Using a cascade approach to assess condom uptake in female sex workers in India: a review of the Avahan data.

BACKGROUND: The Avahan India AIDS Initiative was implemented to provide HIV prevention services to key populations including female sex workers (FSWs) who carry the burden of India's concentrated HIV epidemic. Established in 2003 and handed over to the Indian government in 2009, the Initiative included peer-led outreach education, condom promotion and distribution and STI treatment. This study aimed to determine if HIV prevention cascades could be generated using routine monitoring and evaluation data from the Avahan program and to assess their value in identifying and responding to program gaps for FSWs. METHODS: Two data sources were used namely the Integrated Behavioural and Biological Assessment reports and the Centralized Management Information System dataset. Indicators selected for the cascades were: FSWs at risk, belief that HIV can be prevented, condom access and consistent condom use with an occasional partner. Six districts were selected and stratified by HIV prevalence at baseline and two cascades were generated per district reflecting changes over time. RESULTS: Consistent condom use with occasional partners in this population increased in all six districts during program implementation, with statistically significant increases in four of the six. No patterns in the cascades were detected according to HIV prevalence either at baseline (2005) or at follow-up (2009). Cascades were able to identify key programmatic bottlenecks at baseline that could assist with focusing program efforts and direct resources at district levels. In some districts the belief that HIV could not be prevented contributed to inconsistent condom use, while in others, low levels of condom access were a more important barrier to consistent condom use. CONCLUSION: This HIV prevention cascade analysis among FSWs in India suggests that cascades could assist in identifying program gaps, focus intervention efforts and monitor their effect. However, cascades cannot replace a detailed understanding of the multiple factors at individual, community and structural levels that lead to consistent condom use in this key population. Careful indicator selection coupled with innovative data collection methods will be required. Pilot projects are proposed to formally evaluate the value of HIV prevention cascades at district level.

Extracurricular School-Based Social Change Communication Program Associated with Reduced HIV Infection Among Young Women in South Africa.

BACKGROUND: Young women in South Africa are at high risk for HIV, particularly after they leave school. There are few studies examining the long-term impact of school-based public health interventions aimed at protecting young women from HIV. We undertook a long-term evaluation of an extracurricular, school-based HIV prevention program, that leveraged off a mass media television series in South Africa. METHODS: We recruited 403 women aged 18-28 years. One hundred and seventy were members of Soul Buddyz Clubs (SBCs) between 2004 and 2008 and 233 were matched controls from the same communities as the ex-Buddyz. Face-to-face interviews were conducted and HIV testing undertaken. Analysis was restricted to 320 women who had ever had sex (136 ex-Buddyz and 184 controls). Multivariate analysis in Stata v14 was conducted. FINDINGS: 16.4% of women tested HIV positive. Ex-Buddyz were more likely to be HIV negative than controls (AOR 2.92, 95% CI 1.26-6.77, p = 0.013). Ex-Buddyz were more likely to have only had one sexual partner in the past year (AOR 2.14, 95% CI 1.17-3.89, p = 0.013) and 1.7 times more likely to have used a condom at first sex (95% CI 0.99-2.92, p = 0.053). INTERPRETATION: Participation in an SBC is associated with a decrease in young women's HIV risk and suggests an impact on some key risky sexual behaviors. School-based prevention programs that leverage off of other media platforms demonstrate a positive outcome on health status.

The HIV prevention cascade: integrating theories of epidemiological, behavioural, and social science into programme design and monitoring.

Theories of epidemiology, health behaviour, and social science have changed the understanding of HIV prevention in the past three decades. The HIV prevention cascade is emerging as a new approach to guide the design and monitoring of HIV prevention programmes in a way that integrates these multiple perspectives. This approach recognises that translating the efficacy of direct mechanisms that mediate HIV prevention (including prevention products, procedures, and risk-reduction behaviours) into population-level effects requires interventions that increase coverage. An HIV prevention cascade approach suggests that high coverage can be achieved by targeting three key components: demand-side interventions that improve risk perception and awareness and acceptability of prevention approaches; supply-side interventions that make prevention products and procedures more accessible and available; and adherence interventions that support ongoing adoption of prevention behaviours, including those that do and do not involve prevention products. Programmes need to develop delivery platforms that ensure these interventions reach target populations, to shape the policy environment so that it facilitates implementation at scale with high quality and intensity, and to monitor the programme with indicators along the cascade.

Alcohol Use and Transactional Sex among Women in South Africa: Results from a Nationally Representative Survey.

BACKGROUND: Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa. METHODS: A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16-55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex. RESULTS: About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1-4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5-6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex. CONCLUSION: Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.

Variations of Sexual Scripts Relating to Concurrency by Race, Class, and Gender in South Africa.

It is unclear whether higher rates of sexual partner concurrency in Black South Africans are due to socioeconomic or cultural factors. We used a nationally representative sample of 9,728 individuals aged 16 to 55 from a study conducted in 2009 to examine how the norms pertaining to concurrency and the practice of concurrency vary by race, class, and gender. The percentage of men reporting point concurrency was 14%, 6.5%, and 2.5% in Blacks, coloreds, and Whites, respectively (p < 0.001). These percentages increased to 45.7%, 24.7%, and 11.7%, respectively, for those reporting lifetime concurrency (p < 0.001). In all the racial groups, men exhibited more favorable attitudes toward concurrency than women did. For a range of indicators, White men and women had less favorable attitudes toward concurrency than Black men and women. These differences remained after controlling for a range of confounding variables. In the adjusted logistic regression model, reported concurrency in men was associated with a younger age, Black race, being in the lowest income tertile, not being in a stable relationship, and expressing various positive attitudes toward concurrency.

Tolerance and safety of different concentrations of chlorhexidine for peripartum vaginal and infant washes: HIVNET 025.

BACKGROUND: There is a continuing need to evaluate sustainable interventions for prevention of mother-to-child transmission (MTCT) of HIV type 1. We evaluated different concentrations (0.25%, 1%, and 2%) of chlorhexidine (CHX) for perinatal maternal and infant washes to identify the maximum tolerable concentration of CHX for such an intervention. METHODS: Women were enrolled during their third trimester at the maternity unit of the Chris Hani Baragwanath Hospital in Soweto, South Africa, and perinatal maternal and infant washes were completed. Subjective maternal symptoms as well as infant examinations were used to assess tolerability of the washes. RESULTS: The 0.25% concentration of CHX was well tolerated by the mothers (n = 29). Ten of 79 women (13%) with 1% CHX washes complained of mild vaginal area burning or itching, and washes were stopped in 5 (6%). Twenty-three of 75 women (31%) in the 2% CHX wash group had subjective complaints, and the washes were stopped in 12 (16%). There were no clinical indications of toxicity of the CHX washes among infants. CONCLUSION: A 1% solution of CHX appears to be a safe and tolerable concentration of CHX for consideration in an MTCT prevention trial.