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Diversion of antiretroviral therapy (ART) for recreational use is concerning for countries with high HIV prevalence. This paper presents reports of recreational use of ART among adolescents from two HIV prevention studies in South Africa: (1) a cross-sectional survey of N = 200 adolescents and (2) a qualitative study of pre-exposure prophylaxis with N = 57 adolescents and N = 25 clinicians. Among adolescents, 3% used and 14% knew someone who used non-prescribed ART for recreational purposes. Administration included smoking (71%), snorting (15%), injecting (15%), ingesting (15%), and inserting (3%). Participants predicted increased crime as recreational use of ART increased. Future studies should investigate prevalence, composition, and diversion of ART from HIV prevention and treatment. [ABSTRACT FROM AUTHOR]

This paper reports on participants' views regarding factors contributing to the vulnerability of teenagers with intellectual disability to sexual abuse. The study took place at two special schools located in a village of KwaZulu-Natal. Data were gathered using by individual interviews, which were conducted in a face-to-face manner with life orientation teachers (8), school nurses (2), a clinical psychologist at the local hospital, and social workers (2). The interviews were also conducted with two parents, a traditional healer and spiritual diviner. Data was thematically analysed. The vulnerability factors were grouped into three broad categories, namely: individual, family and community factors. The existence of a number of vulnerability factors suggests that efforts to mitigate the problem should occur at various levels, with which an individual is interacting. [ABSTRACT FROM AUTHOR]

Objective: The objective of this article was to analyse women's perceptions of ICMC and to propose a framework for ICMC decision-making that can inform ICMC policies. Method: Using qualitative interviews, this study investigated twenty-five Black women's perceptions of ICMC decisionmaking in South Africa. Black women who had opted not to circumcise their sons, were selected through purposive and snowball sampling. Underpinned by the Social Norms Theory, their responses were analysed through in-depth interviews and a framework analysis. We conducted the study in the townships of Diepsloot and Diepkloof, Gauteng, South Africa. Results: Three major themes emerged: medical mistrust, inaccurate knowledge leading to myths and misconceptions, and cultural practices related to traditional male circumcision. Building Black women's trust in the public health system is important for ICMC decision-making. Conclusions for Practice: Policies should address misinformation through platforms that Black women share. There should be an acknowledgement of the role that cultural differences play in the decision-making process. This study developed an ICMC perception framework to inform policy. Significance: What is already known on this subject? Male circumcision decision-making is complex because multiple, interrelated factors influence it. Deciding about circumcising infants and children is a challenge that many parents face. What this study adds? This study found that social pressure from the social network, myths and misconceptions resulting from inaccurate knowledge, medical mistrust and traditional male circumcision practices influence the decisions of Black women not to circumcise their sons. The study proposes a perceptions framework to demonstrate consideration for Black women's voices in the male circumcision discourse. [ABSTRACT FROM AUTHOR]

The monthly dapivirine vaginal ring has proven efficacious in reducing HIV incidence in two Phase 3 clinical trials. When considering the potential future availability of the ring to the public, key questions remain about the feasibility of integrating the ring as an HIV prevention intervention into women's lives. We conducted qualitative mapping interviews (n = 66) among women enrolled in MTN-025/HOPE, an open-label trial conducted in Malawi, South Africa, Uganda and Zimbabwe, to examine how home environments influenced use of the dapivirine vaginal ring. Most women had secure places to store their rings including wardrobes, suitcases, and bags. The primary concerns for ring storage were potential tampering from children or rodents. Household overcrowding limited the privacy some women had which made removal and insertion of vaginal rings challenging. Despite these challenges, ring storage, insertion, and removal was feasible across social and living contexts. [ABSTRACT FROM AUTHOR]

While palliative care is beginning to gain prominence in South Africa, spiritual care remains less understood. Spiritual care is less prioritised and, consequently, this service, if offered, is mostly entrusted to volunteers. It therefore becomes prudent to understand who these volunteers are, what motivates them to volunteer, and how they see spiritual care being sustainable in the future. A cohort of spiritual care workers from a prominent hospice in Cape Town, South Africa, participated in this qualitative study. The participants made suggestions about formalising spiritual care as well as making a call for a basic entry requirement into spiritual care work. [ABSTRACT FROM AUTHOR]

Given task-sharing mental health counselling to non-specialist providers is a recognised strategy to increase service capacity, ensuring that their training, supervision, and support needs are met is necessary to facilitate the sustainable delivery of a high-quality service. Using in-depth interviews, we qualitatively explored the experiences of 18 facility-based counsellors (FBCs) tasked with delivering a counselling intervention within chronic disease services offered within primary care facilities participating in the project MIND cluster randomised controlled trial. Findings show that project MIND training with a strong emphasis on role playing and skills rehearsal improved FBCs' confidence and competence, complemented by highly structured supervision and debriefing provided by a registered counsellor, were key strategies for supporting the implementation of task-shared mental health counselling. FBCs perceived many benefits to providing mental health counselling in primary healthcare but systemic interventions are needed for sustained implementation. [ABSTRACT FROM AUTHOR]

Despite demonstrated efficacy for HIV prevention, substantial challenges remain for the successful rollout of oral pre-exposure prophylaxis (PrEP), especially among adolescent girls and young women (AGYW). We characterized trajectories of PrEP adherence among 200 AGYW in South Africa and analyzed data from 22 qualitative interviews and 3 focus group discussions for explanatory purposes. Two adherence trajectory groups were identified: 52% with high early adherence that declined after month three and 48% with low adherence throughout. Adherence in the "consistently low" group was related to social support and logistical concerns, while the decrease in the "high declining" group corresponded to a change in the frequency of study visits from monthly to quarterly. PrEP support should be differentiated for those who need more frequent visits and adherence support initially versus later in PrEP use. Visits every month, when needed, should be considered for AGYW who need sustained support later into use. [ABSTRACT FROM AUTHOR]

The dapivirine vaginal ring has been well-tolerated and shown to prevent HIV in clinical trials. The ring is female initiated, yet endorsement for use is sought from male partners in many relationships. In clinical studies, participants have expressed worries about men detecting rings during vaginal sex, which introduces concerns about product use disclosure, sexual pleasure, penile harm, inter-partner dynamics, and ring removals. This study reports African men's firsthand sexual experiences with the ring. Qualitative data were captured through 11 focus group discussions and one in-depth interview with 54 male partners of ring-users at six research sites in Malawi, South Africa, Uganda and Zimbabwe. Following a semi-structured guide, and using demonstration rings, vulva and penis models, men were asked to discuss the ring's impact on sex and views on male engagement and ring use. Interviews were facilitated by local male social scientists, audio-recorded, translated into English, and analyzed thematically. 22 (41%) of the male partners reported feeling the ring during sex, often attributed to perceived incorrect insertion. Many men described the ring as "scratching" the tip of their penises, and sensations of "prodding" something that "blocked" the vagina and prohibited "full entry". In most cases, feelings dissipated with time or when sexual fluids increased. Less common descriptions included perceiving the vaginal texture, wetness and size as different, which increased pleasure for some, and decreased for others. Over half (59%) never noticed the ring; some attempting and failing to feel it during intercourse. A majority of men reported that the ring did not lead to changes in sexual positions, feelings, frequency or experience of sex, although some were initially afraid that the ring was a "magic snake" or "potion". Male partners expressed strong opinions that ring use was a shared prevention responsibility that men should be engaged in, especially for maintaining trust and open communication in relationships. The ring was noticed by many male partners, particularly during women's initial stages of ring use, although this led to few sexual problems or changes. Nevertheless, results suggest that risk of ring discovery should be discussed with women to mitigate any potential negative reactions or social harm. Strategies to increase male partner engagement will enhance support of this prevention method for women. [ABSTRACT FROM AUTHOR]

Consistent over-reporting of product use limits researchers' ability to accurately measure adherence and estimate product efficacy in HIV prevention trials. While lying is a universal characteristic of the human condition, growing evidence of a stark discrepancy between self-reported product use and biologic or pharmacokinetic evidence demands examination of the reasons research participants frequently misrepresent product use in order to mitigate this challenge in future research. This study (VOICE-D) was an ancillary post-trial study of the vaginal and oral interventions to control the epidemic (VOICE) phase IIb trial (MTN 003). It was conducted in three African countries to elicit candid accounts from former VOICE trial participants about why actual product use was lower than reported. In total 171 participants were enrolled between December 2012 and March 2014 in South Africa (n = 47), Uganda (n = 59) and Zimbabwe (n = 65). Data suggested that participants understood the importance of daily product use and honest reporting, yet acknowledged that research participants typically lie. Participants cited multiple reasons for misreporting adherence, including human nature, self-presentation with study staff, fear of repercussions (study termination resulting in loss of benefits and experience of HIV-related stigma), a permissive environment in which it was easy to get away with misreporting, and avoiding inconvenient additional counseling. Some participants also reported mistrust of the staff and reciprocal dishonesty about the study products. Many suggested real-time blood-monitoring during trials would encourage greater fidelity to product use and honesty in reporting. Participants at all sites understood the importance of daily product use and honesty, while also acknowledging widespread misreporting of product use. Narratives of dishonesty may suggest a wider social context of hiding products from partners and distrust about research, influenced by rumors circulating in clinic waiting-rooms and surrounding communities. Prevailing power hierarchies between staff and participants may exacerbate misreporting. Participants recognized and suggested that objective, real-time feedback is needed to encourage honest reporting. [ABSTRACT FROM AUTHOR]

There is widespread evidence that male partners influence women's ability and willingness to join HIV prevention trials and to use female-controlled prevention strategies such as microbicide gels. VOICE-C was an ancillary study to the Microbicide Trials Network's VOICE trial at the Johannesburg site that explored social and structural factors influencing women's use of study tablets and vaginal gel. Qualitative data were analyzed from 102 randomly-selected VOICE participants interviewed through in-depth interviews (IDI, n = 41); ethnographic interviews (n = 21) or focus group discussions (FGD, n = 40) and 22 male partners interviewed in 14 IDI and 2 FGD. Male partners' 'understanding' pervaded as a central explanation for how male partners directly and indirectly influenced their female partners' trial participation and product use, irrespective of assignment to the gel or tablet study groups. The meaning behind 'understanding' in this context was described by both men and women in two important and complementary ways: (1) 'comprehension' of the study purpose including biological properties or effects of the products, and (2) 'support/agreeability' for female partners being study participants or using products. During analysis a third dimension of 'understanding' emerged as men's acceptance of larger shifts in gender roles and relationship power, and the potential implications of women's increased access to biomedical knowledge, services and prevention methods. Despite displays of some female agency to negotiate and use HIV prevention methods, male partners still have a critical influence on women's ability and willingness to do so. Efforts to increase their understanding of research goals, study design and products' mechanisms of action could ameliorate distrust, empower men to serve as product advocates, adherence buddies, and foster greater adherence support for women in situations where it is needed. Strategies to address gender norms and the broader implications these have for female-initiated HIV prevention should likewise be integrated into future research and program activities. [ABSTRACT FROM AUTHOR]

Gender and HIV risk have been widely examined in southern Africa, generally with a focus on dynamics within sexual relationships. Yet the social construction of women's lives reflects their broader engagement with a gendered social system, which influences both individual-level risks and social and economic vulnerabilities to HIV/AIDS. Using qualitative data from Lesotho, we examine women's lived experiences of gender, family and HIV/AIDS through three domains: (1) marriage; (2) kinship and social motherhood, and (3) multigenerational dynamics. These data illustrate how women caregivers negotiate their roles as wives, mothers, and household heads, serving as the linchpins of a gendered family system that both affects, and is affected by, the HIV/AIDS epidemic. HIV/AIDS interventions are unlikely to succeed without attention to the larger context of women's lives, namely their kinship, caregiving, and family responsibilities, as it is the family and kinship system in which gender, economic vulnerability and HIV risk are embedded. [ABSTRACT FROM AUTHOR]

Post-coital intravaginal cleansing (IVC) could counteract the protective effect of a vaginal microbicide. IVC less than 1 h after sex is discouraged in most microbicide trials. During a microbicide trial in KwaZulu-Natal, we collected quantitative data on post-coital IVC. We discussed IVC during in-depth-interviews (IDIs) and focus-group discussions (FGDs) with women enrolled in the trial, and during FGDs with community members. Nearly one-third (336/1,143) of women reported IVC less than an hour after sex. In multivariate analysis, post-coital IVC was associated with younger age, larger household size, greater sexual activity, consistent gel use, and clinic of enrolment. During IDIs and FGDs, respondents described post-coital IVC as a common hygiene practice motivated by the need to remove semen, vaginal fluids and sweat, although this practice may be amenable to change in the context of microbicide use. We need to consider strategies for influencing post-coital IVC practices in future microbicide trials and delivery programmes. [ABSTRACT FROM AUTHOR]

Disclosure of HIV status is widely promoted in the prevention of mother-to-child transmission (PMTCT), but a number of context-specific factors may mediate disclosure outcomes. To better understand HIV-disclosure dynamics, we conducted in-depth interviews among 62 HIV-positive pregnant women accessing PMTCT services in Durban, South Africa. Transcripts were coded for emergent themes and categories. Thirty-nine women (63 %) had been recently diagnosed with HIV; most ( n = 37; 95 %) were diagnosed following routine antenatal HIV testing. Forty-two women (68 %) reported unplanned pregnancies. Overall, 37 women (60 %) reported an unintended pregnancy and recent HIV diagnosis. For them, 2 life-changing diagnoses had resulted in a double-disclosure bind. The timing and stigma surrounding these events strongly influenced disclosure of pregnancy and/or HIV. PMTCT-related counseling must be responsive to the complex personal implications of contemporaneous, life-changing events, especially their effect on HIV-disclosure dynamics and, ultimately, on achieving better maternal mental-health outcomes. [ABSTRACT FROM AUTHOR]

A community-based needs assessment among men who have sex with men (MSM) in South Africa found that 27 % ( n = 280/1,045) of MSM had never been tested for HIV. The most frequently reported reasons for not having been tested were the perception of not being at risk (57 %) and fear of being tested (52 %). This article explores factors associated with these two reasons among the untested MSM. In multiple logistic regressions, the perception of not being at risk of HIV infection was negatively associated with being black, coloured or Indian, being sexually active, knowing people living with HIV, and a history of sexually transmitted infections (STIs) in the past 24 months (adj. OR = .24, .32, .38, and .22, respectively). Fear of being tested for HIV was positively associated with being black, coloured or Indian, preferred gender expression as feminine, being sexually active, a history of STIs, and experience of victimization on the basis of sexual orientation (adj. OR = 2.90, 4.07, 4.62, 5.05, and 2.34, respectively). Results suggest that HIV prevention programs directed at South African MSM will be more effective if testing and treatment of STIs are better integrated into HIV testing systems. Finally, social exclusion on the basis of race and sexual orientation ought to be addressed in order to reach hidden, at-risk, populations of MSM. [ABSTRACT FROM AUTHOR]