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This paper describes implementation research of an intervention in a complex HIV prevention randomised trial in southern Africa. Researchers collected stories of change attributed by 106 community members to an audio-drama edutainment intervention in 41 sites in Botswana, Namibia and Swaziland. The team analysed themes in the stories following a behaviour change model of conscious knowledge, attitudes, subjective norms, intention to change, agency, discussion and action (CASCADA). Storytellers attributed positive changes to the intervention in the areas of gender violence, multiple sexual partners, transactional and intergenerational sex and condom use. Their stories illustrate each of the steps in the CASCADA behaviour change model. As well as supporting an enabling environment for other interventions in the trial, the audio-drama also helped some participants to make personal changes. Collecting and discussing the stories were encouraging for the trial fieldworkers. Documenting the experiences of participants and framing the analysis of stories in an explicit behaviour change model allowed us to reflect on potential mechanisms and pathways through which the intervention impacts on individuals and communities. It helped in the design of the quantitative instruments to measure intermediate outcomes of the trial. [ABSTRACT FROM PUBLISHER]

Adolescent girls and young women (AGYW) engaging in sex-for-money transactions are at risk of HIV infection. A better understanding of the demographic, socio-economic factors and risks of HIV acquisition is required to guide appropriate public health interventions targeting young sex workers in South Africa. A cross-sectional survey of Female Sex Workers (FSWs), using a chain referral sampling method, was conducted across 12 sites in South Africa in 2019. Three thousand and five participants were enrolled and interviewed assessing demographic characteristics, sexual behaviour, substance use and HIV testing and treatment. Of 3005 women, 13.3% were ≤24 years old (young FSWs); of these, 60.0% entered sex work aged ≤19 years. Economic factors were the primary drivers of entry into sex work. HIV prevalence amongst young FSWs was 40.4%, with 12.4% recently infected. Younger FSWs were significantly less likely to know they were HIV positive (87.6% versus 92.1%), to report any ART exposure (75.2% versus 87.6%) and to be virally suppressed (58.1% versus 75.2%) compared to older FSWs. Our findings highlight that many FSWs enter sex work at a young age. It is essential to develop tailored services and interventions that improve access to HIV prevention and treatment services addressing specific needs. [ABSTRACT FROM AUTHOR]

Although hazardous/harmful alcohol use impacts response to HIV treatment, there have been few attempts to deliver alcohol-reduction interventions within South African HIV treatment services. As a first step towards implementing alcohol-focused interventions in these settings, we explored patients’ views of the acceptability of a brief motivational interviewing and problem-solving intervention. In-depth interviews were conducted with 11 patients recruited from three HIV treatment sites in Tshwane, South Africa, who had completed the intervention. Participants noted that the intervention was acceptable and appropriate. As a result of the intervention, participants reported less use of alcohol as a coping mechanism. They described greater use of problem-focused and emotional coping strategies for dealing with mutable and immutable problems, respectively. Their only recommendation for improving the intervention was the addition of booster sessions. Findings suggest that this intervention is acceptable to patients receiving HIV treatment and is perceived to be helpful for reducing their use of alcohol. [ABSTRACT FROM AUTHOR]

In rural South Africa, high HIV prevalence has the potential to affect the care and support that kin are able to provide to those living with HIV. Despite this, families seem to be largely resilient and a key source of care and support to family affected by HIV. In this article, we explore the motivations for the provision of care and support by kin. We use the results of a small-scale in-depth qualitative study conducted in 10 households over 6 months in rural KwaZulu-Natal, South Africa, to show that family obligation and conditional reciprocity operate in varying degrees and build social capital. We highlight the complexity of kin relations where obligation is not guaranteed or is limited, requiring the consideration of policy measures that provide means of social support that are not reliant on the family. [ABSTRACT FROM AUTHOR]

Children affected by HIV and AIDS have significantly higher rates of mental health problems than unaffected children. There is a need for research to examine how social support functions as a source of resiliency for children in high HIV-prevalence settings such as South Africa. The purpose of this research was to explore how family social support relates to depression, anxiety, and post-traumatic stress (PTS). Using the ecological model as a frame, data were drawn from a 2011 cross-sectional study of 1380 children classified as either orphaned by AIDS and/or living with an AIDS sick family member. The children were from high-poverty, high HIV-prevalent rural and urban communities in South Africa. Social support was analyzed in depth by examining the source (e.g. caregiver, sibling) and the type (e.g. emotional, instrumental, quality). These variables were entered into multiple regression analyses to estimate the most parsimonious regression models to show the relationships between social support and depression, anxiety, and PTS symptoms among the children. Siblings emerged as the most consistent source of social support on mental health. Overall caregiver and sibling support explained 13% variance in depression, 12% in anxiety, and 11% in PTS. Emotional support was the most frequent type of social support associated with mental health in all regression models, with higher levels of quality and instrumental support having the strongest relation to positive mental health outcomes. Although instrumental and quality support from siblings were related to positive mental health, unexpectedly, the higher the level of emotional support received from a sibling resulted in the child reporting more symptoms of depression, anxiety, and PTS. The opposite was true for emotional support provided via caregivers, higher levels of this support was related to lower levels of all mental health symptoms. Sex was significant in all regressions, indicating the presence of moderation. [ABSTRACT FROM PUBLISHER]

In the era of widespread access to antiretroviral therapy, people living with HIV survive; however, this comes with new experiences of comorbidities and HIV-related disability posing new challenges to rehabilitation professionals and an already fragile health system in Southern Africa. Public health approaches to HIV need to include not only prevention, treatment and support but also rehabilitation. While some well-resourced countries have developed rehabilitation approaches for HIV, resource-poor settings of Southern Africa lack a model of care that includes rehabilitation approaches providing accessible and comprehensive care for people living with HIV. In this study, a learning in action approach was used to conceptualize a comprehensive model of care that addresses HIV-related disability and a feasible rehabilitation framework for resource-poor settings. The study used qualitative methods in the form of a focus group discussion with thirty participants including people living with HIV, the multidisciplinary healthcare team and community outreach partners at a semi-rural health facility in South Africa. The discussion focused on barriers and enablers of access to rehabilitation. Participants identified barriers at various levels, including transport, physical access, financial constraints and poor multi-stakeholder team interaction. The results of the group discussions informed the design of an inclusive model of HIV care. This model was further informed by established integrated rehabilitation models. Participants emphasized that objectives need to respond to policy, improve access to patient-centered care and maintain a multidisciplinary team approach. They proposed that guiding principles should include efficient communication, collaboration of all stakeholders and leadership in teams to enable staff to implement the model. Training of professional staff and lay personnel within task-shifting approaches was seen as an essential enabler to implementation. The health facility as well as outreach services such as intermediate clinics, home-based care, outreach and community-based rehabilitation was identified as important structures for potential rehabilitation interventions. [ABSTRACT FROM PUBLISHER]

We examined current challenges with patient engagement in HIV prevention and care in South Africa by assessing the procedures of eight public health clinics in the North West Province. Procedures consisted of (1) an inventory/audit of the HIV Counseling and Testing, pre-antiretroviral therapy (pre-ART), and antiretroviral therapy (ART) patient registers; (2) extraction of data from a convenience sample of 39 HIV-positive patient files; and (3) 13 key informant interviews with clinic staff to characterize retention and re-engagement practices for patients. Incomplete registers revealed little evidence of follow-up services, particularly for pre-ART patients. The more detailed examination of patient files indicated substantial disparities in the proportion of pre-ART versus ART patients retained in care. Key informant interviews contextualized the data, with providers describing multiple procedures for tracking and ensuring service delivery for ART patients and fewer procedures to retain pre-ART patients. These findings suggest that enhanced strategies are needed for ensuring continued engagement in HIV care, with a particular emphasis on improving the retention of pre-ART patients. The preventive benefits of ART scale-up may not be achieved if improvements are not made in the proportion of earlier-stage HIV-positive patients who are successfully engaged in care. [ABSTRACT FROM AUTHOR]

Human immunodeficiency virus (HIV) remains a highly stigmatised condition for people living with HIV (PLWH) and people living close to them (PLC) globally. The research objectives for this study were to explore and describe how HIV stigma and disclosure experiences impact the lives of PLWH and to explore whether there are differences between experiences in urban and rural settings. A qualitative approach was followed and participants were selected through purposive voluntary sampling. Data collection took place using in-depth interviews with 23 PLWH, 11 of whom resided in an urban setting in North-West, South Africa, and 12 resided in a rural setting in the same province. The data were manually analysed through open coding. The HIV stigma experiences expressed by PLWH depicted negative behavioural patterns and attitudes towards them, fear from the community of being infected by PLWH and lastly negative self-judgement by PLWH themselves. During disclosure, PLWH were unsure and they described it as a stressful event. They cautiously considered to whom to disclose their condition and what benefits disclosure will hold. They further had to handle forced disclosure due to being identifiable in health-care settings. HIV stigma and related disclosure practices remained a problem, which detrimentally affected treatment and support efforts. Recommendations focused on HIV stigma reduction in the community that needed to involve PLWH and PLC. [ABSTRACT FROM AUTHOR]

Although there is a high prevalence of anxiety and depression amongst people receiving antiretroviral treatment (ART), many patients are not screened, diagnosed or referred for mental health problems. This study aims to determine whether public sector health care workers in South Africa observe, screen, diagnose and refer ART patients that show symptoms of common mental disorders. It also aims to ascertain the extent of mental health training received by public sector health care workers working in ART. The study was cross-sectional in design. Self-administered questionnaires were completed by 40 nurses and structured interviews were conducted with 23 lay workers across the five districts in the Free State between July 2009 and October 2009. STATA version 12 was used to perform statistical data analysis. The health care workers reported observing a high frequency of symptoms of common mental disorders among public sector ART patients. While 70% of nurses screened and diagnosed, only 40% of lay workers screened and diagnosed patients on ART for a mental disorder. Health care workers who had received training in mental health were more likely to screen or diagnose a mental disorder, but only 14% of the workers had received such training. We recommend that health care workers should receive task-specific training to screen and/or diagnose patients on ART for common mental disorders using the guidelines of the South African HIV Clinicians Society. A positive diagnosis should be referred to a health care practitioner for appropriate evidence-based treatment in the form of medication or psychotherapy. [ABSTRACT FROM PUBLISHER]

Given the importance of couples to the transmission of HIV, interventions focusing on both members of a partnership can play an important role in its prevention. We adapted and pilot-tested Project Connect, an evidence-based HIV prevention intervention for couples, to determine its acceptability and feasibility among a sample of young urban South African couples. We recruited couples from a clinic in inner-city Johannesburg to take part in the study. Interviewer-administered questionnaires were conducted at baseline and postintervention; an in-depth interview (IDI) was also conducted postintervention. Of 75 couples screened, 15 were eligible and enrolled. An important reason for ineligibility was a recent history of intimate partner violence (IPV). Couples attended, on average, five of the seven sessions. Overall, the intervention was acceptable and showed signs of potential efficacy. Couples reported enjoying Connect and feeling comfortable with its content. Participants also reported learning important communication and problem-solving skills, which resulted in more effective engagement in HIV prevention behaviors. However, the number of sessions and strict eligibility criteria proved challenging to the feasibility of the study. We recommend future couples' interventions have fewer sessions and enroll couples with a history of IPV. [ABSTRACT FROM AUTHOR]

Millions of children in sub-Saharan Africa undertake personal and medical care for family members who are unwell with AIDS. To date, no research has investigated whether such care provision places children at heightened risk for pulmonary tuberculosis. This study aimed to address this gap by identifying risk factors for paediatric pulmonary tuberculosis symptomatology. In 2009-2011, 6002 children aged 10 17 years were surveyed using door-to-door household sampling of census enumeration areas, These were randomly sampled from six urban and rural sites with over 30% HIV prevalence, within South Africa's three highest tuberculosis-burden provinces. Validated scales and clinical tuberculosis symptom checklists were modelled in multivariate logistic regressions, controlling for socio-demographic co-factors. Findings showed that, among children, severe pulmonary tuberculosis symptomatology was predicted by primary caregiver HIV/AIDS-illness [odds ratio (OR): 1.63, confidence interval (CI): 1.23-2.15, p <0.001], and AIDS-orphanhood (OR: 1.44, CI: 1.04-2.00, p < 0.029). Three-fold increases in severe tuberculosis symptoms were predicted by the child's exposure to body fluids through providing personal or medical care to an ill adult (OR: 3.12, CI: 1.96-4.95, p <0.001). Symptoms were also predicted by socio-economic factors of food insecurity (OR: 1.52, CI: 1.15-2.02, p <0.003) and household overcrowding (OR: 1.35, CI: 1.06-1.72, p <0.017). Percentage probability of severe tuberculosis symptoms rose from 1.4% amongst least-exposed children, to 18.1% amongst those exposed to all above-stated risk factors, independent of biological relationship of primary caregiver-child and other socio-demographics. Amongst symptomatic children, 75% had never been tested for tuberculosis. These findings identify the risk of tuberculosis among children providing home medical care to their unwell caregivers, and suggest that there are gaps in the health system to screen and detect these cases of paediatric tuberculosis. There is a need for effective interventions to reduce childhood risk, as well as further support for community-based contact-tracing, tuberculosis screening and anti-tuberculosis treatment for children caring for ill adults in contexts with a high burden of HIV and tuberculosis. [ABSTRACT FROM AUTHOR]

To assess the views of potential end-users of a microbicide in KwaZulu-Natal regarding the characteristics that would justify further development, three focus group discussions were conducted in 2009 with 23 local staff members working on a microbicide clinical trial, 20 former trial participants and 14 Community Advisory Board members not enrolled in the trial, in an area with high HIV incidence and low consistent condom use. All participants agreed on the need for additional HIV prevention options that are as effective as possible and can be used by women. The majority of respondents stated that even a highly acceptable HIV prevention option with protection as low as 30% would still be an important addition to condoms for women; that a partially protective microbicide would have to be introduced as part of the existing prevention messages in order to continue promoting condom use; that there should eventually be a choice between antiretroviral (ARV) and non-ARV-based microbicides and a choice of how and where to access microbicides. Respondents also felt it would be important to make plans for access to a microbicide that can offer protection, even if partial, rather than wait to find out if alternative microbicides are equally or more effective. Potential end-users in a high HIV prevalence area believe that a partially effective microbicide would be an important addition to the limited HIV prevention options for women. The significant challenges of introducing a partially protective HIV prevention option were recognised, but seen as ones worth facing, as well as an opportunity to lay the ground work for the introduction of more efficacious HIV prevention methods in the future. [ABSTRACT FROM AUTHOR]

In resource-limited settings, successful HIV treatment scale-up has been tempered by reports of funding shortfalls. We aimed to determine the priorities, including ethical considerations, of decision makers for HIV antiretroviral programs. We conducted qualitative interviews with 12 decision makers, identified using purposive sampling. Respondents engaged in one-on-one, semi-structured interviews. We developed an interview guide to direct questions about key priorities and motivations for decision making about HIV antiretroviral programs. We evaluated textual data from the interviews to identify themes. Among 12 respondents, 10 (83%) lived and worked in South Africa. Respondents came from Western Cape, Gauteng, and KwaZulu-Natal provinces and worked primarily in urban settings. The respondents supported prioritizing individual patients based on treatment adherence, pregnancy status to prevent maternal-to-child HIV transmission and/or orphans, and severity of illness. However, priorities based on severity of illness varied, with first-come/first-serve, prioritization of the most severely ill, and prioritization of the least severely ill discussed. Respondents opposed prioritizing based on patient socioeconomic characteristics. Other priorities included the number of persons receiving treatment; how treated patients are distributed in the population (e.g., urban/rural); and treatment policy (e.g., number of antiretroviral regimens). Motivations included humanitarian concerns; personal responsibility for individual patients; and clinical outcomes (e.g., patient-level morbidity/mortality, saving lives) and/or social outcomes (e.g., restoring patients as functional family members). Decision makers have a wide range of priorities for antiretroviral provision in South Africa, and the motivations underlying these priorities suggest at times conflicting ethical considerations for providing HIV treatment when resources are limited. [ABSTRACT FROM AUTHOR]