Abigail Harrison

HIV prevention for South African youth: which interventions work? A systematic review of current evidence

BackgroundIn South Africa, HIV prevalence among youth aged 15-24 is among the worlds highest. Given the urgent need to identify effective HIV prevention approaches, this review assesses the evidence base for youth HIV prevention in South Africa.MethodsSystematic, analytical review of HIV prevention interventions targeting youth in South Africa since 2000. Critical assessment of interventions in 4 domains: 1) study design and outcomes, 2) intervention design (content, curriculum, theory, adaptation process), 3) thematic focus and HIV causal pathways, 4) intervention delivery (duration, intensity, who, how, where).ResultsEight youth HIV prevention interventions were included; all were similar in HIV prevention content and objectives, but varied in thematic focus, hypothesised causal pathways, theoretical basis, delivery method, intensity and duration. Interventions were school- (5) or group-based (3), involving in- and out-of-school youth. Primary outcomes included HIV incidence (2), reported sexual risk behavior alone (4), or with alcohol use (2). Interventions led to reductions in STI incidence (1), and reported sexual or alcohol risk behaviours (5), although effect size varied. All but one targeted at least one structural factor associated with HIV infection: gender and sexual coercion (3), alcohol/substance use (2), or economic factors (2). Delivery methods and formats varied, and included teachers (5), peer educators (5), and older mentors (1). School-based interventions experienced frequent implementation challenges.ConclusionsKey recommendations include: address HIV social risk factors, such as gender, poverty and alcohol; target the structural and institutional context; work to change social norms; and engage schools in new ways, including participatory learning.

Hidden Love: Sexual ideologies and relationship ideals among rural South African adolescents in the context of HIV/AIDS

In KwaZulu/Natal, South Africa, the social construction of young peoples sexuality reflects both a complex historical process of cultural and religious integration, as well as the contemporary resurgence of ‘traditionalism’. How do young people interpret these factors to construct and give meaning to their own sexualities? This multi‐method qualitative study examined sexuality and relationship formation among sexually experienced young people aged 14–19 in a rural sub‐district. In this setting, sexual activity is highly stigmatised, particularly for young teenage women. Dominant sexual ideologies centre on ‘good behaviour’, the idea that ‘sex is wrong’, and abstinence as a preferred prevention strategy. Young womens relationships are often hidden but sexual relationships are also an important part of the transition to adulthood. These dichotomies of love and romance versus stigma and secrecy frame young peoples discourse about sexuality. A discourse about healthy sexuality is largely absent, impeding the prevention of HIV in this setting.

Why do women seek antenatal care late? Perspectives from rural South Africa.

Despite the widespread availability of free antenatal care services, most women in rural South Africa attend their first antenatal clinic late in pregnancy and fail to return for any followup care, potentially leading to avoidable perinatal and maternal complications. Using interviews with pregnant women from the rural Hlabisa district of South Africa, we documented perceptions of health and health care during pregnancy and investigated factors shaping the utilization of antenatal care. Our findings indicate that most women in this setting do not perceive significant health threats during pregnancy, and in turn view more than one antenatal care visit as unnecessary. In contrast, women perceive labour and delivery as a time of significant health risks that require biomedical attention, and most women prefer to give birth in a health facility. This paradox, in which health care is important for childbirth but not during pregnancy, is embodied in most womens primary reason for seeking antenatal care in this setting: to receive an antenatal attendance card that is required to deliver at a health facility. Health education programs promoting antenatal care are required to explain the importance of effective antenatal care toward maternal and child health.

HIV risk behaviors and the context of sexual coercion in young adults' sexual interactions: results from a diary study in rural South Africa.

Background: Gender inequalities in relationship power may promote unprotected sexual intercourse. Goals: The goal of this study was to gain insight into the specific gender dynamics in the intimate relationships of rural South African young adults that contribute to risk for HIV infection. Study: Using diary methods, 25 female and 25 male secondary school students in rural South Africa provided daily reports (N = 1000) over a 3-week timeframe, including details regarding 466 sexual interactions. Results: Inconsistent condom use was more likely in relationships in which the male partner had ever used threat or force to engage in sex during this period (unadjusted odds ratio, 13.4; 95% confidence interval, 1.57–114.26). Male sexual coercion was more likely in relationships in which alcohol was ever used in conjunction with sex and when a man’s desire to engage in sex was perceived as greater than the woman’s. Conclusion: This study adds to the growing evidence that sexual relationships characterized by gender inequality and sexual coercion are contexts of sexual risk.

Understanding young women's risk for HIV/AIDS: Adolescent sexuality and vulnerability in rural KwaZulu/Natal

Abstract The authors wish to thank the young women of Hlabisa District who participated in this study, and acknowledge the support of the Wellcome Trust, UK in funding the research reported here.

Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: randomized controlled trial.

BackgroundSexually transmitted diseases (STD) are important co-factors in HIV transmission. We studied the impact of health worker training and STD syndrome packets (containing recommended drugs, condoms, partner notification cards and information leaflets) on the quality of STD case management in primary care clinics in rural South Africa. MethodsA randomized controlled trial of five matched pairs of clinics compared the intervention with routine syndromic management. Outcomes were measured by simulated patients using standardized scripts, and included the proportion given recommended drugs; correctly case managed (given recommended drugs plus condoms and partner cards); adequately counselled; reporting good staff attitude; and consulted in privacy. ResultsAt baseline, the quality of STD case management was similarly poor in both groups. Only 36 and 46% of simulated patients visiting intervention and control clinics, respectively, were given recommended drugs. After the intervention, intervention clinics provided better case management than controls: 88 versus 50% (P < 0.01) received recommended drugs; 83 versus 12% (P < 0.005) were correctly case managed; 68 versus 46% (P = 0.06) were adequately counselled; 84 versus 58% experienced good staff attitude (P = 0.07); and 92 versus 86% (P = 0.4) were consulted privately. A syndrome packet cost US

In the Absence of Marriage: Long-Term Concurrent Partnerships, Pregnancy, and HIV Risk Dynamics Among South African Young Adults

1.50; the incremental cost was US

Improving quality of sexually transmitted disease case management in rural South Africa

6.80. The total intervention cost equalled 0.3% of annual district health expenditure. Interpretation A simple and affordable health service intervention achieved substantial improvements in STD case management. Although this is a critical component of STD control and can reduce HIV transmission, community-level interventions to influence health-seeking behaviour are also needed.

Sexually transmitted disease syndromes in rural South Africa: results from health facility surveillance.

In KwaZulu/Natal, South Africa, where HIV prevalence is among the world’s highest, a longitudinal qualitative study of partnership dynamics and HIV preventive behaviors was conducted. 47 young adults aged 18–24 participated in in-depth interviews, and 29 were re-interviewed 2 years later. Five analytical domains emerged: primary partnerships, love and romance; secondary partnerships; pregnancy/parenthood; condom use/prevention; and contextual influences, including schooling and future aspirations. Primary relationships were long-lasting, with most men and women in the same relationship at 2-year follow-up. Secondary, casual partnerships were common for men and women, although these were shorter and changed frequently. Love and marriage aspirations were not viewed as incompatible with secondary partners. Condom use increased over time in some primary relationships, but decreased in others, and was nearly universal with non-primary partners. Pregnancy, school drop-out, and economic need strongly influence young people’s lifecourse. These findings suggest the need to focus prevention efforts on the partnership context, including partner reduction, and structural factors that impede or enhance prevention success.

The Mpondombili Project: Preventing HIV/AIDS and Unintended Pregnancy among Rural South African School-Going Adolescents

Objective:To measure quality of sexually transmitted disease (STD) syndromic case management and aspects of health-seeking behaviour at baseline in an intervention trial. Setting:Ten rural primary care clinics, Hlabisa district, South Africa. Design:Simulated patients (fieldworkers trained to present with STD syndromes) made a total of 44 clinic visits; 49 STD patients were interviewed when exiting clinics; facilities were assessed for availability of necessary equipment and drugs; 10 focus group discussions were held with staff; and STD syndrome surveillance was performed in all 10 clinics. Results:A total of 9% of simulated patients were correctly managed (given correct drugs, plus condoms and partner notification cards), recommended drug treatment was given in only 41% of visits, and appropriate counselling was given in 48% of visits. Among patients leaving the clinic, although 39% waited over an hour to be seen and only 37% were consulted in private, all reported staff attitudes as satisfactory or good. Only six clinics had syndromic management protocols available, three reported intermittent drug shortages, and seven lacked partner notification cards. Focus group discussions revealed good staff knowledge about STD, but showed lack of training in syndromic management and low morale. Surveillance data showed that while 75% of those presenting for care did so within 1 week of symptom onset, 27% had been treated for an STD in the preceding 3 months, and only 6% of those treated were contacts. Conclusions:Quality of STD case management was poor despite good staff knowledge and availability of most essential resources. An intervention comprising staff training and STD syndrome packets has been designed to improve quality of case management.