Barriers to cervical cancer screening in Africa: a systematic review.

INTRODUCTION: Africa has one of the highest burdens of cervical cancer in the world. The unacceptably high incidence and mortality rates could be reduced through implementing a comprehensive approach to its prevention and control that includes screening, which however, is low in most low-and-middle-income countries. Hence, this systematic review aims at exploring factors that prevent women from utilising cervical cancer screening services in the region. METHODS: A mixed method systematic review was conducted. A search was performed on PubMed (Medline), EMBASE, CINAHL (EBSCOHOST) and Scopus databases for articles published until May 2019 without time, language or study design limits. Two reviewers critically appraised the included studies independently using the standard quality assessment criteria for evaluating primary research papers. Results of the quantitative and mixed methods studies were transformed into qualitative data and synthesised using thematic analysis. RESULTS: From a potential 2 365 studies, 24 from 11 countries met the eligibility criteria and were selected; eight qualitative, 13 quantitative, and three that used the mixed-method approach. The primary barriers were identified as poor access to screening services, lack of awareness and knowledge on cervical cancer and screening, and socio-cultural influences. Service providers perceived lack of skills, screening equipment and supplies, and staff shortages as the major barriers to the provision of screening services. CONCLUSION: Barriers to cervical cancer screening in Africa are multifaceted and require a holistic approach that will address them concurrently at the health system, individual, interpersonal, community and structural levels. Political will complimented by stakeholder involvement is required in the development and implementation of strategies that will ensure acceptability, availability, accessibility, and affordability of screening to minimise barriers in accessing the service.

Women and health providers' perspectives on male support for cervical cancer screening in Gwanda district, Zimbabwe.

Several studies have shown that male involvement increases the uptake of sexual and reproductive health programmes for improved family health outcomes. The role of men in reducing the burden of cervical cancer has however not been researched in Zimbabwe. It is for this reason that this study explores male support for cervical cancer screening programmes from the perspective of women and health providers in the Gwanda district of Zimbabwe. A qualitative approach that engaged thirty-six women aged 25-50 years in focus group discussions, and twenty-five health providers with different roles in the cervical cancer screening programme in in-depth interviews was used to determine their perspectives on male support for cervical cancer screening. Data were analysed thematically using ATLAS.ti Computer Assisted Qualitative data analysis software. Key findings reflected that men lacked knowledge on cervical cancer and its risk factors and prevention. Subsequently, they engaged in sexual behaviours that increased their partners' risk of acquiring Human Papillomavirus infection, the virtually necessary cause of cervical cancer. Furthermore, men did not provide the necessary emotional and financial support for their women to access screening and treatment. Participants were optimistic that innovative awareness creation strategies and intense, sustained cervical cancer education efforts targeting men could increase male partner support. Involvement of community leaders was seen as crucial in the facilitation of male involvement for programme acceptance and improved uptake of cervical cancer screening. Male involvement is seen as an integral component of the cervical cancer prevention and control programme that has to be implemented in Gwanda district to minimise male partner-related barriers to cervical cancer screening. Further research focusing on men is required to identify specific knowledge gaps that would enable development of appropriate strategies that best involve men in cervical cancer prevention and control interventions.

Living with someone else's penis: The lived experiences of two South African penile allograft recipients: A descriptive phenomenological study.

BACKGROUND: In South Africa, penile loss is a recognised complication of ritual circumcision which has a profoundly negative effect on these men's psyches and their everyday lives. The purpose of this paper was to investigate the experiences of the first two South African penile allograft transplantation recipients in order to assess the psychosocial impact of this surgery. MATERIALS AND METHODS: A qualitative descriptive phenomenology approach was used. A total of four in-depth interviews were conducted with the two South African penile transplant recipients. The interviews were transcribed verbatim while adding the field and observational notes. Thematic analysis was used to derive meaning from the collected data. RESULTS: After the penile loss, both participants reported feeling suicidal for the following reasons: their communities shunned them and regarded them as 'dead,' they felt severely ashamed of their disfigured bodies, they were unable to develop intimate relationships and could not have children. Transplantation gave them a fully functional penis, which resolved the majority of these issues. The participants were able to build relationships and satisfy their own and their partners' sexual and relationship needs. The transplant led to complete restoration of their self-image and manhood. They were, however, still persecuted by their traditional communities as they had not successfully completed the ritual circumcision ceremony. CONCLUSION: This study emphasises the necessity of offering penile transplantation as treatment for penile loss as this is not only life enhancing but lifesaving, especially within the South African context.

Targeting for male medical circumcision: profiles from two South African cities.

Male circumcision is considered by some to be an acceptable global approach to reduce HIV infections. Consequently, many governments in sub-Saharan Africa run voluntary male circumcision programmes. South Africa also provides male circumcision for free at state clinics and hospitals. Very little is known about the men who use this service. This study uses data from Cape Town, a sample of 1194 in 2016, and from Mangaung, a sample of 277 in 2017 and 2018, to fill this gap. The study finds that age targeting is inadequate, risk targeting is absent, and religious and cultural factors have a negative effect on the cost-efficiency of the service in the long run.

"Please Don't Send Us Spam!" A Participative, Theory-Based Methodology for Developing an mHealth Intervention.

BACKGROUND: Mobile health solutions have the potential of reducing burdens on health systems and empowering patients with important information. However, there is a lack of theory-based mHealth interventions. OBJECTIVE: The purpose of our study was to develop a participative, theory-based, mobile phone, audio messaging intervention attractive to recently circumcised men at voluntary medical male circumcision (VMMC) clinics in the Cape Town area in South Africa. We aimed to shift some of the tasks related to postoperative counselling on wound management and goal setting on safe sex. We place an emphasis on describing the full method of message generation to allow for replication. METHODS: We developed an mHealth intervention using a staggered qualitative methodology: (1) focus group discussions with 52 recently circumcised men and their partners to develop initial voice messages they felt were relevant and appropriate, (2) thematic analysis and expert consultation to select the final messages for pilot testing, and (3) cognitive interviews with 12 recent VMMC patients to judge message comprehension and rank the messages. Message content and phasing were guided by the theory of planned behavior and the health action process approach. RESULTS: Patients and their partners came up with 245 messages they thought would help men during the wound-healing period. Thematic analysis revealed 42 different themes. Expert review and cognitive interviews with more patients resulted in 42 messages with a clear division in terms of needs and expectations between the initial wound-healing recovery phase (weeks 1-3) and the adjustment phase (weeks 4-6). Discussions with patients also revealed potential barriers to voice messaging, such as lack of technical knowledge of mobile phones and concerns about the invasive nature of the intervention. Patients' own suggested messages confirmed Ajzen's theory of planned behavior that if a health promotion intervention can build trust and be relevant to the recipient's needs in the first contacts, then the same recipients will perceive subsequent motivational messages more favorably. The health action process approach was also a useful tool for guiding the phasing of the messages. Participants were more positive and salutogenic than public health experts. CONCLUSIONS: The system showed how a process of consultation can work with a set of potential recipients of an mHealth service to ensure that their needs are included. Classic behavioral theories can and should be used to design modern mHealth interventions. We also believe that patients are the best source of messaging, ensuring that messages are culturally relevant and interesting to the recipient.

Voice-Message-Based mHealth Intervention to Reduce Postoperative Penetrative Sex in Recipients of Voluntary Medical Male Circumcision in the Western Cape, South Africa: Protocol of a Randomized Controlled Trial.

BACKGROUND: There is an increased risk of transmission of sexually transmitted infections (STIs), including HIV, in the postoperative period after receiving voluntary medical male circumcision (VMMC). In South Africa, over 4 million men are being targeted with VMMC services but the health system is not able to offer quality counseling. More innovative strategies for communicating with and altering behavior in men and their partners in the postoperative period after VMMC are needed. OBJECTIVE: This paper presents a study protocol to test the effectiveness of an mHealth intervention designed to task-shift behavior change communication from health care personnel to an automated phone message system, encouraging self-care. METHODS: A single-blind, randomized controlled trial will be used. A total of 1188 participants will be recruited by nurses or clinicians at clinics in the study districts that have a high turnover of VMMC clients. The population will consist of men aged 18 years and older who indicate at the precounseling session that they possess a mobile phone and consent to participating in the study. Consenting participants will be randomized into either the control or intervention arm before undergoing VMMC. The control arm will receive the standard of care (pre- and postcounseling). The intervention arm will received standard of care and will be sent 38 messages over the 6-week recovery period. Patients will be followed up after 42 days. The primary outcome is self-reported sexual intercourse during the recovery period. Secondary outcomes include nonpenetrative sexual activity, STI symptoms, and perceived risk of acquiring HIV. Analysis will be by intention-to-treat. RESULTS: Enrollment is completed. Follow-up is ongoing. Loss to follow-up is under 10%. No interim analyses have been conducted. CONCLUSIONS: The intervention has the potential of reducing risky sexual behavior after VMMC. The platform itself can be used for many other areas of health that require task shifting to patients for better efficiency and access. TRIAL REGISTRATION: Pan-African Clinical Trial Registry: PACTR201506001182385.

"What do You Mean I've Got to Wait for Six Weeks?!" Understanding the Sexual Behaviour of Men and Their Female Partners after Voluntary Medical Male Circumcision in the Western Cape.

BACKGROUND: Several studies have shown that voluntary male medical circumcision (VMMC) reduces the incidence of the Type-1 human immunodeficiency virus (HIV) in heterosexual men by up to 60%. However, there is an increased risk of transmission of STIs, including HIV, in the immediate post-operative period after receiving VMMC. This study is to understand sexual practices of couples in the post-operative period in a Coloured population in the Western Cape Province of South Africa. METHODS: Coloured Males who had undergone VMMC in the previous six months in the Cape Town area and their partners participated in eight single-gender focus group discussions. The groups explored why the men decided to undergo VMMC, what kind of counselling they received, and how they experienced the 6-week post-operative period, including sexually. RESULTS: The primary motivation to VMMC uptake included religious injunction and hygiene reasons and protection against sexually transmitted infections not necessarily HIV. There was some exploration of alternative sexual practices. During the period immediately post operation the respondents spoke of pain and fear of any sexual arousal, but towards the end of the six week period, sexual desire returned. Both men and women felt that sex was important to maintain the relationship. Gaps were identified in the pre- and post-MC procedure counselling. CONCLUSIONS: There is a real risk that men in this population may begin sex before complete healing has occurred. VMMC counselling to encourage men to stay sexually safe in the wound-healing period, needs to take into account the real-life factors of the circumcised men. It is essential from a public health, and gender perspective that effective counselling strategies for the VMMC post-operative period, and the longer term, are developed and tested.

Do Assessments of HIV Risk Behaviors Change Behaviors and Prevention Intervention Efficacy? An Experimental Examination of the Influence of Type of Assessment and Risk Perceptions.

BACKGROUND: Behavioral assessments may change behaviors and responses to behavioral interventions, depending on assessment type and respondents' motivations. PURPOSE: We observed effects on sexual behavior and human immunodeficiency virus (HIV) prevention intervention efficacy of interviews assessing recent HIV risk behavior frequency or HIV risk behavior events among respondents with different perceptions of their risk for HIV. METHODS: Young South African sexually transmitted infection (STI) clinic clients (N=1,728) participated in a 3 (event-based vs. frequency-based vs. no interview) by 2 (evidence-based vs. standard of care risk-reduction session) RCT. RESULTS: The interviews increased reported safer sexual behavior among youth with higher but not lower risk perceptions. The intervention session was less effective when combined with interviews, particularly among lower risk perception youth. Patterns replicated for both interviews. CONCLUSIONS: HIV risk behavior assessments may increase resistance to interventions among unmotivated youth and enhance safer sexual behavior among motivated youth. Behavioral assessments may reduce HIV risk among motivated individuals.

Safety-related moderators of a parent-based HIV prevention intervention in South Africa.

Our study examined factors influencing the effectiveness of a parent-based HIV prevention intervention implemented in Cape Town, South Africa. Caregiver-youth dyads (N = 99) were randomized into intervention or control conditions and assessed longitudinally. The intervention improved a parenting skill associated with youth sexual risk, parent-child communication about sex and HIV. Analyses revealed that over time, intervention participants (female caregivers) who experienced recent intimate partner violence (IPV) or unsafe neighborhoods discussed fewer sex topics with their adolescent children than caregivers in safer neighborhoods or who did not report IPV. Participants with low or moderate decision-making power in their intimate relationships discussed more topics over time only if they received the intervention. The effectiveness of our intervention was challenged by female caregivers' experience with IPV and unsafe neighborhoods, highlighting the importance of safety-related contextual factors when implementing behavioral interventions for women and young people in high-risk environments. Moderation effects did not occur for youth-reported communication outcomes. Implications for cross-cultural adaptations of parent-based HIV prevention interventions are discussed.

Perceived control and communication about sex: a study of South African families.

Caregiver-youth communication about sex protects youth against HIV/AIDS, and caregivers who believe that sex knowledge is important are more likely to talk to their youth about sex. However, caregivers who experience barriers to communication about sex may not talk to their youth about sex even if the caregiver believes that sex education is important. The Theory of Planned Behaviour predicts that an actor has perceived control is necessary for behavioural change. This study therefore hypothesised that caregivers' perceived control moderates the relationship between caregiver attitudes about youth sex knowledge and caregiver-youth communication about sex. Results from a sample of 99 female South African caregivers of adolescent (10-14 year old) youth supported our hypothesis, indicating that caregiver attitudes about providing youth with sex knowledge positively predict communication about sex only when caregivers have perceived control. This finding illustrates the importance of perceived control in predicting caregiver-youth communication, and therefore has implications for family-based interventions aimed at improving caregiver-youth communication about sex.

Preliminary results from a family-based HIV prevention intervention for South African youth.

OBJECTIVES: Approximately 5.6 million South Africans are living with human immunodeficiency virus (HIV; UNAIDS, 2010). Prevalence among Black adolescents and young adults is particularly alarming. This pilot study of an HIV preventive intervention targeting South African youth contributes to the growing body of research on culturally competent family-based interventions. METHOD: A total of 99 parent-child dyads were enrolled in an experimental repeated measures study, using a wait-list control group. Our 6-session intervention targeted general parenting (relationship quality, parental monitoring, and involvement), gender roles, and parent-youth communication about sex (content and quality). Parents and youth were assessed at baseline, postintervention, and 6-month follow-up. Eligibility included being the primary female caregiver of a 10- to 14-year-old child with whom they spent at least 4 nights a week and being able to participate in English or Xhosa. RESULTS: Effect sizes with this small sample met or exceeded those of other family-based HIV interventions for youth in the United States and South Africa (e.g., Bell et al., 2008; Forehand et al., 2007). Parents' reports at postintervention indicated larger effect sizes for general parenting than youths' reports indicated. Parents' reports showed medium to large effects for all sex communication outcomes at postintervention and the 6-month follow-up. Youth reports demonstrated small to medium effects for most communication variables and these effects lasted through the 6-month follow-up period. CONCLUSIONS: Intergenerational social networks (e.g., families) hold promise for HIV prevention among South African youth. A full efficacy trial with longer-term follow-up and attention to maintenance of effects is warranted.

Perceived Control and Communication about Sex: A Study of South African Families

Caregiver-youth communication about sex protects youth against HIV/AIDS; and caregivers who believe that sex knowledge is important are more likely to talk to their youth about sex. However; caregivers who experience barriers to communication about sex may not talk to their youth about sex even if the caregiver believes that sex education is important. The Theory of Planned Behaviour predicts that an actor has perceived control is necessary for behavioural change. This study therefore hypothesised that caregivers' perceived control moderates the relationship between caregiver attitudes about youth sex knowledge and caregiver-youth communication about sex. Results from a sample of 99 female South African caregivers of adolescent (10-14 year old) youth supported our hypothesis; indicating that caregiver attitudes about providing youth with sex knowledge positively predict communication about sex only when caregivers have perceived control. This finding illustrates the importance of perceived control in predicting caregiver-youth communication; and therefore has implications for family-based interventions aimed at improving caregiver-youth communication about sex

Let's Talk!, A South African worksite-based HIV prevention parenting program.

PURPOSE: South African adolescents have high HIV risk, yet few prevention interventions are effective. Parents play a pivotal role in youths' healthy sexual development and may be at risk themselves. We tested whether Let's Talk!, a worksite-based parenting program, improves parent-child communication about HIV and sexual health and parent condom use self-efficacy and behavior. METHODS: We culturally adapted Let's Talk! in two languages, drawing on formative research and community stakeholder input. We then conducted a small randomized test at a large public worksite in Cape Town, South Africa. The intervention consisted of 5 weekly 2-hour group sessions for parents of youth aged 11-15. Sixty-six parents (64% female) and their 64 adolescents (41% female) completed surveys before and 1-2 weeks post-intervention; surveys assessed comfort with talking about sex, communication about 16 HIV- and sex-related topics, and parents' condom use self-efficacy and behavior. Thirty-four black African (Xhosa language) and 32 coloured (mixed-race; Afrikaans language) parent-child dyads participated. Parents were randomized to intervention (n = 34) and control (n = 32) groups; randomization was stratified by language. RESULTS: Multivariate regressions indicated that the intervention significantly increased parents' comfort with talking to their adolescent about sex, b(SE) = .98(.39), p = .02, and the number of sex- and HIV-related topics discussed with their adolescent, b(SE) = 3.26(1.12), p = .005. Compared with control parents, intervention parents were more likely to discuss new sex- and HIV-related topics not discussed before the intervention, b(SE) = 2.85(.80), p <.001. The intervention significantly increased parents' self-efficacy for condom use, b(SE) = .60(.21), p = .007. CONCLUSIONS: Let's Talk! holds promise for improving parent-child communication, a critical first step in preventing HIV among youth.

HIV misconceptions associated with condom use among black South Africans: an exploratory study.

In South Africa, approximately 20% of 15-49-year-olds are infected with HIV. Among black South Africans, high levels of HIV/AIDS misconceptions (e.g. HIV is manufactured by whites to reduce the black African population; AIDS is caused by supernatural forces or witchcraft) may be barriers to HIV prevention. We conducted a cross-sectional study of 150 young, black adults (aged 18-26; 56% males) visiting a public clinic for sexually transmitted infections, to investigate whether HIV/AIDS misconceptions were related to low condom use in main partner relationships. We assessed agreement with HIV/AIDS misconceptions relating to the supernatural (e.g. witchcraft as a cause of HIV) and to genocide (e.g. the withholding of a cure). In multivariate models, agreement that 'Witchcraft plays a role in HIV transmission' was significantly related to less positive attitudes about condoms, less belief in condom effectiveness for HIV prevention, and lower intentions to use condoms among men. The belief that 'Vitamins and fresh fruits and vegetables can cure AIDS' was associated with lower intentions among men to use condoms. Women who endorsed the belief linking HIV to witchcraft had a higher likelihood of unprotected sex with a main partner, whereas women who endorsed the belief that a cure for AIDS was being withheld had a lower likelihood of having had unprotected sex. Knowledge about distinct types of HIV/AIDS misconceptions and their correlates can help in the design of culturally appropriate HIV-prevention messages that address such beliefs.

Associations of poverty, substance use, and HIV transmission risk behaviors in three South African communities.

The majority of the world's HIV infections occur in communities ravished by poverty. Although HIV/AIDS and poverty are inextricably linked, there are few studies of how poverty-related stressors contribute to HIV risk behavior practices. In this study, surveys were conducted in three South African communities that varied by race and socio-economic conditions: people living in an impoverished African township (N = 499); an economically impoverished but well infrastructured racially integrating township (N = 995); and urban non-impoverished neighborhoods (N = 678). Results showed that HIV/AIDS risks were closely related to experiences of poor education, unemployment, discrimination, violence, and crime. Although poverty-related stressors were associated with a history of alcohol and drug use, substance use did not moderate the association between poverty-related stressors and HIV risk behaviors. The findings suggest that HIV prevention strategies should not treat AIDS as a singled out social problem independent of other social ills.

HIV prevalence in three predominantly Muslim residential areas in the Cape Town metropole.

OBJECTIVE: To report on the results of a random and representative household survey of HIV prevalence in 3 predominantly Muslim areas in the Cape Town metropole. METHOD: A cross-sectional representative community household survey was conducted in 3 residential areas. Aerial photographs were used in the selection of a random sample of 548 households, with the objective of obtaining an oral fluid sample and behavioural data from 2 inhabitants per household. Phase 1 of the study involved preparing the communities and notifying the household residents of the study. In phase 2, trained nurses collected oral fluid specimens for HIV testing and administered a confidential and anonymous behavioural questionnaire to household inhabitants aged 15 years and older. RESULTS: A total of 717 people completed a behavioural interview and 512 were tested for HIV, yielding response rates of 65% and 47% respectively. The specimens of 503 respondents were correctly matched with behavioural data; 352 of these respondents indicated that they were Muslim. Of these oral fluid specimens 9 were reactive and 341 were non-reactive. We therefore calculated HIV prevalence among Muslims living in the three areas at 2.56% (95% confidence interval (CI): 1.18 - 4.80%). None of the individuals who tested HIV-positive had been previously tested for HIV. There were no HIV infections in the remainder of the sample. CONCLUSION: The results indicate that HIV prevalence among Muslims living in the 3 targeted residential areas of the Cape Town metropole, while not trivial, is significantly lower than the national prevalence for South Africa. These results imply the need for ongoing prevention and education programmes specifically targeting Muslim youth and adults and support and assistance for Muslims infected with and affected by HIV.

Development of a brief scale to measure AIDS-related stigma in South Africa.

Although there has been progress in AIDS stigma research, there are no multi-item AIDS stigma scales that have been shown reliable and valid in Africa. The current research reports the development of the nine-item AIDS-Related Stigma Scale. Research conducted in five South African communities (N = 2306) found the scale internally consistent, alpha = 0.75 and time stable over 3 months, r = 0.67. The scale was also reliable in three different languages (English, Xhosa, and Afrikaans). Correlations showed that the AIDS-Related Stigma Scale was moderately inversely correlated with years of education and AIDS knowledge. In addition, individuals who stated that HIV positive persons should conceal their HIV status had higher AIDS-Related Stigma Scale scores. Also supporting the scale's construct validity, individuals who refused to report whether they had been tested for HIV scored higher on the AIDS-Related Stigma Scale.