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Background The current debate about the role of concurrent sexual partnerships in the spread of HIV is influenced by limited or weak empirical data on concurrency. There is still uncertainty about the most basic statistics and little is known about how concurrency is changing. Methods: Longitudinal data (n = 2958) with repeated concurrency measures were employed to examine the prevalence of individual concurrency (someone has other partners during their most recent sexual partnership) and perceived partner concurrency (someone perceives his or her partner to have other partners) by population group and gender in 2005 and 2009. Individual fixed-effects logit regression models were created to examine factors associated with changes in individual concurrency among Black men and women. Results: The prevalence of individual concurrency increased among Black men who reported having had sex (from 33% in 2005 to 39% in 2009), remained constant among Black women (14%), decreased among Coloured (mixed-race) men (from 16% to 8%) and remained low among Coloured women (2% in 2005 and 1% in 2009). Overall, a small decrease in perceived partner concurrency was observed. Changes in individual concurrency were positively associated with changes in perceived partner concurrency among men and women. Among Black women, decreases in household income and finding employment increased the odds of reporting a positive change in individual concurrency. Conclusions: Race and gender differences in concurrency should be taken into account in future research and HIV prevention initiatives. High and increasing levels of concurrency within most recent partnerships among Black men highlight this group as a potential focus for such efforts.

Randomized clinical trials (RCTs) have shown that medical male circumcision (MC) substantially reduces the risk of female-to-male HIV transmission.1 Driven by this evidence base, a growing number of countries have adopted large-scale MC campaigns in an effort to prevent heterosexually acquired HIV in men. In South Africa, for example, >130,000 medical male circumcisions were performed during 2010.2Encouraging adoption of MC will require educating millions of men and women about its protective benefits. The success of these policies will depend critically on what people infer from prevention information and the actions they take as a result.

HIV/AIDS-related stigma is conceptualised as multi-dimensional, and indices are designed to measure its different dimensions. Findings show that it is uncommon for young adults to have high levels of negative behavioural intentions towards people living with HIV/AIDS, but the majority show some tendencies to discriminate. Expressions of negative judgement (symbolic stigma) and fear of HIV infection (instrumental stigma) are both prevalent. Instrumental stigma is expressed by more respondents and to greater degrees than symbolic stigma. Resource-based stigma, on the other hand, is rare. Understanding of HIV transmission is the most significant (negative) predictor of HIV/AIDSrelated stigma, thereby highlighting the importance of HIV/AIDS education campaigns for reducing stigma. The importance of education in general is atso indicated by the association of higher levels of education with less instrumental stigma. Symbolic stigma and prejudices towards other groups are also significant (positive) factors predicting negative behavioural intentions and stigmatising attitudes. This suggests that although HIV/AIDS education is necessary for stigma alleviation, it is by no means sufficient. In the case of Cape Town, racial differences are also salient in predicting both the magnitude of HIV/AIDS-related stigma and its determinants. This corroborates the theory of stigma as a complex social process dependent on particular cultural and environmental contexts. It also highlights the necessity of considering cultural and environmental aspects in understanding and addressing stigma.

We examined the impacts of nationwide voluntary medical male circumcision efforts in Tanzania. Using Demographic and Health Surveys (DHS) data, we found that circumcision rates increased from 37 to 47% in regions targeted by the programme. Those who took up medical male circumcision were younger, more educated, wealthier and more likely to use condoms. Efforts going forward should focus on stimulating circumcision demand among more vulnerable men.

Background: HIV counselling and testing (HCT) is a critical component of HIV prevention and treatment efforts. Between April 2010 and June 2011 South Africa ran an ambitious, multi-sector, campaign aiming to test 15 million people nationwide. We assessed the extent to which this campaign reached (1) those who previously had never tested for HIV and (2) high risk and socioeconomically vulnerable populations. Methods: We used data from the National Income Dynamics Study (NIDS, n=18,650), a nationally representative panel study in South Africa, to assess the uptake of first-time testing between 2010 and 2012 at the national level and by age, gender, racial, and province-level subgroups. Multivariate logistic regression analyses were used to compare the factors associated with HIV testing in 2010 and 2012, and to assess the characteristics of first-time testers. Results: The proportion of adults having ever received an HIV test increased from 43.7% (95% CI: 41.48; 45.96) in 2010 to 65.2% [63.28; 67.10] in 2012, as approximately 7.5 million individuals 15 years and older tested for the first time nationally. However, there was large variation in new testing rates across geographic areas and population subgroups. The association between ever testing and both income and self-reported health declined between 2010 and 2012, suggesting the campaign was successful in reaching poorer and healthier individuals. However, disparities in testing by education and gender remained strong between 2010 and 2012. Conclusion: The provision of HCT services in South Africa led to a steady rise in the proportion of individuals ever tested for HIV and has improved equity of HCT uptake. Future initiatives to increase HCT uptake, both within South Africa and in other countries, would gain from lessons learned from the South African effort. However, new interventions may be required to improve testing rates among the less educated and men, particularly poor men, and to achieve universal HCT access and uptake.

Background: HIV-related stigmatisation and discrimination by young children towards their peers have important consequences at the individual level and for our response to the epidemic, yet research on this area is limited. Methods: We used nationally representative data to examine discrimination of HIV-positive children by grade six students (n=39,664) across nine countries in Southern Africa: Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. Descriptive statistics are used to compare discrimination by country, gender, geographic location and socioeconomic status. Multivariate logistic regression is employed to assess potential determinants of discrimination. Results: The levels and determinants of discrimination varied significantly between the nine countries. While one in ten students in Botswana, Malawi, South Africa and Swaziland would ‘‘avoid or shun’’ an HIV positive friend, the proportions in Lesotho, Mozambique, Zambia and Zimbabwe were twice as high (approximately 20%). A large proportion of students believed that HIV positive children should not be allowed to continue to attend school, particularly in Zambia (33%), Lesotho (37%) and Zimbabwe (42%). The corresponding figures for Malawi and Swaziland were significantly lower at 13% and 12% respectively. Small differences were found by gender. Children from rural areas and poorer schools were much more likely to discriminate than those from urban areas and wealthier schools. Importantly, we identified factors consistently associated with discrimination across the region: students with greater exposure to HIV information, better general HIV knowledge and fewer misconceptions about transmission of HIV via casual contact were less likely to report discrimination. Conclusions: Our study points toward the need for early interventions (grade six or before) to reduce stigma and discrimination among children, especially in schools situated in rural areas and poorer communities. In particular, interventions should focus on correcting misconceptions that HIV can be transmitted via casual contact.

Although HIV-related stigma in general is known to deter HIV-testing, the extent to which different dimensions of stigma independently influence testing behaviour is poorly understood. We used data on young black men (n = 553) and women (n = 674) from the 2009 Cape Area Panel Study to examine the independent effects of stigmatising attitudes, perceived stigma and observed enacted stigma on HIV-testing. Multivariate logistic regression models showed that stigma had a strong relationship with HIV-testing among women, but not men. Women who held stigmatising attitudes were more likely to have been tested (OR 3, p < 0.01), while perceived stigma (OR 0.61, p < 0.1) and observed enacted stigma (OR 0.42, p < 0.01) reduced the odds significantly of women having had an HIV test. Our findings highlight that different dimensions of stigma may have opposite effects on HIV testing, and point towards the need for interventions that limit the impact of enacted and perceived stigma on HIV-testing among women.

Poverty may influence HIV risk by increasing vulnerability to economic shocks and thereby preventing key health investments. We explored this possibility by examining the relationship between household shocks and the timing of traditional male circumcision, a practice associated with considerable expense and whose HIV-prevention benefits are larger when done earlier, even within young adulthood. Using unique data on a sample of Xhosa men, a group that almost universally practices traditional circumcision, we found that respondents in the poorest households delayed circumcision by 2 years if a household member experienced loss of income or death and/or illness. The impact of these shocks declined with increasing household income. Our findings suggest that interventions that work to mitigate the impact of shocks among the poor may be useful in HIV prevention efforts. More generally, they illustrate that the relationship between HIV and wealth may be more nuanced than assumed in previous work.

Objective: To examine whether individuals who learn that voluntary medical male circumcision (VMMC) partially reduces female-to-male HIV transmission erroneously infer a reduction in male-to-female HIV transmission risk. Design: Cluster randomised controlled trial. Methods: In 2008, information that VMMC reduces female-to-male HIV transmission risk was randomly disseminated to men in rural Malawi, with follow-up in 2009 (n=917). Data was collected on perceived male and female HIV-transmission risks. We assessed whether beliefs about male circumcision and female HIV-risk varied by receipt of VMMC information and by whether or not individuals believed that VMMC partially protects men from HIV-infection. Results: Men informed about VMMC were more likely to believe that sex with a circumcised male would confer lower transmission risk for women vis-à-vis sex with an uncircumcised male (38% versus 50%, p0.01). Multivariate regression analyses showed that incorrect inferences were most likely to be made by those who believed that circumcised men were partially protected from contracting HIV. Consistent with this, instrumental variable analyses indicated that those individuals who received information about VMMC, and consequently believed it, were 82 percentage points more likely to believe that male circumcision also protects women (p0.01). The inferred reduction in direct HIV infection risk for women due to male circumcision was approximately 50%. Conclusions: Our results suggest the need for VMMC campaigns to make explicit that male circumcision does not directly protect women from HIV-infection. It is also important to assess whether incorrect inferences lead to updated self-perceived HIV-risk and the adoption of riskier sexual behaviours.

ObjectivesWe examined whether knowledge of the HIV-protective benefits of male circumcision (MC) led to risk compensating behavior in a traditionally circumcising population in South Africa. We extend the current literature by examining risk compensation among women, which has hitherto been unexplored.MethodsWe used data on Xhosa men and women from the 2009 Cape Area Panel Study. Respondents were asked if they had heard that MC reduces a man's risk of contracting HIV, about their perceived risk of contracting HIV, and condom use. For each gender group we assessed whether risk perception and condom use differed by knowledge of the protective benefits of MC using bivariate and then multivariate models controlling for demographic characteristics, HIV knowledge/beliefs, and previous sexual behaviors. In a further check for confounding, we used data from the 2005 wave to assess whether individuals who would eventually become informed about the protective benefits of circumcision were already different in terms of HIV risk perception and condom use.Results34% of men (n=453) and 27% of women (n=690) had heard that circumcision reduces a man's risk of HIV infection. Informed men perceived slightly higher risk of contracting HIV and were more likely to use condoms at last sex (pConclusionsWe find evidence consistent with risk compensation among women but not men. Further attention should be paid to the role of new information regarding MC, and drivers of HIV risk more broadly, in modulating sexual behavior among women.

Research on concurrent sexual partnerships has been constrained by inconsistent and inaccurate measurements of these partnerships. Recently, a UNAIDS working group recommended a method based on sexual partner histories to improve the measurement of concurrency. Using recent survey data for young adults living in Cape Town, South Africa, we found that this method could result in underestimates of concurrency due to respondents' failure to report additional sexual partners.

Stigma is a recognised problem for effective prevention, treatment, and care of HIV/AIDS. However, few studies have measured changes in the magnitude and character of stigma over time. This paper provides the first quantitative evaluation in Africa of the changing nature of stigma and the potential determinants of these changes. More specifically, it evaluates the dynamic relationship between stigma and (1) increased personal contact with people living with HIV/AIDS and (2) knowing people who died of AIDS. Panel survey data collected in Cape town 2003 and 2006 for 1074 young adults aged 14-22 years were used to evaluate changes in three distinct dimensions of stigma: behavioural intentions towards people living with HIV/AIDS; instrumental stigma; and symbolic stigma. Individual fixed effects regression models are used to evaluate factors that influence stigma over time. Each dimension of stigma increased in the population as a whole, and for all racial and gender sub-groups. Symbolic stigma increased the most, followed by instrumental stigma, while negative behavioural intentions showed a modest increase. Knowing someone who died of AIDS was significantly associated with an increase in instrumental stigma and symbolic stigma, while increased personal contact with people living with HIV/AIDS was not significantly associated with any changes in stigma. Despite interventions, such as public-sector provision of antiretroviral treatment (which some hoped would have reduced stigma), stigma increased among a sample highly targeted with HIV-prevention messages. These findings emphasise that changes in stigma are difficult to predict and thus important to monitor. They also indicate the imperative for renewed efforts to reduce stigma, perhaps through interventions to weaken the association between HIV/AIDS and death, to reduce fear of HIV/AIDS, and to recast HIV as a chronic manageable disease.

South Africa's government disability grants are considered important in providing income support to low-income AIDS patients. Indeed, anecdotal evidence suggests that some individuals may opt to compromise their health by foregoing Highly Active Antiretroviral Treatment (HAART) to remain eligible for the grant. In this study, we examined the disability grant's importance to individual and household welfare, and the impact of its loss using a unique longitudinal dataset of HAART patients in Khayelitsha, Cape Town. We found that grant loss was associated with sizeable declines in income and changes in household composition. However, we found no evidence of individuals choosing poor health over grant loss. Our analysis also suggested that though the grants officially target those too sick to work, some people were able to keep grants longer than expected, and others received grants while employed. This has helped cushion people on HAART, but other welfare measures need consideration.

HIV prevalence is high among South African youth. Health behavior models posit that the perceived level of risk of HIV infection is associated with the level of HIV risk behavior; however, there has been limited research in Sub-Saharan Africa on factors associated with perceived risk or on the relationship between perceived risk and risk behaviors.Longitudinal data collected in 2002 and 2005 from 3,017 black, colored and white youth in Cape Town, South Africa, were analyzed using multivariate regression to examine whether a reciprocal relationship exists between sexual experience and perceived HIV risk. Independent variables taken from the 2002 survey were used to predict dependent variables taken from the 2005 survey.In 2005, most youth (82% of males and 83% of females) viewed themselves as being at no or small risk of HIV infection. A reciprocal relationship in which higher perceived HIV risk was associated with a delay in sexual debut (odds ratio, 0.8) and sexual experience was associated with higher perceived risk (1.4) was found for females, but not for males. Knowing someone who had died of AIDS was associated with sexual debut and with an elevated perceived HIV risk among females (1.7 and 1.3, respectively). The associations between race and perceived risk of HIV infection varied by gender.HIV/AIDS education and prevention programs should consider more carefully how gender and race may intersect to influence risk perceptions and risk behaviors. In addition, possible reciprocal relationships between risk behaviors and risk perceptions should be considered in education and intervention programs.

HIV prevalence is high among South African youth. Health behavior models posit that perceived risk of HIV/AIDS is associated with HIV/AIDS risk behaviors, but research in sub-Saharan Africa that has considered the predictors of HIV/AIDS risk perceptions and behaviors or the relationship between them has been limited. Longitudinal data collected in 2002 and 2005 from 3,025 black, coloured, and white youth aged 14-22 (in 2002) in Cape Town, South Africa were analyzed using multivariate regression to examine correlates of perceived HIV/AIDS risk and one HIV/AIDS risk behavior, transition to first sex. Independent variables taken from the 2002 survey were used to predict dependent variables taken from the 2005 survey. Results indicate that most respondents viewed themselves at no risk or small risk of HIV infection. Perceived risk of HIV/AIDS was positively associated with having had sex and knowing somebody with HIV/AIDS. Among those who were virgins in 2002, perceived HIV/AIDS risk and knowing somebody with HIV/AIDS predicted entry into first sex by 2005 for females only. The effects of race on risk perceptions also varied by gender. In conclusion, HIV/AIDS education and prevention programs should consider more carefully how gender and race may intersect to influence risk perceptions and risk behaviors. The reciprocal relationship between risk perceptions and risk behaviors should also be considered in education and intervention programs.

Background Incorrect inferences drawn from large-scale HIV prevention messages may hinder their efficacy. We examined whether individuals who are told that medical male circumcision (MMC) partially reduces female-to-male HIV transmission also erroneously infer a reduction in male-to-female HIV transmission risk. Methods In 2008, nearly 1,000 men in rural Malawi were randomised to receive the information that MMC reduces female-to-male HIV transmission risk, with follow-up in 2009. Data was collected on perceived HIV transmission risks faced by men and women by the circumcision status of the male partner. Descriptive and multivariate variable regression analyses were used to assess whether beliefs about male circumcision and female HIV risk varied by receipt of information about MMC and by whether individuals believed that that MMC partially protects men from HIV infection. Results Men randomised to information about MMC were more likely to believe that circumcised men faced reduced HIV transmission risks relative to uncircumcised men (50% versus 65%, p Conclusions Our results point toward the need for male circumcision campaigns to make explicit that male circumcision does not directly protect women from HIV infection.