Church-based social spaces and HIV/AIDS in rural South Africa.

Thesis (Ph.D.)-University of KwaZulul-Natal, Durban, 2013.Primarily, this dissertation examined the extent to which churches have potential in preventing HIV/AIDS. Set in rural KwaZulu-Natal an area marked with both high levels of HIV prevalence and high religious participation, the study used the concept of social space as a framework within which the contribution of churches towards the prevention of further spread of the HIV infection can be understood. Unlike recent studies which have consistently shown that the contribution of churches in the prevention of further spread of HIV infection is likely to emanate from the churches‘ teaching on morality, this study has argued that the contribution of churches in minimizing risky sexual behaviours is likely to emanate from how churches balance their teachings on moral issues and the subsequent practice of social control on the one hand and the provision of social support on the other. This is particularly so because in African settings where behaviour is largely influenced by the prevailing circumstances within society, and where churches are significantly entrenched in the lives of individuals providing a variety of social support services, there is a strong likelihood that churches will have an impact on their adherents‘ behaviour as well. The social space concept, therefore, defines churches not only as institutions enforcing the moral code which churches emphasise but also as caring and integrating forces, providing social support for their members in time of need. The study investigated four churches representing three Christian religious denominations: the Mainline, the Pentecostal and the African Independent churches. In investigating these churches, it used two types of data: The Africa Centre Demographic surveillance Systems (ACDIS) data collected between 2002 and 2004 and the Ethnographic data collected in 2006 consisting of a total of 96 in-depth interviews, 11-13 services of each church type selected, 6-8 church- related activities (or groups in each church), 3 informal discussions with community members and a set of 2 conversational data from each church. The analysis is done in two parts. The first part of the analysis (Chapter Five) focuses on the existing quantitative ACDIS data, examining whether there exists a relationship between church affiliation, participation in church activities and sexual behaviours. The second part uses ethnographic data in order to provide explanations of the observed relationship. Overall, the study found that unlike church affiliation which had no influence on individual sexual behaviour, individuals who participated regularly in church activities were less likely to engage in behaviour that would put them at risk of acquiring the HIV infection. The study found, however, that there existed denominational differences and that churches where participation was high were the same churches likely to influence protective behaviour. The explanation provided from qualitative findings suggested that the ability of these churches to minimise risky sexual behaviour was found in the Intensive Social Spaces that churches and their members constructed. The study concluded that the ability of churches to minimise risky sexual behaviours resulted from an individual negotiating losing the benefits provided by fellow members of the church when she/he ceases to be a member

A comparative analysis of the effect of self-perceived risk of HIV/AIDS on the adoption of safer sex practices as a preventive measure for HIV/AIDS among adolescents : Uganda and South Africa.

Thesis (M.A.)-University of Natal, Durban, 2003.This work examines sexual behavioural change and the likely predisposing factors in the era of HIV/AIDS among young adults in Uganda and South Africa. It explores the potential role of young adults' self-perceived risk of HIV infection in sexual behavioural decisions regarding adoption of safe sex practices, in particular 'use of condoms' and 'limiting number of sexual partners '. This work further recognises that Uganda and South Africa are countries with social, cultural, economic, and political contexts, which contexts have been described by many as inextricably linked with sexual behaviour, and which often determine the choices young adults make regarding sexual activity. These are therefore examined. In order to achieve this, a rigorous examination and analysis of self-perceived risk of HIV/AIDS in relation to societal factors was done to determine which variables of the two categories best explains sexual behaviour. This is placed in the context of young female adults between the ages of 15 to 24 in Uganda and South Africa. The formulation of this study, which places emphasis on examining the potential role of self-perceived risk of HIV/AIDS as a predisposing factor for sexual behavioural change, and in Uganda and South Africa is based on a number of aspects as highlighted below: • That both Uganda and South Africa at one point or another were and/or are faced with high prevalence levels of HIV/AIDS; • That both have and/or are yet to be faced with high mortality, which is HIV/AIDS related and such profound consequences will/or have had inadvertent effects on individual, both socially and economically. In some respects, this has also affected individual perceptions regarding HIV infection; • Recognition that the progression of HIV/AIDS in Uganda was much faster than in South Africa, and this meant higher prevalence, higher mortality rates, which then triggered both government and non-governmental response towards preventing further spread. Since these factors are beginning to emerge in South Africa, one therefore asks the question as to whether the pandemic will take similar trends as those reported in Uganda. This would also enable the identification of similarities and differences in the likely determinants of sexual behavior considering these countries have different backgrounds; • In both countries, education programmes have been rigorous and that the level of awareness is at a point that would enable sexual behavioural change to occur; • A recognition that in Uganda, as shown in a number of reports and existing literature, the prevalence of HIV has declined and for this reason, it has become imperative to try and examine the likely factors leading to reduced HIV/AIDS prevalence, and to compare with what is happening in South Africa. This would enable the examination of any possible lessons that could be learnt in the reduction of the prevalence in South Africa. In the quest to achieve the set goals, a number of steps were undertaken which included looking at available literature and more importantly analysing two sets of Demographic Health Survey (DHS) data. The South Africa Demographic Health Survey of 1998 (SADHS) and the Ugandan Demographic Health Survey (UDHS) of 2000/1. All young female adults between the ages of 15 to 24 were selected from both data sets. 3,229 and 4,559 young female adults were selected in Uganda and South Africa respectively leading to a total sample size of 7,688. Findings showed that self-perceived risk of HIV/AIDS was one of the factors that did impact on sexual behaviour. This was more prominent in Uganda and less so in South Africa. Other factors found to affect sexual behaviour included age of respondent, socio-cultural and to a small extent, socio-economic factors. The conclusion that can be drawn from this work shows clearly that self-perceived risk of HIV/AIDS is an important factor determining sexual behaviour, but also shows that some societal variables are important. Therefore, in the face of HIV/AIDS and with increased levels of number of people experiencing deaths due to AIDS, selfperceived risk of HIV/AIDS is a factor worth considering when looking at sexual behaviour. As part of the recommendations, education programmes yet to be formulated should take into account the effect of HIV and AIDS on sexual behavioural change

Experiences with HPTN 067/ADAPT Study-Provided Open-Label PrEP Among Women in Cape Town: Facilitators and Barriers Within a Mutuality Framework.

Placebo-controlled trials of pre-exposure prophylaxis (PrEP) have reported challenges with study-product uptake and use, with the greatest challenges reported in studies with young women in sub-Saharan Africa. We conducted a qualitative sub-study to explore experiences with open-label PrEP among young women in Cape Town, South Africa participating in HTPN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT). HPTN 067/ADAPT provided open label oral FTC/TDF PrEP to young women in Cape Town, South Africa who were randomized to daily and non-daily PrEP regimens. Following completion of study participation, women were invited into a qualitative sub-study including focus groups and in-depth interviews. Interviews and groups followed a semi-structured guide, were recorded, transcribed, and translated to English from isiXhosa, and coded using framework analysis. Sixty of the 179 women enrolled in HPTN 067/ADAPT participated in either a focus group (six groups for a total of 42 participants) or an in-depth interview (n = 18). This sample of mostly young, unmarried women identified facilitators of and barriers to PrEP use, as well as factors influencing study participation. Cross-cutting themes characterizing discourse suggested that women placed high value on contributing to the well-being of one's community (Ubuntu), experienced a degree of skepticism towards PrEP and the study more generally, and reported a wide range of approaches towards PrEP (ranging from active avoidance to high levels of persistence and adherence). A Mutuality Framework is proposed that identifies four dynamics (distrust, uncertainty, alignment, and mutuality) that represent distinct interactions between self, community and study and serve to contextualize women's experiences. Implications for better understanding PrEP use, and non-use, and intervention opportunities are discussed. In this sample of women, PrEP use in the context of an open-label research trial was heavily influenced by underlying beliefs about safety, reciprocity of contributions to community, and trust in transparency and integrity of the research. Greater attention to factors positioning women in the different dynamics of the proposed Mutuality Framework could direct intervention approaches in clinical trials, as well as open-label PrEP scale-up

Disseminating Evidence-Based Interventions for Adolescent HIV Treatment and Prevention in Sub-Saharan Africa.

Over two-thirds of adolescents living with HIV worldwide reside in sub-Saharan Africa (SSA). Despite widespread availability and access to evidence-based HIV prevention and treatment, dissemination has been inadequate. This commentary distinguishes between implementation and dissemination, reflecting on the unique barriers to dissemination of evidence-based programs in SSA. We present a seven-strategy blueprint developed by United States Agency for International Development (USAID) that emphasizes targeted communication about research findings. Two case studies from the Adolescent HIV Implementation Science Alliance are presented to illustrate the value of planning for dissemination. We propose recommendations to strengthen dissemination recognizing that these may not be possible or appropriate in all situations, including developing a plan early in the process, engaging a dissemination technical team for support, the application of methodological rigor and theory to inform dissemination, active involvement of youth voices and digital tools to maximize message reach, and a keen recognition of evolving contexts and shifting priorities in order to nimbly tailor messages as needed

Developing family interventions for adolescent HIV prevention in South Africa.

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 (ClinicalTrials.gov #NCT02432352)

Khuluma : using participatory, peer-led and digital methods to deliver psychosocial support to young people living with HIV in South Africa

Khuluma is a psychosocial and peer-to-peer mHealth intervention that uses text messaging to facilitate support groups for adolescents living with HIV (ALWH) with the aim of contributing toward positive health outcomes. Although use of mobile technology in the form of mHealth interventions has proliferated recently in the field of health, published literature describing methods and processes of its application are limited. We present a set of methods and processes utilised to develop and pilot the Khuluma mHealth intervention amongst young people (15–20 years) in South Africa. We recruited and enrolled 52 adolescents (15–20-year olds) from four clinics in Pretoria and Cape Town to participate in a 6-month pilot of Khuluma. Participants were ALWH, aware of their status, on antiretroviral therapy for more than 12 months, and not suffering from severe depression. We conducted four pre and post intervention focus group discussions (FGDs) with a proportion of ALWH (n = 36) enrolled in the pilot study using participatory methods. Several processes were utilised to then implement this pilot study. These included engaging ALWH for minor study implementation modifications; forming virtual groups; activating the mHealth platform; facilitating and delivering the Khuluma intervention. The acceptability of the intervention was informed by follow-up focus group discussions and text message data. The initial participatory processes helped to tailor the intervention design to participants’ needs. The peer-led facilitation of the groups allowed for the provision of sensitive psychosocial support that allowed young people to express themselves freely, develop a sense of self-worth, and interact more. The nature of themobile technology also allowed participants to build friendships beyond their geographic area and interact with their peers in real time. Within the evolving context of COVID-19, establishing evidence-based processes and methods for intervention design and curation in virtual spaces is critical.SHM Foundation. Text messages were donated by Vodacom SA.https://www.frontiersin.org/journals/reproductive-health#am2022Psycholog

The Community PrEP Study: a randomized control trial leveraging community-based platforms to improve access and adherence to pre-exposure prophylaxis to prevent HIV among adolescent girls and young women in South Africa—study protocol

Background HIV incidence among South African adolescent girls and young women (AGYW) remains high, but could be reduced by highly effective pre-exposure prophylaxis (PrEP). Unfortunately, AGYW report significant barriers to clinic-based sexual and reproductive health services. Even when AGYW access PrEP as an HIV prevention method, poor prevention-effective use was a serious barrier to achieving its optimal HIV prevention benefits. Determining the acceptability and feasibility of community-based platforms to increase AGYW’s access to PrEP, and evaluating behavioural interventions to improve prevention-effective use of PrEP are needed. Methods We propose a mixed-methods study among AGYW aged 16–25 years in Eastern Cape Province, South Africa. In the first component, a cross-sectional study will assess the acceptability and feasibility of leveraging community-based HIV counselling and testing (CBCT) platforms to refer HIV-negative, at-risk AGYW to non-clinic-based, same-day PrEP initiation services. In the second component, we will enrol 480 AGYW initiating PrEP via our CBCT platforms into a three-armed (1:1:1) randomized control trial (RCT) that will evaluate the effectiveness of adherence support interventions to improve the prevention-effective use of PrEP. Adherence will be measured over 24 months via tenofovir-diphosphate blood concentration levels. Qualitative investigations will explore participant, staff, and community experiences associated with community-based PrEP services, adherence support activities, study implementation, and community awareness. Costs and scalability of service platforms and interventions will be evaluated. Discussion This will be the first study to assess the acceptability and feasibility of leveraging CBCT platforms to identify and refer at-risk AGYW to community-based, same-day PrEP initiation services. It will also provide quantitative and qualitative results to inform adherence support activities and services that promote the prevention-effective use of PrEP among AGYW. By applying principles of implementation science, behavioural science, and health economics research, we aim to inform strategies to improve access to and prevention-effective use of PrEP by AGYW. Trial registration ClinicalTrials.gov NCT03977181 . Registered on 6 June 2019—retrospectively registered

The potential effect of pre-exposure prophylaxis (PrEP) roll-out on sexual-risk behaviour among adolescents and young people in East and southern Africa.

Pre-exposure prophylaxis (PrEP) is an HIV-prevention strategy recommended for those at high-risk of infection, including adolescents and young people (AYP). We explored how PrEP roll-out could influence sexual risk behaviour among AYP in East and southern Africa. Twenty-four group discussions and 60 in-depth interviews were conducted with AYP between 13 and 24 years old, recruited from community settings in Uganda, Zimbabwe and South Africa, from September 2018 to January 2019. Participants perceived that PrEP availability could change sexual behaviour among AYP, influencing: (1) condom use (increased preference for condomless sex, reduced need and decrease in use of condoms, relief from condom use discomfort, consistent condom use to curb sexually transmitted infections and pregnancies); (2) sexual activities (increase in sexual partners and sexual encounters, early sexual debut, sexual experimentation and peace of mind during risky sex, sexual violence and perversion); (3) HIV risk perception (neglect of other HIV prevention strategies, unknown sexual partner HIV status, adoption of PrEP). PrEP initiation may be associated with increased interest in sexual activities and risky sexual behaviour among AYP. PrEP should be included as part of a combination package of HIV prevention strategies for AYP with methods to prevent other sexually transmitted infections and unwanted pregnancies

A qualitative study to explore daily versus on-demand oral pre-exposure prophylaxis (PrEP) in young people from South Africa, Uganda and Zimbabwe.

BACKGROUND: Adolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS. METHODS: Purposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP. RESULTS: Reasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP. CONCLUSIONS: Our study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection

A qualitative study to identify critical attributes and attribute-levels for a discrete choice experiment on oral pre-exposure prophylaxis (PrEP) delivery among young people in Cape Town and Johannesburg, South Africa

Background The uptake and adherence of daily oral PrEP has been poor in high-risk populations in South Africa including young people. We used qualitative research methods to explore user preferences for daily and on-demand oral PrEP use among young South Africans, and to inform the identification of critical attributes and attribute-levels for quantitative analysis of user preferences, i.e. a discrete choice experiment (DCE). Methods Data were collected between September and November 2018 from eight group discussions and 20 in-depth interviews with young people 13 to 24 years in Cape Town and Johannesburg. Using a convenience sampling strategy, participants were stratified by sex and age. Interviewers used a semi-structured interview guide to discuss several attributes (dosing regimen, location, costs, side effects, and protection period) for PrEP access and use. Group discussions and in-depth interviews were audio-recorded, transcribed verbatim and translated to English. We used framework analysis to explore context-specific attributes and attribute-levels for delivering oral PrEP in South Africa. The adolescent community advisory board, expert and study team opinions were consulted for the final DCE attributes and levels. Results We enrolled 74 participants who were 51% (n = 38/74) male, had a median age of 18.5 [Interquartile range = 16–21.25] years, 91% (n = 67/74) identified as heterosexual and 49% (n = 36/74) had not completed 12th grade education. Using the qualitative data, we identified five candidate attributes including (1) dosing regimen, (2) location to get PrEP, (3) cost, (4) route of administration and (5) frequency. After discussions with experts and the study team, we revised the DCE to include the following five attributes and levels: dosing regime: daily, and on-demand PrEP; location: private pharmacy, public clinic, mobile clinic, ATM); cost: free-of-charge, R50 (~2GBP), R265 (~12GBP); side effects: nausea, headache, rash; and duration of protection: fulltime protection versus when PrEP is used). Conclusions There is limited literature on qualitative research methods describing the step-by-step process of developing a DCE for PrEP in adolescents, especially in resource-constrained countries. We provide the process followed for the DCE technique to understand user preferences for daily and on-demand oral PrEP among young people in South Africa