Katherine Fritz

Removing barriers to knowing HIV status: Same-day mobile HIV testing in Zimbabwe

Objectives:We developed a mobile HIV voluntary counseling testing (VCT) strategy. Our aims were (1) to describe those using the services, (2) to assess the acceptability of such services, (3) to assess reasons for not testing previously, and (4) to compare those who used the services with those who did not to determine how to increase acceptability. Methods:We provided free anonymous mobile VCT using 2 rapid HIV tests in 12 marketplaces in Epworth and Seke, Zimbabwe. Qualitative interviews were conducted to assess motivations for and barriers to testing. A subsample of HIV testers and individuals near testing vans who declined testing (nontesters) completed a questionnaire. Results:A total of 1099 individuals participated in mobile VCT between March 2002 and August 2003. The proportion of participants infected with HIV was 29.2%. Overall, 98.8% of participants elected to receive HIV test results the same day. Reasons for not testing previously were often logistic (eg, inconvenience of hours [25.6%] and location [20.7%] or cost [8%]). Those who used the same-day mobile testing services (testers vs. nontesters) perceived themselves at higher risk for HIV infection (adjusted odds ratio [AOR] = 1.8) but were less likely to have known people with HIV (AOR = 0.49) or where to get tested (AOR = 0.57). Conclusions:Same-day HIV testing in community settings seems to be acceptable in sub-Saharan Africa. Barriers to HIV testing are often logistic and can be overcome with community-based strategies. These strategies need to be refined to address the needs of those not using mobile testing services.

A comparison of HIV stigma and discrimination in five international sites: The influence of care and treatment resources in high prevalence settings

What accounts for differences in HIV stigma across different high prevalence settings? This study was designed to examine HIV stigma and discrimination in five high prevalence settings. Qualitative data were collected as part of the U.S. National Institute of Mental Health (NIMH) Project Accept, a multi-site community randomized trial of community-based HIV voluntary counseling and testing. In-depth interviews were conducted with 655 participants in five sites, four in Sub-Saharan Africa and one in Southeast Asia. Interviews were conducted in the local languages by trained research staff. Data were audiotaped, transcribed, translated, coded and computerized for thematic data analysis. Participants described the stigmatizing attitudes and behaviors perpetuated against people living with HIV/AIDS (PLWHA). The factors that contribute to HIV stigma and discrimination include fear of transmission, fear of suffering and death, and the burden of caring for PLWHA. The family, access to antiretrovirals and other resources, and self-protective behaviors of PLWHA protected against HIV stigma and discrimination. Variation in the availability of health and socioeconomic resources designed to mitigate the impact of HIV/AIDS helps explain differences in HIV stigma and discrimination across the settings. Increasing access to treatment and care resources may function to lower HIV stigma, however, providing services is not enough. We need effective strategies to reduce HIV stigma as treatment and care resources are scaled up in the settings that are most heavily impacted by the HIV epidemic.

Project Accept (HPTN 043): a community-based intervention to reduce HIV incidence in populations at risk for HIV in sub-Saharan Africa and Thailand.

Background:Changing community norms to increase awareness of HIV status and reduce HIV-related stigma has the potential to reduce the incidence of HIV-1 infection in the developing world. Methods:We developed and implemented a multilevel intervention providing community-based HIV mobile voluntary counseling and testing, community mobilization, and posttest support services. Forty-eight communities in Tanzania, Zimbabwe, South Africa, and Thailand were randomized to receive the intervention or clinic-based standard voluntary counseling and testing (VCT), the comparison condition. We monitored utilization of community-based HIV mobile voluntary counseling and testing and clinic-based standard VCT by community of residence at 3 sites, which was used to assess differential uptake. We also developed quality assurance procedures to evaluate staff fidelity to the intervention. Findings:In the first year of the study, a 4-fold increase in testing was observed in the intervention versus comparison communities. We also found an overall 95% adherence to intervention components. Study outcomes, including prevalence of recent HIV infection and community-level HIV stigma, will be assessed after 3 years of intervention. Conclusions:The provision of mobile services, combined with appropriate support activities, may have significant effects on utilization of voluntary counseling and testing. These findings also provide early support for community mobilization as a strategy for increasing testing rates.

The Association Between Alcohol Use, Sexual Risk Behavior, and HIV Infection Among Men Attending Beerhalls in Harare, Zimbabwe

HIV testing and a behavioral survey were conducted with a cross-sectional sample of 324 men recruited at beerhalls in Harare, Zimbabwe, to examine the relationship among alcohol use, high-risk sexual behavior, and HIV infection among male beerhall patrons and to evaluate the feasibility of using beerhalls as venues for male-centered HIV prevention activities. Recent HIV seroconversions were identified using the less-sensitive enzyme immunoassay. HIV education activities were provided inside beerhalls and qualitative methods were used to assess the acceptability of conducting HIV prevention activities and research at beerhalls. The prevalence of HIV infection was 30%; the prevalence of recent seroconversion was 3.4%. Having sex while intoxicated in the previous 6 months was reported by 31% of men and was strongly associated with recent HIV seroconversion as well as unprotected sex with casual partners and paying for sex. Acceptability of prevention and research activities was high among beerhall patrons, managers, and owners. Beerhalls present an environment associated with high-risk sexual behavior and concomitantly high rates of HIV seroconversion. Beerhalls are appropriate and feasible venues for delivering HIV prevention programs targeted at men in many regions of sub-Saharan Africa and the world.

Alcohol: the forgotten drug in HIV/AIDS

Alcohol has long been recognized as a significant contributor to illness and injury, accounting for 4% of the global burden of disease.1 Yet alcohol remains conspicuously absent from the larger field of HIV and substance use research and programming. Perhaps because of its very ubiquity, alcohol use remains an easily overlooked backdrop of HIV epidemics around the world. Patterns of hazardous alcohol consumption prevail in countries experiencing the most severe HIV epidemics, most notably in eastern and southern Africa (Figure 1). In South Africa, for example, where nearly one out of five sexually active adults is HIV positive, the yearly per capita consumption of alcohol is among the highest in the world.3 Strikingly, hazardous drinking patterns also dominate in the concentrated epidemics of Eastern Europe and Asia, where alcohol use among IDU and other marginalized groups may be an additional barrier to effective HIV prevention efforts. Figure 1 Global Distribution of Hazardous Alcohol Use. Based on data from the Comparative Risk Assessment for Alcohol, Global Burden of Disease 2000 study. Rehm J, Room R, Monteiro M, Gmel G, Graham K, Rehn N, Sempos C, Frick U, Jernigan D. Alcohol use. In: M. ... Numerous studies conducted in southern and eastern Africa have shown that alcohol use is associated with prevalent and incident HIV infection as well as the behaviours that lead to infection, including unprotected sex, multiple partnering and commercial sex.4 Drinking venues themselves are, not surprisingly, associated with HIV risk.5,6 The pharmacological properties of alcohol help explain a portion of the widely observed association between alcohol use and sexual risk behaviour.7 A nexus of psychological and social influences also appears to be at play. 8,9 A substantial body of research implicating alcohol consumption in sexual risk behaviour provides a compelling call to action. Lessons learned from the small amount of intervention research that has taken place on alcohol-related HIV risk closely mirrors many of the key messages put forth in the paper by Strathdee et al (this issue). We echo the importance of intervening on the structural and environmental influences that shape risk practices and vulnerability to HIV. Because alcohol is a legal commodity in most countries and is typically consumed in public social environments, alcohol-serving venues (both formal and informal) create dynamic opportunities for structural HIV prevention interventions. The most widely tested venue-based interventions have used bar patrons themselves as agents of change to shift community norms and behaviour.10 Implemented in US gay bars, these interventions were shown effective throughout the 1990s but unfortunately have not been replicable in other countries. More successful interventions have infused HIV prevention services into high-risk drinking venues using multilevel models that attempt to simultaneously change individual behaviour, shift social norms, and change HIV prevention policies. One example of a multilevel venue-based intervention was tested in the Philippines with sex workers in bars, discos, and night clubs.11 Peer counselling, focused on condom use and sexual negotiation skills, formed the basis for individual and social norm change. Changes to the bar environment were achieved through working with bar managers to implement HIV prevention practices. The combination of individual, social and environmental intervention elements demonstrated a significant impact on condom use and reductions in subsequent STI. While interventions aimed at social and physical structures within drinking environments appear promising, they have not thus far addressed broader social factors underlying alcohol-associated HIV risks, such as disproportionate gender power-imbalances. Hazardous alcohol use is often assumed primarily to affect men, but it is clear that women are harmed in large numbers by alcohol use—either their own or that of their partner. Women are at risk of alcohol-related sexual risk behaviour in multiple ways. Women who sell and serve alcohol in bars, hotels and other venues, are at increased risk of drinking alcohol themselves, engaging in unprotected sex with their clients, and HIV infection.12 Women’s risk of gender-based and sexual violence is also increased by their partner’s alcohol consumption. Without addressing gender, efforts to reduce alcohol-related sexual risk behaviour may only be partially successful. Programs combining alcohol reduction and gender transformative approaches are needed to reduce sexual risk behaviour and HIV incidence, particularly in resource constrained settings characterized by episodic binge drinking, gender inequalities and high rates of HIV infection. More research, conducted by gender and alcohol researchers jointly, is needed to determine methods of integrating gender into programs focused on reducing alcohol-related sexual risk behaviour and may offer valuable lessons for the wider field of HIV and substance use research.

Acceptability of adult male circumcision for sexually transmitted disease and HIV prevention in Zimbabwe

Worldwide over 35 cross-sectional and prospective studies1–6 various ecologic analyses and investigations of biologic plausibility sexually transmitted infection (STI) epidemiology and a longitudinal study of HIV-discordant heterosexual couples have identified lack of male circumcision as a significant risk factor for HIV acquisition. (However some crosssectional studies have found no correlation and in a Rwandan study women who reported that their current partners were circumcised had an increased risk of HIV.) In the regions of east and southern Africa where heterosexually spread HIV epidemics are especially severe large populations of men are uncircumcised pointing to a possible prevention intervention. Previous studies in 6 sub-Saharan African countries have explored men’s and women’s awareness of the potential health benefits of male circumcision and men’s willingness to undergo adult circumcision. Currently pilot programs to introduce safe affordable circumcision as part of male reproductive health services are being implemented or are planned in Botswana Haiti Kenya South Africa and Zambia. (excerpt)

Alcohol Use and High-Risk Sexual Behavior Among Adolescents and Young Adults in Harare, Zimbabwe

We conducted a quantitative and qualitative study of alcohol use and high-risk sexual behavior among adolescents and young adults of age 15–21 years in Harare, Zimbabwe. Methods included a cross-sectional survey of youth sampled at nightclubs and bottle stores informed by participant observation, key informant interviews, and focus group discussions. Findings corroborated a cycle of HIV transmission that involves older men, younger women, and ultimately the steady partners of both. Nightclubs and other drinking establishments catering to youth can provide opportunities for preventing HIV transmission through stuctural interventions or targeted outreach education.

The influence of antiretroviral treatment on willingness to test: a qualitative study in rural KwaZulu-Natal, South Africa

Previous quantitative studies suggest a mutually reinforcing relationship between HIV counselling and testing (HCT) and antiretroviral treatment (ART). HCT is the entry into ART, and access to ART appears to increase HIV-testing uptake in settings with historically low uptake. Adopting a qualitative approach, this study examined the influence of ART on willingness to test for HIV, in a rural community in South Africa. Ninety-six in-depth interviews from a large community-based HIV-prevention trial were analysed. The data provide insight into the community members’ views, perceptions and experiences regarding ART, and how they draw on these in making decisions about HIV testing. Several key factors that supported a positive relationship between ART and HIV testing were noted. These included the beliefs that ART brings hope and that it prolongs life; the powerful positive effect of witnessing the recovery of someone on treatment; and that ART encourages early HIV-testing behaviour. A few negative factors that could potentially weaken the effects of this positive relationship between ART and HCT uptake were the disclosure difficulties experienced by those enrolled in treatment, beliefs that ART does not cure HIV disease, and the travel distance to testing and treatment facilities from where people live and work. HIV/AIDS-service providers and programme planners should actively draw on these observations, to encourage increased HIV testing in communities and to ensure that the maximum number of people get the HIV treatment and care services that they require.

Understanding and addressing socio-cultural barriers to medical male circumcision in traditionally non-circumcising rural communities in sub-Saharan Africa

Given recent clinical trials establishing the safety and efficacy of adult medical male circumcision (MMC) in Africa, attention has now shifted to barriers and facilitators to programmatic implementation in traditionally non-circumcising communities. In this study, we attempted to develop a fuller understanding of the role of cultural issues in the acceptance of adult circumcision. We conducted four focus-group discussions with 28 participants in Mutoko, Zimbabwe, and 33 participants in Vulindlela, KwaZulu-Natal, South Africa, as well as 19 key informant interviews in both settings. We found the concept of male circumcision to be an alien practice, particularly as expressed in the context of local languages. Cultural barriers included local concepts of ethnicity, social groups, masculinity and sexuality. On the other hand, we found that concerns about the impact of HIV on communities resulted in willingness to consider adult male circumcision as an option if it would result in lowering the local burden of the epidemic. Adult MMC-promotional messages that create a synergy between understandings of both traditional and medical circumcision will be more successful in these communities.

Using Participatory Mapping to Inform a Community-Randomized Trial of HIV Counseling and Testing

Participatory mapping and transect walks were used to inform the research and intervention design and to begin building community relations in preparation for Project Accept, a community-randomized trial sponsored by the National Institute of Mental Health. Project Accept is being conducted at five sites in four countries: Thailand, Zimbabwe, South Africa, and Tanzania. Results from the mapping exercises informed decisions such as defining community boundaries and identifying appropriate criteria for matching community pairs for the trial as well as where to situate the services. The mapping also informed intervention-related decisions such as where to situate the services. The participatory methods enabled researchers at each site to develop an understanding of the communities that could not have been derived from existing data or data collected through standard data collection techniques. Furthermore, the methods lay the foundation for collaborative community research partnerships.