User assessments and the use of information from MomConnect, a mobile phone text-based information service, by pregnant women and new mothers in South Africa.

MomConnect was designed to provide crucial health information to mothers during pregnancy and in the early years of child rearing in South Africa. The design drew on the success of the Mobile Alliance for Maternal Action's programme in South Africa, as well as a growing list of mobile health (mHealth) interventions implemented internationally. Services such as MomConnect are dependent on user acceptability as all engagements are voluntary, meaning that tools have to be easy to use and useful to be successful. This paper describes the evaluation of the tool by pregnant women and new mothers using the tool. A purposive sample of 32 individual semistructured interviews and 7 focus groups were conducted, across five provinces in South Africa. All the sessions were transcribed and then analysed using a contextualised interpretative approach, with the assistance of Atlas.ti. The women were consistently positive about MomConnect, attaching high value to the content of the messages and the medium in which they were delivered. The system was found to work well, with minor problems in some language translations. Respondents were enthusiastic about the messages, stating that the information was of great use and made them feel empowered in their role as a mother, with some saving the messages to use as a resource or to share with others. The most significant problems related to network coverage. There was strong support for this intervention to continue. Given the user acceptability of mHealth interventions, MomConnect appeared to meet the target of identifying and responding to the recipient's needs.

Men's Behavior Predicts Women's Risks for HIV/AIDS: Multilevel Analysis of Alcohol-Serving Venues in South Africa.

South Africa has among the highest rates of HIV infection in the world, with women disproportionately affected. Alcohol-serving venues, where alcohol use and sexual risk often intersect, play an important role in HIV risk. Previous studies indicate alcohol use and gender inequity as drivers of this epidemic, yet these factors have largely been examined using person-level predictors. We sought to advance upon this literature by examining venue-level predictors, namely men's gender attitudes, alcohol, and sex behavior, to predict women's risks for HIV. We recruited a cohort of 554 women from 12 alcohol venues (6 primarily Black African, and 6 primarily Coloured [i.e., mixed race] venues) in Cape Town, who were followed for 1 year across four time points. In each of these venues, men's (N = 2216) attitudes, alcohol use, and sexual behaviors were also assessed. Men's attitudes and behaviors at the venue level were modeled using multilevel modeling to predict women's unprotected sex over time. We stratified analyses by venue race. As predicted, venue-level characteristics were significantly associated with women's unprotected sex. Stratified results varied between Black and Coloured venues. Among Black venues where men reported drinking alcohol more frequently, and among Coloured venues where men reported meeting sex partners more frequently, women reported more unprotected sex. This study adds to the growing literature on venues, context, and HIV risk. The results demonstrate that men's behavior at alcohol drinking venues relate to women's risks for HIV. This novel finding suggests a need for social-structural interventions that target both men and women to reduce women's risks.

Addiction and treatment experiences among active methamphetamine users recruited from a township community in Cape Town, South Africa: A mixed-methods study.

BACKGROUND: Since 2000, there has been a dramatic increase in methamphetamine use in South Africa, but little is known about the experiences of out-of-treatment users. This mixed-methods study describes the substance use histories, addiction symptoms, and treatment experiences of a community-recruited sample of methamphetamine users in Cape Town. METHODS: Using respondent driven sampling, 360 methamphetamine users (44% female) completed structured clinical interviews to assess substance abuse and treatment history and computerized surveys to assess drug-related risks. A sub-sample of 30 participants completed in-depth interviews to qualitatively explore experiences with methamphetamine use and drug treatment. RESULTS: Participants had used methamphetamine for an average of 7.06 years (SD=3.64). They reported using methamphetamine on an average of 23.49 of the past 30 days (SD=8.90); 60% used daily. The majority (90%) met ICD-10 criteria for dependence, and many reported severe social, financial, and legal consequences. While only 10% had ever received drug treatment, 90% reported that they wanted treatment. In the qualitative interviews, participants reported multiple barriers to treatment, including beliefs that treatment is ineffective and relapse is inevitable in their social context. They also identified important motivators, including desires to be drug free and improve family functioning. CONCLUSION: This study yields valuable information to more effectively respond to emerging methamphetamine epidemics in South Africa and other low- and middle-income countries. Interventions to increase uptake of evidence-based services must actively seek out drug users and build motivation for treatment, and offer continuing care services to prevent relapse. Community education campaigns are also needed.

HIV/AIDS-related stigma in South African alcohol-serving venues and its potential impact on HIV disclosure, testing and treatment-seeking behaviours.

Alcohol-serving venues in South Africa are sites for high-risk behaviours that may lead to HIV transmission. Prevention and treatment interventions are sorely needed in these settings, but HIV-related stigma may limit their effectiveness. This study explored expressions of stigma among alcohol-serving venue patrons in Cape Town and examined the potential impact of stigma on HIV disclosure, testing and treatment-seeking behaviours. A total of 92 in-depth interviews with male and female, black and coloured patrons were conducted. Transcripts were analysed via memo-writing and diagramming techniques. Many participants mentioned knowing other patrons living with HIV/AIDS (PLWH), and this visibility of HIV impacted expressions of HIV-related stigma. Participants discussed four forms of HIV-related stigma in the venues: fearing PLWH, fearing HIV acquisition, blaming others for spreading HIV and isolating PLWH. HIV visibility and expressions of HIV-related stigma, particularly fear of isolation, influenced participants' willingness to disclose their status. HIV-related stigma in the venues also appeared to indirectly influence testing and treatment-seeking behaviour outside the venue. Results suggest that efforts to change norms and reduce expressions of HIV-related stigma in alcohol-serving venues are necessary to successfully deliver tailored HIV prevention interventions and increase uptake of HIV testing and care in this important social setting.

Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: results from a longitudinal cohort of South African women who attend alcohol-serving venues.

BACKGROUND: In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use. METHODS: Data were collected in 4 waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined (1) the relationship between traumatic stress and counts of unprotected sex and (2) whether alcohol use mediated the association between traumatic stress and unprotected sex. RESULTS: Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b = 0.28, SE = 0.06, t = 4.82, P < 0.001). In addition, traumatic stress was associated with alcohol use (b = 0.27, SE = 0.02, t = 14.25, P < 0.001) and was also associated with unprotected sex (b = 0.20, SE = 0.06, t = 3.27, P < 0.01) while controlling for alcohol use (b = 0.28, SE = 0.07, t = 4.25, P < 0.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex. CONCLUSIONS: These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.

HIV testing behaviors and attitudes among community recruited methamphetamine users in a South African township.

Methamphetamine users in South Africa are at high risk for HIV infection and transmission, but little is known about HIV testing in this population. We examined HIV testing behaviors and attitudes in 362 methamphetamine users recruited using chain referral sampling from one peri-urban community. Many (44 %) had not been HIV tested in the past year. HIV testing was associated with positive testing attitudes, less AIDS stigma, and greater methamphetamine stigma. Among participants who reported HIV infection (8 %), less than half were linked to care. Findings highlight the need to identify barriers to HIV service uptake for methamphetamine users.

Experiences of forced sex among female patrons of alcohol-serving venues in a South African township.

South Africa has among the highest rates of forced sex worldwide, and alcohol use has consistently been associated with risk of forced sex in South Africa. However, methodological challenges affect the accuracy of forced sex measurements. This study explored the assessment of forced sex among South African women attending alcohol-serving venues and identified factors associated with reporting recent forced sex. Women (n = 785) were recruited from 12 alcohol-serving venues in a peri-urban township in Cape Town. Brief self-administered surveys included questions about lifetime and recent experiences of forced sex. Surveys included a single question about forced sex and detailed questions about sex by physical force, threats, verbal persuasion, trickery, and spiked drinks. We first compared the single question about forced sex to a composite variable of forced sex as unwanted sex by physical force, threats, or spiked drinks. We then examined potential predictors of recent forced sex (demographics, drinking behavior, relationship to the venue, abuse experiences). The single question about forced sex had low sensitivity (0.38); more than half of the respondents who reported on the detailed questions that they had experienced forced sex by physical force, threats, or spiked drinks reported on the single question item that they had not experienced forced sex. Using our composite variable, 18.6% of women reported lifetime and 10.8% reported recent experiences of forced sex. In our adjusted logistic regression model, recent forced sex using the composite variable was significantly associated with hazardous drinking (OR = 1.92), living farther from the venue (OR = 1.81), recent intimate partner violence (OR = 2.53), and a history of childhood sexual abuse (OR = 4.35). The findings support the need for additional work to refine the assessment of forced sex. Efforts to prevent forced sex should target alcohol-serving venues, where norms and behaviors may present particular risks for women who frequent these settings.

Respondent driven sampling is an effective method for engaging methamphetamine users in HIV prevention research in South Africa.

BACKGROUND: South Africa, in the midst of the world's largest HIV epidemic, has a growing methamphetamine problem. Respondent driven sampling (RDS) is a useful tool for recruiting hard-to-reach populations in HIV prevention research, but its use with methamphetamine smokers in South Africa has not been described. This study examined the effectiveness of RDS as a method for engaging methamphetamine users in a Cape Town township into HIV behavioral research. METHODS: Standard RDS procedures were used to recruit active methamphetamine smokers from a racially diverse peri-urban township in Cape Town. Effectiveness of RDS was determined by examining social network characteristics (network size, homophily, and equilibrium) of recruited participants. RESULTS: Beginning with eight seeds, 345 methamphetamine users were enrolled over 6 months, with a coupon return rate of 67%. The sample included 197 men and 148 women who were racially diverse (73% Coloured, 27% Black African) and had a mean age of 28.8 years (SD=7.2). Social networks were adequate (mean network size >5) and mainly comprised of close social ties. Equilibrium on race was reached after 11 waves of recruitment, and after ≤3 waves for all other variables of interest. There was little to moderate preference for either in- or out-group recruiting in all subgroups. CONCLUSIONS: Results suggest that RDS is an effective method for engaging methamphetamine users into HIV prevention research in South Africa. Additionally, RDS may be a useful strategy for seeking high-risk methamphetamine users for HIV testing and linkage to HIV care in this and other low resource settings.

Longitudinal cohort study of depression, post-traumatic stress, and alcohol use in South African women who attend alcohol serving venues.

BACKGROUND: In South Africa, alcohol use poses a public health burden. Hazardous alcohol use often co-occurs with psychological distress (e.g., depression and post-traumatic stress). However, the majority of the research establishing the relationship between alcohol use and psychological distress has been cross-sectional, so the nature of co-occurring changes in psychological distress and alcohol use over time is not well characterized. The objective of this study is to examine the longitudinal relationship between psychological distress and alcohol use among South African women who attend alcohol serving venues. METHODS: Four waves of data were collected over the course of a year from 560 women in a Cape Town township who attended drinking venues. At each assessment wave, participants reported depressive symptoms, post-traumatic stress symptoms, and alcohol use. Multilevel growth models were used to: 1) assess the patterns of alcohol use; 2) examine how depressive symptoms uniquely, post-traumatic stress symptoms uniquely, and depressive and post-traumatic stress symptoms together were associated with alcohol use; and 3) characterize the within person and between person associations of depressive symptoms and post-traumatic stress symptoms with alcohol use. RESULTS: Women reported high levels of alcohol use throughout the study period, which declined slightly over time. Post-traumatic stress symptoms were highly correlated with depressive symptoms. Modeled separately, both within person and between person depressive and post-traumatic stress symptoms were uniquely associated with alcohol use. When modeled together, significant between person effects indicated that women who typically have more post-traumatic stress symptoms, when controlling for depressive symptoms, are at risk for increased alcohol use; however, women with more depressive symptoms, controlling for post-traumatic stress symptoms, do not have differential risk for alcohol use. Significant within person effects indicated an interaction between depressive and post-traumatic stress symptoms; women reported more alcohol use than usual at times when they had higher post-traumatic stress symptoms, and this increase in alcohol use was further exacerbated for women who also had higher depressive symptoms than usual. CONCLUSIONS: These findings suggest that interventions targeting post-traumatic stress, especially when post-traumatic stress is comorbid with depression, may reduce alcohol use among South African women who drink.

Drinking before and after pregnancy recognition among South African women: the moderating role of traumatic experiences.

BACKGROUND: South Africa has one of the world's highest rates of fetal alcohol spectrum disorder (FASD) and interpersonal trauma. These co-occurring public health problems raise the need to understand alcohol consumption among trauma-exposed pregnant women in this setting. Since a known predictor of drinking during pregnancy is drinking behavior before pregnancy, this study explored the relationship between women's drinking levels before and after pregnancy recognition, and whether traumatic experiences - childhood abuse or recent intimate partner violence (IPV) - moderated this relationship. METHODS: Women with incident pregnancies (N = 66) were identified from a longitudinal cohort of 560 female drinkers in a township of Cape Town, South Africa. Participants were included if they reported no pregnancy at one assessment and then reported pregnancy four months later at the next assessment. Alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT), and traumatic experiences of childhood abuse and recent IPV were also assessed. Hierarchical linear regressions controlling for race and age examined childhood abuse and recent IPV as moderators of the effect of pre-pregnancy recognition drinking on post-pregnancy recognition AUDIT scores. RESULTS: Following pregnancy recognition, 73% of women reported drinking at hazardous levels (AUDIT ≥ 8). Sixty-four percent reported early and/or recent exposure to trauma. While drinking levels before pregnancy significantly predicted drinking levels after pregnancy recognition, t(64) = 3.50, p < .01, this relationship was moderated by experiences of childhood abuse, B = -.577, t(60) = -2.58, p = .01, and recent IPV, B = -.477, t(60) = -2.16, p = .04. Pregnant women without traumatic experiences reported drinking at levels consistent with levels before pregnancy recognition. However, women with traumatic experiences tended to report elevated AUDIT scores following pregnancy recognition, even if low-risk drinkers previously. CONCLUSION: This study explored how female drinkers in South Africa may differentially modulate their drinking patterns upon pregnancy recognition, depending on trauma history. Our results suggest that women with traumatic experiences are more likely to exhibit risky alcohol consumption when they become pregnant, regardless of prior risk. These findings illuminate the relevance of trauma-informed efforts to reduce FASD in South Africa.

Beliefs about fetal alcohol spectrum disorder among men and women at alcohol serving establishments in South Africa.

BACKGROUND: South Africa has one of the highest rates of fetal alcohol spectrum disorder (FASD) in the world. However, little is known about what men and women who attend alcohol serving establishments believe about alcohol use during pregnancy and how these beliefs may be related to alcohol use. OBJECTIVES: To understand FASD beliefs and related behaviors among men and women attending alcohol-serving establishments. METHODS: We surveyed 1047 men (n = 565) and women (n = 482) -including pregnant women and men with pregnant partners- attending alcohol serving establishments in a township located in Cape Town, South Africa. RESULTS: Among both pregnant (n = 53) and non-pregnant (n = 429) women, 54% reported drinking alcohol at least 2-4 times per month, and 57% reported having at least 3-4 alcohol drinks during a typical drinking session. Pregnant women were less likely to believe that they should not drink alcohol and that alcohol can harm a fetus when compared to non-pregnant women. Similar findings were observed between men with pregnant partners compared to men without pregnant partners. Among women, beliefs about how much alcohol pregnant women can safely drink were associated with self-reported alcohol use. CONCLUSIONS: Efforts to address FASD need to focus on understanding how men and women perceive alcohol use during pregnancy and situational factors that contribute to alcohol consumption among pregnant women attending alcohol serving establishments. Structural and individual-level interventions targeting women at alcohol serving establishments should be prioritized to mitigate alcohol use during pregnancy.

The relationship between attending alcohol serving venues nearby versus distant to one's residence and sexual risk taking in a South African township.

South Africa remains a country with one of the highest prevalence rates of HIV/AIDS at 18% among 15-49 year olds. Underdeveloped urban areas, or townships, are particularly hard hit by the HIV/AIDS epidemic. Alcohol use in these townships has been established as an important risk factor for HIV transmission. Likewise, alcohol serving venues (shebeens) have been identified as sites where substance abuse and sexual risk taking occur. However, little is known about how proximity of alcohol serving establishments (shebeens) to one's residence may be related to sexual risk-taking We surveyed 3,261 men and women attending shebeens in a township located in Cape Town, South Africa. We investigated the relationships between attending nearby (<15 min walk) versus distant (>15 min walk) shebeens, and sex and substance abuse related risk-taking. Women who attended distant shebeens versus nearby shebeens relative to their residence were approximately twice as likely to report HIV positive status. Bivariate analyses demonstrated that these women were also more likely to report other sexually transmitted infections, greater numbers of sex partners, higher rates of alcohol and drug use, and seeking out new sex partners at shebeen. No differences in sex behavior, substance use or HIV/STI were identified among men. Proximity of shebeens appears to be an important contextual factor in explaining HIV/STI transmission risk-taking. Future studies should focus on how anonymity may be related to sexual risk and substance use behaviors among women in South African townships.

Men (and women) as "sellers" of sex in alcohol-serving venues in Cape Town, South Africa.

The relationship between transactional sex, HIV risk, and partner violence has been well documented in South Africa, but research has focused primarily on women and has not been conducted in high-risk social contexts. The aim of this study was to examine associations between transactional sex and HIV risk among women and men in alcohol-serving venues in Cape Town, South Africa. We surveyed 1,989 women and 2,468 men attending alcohol-serving venues in Cape Town, South Africa to assess transactional sex behavior (i.e., receiving money or goods in exchange for sex), alcohol and drug use, history of childhood abuse, current relationship violence, and sexual risk behaviors. Among both women and men, trading sex was related to higher alcohol use, greater likelihood of drug use, substance use in sexual contexts, and a greater likelihood of experiencing physical and sexual violence. Compared to other women, women who traded sex reported a greater proportion of condom-unprotected sex; this relationship was not found for men. Analyses showed that men were almost twice as more likely to report trading sex for items, including money or alcohol, than women (9.7 vs. 5.8 %). Overall, men who traded sex were similar to their female counterparts. Similar associations between trading sex and different risk behaviors were found among women and men with limited economic means and substance use problems. Future research should more closely study transactional sex in high-risk venues as it relates to violence and should examine men who trade sex as a potential bridge population between heterosexual women and men who have sex with men.

Food insecurity and alcohol use among pregnant women at alcohol-serving establishments in South Africa.

South Africa has the highest rate of fetal alcohol syndrome (FAS) in the world. While efforts have been made to curb the high rate of FAS, little is known about situational factors that may contribute to alcohol use during pregnancy. In the current paper, we focus on the role of food insecurity and its relationship to alcohol use among pregnant women. Women completed computer-assisted interviews. Generalized linear modeling was used in all analyses. Women attending alcohol-serving establishments in a township in Cape Town, South Africa were recruited for the study. Five hundred sixty women were sampled and 95 women reported being pregnant. High levels of alcohol use were reported among pregnant women: 65 % of women consumed alcohol at least every month and 29 % consumed alcohol as often as two to three times per week. Thirty-four percent of the women reported having six or more drinks per occasion on at least a weekly basis. The majority (87 %) of pregnant women reported experiencing some form of food insecurity (e.g., food unavailable, eating less) in the past month. Alcohol use was significantly associated with food insecurity, even when controlling for relevant demographic variables. Intervention with pregnant women who consume alcohol is urgently needed. Future research should focus on understanding the intersection of food insecurity and alcohol, and how the experience of food insecurity may contribute to greater rates of alcohol use and abuse among pregnant women.

The impact of methamphetamine ("tik") on a peri-urban community in Cape Town, South Africa.

BACKGROUND: Over the last decade, South Africa's Western Cape has experienced a dramatic increase in methamphetamine ("tik") use. Our study explored local impressions of the impact of tik use in a peri-urban township community in Cape Town, South Africa. METHODS: We conducted individual in-depth interviews with 55 women and 37 men who were regular attendees of alcohol-serving venues. Interviews were recorded and transcribed. A content analysis approach was used to identify themes related to the impact of tik use based on levels of the socio-ecological framework (individual, inter-personal and community). RESULTS: Tik use was reported to be a greater issue among Coloureds, compared to Blacks. At an individual level, respondents reported that tik use had adverse effects on mental, physical, and economic well-being, and limited future opportunities through school drop-out and incarceration. At an inter-personal level, respondents reported that tik use contributed to physical and sexual violence as well as increased rates of sexual risk behaviour, particularly through transactional sex relationships. Respondents described how tik use led to household conflict, and had negative impacts on children, including neglect and poor birth outcomes. At a community level, respondents linked tik use to increased rates of crime, violence and corruption, which undercut community cohesion. CONCLUSIONS: Our results highlight the negative impact that tik is having on individuals, households and the overall community in a peri-urban setting in South Africa. There is a clear need for interventions to prevent tik use in South Africa and to mitigate and address the impact of tik on multiple levels.

Drinking in the Context of Life Stressors: A Multidimensional Coping Strategy Among South African Women.

This study explored narratives of drinking as a coping strategy among female drinkers in a South African township. In 2010-2011, we conducted qualitative in-depth interviews with 54 women recruited from 12 alcohol-serving venues. Most women drank heavily and linked their drinking to stressors. They were motivated to use drinking to manage their emotions, facilitate social engagement, and achieve a sense of empowerment, even while recognizing the limitations of this strategy. This study helps to contextualize heavy drinking behavior among women in this setting. Multifaceted interventions that help female drinkers to more effectively manage stressors may aid in reducing hazardous drinking.

Men who report recent male and female sex partners in Cape Town, South Africa: an understudied and underserved population.

The HIV/AIDS epidemic in South Africa has largely focused on the needs of heterosexual men and women. However, little is known about the sexual risk histories of men who have sex with both men and women (MSMW). Furthermore, we know very little about the psychosocial health needs or of the possibility of a syndemic (numerous interrelated epidemics) among MSMW. We surveyed 1,203 men attending drinking establishments in a township located in Cape Town, South Africa. We compared the behaviors and experiences of MSMW to men reporting only having sex with women (MSW). Twelve percent of the sample reported having sex with both men and women in the past 4 months. MSMW were twice as likely as MSW to report being HIV positive (10.5 vs. 4.6 %). MSW were more likely to be married than MSMW but reported similar numbers of female sex partners. MSMW were more likely to report a history of childhood sexual abuse, recent experienced and perpetrated physical and sexual partner violence, both receiving and giving sex for money, drugs, or shelter, and a recent STI. These factors were found to be interrelated among MSW but not MSMW. Although MSMW demonstrate considerable risk taking and report higher rates of HIV infection than MSW, their needs are largely unmet and underemphasized. Findings suggest the need to better understand factors contributing to sexual risk taking among MSMW. HIV prevention interventions should consider psychosocial health problems unique to MSMW residing in South African townships.

Gender-based violence, alcohol use, and sexual risk among female patrons of drinking venues in Cape Town, South Africa.

Gender-based violence is a well-recognized risk factor for HIV infection among women. Alcohol use is associated with both gender-based violence and sexual risk behavior, but has not been examined as a correlate of both in a context of both high HIV risk and hazardous drinking. The purpose of this paper is to examine the association between recent abuse by a sex partner with alcohol and sexual risk behavior among female patrons of alcohol serving venues in South Africa. Specifically, the aim of this study is to determine whether sexual risk behaviors are associated with gender-based violence after controlling for levels of alcohol use. We surveyed 1,388 women attending informal drinking establishments in Cape Town, South Africa to assess recent history of gender-based violence, drinking, and sexual risk behaviors. Gender-based violence was associated with both drinking and sexual risk behaviors after controlling for demographics among the women. A hierarchical logistic regression analysis showed that after controlling for alcohol use sexual risk behavior remained significantly associated with gender-based violence, particularly with meeting a new sex partner at the bar, recent STI diagnosis, and engaging in transactional sex, but not protected intercourse or number of partners. In South Africa where heavy drinking is prevalent women may be at particular risk of physical abuse from intimate partners as well as higher sexual risk. Interventions that aim to reduce gender-based violence and sexual risk behaviors must directly work to reduce drinking behavior.

Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African township: a syndemic approach.

BACKGROUND: In South Africa, women comprise the majority of HIV infections. Syndemics, or co-occurring epidemics and risk factors, have been applied in understanding HIV risk among marginalized groups. PURPOSE: The purposes of this study are to apply the syndemic framework to examine psychosocial problems that co-occur among women attending drinking venues in South Africa and to test how the co-occurrence of these problems may exacerbate risk for HIV infection. METHOD: Five hundred sixty women from a Cape Town township provided data on multiple psychosocial problems, including food insufficiency, depression, abuse experiences, problem drinking, and sexual behaviors. RESULTS: Bivariate associations among the syndemic factors showed a high degree of co-occurrence and regression analyses showed an additive effect of psychosocial problems on HIV risk behaviors. CONCLUSIONS: These results demonstrate the utility of a syndemic framework to understand co-occurring psychosocial problems among women in South Africa. HIV prevention interventions should consider the compounding effects of psychosocial problems among women.

Food insufficiency, substance use, and sexual risks for HIV/AIDS in informal drinking establishments, Cape Town, South Africa.

HIV/AIDS is concentrated in impoverished communities. Two critical aspects of poverty are food insufficiency and substance abuse, and both are associated with sexual risks for HIV/AIDS in southern Africa. The current study is the first to examine both hunger and substance use in relation to sexual risks for HIV infection in South African alcohol serving establishments. Anonymous venue-based intercept surveys were completed by men (n = 388) and women (n = 407) patrons of six informal drinking places (e.g., shebeens) in Cape Town, South Africa. Food insufficiency and its more extreme form hunger were common in the sample, with 24 % of men and 53 % of women experiencing hunger in the previous 4 months. Multiple regression analyses showed that quantity of alcohol use was related to higher rates of unprotected sex for men and women. Trading sex to meet survival needs was related to food insufficiency and methamphetamine use among men but not women. Food insufficiency and substance use may both contribute to HIV risks in South African shebeens. However, the influence of hunger and substance use on sexual risks varies for men and women. Interventions to reduce HIV transmission risks may be bolstered by reducing both food insufficiency and substance use.