Articles tagged as "Structural determinants and vulnerability"

Intimate partner violence is a challenge to PrEP adherence

Intimate partner violence and adherence to HIV pre-exposure prophylaxis (PrEP) in African women in HIV serodiscordant relationships: a prospective cohort study.

Roberts ST, Haberer J, Celum C, Mugo N, Ware NC, Cohen CR, Tappero JW, Kiarie J, Ronald A, Mujugira A, Tumwesigye E, Were E, Irungu E, Baeten JM. J Acquir Immune Defic Syndr. 2016 May 26. [Epub ahead of print]

Background: Intimate partner violence (IPV) is associated with higher HIV incidence, reduced condom use, and poor adherence to antiretroviral therapy and other medications. IPV may also affect adherence to pre-exposure prophylaxis (PrEP).

Methods: We analyzed data from 1785 HIV-uninfected women enrolled in a clinical trial of PrEP among African HIV-serodiscordant couples. Experience of verbal, physical, or economic IPV was assessed at monthly visits by face-to-face interviews. Low PrEP adherence was defined as clinic-based pill count coverage <80% or plasma tenofovir levels <40 ng/mL. The association between IPV and low adherence was analyzed using generalized estimating equations, adjusting for potential confounders. In-depth interview transcripts were examined to explain how IPV could impact adherence.

Results: 16% of women reported IPV during a median of 34.8 months of follow-up (IQR 27.0 - 35.0). Overall, 7% of visits had pill count coverage <80% and 32% had plasma tenofovir <40 ng/mL. Women reporting IPV in the past 3 months had increased risk of low adherence by pill count (adjusted RR 1.49, 95% CI 1.17-1.89) and by plasma tenofovir (adjusted RR 1.51, 95% CI 1.06-2.15). Verbal, economic, and physical IPV were all associated with low adherence. However, the impact of IPV diminished and was not statistically significant 3 months after the reported exposure. In qualitative interviews, women identified several ways in which IPV affected adherence, including stress and forgetting, leaving home without pills, and partners throwing pills away.

Conclusion: Women who reported recent IPV in the Partners PrEP Study were at increased risk of low PrEP adherence. Strategies to mitigate PrEP non-adherence in the context of IPV should be evaluated.

Abstract access

Editor’s notes: The high rates of HIV infection in women underscore persistent gender inequalities, in particular that of violence against women. Intimate partner violence (IPV) puts women at increased risk of HIV infection. Further, among women living with HIV, IPV has also been associated with lower rates of treatment uptake and adherence to antiretroviral therapy (ART). The interaction between IPV and HIV is complex, and includes biological, socio-economic and cultural mechanisms. This is the first study to examine the association between IPV and adherence to HIV pre-exposure prophylaxis (PrEP).  Women who had experienced IPV in the past three months were 50% more likely than women who had never experienced IPV to have poor adherence, as measured by both pills counts and drug levels in the blood.  Recent IPV was also associated with an increase in the risk of HIV infection.  Women in the study were in stable, serodiscordant relationships, had enrolled in the study together with their partners, and were using PrEP with their partner’s consent. The proportion of women reporting IPV during the study was much lower than national estimates in the region.  These findings are thus of concern for PrEP demonstration projects focusing on key populations at high risk of HIV, who may experience higher rates of IPV and be less likely to have partner support. 

PrEP is a key element of combination HIV prevention strategies in high-risk populations, but requires high adherence in order to be effective. Programmes focusing on promoting PrEP adherence in women who have experienced violence are urgently needed.  More broadly, HIV prevention programmes should be expanded to integrate IPV prevention as an important component to reducing women’s risk of HIV.

Africa
Kenya, Uganda
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Inequalities in access to health care for older people living with HIV in South Africa

Health expenditure and catastrophic spending among older adults living with HIV.

Negin J, Randell M, Raban MZ, Nyirenda M, Kalula S, Madurai L, Kowal P. Glob Public Health. 2016 Apr 30:1-15. [Epub ahead of print]

Introduction: The burden of HIV is increasing among adults aged over 50, who generally experience increased risk of comorbid illnesses and poorer financial protection. We compared patterns of health utilisation and expenditure among HIV-positive and HIV-negative adults over 50.

Methods: Data were drawn from the Study on global AGEing and adult health in South Africa with analysis focusing on individual and household-level data of 147 HIV-positive and 2725 HIV-negative respondents.

Results: HIV-positive respondents reported lower utilisation of private health-care facilities (11.8%) than HIV-negative respondents (25.0%) (p = .03) and generally had more negative attitudes towards health system responsiveness than HIV-negative counterparts. Less than 10% of HIV-positive and HIV-negative respondents experienced catastrophic health expenditure (CHE). Women (OR 1.8; p < .001) and respondents from rural settings (OR 2.9; p < .01) had higher odds of CHE than men or respondents in urban settings. Over half the respondents in both groups indicated that they had received free health care.

Conclusions: These findings suggest that although HIV-positive and HIV-negative older adults in South Africa are protected to some extent from CHE, inequalities still exist in access to and quality of care available at health-care services - which can inform South Africa's development of a national health insurance scheme.

Abstract access

Editor’s notes: The study provides a valuable overview of the health expenditures of HIV-positive and negative older people (50 years and older) in South Africa. It should be noted that the data used in this analysis are from 2007-2008. Therefore, it is likely that some things may have changed as anti-retroviral therapy has become more available. Perhaps some of the negative experiences reported by people living with HIV may have changed. However, it is likely that waiting times in clinics and concerns about drug-stockouts, may not have changed. Nearly a decade on, the number of people in need of HIV-associated care, and the resulting burden on the health service remain immense. The authors point to the valuable role of the social security system in reducing the financial impact of HIV, and mitigating catastrophic health expenditures. 

The authors have produced an important paper, highlighting some of the inequities in health care access. Many of these inequities are likely to have persisted. It would be invaluable to have a similar analysis of more recent data in order to chart progress. 

Africa
South Africa
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What works to link people living with HIV to care - a review

Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review.

Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, Hall BJ, Yang B, Tucker JD. AIDS. 2016 Apr 6. [Epub ahead of print]

Objective: To synthesize qualitative evidence on linkage to care interventions for people living with HIV.

Design: Systematic literature review.

Methods: We searched nineteen databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the CASP tool and certainty of evidence was evaluated using the CERQual approach.

Results: Twenty-five studies from eleven countries focused on adults (24 studies), adolescents (8 studies), and pregnant women (4 Facilitators included community-level factors (i.e. task-shifting, mobile outreach, integrated HIV and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams) and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions.

Conclusions: Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, and integrated HIV and primary services. Both community and individual level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.

Abstract access  

Editor’s notes: As the authors of this paper observe, most evaluations of linkage to care programmes have focused on quantitative assessment. This useful paper provides a thorough overview of the findings from 25 studies which used qualitative methods for assessment. Linkage-to- care programmes feasible in different country settings were identified in this review.  The authors also highlight gaps, most notably a lack of information on linkage-to-care programmes for men. They also note the need for longitudinal assessments that look at changes over time.

This paper is a useful synthesis of findings. But it is also an excellent example of how to carry out a systematic review of qualitative research. The description of the qualitative meta-synthesis the authors performed adds additional value to this paper. 

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What works to link people living with HIV to care - a review

Facilitators and barriers in HIV linkage to care interventions: a qualitative evidence review.

Tso LS, Best J, Beanland R, Doherty M, Lackey M, Ma Q, Hall BJ, Yang B, Tucker JD. AIDS. 2016 Apr 6. [Epub ahead of print]

Objective: To synthesize qualitative evidence on linkage to care interventions for people living with HIV.

Design: Systematic literature review.

Methods: We searched nineteen databases for studies reporting qualitative evidence on linkage interventions. Data extraction and thematic analysis were used to synthesize findings. Quality was assessed using the CASP tool and certainty of evidence was evaluated using the CERQual approach.

Results: Twenty-five studies from eleven countries focused on adults (24 studies), adolescents (8 studies), and pregnant women (4 Facilitators included community-level factors (i.e. task-shifting, mobile outreach, integrated HIV and primary services, supportive cessation programs for substance users, active referrals, and dedicated case management teams) and individual-level factors (encouragement of peers/family and positive interactions with healthcare providers in transitioning into care). One key barrier for people living with HIV was perceived inability of providers to ensure confidentiality as part of linkage to care interventions. Providers reported difficulties navigating procedures across disparate facilities and having limited resources for linkage to care interventions.

Conclusions: Our findings extend the literature by highlighting the importance of task-shifting, mobile outreach, and integrated HIV and primary services. Both community and individual level factors may increase the feasibility and acceptability of HIV linkage to care interventions. These findings may inform policies to increase the reach of HIV services available in communities.

Abstract access  

Editor’s notes: As the authors of this paper observe, most evaluations of linkage to care programmes have focused on quantitative assessment. This useful paper provides a thorough overview of the findings from 25 studies which used qualitative methods for assessment. Linkage-to- care programmes feasible in different country settings were identified in this review.  The authors also highlight gaps, most notably a lack of information on linkage-to-care programmes for men. They also note the need for longitudinal assessments that look at changes over time.

This paper is a useful synthesis of findings. But it is also an excellent example of how to carry out a systematic review of qualitative research. The description of the qualitative meta-synthesis the authors performed adds additional value to this paper. 

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Strengthening PMTCT implementation through systems engineering

Impact of a systems engineering intervention on PMTCT service delivery in Cote d'Ivoire, Kenya, Mozambique: a cluster randomized trial.

Rustagi AS, Gimbel S, Nduati R, Cuembelo MF, Wasserheit JN, Farquhar C, Gloyd S, Sherr K, with input from the SST. J Acquir Immune Defic Syndr. 2016 Apr 14. [Epub ahead of print]

Background: Efficacious interventions to prevent mother-to-child HIV transmission (PMTCT) have not translated well into effective programs. Prior studies of systems engineering applications to PMTCT lacked comparison groups or randomization.

Methods: Thirty-six health facilities in Cote d'Ivoire, Kenya, and Mozambique were randomized to usual care or a systems engineering intervention, stratified by country and volume. The intervention guided facility staff to iteratively identify and then rectify barriers to PMTCT implementation. Registry data quantified coverage of HIV testing during first antenatal care visit, antiretrovirals (ARVs) for HIV-positive pregnant women, and screening HIV-exposed infants (HEI) for HIV by 6-8 weeks. We compared the change between baseline (January 2013-January 2014) and post-intervention (January-March 2015) periods using t-tests. All analyses were intent-to-treat.

Results: ARV coverage increased 3-fold (+13.3 percentage points [95% CI: 0.5, 26.0] in intervention vs. +4.1 [-12.6, 20.7] in control facilities) and HEI screening increased 17-fold (+11.6 [-2.6, 25.7] in intervention vs. +0.7 [-12.9, 14.4] in control facilities). In pre-specified sub-group analyses, ARV coverage increased significantly in Kenya (+20.9 [-3.1, 44.9] in intervention vs. -21.2 [-52.7, 10.4] in controls; p=0.02). HEI screening increased significantly in Mozambique (+23.1 [10.3, 35.8] in intervention vs. +3.7 [-13.1, 20.6] in controls; p=0.04). HIV testing did not differ significantly between arms.

Conclusions: In this first randomized trial of systems engineering to improve PMTCT, we saw substantially larger improvements in ARV coverage and HEI screening in intervention facilities compared to controls, which were significant in pre-specified sub-groups. Systems engineering could strengthen PMTCT service delivery and protect infants from HIV.

Abstract access

Editor’s notes: Systems engineering is an interdisciplinary approach to optimise complex processes or systems. In this randomised trial of a systems engineering approach to improving prevention  of mother-to-child HIV transmission programmes, the study programme was a five-step, iterative package of systems analysis and quality improvement tools. In lay terms, the systems engineering activity helped facility staff understand implementation barriers to prevention of mother-to-child transmission programme service delivery, identify bottlenecks and patient dropout along the cascade and develop a facility-specific microintervention to address these issues. This was then repeated in a quality improvement iterative cycle with the overall aim to improve the flow of mother-infant pairs through the prevention of mother-to-child HIV transmission cascade. Study findings suggest that a systems engineering approach could markedly increase antiretroviral therapy coverage and HIV-exposed infant screening in prevention of mother-to-child HIV transmission programmes.  Further studies evaluating a systems engineering approach in the context of programmatic HIV care, especially in resource-poor settings, are required.

Africa
Côte d'Ivoire, Kenya, Mozambique
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Addressing alcohol use can improve structural factors in the lives of sex workers

The impact of an alcohol harm reduction intervention on interpersonal violence and engagement in sex work among female sex workers in Mombasa, Kenya: Results from a randomized controlled trial.

Parcesepe AM, KL LE, Martin SL, Green S, Sinkele W, Suchindran C, Speizer IS, Mwarogo P, Kingola N. Drug Alcohol Depend. 2016 Apr 1;161:21-8. doi: 10.1016/j.drugalcdep.2015.12.037. Epub 2016 Jan 22.

Aims: To evaluate whether an alcohol harm reduction intervention was associated with reduced interpersonal violence or engagement in sex work among female sex workers (FSWs) in Mombasa, Kenya.

Design: Randomized controlled trial.

Setting: HIV prevention drop-in centers in Mombasa, Kenya.

Participants: 818 women 18 or older in Mombasa who visited HIV prevention drop-in centers, were moderate-risk drinkers and engaged in transactional sex in past six months (410 and 408 in intervention and control arms, respectively).

Intervention: 6 session alcohol harm reduction intervention.

Comparator: 6 session non-alcohol related nutrition intervention.

Measurements: In-person interviews were conducted at enrollment, immediately post-intervention and 6-months post-intervention. General linear mixed models examined associations between intervention assignment and recent violence (physical violence, verbal abuse, and being robbed in the past 30 days) from paying and non-paying sex partners and engagement in sex work in the past 30 days.

Findings: The alcohol intervention was associated with statistically significant decreases in physical violence from paying partners at 6 months post-intervention and verbal abuse from paying partners immediately post-intervention and 6-months post-intervention. Those assigned to the alcohol intervention had significantly reduced odds of engaging in sex work immediately post-intervention and 6-months post-intervention.

Conclusions: The alcohol intervention was associated with reductions in some forms of violence and with reductions in engagement in sex work among FSWs in Mombasa, Kenya.

Abstract access  

Editor’s notes: Modifying structural drivers, such as alcohol, violence, or socio-economic status is a challenging but necessary component of developing sustainable, effective solutions to the HIV epidemic. This study presents findings from an individually randomised trial, where female sex workers were randomised to receive an individual-level programme focused on alcohol and substance use, and to assess non-alcohol associated outcomes of violence, and indirectly economic vulnerability. While the programme did not produce persistent effects at six months for all components, it very usefully demonstrated how addressing alcohol use, a structural factor central to sex workers’ lives, can potentially also improve non-alcohol associated outcomes. These included experiences of violence, economic status, and even ability to reduce time spent in sex work. Alcohol harm reduction programming should be integrated into HIV prevention programming with female sex workers, regardless of HIV status.

Africa
Kenya
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Intimate partner violence among female sex workers living with HIV must be addressed to improve their wellbeing and reduce onward transmission of HIV

A prospective cohort study of intimate partner violence and unprotected sex in HIV-positive female sex workers in Mombasa, Kenya.

Wilson KS, Deya R, Yuhas K, Simoni J, Vander Stoep A, Shafi J, Jaoko W, Hughes JP, Richardson BA, McClelland RS. AIDS Behav. 2016 Apr 19. [Epub ahead of print]

We conducted a prospective cohort study to test the hypothesis that intimate partner violence (IPV) is associated with unprotected sex in HIV-positive female sex workers in Mombasa, Kenya. Women completed monthly visits and quarterly examinations. Any IPV in the past year was defined as ≥1 act of physical, sexual, or emotional violence by the current or most recent emotional partner ('index partner'). Unprotected sex with any partner was measured by self-report and prostate specific antigen (PSA) test. Recent IPV was associated with significantly higher risk of unprotected sex (adjusted relative risk [aRR] 1.91, 95 % CI 1.32, 2.78, p = 0.001) and PSA (aRR 1.54, 95 % CI 1.17, 2.04, p = 0.002) after adjusting for age, alcohol use, and sexual violence by someone besides the index partner. Addressing IPV in comprehensive HIV programs for HIV-positive women in this key population is important to improve wellbeing and reduce risk of sexual transmission of HIV.

Abstract access  

Editor’s notes: Intimate partner violence (IPV) is the most common form of gender-based violence globally. A recent systematic review reported high prevalence of IPV in sub-Saharan Africa, ranging from 30% to 66% among ever partnered women. Negative outcomes associated with IPV include increased risk of HIV infection and there are multiple pathways through which IPV may increase the risk of HIV infection in women. These include reduced sexual relationship power and ability to negotiate condom, and more risky sexual behaviour. Furthermore, IPV may be a marker of relationships with men who have a history of violent behaviour and may be at increased risk of HIV themselves. Women living with HIV are also at increased risk of IPV, which in turn can increase the risk of condomless sex and onward transmission of HIV.

Female sex workers are a key population disproportionately affected by violence, substance abuse and HIV. This longitudinal study of female sex workers in Kenya found a significant association between IPV and condomless sex. It highlights the value of using both self-reported behavioural and biological markers of sexual behaviour to gain a more complete understanding of the relationship between IPV and risky sexual behaviour. Comprehensive HIV programmes must address IPV to improve both the health and well-being of women living with HIV and to reduce sexual transmission of HIV. 

Africa
Kenya
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The right kind of sex

The feminine ideal and transactional sex: navigating respectability and risk in Swaziland.

Fielding-Miller R, Dunkle KL, Jama-Shai N, Windle M, Hadley C, Cooper HL. Soc Sci Med. 2016 Apr 7;158:24-33. doi: 10.1016/j.socscimed.2016.04.005. [Epub ahead of print]

Women who engage in transactional sex are not only at increased risk of HIV and intimate partner violence, but also face social risks including gossip and ostracism. These social and physical risks may be dependent on both what a woman expects and needs from her partner and how her community perceives the relationship. Gender theory suggests that some of these social risks may hinge on whether or not a woman's relationship threatens dominant masculinity. We conducted a qualitative study in Swaziland from September 2013 to October 2014 to explore transactional sex and respectable femininity through the lens of hegemonic gender theory. Using cultural consensus modeling, we identified cultural models of transactional sex and conducted 16 in-depth interviews with model key informants and 3 focus group discussions, for a total of 41 participants. We identified 4 main models of transactional relationships: One typified by marriage and high social respectability, a second in which women aspire towards marriage, a third particular to University students, and a fourth "sugar daddy" model. Women in all models expected and received significant financial support from their male partners. However, women in less respectable relationships risked social censure and stigma if they were discovered, in part because aspects of their relationship threatened hegemonic masculinity. Conversely, women who received male support in respectable relationships had to carefully select HIV risk reduction strategies that did not threaten their relationship and associated social status. Research and programming efforts typically focus only on the less socially respectable forms of transactional sex. This risks reinforcing stigma for women in relationships that are already considered socially unacceptable while ignoring the unique HIV risks faced by women in more respectable relationships.

Abstract access

Editor’s notes: Adolescent girls and young women are at a disproportionate risk of HIV infection when compared to their male counterparts. Transactional sex is associated with gendered HIV vulnerability in sub-Saharan Africa and is also associated with intimate partner violence. While economic exchange is present in many relationships, adolescent girls and young women are required to navigate a line between acceptable and unacceptable economic dependence. This line is further complicated by the fact that in much of the world, the notion of ‘men as providers’ is considered the norm. 

The findings illustrate, as with previous research, that women’s economic dependence in relationships was seen to be a risk. So too was social pressure. Women whose relationships manifested an emphasised femininity used health protection strategies that did not jeopardise their relationship (for example always being sexually available) so as to maintain their social and economic stability. Health protection strategies of women, whose relationship was deemed less acceptable, were more mixed.  They may have been less able to negotiate condom use or sexual encounters if they were financially dependent on their partners. But they may also have been more willing to leave a partner or demand condom use. Women who were ‘too independent’ were condemned and stigmatised by community members because of their threat to male dominance.  Programmes designed to reduce risk associated with transactional sex may have greater impact if they focus on the power dynamics created by gender norms. This may be more effective than focusing on the exchange of gifts or money within a relationship. It is important to pay careful attention to local understandings and interpretation of women’s financial, sexual and romantic obligations. We also need to understand women’s motivations for entering or remaining in sexual relationships.

Africa
Swaziland
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Risky young love

Perspectives on intimate relationships among young people in rural South Africa: the logic of risk. 

Edin K, Nilsson B, Ivarsson A, Kinsman J, Norris SA, Kahn K. Cult Health Sex. 2016 Mar 17:1-15. [Epub ahead of print]

This paper explores how young people in rural South Africa understand gender, dating, sexuality and risk-taking in adolescence. The empirical material drawn upon consists of 20 interviews with young men and women (aged 18-19) and reflects normative gender patterns characterised by compulsory heterosexuality and dating as obligatory, and representing key symbols of normality. However, different meanings of heterosexual relationships are articulated in the interviews, for example in the recurring concept of 'passing time', and these meanings show that a relationship can be something arbitrary: a way to reduce boredom and have casual sex. Such a rationale for engaging in a relationship reflects one of several other normative gender patterns, which relate to the trivialisation of dating and sexual risk-taking, and which entail making compromises and legitimising deviations from the 'ideal' life-script and the hope of a better future. However, risks do not exclusively represent something bad, dangerous or immoral, because they are also used as excuses to avoid sex, HIV acquisition and early pregnancy. In conclusion, various interrelated issues can both undermine and/or reinforce risk awareness and subsequent risk behaviour. Recognition of this tension is essential when framing policies to support young people to reduce sexual risk-taking behaviour.

Abstract access

Editor’s notes: This article explores how young people in a poor, rural area in South Africa articulate and understand gender, dating, sexuality, and risk-taking.  Twenty young people (10 female, 10 male) aged between 18 and 19 years of age were randomly selected from three villages that participate in the Health and Socio-Demographic Surveillance System in Mpumalanga Province in north-eastern South Africa. 

Participants’ narratives highlight how normative gender patterns characterised by compulsory heterosexuality and dating as obligatory represent key symbols of normality. The authors highlight how two themes, early pregnancy and HIV, are central to understanding practices of dating and heterosexual relationships. They are also important for understanding ideas about the consequences of a dissolute lifestyle and the risk it exerts on plans and hopes for a better future. This risk was perceived to be particularly acute by, and for, young women who are seen to bear the brunt of negative outcomes, particularly relating to early school dropout.

The findings of this study have important implications for HIV prevention programmes, particularly for adolescent girls and young women. Where intimate relationships are trivialised as guided by normative gender patterns and pressure to have heterosexual relationships, young people risk becoming infected with HIV, becoming parents too early, and interrupting their education. The findings highlight the potential for context-sensitive programmes which play careful attention to local norms and young people’s internalised relationship discourses. These could usefully include opportunities for critical reflection in order to support young people to reduce their exposure to risks.  It is also important to recognise young people’s aspirations, and the perceived benefits they derive from relationships.

Africa
South Africa
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An innovative method to evaluate community support for children: Using existing datasets

How effective is help on the doorstep? A longitudinal evaluation of community-based organisation support. 

Sherr L, Yakubovich AR, Skeen S, Cluver LD, Hensels IS, Macedo A, Tomlinson M. PLoS One. 2016 Mar 11;11(3):e0151305. doi: 10.1371/journal.pone.0151305. eCollection 2016.

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9-13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included—446 CBO attenders compared to 1402 9-13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12-15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input.

Abstract  Full-text [free] access 

Editor’s notes: This study is novel in both its research question and its methodology. The study aims to assess whether receipt of support from community-based organisations (CBOs) impacts the mental and social well-being of children in high HIV prevalence areas. The CBOs studied include many different organisations with diverse services, giving the study the benefit of assessing the overall impact of a combination of small, motivated groups. This helps lend credibility to CBOs and to convince policymakers and funders to support small-scale CBOs.

In terms of methodology, the study utilises two longitudinal datasets from southern Africa to explore the study aims. One survey is from a study of children affected by HIV served by CBOs, while the other is from a study of children affect by HIV without CBO support. There are some limitations to using two different studies, most especially unclear comparability and, in this case, lack of control data to adjust for possible differences, for example on socio-economic status or how HIV specifically affected the child. Despite these, this paper has striking results, and is an innovative effort to improve our understanding of the impact of CBOs on children’s well-being and should spur further creativity in impact evaluation methods.

Africa
South Africa
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