Sex work and young women: a cross sectional study to understand the overlap of age and sex work as a central tenet to epidemic control in South Africa.

Adolescent girls and young women (AGYW) engaging in sex-for-money transactions are at risk of HIV infection. A better understanding of the demographic, socio-economic factors and risks of HIV acquisition is required to guide appropriate public health interventions targeting young sex workers in South Africa. A cross-sectional survey of Female Sex Workers (FSWs), using a chain referral sampling method, was conducted across 12 sites in South Africa in 2019. Three thousand and five participants were enrolled and interviewed assessing demographic characteristics, sexual behaviour, substance use and HIV testing and treatment. Of 3005 women, 13.3% were ≤24 years old (young FSWs); of these, 60.0% entered sex work aged ≤19 years. Economic factors were the primary drivers of entry into sex work. HIV prevalence amongst young FSWs was 40.4%, with 12.4% recently infected. Younger FSWs were significantly less likely to know they were HIV positive (87.6% versus 92.1%), to report any ART exposure (75.2% versus 87.6%) and to be virally suppressed (58.1% versus 75.2%) compared to older FSWs. Our findings highlight that many FSWs enter sex work at a young age. It is essential to develop tailored services and interventions that improve access to HIV prevention and treatment services addressing specific needs.

Factors to Consider During Identification and Invitation of Individuals in a Multi-stakeholder Research Partnership.

BACKGROUND: Health research teams increasingly partner with stakeholders to produce research that is relevant, accessible, and widely used. Previous work has covered stakeholder group identification. OBJECTIVE: We aimed to develop factors for health research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership, with the aim of forming equitable and informed teams. DESIGN: Consensus development. PARTICIPANTS: We involved 16 stakeholders from the international Multi-Stakeholder Engagement (MuSE) Consortium, including patients and the public, providers, payers of health services/purchasers, policy makers, programme managers, peer review editors, and principal investigators. APPROACH: We engaged stakeholders in factor development and as co-authors of this manuscript. Using a modified Delphi approach, we gathered stakeholder views concerning a preliminary list of 18 factors. Over two feedback rounds, using qualitative and quantitative analysis, we concentrated these into ten factors. KEY RESULTS: We present seven highly desirable factors: 'expertise or experience', 'ability and willingness to represent the stakeholder group', 'inclusivity (equity, diversity and intersectionality)', 'communication skills', 'commitment and time capacity', 'financial and non-financial relationships and activities, and conflict of interest', 'training support and funding needs'. Additionally, three factors are desirable: 'influence', 'research relevant values', 'previous stakeholder engagement'. CONCLUSIONS: We present factors for research teams to consider during identification and invitation of individual representatives in a multi-stakeholder research partnership. Policy makers and guideline developers may benefit from considering the factors in stakeholder identification and invitation. Research funders may consider stipulating consideration of the factors in funding applications. We outline how these factors can be implemented and exemplify how their use has the potential to improve the quality and relevancy of health research.

Factors influencing adolescent girls and young women's participation in a combination HIV prevention intervention in South Africa.

BACKGROUND: For interventions to reach those they are intended for, an understanding of the factors that influence their participation, as well as the facilitators and barriers of participation are needed. This study explores factors associated with participation in a combination HIV prevention intervention targeting adolescent girls and young women (AGYW) aged 15-24-years-old, as well as the perspectives of AGYW, intervention implementers, and facilitators who participated in this intervention. METHODS: This study used mixed-methods approach with quantitative household survey data from 4399 AGYW aged 15-24-years-old in six of the ten districts in which the intervention was implemented. In addition, qualitative methods included a total of 100 semi-structured in-depth interviews and 21 focus group discussions in five of the ten intervention districts with 185 AGYW who participated in one or more of the key components of the intervention, and 13 intervention implementers and 13 facilitators. Thematic analysis was used to explore the perspectives of participating and implementing the intervention. RESULTS: Findings reveal that almost half of AGYW (48.4%) living in the districts where the intervention took place, participated in at least one of the components of the intervention. For both 15-19-year-olds and 20-24-year-olds, factors associated with increased participation in the intervention included being HIV negative, in school, never been pregnant, and having had a boyfriend. Experiencing intimate partner violence (IPV) and/or sexual violence in the past 12 months was associated with increased levels of participation in the intervention for 20-24-year-olds only. In our analysis of the qualitative data, facilitators to participation included motivating participants to join the interventions through explaining the benefits of the programme. Barriers included misguided expectations about financial rewards or job opportunities; competing responsibilities, interests or activities; family responsibilities including childcare; inappropriate incentives; inability to disrupt the school curriculum and difficulties with conducting interventions after school hours due to safety concerns; miscommunication about meetings; as well as struggles to reach out-of-school AGYW. CONCLUSION: Designers of combination HIV prevention interventions need to address the barriers to participation so that AGYW can attend without risking their safety and compromising their family, childcare and schooling responsibilities. Strategies to create demand need to include clear communication about the nature and potential benefits of such interventions, and the inclusion of valued incentives.

Perceptions of contraception services among recipients of a combination HIV-prevention interventions for adolescent girls and young women in South Africa: a qualitative study.

BACKGROUND: Adolescent girls and young women (AGYW) in low- and middle- income countries (LMICs) have high rates of unintended pregnancies and are at higher risk for HIV infection compared to older women of reproductive age. Using a socio-ecological model approach, this research investigated perceptions of contraception services among AGYW who had been recipients of a combination HIV-prevention intervention, to better understand factors affecting their access to and use of contraception services. METHOD: Qualitative methods used in this study included focus group discussions (FGDs) and in-depth interviews (IDIs) with 185 AGYW aged 15-24 years living in five of the ten intervention districts. All interviews and FGDs were audio-recorded and data were analyzed thematically using Nvivo 12 software with manual identification of themes and labelling of raw data. RESULTS: The findings reveal that many AGYW, especially those in the younger age group 15-19 years, experience difficulties in accessing contraception services, mainly at the interpersonal and health service levels. Lack of support for the use of contraceptives from parents/caregivers as well as from sexual partners were key barriers at the interpersonal level; while providers' negative attitude was the main barrier at the health service level. The majority of school-going AGYW felt that bringing contraception services and other sexual and reproductive health (SRH) services on to the school premises would legitimize their use in the eyes of parents and help to overcome barriers related to parental support and acceptance, as well as overcome some of the health service and structural level barriers. However, views among school-going AGYW about school-based provision of contraception services were mixed, clouded with concerns relating to confidentiality. CONCLUSION: Interventions to improve parental/caregiver and sexual partner support for the use of contraception services by AGYW, as well as efforts to expand the provision of contraception services on the school premises are urgently needed. Future interventions should incorporate multi-level approaches to address structural and contextual barriers to access and use of contraception services to gain maximum effect.

Feasibility of Provision and Vaccine Hesitancy at a Central Hospital COVID-19 Vaccination Site in South Africa after Four Waves of the Pandemic.

BACKGROUND: As mortality declined significantly during the fourth and fifth waves compared to previous waves, the question of the future role of COVID-19 vaccination arose among both experts and the public in South Africa. Turning attention away from the general public, now considered to be at very low risk of severe COVID-19 disease, a commonly held view was that the vaccination campaign should focus only on those who remain highly vulnerable to severe disease and death from COVID-19. Primary amongst this group are patients with common chronic diseases attending hospital outpatient departments. We hypothesized that providing COVID-19 vaccinations on-site at a central hospital will increase uptake for the patients with co-morbid chronic conditions who need them most in the Omicron phase of the pandemic. AIM: Evaluate the acceptability, need, and uptake of a hospital-based vaccination site for patients attending the medical hospital outpatient departments. OBJECTIVES: To assess vaccination uptake, coverage, and hesitancy in people attending a central hospital, to determine factors associated with and influencing vaccination uptake, and to document implementation and assess acceptability of the vaccination project among staff and persons attending the hospital. METHODS: Mixed-methods study using quantitative and qualitative methods. RESULTS: Of the 317 participants enrolled in the study, 229 (72%) had already received at least one dose of the COVID-19 vaccine. A total of 296 participants were eligible for a first vaccination, additional vaccination, or booster vaccination according to the South African Department of Health guidelines. Of those previously vaccinated, 65% opted for an additional dose on the day it was offered (same day). Only 13 previously unvaccinated participants (15% of vaccine naïve participants) opted for vaccination, increasing vaccine coverage with at least one dose from 72% to 76%. Approximately 24% (n = 75) of all participants refused vaccination (vaccine hesitant). Variables tested for an association with vaccination status demonstrated that age reached statistical significance. Emerging themes in the qualitative analysis included perceptions of vulnerability, vaccine safety and efficacy concerns, information gaps regarding vaccinations, the value of convenience in the decision to vaccinate, and the role of health promoters. CONCLUSIONS: This study has shown that it is logistically acceptable to provide a vaccination site at a large hospital targeting patients attending outpatient services for chronic medical conditions. This service also benefits accompanying persons and hospital staff. Access and convenience of the vaccination site influence decision-making, increasing the opportunity to vaccinate. However, vaccine hesitancy is widespread with just under one-quarter of all those offered vaccinations remaining unvaccinated. Strengthening health education and patient-clinician engagement about the benefits of vaccination is essential to reach highly vulnerable populations routinely attending hospital outpatient departments with an appropriate vaccination program.

Factors Associated with COVID-19 Vaccine Uptake among Schoolgoing Adolescent Girls and Young Women in South Africa.

(1) Background: By October 2022, vaccination rates with at least one dose of a COVID-19 vaccine were low among adolescent girls aged 12-17 (38%) and young women aged 18-34 (45%) in South Africa. This study aimed to measure and identify barriers to and facilitators of motivation to take up, access to, and uptake of COVID-19 vaccines among schoolgoing adolescent girls and young women in two districts in South Africa. (2) Methods: Using the theory of the HIV prevention cascade, we conceptualised the relationship between motivation, access, and uptake of COVID-19 vaccines, and associated barriers. Potential barriers and facilitators were identified using bivariate and multivariable Poisson regression. (3) Results: Among all 2375 participants, access was high (69%), but motivation (49%) and vaccination with at least one COVID-19 vaccine (45%) were lower. Fear of injections was a barrier to vaccine uptake (aRR 0.85 95% CI 0.82-0.88), while being tested for COVID-19 (aRR 2.10 95% CI 1.85-2.38) and believing that the COVID-19 vaccine was safe (aRR 1.31 95% CI 1.18-1.44) and would prevent you from getting very sick (aRR 1.11 95% CI 1.04-1.19) were facilitators. (4) Conclusions: The controversy about the value of vaccinating adolescents and the delay in vaccine rollout for adolescents and young adults may have contributed to fears about the safety and efficacy of COVID-19 vaccines, as well as a lack of motivation to get vaccinated.

Key issues for stakeholder engagement in the development of health and healthcare guidelines.

Established in 2015, the Multi-Stakeholder Engagement (MuSE) Consortium is an international network of over 120 individuals interested in stakeholder engagement in research and guidelines. The MuSE group is developing guidance for stakeholder engagement in the development of health and healthcare guideline development. The development of this guidance has included multiple meetings with stakeholders, including patients, payers/purchasers of health services, peer review editors, policymakers, program managers, providers, principal investigators, product makers, the public, and purchasers of health services and has identified a number of key issues. These include: (1) Definitions, roles, and settings (2) Stakeholder identification and selection (3) Levels of engagement, (4) Evaluation of engagement, (5) Documentation and transparency, and (6) Conflict of interest management. In this paper, we discuss these issues and our plan to develop guidance to facilitate stakeholder engagement in all stages of the development of health and healthcare guideline development.

A group of international researchers, patient partners, and other stakeholders are working together to create a checklist for when and how to involve stakeholders in health guideline development. Health guidelines include clinical practice guidelines, which your healthcare provider uses to determine treatments for health conditions. While working on this checklist, the team identified key issues to work on, including: (1) Definitions, roles, and settings (2) Stakeholder identification and selection (3) Levels of engagement, (4) Evaluation of engagement, (5) Documentation and transparency, and (6) Conflict of interest management. This paper describes each issue and how the team plans to produce guidance papers to address them.

Predictors of Resilience Among Adolescent Girls and Young Women Who Have Experienced Intimate Partner Violence and Sexual Violence in South Africa.

South Africa has some of the highest rates of intimate partner and sexual violence globally, with prevalence ranging from 10% to 21% among adolescent girls and young women (AGYW). Yet, few studies characterize the relationship between violence and resilience. Identifying factors associated with resilience following exposure to violence can guide the development of strength-based interventions that change modifiable protective factors to bolster resilience. Data were derived from a cross-sectional survey of AGYW aged 15 to 24 years in South Africa that took place from 2017 to 2018. This survey was part of a national evaluation of a South African combination HIV intervention for AGYW funded by the Global Fund to Fight AIDS, TB, and Malaria. A sample of 4,399 observations was achieved through a systematic random sampling frame of 35% of households in districts where AGYW were at highest risk for HIV, and where the intervention was implemented. Resilience was assessed using the Connor-Davidson Resilience Scale. Intimate partner and sexual violence were assessed using: (a) an adapted version of a questionnaire from the World Health Organization's 2005 multicountry study on domestic violence against women, and (b) questions on lifetime experience of forced sex/rape. Nearly a third of AGYW (29.6%) reported intimate partner emotional and/or physical and/or sexual violence in the past year. Nearly a quarter of AGYW (23.74%) reported emotional violence, 17.48% reported physical violence, and 6.37% reported sexual violence from intimate partners. Nearly 8% (7.72%) reported forced sex/rape from intimate partners and/or nonpartners. More equitable gender norms, higher social support, and hazardous drinking were positively associated with higher resilience among those who experienced physical or sexual violence. This study addresses a gap in the resilience and violence literature. Future research should focus on the development of resilience-promoting interventions for individuals who have experienced violence.

An Emerging Substance Use Epidemic: Recreational Use of HIV Pre-Exposure Prophylaxis and Treatment in South Africa.

South Africa has the largest HIV burden and treatment program in the world. Diversion of HIV prevention and treatment medication for recreational use-or nonmedical use for psychoactive effects-is a public health concern globally and in South Africa. Few South African studies examine recreational use of HIV antiretrovirals (ARVs). The objective of this article is to evaluate the prevalence of recreational ARV use and to identify risk and protective factors associated with use. Data are drawn from a cross-sectional household survey of N = 4399 adolescent girls and young women (AGYW) aged 15-24 years in six districts across South Africa where an evaluation of a South African combination HIV prevention for girls and young women was implemented. The use of ARVs to "get high" was reported by 8.3% of AGYW across all districts. Logistic regressions showed that those engaging in transactional sex were at two times higher odds of recreational ARV use [adjusted odds ratio (aOR) = 2.01; confidence interval (95% CI): 1.51-2.68]. Recreational ARV use was more likely among those who used pre-exposure prophylaxis (PrEP) (aOR = 2.17; 95% CI: 1.36-3.48); HIV-positive participants who were not on ARVs for treatment (aOR = 0.36; 95% CI: 0.18-0.68); and those who were not virally suppressed (aOR, no vs. yes = 2.84; 95% CI: 1.21-6.66). As ARVs become more widely available for prevention and treatment, it will be important to monitor and address the possible emergence of ARVs as a substance for misuse or abuse.

Community-led cross-sectional study of social and employment circumstances, HIV and associated factors amongst female sex workers in South Africa: study protocol.

BACKGROUND: In South Africa, female sex workers (FSWs) are perceived to play a pivotal role in the country's HIV epidemic. Understanding their health status and risk factors for adverse health outcomes is foundational for developing evidence-based health care for this population. OBJECTIVE: Describe the methodology used to successfully implement a community-led study of social and employment circumstances, HIV and associated factors amongst FSWs in South Africa. METHOD: A community-centric, cross-sectional, survey of 3,005 adult FSWs was conducted (January-July 2019) on 12 Sex Work (SW) programme sites across nine provinces of South Africa. Sites had existing SW networks and support programmes providing peer education and HIV services. FSWs were involved in the study design, questionnaire development, and data collection. Questions included: demographic, sexual behaviour, HIV testing and treatment/PrEP history, and violence exposure. HIV rapid testing, viral load, CD4 count, HIV recency, and HIV drug resistance genotypic testing were undertaken. Partner organisations provided follow-up services. RESULTS: HIV Prevalence was 61.96%, the median length of selling sex was 6 years, and inconsistent condom use was reported by 81.6% of participants, 88.4% reported childhood trauma, 46.2% reported physical or sexual abuse by an intimate partner and 57.4% by a client. More than half of participants had depression and post-traumatic stress disorder (52.7% and 54.1%, respectively). CONCLUSION: This is the first national survey of HIV prevalence amongst FSWs in programmes in South Africa. The data highlight the vulnerability of this population to HIV, violence and mental ill health, suggesting the need for urgent law reform. Based on the unique methodology and the successful implementation alongside study partners, the outcomes will inform tailored interventions. Our rapid rate of enrolment, low rate of screening failure and low proportion of missing data showed the feasibility and importance of community-centric research with marginalised, highly vulnerable populations.