Prevalence and correlates of anal sex among secondary school students in Cape Town, South Africa.

Research efforts have overlooked anal sex as a risk factor for adolescents' acquisition of HIV despite the high rates of HIV among South African youth. Here, we report findings from a survey conducted in 2012 among secondary school youth, ages 16-24, in Cape Town. 937 adolescents completed a pencil-and-paper survey. Eleven and 31% of female and male youth, respectively, reported ever having anal sex. By comparison, 59% and 78% of female and male youth reported ever having vaginal sex. The percentage of youth reporting lifetime rates of anal sex increased with age: 32% of 20-to-24 year olds had anal sex compared to 16% of 16-to-17-year olds. When the sample was stratified by sex, this difference appeared to be driven by older male, but not female, sexual behavior. Despite noted differences in prevalence rates by sex, both boys and girls who had anal sex were more likely than their same-sex peers who had vaginal sex to report sexual coercion victimization and perpetration experiences and inconsistent condom use. Interestingly, some differences in HIV motivation, information, and behavioral skills were noted for youth who had vaginal sex versus youth who had never had sex; scores were largely similar for youth who had anal sex versus youth who had never had sex however. Together, these findings suggest that anal sex is not uncommon and may be an important marker for other HIV risk behaviors in at least one lower income South African community. Anal sex needs to be explicitly discussed in adolescent HIV prevention and healthy sexuality programing, incorporating age-relevant scenarios about negotiating condoms and other healthy relationship behaviors (e.g., refusing sex when it is not wanted).

Opportunities for technology-based HIV prevention programming among high school students in Cape Town, South Africa.

One in three new cases of HIV in South Africa is among adolescents. Given that adolescents are particularly affected, scalable, and cost-effective prevention programs are urgently needed. This study aims to identify opportunities to integrate technology into youth HIV prevention efforts. In 2012, 1107 8th-11th graders completed a paper-and-pencil survey. Respondents were enrolled in one of three public high schools in Langa, a lower income community in Cape Town, South Africa. Eighty-nine percent of respondents have used text messaging (SMS) and 86% have gone online. If an HIV prevention program was offered online, 66% of youth would be somewhat or extremely likely to access it; slightly fewer (55%) felt the same about SMS-based programming. In comparison, 85% said they would be somewhat or extremely likely to access a school-based HIV prevention program. Interest in Internet- (60%) and SMS-based (54%) HIV prevention programming was similar for youth who had a self-appraised risk of HIV compared to youth who appraised their risk to be lower, as it was for youth who were tired of hearing messages about HIV prevention. Technology use is common - even among high school students who live in lower income communities. At the same time, these data reveal that it is not uncommon for youth to be tired of hearing messages about HIV prevention, and many of the typical topics key to HIV prevention have low interest levels among youth. HIV prevention researchers need to be mindful of the extent of existing programming that youth are exposed to. Technology-based programming may be especially amenable to meeting these requirements because of its novelty especially in developing countries, and because interactive functionality can be easily integrated into the program design. Given the preference for school- and Internet-based programming, it seems that a hybrid approach is likely feasible and acceptable.

Exploring the relationships among food insecurity, alcohol use, and sexual risk taking among men and women living in South African townships.

South African townships have among the highest rates of HIV infection in the world. Considerable research on understanding the high rates of HIV transmission in this country has identified alcohol use as a critical factor in driving the HIV epidemic. Although the relationship between alcohol use and sexual risk-taking is well documented, less is known about how other factors, such as food insecurity, might be important in understanding alcohol's role in sexual risk-taking. Furthermore, prior research has highlighted how patterns of alcohol use and sexual risk-taking tend to vary by gender. We examined how food insecurity is related to both alcohol use and sexual risk-taking. We administered anonymous community surveys to men (n = 1,137) and women (n = 458) residing within four contiguous Black African townships outside of Cape Town, South Africa. In multivariate linear regression, we found that food insecurity was related to having higher numbers of male sex partners and condom-protected sex acts among women only. These relationships, however, were fully mediated by women's alcohol use. Among men, we found that food insecurity was negatively related to unprotected sex; that is, men with greater food security reported more unprotected sex acts. Unlike the results found among women, this relationship was not mediated by alcohol use. Food insecurity appears to be an important factor in understanding patterns of sexual risk-taking in regards to gender and alcohol use, and may serve as an important point of intervention for reducing HIV transmission rates.

Randomized community-level HIV prevention intervention trial for men who drink in South African alcohol-serving venues.

BACKGROUND: South African alcohol-serving establishments (i.e., shebeens) offer unique opportunities to reduce HIV risks among men who drink. PURPOSE: To test an individual- and a social structural-level HIV prevention intervention for men who drink in shebeens. METHODS: Twelve matched pairs of township neighbourhoods were randomized to receive either (i) an HIV prevention intervention (guided by Social Action Theory) to reduce sexual risk and increase risk reduction communication in social networks, or (ii) an attention-matched control intervention that focused on the prevention of relationship violence. At the individual level, the interventions delivered skills building workshops focused on sexual risk reduction. At the social structural level, the intervention aimed to increase conversations about safer sex among men in the shebeens, distributed small media and implemented community educational events. Individual-level outcomes were assessed by following the workshop cohorts for 1 year (N = 984), and community-level outcomes were examined through cross-sectional community surveys conducted for 1 year in the shebeens (N = 9,678). RESULTS: Men in the HIV prevention workshops demonstrated greater condom use, more HIV prevention-oriented conversations and greater perceptions of safer sex norms than men in the comparison workshops. Changes at the community level demonstrated significant differences in condom use, although the pattern was not consistent over time. CONCLUSIONS: Multi-level interventions that target men who drink in South African shebeens may help reduce risks for HIV and other sexually transmitted infections.

Collective efficacy and HIV prevention in South African townships.

South African townships have high HIV prevalence and a strong need for collective action to change normative sexual risk behaviors. This study investigated the relationship between perceptions of individuals about collective efficacy in the community's ability to prevent HIV and their personal HIV risk behaviors. Men (n = 1,581) and women (n = 718) completed anonymous surveys within four Black African Townships in Cape Town, South Africa from June 2008 to December 2010. Measures included demographics, alcohol use, attitudinal and behavioral norms, sexual health communications, and sexual risk behaviors. In multivariate logistic regressions, men were more likely to endorse collective efficacy if they were married, drank less often in alcohol serving establishments, believed that fewer men approve of HIV risk behaviors, talk more with others about HIV/AIDS, and had more sex partners in the past month. Women were more likely to endorse collective efficacy if they drank alcohol less often, talked more with others about HIV/AIDS, had more sex partners in the past month, but reported fewer unprotected sex acts in the past month. Community level interventions that strengthen collective efficacy beliefs will have to consider both protective and risk behaviors associated with believing that the community is ready and capable of preventing HIV.

Bringing it home: community survey of HIV risks to primary sex partners of men and women in alcohol-serving establishments in Cape Town, South Africa.

BACKGROUND: Concurrent sexual relationships facilitate the spread of HIV infection, and sex with non-primary partners may pose particularly high risks for HIV transmission to primary partners. OBJECTIVE: We examined the sexual and alcohol-related risks associated with sex partners outside of primary relationships among South African men and women in informal drinking establishments. METHODS: Men (n=4959) and women (n=2367) with primary sex partners residing in a Xhosa-speaking South African township completed anonymous surveys. Logistic regressions tested associations between having outside partners and risks for sexually transmitted infections (STI)/HIV. RESULTS: Forty-four percent of men and 26% women with primary sex partners reported also having outside sex partners in the previous month. Condom use with outside partners was inconsistent for men and women; only 19% of men and 12% of women used condoms consistently with outside sex partners. Multivariable regressions for men and women showed that having outside partners was significantly associated with having been diagnosed with an STI, consuming alcohol in greater frequency and quantity, alcohol use during sex, meeting sex partners in alcohol-serving venues, and higher rates of unprotected sex. CONCLUSIONS: Having outside sex partners was associated with multiple risk factors for HIV infection among South African shebeen patrons. Social and structural interventions that encourage condom use are needed for men and women with outside partners who patronise alcohol-serving venues.

Condom negotiation, HIV testing, and HIV risks among women from alcohol serving venues in Cape Town, South Africa.

BACKGROUND: Women in South Africa are at particularly high-risk for HIV infection and are dependent on their male partners' use of condoms for sexual risk reduction. However, many women are afraid to discuss condoms with male partners, placing them at higher risk of HIV infection. PURPOSE: To examine the association between fear of condom negotiation with HIV testing and transmission risk behaviors, including alcohol use and sexual risks among South African women. METHOD: Women (N = 1333) residing in a primarily Xhosa-speaking African township in Cape Town and attending informal alcohol-serving venues (shebeens) completed anonymous surveys. Logistic regression was used to test the hypothesis that fear of condom negotiation would be associated with increased risk for HIV. RESULTS: Compared to women who did not fear condom negotiation, those who did were significantly less likely to have been tested for HIV, were more likely to have experienced relationship abuse, and to report more alcohol use and more unprotected sex. CONCLUSIONS: For women in South Africa, fear of condom negotiation is related to higher risk of HIV. HIV prevention efforts, including targeted HIV counseling and testing, must directly address gender issues.

HIV risks associated with patronizing alcohol serving establishments in South African Townships, Cape Town.

Alcohol use has been closely linked with HIV risk behaviors in South Africa. The places where people drink are often the same settings in which they meet new sex partners and may contribute independently to sexual risk. This current study examines the independent effects of patronizing alcohol serving establishments (shebeens) and alcohol use in predicting HIV risk behaviors. Men (n = 981) and women (n = 492) were recruited from inside shebeens and surrounding areas proximal to shebeens in eight separate neighborhoods in a Township in Cape Town, South Africa. Anonymous community surveys measured demographic characteristics, alcohol use, shebeen attendance, and sexual risk behaviors. Comparisons of 1210 (82 %) participants who patronized shebeens in the past month with 263 (18 %) participants who did not patronize shebeens demonstrated higher rates of alcohol use frequency and quantity, more sexual partners, and higher rates of vaginal intercourse without condoms for the patrons. Multiple linear regression analysis found shebeen attendance in the past month predicted greater sexual risk for HIV beyond demographic characteristics and alcohol use. Social influences and environmental factors in shebeens could be contributing to sexual risk behavior independently of alcohol consumption. Further research is needed to understand the environmental factors of shebeens that promote and influence HIV risk behaviors.

Patterns of alcohol use and sexual behaviors among current drinkers in Cape Town, South Africa.

OBJECTIVE: This study examined the association between alcohol use and sexual behaviors among South African adults who reported current drinking. METHOD: Street-intercept surveys were administered to adults residing in neighborhoods in a South African township. RESULTS: Analyses were restricted to participants reporting current drinking (N=1285; mean age=32; 27% women; 98% Black). Most participants (60%) reported heavy episodic drinking (i.e., 5 or more drinks on a single occasion) at least once per week in the past 30 days. Compared to non-heavy episodic drinkers, participants who reported heavy episodic drinking were more likely to drink before sex (79% vs. 66%) and have sex with a partner who had been drinking (59% vs. 44%). Overall, drinking before sex (self or partner) and heavy episodic drinking was associated with multiple sexual partners, discussing condom use with sexual partner(s), and proportion of protected sex. The frequency of condom use varied among participants with steady, casual, or both steady and casual sexual partners. CONCLUSIONS: Alcohol use among South African adults is associated with sexual risk behaviors, but this association differs by partner type. Findings suggest the need to strengthen alcohol use components in sexual risk reduction interventions especially for participants with both steady and casual sex partners.

Heterosexual anal intercourse and HIV infection risks in the context of alcohol serving venues, Cape Town, South Africa.

BACKGROUND: The most efficient sexual behavior for HIV transmission is unprotected receptive anal intercourse. However, it is unclear what role heterosexual unprotected anal sex is playing in the world's worst HIV epidemics of southern Africa. The objective is to examine the prevalence of heterosexual unprotected anal intercourse among men and women who drink at informal alcohol serving establishments (shebeens) in South Africa. METHODS: Cross-sectional surveys were collected from a convenience sample of 5037 patrons of 10 shebeens in a peri-urban township of Cape Town, South Africa. Analyses concentrated on establishing the rates of unprotected anal intercourse practiced by men and women as well as the factors associated with practicing anal intercourse. RESULTS: We found that 15% of men and 11% of women reported anal intercourse in the previous month, with 8% of men and 7% of women practicing any unprotected anal intercourse. Multiple logistic regression showed that younger age, having primary and casual sex partners, and meeting sex partners at shebeens were independently associated with engaging in anal intercourse. Mathematical modeling showed that individual risks are significantly impacted by anal intercourse but probably not to the degree needed to drive a generalized HIV epidemic. CONCLUSIONS: Anal intercourse likely plays a significant role in HIV infections among a small minority of South Africans who patronize alcohol serving establishments. Heterosexual anal intercourse, the most risky sexual behavior for HIV transmission, should not be ignored in HIV prevention for South African heterosexuals. However, this relatively infrequent behavior should not become the focus of prevention efforts.

A brain-behaviour initiative for South Africa: the time is right.

BACKGROUND: Many have advocated for science and health research in developing world settings. However, there has been less focus on the value of basic and clinical neuroscience research in this context. The current paper focuses on the relevance of a brain-behaviour research initiative in South Africa. METHODS: Workshops sponsored by the University of Cape Town Research Office and by the National Research Foundation have recently focused on the state of South African basic and clinical neuroscience, and on how to strengthen research in these areas. The context of the discussion included national science and health priorities, as well as local research opportunities. RESULTS: Neuropsychiatric disorders account for the second largest proportion of the burden of disease in South Africa, but receive relatively little research funding. There is a critical need for research, and there are unique research opportunities, in areas such as trauma and resilience, impulsive behaviour (eg violence, sexual risk taking, and substance abuse), and neuroAIDS. Basic, clinical, and systems research can all make important contributions. CONCLUSION: There is a need to apprise policy-makers in developing world countries such as South Africa of the need for increased expenditure on basic and clinical neuroscience research. Local and international collaboration may be useful in increasing research capacity in South Africa, and ultimately in improving mental health services.