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Abstract Background Health technology assessment uses explicit economic evaluation evidence to support health benefits package design. However, the limited availability of technical expertise, data, and methods has restricted the production of economic evaluation evidence in low- and middle-income countries. Zambia has initiated a roadmap to support its policy of reviewing and implementing its national benefits package. This study characterises economic evaluation evidence to support this process's evidence mapping, synthesis, and appraisal stages. Methods This systematic review applies deductive analysis and the preferred reporting items for systematic review and meta-analyses. Four databases were searched to identify studies from 1993 that coincided with Zambia's health benefits package reform. Results A total of 61 studies met the inclusion criteria. Most of the studies were first authored by nonlocal authors, and the number of local-based authors in each study was low. Almost all funding for economic evaluation research was not local, and only a few studies sought local ethical clearance to conduct research. Infectious diseases were the highest disease control priority for the studies, with HIV research having the highest output. Most of the studies were cost-effectiveness studies that utilised trial-based data and a combination of program, published, and unpublished data for analysis. The studies generally utilised direct cost and applied the ingredient-based costing approach. Natural units were predominantly used for outcomes alongside DALYs. Most studies reported using a 3% discount rate for both costs and outcomes, with only a few reporting methods for sensitivity analysis. Conclusion Economic evaluation evidence in Zambia has increased, revealing limited local research leadership, methodological inconsistencies, and a focus on infectious diseases. These findings are crucial for revising Zambia's benefits package and may guide researchers and decision-makers in improving the transparency and quality of future research.

Abstract Despite the common belief that human papillomavirus (HPV) primarily affects women, it is imperative to recognize and address the impact of HPV on boys and men. Overlooking the health implications for males is a notable gap, as efforts have predominantly focused on preventing HPV-related infections in women. This commentary aims to emphasize the importance of HPV awareness and vaccination for boys and men by highlighting the prevalence and consequences of HPV infection, elaborating on the associated health risks, elucidating the benefits of vaccination, and urging readers to recognize the necessity of protecting males from HPV. In addition, the increase in HPV-related cancers in men underscores the urgent need for increased awareness and vaccination. Although specific testing for HPV in men is not available, the inclusion of men and boys in gender-neutral vaccination programs can help reduce the harmful effects of this virus in both genders.

Abstract Background Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. Methods We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. Results We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants’ mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X 2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X 2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one’s sexuality and HIV status had a compounding effect and was described as living “a private lie.” Conclusion Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

In 2019, there were 21 million pregnancies among adolescents aged 15–19 years globally; close to half of these pregnancies were unintended. Early and unintended pregnancy (EUP) remains a pressing concern with severe socioeconomic and health outcomes for adolescent girls aged 15–19 years, their offspring and society. In Eastern and Southern Africa (ESA), Zambia, the United Republic of Tanzania, the Democratic Republic of Congo, Malawi and Uganda have adolescent fertility rates (AFR) of more than 100 live births per 1000 adolescent girls aged 15–19 years. Ministers of Health and Education, through the ESA Ministerial Commitment, aimed to reduce EUP by 75% by 2020; the renewed ESA Ministerial Commitment aims to reduce EUP by 40% by 2030. This descriptive policy content analysis assesses the prioritisation of EUP within adolescent sexual and reproductive health and rights (ASRHR) policies. An assessment of nine countries in the region shows that EUP is a key policy priority among countries; however, other than Kenya, the majority of ASRHR policies in the region do not set out clear and costed interventions for EUP, and few have monitoring and evaluation frameworks in place. Despite AFRs declining in Kenya and strong policies in place, the gains made are at risk due to the rollback on SRHR, and the country has not renewed the ESA Ministerial Commitment. This policy content analysis points towards the gaps we are still to meet within the universal health coverage agenda: better planning, prioritisation, sound policy frameworks and long-term commitments to meet the needs of adolescents.

BackgroundHealth technology assessment uses a multidisciplinary approach to support health benefits package design towards universal health coverage. The evidence-informed deliberative process framework has been used alongside Health technology assessment to enhance stakeholder participation and deliberations in health benefits package design. Applying the evidence-informed deliberative framework for Health assessment could support the morally diverse sexual reproductive health and rights (SRHR) benefits package design process. However, evidence on participation and deliberations for stakeholders in health technology assessment for SRHR benefits package design has not been curated in sub-Saharan Africa. This study synthesises literature to fill this gap.MethodsThis scoping review applies the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, and deductive analysis following the evidence-informed deliberative processes framework. The search strategy uses the Guttmacher-Lancet Commission-proposed comprehensive definition of SRHR and the World Health Organisation's universal health coverage compendium of SRHR interventions to generate search terms. Six databases and biographical hand searches were used to identify studies in Sub-Saharan Africa from 1994.ResultsA total of 14 studies met the inclusion criteria. Evidence for yearly public budgets and explicit SRHR health technology assessment processes was not found. In 12 of the studies reviewed, new advisory committees were set up specifically for health technology assessment for SRHR priority-setting and benefits package design. In all decision-making processes reviewed, the committee member roles, participation and deliberations processes, and stakeholder veto powers were not clearly defined. Patients, the public, and producers of health technology were often excluded in the health technology assessment for the SRHR benefits package design. Most health technology assessment processes identified at least one decision-making criterion but failed to use this in their selection and appraisal stages for SRHR benefits design. The identification, selection, and scoping stages in health technology assessment for SRHR were non-existent in most studies. In 11 of the 14 processes of the included studies, stakeholders were dissatisfied with the health policy recommendation from the appraisal process in health technology assessment. Perceived benefits for evidence-informed deliberative processes included increased stakeholder engagement and fairness in decision-making.ConclusionTo support the integration of diverse social values in health technology assessment for fairer SRHR benefits package design, evidence from this review suggests the need to institutionalise health technology assessment, establish prioritisation decision criteria, involve all relevant stakeholders, and standardise the process and assessment methodological approaches.

This study explores the experiences and coping strategies of female frontline healthcare workers (HCWs) fighting the COVID-19 pandemic in resource-constrained settings. Female frontline HCWs face an elevated risk of contracting the COVID-19 infection and infecting their loved ones because when they return from work. The study adopted a qualitative approach to explore the experiences of female frontline HCWs working in high-volume departments at Bindura provincial hospital in Zimbabwe. Using purposive sampling, 15 participants were recruited. HCWs were asked to share their views and perspectives on COVID-19 and their work environment. The study focused on HCWs’ experiences of stigma and discrimination once infected; access to treatment; understanding of transmission; and life experiences of living with COVID-19. The findings suggest that female HCWs working in high-volume departments experience a higher risk of exposure to infection, barriers to assessing personal protective equipment (PPE) and stigma, which impact their mental health. However, despite the complex interrelated challenges female frontline HCWs face in Zimbabwe, there are limited interventions to ameliorate this burden, a knowledge gap this research aims to illuminate.

Abstract Globally, South Africa hosts the highest number of people living with HIV (PLHIV) and the unique legacy of internal labour migration continues to be a major driver of the regional epidemic, interrupting treatment-as-prevention efforts. The study examined levels, trends, and predictors of migration in rural KwaZulu-Natal Province, South Africa, using population-based surveillance data from 2005 through 2017. We followed 69 604 adult participants aged 15–49 years and recorded their migration events (i.e., out-migration from the surveillance area) in 423 038 person-years over 525 397 observations. Multiple failure Cox-regression models were used to measure the risk of migration by socio-demographic factors: age, sex, educational status, marital status, HIV, and community antiretroviral therapy (ART) coverage. Overall, 69% of the population cohort experienced at least one migration event during the follow-up period. The average incidence rate of migration was 9.96 events and 13.23 events per 100 person-years in women and men, respectively. Migration rates declined from 2005 to 2008 then peaked in 2012 for both women and men. Adjusting for other covariates, the risk of migration was 3.4-times higher among young women aged 20–24 years compared to those aged ≥ 40 years (adjusted Hazard Ratio [aHR] = 3.37, 95% Confidence Interval [CI]: 3:19–3.57), and 2.9-times higher among young men aged 20–24 years compared to those aged ≥ 40 years (aHR = 2.86, 95% CI:2.69–3.04). There was a 9% and 27% decrease in risk of migration among both women (aHR = 0.91, 95% CI: 0.83 – 0.99) and men (aHR = 0.73, 95% CI 0.66 – 0.82) respectively per every 1% increase in community ART coverage. Young unmarried women including those living with HIV, migrated at a magnitude similar to that of their male counterparts, and lowered as ART coverage increased over time, reflecting the role of improved HIV services across space in reducing out-migration. A deeper understanding of the characteristics of a migrating population provides critical information towards identifying and addressing gaps in the HIV prevention and care continuum in an era of high mobility.

Abstract Background HIV incidence among adolescent girls and young women (AGYW) remains high, with their male partners a prominent factor in sustaining these elevated rates. Partnership characteristics remain important metrics for determining HIV risk, with evidence indicating that AGYW engaged in transactional and age-disparate relationships face greater HIV exposure. This study examines the risk posed to AGYW in a relationship with a “Blesser”, defined as male who provides his female partner with their material needs or desires in exchange for a sexual relationship, an age-disparate (5 or more years older) partner, and the potential compounded risk of being a relationship with a partner or partners who are considered both a “Blesser” and age-disparate. Methods A cross -sectional household based representative sample of AGYW (aged between 12–24 years) were enrolled in the study (n = 18 926) from the districts of City of Johannesburg and Ekurhuleni in the Gauteng province and the Districts of eThekwini and uMgungundlovu in the province of KwaZulu-Natal (KZN) in South Africa between March 13, 2017 to June 22, 2018. Participants completed a structured questionnaire and provided finger-prick blood samples for laboratory measurements. Our analysis used descriptive statistics and multiple binary logistic regressions accounting for survey weights, clustering and stratification. Findings The median age of the sample was 21 years old (Interquartile range: 19–23) and nearly three quarters (73.7%) were currently attending school. Whilst all relationships exposed AGYW to potential HIV risk, multiple binary logistic regression analysis revealed that AGYW in a relationship with both a Blesser and an age-disparate partner were more likely to be HIV positive (AOR: 3.12, 95% CI: 1.76–5.53, p

BackgroundIn sub-Saharan Africa, truckers and female sex workers (FSWs) have high HIV risk and face challenges accessing HIV testing. Adding HIV self-testing (HIVST) to standard of care (SOC) programs increases testing rates. However, the underlying mechanisms are not fully understood. HIVST may decrease barriers (inconvenient clinic hours, confidentiality concerns) and thus we would expect a greater impact among those not accessing SOC testing (barriers prevented previous testing). As a new biomedical technology, HIVST may also be a cue to action (the novelty of a new product motivates people to try it), in which case we might expect the impact to be similar by testing history.MethodsWe used data from two randomized controlled trials evaluating the announcement of HIVST availability via text-message to male truckers (n = 2,260) and FSWs (n = 2,196) in Kenya. Log binomial regression was used to estimate the risk ratio (RR) for testing ≤ 2 months post-announcement in the intervention vs. SOC overall and by having tested in the previous 12-months (12m-tested); and we assessed interaction between the intervention and 12m-tested. We also estimated risk differences (RD) per 100 and tested additive interaction using linear binomial regression.ResultsWe found no evidence that 12m-tested modified the HIVST impact. Among truckers, those in the intervention were 3.1 times more likely to test than the SOC (p < 0.001). Although testing was slightly higher among those not 12m-tested (RR = 3.5, p = 0.001 vs. RR = 2.7, p = 0.020), the interaction was not significant (p = 0.683). Among FSWs, results were similar (unstratified RR = 2.6, p < 0.001; 12m-tested: RR = 2.7, p < 0.001; not 12m-tested: RR = 2.5, p < 0.001; interaction p = 0.795). We also did not find significant interaction on the additive scale (truckers: unstratified RD = 2.8, p < 0.001; 12m-tested RD = 3.8, p = 0.037; not 12m-tested RD = 2.5, p = 0.003; interaction p = 0.496. FSWs: unstratified RD = 9.7, p < 0.001; 12m-tested RD = 10.7, p < 0.001, not 12m-tested RD = 9.1, p < 0.001; interaction p = 0.615).ConclusionThe impact of HIVST was not significantly modified by 12m-tested among truckers and FSWs on the multiplicative or additive scales. Announcing the availability of HIVST likely served primarily as a cue to action and testing clinics might maximize the HIVST benefits by holding periodic HIVST events to maintain the cue to action impact rather than making HIVST continually available.

IntroductionClinical trials in sub-Saharan Africa support that HIV self-testing (HIVST) can increase testing rates in difficult-to-reach populations. However, trials mostly evaluate oral fluid HIVST only. We describe preferences for oral fluid vs. blood-based HIVST to elucidate prior trial results and inform testing programs.MethodsParticipants were recruited from a HIVST randomized controlled trial in Nakuru County, Kenya, which aimed to test the effect of choice between oral HIVST and facility-based testing compared to standard-of-care on HIV testing among truck drivers. We conducted in-depth interviews (IDIs) with purposively sampled trial participants who declined HIV testing at baseline or who were offered access to oral fluid HIVST and chose not to pick up the kit during follow-up. IDIs were conducted with all consenting participants. We first describe IDI participants compared to the other study participants, assessing the statistical significance of differences in characteristics between the two samples and then describe preferences, beliefs, and attitudes about HIVST biospecimen type expressed in the IDIs.ResultsThe final sample consisted of 16 men who refused HIV testing at baseline and 8 men who did not test during follow-up. All IDI participants had tested prior to study participation; mean number of years since last HIV test was 1.55, vs. 0.98 among non-IDI participants (p = 0.093). Of the 14 participants who answered the question about preferred type of HIVST, nine preferred blood-based HIVST, and five, oral HIVST. Preference varied by study arm with four of five participants who answered this question in the Choice arm and five of nine in the SOC arm preferring blood-based HIVST. Six key themes characterized truckers' views about test type: (1) Rapidity of return of test results. (2) Pain and fear associated with finger prick. (3) Ease of use. (4) Trust in test results; (5) fear of infection by contamination; and (6) Concerns about HIVST kit storage and disposal.ConclusionWe found no general pattern in the themes for preference for oral or blood-based HIVST, but if blood-based HIVST had been offered, some participants in the Choice arm might have chosen to self-test. Offering choices for HIVST could increase testing uptake.

Vaccination plays a crucial role in combating the global COVID-19 pandemic. Immunizing all healthcare workers (HCWs) is essential for increasing vaccine confidence and acceptance within the general population. Understanding the factors that hinder or facilitate vaccine uptake among HCWs is of utmost importance, considering they are among the first to be vaccinated. This review follows Arksey and O’Malley’s five-stage methodological framework. We searched PubMed, Web of Science, ProQuest, WorldCat Discovery, and Google Scholar for peer-reviewed articles published from 2020 to 2023. A descriptive analysis and narrative synthesis approach were employed to collect and synthesize data. Using the social-ecological model as a framework, the literature was categorized into themes at the intrapersonal, interpersonal, organizational, community, and policy levels. We reviewed a total of fifty-three published academic articles, with the majority of studies conducted in Ethiopia and Nigeria. The intention for vaccine uptake resulted in an unsatisfactory (52%) overall uptake rate among HCWs. Individual-level determinants associated with vaccine uptake included being male, middle-aged, being a physician, having a higher level of education, and having a chronic illness. This review identified significant barriers at each level, such as safety concerns, perceived scientific uncertainty, vaccine ineffectiveness, lack of trust in stakeholders, and religious beliefs. Additionally, we identified facilitators at each level, with the most common factors promoting intention to uptake being the desire to protect oneself and others and a high perceived susceptibility to contracting COVID-19. This review highlights the existence of significant barriers to vaccine uptake on the African continent. Given that HCWs play a crucial role in guiding the public’s vaccination decisions, it is imperative to prioritize education and training efforts about the safety and effectiveness of COVID-19 vaccines.

Background: Donor–nongovernmental organisation (NGO) partnerships may enable earlier infusion of implementation science principles into developing evidence-based interventions. Yet, donors and NGOs often report difficulty leveraging resources, personnel and expertise to create beneficial outcomes for all. Drawing from a PhD thesis, the authors report how the asymmetrical nature of the relationships manifests in practice in the work of NGOs. The study focused on human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV and AIDS) NGOs in Gauteng province in South Africa. Objectives: This study examines whether the asymmetrical relationships can be termed partnerships and highlights the potential for such a discourse to reinforce existing relationship inequalities. Method: Qualitative data were collected through in-depth individual interviews with key informants from five purposively selected HIV and AIDS NGOs. A total of 28 interviews were analysed deductively using thematic analysis. The Dóchas Partnership Assessment and Development Process framework guided this analysis. The NGOs under study have implemented various HIV and AIDS programmes and policies in their workspace. Results: The findings have revealed that ‘partnership’ is a false representation of the actual relationships between donors and NGOs. Conclusion: The study concluded that although the notion of partnerships accurately describes the intention of ‘donors’ and ‘NGOs’ to collaborate in ways that ensure improved services and outcomes, the unintended consequences of how partnerships are managed and run inhibit that common agenda. The article concludes with suggestions to build and sustain effective working relationships between partners. Contribution: Assessing how donor-NGO partnerships are operationalised can assist in determining the extent to which their relationship is operating and point to areas where partnerships practice can be further developed.

Background: Sexually transmitted infections (STIs) and Human immunodeficiency virus (HIV) share a complex bidirectional relationship, however, population prevalence and the association between the presence of STIs and HIV in a high HIV burden district in KwaZulu-Natal, South Africa is not known. Methods: A total of 9812 participants aged 15–49 years were enrolled in a cross-sectional population-based household survey. Participants completed a structured questionnaire and provided first-pass urine (males) or self-collected vulvo-vaginal swabs (females) for the detection of STIs. Results: Prevalence of herpes simplex virus type-2 (HSV-2) was 57.8%, syphilis was 1.6%, Neisseria gonorrhoeae was 2.8%, Chlamydia trachomatis was 7.1%, Trichomonas vaginalis was 9.0%, Mycoplasma genitalium was 5.5% and HIV was 36.3%. HIV positive status was associated with an increased probability of having M. genitalium (aPR = 1.49, 95% CI 1.02–2.19) among males and syphilis (aPR = 2.54, 95% CI 1.32–4.86), N. gonorrhoeae (aPR = 2.39, 95% CI 1.62–3.52), T. vaginalis (aPR = 1.70, 95% CI 1.43–2.01) and M. genitalium (aPR = 1.60, 95% CI 1.15–2.22) among females. HIV viral load ≥400 copies per mL was associated with an increased probability of N. gonorrhoeae (aPR = 1.91, 95% CI 1.36–2.70), C. trachomatis (aPR = 1.52, 95% CI 1.12–2.05) and M. genitalium (aPR = 1.83, 95% CI 1.27–2.63). Conclusions: The high prevalence of STIs and the association between STIs and HIV, and HIV viral load underscores the public health implications of sustained transmission risk of STIs and HIV. These findings highlight the urgent need for expanding STI surveillance and implementing interventions to monitor and reduce the STI burden.

The COVID-19 pandemic is a severe concern worldwide, particularly in Africa. Vaccines are crucial in the fight against the COVID-19 pandemic. This scoping review examined existing literature from 2020 to 2022 on individual, interpersonal, and structural barriers and facilitators to COVID-19 vaccination within Africa to facilitate more informed health promotion interventions to improve vaccine uptake. This review was conducted using Arksey and O’Malley’s five-stage methodological framework. A comprehensive search was undertaken from 2021 to 2022 using six electronic databases: EBSCOhost, PubMed, Web of Science, ProQuest, WorldCat Discovery, and Google Scholar. Data was collected, charted into themes, and summarized using a standard data extraction sheet in Microsoft Excel. A total of forty (n = 40) published academic articles were reviewed, with many conducted in Nigeria (n = 10), followed by Ethiopia (n = 5) and Ghana (n = 4) and the rest elsewhere in Africa. Thematic narratives were used to report data into six themes: attitudes and perceptions about COVID-19 vaccines, intention to uptake COVID-19 vaccines; factors and barriers associated with COVID-19 vaccine uptake; socio-demographic determinants affecting the intention and uptake; and information sources for COVID-19 vaccines. The intention for uptake ranged from 25% to 80.9%, resulting in a suboptimal uptake intention rate (54.2%) on the African continent. Factors that promoted vaccine acceptance included confidence in the COVID-19 vaccines and the desire to protect people. Age, education, and gender were the most common factors significantly associated with vaccine acceptance. Most studies revealed that considerable barriers to vaccine uptake exist in Africa. Concerns about potential side effects, vaccine ineffectiveness, a perceived lack of information, and inaccessibility were among the individual, interpersonal, and structural barriers to COVID-19 vaccine uptake. The unwillingness to receive the COVID-19 vaccine was strongly correlated with being female. Mass and social media were the main sources of information regarding COVID-19 vaccines. To encourage vaccine uptake, governments should pay attention to refuting misinformation through integrated community-based approaches, such as creating messages that convey more than just information.

BackgroundIn sub-Saharan Africa, high HIV incidence rates in adolescent girls and young women (AGYW) persist despite extensive HIV prevention efforts.MethodsA prospective cohort of 2,710 HIV-negative AGYW (15-24 years) in KwaZulu-Natal, South Africa were interviewed at baseline and followed-up approximately 18 months later (2014-2017). Associations between HIV seroconversion and socio-demographic and behavioural variables measured at baseline and follow-up were examined using Cox regression and a proximate determinants framework. Inter-relationships between determinants were measured using logistic regression. Separate models were built for 15-19 and 20-24-year-olds.ResultsWeighted HIV incidence was 3.92 per 100 person-years (95% confidence interval: 3.27-4.69; 163 seroconversions over 4,016 person-years). Among 15-19-year-olds, absence of family support (adjusted hazards ratio (aHR): 3.82 (1.89-7.72)), having a circumcised partner (aHR: 0.5 (0.27-0.94)) or one who was HIV-positive and not on antiretroviral therapy (ART) (aHR: 6.21 (2.56-15.06)) were associated with HIV incidence. Those reporting an absence of family support were also more likely to report >1 partner during follow-up (odds ratio (OR): 2.7(1.11-6.57)). Among 20-24-year-olds, failure to complete secondary school (aHR: 1.89 (1.11-3.21)), inconsistent condom use (aHR: 3.01 (1.14-7.96)) and reporting partner(s) who were HIV-positive and not on ART (aHR: 7.75 (3.06-19.66)) were associated with HIV incidence. Failure to complete secondary school among 20-24-year-olds was associated with inconsistent condom use (OR: 1.82 (1.20-2.77)) and reporting an HIV-positive partner not on ART (OR: 3.53(1.59-7.82)) or an uncircumcised partner (OR: 1.39 (1.08-1.82).ConclusionAbsence of family support and incomplete schooling are associated with risky sexual behaviours and HIV acquisition in AGYW. In addition, partner-level prevention-condom use, medical circumcision, and viral suppression-continue to play an important role in reducing HIV risk in AGYW. These findings support the use of combination HIV prevention programs that consider structural as well as biological and behavioural HIV risk factors in their design.

There is limited research on adolescent boys and young men (ABYM)'s initial and onward HIV seropositive status disclosure, coping strategies and treatment adherence journeys especially in Zimbabwe. This qualitative exploratory study employed in-depth individual interviews at Chiredzi General Hospital in Zimbabwe to explore the dynamics of disclosure, coping and treatment adherence among ABYM. Twenty-one HIV positive ABYM with ages ranging from 14 to 21 were recruited from their scheduled visit to collect medication at the hospital. Findings indicate that ABYM disclosure journeys began with shock, confusion or misunderstanding and ended in a positive life outlook. Treatment adherence among ABYM was very poor due to poverty, erratic food supply, feeling sick after taking medication, forgetfulness and the public nature of medication collection centers. The study concluded that ABYM maintained secrecy in order to be accepted by their peers but also to protect themselves from stigma and isolation.

Capitalising further on the benefits of antiretroviral therapy (ART) for individual treatment requires an improved understanding of the psychological processes that may affect optimal ART adherence among people living with HIV. We examined internalised HIV/AIDS-related stigma and body appreciation as mediators of the association between self-esteem and ART adherence among young people living with HIV (YPLHIV). A sample of 76 YPLHIV (Mage = 19.36, s.d.age = 2.56; male 56.58%) residing in an HIV hyperendemic region of South Africa completed self-report measures of self-esteem, internalised HIV/AIDS-related stigma, body appreciation, and ART adherence. Path-analytic mediation modelling was performed to test for direct and indirect effects linking self-esteem with ART adherence. Results of serial mediation analyses indicated that self-esteem and ART adherence were indirectly associated through a two-step path of internalised HIV/AIDS-related stigma and then body appreciation, as well as a one-step path through internalised HIV/AIDS-related stigma. The results provide preliminary support for internalised HIV/AIDS-related stigma and body appreciation as mechanisms underlying the association between self-esteem and ART adherence. Implications of the findings for promoting ART adherence among YPLHIV are discussed. Significance: • Self-esteem and ART adherence were indirectly related through internalised HIV/AIDS-related stigma followed by body appreciation. • Outcomes of intervention initiatives designed to promote ART adherence among young people living with HIV may be further improved by integrating components that target internalised HIV/AIDS-related stigma and body appreciation.

Background: Studies suggest that offering HIV self-testing (HIVST) increases short-term HIV testing rates, but few have looked at long-term outcomes.Methods: We conducted a randomized controlled trial (RIDIE 55847d64a454f) on the impact of offering free oral HIVST to 305 truck drivers recruited from two clinics in Kenya. We previously reported that those offered HIVST were more likely to accept testing. Here we report on the 6-month follow-up during which intervention participants could pick-up HIVST kits from eight clinics.Results: There was no difference in HIV testing during 6-month follow-up between participants in the intervention and the standard of care (SOC) arms (OR = 1.0, p = 0.877). The most common reasons given for not testing were lack of time (69.6%), low risk (27.2%), fear of knowing HIV status (20.8%), and had tested recently (8.0%). The null association was not modified by having tested at baseline (interaction p = 0.613), baseline risk behaviors (number of partners in past 6 months, interaction p = 0.881, had transactional sex in past 6 months, interaction p = 0.599), nor having spent at least half of the past 30 nights away from home for work (interaction p = 0.304). Most participants indicated a preference for the characteristics associated with the SOC [preference for blood-based tests (69.4%), provider-administered testing (74.6%) testing in a clinic (70.1%)]. However, those in the intervention arm were more likely to prefer an oral swab test than those in the SOC (36.6 vs. 24.6%, p = 0.029).Conclusions: Offering HIVST kits to truck drivers through a clinic network had little impact on testing rates over the 6-month follow-up when participants had to return to the clinic to access HIVST. Clinic-based distribution of HIVST kits may not address some major barriers to testing, such as lack of time to go to a clinic, fear of knowing one’s status and low risk perception. Preferred HIV testing attributes were consistent with the SOC for most participants, but oral swab preference was higher among those in the intervention arm, who had seen the oral HIVST and had the opportunity to try it. This suggests that preferences may change with exposure to different testing modalities.

Abstract Background Young women in sub-Saharan Africa remain at the epicentre of the HIV epidemic, with surveillance data indicating persistent high levels of HIV incidence. In South Africa, adolescent girls and young women (AGYW) account for a quarter of all new HIV infections. Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) is a strategy introduced by the United States President’s Emergency Plan for AIDS Relief (PEPFAR) aimed at reducing HIV incidence among AGYW in 10 countries in sub-Saharan Africa by 25% in the programme’s first year, and by 40% in the second year. This study will assess the change in HIV incidence and reduction in risk associated behaviours that can be attributed to the DREAMS initiative in South Africa, using a population-based cross-sectional survey. Methods Data will be collected from a household-based representative sample of AGYW (between the ages 12–24 years) in four high prevalence districts (more than 10% of the population have HIV in these districts) in South Africa in which DREAMS has been implemented. A stratified cluster-based sampling approach will be used to select eligible participants for a cross-sectional survey with 18,500, to be conducted over 2017/2018. A questionnaire will be administered containing questions on sexual risk behaviour, selected academic and developmental milestones, prevalence of gender based violence, whilst examining exposure to DREAMS programmes. Biological samples, including two micro-containers of blood and self-collected vulvovaginal swab samples, are collected in each survey to test for HIV infection, HIV incidence, sexually transmitted infections (STIs) and pregnancy. This study will measure trends in population level HIV incidence using the Limiting antigen (LAg) Avidity Enzyme Immuno-Assay (EIA) and monitor changes in HIV incidence. Discussion Ending the HIV/AIDS pandemic by 2030 requires the continual monitoring and evaluation of prevention programmes, with the aim of optimising efforts and ensuring the achievement of epidemic control. This study will determine the impact DREAMS interventions have had on HIV incidence among AGYW in a ‘real world, non-trial setting’.

Abstract Introduction The South African public health system plays an important role in the delivery of HIV testing and treatment services. The health system is also an important conduit for targeted behaviour change communication with the expectation that clients who undergo counselling from health personnel, adopt safer sexual practices. Literature remains mixed on the impact these HIV services have on risky sexual behaviour. This analysis examines the sexual behaviour of clients following the utilisation of HIV testing and treatment services in Kwazulu-Natal, South Africa. Methods Data were used from two consecutive cross-sectional household surveys undertaken from June 2014 to June 2015 (2014/2015 survey) and from July 2015 to June 2016 (2015/2016 survey) in the uMgungundlovu District of KwaZulu-Natal, South Africa. Collectively, 20,048 randomly selected individuals aged 15 to 49 years old were interviewed across the two surveys. Utilisation of HIV testing and treatment services were used as independent variables and three sexual risk behaviours were used as dependent variables. Multiple regression models assessed the impact HIV testing and treatment services had on sexual risk behaviour while controlling for socio-demographic characteristics. Results Having tested for HIV had no association with any of the three sexual risk behaviours. However, receiving an HIV positive diagnosis reduced the likelihood of using condoms inconsistently with the respondents’ most recent partner (AOR: 0.64; 95% CI 0.54–0.77). Antiretroviral use was negatively associated with inconsistent condom use (AOR: 0.45; 95% CI 0.35–0.58) and number of sexual partners in the previous year (AOR: 0.61; 95% CI 0.46–0.81). Conclusions Results indicate that HIV testing and treatment services and the assumed exposure of clients to behaviour change communication, had a limited effect in reducing risky sexual behaviour. Data suggests that the engagement between health personnel and individuals accessing HIV testing and treatment services does not necessarily translate into the adoption of safer sexual practices, with the exception of individuals testing positive for HIV and those on ARV treatment, who had adopted safer sexual practices.

Abstract Background Despite increased antiretroviral therapy (ART) coverage, the incidence of HIV infection among women in rural South Africa remains high. While many socio-demographic and behavioral factors have been identified, the effect of female migration intensity on the risk of HIV acquisition before and after ART scale-up has not been evaluated in the country. Methods We followed 13,315 female participants aged 15–49 who were HIV-uninfected at baseline and recorded their migration events between 2004 and 2015. Using a Cox proportional hazard model, we estimated the time to HIV acquisition among the women, adjusting for annual migration intensity (high: ≥2 events/year, moderate = 1 event/year, and low = 0 event/year) before and after ART scale-up in 2010. Results 1998 (15%) new HIV-infection events were recorded during the observation period. Overall, high migration intensity was associated with an increased HIV acquisition risk among women when compared with low migration intensity (HR = 2.88, 95% CI: 1.56–5.53). Among those with high migration intensity, the risk of HIV acquisition was significantly lower in the post-ART period compared to the pre-ART period, after controlling for key socio-demographic and behavioural covariates (aHR = 0.18, 95% CI 0.04–0.83). Conclusions Women who migrated frequently after ART scale-up had a significantly reduced HIV acquisition risk compared to those before its implementation. While this reduction is encouraging, women who migrate frequently remain at high risk of HIV acquisition. In the era of ART, there remains a critical need for public health interventions to reduce the risk of HIV acquisition in this highly vulnerable population.

Introduction Adherence to antiretroviral therapy (ART) remains a key challenge to achieving the fast-track goal of ending the HIV epidemic by 2030. To provide a more comprehensive indication of whether interventions designed to promote ART adherence might benefit from targeting body image perceptions, we aim to conduct a systematic review to synthesise existing evidence on the association between body image and ART adherence.Methods and analysis A systematic review of peer-reviewed observational studies and randomised controlled trials that have investigated the association between body image and adherence to ART will be performed. JSTOR, PsycARTICLES, PsycINFO, PubMed, ScienceDirect and Web of Science databases will be searched from 1 January 2000 to 31 March 2021. Eligible records will consider body image as either an independent variable or a mediator, whereas ART adherence will be assessed as an outcome variable. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and study quality will be assessed using relevant tools developed by the National Institute of Health. If sufficient data are available, a meta-analysis will be conducted. Effect size estimates will be aggregated using a random effects meta-analysis approach. Publication bias and its impact will be evaluated through the use of a funnel plot and the trim-and-fill method. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to report on the overall quality of evidence.Ethics and dissemination Ethical approval is not required for a systematic review protocol. Findings of the proposed systematic review will be disseminated through conference presentations and publication in a peer-reviewed journal.PROSPERO registration number CRD42020212597.

The coronavirus disease 2019 (COVID-19) pandemic has created extraordinary challenges and prompted remarkable social changes around the world. The effects of COVID-19 and the public health control measures that have been implemented to mitigate its impact are likely to be accompanied by a unique set of consequences for specific subpopulations living in low-income countries that have fragile health systems and pervasive social-structural vulnerabilities. This paper discusses the implications of COVID-19 and related public health interventions for children and young people living in Eastern and Southern Africa. Actionable prevention, care, and health promotion initiatives are proposed to attenuate the negative effects of the pandemic and government-enforced movement restrictions on children and young people.

Abstract Background Truckers in sub-Saharan Africa are at higher risk of contracting HIV than the general population. HIV self-testing may be a way to increase testing rates in this high-risk population. The objective of this randomized controlled trial was to assess whether informing truckers who do not test for HIV regularly about the availability of HIV self-testing kits at roadside wellness centers in Kenya using text messages would increase HIV testing rates compared to the current program in which they are sent text messages about the availability of HIV testing in general. Methods A sample of 2262 male truckers registered in the North Star Alliance electronic health record system who, based on these records, were not testing for HIV regularly were randomized to one of three study groups in which they were sent text messages about the availability of (1) oral HIV self-test kits at all 8 North Star Alliance Kenya clinics that was sent three times (intervention), (2) HIV testing in general (not self-testing) at all North Star Alliance clinics sent three times (enhanced standard of care [SOC]), or (3) HIV testing in general (not self-testing) at all North Star Alliance clinics sent one time (SOC). We looked at HIV testing over a 2-month study period following the first text. Results Truckers in the intervention group were significantly more likely to test for HIV compared to those in the enhanced SOC (OR = 2.7, p = 0.009). There was no difference in HIV testing between those in the enhanced SOC and the SOC groups. Of those in the intervention group who tested, 64.5% chose the self-test and 35.5% chose the standard provider-administered blood-based HIV test. Although the intervention more than doubled HIV testing rates, because HIV testing rates were so low in this population (by design as we selected irregular testers), even in the intervention group more than 96% of participants did not test. Conclusions Announcing the availability of HIV self-testing via text message increased HIV testing rates among truckers who were not regularly accessing HIV testing. However, self-testing is only a partial solution to increasing testing rates in this hard to reach population. Trial registration This trial was registered prior to enrollment at the Registry for International Impact Evaluations (RIDIE STUDY ID: 582a2462ae2ab): http://ridie.3ieimpact.org/index.php?r=search/detailView&id=492. It was also registered after completion at ClinicalTrials.gov (ClinicalTrials.gov Identifier: NCT03662165): https://clinicaltrials.gov/ct2/show/NCT03662165?term=NCT03662165&type=Intr&cond=HIV&rank=1.

Abstract Background Although most pregnant women in Rwanda visit antenatal care (ANC) clinics, little has been studied about the quality of services being provided. We investigated the ANC providers’ (HCPs) current practices in relation to prevention, management and referral of maternal conditions as well as the information provided to pregnant women attending ANC services in Rwanda. Methods This facility-based, cross-sectional study included 312 ANC providers as participants and a review of 605 ANC medical records from 121 health centers. Data collection was performed using an interviewer-administered questionnaire and a structured observation checklist. For the analyses, descriptive statistics and bi-and multivariable logistic regression were used. Results Nurses and midwives in ANC services failed to report a number of pregnancy-related conditions that would need urgent referral to a higher level of health care. Midwives did somewhat better than nurses in reporting these conditions. There was no statistically significant difference in how nurses and midwives informed pregnant women about pregnancy-related issues. Ever been trained in how to manage a pregnant woman exposed to violence was reported by 14% of the participants. In 12, 13 and 15% of the medical records there was no report on tetanus immunization, anthelmintic treatment and syphilis testing, respectively. Conclusion The providers in ANC clinics reported suboptimal practices on conditions of pregnancy that needed urgent referral for adequate management. Information to pregnant women on danger signs of pregnancy, recommended medicines and tests do not seem to be consistently provided. Midwifery training in Rwanda should be expanded so that most of staff at ANC clinics are trained as midwives to help lower maternal and child mortality and morbidity.

Abstract Background Long-distance truck drivers in Africa are particularly at risk of HIV acquisition and offering self-testing could help increase testing coverage in this hard-to-reach population. The aims of this study are twofold: (1) to examine the preference structures of truck drivers in Kenya regarding HIV testing service delivery models and what they mean for the roll-out of HIV self-testing, and (2) to compare the preference data collected from a hypothetical discrete choice experiment with the actual choices made by participants in the intervention arm of a randomised controlled trial (RCT) who were offered HIV testing choices. Methods Using data from 150 truck drivers, this paper examines whether the stated preferences regarding HIV testing in a discrete choice experiment predict the actual test selected when offered HIV testing choices. Conditional logit models were used for main effects analysis and stratified models were run by HIV testing choices made in the trial to assess if the attributes preferred differed by test chosen. Results The strongest driver of stated preference among all participants was cost. However, two preferences diverged between those who actually chose self-testing in the RCT and those who chose a provider administered test: the type of test (p

Abstract Background In South Africa (home of the largest HIV epidemic globally), there are high levels of mobility. While studies produced in the recent past provide useful perspectives to the mobility-HIV risk linkage, systematic analyses are needed for in-depth understanding of the complex dynamics between mobility and HIV risk. We plan to undertake an evidence-based review of existing literature connecting mobility and increased risky sexual behavior as well as risk of HIV acquisition in South Africa. Methods/design We will conduct a mixed-method systematic review of peer-reviewed studies published between 2000 and 2015. In particular, we will search for relevant South African studies from the following databases: MEDLINE, EMBASE, Web of Science, and J-STOR databases. Studies explicitly examining HIV and labor migration will be eligible for inclusion, while non-empirical work and other studies on key vulnerable populations such as commercial sex workers (CSW) and men who have sex with men (MSM) will be excluded. Discussion The proposed mixed-method systematic review will employ a three-phase sequential approach [i.e., (i) identifying relevant studies through data extraction (validated by use of Distiller-SR data management software), (ii) qualitative synthesis, and (iii) quantitative synthesis including meta-analysis data]. Recurrent ideas and conclusions from syntheses will be compiled into key themes and further processed into categories and sub-themes constituting the primary and secondary outcomes of this study. Synthesis of main findings from different studies examining the subject issue here may uncover important research gaps in this literature, laying a strong foundation for research and development of sustainable localized migrant-specific HIV prevention strategies in South Africa. Systematic review registration Our protocol was registered with PROSPERO under registration number: CRD 42017055580. (https://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42017055580)

Body image concerns are common among people living with HIV (PLHIV). Research into how young people living with HIV (YPLHIV) experience and make sense of feared or actual body changes is limited, yet these changes have emotional, psychological and interpersonal implications for young people who associate physical attractiveness with social desirability. The current study examined the subjective perceptions of body appearance and coping mechanisms among a sample of YPLHIV in Durban, South Africa. An interpretive qualitative inquiry was adopted to understand their lived experiences in relation to their body image and body satisfaction. In-depth interviews were conducted with 18 YPLHIV (15-24 years). Findings indicate physical and psychosocial effects of living with HIV among young people including weight loss, skin sores, body dissatisfaction, loss of self-esteem and social withdrawal. The study builds on previous research suggesting that PLHIV may experience a discrepancy between their actual self and ideal self. Enhancing existing coping mechanisms such as religious beliefs, support networks and physical exercises among YPLHIV can counter the physical and psychosocial effects of living with HIV and improve well-being. Body image concerns should be acknowledged when addressing HIV-related health in both health and family settings.

Objective This study investigated the behavioural, psychosocial and biological factors associated with HIV in a younger group of men (15 to 24 years) compared with an older group of men (25 to 35 years).Design A household-based, cross-sectional study was conducted.Setting Men were randomly selected using a two-stage random sampling method in KwaZulu-Natal, South Africa, between June 2014 and June 2015.Participants Overall, we interviewed 1472 younger men and 1138 older men. Only participants who could speak English or Zulu, were able to provide informed consent and who were expected to be living in the study area for the next 12 months were enrolled into the study.Primary and secondary outcomes HIV status was the primary outcome for the study. Men’s HIV status was derived from blood samples collected in the study which were tested for HIV antibodies.Results HIV prevalence was higher among older men (35.4%, 95% CI: 31.7 to 39.1) than younger men (7.6%, 95% CI: 6.2 to 9.4, p

Background Truck drivers in sub-Saharan Africa are at high risk for both mental health disorders and sexually transmitted infections. We sought to determine the prevalence of depression among a sample of long-distance truck drivers seeking services at roadside wellness clinics in Kenya and explore the relationship between depression and sexual risk behavior. Methods We used data from an interviewer-administered questionnaire from 284 truck drivers in Kenya who participated in a randomized controlled trial evaluating whether offering oral HIV self-testing could increase HIV test uptake. Depression was categorized based on the Patient Health Questionnaire-9 score, with a score ≥10 indicative of probable major depressive disorder (MDD). Sexual risk behavior was operationalized as the number of condomless sex partners in the past 6 months. Results The mean participant age was 36.9 years, 83.0% were married, and 37.0% had a secondary school education or higher. Overall, 24% of participants had probable MDD, and 58.2% reported having one condomless sex partner in the past 6 months, whereas 27.3% reported having had two or more. In a multivariable Poisson regression model adjusted for demographic and other relevant variables, including number of sex partners, MDD was significantly associated with a greater number of condomless sex partners (adjusted prevalence ratio 1.63, 95% confidence interval [1.25–2.12], p < 0.001). General self-efficacy significantly mediated the association between MDD and number of condomless sex partners. Conclusions The high prevalence of depression highlights the need to test the feasibility and acceptability of mental healthcare interventions for this population, possibly integrated with HIV prevention services. Future research is needed to better understand the association between depression and sexual risk behavior, as well as the role of self-efficacy.

OBJECTIVE:HIV testing rates in many sub-Saharan African countries have remained suboptimal, and there is an urgent need to explore strategic yet cost-effective approaches to increase the uptake of HIV testing, especially among high-risk populations. METHODS:A costing analysis was conducted for a randomized controlled trial (RCT) with male truckers and female sex workers (FSWs) registered in the electronic health record system (EHRS) of the North Star Alliance, which offers healthcare services at major transit hubs in Southern and East Africa. The RCT selected a sample of truckers and FSWs who were irregular HIV testers, according to the EHRS, and evaluated the effect of SMSs promoting the availability of HIV self-testing (HIVST) kits in Kenyan clinics (intervention program) versus a general SMS reminding clients to test for HIV (enhanced and standard program) on HIV testing rates. In this paper, we calculated costs from a provider perspective using a mixed-methods approach to identify, measure, and value the resources utilized within the intervention and standard programs. The results of the analysis reflect the cost per client tested. RESULTS:The cost of offering HIVST was calculated to be double that of routine facility-based testing (USD 10.13 versus USD 5.01 per client tested), primarily due to the high price of the self-test kit. In the two study arms that only offered provider-administered HIV testing in the clinic, only 1% of truckers and 6% of FSWs tested during the study period, while in the intervention arm, which also offered HST, approximately 4% of truckers and 11% of FSWs tested. These lower than expected outcomes resulted in relatively high cost per client estimates for all three study arms. Within the intervention arm, 65% of truckers and 72% of FSWs who tested chose the HIVST option. However, within the intervention arm, the cost per additional client tested was lower for FSWs than for truckers, at USD 0.15 per additional client tested versus USD 0.58 per additional client tested, driven primarily by the higher response rates. CONCLUSION:Whilst the availability of HIVST increased HIV testing among both truckers and FSWs, the cost of providing HIVST is higher than that of a routine health facility-based test, driven primarily by the price of the HIV self-test kit. Future research needs to identify strategies which increase demand for HIVST, and determine whether these strategies and the subsequent increased demand for HIVST are cost-effective in relation to the conventional facility based testing currently available.

Resilience is a dynamic, interactive process between resources that contribute to safeguarding a person and the adversities they experience. Within this promotional framework of resilience, this study sought to validate the Child and Youth Resilience Measure (CYRM-28) among a sample of South African adolescents (N = 1854). Confirmatory factor analysis supported a superior level of fit for a 24-item, three-factor model (i.e., individual/social, familial, and community/spiritual). Internal consistency and test-retest reliability estimates at a 12-month interval (N = 648) supported the reliability of the scales. Higher scores on the scales were associated with feeling more connected at school, greater parental monitoring perceptions, and lower sexual risk, confirming the convergent and criterion validity of the instrument. Partial discriminative power was evidenced based on selected scale distinctions according to age and sex groupings. Collectively, the findings suggest the 24-item CYRM is a valid and reliable self-report measure to assess the availability of resources associated with resilience in South African youth.

Despite being one of the worst affected sectors in South Africa, the mining sector has proven to be one of the most active in intervention efforts in the fight against HIV and AIDS (Ellis, 2007). Owing to low uptake rates of antiretroviral therapy (ART) in mining companies in recent years (Connelly & Rosen, 2006) and the positive relationship between attitudes towards ART and ART uptake (Cooper et al., 2002; Horne, Cooper, Gellaitry, Leake, & Fisher, 2007), this study sought to describe and investigate the psychosocial and behavioural correlates of attitudes towards ART in a sample of South African mineworkers. A total of 806 mineworkers from a large South African mine participated in this quantitative study. Despite a high rate of HIV testing behaviour (83.0%) as well as favourable attitudes towards ART, analysis indicated that temporary employees and contractors were more vulnerable in terms of HIV risk, HIV testing behaviours and ART knowledge and attitudes. Employees who had more positive attitudes towards ART were more knowledgeable of ART and, importantly, had a more favourable attitude towards the mine's HIV/AIDS treatment programme. These findings are discussed in relation to the low ART uptake rates in this context and recommendations for the improvement of ART uptake amongst employees at this mining site.

Voluntary medical male circumcision is an integral part of the South African government's response to the HIV and AIDS epidemic. Following circumcision, it is recommended that patients abstain from sexual activity for six weeks, as sex may increase the risk of female-to-male HIV transmission and prolong the healing period. This paper investigates the resumption of sexual activity during the healing period among a cohort of school-going males in the KwaZulu-Natal province of South Africa. The analysis for this paper compares two groups of sexually active school-going males: the first group reported having sex during the healing period (n = 40) and the second group (n = 98) reported no sex during the healing period (mean age: 17.7, SD: 1.7).The results show that 29% (n = 40) of young males (mean age: 17.9, SD: 1.8) who were previously sexually active, resumed sexual activity during the healing period, had on average two partners and used condoms inconsistently. In addition, those males that engage in sexual activity during the healing period were less inclined to practice safe sex in the future (AOR = 0.055, p = 0.002) than the group of males who reported no sex during the healing period. These findings suggest that a significant proportion of young males may currently and in the future, subject themselves to high levels of risk for contracting HIV post circumcision. Education, as part of a VMMC campaign, must emphasize the high risk of HIV transmission for both the males their partners during the healing period.