Articles tagged as "Reduce sexual transmission"

Longitudinal study illustrates link between alcohol use, traumatic stress and risk of HIV

Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: Results from a longitudinal cohort of South African women who attend alcohol-serving venues.

Abler L, Sikkema KJ, Watt MH, Pitpitan EV, Kalichman SC, Skinner D, Pieterse D. J Acquir Immune Defic Syndr. 2014 Nov 12. [Epub ahead of print]

Background: In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use.

Methods: Data were collected in four waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined: 1) the relationship between traumatic stress and counts of unprotected sex, and 2) whether alcohol use mediated the association between traumatic stress and unprotected sex.

Results: Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b=0.28, SE=0.06, t=4.82, p<.001). In addition, traumatic stress was associated with alcohol use (b=0.27, SE=0.02, t=14.25, p<.001), and was also associated with unprotected sex (b=0.20, SE=0.06, t=3.27, p<.01) while controlling for alcohol use (b=0.28, SE=0.07, t=4.25, p<.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex.

Conclusions: These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.

Abstract access

Editor’s notes: There is an established link between alcohol use and high-risk sexual behaviour, but the role of mental health in this relationship is often overlooked. Traumatic stress can lead to problematic drinking patterns and increased high-risk sexual behaviour. These negative coping mechanisms may in turn increase traumatic stress, further elevating the risk of HIV infection. A longitudinal cohort study of 560 South African women was conducted to quantify this association. The study benefits from a large sample size and good participant retention throughout the study period.

Traumatic stress was measured using a 17-item Post Traumatic Stress Disorder checklist (PCL) and alcohol use was measured using the 10-item Alcohol Use Disorders Identification Test (AUDIT). The primary outcome was the number of unprotected sexual events that participants reported having in the previous four months. Participants who scored higher for traumatic stress and alcohol use reported having more unprotected sex. Traumatic stress was also found to be independently associated with alcohol use. These findings provide support for programmes that focus on both alcohol use and traumatic stress, owing to their tendency to co-occur and heighten the risk of HIV infection. The authors recommend adapting such programmes to the South African setting and call for further research into how best to identify women at risk of traumatic stress in South African drinking venues.

Africa
South Africa
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Modelling combination prevention for men who have sex with men in South Africa: strategies for success

Combination HIV prevention among MSM in South Africa: results from agent-based modeling.

Brookmeyer R, Boren D, Baral SD, Bekker LG, Phaswana-Mafuya N, Beyrer C, Sullivan PS. PLoS One. 2014 Nov 14;9(11):e112668. doi: 10.1371/journal.pone.0112668. eCollection 2014.

HIV prevention trials have demonstrated the effectiveness of a number of behavioral and biomedical interventions. HIV prevention packages are combinations of interventions and offer potential to significantly increase the effectiveness of any single intervention. Estimates of the effectiveness of prevention packages are important for guiding the development of prevention strategies and for characterizing effect sizes before embarking on large scale trials. Unfortunately, most research to date has focused on testing single interventions rather than HIV prevention packages. Here we report the results from agent-based modeling of the effectiveness of HIV prevention packages for men who have sex with men (MSM) in South Africa. We consider packages consisting of four components: antiretroviral therapy for HIV infected persons with CD4 count <350; PrEP for high risk uninfected persons; behavioral interventions to reduce rates of unprotected anal intercourse (UAI); and campaigns to increase HIV testing. We considered 163 HIV prevention packages corresponding to different intensity levels of the four components. We performed 2252 simulation runs of our agent-based model to evaluate those packages. We found that a four component package consisting of a 15% reduction in the rate of UAI, 50% PrEP coverage of high risk uninfected persons, 50% reduction in persons who never test for HIV, and 50% ART coverage over and above persons already receiving ART at baseline, could prevent 33.9% of infections over 5 years (95% confidence interval, 31.5, 36.3). The package components with the largest incremental prevention effects were UAI reduction and PrEP coverage. The impact of increased HIV testing was magnified in the presence of PrEP. We find that HIV prevention packages that include both behavioral and biomedical components can in combination prevent significant numbers of infections with levels of coverage, acceptance and adherence that are potentially achievable among MSM in South Africa.

Abstract Full-text [free] access

Editor’s notes: The HIV epidemic among men who have sex with men (MSM) in sub-Saharan Africa continues to grow and focused prevention efforts are needed for this population. This is one the first studies to model the effectiveness of a combination HIV prevention study among MSM, and one of few modelling studies among MSM in Africa. This paper finds that a potentially achievable combination package of increased HIV testing, condom use, PrEP and antiretroviral therapy could prevent about a third of new infections over the next five years. The component with the largest incremental impact on infections was the behavioural component. This resulted in a 15% reduction in unprotected anal intercourse. This finding emphasises the need for renewed efforts to reinforce behavioural approaches to HIV prevention, which also have lower resource requirements than the biomedical components included in these models. Further work on understanding associations with regard to uptake and adherence to programmes among MSM in sub-Saharan Africa would be very useful to help design focused programme packages.

Africa
South Africa
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Home visits by community workers in South Africa improve maternal and child outcomes

A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants.

Rotheram-Borus MJ, Tomlinson M, le Roux IM, Harwood JM, Comulada S, O'Connor MJ, Weiss RE, Worthman CM. PLoS One. 2014 Oct 23;9(10):e105934. doi: 10.1371/journal.pone.0105934. eCollection 2014.

Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.

Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.

Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).

Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.

Abstract  Full-text [free] access

Editor’s notes: This trial combines two major trends in the delivery of health care. These include the shift of HIV services from specialist to generalist providers, and task-sharing between generalist and community providers. Community-based workers (CBW) from the Philani Maternal, Child Health and Nutrition Programme in Cape Town, South Africa were recruited to provide and apply health information about maternal and child health, HIV, alcohol use and nutrition to 644 perinatal women in the programme communities. The CBWs complemented the standard of care for health services, which were also available to 594 perinatal women in the control communities. About a quarter of participants were living with HIV. This study is notable for its real-world applicability through its trial design, provision of services to the entire population of eligible perinatal women, range of behavioural and clinical outcomes and rigorous analytic methods. At six months post-partum, women living with HIV in the programme arm were more likely to implement the prevention of mother-to-child regimen and to use condoms with their sex partners. Additionally, the children of these women had improved growth characteristics. Future research must determine whether CBWs can improve the other outcomes assessed in this trial, the cost-effectiveness of the CBWs, and how these gains can be extended to 18 months post-partum.

Africa
South Africa
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More, older people living with HIV, but how many more?

Increasing trends in HIV prevalence among people aged 50 years and older: evidence from estimates and survey data.

Mahy M, Autenrieth CS, Stanecki K, Wynd S. AIDS. 2014 Sep 12. [Epub ahead of print]

Objective: To present the most recent 2013 UNAIDS estimates of HIV prevalence among people aged 50 years and older, and to validate these estimates using data from national household surveys.

Design: Modelled estimates of HIV prevalence were validated against nationally representative household survey measures of HIV prevalence.

Methods: The UNAIDS 2013 HIV estimates were used to compute HIV prevalence and number of people living with HIV aged 50 years and older. Sex-specific HIV-prevalence rates by 5-year age groups were calculated from nationally representative household surveys conducted between 2003 and 2013, and were compared to prevalence rates from the modelled estimates. The ratios of the prevalence rates from the two sources were analysed.

Results: In 2013, an estimated 4.2 million (4.0-4.5 million) people aged 50 years and older were living with HIV. The global HIV prevalence among older individuals more than doubled in almost all the 5-year age groups since 1995. There was a relatively good agreement between the modelled HIV-prevalence rates and the survey-based rates among men and women aged 50-54 years (0.90 and 0.98 median ratio, respectively), whereas for 55-59-year-olds, the differences were more notable (ratios of 0.63 for men and 0.9 for women).

Conclusion: Both data sources suggest HIV-prevalence rates among people aged over 50 have increased steadily in recent years. Care and treatment services need to address the specific needs of older people living with HIV. Action is needed to incorporate older age groups into HIV surveillance systems.

Abstract access 

Editor’s notes: According to the most recent estimates, the global number of people above age 50 years and living with HIV, has more than doubled since the mid-1990s. In southern Africa, it has more than tripled. These numbers are expected to increase further as treatment programmes continue to expand. This study by the UNAIDS secretariat, underscores the numeric importance of this population subgroup. Above all, it highlights how little we know about the epidemic in older adults. The authors compare UNAIDS (modelled) HIV prevalence estimates with those from nationally representative surveys. They find good correspondence among 50-54 year-old men and women. The discrepancy between the two sources are more pronounced above age 54 years where the UNAIDS figures tend to fall short of the empirical estimates. This is particularly the case for men. HIV prevalence estimates among older women are rather scarce as surveys and data collection at antenatal clinics typically focus on women of reproductive age. Longer than expected survival of people living with HIV and higher than anticipated HIV incidence at older ages, could explain the discrepancy between the estimates. But we need more and better data about these age groups to be in a position to adjudicate between these explanations.

Epidemiology
Africa
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Diagnosis of syphilis as an entry point for PrEP initiation among men who have sex with men

Syphilis predicts HIV incidence among men and transgender women who have sex with men in a preexposure prophylaxis trial.

Solomon MM, Mayer KH, Glidden DV, Liu AY, McMahan VM, Guanira JV, Chariyalertsak S, Fernandez T, Grant RM, iPrEx Study Team. Clin Infect Dis. 2014 Oct;59(7):1020-6. doi: 10.1093/cid/ciu450. Epub 2014 Jun 13.

Background: Syphilis infection may potentiate transmission of human immunodeficiency virus (HIV). We sought to determine the extent to which HIV acquisition was associated with syphilis infection within an HIV preexposure prophylaxis (PrEP) trial and whether emtricitabine/tenofovir (FTC/TDF) modified that association.

Methods: The Preexposure Prophylaxis Initiative (iPrEx) study randomly assigned 2499 HIV-seronegative men and transgender women who have sex with men (MSM) to receive oral daily FTC/TDF or placebo. Syphilis prevalence at screening and incidence during follow-up were measured. Hazard ratios for the effect of incident syphilis on HIV acquisition were calculated. The effect of FTC/TDF on incident syphilis and HIV acquisition was assessed.

Results: Of 2499 individuals, 360 (14.4%) had a positive rapid plasma reagin test at screening; 333 (92.5%) had a positive confirmatory test, which did not differ between the arms (FTC/TDF vs placebo, P = .81). The overall syphilis incidence during the trial was 7.3 cases per 100 person-years. There was no difference in syphilis incidence between the study arms (7.8 cases per 100 person-years for FTC/TDF vs 6.8 cases per 100 person-years for placebo, P = .304). HIV incidence varied by incident syphilis (2.8 cases per 100 person-years for no syphilis vs 8.0 cases per 100 person-years for incident syphilis), reflecting a hazard ratio of 2.6 (95% confidence interval, 1.6-4.4; P < .001). There was no evidence for interaction between randomization to the FTC/TDF arm and incident syphilis on HIV incidence.

Conclusions: In HIV-seronegative MSM, syphilis infection was associated with HIV acquisition in this PrEP trial; a syphilis diagnosis should prompt providers to offer PrEP unless otherwise contraindicated.

Abstract  Full-text [free] access

Editor’s notes: The Preexposure Prophylaxis Initiative (iPrEx) trial and other recent trials have illustrated clearly that preexposure prophylaxis (PrEP) with emtricitabine/tenofovir (FTC/TDF) dramatically reduces the risk of HIV when used correctly and consistently. There is current discussion about the practical implications of these findings. This paper confirms a strong association between incident syphilis and HIV acquisition among men who have sex with men (MSM), and illustrates that syphilis did not attenuate the protective benefit of FTC/TDF against HIV. Syphilis continues to be prevalent among MSM in many settings, and the screening prevalence of 13% in this study is consistent with global estimates. These results highlight that individuals with syphilis are a key group for HIV acquisition. The results suggest that a new diagnosis of syphilis is an important opportunity for PrEP initiation, unless contraindications are present. This would be in addition to immediate syphilis treatment, and treatment for sexual partners. 

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Exploring transmission networks of HIV among schoolchildren in South Africa using phylogenetic analysis

HIV infection in high school students in rural South Africa: role of transmissions among students.

Kharsany AB, Buthelezi TJ, Frohlich JA, Yende-Zuma N, Samsunder N, Mahlase G, Williamson C, Travers SA, Marais JC, Dellar R, Karim SS, Karim QA. AIDS Res Hum Retroviruses. 2014 Oct;30(10):956-65. doi: 10.1089/AID.2014.0110. Epub 2014 Sep 4.

In South Africa, adolescents constitute a key population at high risk of HIV acquisition. However, little is known about HIV transmission among students within schools. This study was undertaken to assess the risk factors for HIV infection and the extent of transmission among rural high school students. Between February and May 2012, consenting students from five randomly selected public sector high schools in rural KwaZulu-Natal participated in an anonymous cross-sectional survey. Dried blood spot samples were collected and tested for HIV. beta-Human chorionic gonadotropin (betaHCG) levels were measured in females for pregnancy. Family circumstances as well as sociodemographic and behavioral factors were assessed as potential risk factors. A subset (106/148, 72%) of HIV-positive samples underwent gag p17p24 sequencing for phylogenetic analysis. A total of 3 242 students (81.7% of enrolled students) participated. HIV prevalence was 6.8% [95% confidence interval (CI) 3.9-9.8%] in girls and 2.7% (CI 1.6-3.8%) in boys [adjusted odds ratio (aOR)=3.0, CI 2.4-3.8; p<0.001]. HIV prevalence increased from 4.6% (95% CI 1.9-7.3) in the 12- to 15-year-old girls to 23.1% (95% CI 7.7-38.5) in girls over 20 years, while in boys HIV prevalence increased from 2.7% (95% CI 0.6-4.9) in the 12- to15-year-old boys to 11.1% (95% CI 2.7-19.4) in those over 20 years. Sequencing of samples obtained from students revealed only two clusters suggesting within-school transmission and three interschool clusters, while the remainder was most likely acquired from sources other than those currently found in students attending the school concerned. HIV prevalence in both girls (aOR=3.6, CI 2.9-4.5; p<0.001) and boys (aOR=2.8, CI 1.2-6.2; p=0.01) was higher in those without a living biological mother. The high burden of HIV infection among students was not associated with intraschool transmission in this rural setting. Lack of a living parent is an important factor defining high risk in this group of adolescents.

Abstract access 

Editor’s notes: This is a novel study which explores HIV prevalence, risk factors and acquisition patterns among adolescents in a high prevalence setting in South Africa. A quarter of school going adolescents were sexually active in this study and the prevalence in this rural population was strikingly high, with one in 20 school students living with HIV. The preliminary phylogenetic analysis found that intra-school HIV transmission was limited. Further work is needed to better understand the sources of infection and direction of transmission. This would involve larger sample sizes, more diverse populations and sequencing of more school participants and community members. This study highlights the opportunities that schools provide to conduct surveillance among individuals with recently acquired HIV and the important role that sex education in schools could have to promote safer sexual behaviours among school-going adolescents.

Africa
South Africa
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Taking oral and vaginal antiretrovirals for HIV prevention, and the fear of a ‘spoilt identity’

Perspectives on use of oral and vaginal antiretrovirals for HIV prevention: the VOICE-C qualitative study in Johannesburg, South Africa.

van der Straten A, Stadler J, Luecke E, Laborde N, Hartmann M, Montgomery ET. J Int AIDS Soc. 2014 Sep 8;17(3 Suppl 2):19146. doi: 10.7448/IAS.17.3.19146. eCollection 2014.

Introduction: Antiretroviral (ARV)-based pre-exposure prophylaxis (PrEP) is a promising new HIV prevention strategy. However, variable levels of adherence have yielded mixed results across several PrEP trials and populations. It is not clear how taking ARV - traditionally used for HIV treatment - is perceived and how that perception may affect the use of these products as preventives. We explored the views and experiences of VOICE participants, their male partners and community members regarding the use of ARV as PrEP in the VOICE trial and the implications of these shared meanings for adherence.

Methods: VOICE-C was a qualitative ancillary study conducted at the Johannesburg site of VOICE, a multisite, double-blind, placebo-controlled randomised trial testing tenofovir gel, oral tenofovir and oral Truvada(R) for HIV PrEP. We interviewed 102 randomly selected female VOICE participants, 22 male partners and 40 community members through in-depth interviews, serial ethnography, or focus group discussions. All interviews were audiotaped, transcribed, translated and coded thematically for analysis.

Results: The concept of ARV for prevention was understood to varying degrees across all study groups. A majority of VOICE participants understood that the products contained ARV, more so for the tablets than for the gel. Although participants knew they were HIV negative, ARV was associated with illness. Male partners and community members echoed these sentiments, highlighting confusion between treatment and prevention. Concerned that they would be mistakenly identified as HIV positive, VOICE participants often concealed use of or hid their study products. This occasionally led to relationship conflicts or early trial termination. HIV stigma and its association with ARV, especially the tablets, was articulated in rumour and gossip in the community, the workplace and the household. Although ARV were recognised as potent and beneficial medications, transforming the AIDS body from sickness to health, they were regarded as potentially harmful for those uninfected.

Conclusions: VOICE participants and others in the trial community struggled to conceptualise the idea of using ARV for prevention. This possibly influenced willingness to adopt ARV-based prevention in the VOICE clinical trial. Greater investments should be made to increase community understanding of ARV for prevention and to mitigate pervasive HIV stigma.

Abstract  Full-text [free] access

Editor’s notes: VOICE C was a qualitative ancillary study looking at the experiences of women participating in the VOICE clinical trial, testing the efficacy of pre-exposure prophylaxis (PrEP) and topical microbicides. Other work published by these authors has focused on the challenges of adherence to these products. This paper investigates the views and experiences of the women participants, male partners and community members on PrEP and the microbicide gel. Women using the microbicide gel preferred it to the tablet, perhaps because of the association of tablets with being HIV-positive. However, half of the women using the gel were reported to be unaware that the gel contained antiretroviral drugs (ARV), which may also have been a factor in this preference. A number of women taking tablets worried about being thought to be HIV-positive if seen with the drug. Another of their and their partner’s concerns was that the drug may not be safe for people who were HIV negative. The authors note that the strong association of ARV with an HIV-positive status challenged adherence and trial participation. The findings point to the need for careful attention to provide sufficient information to engender participant understandings of trial products and procedures. Also, beliefs in the wider community where trials take place need to be understood, and where possible addressed, not only to support trial participation, but also to mitigate pervasive HIV stigma.

Africa
South Africa
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Problematic risk perception: half of women acquiring HIV reported that they were not at risk

A descriptive analysis of perceptions of HIV risk and worry about acquiring HIV among FEM-PrEP participants who seroconverted in Bondo, Kenya, and Pretoria, South Africa.

Corneli AL, McKenna K, Headley J, Ahmed K, Odhiambo J, Skhosana J, Wang M, Agot K. J Int AIDS Soc. 2014 Sep 8;17(3 Suppl 2):19152. doi: 10.7448/IAS.17.3.19152. eCollection 2014.

Methods: FEM-PrEP was a phase III clinical trial of once-daily, oral emtricitabine and tenofovir disoproxil fumarate for HIV prevention among women in sub-Saharan Africa. We asked all participants about their perceived HIV risk in the next four weeks, prior to HIV testing, during a quantitative face-to-face interview at enrolment and at quarterly follow-up visits. Among participants who seroconverted, we calculated the frequencies of their responses from the visit conducted closest to, but before, HIV acquisition. Also among women who seroconverted, we conducted qualitative, semi-structured interviews (SSIs) at weeks 1, 4 and 8 after participants' HIV diagnosis visit to retrospectively explore feelings of HIV worry. Applied thematic analysis was used to analyse the SSI data.

Results: Among participants who seroconverted in Bondo and Pretoria, 52% reported in the quantitative interview that they had no chance of acquiring HIV in the next four weeks. We identified four processes of risk rationalization from the SSI narratives. In "protective behaviour," participants described at least one risk reduction behaviour they used to reduce their HIV risk; these actions made them feel not vulnerable to HIV, and therefore they did not worry about acquiring the virus. In "protective reasoning," participants considered their HIV risk but rationalized, based on certain events or beliefs, that they were not vulnerable and therefore did not worry about getting HIV. In "recognition of vulnerability," participants described reasons for being worried about getting HIV but said no or limited action was taken to reduce their perceived vulnerability. Participants with "no rationalization or action" did not describe any HIV worry or did not engage in HIV risk reduction behaviours.

Conclusions: Women who are at substantial risk of acquiring HIV may underestimate their actual risk. Yet, others who accurately understand their HIV risk may be unable to act on their concerns. Perceived HIV risk and risk rationalization are important concepts to explore in risk reduction counselling to increase the use of HIV prevention strategies among women at risk of HIV.

Abstract  Full-text [free] access

Editor’s notes: Risk perception has been thought to be a significant driver of accessing and using HIV prevention methods. However, over the years, researchers have struggled to present a definitive argument as to the role risk perception plays in HIV prevention. While the FemPrEP study failed to show efficacy, or rather effectiveness of oral pre-exposure prophylaxis (PrEP) in preventing HIV acquisition in women in several sites in Africa, valuable data have been collected relating to risk perception. About half of the women who seroconverted to HIV during the trial and were interviewed, indicated that they did not perceive themselves to be at risk of contracting HIV. Interviews revealed different cognitive mechanisms by which women rationalised their perceptions and/or behaviours, some of which were outside their immediate control. A key finding was that women who were actually at significant risk of acquiring HIV did not accurately perceive their risk. While this analysis focused on risk perception, the narratives from some participants suggest that risk perception is only a small piece of the puzzle in understanding how and why women may access and use HIV prevention methods. While this study demonstrates that risk perception clearly plays an important role, it would be valuable to understand further the context within which the women are living and making decisions to fully comprehend HIV access and use. 

Africa
Kenya, South Africa
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Rural-urban migration associated with earlier sexual debut in Thailand

Rural-to-urban migration and sexual debut in Thailand.

Anglewicz P, VanLandingham M, Phuengsamran D. Demography. 2014 Aug 22. [Epub ahead of print]

Migration from one's parents' home and sexual debut are common features of the transition to adulthood. Although many studies have described both of these features independently, few have examined the relationship between migration and sexual debut in a systematic manner. In this study, we explore this link for young adults in Thailand. With relatively high rates of internal migration, rapid modernization, a moderate HIV epidemic, and a declining average age of sexual debut, Thailand presents an instructive environment in which to examine migration and sexual debut. We use two waves of a longitudinal data set (2005 and 2007) that includes a subsample of young adults who migrated to urban areas during that period. We identify characteristics and behaviors associated with sexual debut and examine the role of migration on debut. Our approach reduces several common sources of bias that hamper existing work on both migration and sexual debut: (1) the longitudinal nature of the data enables us to examine the effects of characteristics that predate both behaviors of interest; (2) the survey on sexual behavior employed a technique that reduces response bias; and (3) we examine differences in debut by marital status. We find that migrants have a higher likelihood of sexual debut than nonmigrants.

Abstract access 

Editor’s notes: Much of the research on sexual behaviour comes from sub-Saharan Africa. It is useful to see a study on rural-urban migration and sexual debut in Thailand, a rapidly urbanizing country. The share of the urban population is expected to double by 2050. Rural-urban migration has become part of the experience of many young men and women, growing up. In this study of 4 000 young people aged 15-29 years, 16% of respondents at baseline had migrated within a two-year period. Thailand has been successful in reducing HIV incidence, but there are now concerns over reduced awareness of sexually transmitted infections in young people, increased sexual activity, and reductions in the age of sexual debut. Using a longitudinal dataset, the authors found that rural-urban migration was associated with higher likelihood of sexual debut.  It seems this is not solely due to non-residence with a parent, as this was not associated with sexual debut. The findings raise a number of interesting hypotheses about the implications for HIV prevention, and about the mechanisms that produce this association between migration and sexual debut. These include ideational changes, weakening of the social control mechanisms, a larger pool of potential partners in urban areas, or reverse causality. 

Asia
Thailand
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HIV education programme replicates success in national Kenyan roll-out

Replicating impact of a primary school HIV prevention programme: primary school action for better health, Kenya.

Maticka-Tyndale E, Mungwete R, Jayeoba O. Health Educ Res. 2014 Aug;29(4):611-23. doi: 10.1093/her/cyt088. Epub 2013 Aug 20.

School-based programmes to combat the spread of HIV have been demonstrated to be effective over the short-term when delivered on a small scale. The question addressed here is whether results obtained with small-scale delivery are replicable in large-scale roll-out. Primary School Action for Better Health (PSABH), a programme to train teachers to deliver HIV-prevention education in upper primary-school grades in Kenya demonstrated positive impact when tested in Nyanza Province. This article reports pre-, 10-month post- and 22-month post-training results as PSABH was delivered in five additional regions of the country. A total of 26 461 students from 110 primary schools in urban and rural, middle- and low-income settings participated in this repeated cross-sectional study. Students ranged in age from 11 to 16 years, were predominantly Christian (10% Muslim), and the majority were from five different ethnic groups. Results demonstrated positive gains in knowledge, self-efficacy related to changes in sexual behaviours and condom use, acceptance of HIV+ students, endorsement of HIV-testing and behaviours to postpone sexual debut or decrease sexual activity. These results are as strong as or stronger than those demonstrated in the original impact evaluation conducted in Nyanza Province. They support the roll-out of the programme across Kenyan primary schools.

Abstract access 

Editor’s notes: There are school-based HIV education programmes, demonstrated to be effective in improving knowledge and reported behaviours in trials. But few have been implemented and evaluated across an entire school system. After a successful trial in Nyanza Province, the Kenyan Ministry of Education, Science and Technology implemented the Primary School Action for Better Health (PSABH) nationwide. The national implementation is notable for its commitment to quality control. Quality Assurance Officers conducted teacher trainings and monitored the strength of programme implementation at each school. At scale, the national PSABH programme replicated and sustained the successes of the Nyanza trial. These included increased HIV-related knowledge and communications, condom and sexual self-efficacy but not reported condom use at last intercourse.  This raises the larger question of whether these improvements in knowledge and reported behaviours translate into actual behaviour change, and reduced HIV transmission. And there is little evidence for successful programmes on this.

Africa
Kenya
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