Heterosexual penile/anal intercourse and HIV in five sub-Saharan African countries

The HIV epidemic in sub-Saharan Africa is understood to be primarily 'sexually transmitted'. The majority of HIV prevention efforts in the region have focused on 'heterosexual sex' as the key transmission vector, without defining what 'heterosexual sex' refers to. Penile-anal intercourse (PAI) has the highest per act risk of HIV acquisition sexually and potentially accounts for a large proportion of HIV infection. Inclusion of PAI in HIV programming has typically only been in reference to men who have sex with men. Despite evidence suggesting that heterosexual PAI is common practice in sub-Saharan Africa, and is likely to be a significant contributor to HIV transmission, it has been largely excluded from HIV interventions. Greater understanding of sexual decision-making and risk-taking related to heterosexual PAI would enable evidence-based HIV intervention. This thesis presents data on conceptualisations and perceptions of heterosexual PAI and associated practices in sub-Saharan Africa, language and discourse pertaining to PAI, as well as challenges in conducting research on it. Qualitative data were gathered in five sub-Saharan African countries between 2010 and 2014. These findings demonstrate that heterosexual PAI is practiced in sub-Saharan Africa for a variety of reasons, some of which have implications for HIV transmission. Many of the factors that influence sexual decision-making and risk-taking related to heterosexual PAI are specific to this sexual behaviour. In addition, the relationship contexts in which heterosexual PAI takes place, gendered power dynamics, sexual agency and 'sexual scripts' framing PAI behaviour, are distinct from those for penile/vaginal intercourse. HIV transmission risks associated with PAI are exacerbated by taboos, social stigmatisation and sexual communication norms, impeding effective communication and safe sex negotiation, limiting individuals' ability to make informed decisions, and impacting on the reporting of PAI in research and clinical settings. Drawing on socio-behavioural theories to guide the data analysis, I developed theoretical models to explain and understand heterosexual PAI practice. The findings presented in this thesis make a unique contribution to the field, being the first in-depth description and analysis of heterosexual PAI behaviour and related practices in sub-Saharan Africa. This research highlights the importance of paying careful attention to the role of heterosexual PAI in HIV transmission in Africa

Heterosexual anal sex in the age of HIV : an exploratory study of a silenced subject

Includes bibliographical references (p. 89-103).This dissertation serves as a discursive exploration into the underdiscussed topic of heterosexual anal sex and pervading penile-vaginal heteronormativity. To understand the origins and character of the seemingly universal ambivalence towards heterosexual anal intercourse I attempt to situate it historically. There is general ignorance concerning the prevalence of this sexual behaviour, but there exist deep-seated taboos and undertones of immorality and abnormality associated with it. All these factors play a part in individual sexual decision making; an attempt is made at exploring the motivations and personal choices that culminate in an act of heterosexual anal intercourse

‘Scared of going to the clinic’: Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities

Background: Men who have sex with men (MSM), sex workers (SW) and people who use drugs (PWUD) are at increased risk for HIV because of multiple socio-structural barriers and do not have adequate access to appropriate HIV prevention, diagnosis and treatment services.Objective: To examine the context of access to healthcare experienced by these three ‘Key Populations’, we conducted a qualitative study in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province.Method: We carried out in-depth interviews to explore healthcare workers’ perceptions, beliefs and attitudes towards Key Populations. Focus group discussions were also conducted with members of Key Populations exploring their experiences of accessing healthcare.Results: Healthcare workers described their own attitudes towards Key Populations and demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing Key Populations. Female SW, MSM and PWUD described their experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. Our findings suggest that the uptake and effectiveness of health services amongst Key Populations in South Africa is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers.Conclusion: This research highlights the need to address the broader healthcare provision environment, improving alignment of policies and programming in order to strengthen provision of effective health services that people from Key Populations will be able to access

Adolescent Girls Empowerment Programme in Zambia: Qualitative evaluation report

The Adolescent Girls Empowerment Program (AGEP) reaches over 10,000 vulnerable girls 10–19 years old in five urban and five rural sites spread across four provinces in Zambia. The program works to build adolescent girls’ social, health, and economic assets, providing them with key skills and opportunities to help them transition from adolescence to adulthood in a healthy way. This report presents these valuable insight into the views and experiences of girls who were involved in the AGEP program, as well as the perceptions of program mentors, the girls’ parents, and community leaders. In addition, these findings highlight the areas in which the experiences of girls in the control groups, who had not been engaged in AGEP’s programs and activities, differed from or were similar to those of the AGEP girls. The findings also highlight issues and factors in the community that contribute to the problem of pregnancies among young girls in the study communities

Attitude shifts and knowledge gains: Evaluating men who have sex with men sensitisation training for healthcare workers in the Western Cape, South Africa

Background: Men who have sex with men (MSM) in South Africa experience discrimination from healthcare workers (HCWs), impeding health service access.Objectives: To evaluate the outcomes of an MSM sensitisation training programme for HCWs implemented in the Western Cape province (South Africa).Methods: A training programme was developed to equip HCWs with the knowledge, awareness and skills required to provide non-discriminatory, non-judgemental and appropriate services to MSM. Overall, 592 HCWs were trained between February 2010 and May 2012. Trainees completed self-administered pre- and post-training questionnaires assessing changes in knowledge. Two-sample t-tests for proportion were used to assess changes in specific answers and the Wilcoxon rank-sum test for overall knowledge scores. Qualitative data came from anonymous post-training evaluation forms completed by all trainees, in combination with four focus group discussions (n = 28) conducted six months after their training.Results: Fourteen per cent of trainees had received previous training to counsel clients around penile–anal intercourse, and 16% had previously received training around sexual health issues affecting MSM. There was a statistically significant improvement in overall knowledge scores (80% – 87%, p < 0.0001), specifically around penile–anal intercourse, substance use and depression after the training. Reductions in negative attitudes towards MSM and increased ability for HCWs to provide non-discriminatory care were reported as a result of the training.Conclusion: MSM sensitisation training for HCWs is an effective intervention to increase awareness on issues pertaining to MSM and how to engage around them, reduce discriminatory attitudes and enable the provision of non-judgemental and appropriate services by HCWs

‘I can’t go to her when I have a problem’: sexuality communication between South African adolescent girls and young women and their mothers

Parent–adolescent sexuality communication, the process in which parents and their adolescent children discuss sexuality and sexual and reproductive health, is a key component for adolescents’ protective behaviours. Open communication with parents, particularly mothers, enables informed sexual and reproductive health (SRH) decision- aking amongst adolescent girls and young women (AGYW). As part of a qualitative study evaluating a South African combination HIV prevention intervention for AGYW, we explored perspectives on SRH communication among AGYW and mothers of AGYW, and the effects of the intervention on sexuality communication as perceived by AGYW, mothers of AGYW, intervention facilitators and implementers, and community leaders. In-depth interviews and focus group discussions were conducted with 185 AGYW aged 15–24 years who had participated in the intervention, seven mothers of AGYW intervention recipients, 14 intervention facilitators, six community leaders, and 12 intervention implementers. Key themes that emerged in analysis were (1) Barriers to Sexuality communication, (2) Implications of Gaps in Sexuality Communication, and (3) Addressing Barriers to Sexuality communication. Barriers to sexuality communication included inability or unwillingness to discuss sex, a generation gap, proscriptive socio-cultural guidelines, and mothers’ discomfort, lack of knowledge and self-efficacy, and fear of encouraging promiscuity. AGYW described making poorly-informed SRH decisions alone, expressing a desire for more open communication with and support from parents/mothers. Framed within the social cognitive theory, these findings can help to guide efforts to address barriers around parent–adolescent  sexuality communication, inform interventions aimed at targeting SRH issues amongst AGYW, such as unintended pregnancy and HIV, and support meaningful engagement of parents in supporting AGYW in navigating pathways to achieving their SRH goals

‘We must treat them like all the other people’: Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa

Background: Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The ‘Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa’ aimed to improve access to appropriate and non-judgemental health services for ‘key populations’, specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers. Objectives: The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa. Methods: This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex. Results: The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes. Conclusion: The findings suggest that sensitisation training increases healthcare workers’ knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services

“We can’t share things with our teachers” : Narratives of mistrust and disconnect between South African female learners and their teachers

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The psychology of “cure” - unique challenges to consent processes in HIV cure research in South Africa

BACKGROUND : Consent processes for clinical trials involving HIV prevention research have generated considerable debate globally over the past three decades. HIV cure/eradication research is scientifically more complex and consequently, consent processes for clinical trials in this field are likely to pose a significant challenge. Given that research efforts are now moving toward HIV eradication, stakeholder engagement to inform appropriate ethics oversight of such research is timely. This study sought to establish the perspectives of a wide range of stakeholders in HIV treatment and research to inform consent processes for cure research. METHODS : In total, 68 South African stakeholders participated in two qualitative research modalities. In-depth interviews (IDIs) were conducted with a purposive sample of 42 individuals - audiotaped with consent. Twenty-six stakeholders participated in three focus group discussions (FGDs). Thematic analysis of transcribed IDIs and FGDs was conducted. RESULTS : The majority of respondents indicated that there could be unique challenges in HIV cure research requiring special attention. In particular, given the complexity of cure science, translation of concepts into lay language would be critical for potential participants to adequately appreciate risks and benefits in early phase research with experimental interventions. Furthermore, to aid understanding of risks and benefits against a background of desperation for a cure, specially trained facilitators would be required to assist with a psychological assessment prior to consent to avoid curative misconceptions. Long-term participant engagement to assess durability of a cure would mean that the consent process would be prolonged, necessitating annual re-consent. Building trust to maintain such long-term relationships would be critical to retain study participants. CONCLUSION : Unique consent requirements for cure research in South Africa would include significant efforts to maximise understanding of trial procedures, risks and the need for long-term follow-up. However, the psychological dimension of cure must not be underestimated. Beyond an understanding of cure science, the emotional impact of HIV cure advances the discourse from cure to healing. Consequently, the consent process for cure research would need to be enhanced to include psychological support and counselling. This has several important implications for research ethics review requirements for consent in HIV cure research.Fogarty International Center and Office of AIDS Research, OD and National Institute of Allergy and Infectious Diseases and the National Institute of Mental Health of the National Institutes of Health.http://www.biomedcentral.com/bmcmedethicsam2020Immunolog

From Survival to Glamour: Motivations for Engaging in Transactional Sex and Relationships Among Adolescent Girls and Young Women in South Africa

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