Articles tagged as "Combination prevention"

Stopping PrEP use due to changes in partnership dynamics and life events could increase HIV risk

When and why women might suspend PrEP use according to perceived seasons of risk: implications for PrEP-specific risk-reduction counselling.

Namey E, Agot K, Ahmed K, Odhiambo J, Skhosana J, Guest G, Corneli A. Cult Health Sex. 2016 Apr 19:1-11. [Epub ahead of print]

Oral pre-exposure prophylaxis (PrEP) using the antiretroviral drug emtricitabine/tenofovir disoproxil fumarate (Truvada) has been shown to dramatically reduce the risk of HIV acquisition for women at higher risk of infection if taken daily. Understanding when and why women would intentionally stop using an efficacious oral PrEP drug within the context of their 'normal' daily lives is essential for delivering effective PrEP risk-reduction counselling. As part of a larger study, we conducted 60 qualitative interviews with women at higher risk of HIV in Bondo, Kenya, and Pretoria, South Africa. Participants charted their sexual contacts over the previous six months, indicated whether they would have taken PrEP if available and discussed whether and why they would have suspended PrEP use. Nearly all participants said they would have used PrEP in the previous six months; half indicated they would have suspended PrEP use at some point. Participants' reasons for an extended break from PrEP were related to partnership dynamics (e.g., perceived low risk of a stable partner) and phases of life (e.g., trying to conceive). Life events (e.g., holidays and travel) could prompt shorter breaks in PrEP use. These circumstances may or may not correspond to actual contexts of lower risk, highlighting the importance of tailored PrEP risk-reduction counselling.

 Abstract access 

Editor’s notes: This paper presents findings from a qualitative study that aimed to understand why and when women would stop using oral PrEP in the context of their everyday lives. The study included 30 semi-structured interviews with women in Kenya and 30 with women in South Africa.  All were participants in a larger study exploring PrEP and risk compensation who were HIV negative (aged between 18 and 35 years).

The authors found that nearly all women would have taken PrEP six months before the interview. Reasons for stopping PrEP use due to partnership dynamics included the absence of a partner, the end of a relationship, infrequent sex, marriage and stable or faithful relationships. Phases of life which would stop women using PrEP included trying to conceive, pregnancy and older age.  Life events such as illness, stressful events, travelling and festivals affected PrEP use.

The authors provided a number of suggestions for counsellors to support women to assess risk and need to use PrEP. This could include information on the HIV-infection risk due to the difficulty of negotiating condom use. The authors also suggested the use of couples counselling and male engagement strategies. The authors recommended that counsellors should counsel that risk may increase during travel and holidays. Such suggestions highlight the usefulness of this study in understanding why women would stop PrEP use.

Africa
Kenya, South Africa
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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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Couples programme illustrates benefits in effecting change in drinking and HIV risk behaviours among men

The male factor: outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township.

Wechsberg WM, Zule WA, El-Bassel N, Doherty IA, Minnis AM, Novak SD, Myers B, Carney T. Drug Alcohol Depend. 2016 Apr 1;161:307-15. doi: 10.1016/j.drugalcdep.2016.02.017. Epub 2016 Feb 18.

Background: This study examined the effects of the Couples Health CoOp intervention on heavy drinking, condom use, and HIV incidence.

Methods: Thirty neighborhoods from one South African township were cluster randomized into three intervention arms: Couples Health CoOp (CHC), Women's Health CoOp/Men's Health CoOp (WHC/MHC), or a comparison arm. We recruited 290 men from informal drinking establishments who reported drinking alcohol regularly. We also recruited their main heterosexual sex partners.

Results: At 6-month follow-up, men in the CHC arm were less likely to report heavy drinking (OR 0.47, 95% CI: 0.25, 0.90) and were more likely to report consistent condom use during the past month (OR 2.66, 95% CI: 1.23, 5.76) than men in the comparison arm. At baseline, 26% of women and 13% of men were HIV-infected; at 6-month follow-up, 16 females and 5 males had seroconverted. HIV incidence was significantly lower among women in the CHC arm (IRR 0.22, 95% CI: 0.04, 1.01) than in the WHC/MHC arm.

Conclusions: A couples-based intervention focusing on intersecting risks for HIV can improve bio-behavioral outcomes, underscoring the importance of engaging couples together in HIV prevention.

Abstract access

Editor’s notes: This study describes the benefits of a novel couples-based programme that addresses key drivers of HIV incidence in South Africa. It focuses on the intersection of alcohol use, relationship contexts, and gender norms. Heavy drinking among men in South Africa is associated with HIV risks including multiple concurrent sexual partnerships and low rates of condom use. In addition, heavy drinking alongside gender norms that disempower women can lead to increased HIV risk for female partners. For example, women may seek sexual partners outside of their main relationship for money, due to male regular partners spending household income on alcohol instead. The study extends the Women’s Health CoOp (an evidence-based programme to reduce substance use, violence, and sexual risks among vulnerable women) to include both partners. The hypothesis is that a programme addressing both partners together (the Couples Health CoOp [CHC] arm) would be more effective than the original female-focused programme at reducing alcohol use and risk behaviors. They found that men reported reduced heavy drinking in all three arms including the control arm after six months (compared to baseline) and the reduction in heavy drinking was greatest in the CHC arm. This highlights the role of couples-based programmes for HIV prevention in women. The high HIV incidence in this setting (16 per 100 person-years in women; 4 per 100 person-years in men) is a reminder that innovative activities are necessary. Future work should continue to include exploration of the effectiveness of adapting of single-gender programmes to be couple-based. 

Africa
South Africa
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Tackling taboos and preventing HIV: family programmes to prevent HIV in adolescence

Developing family interventions for adolescent HIV prevention in South Africa. 

Kuo C, Atujuna M, Mathews C, Stein DJ, Hoare J, Beardslee W, Operario D, Cluver L, L KB. AIDS Care. 2016 Mar;28 Suppl 1:106-10. doi: 10.1080/09540121.2016.1146396. Epub 2016 Feb 26.

Adolescents and young people account for 40% of all new HIV infections each year, with South Africa one of the hardest hit countries, and having the largest population of people living with HIV. Although adolescent HIV prevention has been delivered through diverse modalities in South Africa, and although family-based approaches for adolescent HIV prevention have great potential for highly affected settings such as South Africa, there is a scarcity of empirically tested family-based adolescent HIV preventive interventions in this setting. We therefore conducted focus groups and in-depth interviews with key informants including clinicians, researchers, and other individuals representing organizations providing HIV and related health services to adolescents and parents (N = 82). We explored family perspectives and interactions around topics such as communication about sex, HIV, and relationships. Participants described aspects of family interactions that presented both challenges and opportunities for family-based adolescent HIV prevention. Parent-child communication on sexual topics were taboo, with these conversations perceived by some adults as an invitation for children to engage in HIV risk behavior. Parents experienced social sanctions for discussing sex and adolescents who asked about sex were often viewed as disrespectful and needing discipline. However, participants also identified context-appropriate strategies for addressing family challenges around HIV prevention including family meetings, communal parenting, building efficacy around parent-adolescent communication around sexual topics, and the need to strengthen family bonding and positive parenting. Findings indicate the need for a family intervention and identify strategies for development of family-based interventions for adolescent HIV prevention. These findings will inform design of a family intervention to be tested in a randomized pilot trial.

Abstract  Full-text [free] access

Editor’s notes: This short paper presents a qualitative study about family discussions about HIV and sex in Khayelitsha, South Africa. The results illustrate that sex is considered by many adults a taboo subject with adolescents younger than 18 years old. Young people who initiate discussion about sex, HIV risk or pregnancy can be scolded for being disrespectful. Sex is often discussed as a problem after young people have already started being sexually active. Study participants identified ‘family conferences’, with parents but also relatives more broadly, as promising settings for programmes. The activities should facilitate discussions that frame communication about sex and HIV prevention as positive. 

Africa
South Africa
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The dapivirine ring confers moderate efficacy, but hope for a new prevention option

Use of a vaginal ring containing dapivirine for HIV-1 prevention in women.

Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, Mgodi NM, Matovu Kiweewa F, Nair G, Mhlanga F, Siva S, Bekker LG, Jeenarain N, Gaffoor Z, Martinson F, Makanani B, Pather A, Naidoo L, Husnik M, Richardson BA, Parikh UM, Mellors JW, Marzinke MA, Hendrix CW, van der Straten A, Ramjee G, Chirenje ZM, Nakabiito C, Taha TE, Jones J, Mayo A, Scheckter R, Berthiaume J, Livant E, Jacobson C, Ndase P, White R, Patterson K, Germuga D, Galaska B, Bunge K, Singh D, Szydlo DW, Montgomery ET, Mensch BS, Torjesen K, Grossman CI, Chakhtoura N, Nel A, Rosenberg Z, McGowan I, Hillier S, Team M-AS N Engl J Med. 2016 Feb 22. [Epub ahead of print]

Background: Antiretroviral medications that are used as prophylaxis can prevent acquisition of human immunodeficiency virus type 1 (HIV-1) infection. However, in clinical trials among African women, the incidence of HIV-1 infection was not reduced, probably because of low adherence. Longer-acting methods of drug delivery, such as vaginal rings, may simplify use of antiretroviral medications and provide HIV-1 protection.

Methods: We conducted a phase 3, randomized, double-blind, placebo-controlled trial of a monthly vaginal ring containing dapivirine, a non-nucleoside HIV-1 reverse-transcriptase inhibitor, involving women between the ages of 18 and 45 years in Malawi, South Africa, Uganda, and Zimbabwe.

Results: Among the 2629 women who were enrolled, 168 HIV-1 infections occurred: 71 in the dapivirine group and 97 in the placebo group (incidence, 3.3 and 4.5 per 100 person-years, respectively). The incidence of HIV-1 infection in the dapivirine group was lower by 27% (95% confidence interval [CI], 1 to 46; P=0.05) than that in the placebo group. In an analysis that excluded data from two sites that had reduced rates of retention and adherence, the incidence of HIV-1 infection in the dapivirine group was lower by 37% (95% CI, 12 to 56; P=0.007) than that in the placebo group. In a post hoc analysis, higher rates of HIV-1 protection were observed among women over the age of 21 years (56%; 95% CI, 31 to 71; P<0.001) but not among those 21 years of age or younger (-27%; 95% CI, -133 to 31; P=0.45), a difference that was correlated with reduced adherence. The rates of adverse medical events and antiretroviral resistance among women who acquired HIV-1 infection were similar in the two groups.

Conclusions: A monthly vaginal ring containing dapivirine reduced the risk of HIV-1 infection among African women, with increased efficacy in subgroups with evidence of increased adherence.

 Abstract  Full-text [free] access 

Editor’s notes: Women bear a larger proportion of the HIV burden worldwide due to biological and behavioural factors. As a result, the HIV prevention field has focused research over the past couple of decades to identify new prevention options especially for women, to reduce this burden. The study presented in this paper is the first to publish phase III efficacy trial results for a vaginal ring containing the antiretroviral drug dapivirine for HIV prevention. The ring is designed to prevent HIV acquisition locally within the vagina in HIV negative women and kept in the body for a period of four weeks. This strategy is meant to address two components of adherence and side effects. A longer-acting product and local application is contrasted with the daily and systemic use of oral pre-exposure prophylaxis, a regimen which can be difficult to maintain. This study found that the dapivirine ring did not protect women with a high rate of efficacy, 27% overall. Interestingly, the sub-analyses of the data illustrated that there was better protection in women with better adherence, and in women who were over the age of 21. Further explorations of the data along with the qualitative findings from the study will surely provide more valuable insights into the low overall rate of efficacy, and perhaps most importantly into why age made such a difference in rates of protection. As mentioned in the paper, a second study on the ring, which was presented at CROI 2016, publishing similar results, and those results combined with the data from this study will further our knowledge regarding the viability of this HIV prevention option.  

Africa
Malawi, South Africa, Uganda, Zimbabwe
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Couples talking about prevention and supporting each other on PrEP and ART: lessons from Kenya

I knew I would be safer. Experiences of Kenyan HIV serodiscordant couples soon after pre-exposure prophylaxis (PrEP) initiation.

Ngure K, Heffron R, Curran K, Vusha S, Ngutu M, Mugo N, Celum C, Baeten JM. AIDS Patient Care STDS. 2016 Feb;30(2):78-83. doi: 10.1089/apc.2015.0259.

Pre-exposure prophylaxis (PrEP) for HIV-uninfected persons is highly efficacious for HIV prevention. Understanding how people at risk for HIV will use PrEP is important to inform PrEP scale-up and implementation. We used qualitative methods to gather insights into couples' early experiences with PrEP use within the Partners Demonstration Project, an open-label implementation study evaluating integrated delivery of PrEP and antiretroviral therapy (ART). PrEP is offered to HIV uninfected partners until the HIV-infected partner initiates and sustains ART use (i.e., PrEP as a "bridge" to ART initiation and viral suppression). From August 2013 to March 2014 we conducted 20 in-depth dyadic interviews (n = 40) with heterosexual HIV serodiscordant couples participating at the Thika, Kenya study site, exploring how couples make decisions about using PrEP for HIV prevention. We developed and applied deductive and inductive codes to identify key themes related to experiences of PrEP initiation and use of time-limited PrEP. Couples reported that PrEP offered them an additional strategy to reduce the risk of HIV transmission, meet their fertility desires, and cope with HIV serodiscordance. Remaining HIV negative at follow-up visits reinforced couples' decisions and motivated continued adherence to PrEP. In addition, confidence in their provider's advice and client-friendly services were critical to their decisions to initiate and continue use of PrEP. Strategies for wide-scale PrEP delivery for HIV serodiscordant couples in low resource settings may include building capacity of health providers to counsel on PrEP adoption while addressing couples' concerns and barriers to adoption and continued use.

Abstract access

Editor’s notes: This paper is based on findings from the Partners Demonstration Project. This project evaluated the implementation of ART and PrEP for HIV-1 prevention in African heterosexual HIV-1 serodiscordant couples in Uganda and Kenya. As has been reported elsewhere, the research achieved impressive reductions in HIV-incidence. The strategy adopted in the project was to provide PrEP to the HIV-negative partner until the HIV-positive partner had sustained their use of ART for six months. Using data from Kenya, the authors describe in this paper the value placed by couples on PrEP, which underpinned the study success. Couples wanted to use PrEP because PrEP (and ART) provided the possibility of reduced HIV transmission. In addition to the findings on reasons for PrEP use, this paper also offers insights into couple dynamics. The research was conducted with mutually disclosed HIV serodiscordant couples. The authors illustrated through their analysis and the excerpts from interviews used in the text, the importance of communication between partners. They also, importantly, illustrate differences between couples. The authors describe the use of both verbal and non-verbal communication in discussions about PrEP and ART. Through the data in this paper a picture is built up on the importance of open and frank communication in decisions about using and sustaining the use of PrEP and ART. In a study setting, couples could be afforded support which might be scarce in public health settings. Even so, the findings underline the value of being sensitive to context and individual needs, in supporting PrEP and ART roll-out.

Africa
Kenya
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Multifaceted approaches necessary to reduce HIV risk among orphaned and vulnerable adolescents

Psychological and behavioral interventions to reduce HIV risk: evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa.

Thurman TR, Kidman R, Carton TW, Chiroro P. AIDS Care. 2016 Feb 17:1-8. [Epub ahead of print]

Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (beta = -.48, p = .05) and girls reported more consistent condom (beta = 1.37, p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population.

Abstract   Ful-text [free] access

Editor’s notes: HIV infection is the leading cause of mortality among adolescents in sub-Saharan Africa and this age group is a priority group for programmes. Within this age-group, orphaned adolescents are particularly vulnerable, and a major risk factor for HIV infection in this population is psychological distress, which is a key factor in sexual decision-making. This study suggests that a multifaceted approach that addresses both psychological well-being and sexual risk taking behaviour may reduce risky sexual behaviour. Such activities are more likely to be successful if other more basic needs, such as economic security, are already being met. However, the strength of the findings is limited by the reliance on self-reported behaviours rather than biological endpoints. The authors highlight a number of issues that could improve the efficacy of programmes, including introducing gender specific sessions and activities and supplemental school-based programmes.    

Africa
South Africa
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‘Cash, care and classroom’: social protection to reduce adolescents’ risk of HIV

Applying a family-level economic strengthening intervention to improve education and health-related outcomes of school-going AIDS-orphaned children: lessons from a randomized experiment in southern Uganda.

Ssewamala FM, Karimli L, Torsten N, Wang JS, Han CK, Ilic V, Nabunya P. Prev Sci. 2016 Jan;17(1):134-43. doi: 10.1007/s11121-015-0580-9.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

Abstract access 

Editor’s notes: The HIV epidemic has left many sub-Saharan countries with an extraordinarily large youth population, many of whom lost one or both parents to HIV-associated mortality. As a result, younger children tend to have much less support to stay in education and older children often have increased responsibility to support the household. There is thus a need to provide orphaned children with both financial and psycho-social support to achieve their educational goals, and on a broader scale, to prepare the youth for the workforce. This study found that providing orphaned children with a package of school supplies and support services as well as financial services (opening a matched child savings account and workshops on microenterprise development) yielded better educational outcomes than the package without the additional financial services. However, how either group compares to non-orphaned children is unclear. Future research would benefit from a third comparison group, in which non-orphaned children’s educational outcomes are also compared.

The effect of the programme on both educational and mental outcomes among orphans is important. Educational outcomes may have been driven by improved self-confidence and motivation as a result of the savings account and microenterprise training. It is unclear whether these supplemental activities were simply a signal of the community support for the orphaned children, which in turn increased self-confidence, or if the children were directly influenced by their improved economic prospects. Further research to uncover the actual mechanism of the improved outcomes would be useful for future programme design. 

Africa
Uganda
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Emphasising and supporting educational goals among orphaned children

Combination social protection for reducing HIV-risk behavior amongst adolescents in South Africa.

Cluver LD, Orkin MF, Yakubovich AR, Sherr L. J Acquir Immune Defic Syndr. 2016 Jan 27. [Epub ahead of print]

Background: Social protection (i.e. cash transfers, free schools, parental support) has potential for adolescent HIV prevention. We aimed to identify which social protection interventions are most effective and whether combined social protection has greater effects in South Africa.

Methods: In this prospective longitudinal study, we interviewed 3516 adolescents aged 10-18 between 2009 and 2012. We sampled all homes with a resident adolescent in randomly-selected census areas in four urban and rural sites in two South African provinces. We measured household receipt of fourteen social protection interventions and incidence of HIV-risk behaviors. Using gender-disaggregated multivariate logistic regression and marginal-effects analyses, we assessed respective contributions of interventions and potential combination effects.

Results: Child-focused grants, free schooling, school feeding, teacher support, and parental monitoring were independently associated with reduced HIV-risk behavior incidence (OR 0.10-0.69). Strong effects of combination social protection were shown, with cumulative reductions in HIV-risk behaviors. For example, girls' predicted past-year incidence of economically-driven sex dropped from 11% with no interventions, to 2% amongst those with a child grant, free school and good parental monitoring. Similarly, girls' incidence of unprotected/casual sex or multiple-partners dropped from 15% with no interventions to 10% with either parental monitoring or school feeding, and to 7% with both interventions.

Conclusion: In real-world, high-epidemic conditions, 'combination social protection' shows strong HIV-prevention effects for adolescents and may maximize prevention efforts.

Abstract access 

Editor’s notes: Social and structural programmes help address the disadvantages and inequalities that make people vulnerable to HIV, and may therefore play a key role in adolescent HIV prevention.  However, the particular combination of programmes that may be most effective is not well understood. This longitudinal survey of adolescents aged 10-18 years in high HIV prevalence districts (>30% antenatal prevalence) in South Africa examined the effect of a range of social protection programmes on HIV risk behaviour. The programmes were existing activities provided by the South African government, NGOs or communities.

Receipt of some stand-alone social protection programmes in the areas of cash, psychological support or education was associated with a reduced incidence of HIV risk behaviour.  The optimal combination of programmes depended on the particular risk behaviour under consideration, and differed between boys and girls. Since adolescents may vary in the type of risk to which they are most vulnerable, a multi-component approach is likely to be necessary to have a population-level impact on HIV.

There are some limitations to this study, including the relatively small number of adolescents reporting some risk behaviours. However, the findings illustrate the potential of combination social protection in reducing adolescents’ vulnerability to HIV, and further work in this area would be useful to highlight the important role of public programmes in HIV prevention.

Africa
South Africa
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SMS reminders for HIV treatment adherence had a broader, positive impact on HIV-programme trial participants

The meanings in the messages: how SMS reminders and real-time adherence monitoring improve ART adherence in rural Uganda.

Ware NC, Pisarski EE, Tam M, Wyatt MA, Atukunda E, Musiimenta A, Bangsberg DR, Haberer JE. AIDS. 2016 Jan 23. [Epub ahead of print]

Objective: To understand how a pilot intervention combining SMS reminders with real-time adherence monitoring improved adherence to HIV antiretroviral therapy (ART) for adults initiating treatment in rural Uganda.

Design: Qualitative study, conducted with a pilot randomized controlled trial.

Methods: Sixty-two pilot intervention study participants took part in qualitative interviews on: (a) preferences for content, frequency and timing of SMS adherence reminders; (b) understandings and experiences of SMS reminders; and (c) understandings and experiences of real-time adherence monitoring. Analysis of interview data was inductive and derived categories describing how participants experienced the intervention, and what it meant to them.

Results: SMS reminders prompted taking individual doses of antiretroviral therapy, and helped to develop a "habit" of adherence. Real-time adherence monitoring was experienced as "being seen"; participants interpreted "being seen" as an opportunity to demonstrate seriousness of commitment to treatment and "taking responsibility" for adherence. Both SMS reminders and real-time monitoring were interpreted as signs of "caring" by the health care system. Feeling "cared about" offset depressed mood and invigorated adherence.

Conclusions: While serving as reminders, SMS messages and real-time adherence monitoring also had larger emotional and moral meanings for participants that they felt improved their adherence. Understanding the larger "meanings in the messages," as well as their more literal content and function, will be central in delineating how SMS reminders and other adherence interventions using cellular technology work or do not work in varying contexts.  

Abstract access 

Editor’s notes: SMS reminders have been used in a number of trials in an effort to increase adherence to antiretroviral treatment (ART). The quantitative evidence generally suggests that SMS reminders do not have a significant impact on adherence to ART. However, little is known about why reminders may or may not work for different people in different contexts. This study uses qualitative interviews with trial participants to explore why reminders improved ART adherence in rural Uganda. Participants suggested that the SMS reminders made them “feel seen”, increasing their sense of taking responsibility for adherence. They also felt “cared for” by the health system which offset some negative emotions. This study suggests that SMS reminders may have broader, unmeasured impact on trial participants than simply encouraging adherence. Receiving messages directly from the health care system may have a positive impact on participant morale and attitudes towards trials. 

  
Africa
Uganda
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