"It's Better If I Die Because Even in the Hospital, There is a Stigma, People Still Gossip": Gossip as a Culturally Shaped Labeling Process and Its Implications for HIV-Related Stigma in Botswana.

This study qualitatively explores HIV-related gossip as both a manifestation and driver of HIV-related stigma, which is a known barrier to HIV testing and treatment in Botswana. Data were elicited from 5 focus group discussions and 46 semi-structured in-depth interviews with individuals living with HIV and community members with undisclosed serostatus in Gaborone, Botswana in 2017 (n = 84). Directed content analysis using the 'What Matters Most' theoretical framework identified culturally salient manifestations of HIV-related stigma; simultaneous use of Modified Labeling Theory allowed interpretation and stepwise organization of how the social phenomenon of gossip leads to adverse HIV outcomes. Results indicated that HIV-related gossip can diminish community standing through culturally influenced mechanisms, in turn precipitating poor psychosocial well-being and worsened HIV-related outcomes. These harms may be offset by protective factors, such as appearing healthy, accepting one's HIV status, and community education about the harms of gossip.

Improvement studies for equitable and evidence-based innovation: an overview of the 'IM-SEEN' model.

BACKGROUND: Health inequalities are ubiquitous, and as countries seek to expand service coverage, they are at risk of exacerbating existing inequalities unless they adopt equity-focused approaches to service delivery. MAIN TEXT: Our team has developed an equity-focused continuous improvement model that reconciles prioritisation of disadvantaged groups with the expansion of service coverage. Our new approach is based on the foundations of routinely collecting sociodemographic data; identifying left-behind groups; engaging with these service users to elicit barriers and potential solutions; and then rigorously testing these solutions with pragmatic, embedded trials. This paper presents the rationale for the model, a holistic overview of how the different elements fit together, and potential applications. Future work will present findings as the model is operationalised in eye-health programmes in Botswana, India, Kenya, and Nepal. CONCLUSION: There is a real paucity of approaches for operationalising equity. By bringing a series of steps together that force programme managers to focus on groups that are being left behind, we present a model that can be used in any service delivery setting to build equity into routine practice.

The association of household food insecurity and HIV infection with common mental disorders among newly diagnosed tuberculosis patients in Botswana.

OBJECTIVE: To determine the association between food insecurity and HIV infection with depression and anxiety among new tuberculosis (TB) patients. DESIGN: Our cross-sectional study assessed depression, anxiety and food insecurity with Patient Health Questionnaire (PHQ-9), Zung Anxiety Self-Assessment Scale (ZUNG) and Household Food Insecurity Access Scale, respectively. Poisson regression models with robust variance were used to examine correlates of depression (PHQ-9 ≥ 10) and anxiety (ZUNG ≥ 36). SETTING: Gaborone, Botswana. PARTICIPANTS: Patients who were newly diagnosed with TB. RESULTS: Between January and December 2019, we enrolled 180 TB patients from primary health clinics in Botswana. Overall, 99 (55·0 %) were HIV positive, 47 (26·1 %), 85 (47·2 %) and 69 (38·5 %) indicated depression, anxiety and moderate to severe food insecurity, respectively. After adjusting for potential confounders, food insecurity was associated with a higher prevalence of depression (adjusted prevalence ratio (aPR) = 2·30; 95 % CI 1·40, 3·78) and anxiety (aPR = 1·41; 95 % CI 1·05, 1·91). Prevalence of depression and anxiety was similar between HIV-infected and HIV-uninfected participants. Estimates remained comparable when restricted to HIV-infected participants. CONCLUSIONS: Mental disorders may be affected by food insecurity among new TB patients, regardless of HIV status.

A pilot pragmatic trial of a "what matters most"-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana.

We conducted a pilot trial of an intervention targeting intersectional stigma related to being pregnant and living with HIV while promoting capabilities for achieving 'respected motherhood' ('what matters most') in Botswana. A pragmatic design allocated participants to the intervention (N = 44) group and the treatment-as-usual (N = 15) group. An intent-to-treat, difference-in-difference analysis found the intervention group had significant decreases in HIV stigma (d = - 1.20; 95% CI - 1.99, - 0.39) and depressive symptoms (d = - 1.96; 95% CI - 2.89, - 1.02) from baseline to 4-months postpartum. Some, albeit less pronounced, changes in intersectional stigma were observed, suggesting the importance of structural-level intervention components to reduce intersectional stigma.

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Objectives. To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. Methods. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Results. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Conclusions. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies.

Psychometric Validation of a Scale to Assess Culturally-Salient Aspects of HIV Stigma Among Women Living with HIV in Botswana: Engaging "What Matters Most" to Resist Stigma.

Perceived stigma deters engagement in HIV care and is powerfully shaped by culture. Yet few stigma measures consider how cultural capabilities that signify "full personhood" could be engaged to resist stigma. By applying a theory conceptualizing how culturally-salient mechanisms can worsen or mitigate HIV stigma in relation to "what matters most" (WMM), we developed the WMM Cultural Stigma Scale for Women Living with HIV in Botswana (WMM-WLHIV-BW) and psychometrically evaluated it among 201 respondents with known and unknown HIV status. The two subscales, Cultural Factors Shape Stigma (CFSS) and Cultural Capabilities Protect against Stigma (CCPS) were reliable (both [Formula: see text]). Among WLHIV, the CFSS Subscale showed initial construct validity with depressive symptoms (r = .39, p = .005), similar to an established HIV stigma scale, whereas the CCPS Subscale showed initial construct validity with self-esteem (r = .32, p = .026) and social support number (r = .29, p = .047), suggesting that achieving local cultural capabilities mitigates stigma and is linked with positive psychosocial outcomes. This culturally-derived scale could help WLHIV in Botswana experience improved stigma-related outcomes.

RESUMEN: El estigma percibido detetiza la participación en la atención de VIH y está fuertemente moldeado por la cultura. Sin embargo, pocas medidas de estigma consideran cómo las capacidades culturales que significan "personalidad plena" podrían ser utilizadas para resistir el estigma. Mediante la aplicación de una teoría que conceptualiza cómo los mecanismos culturalmente destacados pueden empeorar o mitigar el estigma del VIH en relación con "lo que más importa" (WMM), desarrollamos la Escala de Estigma Cultural WMM para mujeres que viven con VIH en Botswana (WMM-WLHIV-BW) y lo evaluamos psicométricamente entre 201 encuestados con estatus de VIH conocido y desconocido. Las dos subescalas, Factores Culturales dan Forma al Estigma (CFSS) y la protección de las Capacidades Culturales contra el Estigma (CCPS) eran fiables (ambos α = 0.90). Entre WLHIV, la subescala CFSS mostró la validez inicial de la construcción con síntomas depresivos (r = .39, p =.005), similar a una escala establecida de estigma del VIH, mientras que la subescala CCPS mostró la validez de la construcción inicial con autoestima (r = .32, p = .026) y el numero de apoyo social (r = .29, p = .047), lo que sugiere que lograr capacidades culturales locales mitiga el estigma y esta asociado con resultados psicosociales positivos. Esta escala culturalmente derivada podría ayudar a WLHIV en Bostwana a mejorar los resultados relacionados con el estigma.

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma.

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups (n = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.

Botswana's HIV response: Policies, context, and future directions.

This brief report describes key periods in the history of the national public health response to the human immunodeficiency virus (HIV) epidemic in Botswana. It reveals the context leading to the development of HIV policies presently in place and current challenges that remain. The report concludes with opportunities for future directions, initiatives, and policy changes to reduce the high rates of HIV.

"It's When the Trees Blossom": Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in Botswana.

Mental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring "when the trees blossom," underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.

HIV Prevalence Among Hospitalized Patients at the Main Psychiatric Referral Hospital in Botswana.

We examined HIV prevalence among patients 18-49 year olds admitted to a psychiatric hospital in Botswana in 2011 and 2012. The retrospective study analyzed females (F) and males (M) separately, comparing proportions with Chi square test and continuous variables with Wilcoxon rank-sum test, assessing significance at the 5% level. HIV seroprevalence among hospitalized psychiatric patients was much more common among females (53%) compared with males (19%) (p < 0.001). These women also appeared more vulnerable to infection compared with females in the general population (29%) (p < 0.017). Among both women and men, HIV-infection appeared most common among patients with organic mental disorders (F:68%, M:41%) and neurotic, stress related and somatoform disorders (F:68%, M:42%). The largest proportion of HIV infections co-occurred among patients diagnosed with schizophrenia, schizotypal and other psychotic disorders (F:48%; M:55%), mood (affective) disorders (F:21%; M:16%) and neurotic, stress-related and somatoform disorders (F:16%; M:20%). Interventions addressing both mental health and HIV among women and men require development.

Evaluation of a Mobile Health Approach to Tuberculosis Contact Tracing in Botswana.

Tuberculosis (TB) contact tracing is typically conducted in resource-limited settings with paper forms, but this approach may be limited by inefficiencies in data collection, storage, and retrieval and poor data quality. In Botswana, we developed, piloted, and evaluated a mobile health (mHealth) approach to TB contact tracing that replaced the paper form-based approach for a period of six months. For both approaches, we compared the time required to complete TB contact tracing and the quality of data collected. For the mHealth approach, we also administered the Computer System Usability Questionnaire to 2 health care workers who used the new approach, and we identified and addressed operational considerations for implementation. Compared to the paper form-based approach, the mHealth approach reduced the median time required to complete TB contact tracing and improved data quality. The mHealth approach also had favorable overall rating, system usefulness, information quality, and interface quality scores on the Computer System Usability Questionnaire. Overall, the mHealth approach to TB contact tracing improved on the paper form-based approach used in Botswana. This new approach may similarly benefit TB contact tracing efforts in other resource-limited settings.

Yield of screening for TB and HIV among children failing to thrive in Botswana.

BACKGROUND: Failure to thrive (FTT) is a sign of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. We assessed TB and HIV prevalence in children with FTT at one clinic in Botswana. METHODS: In July 2010, we screened all children attending a 'Well Child' clinic for FTT. Children with FTT were referred to a paediatrician who: (i) assessed causes of FTT, (ii) evaluated for HIV and TB and (iii) reviewed the patient chart for evaluations for TB and HIV. RESULTS: Of 919 children screened, 176 (19%) had FTT. One hundred eighteen (67%) children saw a paediatrician, and of these, 95 (81%) completed the TB evaluation. TB was newly diagnosed in 6 of 95 (6%). At review, HIV status was known in 23 of 118 (19%). Ninety-five had an unknown HIV status. Forty-five (47%) tested for HIV; all tested HIV-negative. CONCLUSION: TB and HIV screening among children with FTT diagnosed TB in 6% of cases completing an evaluation, but no new HIV infections.

Implementation Planning for Integrating Depression Screening in Diabetes Mellitus and HIV Clinics in Botswana.

Depression is highly prevalent and, when comorbid with other medical conditions, can worsen health outcomes. Implementing routine depression screening within medical clinics can ensure that patients receive suitable treatment and improve overall health outcomes. Unfortunately, depression screening within medical settings is rare, particularly in low- and middle-income countries. This qualitative study evaluated patient and clinician perspectives on implementing depression screening within HIV and diabetes clinics in Botswana. Seven clinicians and 23 patients within these clinics were purposively selected and interviewed using a guide informed by the Consolidated Framework for Implementation Research (CFIR) to understand barriers and facilitators to depression screening in medical clinics in Botswana. Interviews were recorded, transcribed, and analyzed using NVivo. Three general themes emerged: (1) Appropriateness and Acceptability: attitudes and beliefs from clinicians and patients about whether depression screening should occur in this setting; (2) Stigma as an important barrier: the need to address the negative associations with depression to facilitate screening; and (3) Recommendations to facilitate screening including improving knowledge and awareness about depression, offering incentives to complete the screening, providing staff training, ensuring resources for treatment, the need to preserve confidentiality, and utilizing leadership endorsement. These results offer insights into how to implement depression screening within medical clinics in Botswana. These results can help design implementation strategies to increase depression screening in these clinics, which can be tested in future studies. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-022-00062-3.

Protocol for an automated, pragmatic, embedded, adaptive randomised controlled trial: behavioural economics-informed mobile phone-based reminder messages to improve clinic attendance in a Botswanan school-based vision screening programme.

BACKGROUND: Clinic non-attendance rates are high across the African continent. Emerging evidence suggests that phone-based reminder messages could make a small but important contribution to reducing non-attendance. We will use behavioural economics principles to develop an SMS and voice reminder message to improve attendance rates in a school-based eye screening programme in Botswana. METHODS: We will test a new theory-informed SMS and voice reminder message in a national school-based eye screening programme in Botswana. The control will be the standard SMS message used to remind parents/guardians to bring their child for ophthalmic assessment. All messages will be sent twice. The primary outcome is attendance for ophthalmic assessment. We will use an automated adaptive approach, starting with a 1:1 allocation ratio. DISCUSSION: As far as we are aware, only one other study has used behavioural economics to inform the development of reminder messages to be deployed in an African healthcare setting. Our study will use an adaptive trial design, embedded in a national screening programme. Our approach can be used to trial other forms of reminder message in the future. TRIAL REGISTRATION: ISRCTN 96528723 . Registered on 5 January 2022.

Theory-Driven, Multi-Stage Process to Develop a Culturally-Informed Anti-Stigma Intervention for Pregnant Women Living with HIV in Botswana.

Background and Objectives: Despite a well-established universal HIV diagnosis and treatment program, Botswana continues to face a high HIV prevalence, in large part due to persistent stigma, which particularly affects pregnant women and interferes with healthcare engagement. Tackling stigma as a fundamental cause of HIV disparities is an important but understudied aspect of current HIV interventions. Our multinational and multicultural team used a theory-driven, multi-stage iterative process to develop measures and interventions to first identify and then target the most culturally-salient aspects of stigma for mothers living with HIV in Botswana. This methodology report examines the stage-by-stage application of the "What Matters Most" (WMM) theory and lessons learned, sharing a replicable template for developing culturally-shaped anti-stigma interventions. Methods: First, we conducted initial qualitative work based on the WMM theory to identify key structural and cultural factors shaping stigma for women living with HIV in Botswana. Second, we developed a psychometrically validated scale measuring how "what matters most" contributes to and protects against stigma for this population. Third, we designed an anti-stigma intervention, "Mothers Moving towards Empowerment" (MME), centered on the local values identified using WMM theory that underly empowerment and motherhood by adapting a cognitive behavioral therapy (CBT)-informed, group-based, and peer-co-led anti-stigma intervention specifically for pregnant women living with HIV. Fourth, we conducted a pilot study of MME in which participants were allocated to two trial arms: intervention or treatment-as-usual control. Results: Our qualitative research identified that bearing and caring for children are capabilities essential to the concept of respected womanhood, which can be threatened by a real or perceived HIV diagnosis. These values informed the development and validation of a scale to measure these culturally-salient aspects of stigma for women living with HIV in Botswana. These findings further informed our intervention adaptation and pilot evaluation, in which the intervention group showed significant decreases in HIV stigma and depressive symptoms compared to the control group. Participants reported overcoming reluctance to disclose their HIV status to family, leading to improved social support. Conclusion and Global Health Implications: Previous studies have not utilized culturally-based approaches to assess, resist, and intervene with HIV-related stigma. By applying WMM in each stage, we identified cultural and gendered differences that enabled participants to resist HIV stigma. Focusing on these capabilities that enable full personhood, we developed an effective culturally-tailored anti-stigma intervention for pregnant women living with HIV in Botswana. This theory-driven, multi-stage approach can be replicated to achieve stigma reduction for other outcomes, populations, and contexts.

Sociodemographic characteristics of community eye screening participants: protocol for cross-sectional equity analyses in Botswana, India, Kenya, and Nepal.

Background: Attendance rates for eye clinics are low across low- and middle-income countries (LMICs) and exhibit marked sociodemographic inequalities. We aimed to quantify the association between a range of sociodemographic domains and attendance rates from vision screening in programmes launching in Botswana, India, Kenya and Nepal. Methods: We performed a literature review of international guidance on sociodemographic data collection. Once we had identified 13 core candidate domains (age, gender, place of residence, language, ethnicity/tribe/caste, religion, marital status, parent/guardian status, place of birth, education, occupation, income, wealth) we held workshops with researchers, academics, programme implementers, and programme designers in each country to tailor the domains and response options to the national context, basing our survey development on the USAID Demographic and Health Survey model questionnaire and the RAAB7 eye health survey methodology. The draft surveys were reviewed by health economists and piloted with laypeople before being finalised, translated, and back-translated for use in Botswana, Kenya, India, and Nepal. These surveys will be used to assess the distribution of eye disease among different sociodemographic groups, and to track attendance rates between groups in four major eye screening programmes. We gather data from 3,850 people in each country and use logistic regression to identify the groups that experience the worst access to community-based eye care services in each setting. We will use a secure, password protected android-based app to gather sociodemographic information. These data will be stored using state-of-the art security measures, complying with each country's data management legislation and UK law. Discussion: This low-risk, embedded, pragmatic, observational data collection will enable eye screening programme managers to accurately identify which sociodemographic groups are facing the highest systematic barriers to accessing care at any point in time. This information will be used to inform the development of service improvements to improve equity.

Depression and delayed tuberculosis treatment initiation among newly diagnosed patients in Botswana.

Comorbidity of tuberculosis (TB) and depression may lead to delayed TB treatment initiation. A cross-sectional study was conducted between January and December 2019 to examine the association between depression and delayed TB treatment initiation among newly diagnosed TB patients in Botswana. We used the Patient Health Questionnaire-9 and the ZUNG self-rating anxiety scale to assess depressive and anxiety symptoms, respectively. Delayed TB treatment was defined as experiencing common TB symptoms for more than 2 months before treatment initiation. We used Poisson regression models with robust variance to assess the association between covariates and delayed treatment initiation. Majority of the enrolled 180 study participants were males (n =116, 64.4%). Overall, 99 (55%) were co-infected with HIV; depression and anxiety symptoms were reported by 47.2% and 38.5% of the participants respectively. The prevalence of delayed TB treatment was 42.6% and 18.8% among participants who indicated symptoms of depression and among participants without depression respectively. After adjusting for age, HIV status, gender and anxiety symptoms, depression was still associated with delayed TB treatment (adjusted prevalence ratio [aPR] = 2.09; 95% CI = 1.23-3.57). Integrating management of depressive symptoms during TB treatment may help in improving overall TB treatment outcomes.

What happened to multiple sexual partnerships in Swaziland? Analysis of five linked national surveys between 2002 and 2008.

Multiple sexual partnerships are a driver of the HIV epidemic in southern Africa. Five linked cluster surveys in 2002, 2005, 2006, 2007 and 2008 allowed us to measure changes in rates of multiple partnerships in these clusters in Swaziland. We selected a stratified random sample of census enumeration areas in 2002 and survey teams subsequently revisited this same sample (a random sub-sample in 2005 and 2006). For this study, analysis includes only people aged 18-29 years interviewed in communities included in all five surveys (1862 men and 2701 women). Among men, there was a significant fall in the proportion having multiple partners in the last 12 months (MP12), among those that had any, between 2002 (61%) and 2007 (46%), followed by a slight rise in 2008 (49%). For multiple partnerships in the last six months (MP6 - measured in 2005 and 2006), there was a decrease between 2005 (43%) and 2006 (25%). There was a significant decrease in multiple partnerships in the last month (MP1) between 2005 (35%) and 2006 (16%), followed by an increase in 2007 (24%) and 2008 (25%). Among women, there was a significant decrease in MP12 between 2002 (22%) and 2007 (9%), then a significant increase in 2008 (15%). There was little difference in women's MP6 between 2005 (7%) and 2006 (6%). There was also little change in women's MP1 between 2005 (5%) and 2006 (3%), with an increase from 2007 (3%) to 2008 (6%); the 2006-2008 difference was significant. A 2006 campaign to reduce multiple partnerships may have changed behaviour among men or it may have made them less likely to admit to multiple partners. The recent increase in MP12 and MP1, especially among women, may reflect behaviour or it could reflect increased willingness to report.

Gender-specific patterns of multiple concurrent sexual partnerships: a national cross sectional survey in Botswana.

A priority of AIDS prevention in Botswana is to reduce multiple concurrent sexual partnerships. We analysed data from interviews with people aged 16-60 years in a 2007 national stratified random cluster sample of communities across Botswana. Among 768 male and 1784 female respondents, 10% reported multiple sexual partners in the month prior to the survey (MP1); 19% of men and 6% of women. In a multivariate analysis, men were more likely to report MP1 if they had not completed primary education (adjusted Odds Ratio (ORa) 2.13, 95% confidence intervals with adjustment for clustering (CIca) 1.19-3.85), if they were single (ORa 2.29, 95% CIca 1.28-4.11), if they had experienced intimate partner violence in the last year (ORa 2.59, 95% CIca 1.51-4.45) and if they reported acquiescence to high risk sex (ORa 8.32, 95% CIca 3.38-20.46). Women who said they earned more or the same as their partner were also more likely to report MP1 (ORa 1.76, 95% CIca 1.21-2.56). The higher rate of MP1 among men with different forms of choice-disability shows an important potential multiplication of male risk factors. Women with higher income were more likely to have more partners, questioning the idea that multiple concurrent partners is mainly a question of male disposable income.

Community views of inter-generational sex: findings from focus groups in Botswana, Namibia and Swaziland.

Inter-generational sex is an important driver of the AIDS epidemic in Southern Africa, contributing to the high incidence of HIV among young women. We conducted 12 focus group discussions with women aged 15-24 years and 11 with men aged 40-55 years in urban and rural locations in Botswana, Namibia and Swaziland. There was consensus that inter-generational sex is commonplace. The young women were clear they had sex with older men to get money and material goods. In urban sites, they spoke about requirements for a "modern" lifestyle and to keep up with their friends, but in rural sites they also said they needed money for school fees, food and household goods. Young women used disparaging names for the older men and they were well aware of the risk of HIV from inter-generational sex. They believed older men were more risky than younger men: They were more likely to be infected and it was harder to negotiate use of a condom with them. They were willing to take the risk to get what they wanted; some also had a fatalistic attitude. Older men described sexual motivation and blamed young women for seducing them. They believed there was a higher risk of HIV from younger women, because they have more partners and do not insist on using a condom. But this did not deter them from taking the risk. Older men and young women discount the risks of inter-generational sex against short-term benefits. Isolated efforts to increase risk awareness are unlikely to be effective. Making older men aware they are ridiculed by young women may be a promising approach, combined with interventions that give alternatives to young women and increase their self-worth.