Allanise Cloete

Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale

Abstract AIDS stigmas create significant barriers to HIV prevention, testing, and care and can become internalized by people living with HIV/AIDS. We developed a psychometric scale to measure internalized AIDS-related stigmas among people infected with HIV. Items were adapted from a psychometrically sound test of AIDS-related stigmas in the general population. Six items reflecting self-defacing beliefs and negative perceptions of people living with HIV/AIDS were responded to dichotomously, Agree/Disagree. Data collected from people living with HIV/AIDS in Cape Town South Africa (n=1068), Swaziland (n=1090), and Atlanta US (n=239) showed that the internalized AIDS Stigma Scale was internally consistent (overall alpha coefficient=0.75) and time stable (r=0.53). We also found evidence in support of the scales convergent, discriminant, and criterion-related validity. The Internalized AIDS-Related Stigma Scale appears reliable and valid and may be useful for research and evaluation with HIV-positive populations across southern African and North American cultures.

Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa.

Background: The HIV epidemic continues to amplify in southern Africa and there is a growing need for HIV prevention interventions among people who have tested HIV positive. Methods: Anonymous surveys were completed by 413 HIV-positive men and 641 HIV-positive women sampled from HIV/AIDS services; 73% were <35 years old, 70% Black African, 70% unemployed, 75% unmarried, and 50% taking antiretroviral treatment. Results: Among the 903 (85%) participants who were currently sexually active, 378 (42%) had sex with a person to whom they had not disclosed their HIV status in the previous 3 months. Participants who had not disclosed their HIV status to their sex partners were considerably more likely to have multiple partners, HIV-negative partners, partners of unknown HIV status and unprotected intercourse with non-concordant sex partners. Not disclosing their HIV status to partners was also associated with having lost a job or a place to stay because of being HIV positive and feeling less able to disclose to partners. Conclusions: HIV-related stigma and discrimination are associated with not disclosing HIV status to sex partners, and non-disclosure is closely associated with HIV transmission risk behaviours. Interventions are needed in South Africa to reduce the AIDS stigma and discrimination and to assist people with HIV to make effective decisions on disclosure.

Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa

The links between gender roles, gender-based violence and HIV/AIDS risk are complex and culturally specific. In this qualitative study we investigated how women and men in two black communities in the Western Cape, South Africa, constructed their gender identities and roles, how they understood gender-based violence, and what they believed about the links between gender relations and HIV risk. First we conducted 16 key informant interviews with members of relevant stakeholder organisations.Then we held eight focus group discussions with community members in single-sex groups. Key findings included the perception that although traditional gender roles were still very much in evidence, shifts in power between men and women were occurring. Also, genderbased violence was regarded as a major problem throughout communities, and was seen to be fuelled by unemployment, poverty and alcohol abuse. HIV/AIDS was regarded as particularly a problem of African communities, with strong themes of stigma, discrimination, and especially ‘othering’ evident. Developing effective HIV/AIDS interventions in these communities will require tackling the overlapping as well as divergent constructions of gender, gender violence and HIV which emerged in the study.

Integrated gender-based violence and HIV risk reduction intervention for South African men: results of a quasi-experimental field trial.

South Africa is in the midst of one of the world’s most devastating HIV/AIDS epidemics and there is a well-documented association between violence against women and HIV transmission. Interventions that target men and integrate HIV prevention with gender-based violence prevention may demonstrate synergistic effects. A quasi-experimental field intervention trial was conducted with two communities randomly assigned to receive either: (a) a five session integrated intervention designed to simultaneously reduce gender-based violence (GBV) and HIV risk behaviors (N = 242) or (b) a single 3-hour alcohol and HIV risk reduction session (N = 233). Men were followed for 1-, 3-, and 6-months post intervention with 90% retention. Results indicated that the GBV/HIV intervention reduced negative attitudes toward women in the short term and reduced violence against women in the longer term. Men in the GBV/HIV intervention also increased their talking with sex partners about condoms and were more likely to have been tested for HIV at the follow-ups. There were few differences between conditions on any HIV transmission risk reduction behavioral outcomes. Further research is needed to examine the potential synergistic effects of alcohol use, gender violence, and HIV prevention interventions.

Stigma and discrimination experiences of HIV-positive men who have sex with men in Cape Town, South Africa.

Abstract Since the primary mode of HIV transmission in sub-Saharan Africa is heterosexual, research focusing on the sexual behaviour of men who have sex with men (MSM) is scant. Currently it is unknown how many people living with HIV in South Africa are MSM and there is even less known about the stigmatisation and discrimination of HIV-positive MSM. The current study examined the stigma and discrimination experiences of MSM living with HIV/AIDS in South Africa. Anonymous venue-based surveys were collected from 92 HIV-positive MSM and 330 HIV-positive men who only reported sex with women (MSW). Internalised stigma was high among all HIV-positive men who took part in the survey, with 56% of men reporting that they concealed their HIV status from others. HIV-positive MSM reported experiencing greater social isolation and discrimination resulting from being HIV-positive, including loss of housing or employment due to their HIV status, however these differences were not significant. Mental health interventions, as well as structural changes for protection against discrimination, are needed for HIV-positive South African MSM.

HIV prevalence and risk practices among men who have sex with men in two South African cities.

Background:In South Africa, information on HIV among men who have sex with men (MSM) is limited, and HIV prevention programs for men MSM are not widely available, despite global evidence that MSM are at substantial risk for HIV infection. The Johannesburg/eThekwini Mens Study was conducted during 2008 to provide information on HIV among MSM in Johannesburg and Durban. Methods:MSM aged 18 years or older were recruited using respondent-driven sampling. Participants completed a questionnaire and provided finger-prick blood specimens for anonymous HIV testing in a laboratory. Results:From July to December 2008, 285 MSM were recruited in Johannesburg (n = 204) and Durban (n = 81). Participants had a median age of 22 years and were predominantly black Africans (88.3%). The HIV prevalence was 49.5% [95% confidence interval (CI): 42.5% to 56.5%] in Johannesburg and 27.5% [95% CI: 17.0% to 38.1%] in Durban. HIV infection was associated with gay identification [adjusted odds ratio (aOR): 8.4; 95% CI: 3.7 to 19]. Factors in the previous year that were associated with HIV infection included receptive unprotected anal intercourse [aOR 4.3; 95% CI: 2.4 to 7.6]; sex with a person known to be HIV positive [aOR: 2.3; 95% CI: 1.1 to 4.9]; and a sexually transmitted infection diagnosis [aOR 2.4; 95% CI: 1.1 to 5.2]. Conclusions:HIV prevalence among MSM in Johannesburg and Durban is considerably higher compared with men in the general population. There is an urgent need to establish national HIV surveillance among MSM and to expand the availability of HIV prevention programs for MSM.

You become afraid to tell them that you are gay: health service utilization by men who have sex with men in South African cities.

We describe the utilization of health services by men who have sex with men (MSM) in South African cities, their perceptions of available health services, and their service preferences. We triangulated data from 32 key informant interviews (KIIs), 18 focus group discussions (FGDs) with MSM in four cities, and a survey of 285 MSM in two cities, recruited through respondent-driven sampling in 2008. FGDs and KIIs revealed that targeted public health sector programs for MSM were limited, and that MSM experienced stigma, discrimination, and negative health worker attitudes. Fifty-seven per cent of the survey participants had used public health services in the previous 12 months, and 69 per cent had no private health insurance, with no difference by HIV status. Despite these findings, South Africa is well placed to take the lead in sub-Saharan Africa in providing responsive and appropriate HIV services for MSM.

Sexual assault, sexual risks and gender attitudes in a community sample of South African men

Abstract Sexual assault against women and HIV infection are both prevalent and related social problems in South Africa. The current study examined hostile attitudes toward women, acceptance of violence against women and masculine ideological beliefs in relation to sexual assault history among men in a Cape Town township in South African. Men (n=435) completed anonymous surveys of sexual assault history, HIV risk history and gender-based attitudes. More than one in five men in this community sample reported that they had either threatened to use force or used force to gain sexual access to a woman in their lifetime. Men with a history of sexual assault were at significantly higher risk for HIV transmission than their non-sexually assaultive counterparts. Men with a history of sexual assault were also more likely to endorse hostile attitudes toward women and were more likely to accept violence against women, although these attitudes and beliefs were prevalent and pervasive across men with and without histories of sexual assault. These findings extend previous research to show that men who have a history of sexual assault also exhibit elevated risks for HIV infection and transmission. Interventions are needed to address hostile attitudes toward women, sexual assault and sexual risks for HIV among South African men.

The Sociocultural Aspects of HIV/AIDS in South Africa

In 2005 the Commission for Africa noted that ‘Tackling HIV and AIDS requires a holistic response that recognises the wider cultural and social context’ (p. 197). Cultural factors that range from beliefs and values regarding courtship, sexual networking, contraceptive use, perspectives on sexual orientation, explanatory models for disease and misfortune and norms for gender and marital relations have all been shown to be factors in the various ways that HIV/AIDS has impacted on African societies (UNESCO, 2002). Increasingly the centrality of culture is being recognised as important to HIV/AIDS prevention, treatment, care and support. With culture having both positive and negative influences on health behaviour, international donors and policy makers are beginning to acknowledge the need for cultural approaches to the AIDS crisis (Nguyen et al., 2008).

Methamphetamine use and sexual risks for HIV infection in Cape Town, South Africa

Aims: The current study examined the use of methamphetamine (Meth) in relation to HIV risks in a South African community sample. Design and setting: Street intercept methods were used to collect surveys of substance use and sexual behavior from 441 men and 521 women living in a racially mixed township in Cape Town South Africa. Findings: Results showed that 78 (18%) men and 63 (12%) women had used Meth, and 49 (11%) men and 34 (6%) women ever had used Meth in the preceding 6 months. Other than alcohol, cannabis was the most commonly used drug followed by Meth. We found that Meth use was closely associated with other drug use, indicating a pattern of poly‐substance use among Meth users. Recent Meth use was associated with being male, engaging in unprotected intercourse and having multiple sex partners in the previous 6 months. Meth users also demonstrated greater condom use than non‐users, although less than half of all intercourse occasions among Meth users were condom protected. Conclusions: Meth is used by a substantial number of people in one area of South Africa and the close association of Meth and sexual risk practices raises concern that Meth could fuel the spread of HIV infection in new South African sub‐populations.