Catherine MacPhail

Young people's sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey

Objectives:To determine the prevalence of HIV infection, HIV risk factors, and exposure to national HIV prevention programs, and to identify factors associated with HIV infection among South African youth, aged 15–24 years. Design:A cross-sectional, nationally representative, household survey. Methods:From March to August 2003 we conducted a national survey of HIV prevalence and sexual behavior among 11 904 15–24 year olds. Multivariable models for HIV infection were restricted to sexually experienced youth. Results:Young women were significantly more likely to be infected with HIV in comparison with young men (15.5 versus 4.8%). Among men, a history of genital ulcers in the past 12 months was associated with HIV infection [adjusted odds ratio (AOR), 1.91; 95% confidence interval (CI), 1.04–3.49) whereas among women a history of unusual vaginal discharge in the past 12 months was associated with HIV infection (AOR, 1.75; 95% CI, 1.26–2.44). Young women with older partners were also at increased risk of HIV infection. Among both men and women, increasing partner numbers and inconsistent condom use were significantly associated with HIV infection. Males and females who reported participation in at least one loveLife program were less likely to be infected with HIV (AOR, 0.60; 95% CI, 0.40–0.89; AOR, 0.61; 95% CI, 0.43–0.85, respectively). Conclusion:This survey confirms the high HIV prevalence among young people in South Africa and, in particular, young womens disproportionate risk. Programs for youth must continue to promote partner reduction, consistent condom use and prompt treatment for sexually transmitted infections while also addressing contextual factors that make it difficult for them to implement behavior change.

HIV infection among youth in a South African mining town is associated with herpes simplex virus-2 seropositivity and sexual behaviour.

ObjectivesTo determine the seroprevalence of HIV and herpes simplex virus-2 (HSV-2) by age and gender among young people aged 14-24 years in a South African town and to identify risk factors for HIV infection. DesignA community-based, cross-sectional study was conducted on a random sample of men (n = 723) and women (n = 784) living in a township in the Carletonville district of South Africa. MethodsPotential demographic and behavioural risk factors associated with HIV were recorded by questionnaire and biological tests were performed on serum and urine. Data analysis was performed using multivariate logistic regression. ResultsAmong men and women the prevalence of HIV infection was 9.4 and 34.4%, respectively, and of positive HSV-2 serology was 17.0 and 53.3%, respectively. Among 24-year-old women the prevalence of HIV was 66.7% [95% confidence interval (CI), 54.6–77.3%]. HSV-2 seropositivity was a strong independent risk factor for HIV infection with odds ratios of 5.3 (95% CI, 2.7–10.3) for men and 8.4 (95% CI, 4.9–14.2) for women. There was no independent effect of age at first sex or serological markers of other sexually transmitted infections on HIV infection. ConclusionsHIV infection among young women increases rapidly after the onset of sexual activity and reaches extremely high levels by 24 years of age. These findings suggest that rates of HIV transmission from men to women are high and that HSV-2 plays a major role in the spread of HIV in this population.

Characteristics and outcomes of adult patients lost to follow-up at an antiretroviral treatment clinic in johannesburg, South Africa.

PURPOSE To report an 81-year-old woman with corneal neovascularization secondary to herpetic stromal keratitis treated with subconjunctival bevacizumab and to discuss the role of this novel antiangiogenic treatment. METHODS Case report and review of medical literature. RESULTS A dramatic regression of corneal vessels was observed 1 week after the injection. After a 3-month follow-up, there was no recurrence of corneal revascularization. CONCLUSIONS Bevacizumab may be a valid complementary treatment in patients with corneal neovascularization caused by herpetic stromal keratitis.Background:A significant proportion of those initiating antiretroviral treatment (ART) for HIV infection are lost to follow-up. Causes for discontinuing ART follow-up in resource-limited settings are not well understood. Methods:A retrospective analysis was conducted of all adult patients receiving ART at an urban public clinic in Johannesburg, South Africa between April 2004 and June 2005. Patients discontinuing follow-up for at least 6 weeks were identified and further studied, and causes for treatment default were tabulated. Results:Of 1631 adult patients studied, 267 (16.4%) discontinued follow-up during the study period. Gender, ethnicity, and age were not predictive of loss to follow-up. Of those discontinuing follow-up, 173 (64.8%) were successfully traced. Death accounted for 48% (n = 83) of those traced. Characteristics associated with death were older age at ART initiation (P = 0.022), lower baseline CD4 cell count (P = 0.0073), higher initial HIV RNA load (P = 0.024), and loss of weight on ART (P = 0.033). Date of death was known for 71% (n = 59) of patients traced deceased, of whom 83% (n = 49) had died within 30 days of active ART. Common nonmortality losses included relocation or clinic transfer (25.4%) and hospitalization or illness not resulting in death (10.4%). Few cited financial difficulty or medication toxicity as reasons for discontinuing follow-up. Conclusions:Nearly 1 in 6 patients receiving ART in a resource-constrained setting had discontinued follow-up over a 15-month period. Early mortality was high, especially in those with profound immunosuppression. Improving access to care and streamlining patient tracking may improve ART outcomes.

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.

Keep them in school: the importance of education as a protective factor against HIV infection among young South African women.

OBJECTIVE To identify risk factors for HIV infection among young women aged 15-24 years reporting one lifetime partner in South Africa. Design In 2003, we conducted a nationally representative household survey of sexual behaviour and HIV testing among 11 904 young people aged 15-24 years in South Africa. This analysis focuses on the subset of sexually experienced young women with only one reported lifetime sex partner (n = 1708). METHODS Using the proximate determinants framework and the published literature we identified factors associated with HIV in young women. The associations between these factors and HIV infection were explored in multivariable logistic regression models. RESULTS Of the young women, 15% reporting one lifetime partner were HIV positive. In multivariable analyses, young women who had not completed high school were more likely to be infected with HIV compared with those that had completed high school (AOR 3.75; 95% CI 1.34-10.46). CONCLUSIONS Young South African women in this population were at high risk of HIV infection despite reporting only having one lifetime partner. Few individual level factors were associated with HIV infection, emphasizing the importance of developing HIV prevention interventions that address structural and partner level risk factors.

Factors associated with HIV testing among sexually active South African youth aged 15–24 years

Abstract HIV infection is high among South African youth but most report being unaware of their HIV status. We explored the correlates of HIV testing using data from youth aged 15–24 years old who reported being sexually experienced during a national survey conducted in South Africa in 2003 (N=7665). Among sexually experienced youth, 32.7% of females and 17.7% of males reported having been tested for HIV. In multivariable analysis, ever being pregnant (OR = 2.97; 95% CI 2.36–3.73), ever starting a conversation about HIV/AIDS (OR = 1.29; 95% CI 1.0–1.65) and urban residence (OR = 2.0; 95% CI 1.58–2.52) were independent correlates of HIV testing among sexually experienced females. Among sexually experienced males, HIV-positive status (OR = 1.76; 95% CI 1.14–2.73), personally knowing someone that died of AIDS (OR = 1.68; 95% CI 1.14–2.47), being aged 20–24 years (OR = 1.56; 95% CI 1.10–2.22) and having completed high school (OR = 1.58; 95% CI 1.17–2.12) were independent correlates of HIV testing. The following factors were significantly associated with HIV testing among both men and women; ever talking to parents about HIV/AIDS, ever participating in a loveLife programme, a higher frequency of visits to a clinic in the past 12 months and non-black race (p<0.05). There is a need to better understand the correlates of HIV testing to ensure that adolescent HIV prevention programmes actively promote HIV testing among this group. Specific attention needs to be paid to young women who do not access antenatal care and young men who are less regular users of routine clinical care. Communication is a significant predictor of having tested for HIV and should be encouraged with parents and through intervention programmes for adolescents. Finally, specific attention must be paid to increasing access to HIV testing for at-risk adolescents in rural communities.

Relative risk of HIV infection among young men and women in a South African township

The prevalence of HIV infection in Africa is substantially higher among young women than it is among young men. Biological explanations of this difference have been presented but there has been little exploration of social factors. In this paper we use data from Carletonville, South Africa to explore various social explanations for greater female infection rates. This paper reports on data from a random sample of 507 people between 13 and 24 years old. Subjects were tested for HIV, as well as other sexually transmitted infections (STIs), and answered a behavioural questionnaire. The age-prevalence of HIV infection differs between men and women with considerably higher rates of increase with age among young women. The age of sexual debut did not differ significantly between men and women (15.9 and 16.3 years, respectively) and below the age of 20 years there was no difference in the number or distribution of the number of sexual partners reported by men or women. The risk of infection per partnership was substantially higher among women than among men. Women have sexual partners who are, on average, about five years older than they are with some variation with age. Scaling the age-prevalence curve for men by the age of their sexual partners gives a curve whose shape is indistinguishable from that for women but is about 30% lower for men than for women. In terms of social explanations for HIV rates among women, the data indicates that this difference can be explained by the relative age of sexual partners, but not by other factors explored. In addressing the epidemic among young women it will be essential to deal with the social factors that lead young women to select their partners from older-age cohorts and that shape their sexual networking patterns.

A community‐based study to examine the effect of a youth HIV prevention intervention on young people aged 15–24 in South Africa: results of the baseline survey

Objectives  To determine whether South African youths living in communities that had either of two youth human immunodeficiency virus (HIV) prevention interventions [(a) loveLife Youth Centre or (b) loveLife National Adolescent Friendly Clinic Initiative] would have a lower prevalence of HIV, sexually transmitted infections (STIs), and high risk sexual behaviours than communities without either of these interventions.

“You Must Do the Test to Know Your Status”: Attitudes to HIV Voluntary Counseling and Testing for Adolescents Among South African Youth and Parents

Reduced HIV risk behavior and increased use of care and support services have been demonstrated among adults accessing HIV voluntary counseling and testing (VCT). The impact of VCT on adolescents is, however, not known. Focus group discussions were held with adolescents and parents in two South African townships to establish the perceptions of and needs for VCT among young people. Ecological theory informed the analysis. Adolescents had limited experience of VCT, were afraid of knowing their HIV status, and felt that testing was only for symptomatic individuals. Youth felt that they would disclose their HIV status to family members who they felt would be most supportive. Youth were afraid of stigma and discrimination; rarely referring to the community as a source of support. Discussions highlighted the inappropriateness of clinical facilities for youth VCT. We conclude with recommendations for youth-friendly VCT services.

Potential for an intervention based on male circumcision in a South African town with high levels of HIV infection.

The study aims to investigate the potential for an intervention based on male circumcision in a South African town with a high level of HIV infection. It draws on two cross-sectional studies conducted in August 2000 among a sample of 606 male adults aged 13-59 years, and in August 1999 among a sample of 723 male youth aged 14-24 years. A qualitative study was further conducted on perceptions and attitudes towards male circumcision using focus group discussions and in-depth interview. Among men aged 25-59 years, 36% reported being circumcised. The median reported age at circumcision was 20. A total of 42% of 14-24-year-old circumcised men reported having been circumcised in a medical setting. Circumcised and uncircumcised men did not differ in their sexual behaviour or in sociodemographic characteristics, apart from their age and ethnic group. Among 467 uncircumcised adult men, 59% said that they would be circumcised if circumcision reduced the chances of getting HIV and STDs. Focus group discussions showed that circumcision is still important to many people, and is seen as an essential part of the transition into adulthood. Reluctance to be circumcised was mainly related to the possibility of adverse outcomes of circumcision performed in non-medical settings, although initiation schools remain attractive for education and transmission of cultural values. Some misconceptions remain, however, especially about the preventative nature of circumcision for STD transmission. The cultural importance of male circumcision has weakened over the last century and when it is done it is often by a medical practitioner. An intervention that would include male circumcision seems feasible in communities such as the one where this study was conducted but needs to be carefully planned in order to ensure that participants understand that circumcision probably reduces, but certainly does not eliminate, the risk of HIV infection.