Sexual Self-Efficacy and Gender: A Review of Condom Use and Sexual Negotiation Among Young Men and Women in Sub-Saharan Africa.

Sexual self-efficacy (SSE), one's perceived control of or confidence in the ability to perform a given sexual outcome, predicts sexual behavior; however, important questions remain regarding whether gender modifies observed associations. In a comprehensive review of peer-reviewed HIV-prevention literature focusing on youth (ages 10 to 25) in sub-Saharan Africa, we measured and assessed the influence of SSE on condom use and sexual refusal, overall and by gender. Our results, after reviewing 63 publications, show that SSE is inconsistently measured. Most studies measured condom use self-efficacy (CUSE) (96.8%) and/or sexual refusal self-efficacy (SRSE) (63.5%). On average, young men had higher CUSE than young women, while young women had higher SRSE than young men. While cross-sectional studies reported an association between high SSE and sexual behaviors, this association was not observed in interventions, particularly among young women who face a disproportionate risk of HIV acquisition. In all, 25% of intervention studies demonstrated that fostering CUSE increased condom use among young men only, and one of two studies demonstrated that higher SRSE led to reduced frequency of sexual activity for both men and women. Future research and HIV-prevention interventions must be gender targeted, consider improving CUSE for young men, and move beyond limited individual-level sexual behavior change frameworks.

Gender differences in prevalence and correlates of high sexual self-efficacy among adolescents in Soweto, South Africa: implications for gender-sensitive research and programming.

Sexual self-efficacy (SSE) - one's confidence in their ability to perform given sexual behaviours, has been shown to predict adolescents' HIV-prevention practices (e.g., Condom use). Few studies within sub-Saharan Africa, where HIV incidence and prevalence disproportionately affects young women, have examined gendered differences in SSE. We used multivariable logistic regression to identify correlates of high-SSE separately among adolescent men and women (aged 14-19) in Soweto, South Africa using a previously validated SSE scale (high-SSE [>3/6 items]; study-alpha = 0.75). SSE scale items assessed self-efficacy related to sexual refusal and condom use. Adolescent women were significantly more likely to report high-SSE than adolescent men (72.3% versus 49.5%; p < 0.01). High-SSE among adolescent men was associated with more positive beliefs about sexual relationships and negatively associated with probable depression. High-SSE among adolescent women was associated with increased HIV knowledge, more positive beliefs about condom use and sexual relationships, having an adult in the home, and negatively associated with being an older adolescent (16-17 versus ≤15), and ever experiencing physical violence. Differences in prevalence and correlates of SSE among adolescent men and women in South Africa highlight important areas for gender-sensitive interventions. Targeted efforts to reduce negative sexual beliefs, improve HIV knowledge and mental well-being may improve SSE and thus the uptake of HIV-prevention practices among adolescent men. For adolescent women, findings indicate programming should move beyond individual-levels determinants of behaviour to focus on improving enabling environments (e.g., Reduced violence and improved family relationships) in which sexual agency can be enacted.

Gender, Sexual Self-Efficacy and Consistent Condom Use Among Adolescents Living in the HIV Hyper-Endemic Setting of Soweto, South Africa.

Within HIV-endemic settings, few studies have examined gendered associations between sexual self-efficacy (SSE), one's confidence or perceived control over sexual behavior, and uptake of HIV prevention behaviors. Using cross-sectional survey data from 417 sexually-experienced adolescents (aged 14-19, median age = 18, 60% female) in Soweto, South Africa, we measured SSE using a 6-item scale (range:0-6) with 'high-SSE' = score > 3 (study alpha = 0.75). Gender-stratified logistic regression models assessed associations between high-SSE and lifetime consistent condom use. A higher proportion of women reported high-SSE (68.7%) than men (49.5%, p < 0.001). We observed no difference in reported consistent condom use by gender (45.5% among women, 45.8% among men; p = 0.943). In confounder models, high-SSE was associated with consistent condom use among men (aOR = 3.51, 95%CI = 1.86-6.64), but not women (aOR = 1.43, 95%CI = 0.74-2.77). Findings highlight that individual-level psychosocial factors are insufficient for understanding condom use and must be considered alongside the relational, social, and structural environments within which young women navigate their sexual lives.

Pathways From HIV-Related Stigma to Antiretroviral Therapy Measures in the HIV Care Cascade for Women Living With HIV in Canada.

BACKGROUND: Associations between HIV-related stigma and reduced antiretroviral therapy (ART) adherence are widely established, yet the mechanisms accounting for this relationship are underexplored. There has been less attention to HIV-related stigma and its associations with ART initiation and current ART use. We examined pathways from HIV-related stigma to ART initiation, current ART use, and ART adherence among women living with HIV in Canada. METHODS: We used baseline survey data from a national cohort of women living with HIV in Canada (n = 1425). Structural equation modeling using weighted least squares estimation methods was conducted to test the direct effects of HIV-related stigma dimensions (personalized, negative self-image, and public attitudes) on ART initiation, current ART use, and 90% ART adherence, and indirect effects through depression and HIV disclosure concerns, adjusting for sociodemographic factors. RESULTS: In the final model, the direct paths from personalized stigma to ART initiation (ß = -0.104, P < 0.05) and current ART use (ß = -0.142, P < 0.01), and negative self-image to ART initiation (ß = -0.113, P < 0.01) were significant, accounting for the mediation effects of depression and HIV disclosure concerns. Depression mediated the pathways from personalized stigma to ART adherence, and negative self-image to current ART use and ART adherence. Final model fit indices suggest that the model fit the data well [χ(25) = 90.251, P < 0.001; comparative fit index = 0.945; root-mean-square error of approximation = 0.044]. CONCLUSIONS: HIV-related stigma is associated with reduced likelihood of ART initiation and current ART use, and suboptimal ART adherence. To optimize the benefit of ART among women living with HIV, interventions should reduce HIV-related stigma and address depression.

The adherence gap: a longitudinal examination of men's and women's antiretroviral therapy adherence in British Columbia, 2000-2014.

OBJECTIVE: The aim of this study was to observe the effect of sex on attaining optimal adherence to combination antiretroviral therapy (cART) longitudinally while controlling for known adherence confounders - IDU and ethnicity. DESIGN: Using the population-based HAART Observational Medical Evaluation and Research cohort, data were collected from HIV-positive adults, aged at least 19 years, receiving cART in British Columbia, Canada, with data collected between 2000 and 2014. cART adherence was assessed using pharmacy refill data. The proportion of participants reaching optimal (≥95%) adherence by sex was compared per 6-month period from initiation of therapy onward. Generalized linear mixed models with logistic regression examined the effect of sex on cART adherence. RESULTS: Among 4534 individuals followed for a median of 65.9 months (interquartile range: 37.0-103.2), 904 (19.9%) were women, 589 (13.0%) were Indigenous, and 1603 (35.4%) had a history of IDU. A significantly lower proportion of women relative to men were optimally adherent overall (57.0 vs. 77.1%; P < 0.001) and in covariate analyses. In adjusted analyses, female sex remained independently associated with suboptimal adherence overall (adjusted odds ratio: 0.55; 95% confidence interval: 0.48-0.63). CONCLUSION: Women living with HIV had significantly lower cART adherence rates then men across a 14-year period overall, and by subgroup. Targeted research is required to identify barriers to adherence among women living with HIV to tailor women-centered HIV care and treatment support services.

Conspiracy beliefs and knowledge about HIV origins among adolescents in Soweto, South Africa.

PURPOSE: We examined adolescents' knowledge regarding the origin of HIV/AIDS and correlates of beliefs surrounding conspiracy theories in Soweto, South Africa. Now, a decade post-AIDS denialism, South Africa has the largest antiretroviral therapy roll-out worldwide. However, conspiracy theories stemming from past AIDS denialism may impact HIV prevention and treatment efforts. METHODS: Study participants were recruited through the Kganya Motsha Adolescent Health Centre and the Perinatal HIV Research Unit's Botsha Bophelo Adolescent Health Study (BBAHS). Adolescents were eligible to participate if aged 14-19 years and living in Soweto. We calculated the proportion of adolescents who correctly believed that HIV originated from non-human primates, and used contingency table analysis and logistic regression modeling to describe correlates associated with accurate knowledge and beliefs in conspiracy theories. RESULTS: Of 830 adolescents, 168 (20.2%) participants correctly identified HIV as originating from chimpanzees and one third (n = 71, 8.6%) believed in a conspiracy theory about the origins of HIV, including that it originated from the US government (2.3%), the pharmaceutical industry (2.2%), a vaccine (2.1%), space (1.5%), and a scientist (0.6%). Participants who were more likely to correctly identify the origin of HIV were older, men, and unemployed. Participants who were men, unemployed or students, and who had a parent or close relative who had died of HIV, were more likely to believe in a conspiracy theory regarding the origins of HIV. CONCLUSIONS: Adolescents living in Soweto did not have high levels of accurate knowledge regarding the origins of HIV/AIDS and conspiracy beliefs were present among a small minority of participants. Accurate knowledge of the origins of HIV and debunking myths are important for improving uptake of HIV prevention tools in this population.

The Botsha Bophelo Adolescent Health Study: A profile of adolescents in Soweto, South Africa.

BACKGROUND: Youth between the ages of 15 years to 24 years account for almost half of new HIV infections in South Africa. OBJECTIVES: To describe the study details of the Botsha Bophelo Adolescent Health Study (BBAHS) which was an investigation of HIV risk among adolescents living in Soweto, South Africa. METHODS: Eligibility criteria for the BBAHS included being 14 years - 19 years old and living in one of the 41 identified formal and informal areas in the township of Soweto. A cross-sectional survey was developed between investigators and an adolescent community advisory board consisting of previously validated scales and original questions including demographics, sexual and reproductive health, health service utilisation and psychosocial behaviours. RESULTS: Between 2010 and 2012, interviewers administered surveys among 830 adolescents (57% females), whose median age was 17 years (Q1, Q3: 16, 18), and found that 43% of participants identified their ethnicity as Zulu, 52% reported high food insecurity, 37% reported at least one parent had died, 15% reported living in a shack and 83% identified as heterosexual. Over half of the participants (55%) reported ever having sex (49% of females and 64% of males), 11% of whom initiated sex at < 15 years of age (3% females and 21% males). Almost half (47%) reported ever testing for HIV, 3% (n = 12) of whom self-reported being HIV-positive and 33% (n = 4) were on antiretroviral therapy. CONCLUSION: Our study highlights important individual, relational and structural level determinants of HIV risk for adolescent men and women growing up within HIV hyperendemic settings.

Prevalence, type, and correlates of trauma exposure among adolescent men and women in Soweto, South Africa: implications for HIV prevention.

BACKGROUND: Youth trauma exposure is associated with syndemic HIV risk. We measured lifetime prevalence, type, and correlates of trauma experience by gender among adolescents living in the HIV hyper-endemic setting of Soweto, South Africa. METHODS: Using data from the Botsha Bophelo Adolescent Health Survey (BBAHS), prevalence of "ever" experiencing a traumatic event among adolescents (aged 14-19) was assessed using a modified Traumatic Event Screening Inventory-Child (TESI-C) scale (19 items, study alpha = 0.63). We assessed self-reported number of potentially traumatic events (PTEs) experienced overall and by gender. Gender-stratified multivariable logistic regression models assessed independent correlates of 'high PTE score' (≥7 PTEs). RESULTS: Overall, 767/830 (92%) participants were included (58% adolescent women). Nearly all (99.7%) reported experiencing at least one PTE. Median PTE was 7 [Q1,Q3: 5-9], with no gender differences (p = 0.19). Adolescent men reported more violent PTEs (e.g., "seen an act of violence in the community") whereas women reported more non-violent HIV/AIDS-related PTEs (e.g., "family member or someone close died of HIV/AIDS"). High PTE score was independently associated with high food insecurity among adolescent men and women (aOR = 2.63, 95%CI = 1.36-5.09; aOR = 2.57, 95%CI = 1.55-4.26, respectively). For men, high PTE score was also associated with older age (aOR = 1.40/year, 95%CI = 1.21-1.63); and recently moving to Soweto (aOR = 2.78, 95%CI = 1.14-6.76). Among women, high PTE score was associated with depression using the CES-D scale (aOR = 2.00, 95%CI = 1.31-3.03,) and inconsistent condom use vs. no sexual experience (aOR = 2.69, 95%CI = 1.66-4.37). CONCLUSION: Nearly all adolescents in this study experienced trauma, with gendered differences in PTE types and correlates, but not prevalence. Exposure to PTEs were distributed along social and gendered axes. Among adolescent women, associations with depression and inconsistent condom use suggest pathways for HIV risk. HIV prevention interventions targeting adolescents must address the syndemics of trauma and HIV through the scale-up of gender-transformative, youth-centred, trauma-informed integrated HIV and mental health services.

Investigating Sociodemographic Factors and HIV Risk Behaviors Associated With Social Networking Among Adolescents in Soweto, South Africa: A Cross-Sectional Survey.

BACKGROUND: Internet access via mobile phones and computers facilitates interaction and potential health communication among individuals through social networking. Many South African adolescents own mobile phones and can access social networks via apps. OBJECTIVE: We investigated sociodemographic factors and HIV risk behaviors of adolescent social networking users in Soweto, South Africa. METHODS: We conducted an interviewer-administered, cross-sectional survey of adolescents aged 14-19 years. Independent covariates of social networking were assessed by multivariate logistic regression analysis. RESULTS: Of 830 adolescents, 57% (475/830) were females and the median age was found to be 18 years (interquartile range 17-18). Social networking was used by 60% of adolescents (494/830); more than half, that is, 87% (396/494) accessed social networks through mobile phones and 56% (275/494) spent more than 4 hours per day using their mobile phones. Social networking was independently associated with mobile usage 2-4 hours (adjusted odds ratio [AOR]: 3.06, CI: 1.69-5.51) and more than 4 hours per day (AOR: 6.16, CI: 3.46-10.9) and one (AOR: 3.35, CI: 1.79-6.27) or more sexual partner(s) (AOR: 2.58, CI: 1.05-6.36). CONCLUSIONS: Mobile phone-based social networking is prevalent among sexually active adolescents living in Soweto and may be used as an entry point for health promotion and initiation of low-cost adolescent health interventions.

Health-seeking behaviours by gender among adolescents in Soweto, South Africa.

BACKGROUND: Adolescents are an important age-group for preventing disease and supporting health yet little is known about their health-seeking behaviours. OBJECTIVE: We describe socio-demographic characteristics and health-seeking behaviours of adolescents in Soweto, South Africa, in order to broaden our understanding of their health needs. DESIGN: The Botsha Bophelo Adolescent Health Study was an interviewer-administered cross-sectional survey of 830 adolescents (14-19 years) conducted in Soweto from 2010 to 2012. Health-seeking behaviours were defined as accessing medical services and/or being hospitalised in the 6 months prior to the survey. Chi-square analysis tested for associations between gender, other socio-demographic and behavioural characteristics, and health-seeking behaviours. RESULTS: Of 830 adolescents, 57% were female, 50% were aged 17-19 years, 85% were enrolled in school, and 78% reported experiencing medium or high food insecurity. Males were more likely than females to report sexual debut (64% vs. 49%; p<0.0001) and illicit drug use (11% vs. 3%; p<0.0001). Approximately 27% (n=224) and 8% (n=65) reported seeking healthcare or being hospitalised respectively in the previous 6 months, with no significant differences by gender. Services were most commonly sought at medical clinics (75%), predominantly because of flu-like symptoms (32%), followed by concerns about HIV (10%). Compared to females, males were more likely to seek healthcare for condom breakage (8% vs. 2%; p=0.02). Relative to males, a significantly higher proportion of females desired general healthcare services (85% vs. 78%; p=0.0091), counselling (82% vs. 70%; p<0.0001), and reproductive health services (64% vs. 56%; p=0.02). CONCLUSIONS: A quarter of male and female adolescents accessed health services in the 6 months prior to the interview. Adolescents reported a gap between the availability and the need for general, reproductive, and counselling services. Integrated adolescent-friendly, school-based health services are recommended to bridge this gap.

Association between childhood physical abuse, unprotected receptive anal intercourse and HIV infection among young men who have sex with men in Vancouver, Canada.

INTRODUCTION: The association between childhood sexual abuse and HIV risk among men who have sex with men (MSM) is well established. However, no studies have examined the potential impact of other forms of childhood maltreatment on HIV incidence in this population. METHODS: We explored the impact of child physical abuse (CPA) on HIV seroconversion in a cohort of gay/bisexual men aged 15 to 30 in Vancouver, Canada. Cox proportional hazard models were used, controlling for confounders. RESULTS: Among 287 participants, 211 (73.5%) reported experiencing CPA before the age of 17, and 42 (14.6%) reporting URAI in the past year. After a median of 6.6 years follow-up, 16 (5.8%) participants HIV-seroconverted. In multivariate analysis, CPA was significantly associated with HIV seroconversion (adjusted hazard ratio [AHR] = 4.89, 95% confidence interval (CI): 1.65-14.48), after controlling for potential confounders. CONCLUSION: Our study uncovered a link between childhood physical violence and HIV incidence. Results highlight an urgent need for screening of young gay and bisexual men for histories of violence, and social and structural supports to prevent HIV transmission in this population.

High rates of lifetime and recent violence observed among harder-to-reach women living with HIV.

This study examined the prevalence and correlates associated with lifetime and recent violence among a sample of harder-to-reach human immunodeficiency virus (HIV)-positive women living in British Columbia (BC), Canada. Interviewer-led surveys with 1000 participants gathered quantitative data on social, economic, and structural characteristics such as housing status, relationship status, family structure, history of drug use, and sexual behavior. Logistic regression analysis modeled associations between independent variables and experiences of violence at baseline. Cox regression analyses with time-dependent covariates determined correlates of lifetime and recent violence among HIV-positive women. Of the 249 women in the study, an overwhelming proportion of women (81%) reported experiences of violence in their lifetime. Among those, 22% reported recent experiences of violence, and 56% of the women reported more than five violent episodes in their lifetime. Lifetime violence was independently associated with HIV-related stigma (adjusted odds ratio [AOR] = 2.18, 95% confidence interval [CI] = 1.14-5.70), previous tobacco use (AOR = 2.79, 95% CI = 1.10-7.07), ever having a drinking problem (AOR = 2.82, 95% CI = 1.28-6.23), and ever having received care for a mental health condition (AOR = 2.42, 95% CI = 1.06-5.52). Recent violence was associated with the current illicit drug use (AOR = 2.60, 95% CI = 1.14-5.90), and currently residing in unstable housing (AOR = 2.75, 95% CI = 1.31-5.78). This study underscores the need to consider potential experiences of historical and current violence as part of comprehensive care for women living with HIV.

Implications for HIV prevention: lesbian, gay and bisexual adolescents in urban South Africa are at increased risk of living with HIV.

Among adolescents (14-19 years) in Soweto, South Africa, 14% (4/29) who identified as lesbian, gay or bisexual (3 female and 1 male) reported living with HIV compared with only 2.3% (8/350) who identified as heterosexual (P = 0.002). These data indicate an urgent need to utilize evidence-based strategies to support access to HIV prevention education and services for lesbian, gay and bisexual youth.

Adolescent experiences of HIV and sexual health communication with parents and caregivers in Soweto, South Africa.

Communication about sexual health between parents and adolescents has been shown to have a protective influence on behaviours that reduce the risk of HIV transmission. This study explored experiences of HIV and sexual health (HSH) communication between parents and/or caregivers and adolescents in an urban HIV-endemic community in Southern Africa. Adolescents (aged 14-19 years) were recruited from the Kganya Motsha Adolescent Centre and the Kliptown community between June and August 2009. Qualitative data were collected through focus group discussions (n=10 adolescents) and semi-structured interviews (n=31 adolescents). In total, 41 adolescents (56% female, 44% male, mean age=17.2) participated in the study. Adolescent participants identified emotional, physical and sociocultural barriers to initiating HSH communication with parents and caregivers including fear of verbal warnings, threats and physical assault. Adolescents also expressed a desire for mentorship around HSH communication beyond abstinence and peer-based information. Public health interventions need to support adolescents' access to bi-directional HSH information from adult mentors that address the lived realities of adolescents beyond expectations of abstinence.

Conversations with mothers: exploring reasons for prevention of mother-to-child transmission (PMTCT) failures in the era of programmatic scale-up in Soweto, South Africa.

Reasons for incident cases of vertical HIV transmission in the era of free access to PMTCT in South Africa were investigated. This mixed-methods study was conducted in Soweto, South Africa from June-August, 2009. Birthmothers of HIV-infected infants born after 1 December 2008 were eligible. All participants completed an interviewer-administered questionnaire. Women also participated in a focus group (n = 10) or individual structured interview (n = 35). Mean age of participants (n = 45) was 28.7 years (SD = 5.4). Major findings are: (i) failure of per-guideline prescription of ARV strategies for infants (31%) and/or mothers (57%); (ii) maternal refusal of treatment (n = 5); (iii) preterm delivery (31%); (iv) delayed ANC attendance because of facility-related barriers and maternal apprehension around HIV testing; (v) fear of stigma; (vi) maternal difficulty with administering infant AZT (n = 9) and (vii) maternal confusion about infant feeding. A variety of individual, social, and structural factors must be addressed to optimize PMTCT service delivery in South Africa.

Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011.

A literature review of original research articles on adherence to antiretroviral therapy (ART) in developed countries, covering January 2000 to June 2011, was conducted to determine if gender differences exist in the prevalence of nonadherence to ART. Of the 1,255 articles reviewed, only 189 included data on the proportion of the study population that was adherent and only 57 (30.2%) of these reported proportional adherence values by gender. While comparing articles was challenging because of varied reporting strategies, women generally exhibit poorer adherence than men. Thirty of the 44 articles (68.2%) that reported comparative data on adherence by gender found women to be less adherent than men. Ten articles (17.5%) reported significant differences in proportional adherence by gender, nine of which showed women to be less adherent than men. These findings suggest that in multiple studies from developed countries, female gender often predicts lower adherence. The unique circumstances of HIV-positive women require specialized care to increase adherence to ART.

Individual and structural vulnerability among female youth who exchange sex for survival.

PURPOSE: Because of growing concerns regarding the heightened vulnerabilities and risk of human immunodeficiency virus infection among youth who exchange sex for survival, we investigated individual risk patterns and structural barriers among young (≤24 years) female sex workers (FSWs) in Vancouver, Canada. METHODS: Between 2005 and 2008, a total of 255 street-based FSWs (≥14 years) were enrolled into a community-based prospective cohort, and were asked to participate in baseline and biannual questionnaires administered through interviews and human immunodeficiency virus screening. We used contingency table analysis to compare individual and structural barrier results obtained at baseline for younger (≤24 years) FSWs with those of the older (>25 years) FSWs. For longitudinal data, we used generalized estimating equations throughout the follow-up period to determine factors associated with being a young FSW in the past 6 months. RESULTS: In comparison with older FSWs (n = 199), youth (n = 56) were more likely to spend fewer years engaging in sex exchange (median: 6.4 [interquartile range: 4.6-9.1] vs. 19.9 [interquartile range: 10.0-26.8]; p ≤ .001), belong to an aboriginal ancestry (59% vs. 44%; p = .052), and be homeless (68% vs. 36%; p ≤ .001). In the multivariate generalized estimating equations analysis, youth reported a significantly elevated proportional odds of being homeless (odds ratio [OR]: 1.26 [confidence interval {CI}: 1.08-1.48]), servicing clients in public places (OR: 1.28 [CI: 1.04-1.57]), injecting heroin on a daily basis (OR: 1.35 [CI: 1.06-1.74]), and a significantly reduced odds of accessing methadone maintenance therapy (OR: .76 [CI: .62-.93]). CONCLUSIONS: This study demonstrates significant displacement of youth who engage in sex exchange to marginalized working and living spaces. The findings of this study bring to attention the critical need for targeted structural interventions including access to youth and gender-specific social housing, safe working spaces, reduction in the amount of harm caused to them, and addiction treatment services for youth engaged in survival sex work.

Relative versus absolute standards for everyday risk in adolescent HIV prevention trials: expanding the debate.

The concept of minimal risk has been used to regulate and limit participation by adolescents in clinical trials. It can be understood as setting an absolute standard of what risks are considered minimal or it can be interpreted as relative to the actual risks faced by members of the host community for the trial. While commentators have almost universally opposed a relative interpretation of the environmental risks faced by potential adolescent trial participants, we argue that the ethical concerns against the relative standard may not be as convincing as these commentators believe. Our aim is to present the case for a relative standard of environmental risk in order to open a debate on this subject. We conclude by discussing how a relative standard of environmental risk could be defended in the specific case of an HIV vaccine trial among adolescents in South Africa.