Hope, the Household Environment, and Sexual Risk Behaviors Among Young Women in Rural South Africa (HPTN 068).

We assessed the psychological trait of hope as an explanatory mediator in the relationship between the home environment and sexual risk behaviors among 2533 young women in rural South Africa. Hope mediated the relationship between average household age and sexual debut (mediated effect = - 0.003, p < 0.05), and between household consumption and sexual debut (mediated effect = - 0.019, p < 0.05). Both higher average household age (ß = 0.01; 95% CI 0.00, 0.01) and greater household consumption (ß = 0.05; 95% CI 0.02, 0.08) were marginally associated with higher hope. In turn, greater hope was associated with lower odds of sexual debut (aOR = 0.62; 95% CI 0.52, 0.74). These results provide important preliminary evidence of the role of the home environment in shaping protective psychological assets and healthy sexual behaviors. Continued exploration of the relationship between hope and the home environment may help to explain why young women in this context have a disproportionate risk for HIV.

HIV-Risk Behaviors and Social Support Among Men and Women Attending Alcohol-Serving Venues in South Africa: Implications for HIV Prevention.

Alcohol use is associated with increased HIV-risk behaviors, including unprotected sex and number of sex partners. Alcohol-serving venues can be places to engage in HIV-related sexual risk behaviors, but are also important sites of social support for patrons, which may mitigate risks. We sought to examine the relationship between alcohol-serving venue attendance, social support, and HIV-related sexual risk behavior, by gender, in South Africa. Adult patrons (n = 496) were recruited from six alcohol-serving venues and completed surveys assessing frequency of venue attendance, venue-based social support, and recent sexual behaviors. Generalized estimating equations tested associations between daily venue attendance, social support, and sexual behaviors, separately by gender. Interaction effects between daily attendance and social support were assessed. Models were adjusted for venue, age, education, and ethnicity. Daily attendance at venues was similar across genders and was associated with HIV-related risk behaviors, but the strength and direction of associations differed by gender. Among women, daily attendance was associated with greater number of partners and higher proportion of unprotected sex. Social support was a significant moderator, with more support decreasing the strength of the relationship between attendance and risk. Among men, daily attendance was associated with a lower proportion of unprotected sex; no interaction effects were found for attendance and social support. Frequent venue attendance is associated with additional HIV-related risks for women, but this risk is mitigated by social support in venues. These results were not seen for men. Successful HIV interventions in alcohol-serving venues should address the gendered context of social support and sexual risk behavior.

Hope Matters: Developing and Validating a Measure of Future Expectations Among Young Women in a High HIV Prevalence Setting in Rural South Africa (HPTN 068).

Hope is a future expectancy characterized by an individual's perception that a desirable future outcome can be achieved. Though scales exist to measure hope, they may have limited relevance in low resource, high HIV prevalence settings. We developed and validated a hope scale among young women living in rural South Africa. We conducted formative interviews to identify the key elements of hope. Using items developed from these interviews, we administered the hope scale to 2533 young women enrolled in an HIV-prevention trial. Women endorsed scale items highly and the scale proved to be unidimensional in the sample. Hope scores were significantly correlated with hypothesized psycholosocial correlates with the exception of life stressors. Overall, our hope measure was found to have excellent reliability and to show encouraging preliminary indications of validity in this population. This study presents a promising measure to assess hope among young women in South Africa.

Depression and HIV Serostatus Disclosure to Sexual Partners Among Newly HIV-Diagnosed Men Who Have Sex with Men.

HIV disclosure to sexual partners facilitates joint decision-making and risk reduction strategies for safer sex behaviors, but disclosure may be impacted by depression symptoms. Disclosure is also associated with disclosure self-efficacy, which in turn may also be influenced by depressive symptoms. This study examined the relationship between depression and HIV disclosure to partners following diagnosis among men who have sex with men (MSM), mediated by disclosure self-efficacy. Newly HIV-diagnosed MSM (n=92) who reported sexual activity after diagnosis completed an assessment soon after diagnosis which measured depressive symptoms, and another assessment within 3 months of diagnosis that measured disclosure self-efficacy and disclosure. Over one-third of the sample reported elevated depressive symptoms soon after diagnosis and equal proportions (one-third each) disclosed to none, some, or all partners in the 3 months after diagnosis. Depressive symptoms were negatively associated with disclosure self-efficacy and disclosure to partners, while disclosure self-efficacy was positively associated with disclosure. Disclosure self-efficacy partially mediated the relationship between depression and disclosure, accounting for 33% of the total effect. These findings highlight the importance of addressing depression that follows diagnosis to enhance subsequent disclosure to sexual partners.

HIV/AIDS-related stigma in South African alcohol-serving venues and its potential impact on HIV disclosure, testing and treatment-seeking behaviours.

Alcohol-serving venues in South Africa are sites for high-risk behaviours that may lead to HIV transmission. Prevention and treatment interventions are sorely needed in these settings, but HIV-related stigma may limit their effectiveness. This study explored expressions of stigma among alcohol-serving venue patrons in Cape Town and examined the potential impact of stigma on HIV disclosure, testing and treatment-seeking behaviours. A total of 92 in-depth interviews with male and female, black and coloured patrons were conducted. Transcripts were analysed via memo-writing and diagramming techniques. Many participants mentioned knowing other patrons living with HIV/AIDS (PLWH), and this visibility of HIV impacted expressions of HIV-related stigma. Participants discussed four forms of HIV-related stigma in the venues: fearing PLWH, fearing HIV acquisition, blaming others for spreading HIV and isolating PLWH. HIV visibility and expressions of HIV-related stigma, particularly fear of isolation, influenced participants' willingness to disclose their status. HIV-related stigma in the venues also appeared to indirectly influence testing and treatment-seeking behaviour outside the venue. Results suggest that efforts to change norms and reduce expressions of HIV-related stigma in alcohol-serving venues are necessary to successfully deliver tailored HIV prevention interventions and increase uptake of HIV testing and care in this important social setting.

Traumatic stress and the mediating role of alcohol use on HIV-related sexual risk behavior: results from a longitudinal cohort of South African women who attend alcohol-serving venues.

BACKGROUND: In South Africa, alcohol contributes to the HIV epidemic, in part, by influencing sexual behaviors. For some, high levels of alcohol consumption may be driven by previous traumatic experiences that result in traumatic stress. The purpose of this study was to quantify the longitudinal association between traumatic stress and unprotected sex among women who attend drinking venues and to assess whether this association was explained by mediation through alcohol use. METHODS: Data were collected in 4 waves over a year from a prospective cohort of 560 women who regularly attended alcohol-serving venues in a Cape Town township. Longitudinal mixed models examined (1) the relationship between traumatic stress and counts of unprotected sex and (2) whether alcohol use mediated the association between traumatic stress and unprotected sex. RESULTS: Most women reported elevated traumatic stress (80%) and hazardous alcohol use (88%) at least once during the study period. In models adjusted for covariates, traumatic stress was associated with unprotected sex (b = 0.28, SE = 0.06, t = 4.82, P < 0.001). In addition, traumatic stress was associated with alcohol use (b = 0.27, SE = 0.02, t = 14.25, P < 0.001) and was also associated with unprotected sex (b = 0.20, SE = 0.06, t = 3.27, P < 0.01) while controlling for alcohol use (b = 0.28, SE = 0.07, t = 4.25, P < 0.001). The test for the mediated effect established that alcohol use was a significant mediator, accounting for 27% of the total effect of traumatic stress on unprotected sex. CONCLUSIONS: These results highlight the need to address traumatic stress among female venue patrons as an important precursor of HIV risk due to alcohol use.

Experiences of forced sex among female patrons of alcohol-serving venues in a South African township.

South Africa has among the highest rates of forced sex worldwide, and alcohol use has consistently been associated with risk of forced sex in South Africa. However, methodological challenges affect the accuracy of forced sex measurements. This study explored the assessment of forced sex among South African women attending alcohol-serving venues and identified factors associated with reporting recent forced sex. Women (n = 785) were recruited from 12 alcohol-serving venues in a peri-urban township in Cape Town. Brief self-administered surveys included questions about lifetime and recent experiences of forced sex. Surveys included a single question about forced sex and detailed questions about sex by physical force, threats, verbal persuasion, trickery, and spiked drinks. We first compared the single question about forced sex to a composite variable of forced sex as unwanted sex by physical force, threats, or spiked drinks. We then examined potential predictors of recent forced sex (demographics, drinking behavior, relationship to the venue, abuse experiences). The single question about forced sex had low sensitivity (0.38); more than half of the respondents who reported on the detailed questions that they had experienced forced sex by physical force, threats, or spiked drinks reported on the single question item that they had not experienced forced sex. Using our composite variable, 18.6% of women reported lifetime and 10.8% reported recent experiences of forced sex. In our adjusted logistic regression model, recent forced sex using the composite variable was significantly associated with hazardous drinking (OR = 1.92), living farther from the venue (OR = 1.81), recent intimate partner violence (OR = 2.53), and a history of childhood sexual abuse (OR = 4.35). The findings support the need for additional work to refine the assessment of forced sex. Efforts to prevent forced sex should target alcohol-serving venues, where norms and behaviors may present particular risks for women who frequent these settings.

Longitudinal cohort study of depression, post-traumatic stress, and alcohol use in South African women who attend alcohol serving venues.

BACKGROUND: In South Africa, alcohol use poses a public health burden. Hazardous alcohol use often co-occurs with psychological distress (e.g., depression and post-traumatic stress). However, the majority of the research establishing the relationship between alcohol use and psychological distress has been cross-sectional, so the nature of co-occurring changes in psychological distress and alcohol use over time is not well characterized. The objective of this study is to examine the longitudinal relationship between psychological distress and alcohol use among South African women who attend alcohol serving venues. METHODS: Four waves of data were collected over the course of a year from 560 women in a Cape Town township who attended drinking venues. At each assessment wave, participants reported depressive symptoms, post-traumatic stress symptoms, and alcohol use. Multilevel growth models were used to: 1) assess the patterns of alcohol use; 2) examine how depressive symptoms uniquely, post-traumatic stress symptoms uniquely, and depressive and post-traumatic stress symptoms together were associated with alcohol use; and 3) characterize the within person and between person associations of depressive symptoms and post-traumatic stress symptoms with alcohol use. RESULTS: Women reported high levels of alcohol use throughout the study period, which declined slightly over time. Post-traumatic stress symptoms were highly correlated with depressive symptoms. Modeled separately, both within person and between person depressive and post-traumatic stress symptoms were uniquely associated with alcohol use. When modeled together, significant between person effects indicated that women who typically have more post-traumatic stress symptoms, when controlling for depressive symptoms, are at risk for increased alcohol use; however, women with more depressive symptoms, controlling for post-traumatic stress symptoms, do not have differential risk for alcohol use. Significant within person effects indicated an interaction between depressive and post-traumatic stress symptoms; women reported more alcohol use than usual at times when they had higher post-traumatic stress symptoms, and this increase in alcohol use was further exacerbated for women who also had higher depressive symptoms than usual. CONCLUSIONS: These findings suggest that interventions targeting post-traumatic stress, especially when post-traumatic stress is comorbid with depression, may reduce alcohol use among South African women who drink.

Positive choices: outcomes of a brief risk reduction intervention for newly HIV-diagnosed men who have sex with men.

Positive choices (PC), a brief sexual risk reduction intervention conducted with newly HIV-diagnosed men who have sex with men (MSM), was evaluated for preliminary efficacy. Participants were enrolled if they reported unprotected anal intercourse (UAI) in the three months prior to HIV diagnosis (n = 102). Three months after diagnosis, participants completed baseline assessments and were randomly assigned to receive the 3-session PC intervention or the comprehensive standard of care (C-SoC) at a community health center. Participants completed assessments at 3- (post intervention), 6-, and 9- months after baseline. Compared to C-SoC participants, PC participants significantly reduced the frequency of UAI with HIV serodiscordant (HIV negative or status unknown) partners over the 9-month follow-up period. No differences by condition were found in the frequency of UAI with all partners. The findings from this trial suggest that brief risk reduction approaches for newly-diagnosed MSM integrated into HIV care can benefit secondary HIV prevention efforts.

Drinking before and after pregnancy recognition among South African women: the moderating role of traumatic experiences.

BACKGROUND: South Africa has one of the world's highest rates of fetal alcohol spectrum disorder (FASD) and interpersonal trauma. These co-occurring public health problems raise the need to understand alcohol consumption among trauma-exposed pregnant women in this setting. Since a known predictor of drinking during pregnancy is drinking behavior before pregnancy, this study explored the relationship between women's drinking levels before and after pregnancy recognition, and whether traumatic experiences - childhood abuse or recent intimate partner violence (IPV) - moderated this relationship. METHODS: Women with incident pregnancies (N = 66) were identified from a longitudinal cohort of 560 female drinkers in a township of Cape Town, South Africa. Participants were included if they reported no pregnancy at one assessment and then reported pregnancy four months later at the next assessment. Alcohol use was measured by the Alcohol Use Disorders Identification Test (AUDIT), and traumatic experiences of childhood abuse and recent IPV were also assessed. Hierarchical linear regressions controlling for race and age examined childhood abuse and recent IPV as moderators of the effect of pre-pregnancy recognition drinking on post-pregnancy recognition AUDIT scores. RESULTS: Following pregnancy recognition, 73% of women reported drinking at hazardous levels (AUDIT ≥ 8). Sixty-four percent reported early and/or recent exposure to trauma. While drinking levels before pregnancy significantly predicted drinking levels after pregnancy recognition, t(64) = 3.50, p < .01, this relationship was moderated by experiences of childhood abuse, B = -.577, t(60) = -2.58, p = .01, and recent IPV, B = -.477, t(60) = -2.16, p = .04. Pregnant women without traumatic experiences reported drinking at levels consistent with levels before pregnancy recognition. However, women with traumatic experiences tended to report elevated AUDIT scores following pregnancy recognition, even if low-risk drinkers previously. CONCLUSION: This study explored how female drinkers in South Africa may differentially modulate their drinking patterns upon pregnancy recognition, depending on trauma history. Our results suggest that women with traumatic experiences are more likely to exhibit risky alcohol consumption when they become pregnant, regardless of prior risk. These findings illuminate the relevance of trauma-informed efforts to reduce FASD in South Africa.

The organization of sex work in low- and high-priced venues with a focus on the experiences of ethnic minority women working in these venues.

Prior research on female sex workers (FSW) in China, and their risk for HIV and STI, neglects the nuanced experiences of ethnic minority FSW. We conducted participant observations and in-depth interviews with 33 FSW and six venue bosses to describe the experiences of FSW and management structures in low and high-priced sex work venues in Liuzhou, China. In low-priced venues, FSW had more autonomy and stronger relationships with their ethnic minority peers. Mid- and high-priced venues had more formal management structures. Ethnic minority FSW working in higher priced venues experienced less support and kinship with their peers. HIV/STI prevention outreach activities occurred in all of the venues, but they were not tailored for different venue types or for ethnic minority FSW. Our findings provide guidance for tailoring public health programs that meet the needs of ethnic minority women working in different types of sex work venues.

Affected by HIV stigma: interpreting results from a population survey of an urban center in Guangxi, China.

We aimed to identify factors related to HIV stigma in Liuzhou, Guangxi province, a city in southwest China with high HIV prevalence. We used a multi-stage cluster randomized sample of the general population to survey 852 adults. We conducted ordinal logistic regression analyses to test factors associated with punishment and isolation stigma. Eighteen percent of respondents agreed that people with HIV should be punished, and 40% agreed that people living with HIV (PLHIV) should be isolated. Punishment stigma was associated with age, having three or more sexual partners, and TV watching. Isolation stigma was associated with age, urban residence and a history of STI. HIV transmission knowledge was low, and having correct knowledge attenuated the association with punishment and isolation stigma. Despite programs in China to provide care and treatment for PLHIV, HIV stigma is common in this region. Targeted interventions need to focus on fears related to HIV and PLHIV.

Understanding the meaning of short-term, yiyeqing relationships and how they are formed: implications for condom use in Liuzhou, China.

Yiyeqing (YYQ) ("one night love", i.e., having sex only once with a non-commercial partner) has increased in China, concomitant with the increase in heterosexual transmission of sexually transmitted infections/human immunodeficiency virus (STI/HIV). Our study explored how participants who had experienced YYQ understood these relationships and characterized YYQ's links to sexual risk behaviors. We conducted in-depth interviews with 45 adults in Liuzhou, a city in southwest China, who had YYQ experience. We analyzed the findings using social construction to interpret the participants' understandings of YYQ. Participants reported that they tend to select YYQ partners whom they trust, which is built through introductions from social connections and within entertainment venues, resulting in the belief that their partners are free of STI/HIV and do not require protected sex. As YYQ relationships become more common, understanding the nature of these relationships is critical for developing public health messages that convey the risks associated with sex in short-term relationships and the need for condoms.

Population-based sexual behavior surveys in China: Liuzhou compared with other prefectural cities.

Sexual behaviors in China are rapidly changing; simultaneously, sexually transmitted infections (STI)/HIV prevalence is increasing in the general population. To investigate these major shifts, we examined sexual behaviors and self-reported STI in one prefectural city in southern China, Liuzhou, and compared it to other prefectural cities throughout China. We used adults age 18-39 from two sets of population-based surveys that paralleled each other in both content and method. The first set was the Liuzhou survey conducted in 2008 (n = 398). The second set consisted of two national surveys collected in 2006 and 2010 (n = 2,186). Liuzhou respondents reported more active social and sexual behaviors than their national counterparts, including more socializing, dancing, drinking excessively, sexual activity among never married men and women, purchasing commercial sex among men, one-night stands among men, multiple sexual partnerships and self-reported STI among both men and women. Women in Liuzhou reported greater sexual risk behavior than their national counterparts, although overall they reported less than their male counterparts; they were also more likely to have had an abortion than women in other prefectural cities. Our findings provide a comprehensive overview of the sexual context of Liuzhou among the general population, which may help explain the greater STI/HIV prevalence in Liuzhou.

A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings.

What accounts for differences in HIV stigma across different high prevalence settings? This study was designed to examine HIV stigma and discrimination in five high prevalence settings. Qualitative data were collected as part of the U.S. National Institute of Mental Health (NIMH) Project Accept, a multi-site community randomized trial of community-based HIV voluntary counseling and testing. In-depth interviews were conducted with 655 participants in five sites, four in Sub-Saharan Africa and one in Southeast Asia. Interviews were conducted in the local languages by trained research staff. Data were audiotaped, transcribed, translated, coded and computerized for thematic data analysis. Participants described the stigmatizing attitudes and behaviors perpetuated against people living with HIV/AIDS (PLWHA). The factors that contribute to HIV stigma and discrimination include fear of transmission, fear of suffering and death, and the burden of caring for PLWHA. The family, access to antiretrovirals and other resources, and self-protective behaviors of PLWHA protected against HIV stigma and discrimination. Variation in the availability of health and socioeconomic resources designed to mitigate the impact of HIV/AIDS helps explain differences in HIV stigma and discrimination across the settings. Increasing access to treatment and care resources may function to lower HIV stigma, however, providing services is not enough. We need effective strategies to reduce HIV stigma as treatment and care resources are scaled up in the settings that are most heavily impacted by the HIV epidemic.