Audrey Pettifor

Can Money Prevent the Spread of HIV? A Review of Cash Payments for HIV Prevention

Cash payments to improve health outcomes have been used for many years; however, their use for HIV prevention is new and the impact not yet well understood. We provide a brief background on the rationale behind using cash to improve health outcomes, review current studies completed or underway using cash for prevention of sexual transmission of HIV, and outline some key considerations on the use of cash payments to prevent HIV infections. We searched the literature for studies that implemented cash transfer programs and measured HIV or HIV-related outcomes. We identified 16 studies meeting our criteria; 10 are completed. The majority of studies have been conducted with adolescents in developing countries and payments are focused on addressing structural risk factors such as poverty. Most have seen reductions in sexual behavior and one large trial has documented a difference in HIV prevalence between young women getting cash transfers and those not. Cash transfer programs focused on changing risky sexual behaviors to reduce HIV risk suggest promise. The context in which programs are situated, the purpose of the cash transfer, and the population will all affect the impact of such programs; ongoing RCTs with HIV incidence endpoints will shed more light on the efficacy of cash payments as strategy for HIV prevention.

Factors Associated with HIV Testing Among Public Sector Clinic Attendees in Johannesburg, South Africa

Uptake of VCT remains low in many sub-Saharan African countries. Men and women aged 15 and older were recruited from a family planning, STI, and VCT clinic in inner-city Johannesburg between 2004 and 2005 to take part in a cross-sectional survey on HIV testing (nxa0=xa0198). Fourty-eight percent of participants reported previously testing for HIV and, of these, 86.9% reported disclosing their status to their sex partner. In multivariable analyses, individuals whose partners had been tested for HIV were more likely to have tested (AOR 2.92; 95% CI: 1.38–6.20). In addition, those who reported greater blame/shame attitudes towards people living with HIV/AIDS were less likely to have tested (AOR 0.35; 95% CI: 0.16–0.77) while those reporting more equitable attitudes towards people living with HIV/AIDS were more likely to have tested (AOR 2.87; 95% CI: 1.20–6.86). Promotion of and increased access to couples HIV testing should be made available within the South African context.

Continued High Risk Sexual Behavior Following Diagnosis with Acute HIV Infection in South Africa and Malawi: Implications for Prevention

Understanding sexual behavior following diagnosis of acute HIV infection (AHI) is key to developing prevention programs targeting individuals diagnosed with AHI. We conducted separate qualitative and quantitative interviews with individuals newly diagnosed (nxa0=xa019) with AHI at 1-, 4- and 12-weeks post-diagnosis and one qualitative interview with individuals who had previously been diagnosed with AHI (nxa0=xa018) in Lilongwe, Malawi and Johannesburg, South Africa between October 2007 and June 2008. The majority of participants reported engaging in sexual activity following diagnosis with AHI with a significant minority reporting unprotected sex during this time. Most participants perceived to have changed their behavior following diagnosis. However, participants reported barriers to condom use and abstinence, in particular, long term relationships and the need for disclosure of sero-status. Understanding of increased infectiousness during AHI was limited. Participants reported a desire for a behavioral intervention at the time of AHI diagnosis, however, there were differences by country in the types of interventions participants found acceptable. Studies are underway to determine the feasibility, acceptability and potential effectiveness of interventions designed for individuals with AHI.

HPTN 068: A Randomized Control Trial of a Conditional Cash Transfer to Reduce HIV Infection in Young Women in South Africa—Study Design and Baseline Results

AbstractnYoung women in South Africa are at high risk for HIV infection. Cash transfers offer promise to reduce HIV risk. We present the design and baseline results from HPTN 068, a phase III, individually randomized trial to assess the effect of a conditional cash transfer on HIV acquisition among South African young women. A total of 2533 young women were randomized to receive a monthly cash transfer conditional on school attendance or to a control group. A number of individual-, partner-, household- and school-level factors were associated with HIV and HSV-2 infection. After adjusting for age, all levels were associated with an increased odds of HIV infection with partner-level factors conveying the strongest association (aOR 3.05 95xa0% CI 1.84–5.06). Interventions like cash transfers that address structural factors such as schooling and poverty have the potential to reduce HIV risk in young women in South Africa.

Acceptability and Feasibility of Cash Transfers for HIV Prevention Among Adolescent South African Women

Women are at increased risk of HIV infection in much of sub-Saharan Africa. Longitudinal and cross-sectional studies have found an association between school attendance and reduced HIV risk. We report feasibility and acceptability results from a pilot of a cash transfer intervention conditional on school attendance paid to young women and their families in rural Mpumalanga, South Africa for the prevention of HIV infection. Twenty-nine young women were randomised to intervention or control and a cash payment based on school attendance made over a 2-month period. Quantitative (survey) and qualitative (focus group and interview) data collection was undertaken with young women, parents, teachers and young men in the same school. Qualitative analysis was conducted in Atlas.ti using a framework approach and basic descriptive analysis in Excel was conducted on the quantitative data. Results indicate it was both feasible and acceptable to introduce such an intervention among this population in rural South Africa. There was good understanding of the process of randomisation and the aims of the study, although some rumours developed in the study community. We address some of the changes necessary to ensure acceptability and feasibility of the main trial.

Depression and Engagement in Care Among Newly Diagnosed HIV-Infected Adults in Johannesburg, South Africa

Delayed engagement in HIV care threatens the success of HIV treatment programs in sub-Saharan Africa and may be influenced by depression. We examined the relationship between depression prior to HIV diagnosis and engagement in HIV care at a primary care clinic in Johannesburg, South Africa. We screened 1683 patients for depression prior to HIV testing using the Patient Health Questionnaire-9. Among patients who tested positive for HIV we assessed linkage to HIV care, defined as obtaining a CD4 count within 3xa0months. Among those who linked to care and were eligible for ART, we assessed ART initiation within 3xa0months. Multivariable Poisson regression with a robust variance estimator was used to assess the association between depression and linkage to care or ART initiation. The prevalence of HIV was 26xa0% (nxa0=xa0340). Among HIV-infected participants, the prevalence of depression was 30xa0%. The proportion of linkage to care was 80xa0% among depressed patients and 73xa0% among patients who were not depressed (risk ratio 1.08; 95xa0% confidence interval 0.96, 1.23). Of the participants who linked to care, 81xa0% initiated ART within 3xa0months in both depressed and not depressed groups (risk ratio 0.99; 95xa0% confidence interval 0.86, 1.15). Depression was not associated with engagement in HIV care in this South African primary care setting. Our unexpected findings suggest that some depressed HIV-infected patients might be more likely to engage in care than their counterparts without depression, and highlight the complex relationship between depression and HIV infection. These findings have led us to propose a new framework relating HIV infection, depression, and the population under study.

Gender Norms, Gender Role Conflict/Stress and HIV Risk Behaviors Among Men in Mpumalanga, South Africa

Men’s gender role conflict and stress (GRC/S), the psychological strain they experience around fulfilling expectations of themselves as men, has been largely unexplored in HIV prevention research. We examined associations between both men’s gender norms and GRC/S and three HIV risk behaviors using data from a population-based survey of 579 18–35xa0year-old men in rural northeast South Africa. Prevalence of sexual partner concurrency and intimate partner violence (IPV) perpetration in the last 12xa0months were 38.0 and 13.4%, respectively; 19.9% abused alcohol. More inequitable gender norms and higher GRC/S were each significantly associated with an increased odds of concurrency (pxa0=xa00.01; pxa0<xa00.01, respectively), IPV perpetration (pxa0=xa00.03; pxa0<xa00.01), and alcohol abuse (pxa0=xa00.02; pxa0<xa00.001), controlling for demographic characteristics. Ancillary analyses demonstrated significant positive associations between: concurrency and the GRC/S sub-dimension subordination to women; IPV perpetration and restrictive emotionality; and alcohol abuse and success, power, competition. Programs to transform gender norms should be coupled with effective strategies to prevent and reduce men’s GRC/S.

Gender, HIV Testing and Stigma: The Association of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa Differ for Men and Women

Stigma remains a significant barrier to HIV testing in South Africa. Despite being a social construct, most HIV-stigma research focuses on individuals; further the intersection of gender, testing and stigma is yet to be fully explored. We examined the relationship between anticipated stigma at individual and community levels and recent testing using a population-based sample (nxa0=xa01126) in Mpumalanga, South Africa. We used multi-level regression to estimate the potential effect of reducing community-level stigma on testing uptake using the g-computation algorithm. Men tested less frequently (OR 0.22, 95% CI 0.14–0.33) and reported more anticipated stigma (OR 5.1, 95% CI 2.6–10.1) than women. For men only, testing was higher among those reporting no stigma versus some (OR 1.40, 95% CI 0.97–2.03; pxa0=xa00.07). For women only, each percentage point reduction in community-level stigma, the likelihood of testing increased by 3% (pxa0<xa00.01). Programming should consider stigma reduction in the context of social norms and gender to tailor activities appropriately.

Measuring Men’s Gender Norms and Gender Role Conflict/Stress in a High HIV-Prevalence South African Setting

Gender norms and gender role conflict/stress may influence HIV risk behaviors among men; however scales measuring these constructs need further development and evaluation in African settings. We conducted exploratory and confirmatory factor analyses to evaluate the Gender Equitable Men’s Scale (GEMS) and the Gender Role Conflict/Stress (GRC/S) scale among 581 men in rural northeast South Africa. The final 17-item GEMS was unidimensional, with adequate model fit and reliability (alphaxa0=xa00.79). Factor loadings were low (0.2–0.3) for items related to violence and sexual relationships. The final 24-item GRC/S scale was multidimensional with four factors: Success, power, competition; Subordination to women; Restrictive emotionality; and Sexual prowess. The scale had adequate model fit and good reliability (alphaxa0=xa00.83). While GEMS is a good measure of inequitable gender norms, new or revised scale items may need to be explored in the South African context. Adding the GRC/S scale to capture men’s strain related to gender roles could provide important insights into men’s risk behaviors.

Hope Matters: Developing and Validating a Measure of Future Expectations Among Young Women in a High HIV Prevalence Setting in Rural South Africa (HPTN 068)

Hope is a future expectancy characterized by an individual’s perception that a desirable future outcome can be achieved. Though scales exist to measure hope, they may have limited relevance in low resource, high HIV prevalence settings. We developed and validated a hope scale among young women living in rural South Africa. We conducted formative interviews to identify the key elements of hope. Using items developed from these interviews, we administered the hope scale to 2533 young women enrolled in an HIV-prevention trial. Women endorsed scale items highly and the scale proved to be unidimensional in the sample. Hope scores were significantly correlated with hypothesized psycholosocial correlates with the exception of life stressors. Overall, our hope measure was found to have excellent reliability and to show encouraging preliminary indications of validity in this population. This study presents a promising measure to assess hope among young women in South Africa.