Multilevel strategies to end HIV for young couples in Cape Town: Study protocol for a cluster randomized trial.

This protocol presents a multilevel cluster randomized study in 24 communities in Cape Town, South Africa. The study comprises four specific aims. Aim 1, conducted during the formative phase, was to modify the original Couples Health CoOp (CHC) intervention to include antiretroviral therapy/pre-exposure prophylaxis (ART/PrEP), called the Couples Health CoOp Plus (CHC+), with review from our Community Collaborative Board and a Peer Advisory Board. Aim 1 has been completed for staging the trial. Aim 2 is to evaluate the impact of a stigma awareness and education workshop on community members' attitudes and behaviors toward young women and men who use AODs and people in their community seeking HIV services (testing/ART/PrEP) and other health services in their local clinics. Aim 3 is to test the efficacy of the CHC+ to increase both partners' PrEP/ART initiation and adherence (at 3 and 6 months) and to reduce alcohol and other drug use, sexual risk and gender-based violence, and to enhance positive gender norms and communication relative to HIV testing services (n = 480 couples). Aim 4 seeks to examine through mixed methods the interaction of the stigma awareness workshop and the CHC+ on increased PrEP and ART initiation, retention, and adherence among young women and their primary partners. Ongoing collaborations with community peer leaders and local outreach staff from these communities are essential for reaching the project's aims. Additionally, a manualized field protocol with regular training, fidelity checks, and quality assurance are critical components of this multilevel community trial for successful ongoing data collection. Trial registration. Clinicaltrials.gov Registration Number: NCT05310773. Pan African Trials: pactr.samrc.ac.za/ Registration Number: PACTR202205640398485.

Outcomes of substance use and sexual power among adolescent girls and young women in Cape Town: Implications for structural and cultural differences.

Adolescent girls and young women (AGYW) in South Africa experience contextual barriers to HIV risk reduction including incomplete schooling, unintended pregnancy, substance use, and gender-based violence. A cluster randomised trial in Cape Town allocated 24 Black and Coloured communities to a gender-focused HIV risk-reduction intervention or HIV testing, with 500 AGYW total enrolled. We evaluated intervention efficacy by comparing mean differences overall, by community population group (Black and Coloured) and among those with structural barriers based on neighbourhood, education, and employment (n = 406). Both arms reported reductions in alcohol, cannabis, and condomless sex, with no intervention efficacy overall. Among AGYW with barriers, intervention participants reported fewer days of methamphetamine use at 6 months (t(210) = 2·08, p = ·04). In population group analysis, we found intervention effects on alcohol and sexual communication. Intervention participants in Black communities had fewer days of alcohol use at 12 months (t(136) = 2·10, p = ·04). Sexual discussion (t(147) = -2·47, p = ·02) and condom negotiation (t(146) = -2·51, p = ·01) increased for intervention participants at 12 months in Coloured communities. Gender-focused interventions must address population group differences and intersecting barriers to decrease substance use and increase education, skills, and sexual health protection.

Reliability and Validity of the Minimum Data Set 3.0 Standardized Self-Care and Mobility Data Elements Among Long-Stay Nursing Home Residents.

PURPOSE: To assess the reliability and validity of a subset of the Minimum Data Set (MDS) 3.0 Section GG data elements (i.e., standardized self-care, mobility) among 147 long-stay nursing home residents in seven nursing homes in five states. METHOD: Trained clinicians assessed residents' functional abilities using select Section GG items and Section G activities of daily living items. We examined the reliability and construct validity of the data using Cronbach's alpha, correlations between Section G and Section GG items, confirmatory factor analysis (CFA), and Rasch measurement analysis. RESULTS: We observed acceptable internal consistency values for all (0.98), self-care (0.93), and mobility (0.98) standardized items. Correlations between conceptually related Section G and Section GG items ranged from -0.53 to -0.84. CFA findings found acceptable values for all fit indices. Rasch analysis showed most items had acceptable fit statistics, except for the easiest and most difficult activities. CONCLUSION: These findings establish the feasibility of data collection, internal consistency reliability, and construct validity of the selected Section GG items among long-stay nursing home residents. Use of the same standardized data elements in post-acute and long-term care populations can support improved coding of function and enhance our understanding of resident functioning. [Research in Gerontological Nursing, 17(2), 57-64.].

Alcohol, drug use, and sexual risk among young African American women in North Carolina: Is educational attainment protective?

Previous research shows that educational attainment is a protective factor for substance use and sexual risk among adolescents and young adults. Evidence also shows that this relationship may differ by race/ethnicity and gender. This study aimed to elucidate the relationship between educational attainment, substance use and sexual risk among African American women in emerging adulthood. This study uses cross-sectional data from 646 African American women (aged 18 to 25) enrolled in a randomized trial of a behavioral HIV risk-reduction intervention. At enrollment, participants completed a risk behavior assessment via audio-computer assisted self-interview and provided a urine sample for drug screening. Bivariate logistic regression analyses were conducted to examine substance use and sexual risk factors associated with educational attainment: completing some college or more vs. completing high school or less). Participants who completed some college or more (52%) were more likely to report heavy alcohol use (four or more drinks in one day) in the past 30 days (OR=1.48; p=0.014) and more likely to report alcohol or other drug use just before or during last sex (OR=1.43; p=0.026) compared with participants who completed high school or less. Completing some college or more was protective for having a positive urine screen for cocaine (OR=0.43; p=0.018) and reporting condomless sex at last sex (OR=0.71; p=0.041). Differences in positive marijuana screens, reporting a previous STI, or reporting their partner used alcohol or other drugs at last sex were not statistically significant. The findings reveal notable differences in the magnitude and direction of associations between educational attainment and substance use and sexual risk. Although educational attainment is subject to change because of the frequent pursuit of education during emerging adulthood, the findings may have important implications for tailoring HIV risk-reduction interventions to key populations, such as African American women.

Binge drinking and condom negotiation behaviours among adolescent girls and young women living in Cape Town, South Africa: sexual control and perceived personal power.

BACKGROUND: Condom use among young people in South Africa has declined in recent years and adolescent girls and young women continue to bear the highest incidence of HIV in the country. Young women who have dropped out of school may be more at risk because of traditional gender norms that create substantial power imbalances and a lack of power to negotiate condom use with their male partners, especially when using alcohol and other drugs. METHODS: This study presents an analysis of baseline data provided by 500 adolescent girls and young women (AGYW) from Cape Town communities between November 2016 and November 2018 who were reached for a cluster-randomised trial conducted to assess the efficacy of an evidence-based, young woman-focused intervention seeking to reduce HIV risk and substance use behaviours. The analysis focuses on associations between binge drinking, condom use, and sexual negotiation, including impaired sex (any substance use at last sex). RESULTS: AGYW who reported frequent condom negotiation with their partners were 8.92 times (95% CI: [4.36, 18.24]) as likely to use a condom when alcohol or other drugs were not used at last sex and 5.50 times (95% CI: [2.06, 14.72]) as likely when alcohol or other drugs were used at last sex (p < 0.05). AGYW who reported frequent binge drinking in the past month (n = 177) had significantly reduced odds of condom use at last sex, irrespective of whether the sex was impaired (OR 0.60, 95% CI: [0.49, 0.73]) or not impaired (OR 0.69, 95% CI: [0.60, 0.81]). DISCUSSION: The findings highlight the need for interventions that reach AGYW in South Africa by specifically aiming to educate AGYW about the effect of binge drinking on negotiating power in their relationships, thus providing them with the knowledge and skills to increase agency regarding condom use. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02974998 (recruitment completed). 29/11/2016.

Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women: conflicting perspectives in South Africa.

BACKGROUND: Globally, an urgent need exists to expand access to HIV prevention among adolescent girls and young women (AGYW), but the need is particularly acute in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) offers an effective HIV prevention method. In many countries, however, accessing PrEP necessitates that AGYW visit their local health clinic, where they may face access challenges. Some countries have implemented youth-friendly services to reduce certain challenges in local health clinics, but barriers to access persist, including clinic stigma. However, evidence of clinic stigma toward AGYW, particularly with respect to PrEP service delivery, is still limited. This mixed methods study explores stigma toward AGYW seeking clinic services, in particular PrEP, from the perspective of both clinic staff (clinical and nonclinical) and AGYW who seek services at clinic sites in Tshwane province, South Africa. METHODS: Six focus group discussions were conducted with AGYW (43 total participants) and four with clinic staff (42 total participants) and triangulated with survey data with AGYW (n = 449) and clinic staff (n = 130). Thematic analysis was applied to the qualitative data and descriptive statistics were conducted with the survey data. RESULTS: Four common themes emerged across the qualitative and quantitative data and with both AGYW and clinic staff, although with varying degrees of resonance between these two groups. These themes included (1) clinic manifestations of stigma toward AGYW, (2) concerns about providing PrEP services for AGYW, (3) healthcare providers' identity as mothers, and (4) privacy and breaches of confidentiality. An additional theme identified mainly in the AGYW data pertained to stigma and access to healthcare. CONCLUSION: Evidence is needed to inform strategies for addressing clinic stigma toward AGYW, with the goal of removing barriers to PrEP services for this group. While awareness has increased and progress has been achieved around the provision of comprehensive, youth-friendly sexual and reproductive health services, these programs need to be adapted for the specific concerns of young people seeking PrEP services. Our findings point to the four key areas noted above where programs seeking to address stigma toward AGYW in clinics can tailor their programming.

The Association of Recurrent and Multiple Types of Abuse with Adverse Mental Health, Substance Use, and Sexual Health Outcomes among Out-of-School Adolescent Girls and Young Women in Cape Town, South Africa.

Although physical and sexual abuse exposure is a well-established risk for poor health, the dimensions of abuse associated with health among socially vulnerable adolescent girls and young women (AGYW) remain underexamined. This article describes associations between combinations of abuse type and timing with mental health, substance use, and sexual risk outcomes among a sample of 499 AGYW (aged 16 to 19) who had left school early and were recruited for a cluster randomized trial in Cape Town, South Africa. Approximately one-third (33.5%; 95% CI: 28.7, 38.6) of participants reported lifetime abuse. Exposure to more than one type of abuse was associated with increased risk of depression (ß = 3.92; 95% CI: 2.25, 5.59) and anxiety (ß = 3.70; 95% CI: 2.11, 5.28), and greater odds of polydrug use (OR = 2.10; 95% CI: 1.02, 4.34) and substance-impaired sex (OR = 2.17; 95% CI: 1.31, 3.86). Exposure to multiple types of abuse during childhood/early adolescence and again in late adolescence was associated with increased risk of depression (ß = 4.65; 95% CI: 3.15, 6.14), anxiety (ß = 4.35; 95% CI: 2.70, 6.02), and polydrug use (OR = 2.37; 95% CI: 1.03, 5.73). Findings underscore the need for trauma-informed interventions that reduce mental health, substance use, and sexual risks among AGYW who have experienced multiple forms of abuse and recurrent abuse.

Antiretroviral Therapy (ART) Adherence and Prenatal Alcohol Use among Women Who Are Pregnant with HIV in South Africa.

This brief report emphasizes the need to focus on women with HIV who are pregnant who use alcohol or other drugs. A recently completed implementation science study tested a gender-focused behavioral intervention, the Women's Health CoOp (WHC), to improve antiretroviral therapy (ART) adherence and reduce alcohol use among women with HIV. The study identified 33 participants who had a positive pregnancy test result at the baseline assessment, of whom five participants remained pregnant during the 6-month duration of the study. Of the 33 pregnant participants at the baseline assessment, 55% reported past-month alcohol use, with 27% reporting a history of physical abuse and 12% reporting a history of sexual abuse. The five women who remained pregnant at 6 months showed improved ART adherence and reduced prenatal alcohol use. The gender-focused WHC intervention shows promise as a cost-effective, sustainable, behavioral intervention to address these intersecting syndemic issues. Future research should focus on identifying the needs of women with HIV who are pregnant who use alcohol or other drugs and developing tailored evidence-based behavioral interventions such as the WHC for preventing FASD in addition to improving ART adherence in this key population of women and reducing the economic burden on society.

Outcomes of Implementing in the Real World the Women's Health CoOp Intervention in Cape Town, South Africa.

Women in South Africa living with HIV who use alcohol may not adhere to ART, affecting the country's 90-90-90 targets. The Women's Health CoOp (WHC), a woman-focused HIV intervention, has shown efficacy in numerous trials with key populations of women in South Africa who use alcohol and drugs. In a hybrid implementation effectiveness study, the WHC was implemented in usual care clinics by healthcare providers in a modified stepped-wedge design. We present the outcomes of alcohol use and ART adherence with 480 women, with a 95% 6-month follow-up rate across 4 implementation cycles. Compared with the first cycle, women in the fourth cycle were significantly less likely (OR = 0.10 [95% CI 0.04, 0.24]) to report alcohol use disorder risk and were 4 times more likely (OR = 4.16 [95% CI 1.05, 16.51]) to report ART adherence at 6-month follow-up. Overall, acceptability and satisfaction were extremely high. The WHC intervention was successful in reaching key populations of women to reduce alcohol use and increase ART adherence, which is essential for South Africa to reach the 90-90-90 goals.

Measuring Relationship Functioning in South African Couples: A Strategy for Improving HIV Prevention Efforts.

Over the past decade there has been increased focus on targeting couples in HIV prevention efforts, particularly in sub-Saharan Africa where HIV transmission primarily occurs through heterosexual contact, in the context of intersecting alcohol use and intimate partner violence (IPV). However, little is known about couples' general relationship functioning. This understanding is needed to augment couple-based HIV prevention programs and address risk for IPV. This paper presents data on domains of relationship functioning with 300 South African couples who were recruited for an HIV prevention study. Exploratory and confirmatory factor analyses were conducted to determine the relevance of 17 individual items, as well as the overall factor structure of the questions. Results revealed three independent factors of relationship functioning: relationship satisfaction, arguing, and open communication; an overarching construct of relationship functioning for these three domains was not observed in the data. Results provide insight into the structure of relationship functioning questions and subscales that can be used to assess South African adult romantic relationships. This may allow for a greater focus on aspects of relationships within couple-based HIV prevention programs going forward.

Exploring the associations between physical and sexual gender-based violence and HIV among women who use substances in South Africa: the role of agency and alcohol.

Objective: South Africa has the highest prevalence of HIV among women, the highest prevalence of gender-based violence (GBV), and the highest rates of per capita alcohol consumption in the world. The nuanced associations between GBV, alcohol misuse, and HIV must be explored and protective factors identified. This study examines the associations between physical and sexual GBV and HIV infection and explores how alcohol misuse and sexual agency may mediate the GBV-HIV association. Method: Participants were 361 Black African women (Mean age = 28.39, SD = 7.92) who reported using alcohol and/or drugs weekly in the past 3 months, engaging in condomless sex, and having a boyfriend. Women were recruited from disadvantaged communities in Pretoria, South Africa. Individuals who met the eligibility criteria and enrolled in the study consented and completed a computer-assisted personal interview assessing GBV, alcohol misuse, and sexual agency and underwent HIV testing (i.e., blood test). Results: The indirect effect of physical assault on HIV status at enrollment through alcohol misuse was significant (log odds = 0.23, SE = 0.12, 95% CI [0.0151, 0.4998]). Conclusions: HIV prevention efforts focusing on reducing alcohol misuse may be more effective, which might reduce the HIV burden among this group of vulnerable South African women.

Medicare Outpatient Physical Therapy Expenditures Vary by Diagnosis and Functional Mobility.

BACKGROUND: Clinical characteristics driving variations in Medicare outpatient physical therapy expenditures are inadequately understood. OBJECTIVE: The objectives of this study were to examine variations in annual outpatient physical therapy expenditures of Medicare fee-for-service beneficiaries by primary diagnosis and baseline functional mobility, and to assess whether case mix groups based on primary diagnosis and functional mobility scores would be useful for expenditure differentiation. DESIGN: This was an observational, longitudinal study. METHODS: Volunteer providers in community settings participated in data collection with Continuity Assessment Record and Evaluation-Community (CARE-C) assessments for Medicare fee-for-service beneficiaries. Annual outpatient physical therapy expenditures were calculated using allowed charges on Medicare claims; primary diagnosis and baseline functional mobility were obtained from CARE-C assessments. Whether annual expenditures varied significantly across primary diagnosis groups and within diagnosis groups by functional mobility was examined. RESULTS: Data for 4210 patients (mean [SD] age = 72.9 [9.9] years; 64.6% women) from 127 providers were included. Mean expenditures differed significantly across 12 primary diagnosis groups created from CARE-C clinician-reported diagnoses (F = 12.73; df = 11). Twenty-five pairwise differences in 66 pairwise diagnosis group comparisons were statistically significant. Within 8 diagnosis groups, expenditures were significantly higher for low-mobility subgroups than for high-mobility subgroups; borderline significance was achieved for 1 diagnosis group. LIMITATIONS: The small convenience sample limited the statistical power and the generalizability of the results. CONCLUSIONS: Significant variations in physical therapy expenditures based on primary diagnosis and baseline functional mobility support the use of these variables in predicting outpatient physical therapy expenditures. Although Medicare's annual therapy spending cap was repealed effective January 2018, the data from this study provide an initial foundation to inform any future policy efforts, such as targeted medical review, risk-adjusted therapy payments, or case mix groups as potential payment alternatives. Additional research with larger samples is needed to further develop and test case mix groups and improve generalizability to the national population. Refined case mix groups could also help providers prognosticate physical therapy expenditures based on patient profiles.

Accuracy and Utility of the AUDIT-C with Adolescent Girls and Young Women (AGYW) Who Engage in HIV Risk Behaviors in South Africa.

Hazardous drinking is a risk factor associated with sexual risk, gender-based violence, and HIV transmission in South Africa. Consequently, sound and appropriate measurement of drinking behavior is critical to determining what constitutes hazardous drinking. Many research studies use internal consistency estimates as the determining factor in psychometric assessment; however, deeper assessments are needed to best define a measurement tool. Rasch methodology was used to evaluate a shorter version of the Alcohol Use Disorders Identification Test, the AUDIT-C, in a sample of adolescent girls and young women (AGYW) who use alcohol and other drugs in South Africa (n =100). Investigations of operational response range, item fit, sensitivity, and response option usage provide a richer picture of AUDIT-C functioning than internal consistency alone in women who are vulnerable to hazardous drinking and therefore at risk of HIV. Analyses indicate that the AUDIT-C does not adequately measure this specialized population, and that more validation is needed to determine if the AUDIT-C should continue to be used in HIV prevention intervention studies focused on vulnerable adolescent girls and young women.

Adolescent female school dropouts who use drugs and engage in risky sex: effects of a brief pilot intervention in Cape Town, South Africa.

Female adolescents from socioeconomically underserved communities in Cape Town, South Africa, who have dropped out of school, use substances, and engage in risky sex behaviour are at risk of HIV. Tailored gender-focused HIV behavioural interventions for this key population are needed to mitigate these risk factors. A pilot trial of a woman-focused risk-reduction intervention for adolescents was conducted (N = 100), with a one-month follow-up appointment. Participants in the intervention group attended two group workshops. Data were examined for significant differences within and between the groups. At baseline, 94% of participants tested positive for cannabis, 17% were HIV-positive and 11% were pregnant. Ninety-two participants returned for 1-month follow-up. At follow-up, the proportion who tested positive for cannabis use decreased significantly in both the intervention (p = 0.07) and control groups (p = 0.04). Impaired sex with any partner (p = 0.02), or with main partner (p = 0.06) decreased among the intervention group. Impaired sex with a main partner was less likely in the intervention group (p = 0.07) in the regression model. In conclusion, findings indicate a need for HIV prevention interventions among out-of-school female adolescents. Intervention acceptability was high, and there were some decreases in sexual risk behaviour among intervention participants which is promising. Future intervention research with this key population involving larger sample sizes and longer follow-up periods will help to determine intervention efficacy.

Addressing the nexus of risk: Biobehavioral outcomes from a cluster randomized trial of the Women's Health CoOp Plus in Pretoria, South Africa.

BACKGROUND: HIV prevalence has increased among South African women who use alcohol and other drugs (AOD). However, HIV prevention and treatment efforts have not focused on this population. This study presents the efficacy of the Women's Health CoOp Plus (WHC+) in a cluster-randomized trial to reduce AOD use, gender-based violence, and sexual risk and to increase linkage to HIV care among women who use AODs, compared with HIV counseling and testing alone. METHODS: Black African women (N = 641) were recruited from 14 geographic clusters in Pretoria, South Africa, and underwent either an evidence-based gender-focused HIV prevention intervention that included HIV counseling and testing (WHC+) or HIV counseling and testing alone. Participants were assessed at baseline, 6-months, and 12-months post enrollment. RESULTS: At 6-month follow-up, the WHC+ arm (vs. HCT) reported more condom use with a main partner and sexual negotiation, less physical and sexual abuse by a boyfriend, and less frequent heavy drinking (ps < 0.05). At 12-month follow-up, the WHC+ arm reported less emotional abuse (p < 0.05). Among a subsample of women, the WHC+ arm was significantly more likely to have a non-detectable viral load (measured by dried blood spots; p = 0.01). CONCLUSION: The findings demonstrate the WHC+'s efficacy to reduce HIV risk among women who use AODs in South Africa. Substance abuse rehabilitation centers and health centers that serve women may be ideal settings to address issues of gender-based violence and sexual risk as women engage in substance use treatment, HIV testing, or HIV care.

An adapted instrument to assess informed consent comprehension among youth and parents in rural western Kenya: a validation study.

OBJECTIVE: To adapt and validate a questionnaire originally developed in a research setting for assessment of comprehension of consent information in a different cultural and linguistic research setting. DESIGN: The adaptation process involved development and customisation of a questionnaire for each of the three study groups, modelled closely on the previously validated questionnaire. The three adapted draft questionnaires were further reviewed by two bioethicists and the developer of the original questionnaire for face and content validity. The revised questionnaire was subsequently programmed into an audio computerised format, with translations and back translations in three widely spoken languages by the study participants: Luo, Swahili and English. SETTING: The questionnaire was validated among adolescents, their parents and young adults living in Siaya County, a rural region of western Kenya. PARTICIPANTS: Twenty-five-item adapted questionnaires consisting of close-ended, multiple-choice and open-ended questions were administered to 235 participants consisting of 107 adolescents, 92 parents and 36 young adults. Test-retest was conducted 2-4 weeks after first questionnaire administration among 74 adolescents, young adults and parents. OUTCOME MEASURE: Primary outcome measures included ceiling/floor analysis to identify questions with extremes in responses and item-level correlation to determine the test-retest relationships. Given the data format, tetrachoric correlations were conducted for dichotomous items and polychoric correlations for ordinal items. The qualitative validation assessment included face and content validity evaluation of the adapted instrument by technical experts. RESULTS: Ceiling/floor analysis showed eight question items for which >80% of one or more groups responded correctly, while for nine questions, including all seven open-ended questions,<20% responded correctly. Majority of the question items had moderate to strong test-retest correlation estimates indicating temporal stability. CONCLUSIONS: Our study demonstrates that cross-cultural adaptation and validation of an informed consent comprehension questionnaire is feasible. However, further research is needed to develop a tool which can estimate a quantifiable threshold of comprehension thereby serving as an objective indicator of the need for interventions to improve comprehension.

Aggressive behaviour among drug-using women from Cape Town, South Africa: ethnicity, heavy alcohol use, methamphetamine and intimate partner violence.

BACKGROUND: Women have generally been found to be the victims of violence, but scant attention has been paid to the characteristics of women who perpetrate aggression and violence. In South Africa, violence is a prevalent societal issue, especially in the Western Cape. METHOD: This study aimed at identifying factors that were associated with aggression among a sample of 720 substance-using women. We conducted multivariate logistic regression to identify factors that are significantly associated with these behaviours. RESULTS: Ethnicity (Wald Χ2 = 17.07(2), p < 0.01) and heavy drinking (Wald Χ2 = 6.60 (2), p = 0.01) were significantly related to verbal aggression, methamphetamine use was significantly related to physical (Wald Χ2 = 2.73 (2), p = 0.01) and weapon aggression (Wald Χ2 = 7.94 (2), p < 0.01) and intimate partner violence was significantly related to verbal (Wald Χ2 = 12.43 (2), p < 0.01) and physical aggression (Wald Χ2 = 25.92 (2), p < 0.01). CONCLUSIONS: The findings show high levels of aggression among this sample, and highlight the need for interventions that address methamphetamine, heavy drinking and intimate partner violence among vulnerable substance-using women.

HIV Prevention Among Women Who Use Substances And Report Sex Work: Risk Groups Identified Among South African Women.

This cross-sectional study presents baseline data from women (n = 641) in a community-based randomized trial in Pretoria, South Africa. Women were eligible if they reported recent alcohol or other drug (AOD) use and condomless sex. Latent class analyses were conducted separately for those who reported sex work and those who did not. Among those who reported sex work, a Risky Sex class (n = 72, 28%) and Low Sexual Risk class (n = 190, 73%) emerged. Those in the Risky Sex class were more likely to report that their last episode of sexual intercourse was with their boyfriend (vs. a client/other partner) compared with the Low Sexual Risk class (p < 0.001). Among participants who did not report sex work, a Drug-Using, Violence-Exposed, and Impaired Sex class (n = 53; 14%) and Risky Sex and Moderate Drinking class (n = 326; 86%) emerged. The findings suggest that interventions for women who engage in sex work should promote safer sexual behavior and empowerment with main partners. Women who use AODs, experience physical or sexual violence, and have impaired sex may be a key population at risk for HIV and should be considered for tailored behavioral interventions in conjunction with South Africa's plan to disseminate HIV prevention methods to vulnerable women. TRIAL REGISTRATION: ClinicalTrials.gov registration NCT01497405.

Efficacy of the Young Women's CoOp: An HIV Risk-Reduction Intervention for Substance-Using African-American Female Adolescents in the South.

HIV/sexually transmitted infection (STI) risk-reduction interventions are needed to address the complex risk behaviors among African-American female adolescents in disadvantaged communities in North Carolina. In a two-group randomized trial, we reached 237 sexually active, substance-using African-American female adolescents, to test a risk-reduction intervention, the Young Women's CoOp (YWC), relative to a nutrition control. In efficacy analyses adjusting for baseline condom use, at three-month follow-up participants in the YWC were significantly less likely to report sex without a condom at last sex relative to control. There were mixed findings for within-group differences over follow-up, underscoring the challenges for intervening with substance-using female youths.

Seek, test, treat: substance-using women in the HIV treatment cascade in South Africa.

BACKGROUND: Women in South Africa who use alcohol and other drugs face multiple barriers to HIV care. These barriers make it difficult for women to progress through each step in the HIV treatment cascade from diagnosis to treatment initiation and adherence. This paper examines correlates of HIV status, newly diagnosed HIV status, and use of antiretroviral therapy (ART). METHODS: Outreach workers recruited sexually active Black African women who used substances in Pretoria as part of a U.S. National Institutes of Health-funded geographically clustered randomized trial examining the effect of an intervention to reduce alcohol and drug use as well as sexual risk behaviors. To address the question of interest in the current investigation, cross-sectional baseline data were used. At study enrollment, all participants (N = 641) completed an interview, and underwent rapid HIV testing and biological drug screening. Those who tested positive for HIV and were eligible for ART were asked about their barriers to initiating or adhering to ART. Bivariate and multivariable logistic regression analyses were conducted to determine correlates of HIV status, newly diagnosed HIV, and ART use. RESULTS: At enrollment, 55% of participants tested positive for HIV, and 36% of these women were newly diagnosed. In multivariable analyses of the entire sample, women who had completed 10th grade were less likely to be living with HIV (OR 0.69; CI 0.48, 0.99) and those from the inner city were more likely to be living with HIV (OR 1.83; CI 1.26, 2.67). Among HIV-positive participants, women were less likely to be newly diagnosed if they had ever been in substance abuse treatment (OR 0.15; CI 0.03, 0.69) or used a condom at last sex (OR 0.58; CI 0.34, 0.98) and more likely to be newly diagnosed if they were physically assaulted in the past year (OR 1.97; CI 1.01, 3.84). Among women eligible for ART, fewer were likely to be on treatment (by self-report) if they had a positive urine test for opiates or cocaine (OR 0.27; CI 0.09, 0.80). CONCLUSIONS: These results, although cross-sectional, provide some guidance for provincial authorities to address barriers to HIV care for sexually active, substance-using vulnerable women in Pretoria. Targeting the inner city with prevention campaigns, expanding and improving substance abuse treatment programs, linking clients with simultaneous HIV testing and treatment, and targeting women who have experienced sexual assault and violence may help the government achieve the UNAIDS 90-90-90 treatment target. Clinical Trials.gov NCT01497405 registered on December 1, 2011.