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Background: Despite known disparities in pediatric perioperative outcomes, few studies have examined factors associated with the use of regional anesthesia for pediatric orthopedic surgery., Aims: This investigation aimed to determine if minority and developmental disability status were associated with the allocation of peripheral nerve blocks in calcaneal osteotomy., Methods: We conducted a single-center, retrospective study of records of patients <18 years who underwent calcaneal osteotomy from 2013 to 2022. Regional technique was classified into three groups: popliteal-sciatic single-shot block, popliteal-sciatic catheter, and no block. Patients were classified as either nonminority (white, non-Hispanic) or minority. Developmental disability status was defined based on medical history and classified as binary. Anesthesiologists were classified as "regional" or "nonregional" based on clinical expertise. A Bayesian hierarchical multinomial model with random intercepts for patients and surgeons was used to investigate the association of minority status, developmental disability, and anesthesiologist expertise with block selection., Results: We analyzed 287 cases in 225 patients; of these, 55% occurred in minority patients and 28% occurred in patients with developmental disability. Catheters were placed in 45% of cases, single shot blocks in 41%, and no block in 14%. Minority and nonminority patients had a similar likelihood of receiving of any block. Patients with developmental disability had a -22% absolute difference of receiving any block (95% credible interval [-38%, -7%]) compared to those without developmental disability (55% vs. 77%), an effect primarily driven by a lower rate of catheter placement in these children. Regional anesthesiologists were more likely to place catheters (23% absolute increase; 36% vs. 13%) and more likely to perform any block in children with developmental disability (30% absolute increase; 67% vs. 37%) than nonregional anesthesiologists., Conclusions: Decision-making surrounding the placement of regional anesthesia techniques is complex. In this study, developmental disability status and anesthesiologist experience were associated with a difference in the use of regional anesthesia in patients undergoing calcaneal osteotomy., (© 2024 John Wiley & Sons Ltd.)

External HIV-related stigma remains pervasive, and its effect debilitating among PLHIV in South Africa, even though the country has made many advances against HIV. External HIV-related stigma impedes both HIV prevention and access to health care and reduces the quality of treatment and care received. This study examined the prevalence of and factors associated with higher levels of HIV-related stigma among youth and adults 15 years and older in South Africa. The analysis used a nationally representative population-based household survey data collected using a multistage cluster random sampling design. Exploratory factor analysis was used to calculate the primary outcome (higher and lower HIV stigma index scores above and below the mean, respectively), based on the total number of factors retained from the 10 item self-reported questions relating to attitudes and beliefs against PLHIV. Bivariate and multivariate generalised linear models with a log link and binomial distribution were fitted to estimate crude and adjusted risk ratios (ARR) with 95% confidence intervals (CI) for factors associated with external HIV-related stigma. Of 38 919 respondents, 49% (49.8%; 95% CI: 48.6-51.1) were categorised as having higher levels of external HIV-related stigma. Higher levels of HIV-related stigma were significantly associated with those who had secondary level education than those with no education/primary education [ARR = 1.14 (95% CI: 1.05-1.24), p = 0.002], those employed than unemployed [ARR = 1.08 (95% CI: 1.02-1.14), p = 0.006], those in rural areas than urban areas [ARR = 1.15 (95% CI: 1.07-1.23), p<0.001], those who were aware of their HIV status than not aware [ARR = 1.34 (95% CI: 1.12-1.61), p<0.001], those who were HIV positive than HIV negative [ARR = 1.09 (95% CI: 1.02-1.17), p = 0.018], and those with no correct HIV knowledge and myth rejection than their counterparts [ARR = 1.09 (95% CI: 1.03-1.15), p = 0.002]. The findings highlight the need for peer-facilitated HIV-stigma reduction interventions targeting all types of educational institutions and the strengthening of work-based interventions. The findings emphasise the prioritisation of rural informal settings/tribal areas when developing and implementing HIV stigma reduction interventions. The study suggests that stigma reduction should be considered an important component of HIV testing and awareness. Addressing public misconceptions about HIV can mitigate externalised stigma., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Mehlomakulu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Population-based serological testing is important to understand the epidemiology and estimate the true cumulative incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to inform public health interventions. This study reports findings of a national household population SARS-CoV-2 serosurvey in people 12 years and older in South Africa. This cross-sectional multi-stage random stratified cluster survey undertaken from November 2020 to June 2021 collected sociodemographic data, medical history, behavioural data, and blood samples from consenting participants. The samples were tested for SARS-CoV-2 antibodies using the Roche ElecsysAnti-SARS-CoV-2 chemiluminescence immunoassay (CLIA) Total Antibody Test. The survey data were weighted by age, race, sex, and province with final individual weights benchmarked against the 2020 mid-year population estimates and accounted for clustering. Descriptive statistics summarize the characteristics of participants and seroprevalence. Logistic regression analyses were used to identify factors associated with seropositivity. From 13290 survey participants (median age 33 years, interquartile range (IQR) 23-46 years), SARS-CoV-2 seroprevalence was 37.8% [95% Confidence Interval (CI) 35.4-40.4] and varied substantially across the country's nine provinces, and by sex, age and locality type. In the final adjusted model, the odds of seropositivity were higher in women than in men [aOR = 1.3 (95% CI: 1.0-1.6), p = 0.027], and those living with HIV (self-report) [aOR = 1.6 (95% CI: 1.0-2.4), p = 0.031]. The odds were lower among those 50 years and older compared to adolescents 12-19 years old [aOR = 0.6 (95% CI: 0.5-0.8), p<0.001] and in those who did not attend events or gatherings [aOR = 0.7 (95% CI: 0.6-1.0), p = 0.020]. The findings help us understand the epidemiology of SARS-CoV-2 within different regions in a low-middle-income country. The survey highlights the higher risk of infection in women in South Africa likely driven by their home and workplace roles and also highlighted a need to actively target and include younger people in the COVID-19 response., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests. All authors were Funded by the Solidarity Fund and the Human Sciences Research Council. The National Institute for Communicable Diseases, South Africa, funded testing with the Roche assay Sizulu Moyo, Leickness C.S. Simbayi, Khangelani Zuma, Nompumelelo Zungu, Edmore Marinda E, Sean Jooste, Whadi-ah Parker, Shandir Ramlagan, Inbarani Naidoo, Musawenkosi Mabaso designed and led the study and were and are still employed by the Human Sciences Research Council. Mirriam Fortuin Beverley Singh, Adrian Puren led and conducted the laboratory testing and were and are still employed by the National Institute for Communicable Diseases, South Africa., (Copyright: © 2023 Moyo et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Despite high HIV prevalence in transgender women in sub-Saharan Africa, to our knowledge no study presents data across the HIV care continuum for this population in the region. The aim of this study was to estimate HIV prevalence and present data to develop the HIV care continuum indicators for transgender women in three South African metropolitan municipalities., Methods: Biobehavioural survey data were collected among sexually active transgender women in the metropolitan municipalities of Johannesburg, Buffalo City, and Cape Town, South Africa. Transgender women (aged ≥18 years, self-reporting consensual sex with a man in the 6 months before the survey) were recruited using respondent-driven sampling (RDS). An interviewer-administered questionnaire was used to determine awareness of HIV status; blood specimens were collected on dried blood spots to test for HIV antibodies, antiretroviral treatment (ART) exposure, and viral load suppression. Population-based estimates of HIV 95-95-95 cascade indicators were derived by use of individualised RDS weights with RDS Analyst software. Multivariate stepwise backward logistic regression modelling was used to determine factors associated with each cascade indicator. All eligible participants were included in the final analysis., Findings: Between July 26, 2018, and March 15, 2019, we enrolled 887 sexually active transgender women: 323 in Johannesburg, 305 in Buffalo City, and 259 in Cape Town. HIV prevalence was highest in Johannesburg where 229 (74·1%) of 309 tests were positive (weighted prevalence estimate 63·3%, 95% CI 55·5-70·5), followed by Buffalo City where 121 (43·7%) of 277 were positive (46·1%, 38·7-53·6), and then Cape Town where 122 (48·4%) of 252 were positive (45·6%, 36·7-54·7). In Johannesburg, an estimated 54·2% (95% CI 45·8-62·4) of transgender women with HIV knew their positive status, in Cape Town this was 24·2% (15·4-35·8), and in Buffalo City this was 39·5% (27·1-53·4). Among those who knew their status, 82·1% (73·3-88·5) in Johannesburg, 78·2% (57·9-90·3) in Cape Town, and 64·7% (45·2-80·2) in Buffalo City were on ART. Of those on ART, 34·4% (27·2-42·4) in Johannesburg, 41·2% (30·7-52·6) in Cape Town, and 55·0% (40·7-68·4) in Buffalo City were virally suppressed., Interpretation: Innovative strategies are needed to inform efforts to diagnose and to treat transgender women living with HIV promptly to achieve viral load suppression. Differentiated HIV services tailored to transgender women of race groups other than Black South African, and those with low education attainment and low outreach exposure, innovative testing, and adherence strategies should be developed to improve the HIV cascade for South African transgender women., Funding: The US President's Emergency Plan For AIDS Relief and US Centers for Disease Control and Prevention., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

South Africa has the largest number of people living with HIV worldwide. South Africa has implemented five population-based HIV prevalence surveys since 2002 aimed at understanding the dynamics and the trends of the epidemic. This paper presents key findings from the fifth HIV prevalence, incidence, and behaviour survey conducted in 2017 following policy, programme, and epidemic change since the prior survey was conducted in 2012. A cross-sectional population-based household survey collected behavioural and biomedical data on all members of the eligible households. A total of 39,132 respondents from 11,776 households were eligible to participate, of whom 93.6% agreed to be interviewed, and 61.1% provided blood specimens. The provided blood specimens were used to determine HIV status, HIV incidence, viral load, exposure to antiretroviral treatment, and HIV drug resistance. Overall HIV incidence among persons aged 2 years and above was 0.48% which translates to an estimated 231,000 new infections in 2017. HIV prevalence was 14.0% translating to 7.9 million people living with HIV. Antiretroviral (ARV) exposure was 62.3%, with the lowest exposure among those aged 15 to 24 years (39.9%) with 10% lower ARV coverage among males compared to females. Viral suppression among those on treatment was high (87.3%), whilst HIV population viral load suppression was much lower (62.3%). In terms of risk behaviours, 13.6% of youth reported having had an early sexual debut (first sex before the age of 15 years), with more males reporting having done so (19.5%) than females (7.6%). Age-disparate relationships, defined as having a sexual partner 5+ years different from oneself,) among adolescents were more common among females (35.8%) than males (1.5%). Self-reported multiple sexual partnerships (MSPs), defined as having more than one sexual partner in the previous 12 months, were more commonly reported by males (25.5%) than females (9.0%). Condom use at last sexual encounter was highest among males than females. Three quarters (75.2%) of people reported they had ever been tested for HIV, with more females (79.3%) having had done so than males (70.9%). Two-thirds of respondents (66.8%) self-reported having tested for HIV in the past 12 months. Finally, 61.6% of males in the survey self-reported as having been circumcised, with circumcision being more common among youth aged 15-24 years (70.2%), Black Africans (68.9%), and those living in both rural informal (tribal) areas (65%) and urban areas (61.9%). Slightly more (51.2%) male circumcisions were reported to have occurred in a medical setting than in traditional settings (44.8%), with more young males aged 15-24 (62.6%) and men aged 25-49 (51.5%) reporting to have done so compared to most men aged 50 and older (57.1%) who reported that they had undergone circumcision in a traditional setting. The results of this survey show that strides have been made in controlling the HIV epidemic, especially in the reduction of HIV incidence, HIV testing, and treatment. Although condom use at last sex act remains unchanged, there continue to be some challenges with the lack of significant behaviour change as people, especially youth, continue to engage in risky behaviour and delay treatment initiation. Therefore, there is a need to develop or scale up targeted intervention programmes to increase HIV testing further and put more people living with HIV on treatment as well as prevent risky behaviours that put young people at risk of HIV infection.

In this paper, risk compensation among individuals on antiretroviral therapy (ART), using the 2017 South African national survey on HIV, is explored. A multi-stage stratified cluster random sampling approach was used to realize 11,130 participants 15 years and older. Logistic regression analysis assessed the association between multiple sexual partners, condom use at last sexual encounter, consistency of condom usage and potential explanatory variables using HIV status and ART exposure as a mediator variable. HIV positive participants who were aware and on ART were less likely to have multiple sexual partners, and less likely not to use a condom at last sex compared to HIV positive participants who were aware but not on ART. The odds of reporting multiple sexual partners were significantly lower among older age groups, females, non-Black Africans, and rural settings, and higher among those with tertiary level education, and risky alcohol users. The odds of no condom use at last sexual encounter were more likely among older age groups, females, other race groups, and less likely among those with secondary level education. The odds of inconsistent condom use were more likely among older age groups, females, and other race groups, and less likely among those with tertiary level education, high risk and hazardous alcohol users. Risk compensation is not apparent among HIV infected adults who are on ART. Risk groups that should receive tailored interventions to reduced risky sexual behaviours were identified.

Objectives: This paper reports HIV prevalence, incidence, progress towards the UNAIDS (90-90-90) targets, and HIV drug resistance among adolescents living with HIV in South Africa. We conducted secondary analyses using data extracted from the South African national HIV prevalence surveys (2005-2017). Analyses were stratified by sex and age (10-14 and 15-19-years), presenting weighted descriptive statistics, and realised totals., Results: HIV prevalence increased from 3.0% in 2012 to 3.7% in 2017, translating to 360 582 (95% CI 302 021-419 144) HIV positive adolescents in 2017. Female adolescents bear a disproportionate HIV burden of 5.6% prevalence versus 0.7% for males. HIV incidence remained relatively stable. For the UNAIDS 90-90-90 targets, approximately 62.3% of adolescents knew their HIV status, 65.4% of whom were on antiretroviral therapy, and of these 78.1% on antiretroviral therapy had attained viral load suppression. There are knowledge gaps pertaining to the magnitude of perinatal infections and postnatal infections, and socio-behavioural risk factors for HIV transmission among adolescents in South Africa. There is still a need for focussed interventions targeting adolescent (1) gender disparities in HIV risk (2) screening for HIV, (3) sustained access and adherence to antiretroviral therapy and (3) retention in care to maintain viral load suppression., (© 2022. The Author(s).)

Background: Adolescents are at increased risk of HIV infection compared to other age groups. There is an urgent need for strategic information that will inform programmes to reduce risk and vulnerability to HIV and reverse the pattern of increasing HIV infection as they transition to adulthood. This paper analysed trends and factors associated with HIV prevalence among adolescents in South Africa using the national HIV population-based household surveys conducted in 2008, 2012 and 2017., Methods: All three surveys used a multistage cross-sectional design. A trend analysis was conducted to assess the differences in HIV prevalence and covariates overtime using P-trend Chi-squared statistic. Univariate and multivariate logistic regression models were used to determine factors associated with HIV prevalence., Results: Overall there was a significant increase in HIV prevalence among adolescents aged 12-19 years from 3.0% (n = 2892) in 2008 to 3.2% (n = 4829) in 2012 and 4.1% (n = 3937) in 2017 (p = 0.031). The odds of being HIV positive among adolescents aged 12-19 years was significantly higher among females [AOR = 2.24; 95% CI (1.73-2.91); p < 0.001] than males, those residing in KwaZulu-Natal province [AOR = 2.01; 95% CI (1.-3.99); p = 0.027] than Northern Cape, and those who did not attend an educational institution and were unemployed [AOR = 2.66; 95% CI (1.91-3.67); p < 0.001] compared to those attending an educational institution. The odds were significantly lower among Whites [AOR = 0.29; 95% CI (0.09-0.93); p = 0.037], Coloureds [AOR = 0.21; 95% CI (0.11-0.37); p ≤ 0.001] and Indian/Asian [AOR = 0.08; 95% CI (0.02-0.34); p = 0.001] population groups than Black Africans., Conclusion: The observed increasing trend and gender disparities in HIV prevalence suggests an urgent need for age appropriate and gender specific HIV interventions tailored and targeted at identified drivers of HIV infection among adolescents., (© 2021. The Author(s).)

Background: Identification of the geographical areas with low uptake of HIV testing could assist in spatial targeting of interventions to improve the uptake of HIV testing., Objectives: The objective of this research study was to map the uptake of HIV testing at the district level in South Africa., Method: The secondary analysis used data from the Human Sciences Research Council's 2017 National HIV Prevalence, Incidence, Behaviour and Communication Survey, where data were collected using a multistage stratified random cluster sampling approach. Descriptive spatial methods were used to assess disparities in the proportion of those ever tested for HIV at the district level in South Africa., Results: The districts with the highest overall coverage of people ever having tested for HIV (> 85%) include West Rand in Gauteng, Lejweleputswa and Thabo Mofutsanyane in Free State, and Ngaka Modiri Molema in North-West. These provinces also had the least variation in HIV testing coverage between their districts. Districts in KwaZulu-Natal had the widest variation in coverage of HIV testing. The districts with the lowest uptake of HIV testing were uMkhanyakude (54.7%) and Ugu (61.4%) in KwaZulu-Natal and Vhembe (61.0%) in Limpopo. Most districts had a higher uptake of HIV testing amongst female than male participants., Conclusion: The uptake of HIV testing across various districts in South Africa seems to be unequal. Intervention programmes must improve the overall uptake of HIV testing, especially in uMkhanyakude and Ugu in KwaZulu-Natal and Vhembe in Limpopo. Interventions must also focus on enhancing uptake of HIV testing amongst male participants in most districts. Strategies that would improve the uptake of HIV testing include HIV self-testing and community HIV testing, specifically home-based testing., Competing Interests: The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article., (© 2021. The Authors.)

Background: Improved understanding of barriers to HIV testing is important for reaching the first of the UNAIDS 90-90-90 targets, which states that 90% of HIV positive individuals ought to know their HIV status. This study examined socio-economic status (SES) differences in HIV testing uptake and associated factors among youth and adults 15 years and older in South Africa., Methods: This study used data from a national cross-sectional, population-based household survey conducted in 2017 using a multi-stage sampling design. A composite SES score was created using multiple correspondence analyses of household assets; households were classified into wealth quintiles and dichotomised into low SES/poorest (lowest 3 quintiles) and high SES/less-poor (highest 2 quintiles). Bivariate and multivariate logistic regression models were used to examine factors associated with the uptake of HIV testing in low and high SES households., Results: HIV testing uptake was 73.8 and 76.7% among low and high SES households, respectively, both of which were below the first 90 targets. Among both low and high SES households, increased HIV testing uptake was significantly associated with females than males. The decreased likelihood was significantly associated with residing in rural formal areas than urban areas, those with no education or low levels of educational attainment and alcohol drinkers among low SES households. Whites and Indians/Asians had a decreased likelihood than Black Africans in high SES households., Conclusions: HIV testing interventions should target males, residents in rural formal areas, those with no or low education and those that consume alcohol in low SES households, including Whites and Indians/Asians from high SES households in order to bridge socio-economic disparities in the uptake of HIV testing. This should entail expanding HIV testing beyond traditional centres for voluntary counselling and testing through outreach efforts, including mobile testing and home-based testing., (© 2021. The Author(s).)

Background: Adequate information and knowledge about COVID-19 has been shown to induce the confidence and positive performance among healthcare workers (HCWs). Therefore, assessing the relationship between confidence in knowledge and associated factors among HCWs is vital in the fight against COVID-19. This paper investigates factors associated with HCWs' confidence in their overall knowledge about COVID-19 in South Africa in the early stages of the epidemic. Methods: Data utilized in this paper were from an online survey conducted among HCWs using a structured questionnaire on a data free online platform. The study population were all the medical fraternity in South Africa including medical and nurse practitioners as well as other healthcare professionals. Bivariate and multivariate logistic regression models were performed to examine the factors associated with confidence in HCWs' overall knowledge about COVID-19. Results: Overall, just below half (47.4%) of respondents indicated that they had confidence in their overall knowledge about COVID-19. Increased odds of having confidence in the knowledge about COVID-19 were significantly associated with being male [aOR = 1.31 95% CI (1.03-1.65), p < 0.05], having a doctorate degree [aOR = 2.01 (1.23-3.28), p < 0.05], being satisfied with the information about COVID-19 guidelines [aOR = 6.01 (4.89-7.39), p < 0.001], having received training in 6-8 areas [aOR = 2.54 (1.89-3.43), p < 0.001] and having received training in 9-11 areas [aOR = 5.33 (3.81-7.47), p < 0.001], and having already treated COVID-19 patients [aOR = 1.43 (1.08-1.90), p < 0.001]. Those who were highly concerned with the levels of training of HCWs [aOR = 0.47 (0.24-0.92), p < 0.05] had decreased odds of having confidence in their overall knowledge about COVID-19. Conclusion: This study sheds light on the importance of capacitating HCWs with knowledge and adequate relevant training as part of infection prevention control measures during pandemics. Future training and information sharing should be sensitive to knowledge gaps by age, gender, qualifications, professional categories, and experience., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Manyaapelo, Mokhele, Sifunda, Ndlovu, Dukhi, Sewpaul, Naidoo, Jooste, Tlou, Moshabela, Mabaso, Zuma and Reddy.)

Background: The first 90 of UNAIDS 90-90-90 targets to have 90% of the people living with HIV know their status is an important entry point to the HIV treatment cascade and care continuum, but evidence shows that there is a large gap between males and females in this regard. It is therefore important to understand barriers and facilitators of achieving the first 90 target. This study examined determinants of the first 90 target among females and males in order to inform strategies aimed at improving the HIV cascade in South Africa., Methods: The data used in the analysis were obtained from a 2017 household-based cross-sectional nationally representative survey conducted using a multi-stage stratified cluster random sampling design. A series of hierarchical multiple logistic regression models were fitted to identify the determinants of the first 90 target by gender., Results: Overall, 84.8% of HIV-positive individuals aged 15 years and older were aware of their HIV status. Females were significantly more aware of their HIV status compared to males (88.7% vs 78.2%, p < 0.001). Both females aged 25 to 49 years [aOR = 3.20 (95% CI 1.35-7.57), p = 0.008], and 50 years and older [aOR = 3.19 (95% CI 1.04-9.76), p = 0.042] and males aged 25 to 49 years [aOR = 3.00 (95% CI 1.13-7.97), p = 0.028], and 50 years and older [aOR = 7.25 (95% CI 2.07-25.36), p = 0.002] were significantly more likely to know their HIV status compared to those aged 15 to 19 years. Males with tertiary education level were significantly more likely to be aware of their HIV positive status [aOR = 75.24 (95% CI 9.07-624.26), p < 0.001] compared to those with no education or with primary level education. Females with secondary [aOR = 3.28 (95% CI 1.20-8.99), p = 0.021] and matric [aOR = 4.35 (95% CI 1.54-12.37), p = 0.006] educational levels were significantly more likely to be aware of their HIV positive status, compared to those with no education or with primary level education., Conclusion: Significant progress has been made with regards to reaching the UNAIDS first 90 target. In this context achieving the first 90 target is feasible but there is a need for additional interventions to reach the males especially youth including those with no education or low levels of education.

Background: The World Health Organization (WHO) declared the COVID-19 pandemic a public health emergency of international concern. South Africa, like many other countries, initiated a multifaceted national response to the pandemic. Self-isolation and quarantine are essential components of the public health response in the country. This paper examined perceptions and preparedness for self-isolation or quarantine during the initial phase of the pandemic in South Africa., Methods: The analysis used data obtained from an online quantitative survey conducted in all nine provinces using a data-free platform. Descriptive statistics and multivariable logistic regression models were used to analyse the data., Results: Of 55,823 respondents, 40.1% reported that they may end up in self-isolation or quarantine, 32.6% did not think that they would and 27.4% were unsure. Preparedness for self-isolation or quarantine was 59.0% for self, 53.8% for child and 59.9% for elderly. The odds of perceived possibility for self-isolation or quarantine were significantly higher among Coloureds, Whites, and Indians/Asians than Black Africans, and among those with moderate or high self-perceived risk of contracting COVID-19 than those with low risk perception. The odds were significantly lower among older age groups than those aged 18-29 years, and those unemployed than fully employed. The odds of preparedness for self-isolation or quarantine were significantly less likely among females than males. Preparedness for self, child and elderly isolation or quarantine was significantly more likely among other population groups than Black Africans and among older age groups than those aged 18-29 years. Preparedness for self, child and elderly isolation or quarantine was significantly less likely among those self-employed than fully employed and those residing in informal dwellings than formal dwellings. In addition, preparedness for self-isolation or quarantine was significantly less likely among those with moderate and high self-perceived risk of contracting COVID-19 than low risk perception., Conclusion: The findings highlight the challenge of implementing self-isolation or quarantine in a country with different and unique social contexts. There is a need for public awareness regarding the importance of self-isolation or quarantine as well as counter measures against contextual factors inhibiting this intervention, especially in impoverished communities.

Background: Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90-90-90 targets for the country stratified by a variety of key factors., Methods: To evaluate progress towards achievement of the 90-90-90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90)., Results: Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one's positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15-24 years old, 25-49 years old and 50-64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25-49 years old, 82.9% of those aged 50-64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90-90-90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%., Conclusions: South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15-24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90-90-90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.

Background: The COVID-19 outbreak is in an accelerating phase, and South Africa (SA) has had the highest number of documented cases during the early phase of the pandemic in sub-Saharan Africa., Objectives: To assess South Africans' understanding of and response to COVID-19 during the first week of the country's lockdown period., Methods: An online survey was conducted in SA from 27 March to 2 April 2020. The survey was distributed widely among several websites and social media networks, including on a data-free platform. Descriptive statistics of knowledge, risk perception, access to and trust in information sources, and public and media opinions were calculated. Estimates were benchmarked to the 2019 national adult population estimates., Results: Of the 55 823 participants, the majority (83.4%) correctly identified the main symptoms of COVID-19. Over 90% had correct knowledge of the incubation period, with lower rates for 18 - 29-year-olds. Knowledge of symptoms and the incubation period varied significantly by population group (p&lt;0.001), dwelling type (p&lt;0.001) and sex (p&lt;0.001). A quarter (24.9%) perceived themselves as at high risk of contracting COVID-19. Risk perception varied by age, population group, employment status and dwelling type (p&lt;0.001). The most prevalent COVID-19 information sources were government sources (72.9%), news websites/apps (56.3%), satellite television (51.6%) and local television (51.4%)., Conclusions: Understanding knowledge, attitudes and behaviours of people facing the COVID-19 pandemic is crucial for guiding strategic policy. These findings provide public understanding of COVID-19 as the phases of the country-level epidemic progress, and also directly inform communication needs and gaps.

Background: HIV testing contributes to the prevention and control of the HIV epidemic in the general population. South Africa has made strides to improve HIV testing towards reaching the first of the UNAIDS 90-90-90 targets by 2020. However, to date no nationally representative analysis has examined temporal trends and factors associated with HIV testing among youth and adults in the country., Aim: This study aimed to examine the trends and associations with ever having tested for HIV among youth and adults aged 15 years and older in South Africa using the 2005, 2008, 2012 and 2017 nationally representative population-based household surveys., Methods: The analysis of the data collected used multi-stage stratified cluster randomised cross-sectional design. P-trend chi-squared test was used to identify any significant changes over the four study periods. Bivariate and multivariate logistic regression analysis was conducted to determine factors associated with HIV testing in each of the survey periods., Results: Ever having tested for HIV increased substantially from 2005 (30.6%, n = 16 112), 2008 (50.4%, n = 13 084), 2012 (65.5%, n = 26 381), to 2017 (75.2%, n = 23 190). Those aged 50 years and older were significantly less likely to ever have tested for HIV than those aged 25-49 years. Those residing in rural areas were significantly less likely to have tested for HIV as compared to people from urban areas. There was a change in HIV testing among race groups with Whites, Coloureds and Indian/Asians testing more in 2005 and 2008 and Black Africans in 2017. Marriage, education and employment were significantly associated with increased likelihood of ever testing for HIV. Those who provided a blood specimen for laboratory HIV testing in the survey rounds and were found to have tested positive were more likely to have ever tested for HIV previously., Conclusion: The results show that overall there has been an increase in ever having an HIV test in the South African population over time. The findings also suggest that for South Africa to close the testing gap and reach the first of the UNAIDS 90-90-90 targets by 2020, targeted programmes aimed at increasing access and utilization of HIV testing in young people, males, those not married, the less educated, unemployed and those residing in rural areas of South Africa should be prioritised., Competing Interests: The authors have declared that no competing interests exist.

Background: In South Africa, persistence of the HIV epidemic and associated gender and racial disparities is a major concern after more than 20 years of democratic dispensation and efforts to create a more healthy and equal society. This paper profiles HIV prevalence and related factors among Black African men and women compared to other race groups in South Africa using the 2012 population-based national household HIV survey., Methods: This secondary data analysis was based on the 2012 population-based nationally representative multi-stage stratified cluster random household sample. Bivariate and multiple logistic regression analysis were used to assess the relationship between HIV prevalence and associated factors by gender and racial profile., Results: Overall HIV prevalence was significantly higher (p < 0.001) among both Black African males (16.6%; 95% CI: 15.0-18.4) and females (24.1%; 95% CI: 22.4-26.0) compared to their counterparts from other races. Among Black African males, increased risk of HIV was significantly associated with age group 25-49 years and those 50 years and older compared with young males 15-25 years. Among all males, reported condom use at last sex was significantly associated with increased risk of HIV. High socio-economic status (SES) and perceived risk of HIV were associated with a decreased risk of HIV. Among female condom use at last sex and ever testing for HIV was associated with increased prevalence of HIV only among Black African females. Lower prevalence of HIV was associated with marriage, tertiary education, high SES, having a partner five years younger, perceived risk of HIV, and awareness of HIV status among Black African females., Conclusion: Gender and racial disparities rooted in structural and contextual inequalities remain important factors for the maintenance of the generalized HIV epidemic in the country. HIV prevention interventions need to cut across all strata of society but also target risk factors salient for specific groups. Alleviating vulnerability to HIV along gender and racial lines should also be viewed as part of a broader public health strategy.

Background: In South Africa, HIV is increasingly becoming a chronic disease as a result of advances in HIV treatment and prevention in the last three decades. This has changed the perception from a life threating to a potentially manageable disease. However, little is known about self-perceived health status of HIV-infected individuals. Self-rated health (SRH) has been shown to be a sensitive indicator of health-relatedchanges directly linked to HIV, but can also be influenced by differences in social and material conditions. The aim of this paper was to identify determinants of excellent/good SRH among HIV-infected individuals using socio-demographic, life style and health related data., Methods: The study used data from the nationally representative 2012 South African population-based household survey on HIV prevalence, incidence and behaviour conducted using multi-stage stratified cluster sampling design. Bivariate and multivariate logistic regression models were used to identify determinants of SRH among HIV-infected individuals., Results: Out of a total of 2632 HIV positive participants 74.1% (95% CI: 68.4-74.2) reported excellent/good SRH. Increased likelihood of reporting excellent/good SRH was significantly associated with being Black African [OR= 1.97 (95%CI: 1.12-3.46), p = 0.019] and belonging to least poor household [OR= 3.13 (95%CI: 1.26-7.78), p = 0.014]. Decreased likelihood of reporting excellent/good SRH was significantly associated with those aged 25 to 34 years [OR= 0.49 (95% CI: 0.31-0.78), p = 0.003], 35 to 44 years[OR= 0.27 (95% CI: 0.17-0.44), p < 0.001], 45 to 54 years [OR= 0.20 (95% CI: 0.12-0.34), p < 0.001], and those 55 years and older [OR= 0.15 (95% CI: 0.09-0.26), p < 0.001], hospitalization in the past twelve months [OR= 0.40 (95% CI: 0.26-0.60), p < 0.001]., Conclusion: To have positive health effects and improve the perceived health status for PLWH social interventions should seek to enhance to support for the elderly HIV-positive individuals, and address the challenge of socio-economic inequalities and underlying comorbid conditions resulting in hospitalization.

Objectives: In Sub-Saharan African countries, including South Africa, uptake of human immunodeficiency virus (HIV) testing among men remains a major challenge. Few studies have explored HIV testing uptake among men and factors that influence their testing behaviours. This article explores trends in HIV testing uptake and associated factors among men aged 15 years and older in South Africa using national HIV population-based household surveys conducted in 2005, 2008 and 2012., Study Design: A multistage cross-sectional design was used in the three nationally representative household-based surveys., Methods: P-trend Chi-squared statistic was used to analyze changes in HIV testing in relation to demographic factors, and HIV-related risk behaviours across the three surveys. Univariate and multivariate logistic regression models were used to assess the associations between ever testing for HIV, demographic factors and HIV-related risk behaviours., Results: HIV testing uptake among men was 28% in 2005, 43% in 2008 and 59% in 2012. A trend was also observed in HIV testing by sociodemographic factors, but differences existed within variables. HIV testing uptake was mainly influenced by the effects of selected population characteristics. Reduced likelihood of HIV testing was significantly associated with males aged 15-24 years, Black African race group, being single and unemployed, those residing in urban informal and rural informal areas, and those men who ever had sex., Conclusion: The observed sociodemographic differentials suggest that an effective expansion strategy for HIV testing needs to prioritize those most unlikely to test as identified by the current findings., (Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

This article presents key findings from the 2012 HIV prevalence, incidence and behaviour survey conducted in South Africa and explores trends in the HIV epidemic. A representative household based survey collected behavioural and biomedical data among people of all ages. Chi-squared test for association and formal trend tests (2002, 2005, 2008 and 2012) were used to test for associations and trends in the HIV epidemic across the four surveys. In 2012 a total of 38 431 respondents were interviewed from 11 079 households; 28 997 (67.5%) of 42 950 eligible individuals provided blood specimens. HIV prevalence was 12.2% [95% CI: 11.4-13.1] in 2012 with prevalence higher among females 14.4% than males 9.9%. Adults aged 25-49 years were most affected, 25.2% [95% CI: 23.2-27.3]. HIV prevalence increased from 10.6% [95%CI: 9.8-11.6] in 2008 to 12.2% [95% CI: 11.4-13.1] in 2012 (p < 0.001). Antiretroviral treatment (ART) exposure doubled from 16.6% in 2008 to 31.2% in 2012 (p < 0.001). HIV incidence in 2012 among persons 2 years and older was 1.07% [95% CI: 0.87-1.27], with the highest incidence among Black African females aged 20-34 years at 4.5%. Sexual debut before 15 years was reported by 10.7% of respondents aged 15-24 years, and was significantly higher among male youth than female (16.7% vs. 5.0% respectively, p < 0.001). Reporting of multiple sexual partners in the previous 12 months increased from 11.5% in 2002 to 18.3% in 2012 (p < 0.001). Condom use at last sex dropped from 45.1% in 2008 to 36.2% in 2012 (p < 0.001). Levels of accurate HIV knowledge about transmission and prevention were low and had decreased between 2008 and 2012 from 31.5% to 26.8%. South Africa is on the right track with scaling up ART. However, there have been worrying increases in most HIV-related risk behaviours. These findings suggest that there is a need to scale up prevention methods that integrate biomedical, behavioural, social and structural prevention interventions to reverse the tide in the fight against HIV.

Background: The interpretation of HIV prevalence trends is increasingly difficult as antiretroviral treatment programs expand. Reliable HIV incidence estimates are critical to monitoring transmission trends and guiding an effective national response to the epidemic., Methods and Findings: We used a range of methods to estimate HIV incidence in South Africa: (i) an incidence testing algorithm applying the Limiting-Antigen Avidity Assay (LAg-Avidity EIA) in combination with antiretroviral drug and HIV viral load testing; (ii) a modelling technique based on the synthetic cohort principle; and (iii) two dynamic mathematical models, the EPP/Spectrum model package and the Thembisa model. Overall, the different incidence estimation methods were in broad agreement on HIV incidence estimates among persons aged 15-49 years in 2012. The assay-based method produced slightly higher estimates of incidence, 1.72% (95% CI 1.38 - 2.06), compared with the mathematical models, 1.47% (95% CI 1.23 - 1.72) in Thembisa and 1.52% (95% CI 1.43 - 1.62) in EPP/Spectrum, and slightly lower estimates of incidence compared to the synthetic cohort, 1.9% (95% CI 0.8 - 3.1) over the period from 2008 to 2012. Among youth aged 15-24 years, a declining trend in HIV incidence was estimated by all three mathematical estimation methods., Conclusions: The multi-method comparison showed similar levels and trends in HIV incidence and validated the estimates provided by the assay-based incidence testing algorithm. Our results confirm that South Africa is the country with the largest number of new HIV infections in the world, with about 1 000 new infections occurring each day among adults aged 15-49 years in 2012.

Background: UNAIDS aims for 90% of HIV-positive individuals to be diagnosed by 2020, but few attempts have been made in developing countries to estimate the fraction of the HIV-positive population that has been diagnosed., Methods: To estimate the rate of HIV diagnosis in South Africa, reported numbers of HIV tests performed in the South African public and private health sectors were aggregated, and estimates of HIV prevalence in individuals tested for HIV were combined. The data were integrated into a mathematical model of the South African HIV epidemic, which was additionally calibrated to estimates of the fraction of the population ever tested for HIV, as reported in three national household surveys., Results: The fraction of HIV-positive adults who were undiagnosed declined from more than 80% in the early 2000s to 23.7% [95% confidence interval (95% CI) 23.1-24.3] in 2012. The undiagnosed proportion in 2012 was substantially higher in men (31.9%, 95% CI 29.7-34.3) than in women (19.0%, 95% CI 17.9-19.9). Projected probabilities of experiencing disease progression (CD4 cell count <350 cells/μl) without diagnosis are more than 50% for most HIV-positive adults over the age of 40. The fraction of HIV-positive adults who are undiagnosed is projected to decline to 8.9% by 2020 if current targets (10 million tests per annum) are met., Conclusion: South Africa has made significant progress in expanding access to HIV testing, and at current testing rates, the target of 90% of HIV-positive adults diagnosed by 2020 is likely to be reached. However, uptake is relatively low in men and older adults.

Objectives: National population-wide HIV prevalence and incidence trends in sub-Saharan Africa (SSA) are indirectly estimated using HIV prevalence measured among pregnant women attending antenatal clinics (ANC), among other data. We evaluated whether recent HIV prevalence trends among pregnant women are representative of general population trends., Design: Serial population-based household surveys in 13 SSA countries., Methods: We calculated HIV prevalence trends among all women aged 15-49 years and currently pregnant women between surveys conducted from 2003 to 2008 (period 1) and 2009 to 2012 (period 2). Log-binomial regression was used to test for a difference in prevalence trend between the two groups. Prevalence among pregnant women was age-standardized to represent the age distribution of all women., Results: Pooling data for all countries, HIV prevalence declined among pregnant women from 6.5 [95% confidence interval (CI) 5.3-7.9%] to 5.3% (95% CI 4.2-6.6%) between periods 1 and 2, whereas it remained unchanged among all women at 8.4% (95% CI 8.0-8.9%) in period 1 and 8.3% (95% CI 7.9-8.8%) in period 2. Prevalence declined by 18% (95% CI -9-38%) more in pregnant women than nonpregnant women. Estimates were similar in Western, Eastern, and Southern regions of SSA; none were statistically significant (P>0.05). HIV prevalence decreased significantly among women aged 15-24 years while increasing significantly among women 35-49 years, who represented 29% of women but only 15% of pregnant women. Age-standardization of prevalence in pregnant women did not reconcile the discrepant trends because at older ages prevalence was lower among pregnant women than nonpregnant women., Conclusion: As HIV prevalence in SSA has shifted toward older, less-fertile women, HIV prevalence among pregnant women has declined more rapidly than prevalence in women overall. Interpretation of ANC prevalence data to inform national HIV estimates should account for both age-specific fertility patterns and HIV-related sub-fertility.

Background: It is generally assumed that orphan status increases the risk to children of a range of negative outcomes. In South Africa, death of parents due to HIV-related illness is contributing to a rapid increase in the prevalence of orphans. This paper presents descriptive data from two South African communities, namely Kopanong, in the Free State and Kanana in the North West province, characterising the differences between orphans (double, maternal and paternal) and non-orphans on key criteria of social vulnerability., Objectives: The objective was to obtain a better understanding of how different types of orphans and non-orphans may differ in these key areas as a crucial starting point for addressing the devastating consequences the AIDS epidemic has on these children's lives. While the study focuses on two specific areas these will provide insight into the general situation of orphans in South Africa., Methods: A cross-sectional census survey was conducted in the two communities of Kopanong, comprising n=5254 households and Kanana, comprising n=12,984 households., Results: In Kopanong, 8.2% of children had lost both parents, 19.1% had lost their father and 6.5% their mother only, whilst in Kanana the results were 6.5%, 28.1% and 3.7% respectively. Loss of both parents appeared to have a consistent impact on material need, including access to food, clothing and essential services, whilst loss of a single parent seems to have a more variable impact. At present, there are very few child headed households, but this constitutes a risk in the longer term., Conclusions: Orphans appear to be more vulnerable in terms of material need. Children assessed in this study as being most in need were not accessing adequately many services directed at them. There is a need to extend understanding and measurement of emotional need and abuse.

We examined the relationship between HIV prevention beliefs related to male circumcision and sexual behaviour/sexually transmitted infection (STI) acquisition among traditionally circumcised men in Cape Town, South Africa. HIV-negative men (n = 304), circumcised for cultural/religious reasons, attending a health clinic in Cape Town, South Africa, completed cross-sectional surveys. Generalized linear models were used to analyse the relationships between unprotected vaginal sex acts, number of female sexual partners, STI diagnoses and male circumcision-related beliefs and risk perceptions. Men who were aware that circumcision offers protection against HIV (relative risk [RR] = 1.19, 95% confidence interval [CI] = 1.06-1.32, P < 0.01), endorsed risk compensation related to male circumcision (RR = 1.15, 95% CI = 1.11-1.12, P < 0.01) and perceived lower risk of HIV infection when circumcised (RR = 1.08, 95% CI = 1.04-1.12, P < 0.01) were more likely to report unprotected vaginal sex acts. Similar patterns were also identified when predicting number of female sexual partners. Men who were more likely to endorse risk compensation related to male circumcision were also more likely to be diagnosed with a chronic STI (odds ratio [OR] = 1.64, 95% CI = 1.06-2.53, P < 0.05). Our findings suggest that we must not overlook the effects of beliefs towards male circumcision for HIV prevention among men traditionally circumcised; doing so may undermine current efforts to reduce HIV transmission through male circumcision.

Objectives: We examined the effects of a brief counseling intervention designed to reduce HIV risk behaviors and sexually transmitted infections (STIs) among patients receiving STI services in Cape Town, South Africa., Methods: After randomization to either a 60-minute risk reduction counseling session or a 20-minute HIV-STI educational session, patients completed computerized sexual behavior assessments. More than 85% of the participants were retained at the 12-month follow-up., Results: There were 24% fewer incident STIs and significant reductions in unprotected vaginal and anal intercourse among participants who received risk reduction counseling relative to members of the control condition. Moderator analyses showed shorter lived outcomes for heavy alcohol drinkers than for lighter drinkers. The results were not moderated by gender., Conclusions: Brief single-session HIV prevention counseling delivered to STI clinic patients has the potential to reduce HIV infections. Counseling should be enhanced for heavier drinkers, and sustained outcomes will require relapse prevention techniques. Disseminating effective, brief, and feasible behavioral interventions to those at highest risk for HIV infection should remain a public health priority.

Background: Three national HIV household surveys were conducted in South Africa, in 2002, 2005 and 2008. A novelty of the 2008 survey was the addition of serological testing to ascertain antiretroviral treatment (ART) use., Methods and Principal Findings: We used a validated mathematical method to estimate the rate of new HIV infections (HIV incidence) in South Africa using nationally representative HIV prevalence data collected in 2002, 2005 and 2008. The observed HIV prevalence levels in 2008 were adjusted for the effect of antiretroviral treatment on survival. The estimated "excess" HIV prevalence due to ART in 2008 was highest among women 25 years and older and among men 30 years and older. In the period 2002-2005, the HIV incidence rate among men and women aged 15-49 years was estimated to be 2.0 new infections each year per 100 susceptible individuals (/100pyar) (uncertainty range: 1.2-3.0/100pyar). The highest incidence rate was among 15-24 year-old women, at 5.5/100pyar (4.5-6.5). In the period 2005-2008, incidence among men and women aged 15-49 was estimated to be 1.3/100 (0.6-2.5/100pyar), although the change from 2002-2005 was not statistically significant. However, the incidence rate among young women aged 15-24 declined by 60% in the same period, to 2.2/100pyar, and this change was statistically significant. There is evidence from the surveys of significant increases in condom use and awareness of HIV status, especially among youth., Conclusions: Our analysis demonstrates how serial measures of HIV prevalence obtained in population-based surveys can be used to estimate national HIV incidence rates. We also show the need to determine the impact of ART on observed HIV prevalence levels. The estimation of HIV incidence and ART exposure is crucial to disentangle the concurrent impact of prevention and treatment programs on HIV prevalence.

Background: Condoms offer the most realistic and available protection against sexually transmissible infections (STIs), including HIV infection. The protective benefits of condoms are, however, compromised by breaks and tears. The objective of the present study was to examine condom failure and associated behavioural risk factors among men at high-risk for HIV transmission in South Africa., Methods: Men (n = 431) receiving STI treatment services at a public clinic completed computer assisted interviews and STI clinic chart abstraction over a 1-year observation period., Results: One in three male STI clinic patients reported a history of condom failure. Condom failure was associated with sexual exchange, alcohol and other drug use, and higher rates of unprotected vaginal intercourse. Men with a history of condom failure were significantly more likely to have an STI diagnosis 1 month before the baseline interview and were significantly more likely to be diagnosed with an STI over the subsequent year., Conclusion: Condom failures are common among STI clinic patients and pose a threat for increased HIV transmission risks.

Background: Anal intercourse is an efficient mode of HIV transmission and may play a role in the heterosexual HIV epidemics of southern Africa. However, little information is available on the anal sex practices of heterosexual individuals in South Africa., Purpose: To examine the occurrence of anal intercourse in samples drawn from community and clinic settings., Methods: Anonymous surveys collected from convenience samples of 2593 men and 1818 women in two townships and one large city sexually transmitted infection (STI) clinic in Cape Town. Measures included demographics, HIV risk history, substance use and 3-month retrospective sexual behaviour., Results: A total of 14% (n = 360) men and 10% (n = 172) women reported engaging in anal intercourse in the past 3 months. Men used condoms during 67% and women 50% of anal intercourse occasions. Anal intercourse was associated with younger age, being unmarried, having a history of STI, exchanging sex, using substances, having been tested for HIV and testing HIV positive., Conclusions: Anal intercourse is reported relatively less frequently than unprotected vaginal intercourse among heterosexual individuals. The low prevalence of anal intercourse among heterosexual individuals may be offset by its greater efficiency for transmitting HIV. Anal sex should be discussed in heterosexual HIV prevention programming.

Background: HIV is devastating southern Africa and alcohol use is closely related to HIV transmission risks., Purpose: The current study tested the efficacy of a brief single-session HIV-alcohol risk-reduction intervention for men and women who drink at informal alcohol serving establishments (i.e., shebeens) in South Africa., Methods: A randomized community field trial recruited men (N = 117) and women (N = 236) through outreach and chain referrals. Participants received either: (a) 3-h theory-based behavioral HIV-alcohol risk-reduction intervention that focused on skills training for sexual negotiation and condom use or (b) 1-h HIV-alcohol information/education control group. Participants were followed up for 3 and 6 months post-intervention with 89% retention., Results: The risk-reduction intervention demonstrated significantly less unprotected intercourse, alcohol use before sex, numbers of sex partners, partners met at drinking establishments and greater condom use relative to the control group. However, intervention effects were moderated by alcohol use; lighter drinkers demonstrated significantly more intervention gains than heavier drinkers in the risk-reduction condition. Intervention effects occurred at 3 months follow-up and dissipated by 6 months., Conclusions: A brief HIV risk-reduction intervention reduced sexual-risk behaviors among drinkers in South Africa. However, intervention effects were weakest for those who drink heaviest. Our results provide a basis for establishing HIV prevention in alcohol serving establishments in South Africa. Research is needed to identify multi-level intervention models that can reduce risks among heavier drinkers and sustain behavior changes over time.

Alcohol is related to HIV risk behaviors in southern Africa and these behaviors are correlated with sensation seeking personality and alcohol outcome expectancies. Here we report for the first time the associations among sensation seeking, substance use, and sexual risks in a prospective study in Africa. Sexually transmitted infection clinic patients in Cape Town South Africa (157 men and 64 women) completed (a) baseline measures of sensation seeking, sexual enhancement alcohol outcome expectancies, alcohol use in sexual contexts, and unprotected sexual behaviors and (b) 6-month follow-up measures of alcohol use in sexual contexts and unprotected sexual acts. Results confirmed that sensation seeking predicts HIV risk behavior and sensation seeking is related to alcohol outcome expectancies which in turn predict alcohol use in sexual contexts. HIV prevention counseling that addresses drinking in relation to sex is urgently needed in southern Africa.

Objectives: To examine perceived HIV prevalence and disease burden in high-risk adults in Cape Town, South Africa., Methods: A convenience sample of 793 male and 188 female sexually transmitted infection clinic patients completed anonymous surveys., Results: Individuals who saw themselves at greater risk for HIV/AIDS also perceived greater local HIV prevalence. Participants presented extremely distorted views of local HIV prevalence that exceed the reality in Cape Town. Perceiving greater local AIDS burden was independently associated with condom use., Conclusions: Interventions that accurately place local AIDS burden in the context of places with relatively lower burden may activate protective motivations.

HIV/AIDS is devastating southern Africa and the spread of HIV is fueled in some populations by alcohol use. Alcohol serving establishments, such as informal drinking places or shebeens, often serve as high-risk venues for HIV transmission. The current study examined the HIV risks of men (N = 91) and women (N = 248) recruited from four shebeens in a racially integrating township in Cape Town South Africa. Participants completed confidential measures of demographic characteristics, HIV risk history, alcohol and drug use, and HIV risk behaviors. Comparisons of 94 (28%) participants who reported meeting sex partners at shebeens to the remaining sample of shebeen goers, controlling for potential confounds, demonstrated a pattern of higher risk for HIV infection among persons who met sex partners at shebeens. Few differences, however, were observed between men (N = 47) and women (N = 47) who had met sex partners at shebeens, suggesting greater gender similarities than gender differences in this important subpopulation. These results indicate an urgent need for multi-level HIV prevention interventions targeting shebeens and the men and women who drink in these settings.

This study examined the differential patterns of alcohol outcome expectancies in relation to drinking before sex and having sex partners who drink before sex among men (N=614) and women (N=158) sexually transmitted infections clinic patients in Cape Town South Africa. Hierarchical regressions, controlling for age, education, and alcohol use showed that men's sexual enhancement alcohol expectancies were associated with drinking before sex and having sex partners who drank before sex. Behavioral disinhibition expectancies were inversely related to drinking before sex. For women, there were no associations between alcohol expectancies and drinking before sex, although sexual enhancement expectancies were related to having sex partners who drank before sex. We conclude that alcohol outcome expectancies, particularly expectancies that alcohol will enhance sexual experiences, are related to HIV transmission risks. Sexual risk reduction interventions for those at greatest risk for HIV/AIDS should directly address alcohol expectancies.

Alcohol consumption is associated with risks for sexually transmitted infections (STI), including HIV/AIDS. In this paper, we systematically review the literature on alcohol use and sexual risk behavior in southern Africa, the region of the world with the greatest HIV/AIDS burden. Studies show a consistent association between alcohol use and sexual risks for HIV infection. Among people who drink, greater quantities of alcohol consumption predict greater sexual risks than does frequency of drinking. In addition, there are clear gender differences in alcohol use and sexual risks; men are more likely to drink and engage in higher risk behavior whereas women's risks are often associated with their male sex partners' drinking. Factors that are most closely related to alcohol and sexual risks include drinking venues and alcohol serving establishments, sexual coercion, and poverty. Research conducted in southern Africa therefore confirms an association between alcohol use and sexual risks for HIV. Sexual risk reduction interventions are needed for men and women who drink and interventions should be targeted to alcohol serving establishments.

Background: HIV is ravaging southern Africa, and HIV transmission risk behaviors are facilitated by alcohol use in sexual contexts. There are no known interventions that directly target HIV risk behavior among people who drink and are at risk for HIV in Africa., Purpose: To test a behavioral risk reduction counseling intervention for use in sexually transmitted infection (STI) clinics in southern Africa., Methods: A randomized intervention trial was conducted with 143 STI clinic patients in Cape Town, South Africa. Participants received an experimental 60-minute HIV and alcohol risk reduction behavioral skills intervention or a control 20-minute HIV education condition. Participants were followed for 3 and 6 months after the intervention, with 73% retention., Results: Overall, the experimental intervention demonstrated more than a 25% increase in condom use and a 65% reduction in unprotected intercourse over the 6-month follow-up period, with risk reduction significantly greater for the experimental condition than for the control condition at both follow-ups. Alcohol use in sexual contexts [F(1,94) = 6.2; P < 0.05] and expectancies that alcohol enhances sexual experiences [F(1,94) = 8.3; P < 0.01] were also significantly lower for the experimental condition at the 3-month follow-up., Conclusions: An HIV prevention counseling intervention reduced HIV transmission risks for up to 6 months in this STI clinic population. Effects may be sustained with structural interventions to reduce alcohol use in sexual contexts and support risk reduction behavior changes over the long-term.

Alcohol use is prevalent in South Africa and alcohol use may be associated with higher risk for HIV transmission. This article reports a study of the association between alcohol use and HIV risk-related behavior among 614 men and 157 women receiving sexually transmitted infection (STI) clinic services in Cape Town, South Africa. Participants completed anonymous surveys of demographic information, substance use, and sexual risk behaviors. Results for men showed that drinking in sexual contexts as well as their partner's drinking were related to higher rates of unprotected intercourse. However, the number of sex partners men reported was only associated with their own use of alcohol before sex. In contrast, women's partners drinking before sex was related to higher frequencies of unprotected intercourse, but it was their own drinking before sex that was related to women's number of sex partners. Results therefore suggest that the context of alcohol use is more closely related to sexual risks than are the quantity or frequency of use. Interventions are needed that integrate HIV risk reduction with alcohol risk reduction in South Africa.

Alcohol use is prevalent in South Africa and alcohol use may be associated with higher risk for HIV transmission. This paper reports a study of the association between alcohol use and HIV risk-related behavior among 134 men and 92 women receiving sexually transmitted infection (STI) clinic services in Cape Town, South Africa. Participants completed anonymous surveys of demographic information, substance use, and sexual risk behaviors. Results showed that problem drinking was common among STI clinic patients; 58% of men and 28% of women scored above a cut-off of 9 on the Alcohol Use Disorders Identification Test (AUDIT) suggesting possible problem drinking and 46% of men and 19% of women scored above 12 on the AUDIT indicating probable drinking problems. For men, heavier alcohol use was associated with having multiple sex partners in the past month, less condom use, and having a history of sexually assaulting women. Among women, higher scores on the AUDIT were also related to having multiple sex partners as well as a history of exchanging sex for money or materials. The association between alcohol use and sexual risk behaviors in a population at high-risk for HIV transmission demonstrates the need for integrating alcohol risk reduction counseling with HIV prevention counseling among STI clinic patients in South Africa.

Alcohol use is associated with risks for HIV/AIDS. The association between alcohol and sexual risk may be accounted for by sensation seeking personality. However, sensation seeking in relation to substance use and HIV risk has not been examined in Africa. In this study, 292 men and 219 women receiving sexually transmitted infection (STI) diagnostic and treatment services in Cape Town, South Africa, completed anonymous behavioral surveys. Structural modeling was used to test a model of alcohol use and sensation seeking in relation to sexual risk behaviors. Results showed that sensation seeking and alcohol use in sexual contexts were related to HIV risks, controlling for gender and marital status. The association between sensation seeking and HIV risk was partly accounted for by alcohol use in proximity to sex. In contrast to studies conducted in the United States, sensation seeking was not related to alcohol-sex outcome expectancies. These findings suggest that alcohol use is an important HIV transmission risk factor for many STI clinic patients and that interventions for individuals who are characterized as sensation seekers are urgently needed in South Africa., (((c) 2006 APA, all rights reserved).)

Background: South Africa has one of the world's fastest growing HIV epidemics. Genital bleeding during sexual intercourse may play a role in facilitating HIV transmission in South Africa., Purpose: The purpose of this study was to examine the prevalence and sources of coital bleeding among men and women living in a Cape Town South Africa township., Methods: A purposive sample of 464 men and 531 women completed anonymous street intercept surveys of HIV risk history and sexual behaviors., Results: Thirty-one percent of men and 26% of women had a lifetime history of engaging in sexual intercourse that involved genital bleeding, and 21% of men and 16% of women reported coital bleeding in the previous 3 months. Over 75% of coital bleeding was attributed to menses. Across genders and controlling for demographic, sexual behavior, and life history factors, coital bleeding in the previous 3 months was associated with being an indigenous African, having multiple sexual partners, and higher rates of unprotected intercourse during that time period. People who reported coital bleeding were over 3 times more likely to have been diagnosed with a sexually transmitted infection even after controlling for having had genital ulcers., Conclusions: Coital bleeding may be common in South Africa. Prevention messages that promote condom use or refraining from sex when there is genital bleeding are therefore needed.

We tested the Information-Motivation-Behavioural Skills (IMB) model of AIDS preventive behaviour in South Africa. Prospective path analyses were performed on measures collected from 131 men and 60 women with sexually transmitted infections (STI) in Cape Town. Results showed that IMB constructs collected at baseline predicted risk reduction behaviour 3 months later. Risk reduction intentions were positively associated with risk reduction self-efficacy and self-efficacy was in turn positively associated with protective behaviour 3 months later. In a second model, AIDS-related stigmas correlated inversely with AIDS knowledge and there was a trend toward AIDS stigmas correlating inversely with behavioural intentions. Accounting for AIDS-related stigmas did not improve model fit. These findings parallel similar tests of the IMB model in US samples and suggest that the IMB model may generalize to South Africa and may therefore be useful in guiding HIV risk reduction interventions.

The majority of the world's HIV infections occur in communities ravished by poverty. Although HIV/AIDS and poverty are inextricably linked, there are few studies of how poverty-related stressors contribute to HIV risk behavior practices. In this study, surveys were conducted in three South African communities that varied by race and socio-economic conditions: people living in an impoverished African township (N = 499); an economically impoverished but well infrastructured racially integrating township (N = 995); and urban non-impoverished neighborhoods (N = 678). Results showed that HIV/AIDS risks were closely related to experiences of poor education, unemployment, discrimination, violence, and crime. Although poverty-related stressors were associated with a history of alcohol and drug use, substance use did not moderate the association between poverty-related stressors and HIV risk behaviors. The findings suggest that HIV prevention strategies should not treat AIDS as a singled out social problem independent of other social ills.

Objective: To examine HIV risks among South African men who report having been sexually assaultive., Methods: Men (N = 412) in Cape Town completed anonymous surveys., Results: Twenty-three percent reported a history of sexual assault. Men who had been sexually assaultive were younger, reported more sex partners, were more likely to have a history of genital ulcers, and more likely to have exchanged money for sex. Sexually assaultive men were also more likely to endorse rape myths., Conclusions: Interventions that target men as the agents of change in reducing sexual assaults and HIV transmission are urgently needed.

This study examined gender attitudes and sexual violence-supportive beliefs (rape myths) in a sample of South African men and women at risk for HIV transmission. Over 40% of women and 16% of men had been sexually assaulted, and more than one in five men openly admitted to having perpetrated sexual assault. Traditional attitudes toward women's social and gender roles, as well as rape myths, were endorsed by a significant minority of both men and women. Multivariate analyses showed that for men, sexual assault history and rape myth acceptance, along with alcohol and other drug use history, were significantly related to cumulative risks for HIV infection. In contrast, although we found that women were at substantial risk for sexually transmitted infection (STI), including HIV, women's risks were only related to lower levels of education and alcohol use history. We speculate that women's risks for STI/HIV are the product of partner characteristics and male-dominated relationships, suggesting the critical importance of intervening with men to reduce women's risks for sexual assault and STI/HIV.

South Africa urgently needs HIV prevention interventions that can be disseminated for use in clinical and community settings. A brief theory-based HIV risk reduction counselling intervention originally developed in the USA has recently been adapted for use in a South African sexually transmitted infection clinic. The 60-minute risk reduction counselling intervention was grounded in the Information-Motivation-Behavioural Skills (IMB) model of HIV preventive behaviour change, adapted through a series of interdisciplinary collaborative workshops. This paper reports the process of developing and culturally adapting the brief risk reduction counselling intervention. The processes used for adapting the HIV risk reduction counselling for South Africa provides a potential model for conducting technology transfer activities with other HIV prevention interventions. Several lessons learned from this process may help guide future efforts to transfer HIV prevention technologies.

Community stress associated with poverty is related to health risks and poor health outcomes. Perceived community stress is specifically related to HIV transmission risk behaviors in the United States, but research has not examined these relationships in southern Africa, the region of the world with the highest rates of HIV infection and among the greatest poverty. Men (N=464) and women (N=531) living in impoverished adjacent communities distinguished by race (e.g., indigenous African and Coloured) completed anonymous surveys of perceptions of 10 poverty-related community stressors and measures of HIV risk-related behaviors. Indigenous African and Coloured communities differed in their perceptions of stressors, with Africans consistently viewing the 10 community stressors as more serious problems. In addition, perceived seriousness of lacking basic living resources was related to higher risk for HIV among Africans. Perceived community stress was also related to alcohol and drug use, but substance use did not mediate the association between perceived community stress and HIV risks. In the Coloured community, perceived community stressors were related to drug use, but perceived community stressors were not associated with HIV risks. These findings extend the findings of previous research to show that poverty-related stressors are associated with HIV transmission risks in some poverty-stricken communities and that these associations are not mediated by substance use.

Although there has been progress in AIDS stigma research, there are no multi-item AIDS stigma scales that have been shown reliable and valid in Africa. The current research reports the development of the nine-item AIDS-Related Stigma Scale. Research conducted in five South African communities (N = 2306) found the scale internally consistent, alpha = 0.75 and time stable over 3 months, r = 0.67. The scale was also reliable in three different languages (English, Xhosa, and Afrikaans). Correlations showed that the AIDS-Related Stigma Scale was moderately inversely correlated with years of education and AIDS knowledge. In addition, individuals who stated that HIV positive persons should conceal their HIV status had higher AIDS-Related Stigma Scale scores. Also supporting the scale's construct validity, individuals who refused to report whether they had been tested for HIV scored higher on the AIDS-Related Stigma Scale.

South Africa is in the midst of a devastating HIV-AIDS epidemic and most new HIV infections occur among young adults and adolescents. The current study examined risk behaviors and HIV risk factors among young people living in a Black South African township. Using community-based outreach methods of street intercept and facility-based surveying, 113 men and 115 women age 25 and younger responded to an anonymous survey. Results showed that men (68%) and women (56%) reported HIV-related high risk sexual behaviors. Although knowledge about HIV transmission was generally high, there was evidence that misconceptions about AIDS persist, particularly myths related to HIV transmission. For young men, HIV risk factors were associated with fewer years of education, lower levels of AIDS-related knowledge, condom attitudes, and Dagga (marijuana) use. Among young women, HIV risk factors were associated with beliefs that condoms get in the way of sex and rates of unprotected vaginal intercourse. Despite adequate general AIDS knowledge and risk sensitization, South African youth demonstrated high rates of sexual practices that place them at risk for HIV infection. There is an urgent need for behavioral interventions targeted to young South Africans living in the most economically disadvantaged areas.

Background: South Africa has the world's fastest growing AIDS epidemic. There is an urgent need for effective HIV risk reduction interventions in South Africa., Objective: The objective of this study was to develop and test the potential efficacy of a brief theory-based HIV prevention counseling intervention for sexually transmitted infection (STI) clinic patients in South Africa., Method: STI clinic patients in Cape Town (N=228) were assessed at baseline and randomized to receive either: 1) a single 60-minute session motivational/skills-building HIV risk reduction counseling intervention or 2) a 20-minute HIV information/education session. Participants completed 1- and 3-month follow ups with 80% retention., Results: The 60-minute motivational/skills risk reduction counseling demonstrated significantly greater risk reduction practices, lower rates of unprotected intercourse, and greater likelihood of receiving HIV testing after the intervention., Conclusions: Brief theory-based HIV prevention counseling may significantly reduce HIV risk behaviors for STI clinic patients in South Africa.