are critical in sub-Saharan African where the burden of the HIV pandemic is devastating. Existing studies suggest that HIV-infected individuals from marginalized populations who know their status do not seek health services because they are unaware of available treatment and care options, may not understand how to access services, or have poor access to and utilization of health care services. This study examined factors associated with health service utilization in a sample of poor, underserved recently diagnosed HIV-positive South African women with sexual and substance use risk behaviors. The data were collected between June 2004 and May 2008. Primary outcomes included consultation with a medical professional and utilization of any health services since learning of HIV status at 3- and 6-month follow-up assessments. The study findings suggest that denial of HIV status may be a barrier to care, leading study participants to avoid utilizing health services specific to their disease and to prefer more general medical care services. In multivariate analyses, prior use of health services, financially supporting others, and sex trading were strongly associated with health service use at follow-up assessments. The study findings suggest a reduced likelihood of health services utilization among participants who met DSM-IV criteria for drug abuse as well as participants with greater numbers of poor physical health symptoms. As an important preliminary step in examining the issue of health services utilization in sub-Saharan Africa, the findings suggest an urgent need to promote HIV prevention and early testing, to strengthen long-term HIV care services, and to increase access to services.