Attitudes Toward Gender-Based Violence Among Sexually Active Adult Men at High Risk for HIV in Rustenburg, South Africa.

Gender-based violence (GBV) toward women is widespread and has been associated with increased HIV risk. We investigated attitudes toward GBV among men living in Rustenburg, South Africa, who were enrolled in a longitudinal HIV incidence study. Participants were 18 to 49 years old, reported high risk sexual activity in the last 3 months, and were HIV-uninfected. Attitudes toward GBV were evaluated using responses to a five-item standardized questionnaire about men perpetrating physical violence on a female spouse; responses to each item were scaled from 1 (no agreement) to 4 (strong agreement) and summed. Total scores >10 were considered permissive toward GBV. Among the 535 men analyzed, nearly half (N = 229, 42.8%) had a GBV score >10. Being young (18-24 years) (adjusted odds ratio [aOR] = 1.53, 95% confidence interval [CI] [1.06, 2.22]), having less years of education (aOR = 1.61, 95% CI [1.11, 2.32]), and reporting no current sexual partner at baseline (aOR = 2.10, 95% CI [1.06, 4.14]) were independently associated with permissive attitudes toward GBV. The following behaviors reported in the last 3 months were also associated with high GBV scores: having a new female partner (aOR = 1.78, 95% CI [1.02, 3.10]), and having had an STI (aOR = 1.85, 95% CI [1.15, 2.99]). Consuming alcohol prior to sex in the last month (aOR = 1.59, 95% CI [1.09, 2.31]) was also associated with high GBV scores. A large proportion of South African HIV-uninfected men in this analysis reported permissive attitudes toward GBV. These attitudes were associated with HIV risk behavior. Integrating GBV and HIV prevention programs is essential.

Principles and framework for assessing the risk of bias for studies included in comparative quantitative environmental systematic reviews.

The internal validity of conclusions about effectiveness or impact in systematic reviews, and of decisions based on them, depends on risk of bias assessments being conducted appropriately. However, a random sample of 50 recently-published articles claiming to be quantitative environmental systematic reviews found 64% did not include any risk of bias assessment, whilst nearly all that did omitted key sources of bias. Other limitations included lack of transparency, conflation of quality constructs, and incomplete application of risk of bias assessments to the data synthesis. This paper addresses deficiencies in risk of bias assessments by highlighting core principles that are required for risk of bias assessments to be fit-for-purpose, and presenting a framework based on these principles to guide review teams on conducting risk of bias assessments appropriately and consistently. The core principles require that risk of bias assessments be Focused, Extensive, Applied and Transparent (FEAT). These principles support risk of bias assessments, appraisal of risk of bias tools, and the development of new tools. The framework follows a Plan-Conduct-Apply-Report approach covering all stages of risk of bias assessment. The scope of this paper is comparative quantitative environmental systematic reviews which address PICO or PECO-type questions including, but not limited to, topic areas such as environmental management, conservation, ecosystem restoration, and analyses of environmental interventions, exposures, impacts and risks.

Description of adverse events among adult men following voluntary medical male circumcision: Findings from a circumcision programme in two provinces of South Africa.

BACKGROUND: Clinical trials showed strong evidence that voluntary medical male circumcision (VMMC) reduces the acquisition of HIV among heterosexual men by up to 60%. However, VMMC uptake in East and Southern Africa remains suboptimal, with safety concerns identified as a barrier to uptake. We investigated the occurrence and severity of adverse events (AEs) in a routine VMMC programme implemented in Gauteng and North West provinces of South Africa. METHODS: We describe the frequency and characteristics of AEs using routinely collected data from a VMMC programme implemented between 01 May 2013 and 31 December 2014. The surgical procedure was provided at fixed clinics and mobile units in three districts. Adult men undertaking the procedure were referred for follow-up appointments where AEs were monitored. RESULTS: A total of 7,963 adult men were offered the VMMC service with 7,864 (98.8%) met the age and consent requirements for inclusion in a research follow-up after the surgical procedure and were followed-up for potential AEs. In total, 37 (0.5%) patients reported AEs post-surgery with infection [11 (29.7%)] and excessive bleeding [11 (29.7%)] commonly reported AEs. In terms of severity, 14 (37.8%) were classified as mild, 13 (35.1%) as moderate, and 10 (27.0%) as severe. Further, 32 (86.5%) of the AEs were classified as definitely related to the surgical procedure, with 36 (97.5%) of all AEs resolving without sequelae. CONCLUSION: The VMMC programme was able to reach adult men at high risk of HIV acquisition. Reported AEs in the programme were minimal, with the observed safety profile comparable to clinical trial settings, suggesting that VMMC can be safely administered in a programmatic setting.

High risk sexual behaviours associated with traditional beliefs about gender roles among men interested in medical male circumcision in South Africa.

BACKGROUND: Beliefs about gender roles and high-risk sexual behaviours underlie the human immunodeficiency virus (HIV) epidemic in South Africa. Yet, there is limited information on the relationships between beliefs about gender roles and risky sexual behaviours. Few studies have explored the association between beliefs about gender roles, high risk sexual behaviour, and health-seeking behaviour among men. METHODS: We investigated associations between gender beliefs (dichotomised as traditional or progressive) and high-risk sexual behaviour among South African men presenting for medical male circumcision (Apr 2014 to Nov 2015). RESULTS: Of 2792 enrolled men, 47.4% reported traditional gender beliefs. Participant ages ranged between 18-46 years (median age 26 years; interquartile range, 21-31 years). Most participants had at least one sex partner over the last 12 months (68.2%). Younger men (18-24 years old vs. 25-46 years old) (odds ratio [OR], 1.5 [95% confidence interval (CI) 1.0-2.0]), those with multiple partners ([OR], 1.5 (CI) 1.3-1.8]) and participants unsure of their last partner's HIV status (OR, 1.4 [95% CI 1.1-1.7]) were more likely to have traditional beliefs on gender roles. CONCLUSION: Young men with traditional beliefs on gender roles may be more likely to engage in high-risk sexual behaviour and could be good candidates for HIV prevention programmes. N = 206 (max 350) Trial registration Name of registry: Clinicaltrials.gov; Trial registration number: NCT02352961; Date of registration: 30 January 2015 "Retrospectively registered"; URL of trial registry record: https://www.clinicaltrials.gov/.

Effect of Xpert MTB/RIF testing introduction and favorable outcome predictors for tuberculosis treatment among HIV infected adults in rural southern Mozambique. A retrospective cohort study.

BACKGROUND: Global roll out of Xpert MTB/RIF technology has resulted in dramatic changes in TB diagnosis. However, benefits in resource-limited, high-burden TB/HIV settings, remain to be verified. In this paper we describe the characteristics of a large cohort of TB patients in a rural hospital in Southern Mozambique before and after Xpert MTB/RIF introduction, together with some determinants of favorable treatment outcome. METHODS: We conducted a retrospective cohort study of TB infected patients ≥15 years of age, diagnosed and treated at Carmelo Hospital of Chókwè between January 1, 2006 and December 31, 2017. Patient demographic and clinical characteristics, and treatment outcomes were recorded and compared before and after Xpert MTB/RIF, which was introduced in the second semester of 2012. RESULTS: 9,655 patients were analyzed, with 44.1% females. HIV testing was conducted in 99.9% of patients, with 82.8% having TB/HIV co-infection. 73.2% of patients had a favorable treatment outcome. No increase was observed in the number of TB patients identified after introduction of Xpert MTB/RIF testing. CONCLUSION: Upon introduction, Xpert testing seemed to have a punctual beneficial effect on TB treatment outcomes, however this effect apparently disappeared shortly afterwards. Challenges remain for integration of TB and HIV care, as worse outcomes are reported for those patients diagnosed with TB shortly after starting ART, and also for those never starting ART. The need of reasonably excluding TB disease before ART start should be highlighted to every health care provider engaged in HIV care.

Trends and gender differences in age at sex debut among adolescents and young adults in urban Cape Area, South Africa.

BACKGROUND: Adolescents and young adults in South Africa are at increased risk of experiencing negative outcomes from early sex initiation due to the context they develop in. This study aimed at investigating trends and gender differences in early age at sexual debut. METHODS: Data from the Cape Area Panel Study (CAPS) of young adults' conducted between 2002 and 2009 in urban Cape Town were used. Correlates of early sex using ecological risk factors were analysed. RESULTS: Overall mean age at sexual debut at follow-up was 17.5 years (standard deviation (SD) =2.5), with males at 16.8 years (SD=2.5) and 18.1 years (SD=2.4) for females. Males consistently reported an earlier age at sex debut across the five waves of the survey. Significant risk factors for early sex appeared at all levels of the ecology to include individual, household, and community factors. CONCLUSIONS: Integrated interventions for delaying early sex debut should consider factors within the ecology of the young adults' development context.

Ecological correlates of multiple sexual partnerships among adolescents and young adults in urban Cape Town: a cumulative risk factor approach.

Studies in South Africa have reported unsafe levels of risky sexual behvaiours among adolescents and young adults, with the country reporting the highest burden of HIV/AIDS globally, as well as a high rate of teenage pregnancy. While determinants of risky sexual behaviours have been investigated for factors occurring at the individual and household levels, not fully explored in the literature is the effect of community level factors. Furthermore, it is unclear whether risk factors occurring within the ecology of adolescents and young adults act cumulatively to influence their sexual practices. This article aims to address this knowledge gap using a case study of the Cape Area Panel Study of adolescents and young adults in urban Cape Town, South Africa. The ecological framework was adopted to guide the selection of risk factors at the individual, household, and community levels. Multivariate linear discriminant function analyses were used to select significant risk factors for multiple sexual partnerships and used to produce risk indices for the respondents. The cumulative risk approach was applied to test whether significant risk factors acted cumulatively. Findings point to the importance of ecological factors in influencing outcomes of multiple sexual partnerships among respondents and further demonstrate that ecological risk factors may act cumulatively. These findings are important for South Africa that is grappling with teenage pregnancy and disproportionate HIV epidemic among the youth.

Women at risk: Gender inequality and maternal health.

Gender inequality has been documented as a key driver of negative health outcomes, especially among women. However, studies have not clearly examined the role of gender inequality in maternal health in an African setting. Therefore, the authors of this study examined the role of gender inequality, indicated by lack of female autonomy, in exposing women to maternal health risk. Data were obtained from the 2007 Zambia Demographic and Health Survey on a weighted sample of 3,906 married or partnered women aged 15-49 years. Multivariable analyses revealed that low autonomy in household decision power was associated with maternal health risk (Odds Ratio (OR) = 1.52, p < .001). Autonomy interacted with household wealth showed that respondents who were in the wealthier households and had low autonomy in household decision power (OR = 2.03, p < .05) were more likely to be exposed to maternal health risk than their counterparts who had more autonomy. Efforts to lower women's exposure to maternal mortality and morbidity in Zambia should involve interventions to alter prevailing gender norms that limit women's active participation in decisions about their own health during pregnancy and delivery.

Making the Most of What We Already Know: A Three-Stage Approach to Systematic Reviewing.

BACKGROUND: Conducting a systematic review in social policy is a resource-intensive process in terms of time and funds. It is thus important to understand the scope of the evidence base of a topic area prior to conducting a synthesis of primary research in order to maximize these resources. One approach to conserving resources is to map out the available evidence prior to undertaking a traditional synthesis. A few examples of this approach exist in the form of gap maps, overviews of reviews, and systematic maps supported by social policy and systematic review agencies alike. Despite this growing call for alternative approaches to systematic reviews, it is still common for systematic review teams to embark on a traditional in-depth review only. OBJECTIVES: This article describes a three-stage approach to systematic reviewing that was applied to a systematic review focusing in interventions for smallholder farmers in Africa. We argue that this approach proved useful in helping us to understand the evidence base. RESULTS: By applying preliminary steps as part of a three-stage approach, we were able to maximize the resources needed to conduct a traditional systematic review on a more focused research question. This enabled us to identify and fill real knowledge gaps, build on work that had already been done, and avoid wasting resources on areas of work that would have no useful outcome. It also facilitated meaningful engagement between the review team and our key policy stakeholders.

Ecological correlates of multiple sexual partnerships among adolescents and young adults in urban Cape Town: a cumulative risk factor approach

Studies in South Africa have reported unsafe levels of risky sexual behaviors among adolescents and young adults, with the country reporting the highest burden of HIV/AIDS globally, as well as a high rate of teenage pregnancy. While determinants of risky sexual behaviours have been investigated for factors occurring at the individual and household levels, not fully explored in the literature is the effect of community level factors. Furthermore, it is unclear whether risk factors occurring within the ecology of adolescents and young adults act cumulatively to influence their sexual practices. This article aims to address this knowledge gap using a case study of the Cape Area Panel Study of adolescents and young adults in urban Cape Town, South Africa. The ecological framework was adopted to guide the selection of risk factors at the individual, household, and community levels. Multivariate linear discriminant function analyses were used to select significant risk factors for multiple sexual partnerships and used to produce risk indices for the respondents. The cumulative risk approach was applied to test whether significant risk factors acted cumulatively. Findings point to the importance of ecological factors in influencing outcomes of multiple sexual partnerships among respondents and further demonstrate that ecological risk factors may act cumulatively. These findings are important for South Africa that is grappling with teenage pregnancy and disproportionate HIV epidemic among the youth

Incidence of HIV-associated tuberculosis among individuals taking combination antiretroviral therapy: a systematic review and meta-analysis.

BACKGROUND: Knowledge of tuberculosis incidence and associated factors is required for the development and evaluation of strategies to reduce the burden of HIV-associated tuberculosis. METHODS: Systematic literature review and meta-analysis of tuberculosis incidence rates among HIV-infected individuals taking combination antiretroviral therapy. RESULTS: From PubMed, EMBASE and Global Index Medicus databases, 42 papers describing 43 cohorts (32 from high/intermediate and 11 from low tuberculosis burden settings) were included in the qualitative review and 33 in the quantitative review. Cohorts from high/intermediate burden settings were smaller in size, had lower median CD4 cell counts at study entry and fewer person-years of follow up. Tuberculosis incidence rates were higher in studies from Sub-Saharan Africa and from World Bank low/middle income countries. Tuberculosis incidence rates decreased with increasing CD4 count at study entry and duration on combination antiretroviral therapy. Summary estimates of tuberculosis incidence among individuals on combination antiretroviral therapy were higher for cohorts from high/intermediate burden settings compared to those from the low tuberculosis burden settings (4.17 per 100 person-years [95% Confidence Interval (CI) 3.39-5.14 per 100 person-years] vs. 0.4 per 100 person-years [95% CI 0.23-0.69 per 100 person-years]) with significant heterogeneity observed between the studies. CONCLUSIONS: Tuberculosis incidence rates were high among individuals on combination antiretroviral therapy in high/intermediate burden settings. Interventions to prevent tuberculosis in this population should address geographical, socioeconomic and individual factors such as low CD4 counts and prior history of tuberculosis.

Virologic response in children treated with abacavir-compared with stavudine-based antiretroviral treatment: a South African multi-cohort analysis.

BACKGROUND: Initiation criteria and pediatric antiretroviral treatment regimens have changed over the past few years in South Africa. We reported worse early virological outcomes associated with the use of abacavir (ABC)-based regimens at 1 large site: here, we expand this analysis to multiple sites in the IeDEA-Southern Africa collaboration. METHODS: Data for 9543 antiretroviral treatment-naïve children <16 years at treatment initiation started on either stavudine/lamivudine (d4T/3TC) or ABC/3TC with efavirenz (EFV) or ritonavir-boosted lopinavir (LPV/r) treated at 6 clinics in Johannesburg and Cape Town, South Africa, were analyzed with χ tests and logistic regression to evaluate viral suppression at 6 and 12 months. RESULTS: Prevalence of viral suppression at 6 months in 2174 children started on a d4T-based LPV/r regimen was greater (70%) than among 438 children started on an ABC-based LPV/r regimen (54%, P < 0.0001). Among 3189 children started on a d4T-based EFV regimen, a higher proportion (86%) achieved suppression at 6 months compared with 391 children started on ABC-containing EFV regimens (78%, P < 0.0001). Relative benefit of d4T versus ABC on 6-month suppression remained in multivariate analysis after adjustment for pretreatment characteristics, cohort and year of program [LPV/r: odds ratio = 0.57 (confidence interval: 0.46-0.72); EFV: odds ratio = 0.46 (confidence interval: 0.32-0.65)]. CONCLUSIONS: This expanded analysis is consistent with our previous report of worse virological outcomes after ABC was introduced as part of first-line antiretroviral treatment in South Africa. Whether due to the drug itself or coincident with other changes over time, continued monitoring and analyses must clarify causes and prevent suboptimal long-term outcomes.

Pregnancy incidence and risk factors among women participating in vaginal microbicide trials for HIV prevention: systematic review and meta-analysis.

INTRODUCTION: Pregnancy is contraindicated in vaginal microbicide trials for the prevention of HIV infection in women due to the unknown maternal and fetal safety of the microbicides. Women who become pregnant are taken off the microbicide during pregnancy period but this result in reduction of the power of the trials. Strategies to reduce the pregnancy rates require an understanding of the incidence and associated risk factors of pregnancy in microbicide trials. This systematic review estimates the overall incidence rate of pregnancy in microbicide trials and describes the associated risk factors. METHODS: A comprehensive literature search was carried out to identify eligible studies from electronic databases and other sources. Two review authors independently selected studies and extracted relevant data from included studies. Meta-analysis of incidence rates of pregnancy was carried out and risk factors of pregnancy were reported narratively. RESULTS: Fifteen studies reporting data from 10 microbicide trials (N=27,384 participants) were included. A total of 4,107 participants (15.0%) fell pregnant and a meta-analysis of incidence rates of pregnancy from 8 microbicide trials (N=25,551) yielded an overall incidence rate of 23.37 (95%CI: 17.78 to 28.96) pregnancies per 100 woman-years. However, significant heterogeneity was detected. Hormonal injectable, intra-uterine device (IUD) or implants or sterilization, older age, more years of education and condom use were associated with lower pregnancy. On the other hand, living with a man, history of pregnancy, self and partner desire for future baby, oral contraceptive use, increased number of unprotected sexual acts and inconsistent use of condoms were associated with higher pregnancy. CONCLUSIONS: The incidence rate of pregnancy in microbicide trials is high and strategies for its reduction are urgently required in order to improve the sample size and power of these trials.