Treatment as Prevention-Provider Knowledge and Counseling Lag Behind Global Campaigns

INTRODUCTION In 2011, the landmark HIV Prevention Trials Network (HPTN) 052 trial found that early initiation of antiretroviral treatment (ART) in persons living with HIV (PLHIV) reduced viral transmission to uninfected partners by 96%. Treatment as prevention (TasP), whereby HIV transmission is prevented by consistent use of HIV treatment and durable viral suppression, has ushered in a new era in worldwide HIV prevention. The combined health benefits of averting new infections and preserving/improving health for PLHIV have translated into rapid scale-up in treatment access across the globe

Built Environment and HIV Linkage to Care in Rural South Africa

Background: We assessed built environment (residential density, landuse mix and aesthetics) and HIV linkage to care (LTC) among 1,681 (18–49 years-old) residents of 15 Mpumalanga villages, South Africa. Methods: Multilevel models (linear-binomial) were used for the association between built environment, measured using NEWS for Africa, and LTC from a clinical database of 9 facilities (2015–2018). Additionally, we assessed effect-measure modification by universal test-and-treat policy (UTT). Results: We observed, a significant association in the adjusted 3-month probability of LTC for residential density (risk difference (RD)%: 5.6, 95%CI: 1.2–10.1), however, no association for land-use mix (RD%: 2.4, 95%CI: −0.4, 5.2) and aesthetics (RD%: −1.2, 95%CI: −4.5–2.2). Among those diagnosed after UTT, residents of high land-use villages were more likely to link-to-care than those of low land-use villages at 12 months (RD%: 4.6, 95%CI: 1.1–8.1, p 0.10). Conclusion: Findings suggest, better built environment conditions (adequate infrastructure, proximity to services etc.) help facilitate LTC. Moreover, UTT appears to have a protective effect on LTC

Fostering gender equality and alternatives to violence: perspectives on a gender-transformative community mobilisation programme in rural South Africa

Gender-based violence and violence against children are significant problems in South Africa. Community mobilisation and gender-transformative programming are promising approaches to address and reduce violence. A quantitative evaluation of One Man Can, a gender-transformative community mobilisation programme in South Africa, found mixed results in increasing gender-equitable behaviours and reducing violence. To better understand these findings, we analyse longitudinal qualitative data from community mobilisers, community members and community action teams, exploring individual and community-level factors that facilitate and hinder change. Interviews and focus groups were transcribed and analysed. Participants self-reported changes in their gender-equitable attitudes and use of violence as a result of participation in the programme, although some participants also reported opposition to shifting to a more gender-equitable culture. Facilitators to change included the internalisation of gender-transformative messaging and supportive social networks, which was buoyed by a shared vocabulary in their community generated by One Man Can. Because the programme targeted a critical mass of community members with gender-transformative programming, mobilisers and community action teams were held accountable by community members to model non-violent behaviour. Results reinforce the importance of addressing facilitators and barriers to change at both individual and community levels

Gender, HIV Testing and Stigma: The Association of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa Differ for Men and Women

Stigma remains a significant barrier to HIV testing in South Africa. Despite being a social construct, most HIV-stigma research focuses on individuals; further the intersection of gender, testing and stigma is yet to be fully explored. We examined the relationship between anticipated stigma at individual and community levels and recent testing using a population-based sample (n = 1126) in Mpumalanga, South Africa. We used multi-level regression to estimate the potential effect of reducing community-level stigma on testing uptake using the g-computation algorithm. Men tested less frequently (OR 0.22, 95% CI 0.14–0.33) and reported more anticipated stigma (OR 5.1, 95% CI 2.6–10.1) than women. For men only, testing was higher among those reporting no stigma versus some (OR 1.40, 95% CI 0.97–2.03; p = 0.07). For women only, each percentage point reduction in community-level stigma, the likelihood of testing increased by 3% (p < 0.01). Programming should consider stigma reduction in the context of social norms and gender to tailor activities appropriately

Measuring Men’s Gender Norms and Gender Role Conflict/Stress in a High HIV-Prevalence South African Setting

Gender norms and gender role conflict/stress may influence HIV risk behaviors among men; however scales measuring these constructs need further development and evaluation in African settings. We conducted exploratory and confirmatory factor analyses to evaluate the Gender Equitable Men’s Scale (GEMS) and the Gender Role Conflict/Stress (GRC/S) scale among 581 men in rural northeast South Africa. The final 17-item GEMS was unidimensional, with adequate model fit and reliability (alpha = 0.79). Factor loadings were low (0.2–0.3) for items related to violence and sexual relationships. The final 24-item GRC/S scale was multidimensional with four factors: Success, power, competition; Subordination to women; Restrictive emotionality; and Sexual prowess. The scale had adequate model fit and good reliability (alpha = 0.83). While GEMS is a good measure of inequitable gender norms, new or revised scale items may need to be explored in the South African context. Adding the GRC/S scale to capture men’s strain related to gender roles could provide important insights into men’s risk behaviors

Community collective efficacy is associated with reduced physical intimate partner violence (IPV) incidence in the rural province of Mpumalanga, South Africa: Findings from HPTN 068

Background Intimate partner violence (IPV) is a human rights violation and is associated with a variety of adverse physical and mental health outcomes. Collective efficacy, defined as mutual trust among community members and willingness to intervene on the behalf of the common good, has been associated with reduced neighbourhood violence. Limited research has explored whether community collective efficacy is associated with reduced incidence of IPV. This is of particular interest among adolescent girls and young women (AGYW) in sub-Saharan Africa, where the burden of HIV is greatest and IPV is common. Methods We collected longitudinal data among 2533 AGYW (ages 13-20) enrolled in the HPTN 068 cohort in Mpumalanga province, South Africa between 2011 and 2016. We included participants from 26 villages where community surveys were collected during the HPTN 068 study. Collective efficacy was measured at the village level via two population-based cross-sectional surveys in 2012 and 2014. Multivariable Poisson generalised estimating equation regression models estimated the relative risk ratio (RR) between village collective efficacy scores and subsequent physical IPV 12 month incidence, adjusting for village-level clustering and covariates. Results Thirty-eight per cent of the cohort (n=950) reported at least one episode of recent physical IPV during follow-up. For every SD higher level of collective efficacy, there was a 6% lower level of physical IPV incidence (adjusted RR: 0.94;95% CI 0.89 to 0.98) among AGYW after adjusting for covariates. Conclusions Community-level interventions that foster the development of collective efficacy may reduce IPV among AGYW

Multilevel Gender-Equitable Norms and Risk of HIV and Herpes Simplex Virus Type 2 Acquisition Among Young South African Women: A Longitudinal Analysis of the HIV Prevention Trials Network 068 Cohort

Purpose: Adolescent girls and young women (AGYW) in South Africa experience a disproportionately high burden of HIV acquisition. National HIV prevalence among AGYW increases nearly three-fold during the transition from late teenage years to their early twenties. We investigated whether beliefs about gender equity influence subsequent HIV acquisition among AGYW in South Africa. Methods: We used data from the HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of AGYW in Mpumalanga Province, South Africa. Gender-equitable beliefs were measured at the level of the individual and summarized among school peers and adults in the community using the Gender Equitable Men's Scale (GEMS). Generalized estimating equation regression was used to assess the association between individual, peer and community GEMS and HIV incidence, herpes simplex virus type 2 (HSV-2) incidence, and other HIV risk factors while accounting for repeated observations and clustering. Results: A total of 2,533 AGYW were followed up for up to 5 years. Adjusting for potential confounders, a unit increase in peer GEMS scores (i.e. more equitable) were significantly protective against subsequent HIV acquisition (risk difference = −.019; 95% confidence interval: −.032, −.006) and subsequent HSV-2 acquisition (risk difference = −.020; 95% confidence interval: −.040, −.000). Low individual and community GEMS scores were associated with multiple HIV risk factors but not with HIV or HSV-2 incidence directly. Conclusion: School-level peer endorsement of gender equity may be protective against HIV and HSV-2 incidence among AGYW. Interventions that increase gender equity at the individual level and at the level of the social environment, particularly among school peers, have the potential for protective effects on the health of AGYW

Limitations of the UNAIDS 90-90-90 metrics: a simulation-based comparison of cross-sectional and longitudinal metrics for the HIV care continuum

OBJECTIVES: The Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 and other cross-sectional metrics can lead to potentially counterintuitive conclusions when used to evaluate health systems' performance. This study demonstrates how time and population dynamics impact UNAIDS 90-90-90 metrics in comparison with a longitudinal analogue. DESIGN: A simplified simulation representing a hypothetical population was used to estimate and compare inference from UNAIDS 90-90-90 metrics and longitudinal metrics based on Kaplan-Meier-estimated 2-year probability of transition between stages. METHODS: We simulated a large cohort over 15 years. Everyone started out at risk for HIV, and then transitioned through the HIV care continuum based on fixed daily probabilities of acquiring HIV, learning status, entering care, initiating antiretroviral therapy (ART), and becoming virally suppressed, or dying. We varied the probability of ART initiation over three five-year periods (low, high, and low). We repeated the simulation with an increased probability of death. RESULTS: The cross-sectional probability of being on ART among persons who were diagnosed responded relatively slowly to changes in the rate of ART initiation. Increases in ART initiation rates caused apparent declines in the cross-sectional probability of being virally suppressed among persons who had initiated ART, despite no changes in the rate of viral suppression. In some cases, higher mortality resulted in the cross-sectional metrics implying improved healthcare system performance. The longitudinal continuum was robust to these issues. CONCLUSION: The UNAIDS 90-90-90 care continuum may lead to incorrect inference when used to evaluate health systems performance. We recommend that evaluation of HIV care delivery include longitudinal care continuum metrics wherever possible

Men’s perceptions of treatment as prevention in South Africa: Implications for engagement in HIV care and treatment

While South Africa provides universal access to treatment, HIV testing and antiretroviral therapy (ART) uptake remains low, particularly among men. Little is known about community awareness of the effects of treatment on preventing transmission, and how this information might impact HIV service utilization. This qualitative study explored understandings of treatment as prevention (TasP) among rural South African men. Narratives emphasized the known value of ART for individual health, but none were aware of its preventive effects. Many expressed that preventing transmission to partners would incentivize testing, earlier treatment, and adherence in the absence of symptoms, and could reduce the weight of a diagnosis. Doubts about TasP impacts on testing and care included enduring risks of stigma and transmission. TasP information should be integrated into clinic-based counseling for those utilizing services, and community-based education for broader reach. Pairing TasP information with alternative testing options may increase engagement among men reluctant to be seen at clinics