Willingness to use HIV prevention methods among vaccine efficacy trial participants in Soweto, South Africa: discretion is important.

BACKGROUND: Despite multiple available HIV prevention methods, the HIV epidemic continues to affect South Africa the most. We sought to understand willingness to use actual and hypothetical HIV prevention methods among participants enrolled in a preventative HIV vaccine efficacy trial in Soweto, South Africa. METHODS: We conducted a qualitative study with 38 self-reporting HIV-uninfected and consenting 18-35 year olds participating in the HVTN 702 vaccine efficacy trial in Soweto. Using a semi-structured interview guide, five focus group discussions (FGDs) were held, stratified by age, gender and sexual orientation. The FGDs were composed of: (i) 10 heterosexual women aged 18-24 years; (ii) 9 heterosexual and bisexual women aged 25-35 years; (iii & iv) heterosexual men aged 25-35 years with 7 in both groups; and (v) 5 men aged 18-35 years who have sex with men. FGDs were audio-recorded, transcribed verbatim, translated into English and analysed using thematic analysis. RESULTS: We present five main themes: (i) long-lasting methods are preferable; (ii) condoms are well-known but not preferred for use; (iii) administration route of HIV prevention method is a consideration for the user; (iv) ideal HIV prevention methods should blend into the lifestyle of the user; and the perception that (v) visible prevention methods indicate sexual indiscretion. CONCLUSIONS: The participants' candour about barriers to condom and daily oral pre-exposure prophylaxis (PrEP) use, and expressed preferences for long-lasting, discreet, lifestyle-friendly methods reveal a gap in the biomedical prevention market aiming to reduce sexually acquired HIV in South Africa. Product developers should consider long-acting injectable formulations, such as vaccines, passive antibodies and chemoprophylaxis, for HIV prevention technologies. Future innovations in HIV prevention products may need to address the desire for the method to blend easily into lifestyles, such as food-medication formulations.

A mixed methods investigation of implementation barriers and facilitators to a daily mobile phone sexual risk assessment for young women in Soweto, South Africa.

BACKGROUND: The HIV epidemiology in South Africa reveals stark age and gender disparities, with young women being the most vulnerable to HIV acquisition in 2017. Evaluation of HIV exposure is a challenge in HIV prevention research. Intermittent in-clinic interviewer-administered risk behaviour assessments are utilised but may be limited by social desirability and recall biases. We piloted a mobile phone application for daily self-report of sexual risk behaviour in fifty 18-25 year old women at risk of HIV infection enrolled in HIV Vaccine Trials Network 915 (HVTN 915) in Soweto, South Africa. Through a mixed-methods investigation, we explored barriers and facilitators to completing daily mobile phone surveys among HVTN 915 study participants and staff. METHODS: We analysed quantitative data on barriers and facilitators to mobile phone study completion collected during the larger HVTN 915 study as well as two post-study focus group discussions (FGDs) with fifteen former participants with a median age of 24 years (IQR 23-25) and six individual in-depth interviews (IDIs) with HVTN 915 staff. FGDs and IDIs utilised semi-structured interview guides, were audio-recorded, transcribed verbatim and translated to English. After coding, thematic analysis was performed. RESULTS: The main facilitator for daily mobile phone survey completion assessed across 336 follow-up visits for 49 participants was the daily short message system (SMS) reminders (93%, 312/336). Across 336 visits, 31/49 (63%) retained participants reported barriers to completion of daily mobile phone surveys: forgetting (20%, 12/49), being too busy (19%, 11/49) and the survey being an inconvenience (15%, 9/49). Five main themes were identified during the coding of IDIs and FGDs: (1) facilitators of mobile phone survey completion, such as daily SMS reminders and follow up calls for non-completers; (2) barriers to mobile phone survey completion, including partner, time-related and technical barriers; (3) power of incentives; (4) response bias in providing sensitive information, and (5) recommendations for future mobile phone based interventions. CONCLUSION: Despite our enthusiasm to use innovation to optimise sexual risk assessments, technical and practical solutions are required to improve implementation. We recommend further engagement with participants to optimise this approach and to further understand social desirability bias and study incentives in sexual risk reporting.

Kganya Motsha Adolescent Centre: a model for adolescent friendly HIV management and reproductive health for adolescents in Soweto, South Africa.

This paper reports on Kganya Motsha Adolescent Centre, an adolescent program specifically established to provide voluntary counseling and testing as well as management of HIV-positive young people in Soweto, South Africa. A retrospective cross-sectional analysis, using clinic records of young people accessing services from 2008 to 2012, was conducted. Of the 11,522 who tested, 7689 (67%) were females. The total number of HIV infections was 410, with an HIV prevalence of 3.6% (95% CI 3.2-3.9%). More females (332, 4% vs. 72, 2%; p < 0.0001) were HIV-infected than males. Of those testing HIV positive, 109 (26.5%) had a median CD4 cell count of 491 (IQR 345-686) cells/mm(3). Only 12/410 individuals (2.9%) were eligible for antiretroviral treatment and 10 (2.4%) of those successfully received treatment. The program observed that young people testing HIV positive would not return for follow up blood specimens or confirmatory results. Future programs should consider innovative ways of retaining adolescents in care to reduce potential HIV transmissions that could lead to deteriorating health.

Predictors of parent-adolescent communication in post-apartheid South Africa: a protective factor in adolescent sexual and reproductive health.

In the HIV context, risky sexual behaviours can be reduced through effective parent-adolescent communication. This study used the Parent Adolescent Communication Scale to determine parent-adolescent communication by ethnicity and identify predictors of high parent-adolescent communication amongst South African adolescents post-apartheid. A cross-sectional interviewer-administered survey was administered to 822 adolescents from Johannesburg, South Africa. Backward stepwise multivariate regressions were performed. The sample was predominantly Black African (62%, n = 506) and female (57%, n = 469). Of the participants, 57% (n = 471) reported high parent-adolescent communication. Multivariate regression showed that gender was a significant predictor of high parent-adolescent communication (Black African OR:1.47, CI: 1.0-2.17, Indian OR: 2.67, CI: 1.05-6.77, White OR: 2.96, CI: 1.21-7.18). Female-headed households were predictors of high parent-adolescent communication amongst Black Africans (OR:1.49, CI: 1.01-2.20), but of low parent-adolescent communication amongst Whites (OR:0.36, CI: 0.15-0.89). Overall levels of parent-adolescent communication in South Africa are low. HIV prevention programmes for South African adolescents should include information and skills regarding effective parent-adolescent communication.

"Group sex" parties and other risk patterns: A qualitative study about the perceptions of sexual behaviors and attitudes of adolescents in Soweto, South Africa.

This study explored perceptions about sexual behaviors and attitudes of adolescents living in Soweto, Johannesburg, South Africa, from the perspective of parents, counselors and adolescents. A qualitative methodology was applied. Nine focus group discussions (FGDs) were held; three with parents of adolescents, two with counselors who work with adolescents, two with female adolescents aged 16-18 years and two with male adolescents aged 16-18 years. In total, 80 participants were recruited from in and around Soweto. FGDs were guided by a semi-structured interview guide, audio-recorded, transcribed verbatim and translated into English. Data were analyzed using Maxqda, a qualitative software analysis program. There were eight key themes related to adolescent sexuality and perceived attitudes towards relationships. Five themes were common to all participant groupings (parents, counselors and adolescents): (1) dating during adolescence, (2) adolescent females dating older males, (3) condom use amongst adolescents, (4) pregnancy and (5) homosexuality. (6) Sex as a regular and important activity among adolescents and (7) group sex practices among adolescents emerged as themes from adolescent and counselor FGDs. Lastly, (8) the role of the media as an influence on adolescent sexuality was common to adolescent and parent groups. Risky sexual behaviors continue among adolescents, with group sex parties a concerning emergent phenomenon that necessitates further study. HIV, other STIs and pregnancy prevention interventions should address multiple levels of influence to address context-specific influences.