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BackgroundWe assessed built environment (residential density, landuse mix and aesthetics) and HIV linkage to care (LTC) among 1,681 (18-49 years-old) residents of 15 Mpumalanga villages, South Africa.MethodsMultilevel models (linear-binomial) were used for the association between built environment, measured using NEWS for Africa, and LTC from a clinical database of 9 facilities (2015-2018). Additionally, we assessed effect-measure modification by universal test-and-treat policy (UTT).ResultsWe observed, a significant association in the adjusted 3-month probability of LTC for residential density (risk difference (RD)%: 5.6, 95%CI: 1.2-10.1), however, no association for land-use mix (RD%: 2.4, 95%CI: -0.4, 5.2) and aesthetics (RD%: -1.2, 95%CI: -4.5-2.2). Among those diagnosed after UTT, residents of high land-use villages were more likely to link-to-care than those of low land-use villages at 12 months (RD%: 4.6, 95%CI: 1.1-8.1, p  0.10).ConclusionFindings suggest, better built environment conditions (adequate infrastructure, proximity to services etc.) help facilitate LTC. Moreover, UTT appears to have a protective effect on LTC.

BackgroundCommunity mobilisation, engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. In South Africa, current rates fall below those needed for epidemic control. We assessed whether community mobilisation increased HIV testing, linkage to care, and retention in care over time in intervention relative to control communities.MethodsWe conducted a cluster-randomised controlled trial in villages in the Agincourt sub-district of the rural Mpumalanga Province in South Africa. 15 villages were randomly assigned to either a community mobilisation intervention engaging residents to address social barriers to HIV testing and treatment (intervention arm) or to a control arm using balanced randomisation. Villages were eligible if they had been fully enumerated in 2014, had not been included in previous mobilisation activities, and included over 500 permanent adult residents aged 18-49 years. Primary outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among residents of the intervention and control communities over the 3-year study period. Intention-to-treat analyses employed generalised estimating equations stratified by sex. This trial is registered with ClinicalTrials.gov, NCT02197793.FindingsBetween Aug 1, 2015, and July 31, 2018, residents in eight intervention communities (n=20 544 residents) and seven control communities (n=17 848) contributed data; 92 residents contributed to both arms. Among men, HIV testing increased quarterly by 12·1% (relative change [RC] 1·121, 95% CI 1·099 to 1·143, p

Poverty alleviation programs can reduce HIV incidence but may have greater impacts when combined with other psychosocial interventions. We modeled the change in HIV incidence among South African adolescent girls and young women (AGYW) associated with combining a cash transfer (the South African Child Support Grant (CSG)) with other structural and behavioral interventions. We modeled observational data from the HPTN 068 study where 2328 HIV negative AGYW (13-20 years) were followed for 4 years. In a Monte Carlo simulation based on this cohort (N = 10,000), CSG receipt was not independently associated with HIV incidence. Providing the CSG combined with increasing caregiver care and reducing adolescent depression had the largest reduction in HIV incidence with the fewest number of combined interventions (RD - 3.0%; (95% CI - 5.1%, - 0.9%). Combining a monthly grant with interventions to increase caregiver care and reduce adolescent depression could substantially reduce HIV incidence above the provision of cash alone.

BackgroundCombination interventions may be an effective way to prevent human immunodeficiency virus (HIV) in adolescent girls and young women. However, current studies are not designed to understand which specific interventions and combinations will be most effective. We estimate the possible impacts of interventions on a combination of factors associated with HIV.MethodsWe used the g-formula to model interventions on combinations of HIV risk factors to identify those that would prevent the most incident HIV infections, including low school attendance, intimate partner violence, depression, transactional sex, and age-disparate partnerships. We used data from the HIV Prevention Trials Network (HPTN) 068 study in rural South Africa from 2011 to 2017. We estimated HIV incidence under a potential intervention that reduced each risk factor and compared this to HIV incidence under the current distribution of these risk factors.ResultsAlthough many factors had strong associations with HIV, potential intervention estimates did not always suggest large reductions in HIV incidence because the prevalence of risk factors was low. When modeling combination effects, an intervention to increase schooling, decrease depression, and decease transactional sex showed the largest reduction in incident infection (risk difference, -1.4%; 95% confidence interval [CI], -2.7% to -.2%), but an intervention on only transactional sex and depression still reduced HIV incidence by -1.3% (95% CI, -2.6% to -.2%).ConclusionsTo achieve the largest reductions in HIV, both prevalence of the risk factor and strength of association with HIV must be considered. Additionally, intervening on more risk factors may not necessarily result in larger reductions in HIV incidence.

PurposeSchooling is associated with a lower risk of Herpes simplex virus type 2 (HSV-2) in adolescent girls and young women, but there is little understanding of the pathways underlying this relationship.MethodsWe used data from adolescent girls and young women in South Africa enrolled in the HIV Prevention Trials Network 068 study. We tested a structural equation model where individual household and community education measures were associated directly and indirectly with incident HSV-2 through HIV knowledge, future aspirations, age-disparate partnerships, sex in the last 12 months, and condomless sex.ResultsCommunity, household, and individual measures of schooling were all associated with incident HSV-2 infection through mediated pathways that increased the likelihood of having sex. Low school attendance (

PurposeAdolescent girls and young women (AGYW) in South Africa experience a disproportionately high burden of HIV acquisition. National HIV prevalence among AGYW increases nearly three-fold during the transition from late teenage years to their early twenties. We investigated whether beliefs about gender equity influence subsequent HIV acquisition among AGYW in South Africa.MethodsWe used data from the HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of AGYW in Mpumalanga Province, South Africa. Gender-equitable beliefs were measured at the level of the individual and summarized among school peers and adults in the community using the Gender Equitable Men's Scale (GEMS). Generalized estimating equation regression was used to assess the association between individual, peer and community GEMS and HIV incidence, herpes simplex virus type 2 (HSV-2) incidence, and other HIV risk factors while accounting for repeated observations and clustering.ResultsA total of 2,533 AGYW were followed up for up to 5 years. Adjusting for potential confounders, a unit increase in peer GEMS scores (i.e. more equitable) were significantly protective against subsequent HIV acquisition (risk difference = -.019; 95% confidence interval: -.032, -.006) and subsequent HSV-2 acquisition (risk difference = -.020; 95% confidence interval: -.040, -.000). Low individual and community GEMS scores were associated with multiple HIV risk factors but not with HIV or HSV-2 incidence directly.ConclusionSchool-level peer endorsement of gender equity may be protective against HIV and HSV-2 incidence among AGYW. Interventions that increase gender equity at the individual level and at the level of the social environment, particularly among school peers, have the potential for protective effects on the health of AGYW.

IntroductionAdolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a 'critical enabler' for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW.MethodsWe examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates.ResultsThere were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role.ConclusionsThese results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.

BackgroundCommunity mobilization (CM) interventions show promise in changing gender norms and preventing HIV, but few have been based on a defined mobilization model or rigorously evaluated. The purpose of this paper is to describe the intervention design and implementation and present baseline findings of a Cluster Randomized Controlled Trial (RCT) of a two-year, theory-based CM intervention that aimed to change gender norms and reduce HIV risk in rural Mpumalanga province, South Africa.MethodsCommunity Mobilizers and volunteer Community Action Teams (CATs) implemented two-day workshops, a range of outreach activities, and leadership engagement meetings. All activities were mapped onto six theorized mobilization domains. The intervention is being evaluated by a randomized design in 22 communities (11 receive intervention). Cross-sectional, population-based surveys were conducted with approximately 1,200 adults ages 18-35 years at baseline and endline about two years later.ConclusionsThis is among the first community RCTs to evaluate a gender transformative intervention to change norms and HIV risk using a theory-based, defined mobilization model, which should increase the potential for impact on desired outcomes and be useful for future scale-up if proven effective.Trial registrationClinicalTrials.gov NCT02129530.

Alcohol use contributes to morbidity and mortality in developing countries by increasing the risk of trauma and disease, including alcohol dependence. Limited research addresses determinants of alcohol use beyond the individual level in sub-Saharan Africa. We test the association of community collective efficacy and alcohol outlet density with young men's drinking in a cross-sectional, locally representative survey conducted in rural northeast South Africa. Informal social control and cohesion show protective associations with men's heavy drinking, while alcohol outlet density is associated with more potential problem drinking. These findings provide initial support for intervening at the community level to promote alcohol reduction.