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Background: Achieving optimal adherence to antiretroviral therapy (ART) is challenging. Consistency in HIV care and treatment is crucial for achieving viral load suppression and preventing HIV-related illnesses, disease progression to AIDS, mortality, drug resistance, and onward transmission. Objectives: The purpose of this research was to gain a comprehensive understanding of the beliefs that play a role in determining the level of ART adherence among individuals newly diagnosed with HIV. By examining these beliefs, the researchers aimed to identify potential barriers and facilitators to adherence, ultimately contributing to the development of effective interventions and strategies to improve ART adherence. Method: An exploratory qualitative approach was employed in this study, utilising the Theory of Planned Behaviour (TPB) as its theoretical framework. To gather insights, in-depth interviews were conducted with 19 participants recruited post diagnosis, who shared their beliefs regarding ART adherence. Thematic analysis identified beliefs, categorised under TPB precursors, namely behavioural outcomes, subjective norms, and perceived behavioural control. Results: Participants emphasised health improvement, treatment effectiveness, and disease prevention as advantages to ART adherence, while disadvantages included fear of lifelong commitment, side effects, and stigma. ART adherence was enhanced by family support but impeded by a number of social factors. Participants expressed confidence in creating personal reminders or seeking external help, but anticipated various challenges. Conclusion: The research has shown that the beliefs affecting ART adherence in individuals recently diagnosed with HIV but not yet on treatment are like those that have been reported to influence adherence in HIV-positive participants currently receiving treatment.

Background: Male circumcision has health benefits and cultural significance in South Africa and elsewhere. We sought to understand perceptions about male circumcision among participants enrolled in a preventive human immunodeficiency virus (HIV) vaccine efficacy trial in South Africa. Methods: We conducted a qualitative study with 28 consenting people aged 18–35 years old who self-reported that they were not living with HIV and who were participating in the HIV Vaccine Trials Network (HVTN) 702 vaccine efficacy trial in Soweto. Using a semi-structured guide, we facilitated four focus group discussions (FGDs) stratified by age, gender and sexual orientation. Focus group discussions were audio-recorded, transcribed verbatim, translated into English and thematically analysed. Results: Four main themes emerged: (1) accurate knowledge about what male circumcision is, with some participants stating that it partially reduces acquisition of HIV and sexually transmitted infections; (2) emerging distrust of cultural circumcision because of perceived lack of transparency and adverse events; (3) misperceptions that circumcision boosted masculinity and (4) the influenced of parents, family and female partners in circumcision decision-making. Conclusion: Young South African HIV vaccine trial participants accurately understand the HIV prevention benefits of male circumcision, but uptake decisions are embedded within a context informed by culture, sexuality, masculinity norms and values and the influence of women. Contribution: In this study, we showed that young South Africans participating in HIV vaccine trials instead embed their circumcision uptake decisions within a context informed by culture, sexuality and masculinity norms and values and influence of women.

BackgroundThe Road to Health Application (RTHA) is essentially a digitalized version of the National Department of Health’s Road to Health book, and a hand-printed booklet given to mothers at the birth of each baby. The RTHA, like the booklet, provides guidelines for maternal and child health outcomes, with the goal of creating a database of children and caregivers in South Africa and teaching them how to raise a healthy child. This paper explored potential barriers and enablers to using the RTHA in the South African context based on user experiences.MethodsUsing a qualitative design, we conducted 50 serial interviews (two separate interviews, 1 month apart). Through convenience, sampling eligible participants were 18 years or older women who were pregnant and/or had a child under the age of 5 years. Participants included 25 existing users and 25 new users of the RTHA, who owned android smart phones at enrollment. Existing users were recruited telephonically through the National Department of Health database, and new users were approached at the antenatal care unit and wellness baby clinic (women with children under 5 years) at the Chris Hani Baragwaneth Academic Hospital. Upon enrollment, participants completed a brief survey on sociodemographics and mobile phone use, and thereafter, they had a baseline interview followed by a telephonic interview 1 month later. A semistructured interview guide was used to explore barriers, enablers, and the usability of the RTHA. Using thematic data analysis, we identified enablers and barriers to the use of the RTHA.ResultsA third (33%) of all participants reported IsiZulu as their main language of communication, and 6% of the participants reported English as their main language of communication. The RTHA was an important addition to the booklet that helped keep new mothers informed about child immunization and provided important information about healthy child rearing practices. However, multiple barriers were cited to using the RTHA; these included the fact that the app was only available in two languages, high data costs, lack of access to smart phones, and app functionalities. The enablers to using the RTHA included the accessibility of important information regarding prenatal and postnatal childcare.ConclusionThis study gives insight into the barriers and enablers from the end-user perspective to improve the RTHA for future use in South Africa and offers guidance on how to improve the RTHA to be more user-friendly, which could increase its usability among mothers. It further emphasizes the need to consider the challenges experienced by users in South Africa when developing future mobile health interventions to increase uptake.

BackgroundAdolescents in sub-Saharan Africa (SSA) remain vulnerable to HIV infection. While pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV transmission as a daily or on-demand regimen, tailored approaches are necessary. The Combined HIV Adolescent PrEP and Prevention Study (CHAPS) is a mixed-methods research program investigating the acceptability and feasibility of implementing daily and on-demand PrEP among young people in SSA. It also aims to determine an on-demand dosing schedule for insertive sex. For this paper, we explored preferences for daily versus on-demand PrEP amongst adolescents as part of CHAPS.MethodsPurposive sampling was used to recruit participants from Soweto and Cape Town (South Africa), Wakiso district (Uganda) and Chitungwiza (Zimbabwe). At the time of the study in 2018/2019, Uganda had not rolled out PrEP to the general population; in Zimbabwe, PrEP for young people was only available at selected sites with one located within the study recruitment area. In South Africa, PrEP was made available to selected high-risk groups. We conducted 60 in-depth interviews and 24 group discussions amongst young people aged 13-24 without HIV in South Africa, Uganda, and Zimbabwe. All in-depth interviews and group discussions were audio-recorded, transcribed verbatim and translated to English. Data were analysed using framework analysis. The main themes were centered around preferences for daily and on-demand PrEP.ResultsReasons for on-demand preferences included stigma, pill fatigue, adherence and side effects. Reasons for daily PrEP preferences included factors related to sexual risk behaviour, continuous protection against incidents of unintentional exposure, and the increased efficacy of a daily dose. Participants at all sites preferring daily PrEP identified the same reasons, with more males than females citing inadvertent blood contact or perceived increased efficacy. Similarly, participants at all sites preferring on-demand PrEP gave the same reasons for their preferences for on-demand PrEP; the exception was South Africans who did not mention the hope of having fewer side effects by not taking daily PrEP. Additionally, more males than females cited intermittent sex as a reason for opting for on-demand PrEP.ConclusionsOur study is the first known to explore and describe youth preferences for daily versus on-demand PrEP. While the choice is clear-cut, the reasons cited in the different options provide invaluable insights into their decisions, and the actual and perceived facilitators and barriers to access to PrEP. Further education is needed amongst young people, not only about PrEP but also in other areas of comprehensive sexuality education. Exploring all options of HIV prevention is crucial to provide a tailored, one-size-does-not-fit-all approach to adolescent care in SSA to reduce and, the continued and increasing risk of this preventable infection.

While vaccines are a well-established method of controlling the spread of infectious diseases, vaccine hesitancy jeopardizes curbing the spread of COVID-19. Through the Vaccine Information Network (VIN), this study explored barriers and motivators to COVID-19 vaccine uptake. We conducted 18 focus group discussions with male and female community members, stratified by country, age group, and—for Zimbabwe only—by HIV status. Participants’ median age across both countries was 40 years (interquartile range of 22–40), and most (65.9%) were female. We conceptualized the key themes within the World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) 3C (convenience, confidence, complacency) vaccine hesitancy model. Barriers to vaccine uptake—lack of convenience, low confidence, and high complacency—included inaccessibility of vaccines and vaccination sites, vaccine safety and development concerns, and disbelief in COVID-19’s existence. Motivators to vaccine uptake—convenience, confidence, and low complacency—included accessibility of vaccination sites, user-friendly registration processes, trust in governments and vaccines, fear of dying from COVID-19, and knowing someone who had died from or become infected with COVID-19. Overall, vaccine hesitancy in South Africa and Zimbabwe was influenced by inconvenience, a lack of confidence, and high complacency around COVID-19 vaccines.

Abstract Background The uptake and adherence of daily oral PrEP has been poor in high-risk populations in South Africa including young people. We used qualitative research methods to explore user preferences for daily and on-demand oral PrEP use among young South Africans, and to inform the identification of critical attributes and attribute-levels for quantitative analysis of user preferences, i.e. a discrete choice experiment (DCE). Methods Data were collected between September and November 2018 from eight group discussions and 20 in-depth interviews with young people 13 to 24 years in Cape Town and Johannesburg. Using a convenience sampling strategy, participants were stratified by sex and age. Interviewers used a semi-structured interview guide to discuss several attributes (dosing regimen, location, costs, side effects, and protection period) for PrEP access and use. Group discussions and in-depth interviews were audio-recorded, transcribed verbatim and translated to English. We used framework analysis to explore context-specific attributes and attribute-levels for delivering oral PrEP in South Africa. The adolescent community advisory board, expert and study team opinions were consulted for the final DCE attributes and levels. Results We enrolled 74 participants who were 51% (n = 38/74) male, had a median age of 18.5 [Interquartile range = 16–21.25] years, 91% (n = 67/74) identified as heterosexual and 49% (n = 36/74) had not completed 12th grade education. Using the qualitative data, we identified five candidate attributes including (1) dosing regimen, (2) location to get PrEP, (3) cost, (4) route of administration and (5) frequency. After discussions with experts and the study team, we revised the DCE to include the following five attributes and levels: dosing regime: daily, and on-demand PrEP; location: private pharmacy, public clinic, mobile clinic, ATM); cost: free-of-charge, R50 (~2GBP), R265 (~12GBP); side effects: nausea, headache, rash; and duration of protection: fulltime protection versus when PrEP is used). Conclusions There is limited literature on qualitative research methods describing the step-by-step process of developing a DCE for PrEP in adolescents, especially in resource-constrained countries. We provide the process followed for the DCE technique to understand user preferences for daily and on-demand oral PrEP among young people in South Africa.

ABSTRACT: Background: Assessment of sexual risk behavior among youths is crucial for HIV prevention strategies. However, the literature on sexual behavior in youth during the COVID-19 pandemic is sparse. Aim: This study surveyed sexual risk behavior among youth in Soweto, South Africa during the COVID-19 pandemic national lockdown in 2020. Methods: We conducted a cross-sectional telephonic survey on socio-demographics and HIV risk behaviors among youth aged 18–24 years during level 3 of the lockdown. Frequencies and their respective percentages were determined for categorical variables and stratified by biological sex. Chi-square analysis was used to compare categorical variables. All data were analyzed using SAS software. Outcomes: A risk assessment for HIV questionnaire was used to assess sexual risk behaviors. Also, substance use was assessed through a developed yes/no questionnaire. Results: Of the 129 participants, 83.0% (n = 107) had a sexual partner; 52% of those who had a sexual partner were females, 60.7% (65/107) had one current sexual partner and 39.2% (42/107) had more than 1 sexual partner. Most reported sex within 1 week (54.2%, n = 58/107) and 30.8% within a month (30.8%, n = 33/107). Sex was with a dating partner (86.0%, n = 92/107) and 63% used a condom during last sexual contact. Males were more likely than females to have one-night stand sexual partners (23.5% vs 7.1%; P = .0176), make weekly changes in partners (17.7% vs 5.4%; P = .0442) and used condoms with their partners (92.2% vs 53.6%; P < .0001) during last sexual contact. The majority reported alcohol use (69.0%, n = 89/129). Males were more likely than females to use alcohol on a weekly basis (21.4% vs 6.4%; P = .0380). About 55.9% had penetrative sex under the influence of substances. Clinical Translation: This study gives an insight to the sexual risk behaviors among young people which is crucial for HIV prevention interventions. Strength & Limitations: This was the first study investigating sexual behavior in youth during the COVID-19 pandemic. The main limitations of this study relate to the sample size and sampling strategy. As the sample was not representative of the population of young people in Soweto and South Africa, the results cannot be generalized. However, the findings have relevance for future research in HIV prevention for young people in other settings in South Africa. Conclusions: Interventions on promoting sexual health and reducing HIV risk behavior such as sex following alcohol consumption in young people are needed, especially during a pandemic such as COVID-19.Mulaudzi M, Kiguwa P, Zharima C, et al., Sexual Risk Behaviors Among Youth in Soweto, South Africa During the COVID-19 National Lockdown. Sex Med 2021;10:100487.

Background: Accurate self-report of sexual behavior assists in identifying potential HIV exposure in HIV prevention trials. Brief mobile phone assessments, completed daily or after sexual activity, can improve the validity and reliability of self-reported sexual behavior and allow for remote survey completion outside of the clinic setting. We conducted a qualitative study to better understand participants mobile phone use and to explore their perspectives on how to improve an existing mobile application-based sexual risk assessment.Methods: Sexually active, HIV seronegative men (n = 14) and women (n = 15) aged 18–39 years were recruited through an HIV counseling and testing clinic and community outreach in Soweto, South Africa. We conducted qualitative research through four age-stratified focus group discussions (FGDs) and analyzed a brief socio-demographics and mobile phone access questionnaire. All participants completed a sexual risk assessment before the FGD. Using a framework analytic approach, data were coded with Nvivo software.Results: All participants had access to mobile phones and internet, and 27 (93.1%) were able to download applications on their personal phones. Participants preferred mobile risk assessments to be offered in a choice of South African languages, using formal language (as opposed to emojis), with straight-forward wording and limited to five to 10 questions. Most participants found it acceptable to complete the assessment once a week, on a weekday, while a few were willing to complete it after each sexual encounter. It was suggested that a message reminder to complete the assessment should be sent at least daily until it is completed. The majority agreed that a password-protected application with a discreet logo was ideal for privacy, ease of use and flexibility for completion in any setting. A concern with this format, however, was the potential data use requirement. Participants expressed privacy concerns with using SMS, WhatsApp and other social media for risk assessments. Most agreed on an airtime incentive between ZAR5-10 (USD 0.29–0.58) per survey. Participants encouraged researchers to provide feedback to them about their sexual risk.Conclusions: Completion of mobile phone sexual risk assessments can be optimized with minimal incentives by ensuring that questionnaires are simple, brief, infrequent and have trusted privacy measures.

Background The ubiquity of cellular phone (cellphone) use in young people’s daily lives has emerged as a priority area of concern for youth mental health. Objective This study measured the prevalence of depression and its association with high cellphone use among youth in Soweto and Durban, South Africa. Methods We analysed cross-sectional, baseline survey data among youth aged 16–24 who participated in a dual-site cohort study, ‘AYAZAZI’, conducted from 2014 to 2017. The primary outcome was depression using the 10-item Center for Epidemiologic Studies Depression Scale, with a score of ≥ 10 indicating probable depression. Cellphone use was measured via self-reported average number of hours of active use, with ‘high cellphone use’ defined as daily usage of ≥ 8. Multivariable logistic regression models assessed the independent relationship between high cellphone use and probable depression, adjusting for potential confounders. Results Of 425 participants with a median age of 19 years (IQR = 18–21), 59.5% were young women. Overall, 43.3% had probable depression, with a higher prevalence among women (49.0% vs. 34.9%, P = .004). Nearly all (94.6%) owned a cellphone. About one-third (29.5%) reported spending ≥ 8 hours per day using their cellphone (39.3% of women vs. 14.9% of men, P

Abstract Background Adolescents in South Africa remain vulnerable to HIV. Therefore, it is crucial to provide accessible adolescent-friendly HIV prevention interventions that are sensitive to their needs. This study aimed to investigate the perceptions of HIV counsellors and other youth-serving professionals about the barriers to providing adolescent youth-friendly sexual and reproductive health services to adolescents in Soweto, South Africa. The study also explored how sexual and reproductive health services in South Africa could be improved to become more accessible to adolescents. Methods The research team conducted two focus group discussions with HIV counsellors, and 19 semi-structured interviews with youth-serving professionals from organisations working with adolescents. Audio-recorded data were transcribed verbatim and analysed using thematic analysis. Results The results of the study reveal that counsellors were expected to give adolescents HIV counselling and testing (HCT) but felt restricted by what they perceived as inflexible standard operating procedures. Counsellors reported inadequate training to address adolescent psychosocial issues during HCT. Healthcare provider attitudes were perceived as a barrier to adolescents using sexual and reproductive health services. Participants strongly recommended augmenting adolescent sexual and reproductive health services to include counsellors and adolescents in developing age- and context-specific HIV prevention services for adolescents. Conclusion Continuous upskilling of HIV counsellors is a critical step in providing adolescent-friendly services. Input from all relevant stakeholders, including counsellors and adolescents, is essential in designing adolescent-friendly services.