Gender Norms and HIV Testing/Treatment Uptake: Evidence from a Large Population-Based Sample in South Africa.

How does the endorsement of different dimensions of gender norms by men and/or women influence their use of HIV testing and antiretroviral treatment? This question was examined using data from a 2014 population-based survey of 1053 women and 1004 men, ages 18-49, in rural South Africa. We used a global measure for views toward gender norms (the GEM Scale), plus four subsets of scale items (all reliabilities ≥ 0.7). In multivariate analyses using the global measure, endorsement of inequitable gender norms was associated with more testing (AOR 2.47, p < 0.01) and less treatment use (AOR 0.15, p < 0.01) among women but not men. When examining specific subsets of inequitable norms (e.g., endorsing men as the primary decision-maker), decreased odds of treatment use was found for men as well (AOR 0.18, p < 0.01). Careful attention to the role specific gender norms play in HIV service uptake can yield useful programmatic recommendations.

Depression and Engagement in Care Among Newly Diagnosed HIV-Infected Adults in Johannesburg, South Africa.

Delayed engagement in HIV care threatens the success of HIV treatment programs in sub-Saharan Africa and may be influenced by depression. We examined the relationship between depression prior to HIV diagnosis and engagement in HIV care at a primary care clinic in Johannesburg, South Africa. We screened 1683 patients for depression prior to HIV testing using the Patient Health Questionnaire-9. Among patients who tested positive for HIV we assessed linkage to HIV care, defined as obtaining a CD4 count within 3 months. Among those who linked to care and were eligible for ART, we assessed ART initiation within 3 months. Multivariable Poisson regression with a robust variance estimator was used to assess the association between depression and linkage to care or ART initiation. The prevalence of HIV was 26 % (n = 340). Among HIV-infected participants, the prevalence of depression was 30 %. The proportion of linkage to care was 80 % among depressed patients and 73 % among patients who were not depressed (risk ratio 1.08; 95 % confidence interval 0.96, 1.23). Of the participants who linked to care, 81 % initiated ART within 3 months in both depressed and not depressed groups (risk ratio 0.99; 95 % confidence interval 0.86, 1.15). Depression was not associated with engagement in HIV care in this South African primary care setting. Our unexpected findings suggest that some depressed HIV-infected patients might be more likely to engage in care than their counterparts without depression, and highlight the complex relationship between depression and HIV infection. These findings have led us to propose a new framework relating HIV infection, depression, and the population under study.

Maximizing HIV Partner Notification Opportunities for Index Patients and their Sexual Partners in Malawi

Background. HIV testing and counselling (HTC) is important to effect positive sexual behaviour change and is an entry point to treatment; care; and psychosocial support. One of the most practical initiatives to increase HTC is to encourage sexual partners of HIV-infected persons to test for HIV. However; partner notification strategies must be feasible in the healthcare setting and acceptable to the population. Methods.We conducted a qualitative study during the pilot phase of an HIV partner notification trial to complement its assessment of feasibility and acceptability of methods of partner notification. We performed in-depth interviews with 16 consecutive HIV-positive index participants who consented and their 12 identifiable sexual partners. We also conducted two focus group discussions with healthcare workers to supplement the patient perspectives. In the main study; newly diagnosed HIV cases (index cases) were randomized to one of three methods of partner notification: passive; contract; and provider referral. Clients in the passive referral group were responsible for notifying their sexual partners themselves. Individuals in the contract referral group were given seven days to notify their partners; after which a healthcare provider contacted partners who had not reported for counselling and testing. In the provider group; a healthcare provider notified partners directly. Results.Although most index participants and partners expressed a preference for passive notification; they also highlighted benefits for provider-assisted notification and the universal right for all HIV-exposed persons to know their HIV exposure and benefit from HIV testing and access antiretroviral treatment. Several participants mentioned couples counselling as a way to diffuse tension and get accurate information. All mentioned benefits to HIV testing; including the opportunity to change behaviour. Conclusions. Provider-assisted partner notification is not preferred; but it is acceptable and may complement the passive method of notification. Couples counselling should also be encouraged

Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa.

BACKGROUND: Integration of depression screening into primary care may increase access to mental health services in sub-Saharan Africa, but this approach requires validated screening instruments. We sought to validate the Patient Health Questionnaire-9 (PHQ-9) as a depression screening tool at a high HIV-burden primary care clinic in Johannesburg, South Africa. METHODS: We conducted a validation study of an interviewer-administered PHQ-9 among 397 patients. Sensitivity and specificity of the PHQ-9 were calculated with the Mini International Neuropsychiatric Interview (MINI) as the reference standard; receiver operating characteristic (ROC) curve analyses were performed. RESULTS: The prevalence of depression was 11.8%. One-third of participants tested positive for HIV. HIV-infected patients were more likely to be depressed (15%) than uninfected patients (9%; p=0.08). Using the standard cutoff score of ≥10, the PHQ-9 had a sensitivity of 78.7% (95% CI: 64.3-89.3) and specificity of 83.4% (95% CI: 79.1-87.2). The area under the ROC curve was 0.88 (95% CI: 0.83-0.92). Test performance did not vary by HIV status or language. In sensitivity analyses, reference test bias associated with the MINI appeared unlikely. LIMITATIONS: We were unable to conduct qualitative work to adapt the PHQ-9 to this cultural context. CONCLUSION: This is the first validation study of the PHQ-9 in a primary care clinic in sub-Saharan Africa. It highlights the potential for using primary care as an access point for identifying depressive symptoms during routine HIV testing. The PHQ-9 showed reasonable accuracy in classifying cases of depression, was easily implemented by lay health workers, and is a useful screening tool in this setting.

Feasibility Analysis of an evidence-based positive prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo.

We evaluated the feasibility of a Positive Prevention intervention adapted for youth living with HIV/AIDS (YLWH) ages 15-24 in Kinshasa, Democratic Republic of the Congo. We conducted in-depth interviews and focus group discussions with intervention facilitators and YLWH participants on the following four areas of a feasibility framework: acceptability, implementation, adaptation, and limited-efficacy. The adapted intervention was suitable, satisfying, and attractive to program facilitators and participants and able to be implemented effectively. It performed well with a new population and showed preliminary efficacy. However, we identified certain aspects of the intervention that must be addressed prior to wider implementation such as: (1) including more content on navigating marriage while living with HIV and disclosure; (2) adjusting intervention timing and session length; and (3) simplifying the more complicated content. An adapted evidencebased intervention was found to be feasible and lessons learned can be applied to YLWH in other low-resource settings.

Adaptation of a U.S. evidence-based Positive Prevention intervention for youth living with HIV/AIDS in Kinshasa, Democratic Republic of the Congo.

Effective HIV prevention programs for people living with HIV/AIDS (PLWH) are important to reduce new infections and to ensure PLWH remain healthy. This paper describes the systematic adaptation of a U.S.-developed Evidence Based Intervention (EBI) using the Centers for Disease Control and Prevention (CDC) Map of Adaption Process for use at a Pediatric Hospital in Kinshasa, Democratic Republic of the Congo (DRC). The adapted intervention, Supporting Youth and Motivating Positive Action or SYMPA, a six-session risk reduction intervention targeted for youth living with HIV/AIDS (YLWH) in Kinshasa was adapted from the Healthy Living Project and guided by the Social Action Theory. This paper describes the process of implementing the first four steps of the ADAPT framework (Assess, Select, Prepare, and Pilot). Our study has shown that an EBI developed and implemented in the U.S. can be adapted successfully for a different target population in a low-resource context through an iterative process following the CDC ADAPT framework. This process included reviewing existing literature, adapting and adding components, and focusing on increasing staff capacity. This paper provides a rare, detailed description of the adaptation process and may aid organizations seeking to adapt and implement HIV prevention EBIs in sub-Saharan Africa and beyond.

Barriers to Provider-Delivered Sexual Behavior Counseling for Youth Living with HIV/AIDS in the Democratic Republic of the Congo.

AIMS: The study aimed to understand providers' role in delivering HIV transmission prevention counseling to youth living with HIV (YLWH). METHODS: We conducted 14 in-depth interviews with providers in Kinshasa, DRC. RESULTS: Providers' lack of knowledge and comfort in talking to youth about sex because of cultural and religious beliefs about sexuality, coupled with confusion about legal issues related to youth and contraception, made it difficult for them to effectively counsel youth. IMPLICATIONS FOR PRACTICE AND POLICY: In order for providers to deliver effective prevention counseling to YLWH, clinics should follow adolescent-friendly clinic standards, provide counseling in an adolescent-friendly style, and institute an effective referral system for additional prevention services. CONCLUSION: HIV prevention services can be improved through the creation of an adolescent-friendly environment and by providing "values clarification" and skill-based trainings so that providers are able to assess the role of their own beliefs and learn new skills.

Do behavioural differences help to explain variations in HIV prevalence in adolescents in sub-Saharan Africa?

OBJECTIVE: To compare adolescent risk factors for HIV infection in two countries with high adolescent HIV prevalence and two lower prevalence countries with the aim of identifying risk factors that may help explain differences in adolescent HIV prevalence. METHODS: Data were available from two nationally representative surveys (South Africa, Zimbabwe), two behavioural intervention trials (Tanzania, Zimbabwe) and one population-based cohort (Uganda). Data on variables known or postulated to be risk factors for HIV infection were compared. RESULTS: Few risk behaviours were markedly more common in the high HIV prevalence populations. Risk factors more common in high HIV prevalence settings were genital ulcers and discharge, and women were more likely to report older male partners. DISCUSSION: Age mixing may be an important determinate of HIV prevalence in adolescents. Potential reasons for the general lack of association between other adolescent risk factors and adolescent HIV prevalence include adult HIV prevalence, misreported behaviour, different survey methods and other unmeasured adolescent behaviours. If adult factors dominate adolescent HIV risk, it would help explain the failure of behavioural interventions targeted at adolescents and suggests future interventions should include adults.

Factors associated with HIV testing among sexually active South African youth aged 15-24 years.

HIV infection is high among South African youth but most report being unaware of their HIV status. We explored the correlates of HIV testing using data from youth aged 15-24 years old who reported being sexually experienced during a national survey conducted in South Africa in 2003 (N=7665). Among sexually experienced youth, 32.7% of females and 17.7% of males reported having been tested for HIV. In multivariable analysis, ever being pregnant (OR = 2.97; 95% CI 2.36-3.73), ever starting a conversation about HIV/AIDS (OR = 1.29; 95% CI 1.0-1.65) and urban residence (OR = 2.0; 95% CI 1.58-2.52) were independent correlates of HIV testing among sexually experienced females. Among sexually experienced males, HIV-positive status (OR = 1.76; 95% CI 1.14-2.73), personally knowing someone that died of AIDS (OR = 1.68; 95% CI 1.14-2.47), being aged 20-24 years (OR = 1.56; 95% CI 1.10-2.22) and having completed high school (OR = 1.58; 95% CI 1.17-2.12) were independent correlates of HIV testing. The following factors were significantly associated with HIV testing among both men and women; ever talking to parents about HIV/AIDS, ever participating in a loveLife programme, a higher frequency of visits to a clinic in the past 12 months and non-black race (p<0.05). There is a need to better understand the correlates of HIV testing to ensure that adolescent HIV prevention programmes actively promote HIV testing among this group. Specific attention needs to be paid to young women who do not access antenatal care and young men who are less regular users of routine clinical care. Communication is a significant predictor of having tested for HIV and should be encouraged with parents and through intervention programmes for adolescents. Finally, specific attention must be paid to increasing access to HIV testing for at-risk adolescents in rural communities.

Working with public sector clinics to provide adolescent-friendly services in South Africa.

Health care facilities can play an important role for adolescents in preventing health problems, in promoting sexual and reproductive health and in shaping positive behaviours. Extensive research has established that South African public health facilities are failing to provide adolescent-friendly health services. The National Adolescent-Friendly Clinic Initiative (NAFCI) is an accreditation programme designed to improve the quality of adolescent health services at the primary care level and strengthen the public sector's ability to respond to adolescent health needs. The key objectives of the programme are to make health services more accessible and acceptable to adolescents, establish national standards and criteria for adolescent health care in clinics throughout the country, and build the capacity of health care workers to provide quality services. One of the indicators for success of NAFCI will be increased utilisation of public sector clinics by adolescents. NAFCI is an integral component of the largest, most innovative, public health programme ever launched in South Africa, loveLife. Achieving NAFCI accreditation involves clinic self-appraisals, quality improvements, external assessments and award of achievement stars. NAFCI is currently being piloted in ten government clinics in South Africa.

The acceptability of reuse of the female condom among urban South African women.

This study assessed whether reuse of the female condom was acceptable among two groups of women in central Johannesburg, South Africa, who were taking part in two separate studies of female condom reuse. The first group consisted of women (aged 17 to 43 years) attending a family planning/sexually transmitted infections (STIs) clinic who were participating in a cross-sectional survey of the acceptability of female condoms reuse (n = 100). The second group included women (aged 18-40 years) at high risk for STI (80% self-declared sex workers) who were taking part in an ongoing cohort study to investigate the safety of reuse of the female condom through a structural integrity and microbial retention study (n = 50). Among women participating in the acceptability study, 83% said that they would be willing to reuse the female condom, and 91% thought the idea of reuse of the female condom was acceptable. All women taking part in the safety of reuse study and who reused the female condom up to seven times (n = 49) reported that the steps involved in reusing the device were easy to perform and acceptable. All 49 women said they would reuse the female condom at least once, while 45% said they would use it a maximum of seven or eight times. From the results of the interviews with both study groups, it can be concluded that, among women in a South African urban environment who have used a male and/or female condom, the concept of reuse of the female condom is acceptable and thought to be a good idea.

How effective is syndromic management of STDs?: A review of current studies.

BACKGROUND: Studies of the accuracy of syndromic management have demonstrated widely varying results depending upon gender, location of infection, risk group, organisms, among other factors. GOAL: To review current knowledge about syndromic management of sexually transmitted diseases (STDs) and to make recommendations about the strengths and weaknesses of different syndromic management algorithms. STUDY DESIGN: The authors identified articles and abstracts about the syndromic management of STDs. Evaluation of the effectiveness of algorithms for urethral discharge, genital ulcer disease, and vaginal discharge was based primarily on published sensitivity and specificity data. RESULTS: Overall, algorithms for the diagnosis and treatment of urethral discharge and genital ulcer disease in men had high sensitivities or cure rates (urethral discharge, 87-99%; genital ulcer disease, 68-98%). The sensitivities for the algorithms for vaginal discharge ranged from 73% to 93% among women presenting with symptoms of vaginal discharge, and from 29% to 86% among women not presenting with symptoms. Vaginal discharge was not found to be an effective indicator of cervical infection and, therefore, is not an independently effective screening tool to detect women with cervical infection, especially in low-risk or asymptomatic populations. Incorporating risk scores can improve the accuracy of algorithms to detect cervical infection. CONCLUSIONS: Algorithms for urethral discharge and genital ulcer disease can be effective in STDs. The current algorithms for vaginal discharge are not highly effective in detecting gonorrhea and chlamydia in women; risk scores can improve their efficacy, but must be tailored to reflect community risks. Without attention to the qualitative aspects of STD syndromic management, these methods will likely have even less accuracy than the studies reviewed above. There remains an urgent need for the development of an affordable, rapid, and effective diagnostic technique that will improve STD detection in resource-poor settings.

In vitro assessment of the structural integrity of the female condom after multiple wash, dry, and re-lubrication cycles.

Since the introduction of the female condom in the early 90s, there have been numerous reports of reuse of the device. In response to these reports, studies were undertaken to evaluate the safety of female condom reuse. If reuse were shown to be safe, then programmatic costs of introduction of the female condom would be reduced allowing it to be more widely available. This article outlines the results of in vitro structural integrity testing of the female condom after multiple wash, dry, and re-lubrication cycles. Devices were tested up to 10 washes using water leakage, burst, and tensile seam testing. All results were compared to the United States Food and Drug Administration (US FDA) standards for an unused female condom. The results of the structural integrity tests for all 6 washing procedures examined in this study were above the FDA minimum standards for seam strength and burst tests. For the water leakage test, 3 of 6 washing procedures tested passed the required FDA minimum standards (no holes detected). From the results of the study, it seems that washing, drying, and re-lubricating the female condom up to 10 times leads to some deterioration in the structural integrity of the device for specified washing procedures. Further studies are currently being conducted to establish the safety of female condom reuse with respect to microbial retention, structural integrity after in vivo use, and viral permeability.