A 5-Year Review of the Impact of Lottery Incentives on HIV-Related Services.

PURPOSE OF REVIEW: Lottery incentives are an innovative approach to encouraging HIV prevention, treatment initiation, and adherence behaviours. This paper reviews the latest research on lottery incentives' impact on HIV-related services, and their effectiveness for motivating behaviours to improve HIV service engagement and HIV health outcomes. RECENT FINDINGS: Our review of ten articles, related to lottery incentives, published between 2018 and 2023 (inclusive) shows that lottery incentives have promise for promoting HIV-related target behaviours. The review highlights that lottery incentives may be better for affecting simpler behaviours, rather than more complex ones, such as voluntary medical male circumcision. This review recommends tailoring lottery incentives, ensuring contextual-relevance, to improve the impact on HIV-related services. Lottery incentives offer tools for improving uptake of HIV-related services. The success of lottery incentives appears to be mediated by context, the value and nature of the incentives, and the complexity of the target behaviour.

Couples motivational interviewing with mobile breathalysers to reduce alcohol use in South Africa: a pilot randomised controlled trial of Masibambisane.

INTRODUCTION: Heavy alcohol use among people living with HIV in sub-Saharan Africa can hinder the success of HIV treatment programmes, impacting progress towards United Nations Programme on HIV/AIDS goals. Primary partners can provide critical forms of social support to reduce heavy drinking and could be included in motivational interviewing (MI) interventions to address heavy drinking; however, few studies have evaluated MI interventions for couples living with HIV in sub-Saharan Africa. We aim to evaluate the feasibility and acceptability of a couple-based MI intervention with mobile breathalyser technology to reduce heavy alcohol use and improve HIV treatment outcomes among HIV-affected couples in South Africa. METHODS AND ANALYSIS: We will employ a three-arm randomised controlled trial to assess the efficacy of couple-based MI (MI-only arm) and in conjunction with mobile breathalysers (MI-plus arm) to address alcohol use and HIV outcomes, as compared with enhanced usual care (control arm). We will enrol heterosexual couples aged 18-49 in a primary relationship for at least 6 months who have at least one partner reporting hazardous alcohol use and on antiretroviral therapy for 6 months. Participants in both MI arms will attend three manualised counselling sessions and those in the MI-plus arm will receive real-time feedback on blood alcohol concentration levels using a mobile breathalyser. Couples randomised in the control arm will receive enhanced usual care based on the South African ART Clinical Guidelines. Feasibility and acceptability indicators will be analysed descriptively, and exploratory hypotheses will be examined through regression models considering time points and treatment arms. ETHICS AND DISSEMINATION: The study was approved by the University of California, San Francisco (HRPP; protocol number 21-35034) and Human Sciences Research Council Research Ethics Committee (REC: protocol number 1/27/20/21). We will disseminate the results at local community meetings, community-level health gatherings and conferences focused on HIV and alcohol use. TRIAL REGISTRATION NUMBER: NCT05756790.

Exploring perceptions of gender roles amongst sexually active adolescents in rural KwaZulu-Natal, South Africa.

Traditional gender and social norms reinforce asymmetrical power relations, increase the risk of experiencing gender-based violence and mediate poor engagement with sexual and reproductive health services. This study explored gender norms and expectations amongst cisgender adolescents in rural KwaZulu-Natal, South Africa. A purposive sample of 29 adolescents aged 16-19 years old were enrolled as part of a longitudinal qualitative study. The current analysis reports on the first round of in-depth interviews, which focused on the role of men and women in their community. A theoretically informed thematic analysis identified three broad themes: 1) Adolescent interpretation and understanding of gender identity, 2) Gendered essentialism and Gender roles (two sub-themes: Young men: Power through providing, and Young women: The domestication process which highlighted that gender roles were defined by being the provider for men, and the successful fulfilment of traditional domestic behaviours amongst women), 3) Gender and fertility highlighted how participants highly valued fertility as affirming of manhood/womanhood. These norms reinforce gender roles that maintain asymmetrical power relations, carrying them over into adulthood. The subtle social pressure to prove fertility could have unintended consequences for driving teenage pregnancy. Structural, gender-based interventions emphasising positive gender-role development in early childhood are needed.

"Words are too small": exploring artmaking as a tool to facilitate dialogues with young South African women about their sexual and reproductive health experiences.

Background: Adolescents and young women are at high risk for sexually transmitted infections (STIs) and unintended pregnancies. However, conversations about sexual and reproductive health (S&RH) are difficult and stigmatised. Visual art-based approaches have been a useful adjunct to language-dependent interviews, encouraging embodied memory recall. Here, we explored a novel visual art-based methodology-"Stories from the Edge"-with a cohort of young women to understand how artmaking might facilitate dialogue of how S&RH experiences influenced behaviour, to enrich dialogues captured in the individual in-depth interviews (IDIs). Methods: Seven isiXhosa-speaking young women (aged 21-25 years) were recruited into a six-session art-based engagement, painting the stories of their S&RH experiences. Large format artmaking and IDIs contributed to the data set. IDIs were audio recorded, transcribed, and translated and then analysed thematically. Results: Young women felt that the visual art-based methodology eased barriers to communicating experiences of S&RH-seeking behaviours, with one woman commenting that "words are too small" to capture lived experiences. Artmaking provided the opportunity to express emotional complexities of the pleasures of intimate relationships and the heartbreak of betrayal for which they had no language. Significant social relationships (family, partners, peers) influenced sexual and reproduction attitudes and practices more than healthcare facilities and staff and more distal socio-cultural attitudes/practices. These influences shifted from adolescence to adulthood-from family to peer and partners. Conclusion: Young women valued using the art-based methodology, which facilitated recall and verbalising their S&RH experiences more fully than language-only research. The process outlined here could provide a creative method that builds communication skills to negotiate the needs and desires of young women with partners and staff at S&RH services.

'A difficult conversation': community stakeholders' and key informants' perceptions of the barriers to talking about sex and HIV with adolescents and young people in KwaZulu-Natal, South Africa.

Adolescence and young adulthood are important periods of transition and therefore for action and intervention to ensure future sexual and reproductive health (SRH). Caregiver-adolescent communication about sex and sexuality is a protective factor for SRH, but there are often barriers to this. Adults' perspectives are limited within the literature but important as they should lead this process. This paper uses exploratory qualitative data from in-depth interviews with 40 purposively sampled community stakeholders and key informants to explore their insights into the perceived, experienced or expected challenges adults' experience when having these conversations within a high HIV prevalence, South African context. Findings suggest that respondents recognised the value of communication and were generally willing to try it. However, they identified barriers such as fear, discomfort and limited knowledge and perceived capacity to do so. They show that in high prevalence contexts adults grapple with their own personal risks, behaviours and fears that may affect their ability to have these conversations. This demonstrates the need to equip caregivers with the confidence and ability to communicate about sex and HIV, alongside managing their own complex risks and situations to overcome barriers. It is also necessary to shift the negative framing of adolescents and sex.

Whole person HIV services: a social science approach.

PURPOSE OF REVIEW: Globally, approximately 38.4 million people who are navigating complex lives, are also living with HIV, while HIV incident cases remain high. To improve the effectiveness of HIV prevention and treatment service implementation, we need to understand what drives human behaviour and decision-making around HIV service use. This review highlights current thinking in the social sciences, emphasizing how understanding human behaviour can be leveraged to improve HIV service delivery. RECENT FINDINGS: The social sciences offer rich methodologies and theoretical frameworks for investigating how factors synergize to influence human behaviour and decision-making. Social-ecological models, such as the Behavioural Drivers Model (BDM), help us conceptualize and investigate the complexity of people's lives. Multistate and group-based trajectory modelling are useful tools for investigating the longitudinal nature of peoples HIV journeys. Successful HIV responses need to leverage social science approaches to design effective, efficient, and high-quality programmes. SUMMARY: To improve our HIV response, implementation scientists, interventionists, and public health officials must respond to the context in which people make decisions about their health. Translating biomedical efficacy into real-world effectiveness is not simply finding a way around contextual barriers but rather engaging with the social context in which communities use HIV services.

Impact of COVID-19 public health responses on income, food security and health services among key and vulnerable women in South Africa.

Globally, COVID-19 has impacted lives and livelihoods. Women living with HIV and/or at high risk of acquiring HIV are socially and economically vulnerable. Less is known of the impact of COVID-19 public health responses on women from key and vulnerable populations. The purpose of this cross-sectional survey conducted in four South African provinces with a high burden of HIV and COVID-19 from September to November 2021 was to advance understanding of the socio-economic and health care access impact of COVID-19 on women living with HIV or at high risk of acquiring HIV. A total of 2 812 women >15 years old completed the survey. Approximately 31% reported a decrease in income since the start of the pandemic, and 43% an increase in food insecurity. Among those accessing health services, 37% and 36% reported that COVID-19 had impacted their access to HIV and family planning services respectively. Economic and service disruptions were enhanced by living in informal housing, urbanisation and being in the Western Cape. Food insecurity was increased by being a migrant, having fewer people contributing to the household, having children and experience of gender-based violence. Family planning service disruptions were greater for sex workers and having fewer people contributing to the household. These differentiated impacts on income, food security, access to HIV and family planning services were mediated by age, housing, social cohesion, employment and household income, highlighting the need for improved structural and systemic interventions to reduce the vulnerability of women living with HIV or at high risk of acquiring HIV.

HIV incidence and associated risk factors in adolescent girls and young women in South Africa: A population-based cohort study.

BACKGROUND: In sub-Saharan Africa, high HIV incidence rates in adolescent girls and young women (AGYW) persist despite extensive HIV prevention efforts. METHODS: A prospective cohort of 2,710 HIV-negative AGYW (15-24 years) in KwaZulu-Natal, South Africa were interviewed at baseline and followed-up approximately 18 months later (2014-2017). Associations between HIV seroconversion and socio-demographic and behavioural variables measured at baseline and follow-up were examined using Cox regression and a proximate determinants framework. Inter-relationships between determinants were measured using logistic regression. Separate models were built for 15-19 and 20-24-year-olds. RESULTS: Weighted HIV incidence was 3.92 per 100 person-years (95% confidence interval: 3.27-4.69; 163 seroconversions over 4,016 person-years). Among 15-19-year-olds, absence of family support (adjusted hazards ratio (aHR): 3.82 (1.89-7.72)), having a circumcised partner (aHR: 0.5 (0.27-0.94)) or one who was HIV-positive and not on antiretroviral therapy (ART) (aHR: 6.21 (2.56-15.06)) were associated with HIV incidence. Those reporting an absence of family support were also more likely to report >1 partner during follow-up (odds ratio (OR): 2.7(1.11-6.57)). Among 20-24-year-olds, failure to complete secondary school (aHR: 1.89 (1.11-3.21)), inconsistent condom use (aHR: 3.01 (1.14-7.96)) and reporting partner(s) who were HIV-positive and not on ART (aHR: 7.75 (3.06-19.66)) were associated with HIV incidence. Failure to complete secondary school among 20-24-year-olds was associated with inconsistent condom use (OR: 1.82 (1.20-2.77)) and reporting an HIV-positive partner not on ART (OR: 3.53(1.59-7.82)) or an uncircumcised partner (OR: 1.39 (1.08-1.82). CONCLUSION: Absence of family support and incomplete schooling are associated with risky sexual behaviours and HIV acquisition in AGYW. In addition, partner-level prevention-condom use, medical circumcision, and viral suppression-continue to play an important role in reducing HIV risk in AGYW. These findings support the use of combination HIV prevention programs that consider structural as well as biological and behavioural HIV risk factors in their design.

Implants for HIV prevention in young women: Provider perceptions and lessons learned from contraceptive implant provision.

Preventing new HIV infections, especially amongst young women, is key to ending the HIV epidemic especially in sub-Saharan Africa. Potent antiretroviral (ARV) drugs used as pre-exposure prophylaxis (PrEP) are currently being formulated as long-acting implantable devices, or nanosuspension injectables that release drug at a sustained rate providing protection from acquiring HIV. PrEP as implants (PrEP Implants) offers an innovative and novel approach, expanding the HIV prevention toolbox. Feedback from providers and future users in the early clinical product development stages may identify modifiable characteristics which can improve acceptability and uptake of new technologies. Healthcare workers (HCWs) perspectives and lessons learned during the rollout of contraceptive implants will allow us to understand what factors may impact the roll-out of PrEP implants. We conducted eighteen interviews with HCWs (9 Nurses and 9 Community Healthcare Workers) in rural KwaZulu-Natal, South Africa. HCWs listed the long-acting nature of the contraceptive implant as a key benefit, helping to overcome healthcare system barriers like heavy workloads and understaffing. However, challenges like side effects, migration of the implant, stakeholder buy-in and inconsistent training on insertion and removal hampered the roll-out of the contraceptive implant. For PrEP implants, HCWs preferred long-acting products that were palpable and biodegradable. Our findings highlighted that the characteristics of PrEP implants that are perceived to be beneficial by HCWs may not align with that of potential users, potentially impacting the acceptability and uptake of PrEP implants. Further our data highlight the need for sustained and multi-pronged approaches to training HCWs and introducing new health technologies into communities. Finding a balance between the needs of HCWs that accommodate their heavy workloads, limited resources at points of delivery of care and the needs and preferences of potential users need to be carefully considered in the development of PrEP implants.

Exploring discrepant knowledge of partner sexual behaviour to inform self-risk assessment in a high HIV burdened district in rural KwaZulu-Natal.

Understanding the sexual relationships of young women is critical for preventing HIV infections. This study aimed to describe the sexual behaviour of partners, comparing the accuracy of sexual health knowledge between partners. The study took place in 2017 in KwaZulu-Natal, South Africa. Purposive sampling was used to select 18-27-year-old sexually active women. Consenting female participants completed a structured and semi-structured interview, while consenting male sexual partners identified through the female participant completed a structured questionnaire on sexual health information. Using a reflexive inductive approach and thematic analysis, we identified key discrepancies in the assumptions partners make about each other's sexual health information. Twenty-three sexual dyads were identified and four key discrepancies were identified: Age: partners either over or underestimated the age of their partners, HIV status: where partners were unaware of, or incorrectly assumed their partner's status, Lack of awareness of partner's concurrent relationships and more general knowledge of the partner's sexual health behaviours. Discussions about sexual health are mediated by relationship length, type of partner, power and perceived fidelity. While it is possible to undertake dyadic level research, ethical tensions remain. Sex-positive and egalitarian sexual health interventions that target the individual, as well as the sexual relationship, are needed.

Impact of COVID-19 public health responses on income, food security and health services among key and vulnerable women in South Africa

Globally, COVID-19 has impacted lives and livelihoods. Women living with HIV and/or at high risk of acquiring HIV are socially and economically vulnerable. Less is known of the impact of COVID-19 public health responses on women from key and vulnerable populations. The purpose of this cross-sectional survey conducted in four South African provinces with a high burden of HIV and COVID-19 from September to November 2021 was to advance understanding of the socio-economic and health care access impact of COVID-19 on women living with HIV or at high risk of acquiring HIV. A total of 2 812 women >15 years old completed the survey. Approximately 31% reported a decrease in income since the start of the pandemic, and 43% an increase in food insecurity. Among those accessing health services, 37% and 36% reported that COVID-19 had impacted their access to HIV and family planning services respectively. Economic and service disruptions were enhanced by living in informal housing, urbanisation and being in the Western Cape. Food insecurity was increased by being a migrant, having fewer people contributing to the household, having children and experience of gender-based violence. Family planning service disruptions were greater for sex workers and having fewer people contributing to the household. These differentiated impacts on income, food security, access to HIV and family planning services were mediated by age, housing, social cohesion, employment and household income, highlighting the need for improved structural and systemic interventions to reduce the vulnerability of women living with HIV or at high risk of acquiring HIV.

Acceptability of point-of-care viral load testing to facilitate differentiated care: a qualitative assessment of people living with HIV and nurses in South Africa.

BACKGROUND: Providing viral load (VL) results to people living with HIV (PLHIV) on antiretroviral therapy (ART) remains a challenge in low and middle-income countries. Point-of-care (POC) VL testing could improve ART monitoring and the quality and efficiency of differentiated models of HIV care. We assessed the acceptability of POC VL testing within a differentiated care model that involved task-shifting from professional nurses to less highly-trained enrolled nurses, and an option of collecting treatment from a community-based ART delivery programme. METHODS: We undertook a qualitative sub-study amongst clients on ART and nurses within the STREAM study, a randomized controlled trial of POC VL testing and task-shifting in Durban, South Africa. Between March and August 2018, we conducted 33 semi-structured interviews with clients, professional and enrolled nurses and 4 focus group discussions with clients. Interviews and focus groups were audio recorded, transcribed, translated and thematically analysed. RESULTS: Amongst 55 clients on ART (median age 31, 56% women) and 8 nurses (median age 39, 75% women), POC VL testing and task-shifting to enrolled nurses was acceptable. Both clients and providers reported that POC VL testing yielded practical benefits for PLHIV by reducing the number of clinic visits, saving time, travel costs and days off work. Receiving same-day POC VL results encouraged adherence amongst clients, by enabling them to see immediately if they were 'good' or 'bad' adherers and enabled quick referrals to a community-based ART delivery programme for those with viral suppression. However, there was some concern regarding the impact of POC VL testing on clinic flows when implemented in busy public-sector clinics. Regarding task-shifting, nurses felt that, with extra training, enrolled nurses could help decongest healthcare facilities by quickly issuing ART to stable clients. Clients could not easily distinguish enrolled nurses from professional nurses, instead they highlighted the importance of friendliness, respect and good communication between clients and nurses. CONCLUSIONS: POC VL testing combined with task-shifting was acceptable to clients and healthcare providers. Implementation of POC VL testing and task shifting within differentiated care models may help achieve international treatment targets. TRIAL REGISTRATION: NCT03066128 , registered 22/02/2017.

Acceptability of Long-Acting Injectable Cabotegravir (CAB LA) in HIV-Uninfected Individuals: HPTN 077.

Long-acting injectable PrEP could offer an alternative to daily oral PrEP, improve adherence and protection, if found acceptable, safe and effective. HPTN 077 evaluated injectable cabotegravir safety, tolerability and pharmacokinetics among HIV-uninfected males and females in sequentially-enrolled cohorts of two dosing strategies. We compared acceptability of product attributes, prevention preferences and future interest in injectable PrEP (FIIP) by region, sex-at-birth, arm and cohort and used multivariable analysis to identify FIIP determinants. Baseline injectable PrEP preferences were higher in non-U.S. sites and increased in both regions over time. In multivariable models, FIIP was most strongly associated with acceptability of product attributes, was higher in non-U.S. sites and more altruistic participants. Treatment arm and report of pain were not associated with FIIP. Injectable acceptability was highest in non-U.S. sites. Preferences for injectable versus other PrEP methods were higher among U.S. males than females, but higher among males and females in non-U.S. settings.

Measuring HIV Risk Perception and Behavior: Results from Round 1 of the Cognitive Interviewing Project with young women and men who have sex with men in South Africa.

Self-reported HIV risk perception and behaviors are used in a variety of settings for diverse purposes, such as HIV prevention program planning and screening. Careful consideration of how youth in high HIV prevalence areas interpret these kinds of questions warrants attention. The Cognitive Interviewing Project (CIP) conducted cognitive interviews on common risk survey items with 30 cis-female and 20 MSM youth (18 to 24), who had recent sex with a male partner, in Cape Town and Vulindlela, South Africa. Results identified a number of potential issues including (1) confusing text; (2) mismatches of terms with local usage; (3) confusion with items requiring self-tailoring; (4) presentation concerns limiting selection of full range of answers; and (5) challenges reporting on information dependent on partner (eg., HIV risk, HIV status of partner). Self-report Items used to identify those at elevated risk for HIV should be evaluated with local populations to optimize shared understanding.

Who is sexually active? Using a multi-component sexual activity profile (MSAP) to explore, identify and describe sexually-active high-school students in rural KwaZulu-Natal, South Africa.

BACKGROUND: Understanding sexual activity is necessary to prevent sexually transmitted infections. Evidence from Sub-Saharan Africa suggests that 10-20% of youth aged 15-24 are sexually active before reaching 15 years, yet estimating sexual activity remains challenging. This study explored the use of multiple sexual health outcomes to identify sexually-active young women in rural KwaZulu-Natal, South Africa. METHODS: Using a multi-component sexual activity profile (MSAP), we aimed to identify sexually active students. Based on data from 2675 grade 9 and 10 students attending 14 high schools) in rural KwaZulu-Natal, we constructed a descriptive diagram identifying students who were sexually active by self-report vs MSAP profile. T-tests for two independent samples was performed to compare by sex and ecological variables that characterise students newly-identified as sexually active. RESULTS: Using self-report only, 40.3% self-reported as sexually active, whilst the MSAP identified 48.7% (223 additional students). More females were identified than males. Younger adolescents were more likely to underreport sexual activity but were identified using MSAP. Newly-identified as sexually active were more likely to be female (p = < 0.000), 15 years old or younger (p = 0.008), less likely to perceive being at risk (p = 0.037) or have ever used alcohol (p = < 0.000). At a relational level, they were less likely to report having ever had a boyfriend/girlfriend (p = 0.000) or to have felt pressured to have sex by their peers (p = < 0.000) or partners (p = 0.008). At a familial level they more likely to be of medium socioeconomic (SES) status (p = 0.037) whilst at a school and community level they were less likely to have repeated a grade (p = 0.024) and were more likely to be engaged in social activities (p = 0.032). CONCLUSIONS: The MSAP profile identified more potentially sexually active students, and gave insight into the characteristics of students who may be unwilling to self-report sexual activity Future work should investigate how this approach could enhance and describe sexually-active adolescents for research and healthcare provision.

'You'll always stay right': understanding vaginal products and the motivations for use among adolescent and young women in rural KZN.

The use of vaginal products may increase the risk of HIV infection by affecting the vaginal biome. Understanding what vaginal products young women are using, and why, is key to assessing the complexity of sexual health and risk. This study reports on findings from research with adolescent and young women in rural KwaZulu-Natal about the vaginal products they use and motivations for using them. The study identified over 26 products that young women used to enhance their sexual experience and found some young women spent time preparing and sourcing vaginal products in order to pleasure and retain partners. Opinions differed about vaginal product use. While some women perceived that vaginal products could provide a means of out-performing other women, retaining a partner and providing sexual autonomy, there was a stigma attached to using them. Study findings highlight the social value of using vaginal products, especially in settings where partner retention is linked to economic survival. Expanding our understanding of what products are used and the reasons young women use them warrants continued investigation.

Exploratory analysis of the ecological variables associated with sexual health profiles in high-risk, sexually-active female learners in rural KwaZulu-Natal.

PURPOSE: Young women are at high risk for negative sexual health outcomes. Despite their high risk, many sexually-active women never experience negative sexual health outcomes. This study explored the ecological risk factors associated with the risk profiles of sexually-active female high school-learners in rural KwaZulu-Natal, South Africa. METHODS: Using baseline data from N = 596 sexually-active school-going women, we explored the ecological factors associated with being sexually-active and managing risk successfully [SARS] or unsuccessfully [SARU]. Generalised estimated equations (GEE) were applied to data collected at multiple levels while adjusting for school and other included variables. GEE were used to calculate probability of being SARU. RESULTS: Amongst SARU learners, 21.9% had HIV, 38.6% had HSV-2, 12.5% were pregnant, 28.7% self-reported STI symptoms and 51.9% reported a previous pregnancy. Individual-level factors had the greatest impact on being SARU. Univariate and multivariate analysis highlighted several important partner factors associated with SARU. Age was significantly associated with the risk profiles (p<0.0001), a greater proportion of SARU learners were 18 or older compared to the SARS learners. The odds of being SARU decreased when ≥18 years (aOR = 0.2577, 95% CI 0.1462-0.4542) or if not falling pregnant was important (aOR = 0.6343, 95% CI 0.4218-0.9538). Having >1 HIV test (aOR = 2.2161, 95% CI 1.3964-3.5169) increased the odds a SARU profile. CONCLUSION: Individual and partner level factors are important for the sexual health profile of an adolescent female. While the exploratory findings require further research; managing multiple sexual health outcomes, tailoring responses around a risk profile and including partners is essential for successful interventions.

Young women's life experiences and perceptions of sexual and reproductive health in rural KwaZulu-Natal South Africa.

Women in South Africa bear a disproportionate burden of the HIV epidemic. Female-controlled HIV prevention methods offer promising interventions to reduce this burden but cannot be effectively employed without a better understanding of young women's perceptions of their sexual and reproductive health. This study examines social, environmental and cultural factors contributing to young women's perceptions of, and experiences with, sexual and reproductive health to identify the challenges of engaging adolescent girls in HIV prevention. Twenty-five 15-19-year-old women were interviewed using semi-structured in-depth interview questions to discover their life context, future goals and relationships with men, and to understand how these factors influence their sexual and reproductive health decisions and outcomes. A thematic analysis of interview findings indicates that although participants are aware of the risks posed by engaging in risky sexual behaviour, life context shapes their perceptions and prioritisation of their health, which presents a barrier to achieving healthy behaviours and positive health outcomes. These findings may influence future research into how young women's health perceptions influence their sexual health behaviours, and how they utilise sexual and reproductive health services in a clinical setting. This has implications for introducing forms of female-controlled HIV prevention for this population.

Empowering patients to link to care and treatment: qualitative findings about the role of a home-based HIV counselling, testing and linkage intervention in South Africa.

To explore the barriers and facilitators of linkage to and retention in care amongst persons who tested positive for HIV, qualitative research was conducted in a home-based HIV counselling and testing (HBCT) project with interventions to facilitate linkages to HIV care in rural KwaZulu-Natal, South Africa. The intervention tested 1272 adults for HIV in Vulindlela of whom 32% were HIV positive, received point-of-care (POC) CD4 testing and referral to local HIV clinics. Those testing positive also received follow-up visits from a counsellor to evaluate linkages to care. The study employed a qualitative methodology collecting data through in-depth semi-structured interviews. Respondents included 25 HIV-positive persons who had tested as part of HBCT project, 4 intervention research counsellors who delivered the HBCT intervention and 9 government clinic staff who received referrals for care. The results show that HBCT helped to facilitate linkage to care through providing education and support to help overcome fears of stigma and discrimination. The results show the perceived value of receiving a POC CD4 result during post-test counselling, both for those newly diagnosed and those previously diagnosed as HIV positive. The results also demonstrate that in-depth counselling creates an "educated consumer" facilitating engagement with clinical services. The study provides qualitative insights into the acceptability of confidential HBCT with same day POC CD4 testing and counselling as factors that influenced HIV-positive persons' decisions to link to care. This model warrants further evaluation in non-research settings to determine impact and cost-effectiveness relative to other HIV testing and referral strategies.