Redwaan Vermaak

HIV/AIDS Risks among Men and Women Who Drink at Informal Alcohol Serving Establishments (Shebeens) in Cape Town, South Africa

HIV/AIDS is devastating southern Africa and the spread of HIV is fueled in some populations by alcohol use. Alcohol serving establishments, such as informal drinking places or shebeens, often serve as high-risk venues for HIV transmission. The current study examined the HIV risks of men (N = 91) and women (N = 248) recruited from four shebeens in a racially integrating township in Cape Town South Africa. Participants completed confidential measures of demographic characteristics, HIV risk history, alcohol and drug use, and HIV risk behaviors. Comparisons of 94 (28%) participants who reported meeting sex partners at shebeens to the remaining sample of shebeen goers, controlling for potential confounds, demonstrated a pattern of higher risk for HIV infection among persons who met sex partners at shebeens. Few differences, however, were observed between men (N = 47) and women (N = 47) who had met sex partners at shebeens, suggesting greater gender similarities than gender differences in this important subpopulation. These results indicate an urgent need for multi-level HIV prevention interventions targeting shebeens and the men and women who drink in these settings.

HIV / AIDS risk reduction counseling for alcohol using sexually transmitted infections clinic patients in Cape Town South Africa.

Background:HIV is ravaging southern Africa, and HIV transmission risk behaviors are facilitated by alcohol use in sexual contexts. There are no known interventions that directly target HIV risk behavior among people who drink and are at risk for HIV in Africa. Purpose:To test a behavioral risk reduction counseling intervention for use in sexually transmitted infection (STI) clinics in southern Africa. Methods:A randomized intervention trial was conducted with 143 STI clinic patients in Cape Town, South Africa. Participants received an experimental 60-minute HIV and alcohol risk reduction behavioral skills intervention or a control 20-minute HIV education condition. Participants were followed for 3 and 6 months after the intervention, with 73% retention. Results:Overall, the experimental intervention demonstrated more than a 25% increase in condom use and a 65% reduction in unprotected intercourse over the 6-month follow-up period, with risk reduction significantly greater for the experimental condition than for the control condition at both follow-ups. Alcohol use in sexual contexts [F(1,94) = 6.2; P < 0.05] and expectancies that alcohol enhances sexual experiences [F(1,94) = 8.3; P < 0.01] were also significantly lower for the experimental condition at the 3-month follow-up. Conclusions:An HIV prevention counseling intervention reduced HIV transmission risks for up to 6 months in this STI clinic population. Effects may be sustained with structural interventions to reduce alcohol use in sexual contexts and support risk reduction behavior changes over the long-term.

Sensation seeking and alcohol use predict HIV transmission risks: Prospective study of sexually transmitted infection clinic patients, Cape Town, South Africa ☆

Alcohol is related to HIV risk behaviors in southern Africa and these behaviors are correlated with sensation seeking personality and alcohol outcome expectancies. Here we report for the first time the associations among sensation seeking, substance use, and sexual risks in a prospective study in Africa. Sexually transmitted infection clinic patients in Cape Town South Africa (157 men and 64 women) completed (a) baseline measures of sensation seeking, sexual enhancement alcohol outcome expectancies, alcohol use in sexual contexts, and unprotected sexual behaviors and (b) 6-month follow-up measures of alcohol use in sexual contexts and unprotected sexual acts. Results confirmed that sensation seeking predicts HIV risk behavior and sensation seeking is related to alcohol outcome expectancies which in turn predict alcohol use in sexual contexts. HIV prevention counseling that addresses drinking in relation to sex is urgently needed in southern Africa.

Impact of HIV testing on sexual health communication in South Africa

Objectives The South African government recently launched a national campaign to test 15 million South Africans for HIV by 2011. Little is known about how receipt of HIV testing might influence interpersonal communication. To explore these questions, the authors examined the effects of prior HIV testing on sexual health communication among South Africans. Methods Adults (N=1284; 98% black, 36% women, mean age 31) residing in a South African township completed street-intercept surveys. Results Of the 1284 participants, 811 (63%) had been tested for HIV. Among those who had been tested, 77% tested negative, 12% tested positive, and 11% did not know their test result or refused to answer. Compared with those who had not been tested, participants who had been tested for HIV were more likely to communicate with community members about (a) HIV/AIDS, (b) getting tested for HIV, and (c) using condoms. Testing positive for HIV was associated with communication with sexual partners about condom use. Among participants who had been tested for HIV, exploratory analyses revealed that those who had engaged in sexual health communication with community members or sexual partners reported more condom-protected sex than those who had not engaged in sexual health communication. Conclusions HIV testing is associated with sexual health communication among South African community members and sexual partners. Offering HIV testing to all South Africans may increase communication and lead to reductions in sexual risk.

Does perceived life stress mediate the association between HIV status and alcohol use? Evidence from adults living in Cape Town, South Africa

South Africa has the highest prevalence of HIV in the world. Because living with HIV is stressful and because alcohol consumption is often used to cope with stress, we examined whether stress mediates the association between HIV status and alcohol use among adults residing in South African townships. Field workers approached pedestrians or patrons of informal alcohol-serving venues (i.e., shebeens) and invited their participation in a survey. Of the 1717 participants (98% Black, 34% women, mean age = 31 years), 82% were HIV-negative, 9% were HIV-positive, and 9% did not know their test result. Participants living with HIV reported greater perceived life stress compared to participants whose HIV status was negative or unknown. Perceived stress was associated with an increase in the frequency of alcohol use (drinking days, intoxication, and drinking in shebeens/taverns). Subsequent analyses showed that stress mediated the association between HIV status and alcohol use. These findings indicate that greater frequency of drinking days, perceived intoxication, and drinking at shebeens was associated with elevated stress levels among participants who were HIV positive. Perceived life stress mediates the association between HIV status and alcohol use. Programs to enhance stress management among HIV-positive South Africans may help to reduce alcohol consumption, which may, in turn, lead to reduced rates of HIV transmission.

Individual and community-level risk factors for Hiv stigma in 21 Zambian and South African communities: analysis of data from the Hptn071 (popart) study

Objective: To describe the prevalence and determinants of HIV stigma in 21 communities in Zambia and South Africa. Design: Analysis of baseline data from the HPTN 071 (PopART) cluster-randomized trial. HIV stigma data came from a random sample of 3859 people living with HIV. Community-level exposures reflecting HIV fears and judgements and perceptions of HIV stigma came from a random sample of community members not living with HIV (n = 5088), and from health workers (HW) (n = 851). Methods: We calculated the prevalence of internalized stigma, and stigma experienced in the community or in a healthcare setting in the past year. We conducted risk-factor analyses using logistic regression, adjusting for clustering. Results: Internalized stigma (868/3859, prevalence 22.5%) was not associated with sociodemographic characteristics but was less common among those with a longer period since diagnosis (P = 0.043). Stigma experienced in the community (853/3859, 22.1%) was more common among women (P = 0.016), older (P = 0.011) and unmarried (P = 0.009) individuals, those who had disclosed to others (P < 0.001), and those with more lifetime sexual partners (P < 0.001). Stigma experienced in a healthcare setting (280/3859, 7.3%) was more common among women (P = 0.019) and those reporting more lifetime sexual partners (P = 0.001) and higher wealth (P = 0.003). Experienced stigma was more common in clusters wherever community members perceived higher levels of stigma, but was not associated with the beliefs of community members or HW. Conclusion: HIV stigma remains unacceptably high in South Africa and Zambia and may act as barrier to HIV prevention and treatment. Further research is needed to understand its determinants.

Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trial

Summary Background The life expectancy of HIV-positive individuals receiving antiretroviral therapy (ART) is approaching that of HIV-negative people. However, little is known about how these populations compare in terms of health-related quality of life (HRQoL). We aimed to compare HRQoL between HIV-positive and HIV-negative people in Zambia and South Africa. Methods As part of the HPTN 071 (PopART) study, data from adults aged 18–44 years were gathered between Nov 28, 2013, and March 31, 2015, in large cross-sectional surveys of random samples of the general population in 21 communities in Zambia and South Africa. HRQoL data were collected with a standardised generic measure of health across five domains. We used β-distributed multivariable models to analyse differences in HRQoL scores between HIV-negative and HIV-positive individuals who were unaware of their status; aware, but not in HIV care; in HIV care, but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more. We included controls for sociodemographic variables, herpes simplex virus type-2 status, and recreational drug use. Findings We obtained data for 19 750 respondents in Zambia and 18 941 respondents in South Africa. Laboratory-confirmed HIV status was available for 19 330 respondents in Zambia and 18 004 respondents in South Africa; 4128 (21%) of these 19 330 respondents in Zambia and 4012 (22%) of 18 004 respondents in South Africa had laboratory-confirmed HIV. We obtained complete HRQoL information for 19 637 respondents in Zambia and 18 429 respondents in South Africa. HRQoL scores did not differ significantly between individuals who had initiated ART more than 5 years previously and HIV-negative individuals, neither in Zambia (change in mean score −0·002, 95% CI −0·01 to 0·001; p=0·219) nor in South Africa (0·000, −0·002 to 0·003; p=0·939). However, scores did differ between HIV-positive individuals who had initiated ART less than 5 years previously and HIV-negative individuals in Zambia (−0·006, 95% CI −0·008 to −0·003; p<0·0001). A large proportion of people with clinically confirmed HIV were unaware of being HIV-positive (1768 [43%] of 4128 people in Zambia and 2026 [50%] of 4012 people in South Africa) and reported good HRQoL, with no significant differences from that of HIV-negative people (change in mean HRQoL score −0·001, 95% CI −0·003 to 0·001, p=0·216; and 0·001, −0·001 to 0·001, p=0·997, respectively). In South Africa, HRQoL scores were lower in HIV-positive individuals who were aware of their status but not enrolled in HIV care (change in mean HRQoL −0·004, 95% CI −0·01 to −0·001; p=0·010) and those in HIV care but not on ART (−0·008, −0·01 to −0·004; p=0·001) than in HIV-negative people, but the magnitudes of difference were small. Interpretation ART is successful in helping to reduce inequalities in HRQoL between HIV-positive and HIV-negative individuals in this general population sample. These findings highlight the importance of improving awareness of HIV status and expanding ART to prevent losses in HRQoL that occur with untreated HIV progression. The gains in HRQoL after individuals initiate ART could be substantial when scaled up to the population level. Funding National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, Presidents Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, the Bill & Melinda Gates Foundation.

Identifying community risk factors for HIV among South African adolescents with mental health problems: A qualitative study of parental perceptions

High risk sexual behaviour, alcohol and drug use, and mental health problems combine to yield high levels of HIV-risk behaviour among adolescents with mental health problems. In South Africa, little research has been conducted on parental perspectives of HIV-risk among this population. We conducted a series of focus group discussions with 28 mothers of adolescents receiving services at two mental health clinics in South Africa to identify, from their perspectives, the key community problems facing their children. Participants indicated that HIV remained a serious threat to their adolescent childrens well-being, in addition to substance abuse, early sexual debut, and teenage pregnancy. These social problems were mentioned as external to their household dynamics, and thus seemingly beyond the purview of the parent–adolescent relationship. These data have implications for the design of family-based interventions to ameliorate the factors associated with HIV-risk among youth receiving mental health services.

Incidence of Tuberculosis amongst HIV positive individuals initiating antiretroviral treatment at higher CD4 counts in the HPTN 071 (PopART) trial in South Africa.

Introduction: Antiretroviral treatment (ART) guidelines recommend life-long ART for all HIV-positive individuals. This study evaluated tuberculosis (TB) incidence on ART in a cohort of HIV-positive individuals starting ART regardless of CD4 count in a programmatic setting at 3 clinics included in the HPTN 071 (PopART) trial in South Africa. Methods: A retrospective cohort analysis of HIV-positive individuals aged ≥18 years starting ART, between January 2014 and November 2015, was conducted. Follow-up was continued until 30 May 2016 or censored on the date of (1) incident TB, (2) loss to follow-up from HIV care or death, or (3) elective transfer out; whichever occurred first. Results: The study included 2423 individuals. Median baseline CD4 count was 328 cells/&mgr;L (interquartile range 195–468); TB incidence rate was 4.41/100 person-years (95% confidence interval [CI]: 3.62 to 5.39). The adjusted hazard ratio of incident TB was 0.27 (95% CI: 0.12 to 0.62) when comparing individuals with baseline CD4 >500 and ⩽500 cells/&mgr;L. Among individuals with baseline CD4 count >500 cells/&mgr;L, there were no incident TB cases in the first 3 months of follow-up. Adjusted hazard of incident TB was also higher among men (adjusted hazard ratio 2.16; 95% CI: 1.41 to 3.30). Conclusions: TB incidence after ART initiation was significantly lower among individuals starting ART at CD4 counts above 500 cells/&mgr;L. Scale-up of ART, regardless of CD4 count, has the potential to significantly reduce TB incidence among HIV-positive individuals. However, this needs to be combined with strengthening of other TB prevention strategies that target both HIV-positive and HIV-negative individuals.

Exploring Risk and Protective Mechanisms Associated With hiv Infection Among Adolescents in South Africa

This study explored South African adolescents’ perceived risk and protection for HIV infection. Adolescents (N=28) with a mean age of 14.6 years receiving mental health care participated in Focus Group Discussions (FGDs) to engage in an in-depth exploration of their perceived risk and protective mechanisms for HIV prevention. The data were analysed using thematic content analysis. Themes that emerged from the FGDs associated with risk for HIV infection were: Alcohol and illicit drug use; Non-condom use; Prostitution and risky sexual activity with multiple partners; and Non-disclosure of HIV status. Themes that emerged as protective mechanisms included: HIV knowledge and appropriate HIV risk reducing behaviour; and Proactive parental attitudes and behaviour. These findings highlight the importance of ascertaining the perceptions of adolescents about risk and protection from HIV infection in order to inform future programs for HIV prevention among adolescents.