Mortality variability and differentials by age and causes of death in rural South Africa, 1994-2018.

INTRODUCTION: Understanding mortality variability by age and cause is critical to identifying intervention and prevention actions to support disadvantaged populations. We assessed mortality changes in two rural South African populations over 25 years covering pre-AIDS and peak AIDS epidemic and subsequent antiretroviral therapy (ART) availability. METHODS: Using population surveillance data from the Agincourt Health and Socio-Demographic Surveillance System (AHDSS; 1994-2018) and Africa Health Research Institute (AHRI; 2000-2018) for 5-year periods, we calculated life expectancy from birth to age 85, mortality age distributions and variation, and life-years lost (LYL) decomposed into four cause-of-death groups. RESULTS: The AIDS epidemic shifted the age-at-death distribution to younger ages and increased LYL. For AHDSS, between 1994-1998 and 1999-2003 LYL increased for females from 13.6 years (95% CI 12.7 to 14.4) to 22.1 (95% CI 21.2 to 23.0) and for males from 19.9 (95% CI 18.8 to 20.8) to 27.1 (95% CI 26.2 to 28.0). AHRI LYL in 2000-2003 was extremely high (females=40.7 years (95% CI 39.8 to 41.5), males=44.8 years (95% CI 44.1 to 45.5)). Subsequent widespread ART availability reduced LYL (2014-2018) for women (AHDSS=15.7 (95% CI 15.0 to 16.3); AHRI=22.4 (95% CI 21.7 to 23.1)) and men (AHDSS=21.2 (95% CI 20.5 to 22.0); AHRI=27.4 (95% CI 26.7 to 28.2)), primarily due to reduced HIV/AIDS/TB deaths in mid-life and other communicable disease deaths in children. External causes increased as a proportion of LYL for men (2014-2018: AHRI=25%, AHDSS=17%). The share of AHDSS LYL 2014-2018 due to non-communicable diseases exceeded pre-HIV levels: females=43%; males=40%. CONCLUSIONS: Our findings highlight shifting burdens in cause-specific LYL and persistent mortality differentials in two populations experiencing complex epidemiological transitions. Results show high contributions of child deaths to LYL at the height of the AIDS epidemic. Reductions in LYL were primarily driven by lowered HIV/AIDS/TB and other communicable disease mortality during the ART periods. LYL differentials persist despite widespread ART availability, highlighting the contributions of other communicable diseases in children, HIV/AIDS/TB and external causes in mid-life and non-communicable diseases in older ages.

Understanding Household Dynamics From the Ground Up: A Longitudinal Study From a Rural South African Setting.

Investigations into household structure in low- and middle-income countries (LMICs) provide important insight into how families manage domestic life in response to resource allocation and caregiving needs during periods of rapid sociopolitical and health-related challenges. Recent evidence on household structure in many LMICs contrasts with long-standing viewpoints of worldwide convergence to a Western nuclearized household model. Here, we adopt a household-centered theoretical and methodological framework to investigate longitudinal patterns and dynamics of household structure in a rural South African setting during a period of high AIDS-related mortality and socioeconomic change. Data come from the Agincourt Health and Socio-Demographic Surveillance System (2003-2015). Using latent transition models, we derived six distinct household types by examining conditional interdependency between household heads' characteristics, members' age composition, and migration status. More than half of households were characterized by their complex and multigenerational profiles, with considerable within-typology variation in household size and dependency structure. Transition analyses showed stability of household types under female headship, while higher proportions of nuclearized household types dissolved over time. Household dissolution was closely linked to prior mortality experiences-particularly, following death of a male head. Our findings highlight the need to better conceptualize and contextualize household changes across populations and over time.

The effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019: a data note.

OBJECTIVES: South Africa is experiencing both HIV and hypertension epidemics. Data were compiled for a study to identify effects of HIV and high systolic blood pressure on mortality risk among people aged 40-plus in a rural South African area experiencing high prevalence of both conditions. We aim to release the replication data set for this study. DATA DESCRIPTION: The research data comes from the 2010-11 Ha Nakekela (We Care) population-based survey nested in the Agincourt Health and socio-Demographic Surveillance System (AHDSS) located in the northeast region of South Africa. An age-sex-stratified probability sample was drawn from the AHDSS. The public data set includes information on individual socioeconomic characteristics and measures of HIV status and blood pressure for participants aged 40-plus by 2019. The AHDSS, through its annual surveillance, provided mortality data for nine years subsequent to the survey. These data were converted to person-year observations and linked to the individual-level survey data using participants' AHDSS census identifier. The data can be used to replicate Houle et al. (2022) - which used discrete-time event history models stratified by sex to assess differential mortality risks according to Ha Nakekela measures of HIV-infection, HIV-1 RNA viral load, and systolic blood pressure.

Biomedical bargains: Negotiating "safe sex" on antiretroviral treatment in rural South Africa.

Wide-scale availability of antiretroviral treatment (ART) has transformed the global landscape for HIV prevention, shifting emphasis away from a strictly behavioral focus on changing sexual practices towards a biomedical approach. Successful ART management is measured by an undetectable viral load, which helps maintain overall health and prevent onward viral transmission. The latter utility of ART, however, must be understood in the context of its implementation. In South Africa, ART has become easily accessible - yet ART knowledge spreads unevenly, while counseling advice and normative expectations and experiences of gender and aging interact to inform sexual practices. As ART enters the sexual lives of middle-aged and older people living with HIV (MOPLH), a population growing rapidly, how has it informed sexual decisions and negotiations? Drawing on in-depth interviews with MOPLH on ART, corroborated with focus group discussions and national ART-related policies and guidelines, we find that for MOPLH, sexual decisions increasingly feature compliance with biomedical directives and concern for ART efficacy. Seeking consensus regarding the biological risks of sex on ART becomes an important feature of sexual negotiations, and anticipated disagreements can pre-empt sexual relationships altogether. We introduce the concept of biomedical bargains to explain what happens when disagreements arise, and the terms of sex are negotiated using competing interpretations of biomedical information. For both men and women, ostensibly gender-neutral biomedical discourses provide new discursive resources and strategies for sexual decisions and negotiations, yet biomedical bargains are still embedded in gender dynamics-women invoke the dangers of jeopardizing treatment efficacy and longevity to insist on condoms or justify abstinence, while men utilize biomedical arguments in an effort to render condomless sex safe. While the full therapeutic benefits of ART are critical for the efficacy and equity of HIV programs, they will nonetheless always affect, and be affected by, social life.

"I'm Getting Life from the Treatment": Perceptions of Life and Death Among Middle-Aged and Older Medication-Adherent Persons Living with HIV in Rural South Africa.

The widespread availability of health information and treatment for HIV in Southern Africa does not reach all populations. Few programs and materials are developed with middle-aged and older rural individuals living with HIV as the target audience, despite this being a growing population. This vacuum inevitably exacerbates the disjuncture between clinical and experiential knowledge. This study uses in-depth interviews from 2018 with middle-aged and older rural South Africans who self-report medication adherence to ART in order to explore experiences of living with HIV and beliefs about anti-retroviral treatment (ART). Participants revealed a general sense of vulnerability as a major motivation for HIV medication adherence. A majority of the participants believed that death was imminent if they defaulted on ART at any point in time. Although the availability of ART brought hope to many, HIV was still perceived as a death sentence, particularly if ART adherence was imperfect. The study findings suggest a need to examine the psychosocial component of community programs for middle-aged and older people living with HIV. For this growing population that experienced the full course of the epidemic, more research is needed on the burden of psychological and mental health issues emerging from the need for long-term HIV medication adherence.

Twin epidemics: the effects of HIV and systolic blood pressure on mortality risk in rural South Africa, 2010-2019.

BACKGROUND: Sub-Saharan African settings are experiencing dual epidemics of HIV and hypertension. We investigate effects of each condition on mortality and examine whether HIV and hypertension interact in determining mortality. METHODS: Data come from the 2010 Ha Nakekela population-based survey of individuals ages 40 and older (1,802 women; 1,107 men) nested in the Agincourt Health and socio-Demographic Surveillance System in rural South Africa, which provides mortality follow-up from population surveillance until mid-2019. Using discrete-time event history models stratified by sex, we assessed differential mortality risks according to baseline measures of HIV infection, HIV-1 RNA viral load, and systolic blood pressure. RESULTS: During the 8-year follow-up period, mortality was high (477 deaths). Survey weighted estimates are that 37% of men (mortality rate 987.53/100,000, 95% CI: 986.26 to 988.79) and 25% of women (mortality rate 937.28/100,000, 95% CI: 899.7 to 974.88) died. Over a quarter of participants were living with HIV (PLWH) at baseline, over 50% of whom had unsuppressed viral loads. The share of the population with a systolic blood pressure of 140mm Hg or higher increased from 24% at ages 40-59 to 50% at ages 75-plus and was generally higher for those not living with HIV compared to PLWH. Men and women with unsuppressed viral load had elevated mortality risks (men: adjusted odds ratio (aOR) 3.23, 95% CI: 2.21 to 4.71, women: aOR 2.05, 95% CI: 1.27 to 3.30). There was a weak, non-linear relationship between systolic blood pressure and higher mortality risk. We found no significant interaction between systolic blood pressure and HIV status for either men or women (p>0.05). CONCLUSIONS: Our results indicate that HIV and elevated blood pressure are acting as separate, non-interacting epidemics affecting high proportions of the older adult population. PLWH with unsuppressed viral load were at higher mortality risk compared to those uninfected. Systolic blood pressure was a mortality risk factor independent of HIV status. As antiretroviral therapy becomes more widespread, further longitudinal follow-up is needed to understand how the dynamics of increased longevity and multimorbidity among people living with both HIV and high blood pressure, as well as the emergence of COVID-19, may alter these patterns.

'Sometimes it is not about men': Gendered and generational discourses of caregiving HIV transmission in a rural South African setting.

ABSTRACTIn this paper, we examine a prominent interpretation of HIV risk in a rural South African setting experiencing a severe HIV epidemic well into older ages: the discourse of caregiving HIV transmission. By caregiving transmission, we refer to HIV infection resulting from caring for family members who are living with HIV and may be sick with AIDS-related illnesses. We draw on individual life history and community focus group interviews with men and women aged 40-80+, as well as interviews with health workers providing HIV counselling and testing services at local health facilities in their communities. We illustrate the social and strategic role caregiving HIV transmission discourses play in re-signifying HIV as a sexless infection for older women, thereby promoting HIV testing as well as blameless acceptance of an HIV diagnosis. We further highlight the role of rural health workers who serve as medical epistemic bricoleurs, vernacularising global HIV counselling and prevention messages by blending ideas of gender, generation, and local lived experiences and practices so that they resonate with community norms, values and understandings. Our study highlights the gendered and generational complexities and challenges experienced by rural South Africans aging in a community over-burdened by an HIV epidemic and AIDS-related mortality.

The end of AIDS? HIV and the new landscape of illness in rural South Africa.

The global HIV/AIDS scientific community has begun to hail the dawn of 'the End of AIDS' with widespread anti-retroviral therapy (ART) and dramatic declines in AIDS-related mortality. Drawing on community focus groups and in-depth individual interviews conducted in rural South Africa, we examine the complex unfolding of the end of AIDS in a hard-hit setting. We find that while widespread ART has led to declines in AIDS-related deaths, stigma persists and is now freshly motivated. We argue that the shifting landscape of illness in the community has produced a new interpretive lens through which to view living with HIV and dying from AIDS. Most adults have one or more chronic illnesses, and ART-managed HIV is now considered a preferred diagnosis because it is seen as easier to manage, more responsive to medication, and less dangerous compared to diseases like cancer, hypertension, and diabetes. Viewed through this comparative lens, dying from AIDS elicits stigmatising individual blame. We find that blame persists despite community acknowledgement of structural barriers to ART adherence. Setting the ending of AIDS within its wider health context sheds light on the complexities of the epidemiological and health transitions underway in much of the developing world.

From "Secret" to "Sensitive Issue": Shifting Ideas About HIV Disclosure Among Middle-Aged and Older Rural South Africans in the Era of Antiretroviral Treatment.

OBJECTIVE: As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout. METHODS: Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure. FINDINGS: Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family). DISCUSSION: Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

Hypertension incidence among middle-aged and older adults: findings from a 5-year prospective study in rural South Africa, 2010-2015.

OBJECTIVES: There is a scarcity of longitudinal cohort studies in sub-Saharan Africa to understand the epidemiology of cardiovascular disease as a basis for intervention. We estimated incident hypertension and associated sociodemographic, health and behavioural risk factors in a population aged 40 years and older over a 5-year period. DESIGN: We assessed the association between incident hypertension and sociodemographic, health and behavioural factors using Poisson regression. We adjusted for non-response in 2015 using inverse probability sampling weights from a logistic regression including sex and age at baseline. SETTING: Rural South Africa. PARTICIPANTS: We used a population-based cohort of normotensive adults in 2010 who were aged 40 years and older at retest in 2015. RESULTS: Of 676 individuals completing baseline and 5-year follow-up, there were 193 incident cases of hypertension. The overall hypertension incidence rate was 8.374/100 person-years. In multivariable analyses, those who became hypertensive were more likely to be older, have a high waist circumference (incidence rate ratio (IRR): 1.557, 95% CI: 1.074 to 2.259) and be employed (IRR: 1.579, 95% CI: 1.071 to 2.329) at baseline. Being HIV positive and not on antiretroviral therapy at baseline was associated with lower risk of incident hypertension. CONCLUSIONS: Over a 5-year period, 29% of respondents developed hypertension. Given the high burden of hypertension in South Africa, continued longitudinal follow-up is needed to understand the complex interplay of non-communicable and infectious diseases and their underlying and modifiable risk factors to inform public health prevention strategies and programmes.

"A NOWADAYS DISEASE": HIV/AIDS AND SOCIAL CHANGE IN A RURAL SOUTH AFRICAN COMMUNITY.

Why do some people adapt successfully to change while others do not? We examine this question in the context of a severe HIV/AIDS epidemic in South Africa, where adapting (or not) to social change has borne life and death consequences. Applying an age-period-cohort lens to the analysis of qualitative life history interviews among middle-aged and older adults, we consider the role of the life course and gendered sexuality in informing Africans' strategies of action, or inaction, and in differentially driving and stalling change in each cohort in response to the HIV/AIDS epidemic. Our study illuminates the unique challenges of adapting to social change that result from dynamic interactions among aging, prevailing social structures, and a cohort's socio-historical orientation to a new period.

Brief Report: HIV Incidence Among Older Adults in a Rural South African Setting: 2010-2015.

INTRODUCTION: In South Africa, evidence shows high HIV prevalence in older populations, with sexual behavior consistent with high HIV acquisition and transmission risk. However, there is a dearth of evidence on older people's HIV incidence. METHODS: We used a 2010-2011 cohort of HIV-negative adults in rural South Africa who were 40 years or older at retest in 2015-2016 to estimate HIV incidence over a 5-year period. We used Poisson regression to measure the association of HIV seroconversion with demographic and behavioral covariates. We used inverse probability sampling weights to adjust for nonresponse in 2015, based on a logistic regression with predictors of sex and age group at August 2010. RESULTS: HIV prevalence increased from 21% at baseline to 23% in the follow-up survey. From a cohort of 1360 individuals, 33 seroconverted from HIV negative at baseline, giving an overall HIV incidence rate of 0.39 per 100 person-years [95% confidence interval (CI): 0.28 to 0.57]. The rate for women was 0.44 (95% CI: 0.30 to 0.67), double than that for men, 0.21 (95% CI: 0.10 to 0.51). Incidence rate ratios (IRRs) again show women's risk of seroconverting double than that of men (IRR = 2.04, P value = 0.098). In past age 60, the IRR of seroconversion was significantly lower than that for those in their 40s (60-69, IRR = 0.09, P value = 0.002; 70-79, IRR = 0.14, P value = 0.010). CONCLUSIONS: The risk of acquiring HIV is not zero for people older than 50 years, especially women. Our findings highlight the importance of acknowledging that older people are at high risk of HIV infection and that HIV prevention and treatment campaigns must take them into consideration.

Clusters of HIV Risk and Protective Sexual Behaviors in Agincourt, Rural South Africa: Findings from the Ha Nakekela Population-Based Study of Ages 15 and Older.

Understanding how sexual behaviors cluster in distinct population subgroups along the life course is critical for effective targeting and tailoring of HIV prevention messaging and intervention activities. We examined interrelatedness of sexual behaviors and variation between men and women across a wide age range in a rural South African setting with a high HIV burden. Data come from the Ha Nakekela population-based survey of people aged 15-85-plus drawn from the Agincourt Health and Socio-Demographic Surveillance System. We used latent class analysis of six sexual behavior indicators to identify distinct subgroup sexual behavior clusters. We then examined associations between class membership and sociodemographic and other behavioral risk factors and assessed the accuracy of a reduced set of sexual behavior indicators to classify individuals into latent classes. We identified three sexual behavior classes: (1) single with consistent protective behaviors; (2) risky behaviors; and (3) in union with lack of protective behaviors. Patterns of sexual behaviors varied by gender. Class membership was also associated with age, HIV status, nationality, and alcohol use. With only two sexual behavior indicators (union status and multiple sexual partners), individuals were accurately assigned to their most likely predicted class. There were distinct multidimensional sexual behavior clusters in population subgroups that varied by sex, age, and HIV status. In this population, only two brief questions were needed to classify individuals into risk classes. Replication in other situations is needed to confirm these findings.

How to "Live a Good Life": Aging and HIV Testing in Rural South Africa.

OBJECTIVE: The African HIV epidemic is aging, yet HIV testing behavior studies either exclude older persons or include too few to say much about age differences. METHOD: Strategically combining focus group interviews (participants in 40s/50s/60s-plus age groups) and survey data from rural South Africa (where HIV prevalence peaks in the late 30s, but continues to be over 10% into the late 60s), we examine gender and life course variation, motivations, and barriers in HIV testing. RESULTS: We find significant gender differences-Women test at higher rates at younger ages, men at older ages. Our qualitative data not only highlight recognition of testing importance but also suggest gendered motivations and perceptions of testing. Men and women report similar barriers, however, including fear of finding out their (positive) HIV status, limited confidentiality, and partner nondisclosure. DISCUSSION: We conclude with recommendations to increase HIV testing uptake among older adults including home testing, couples testing, and HIV testing concurrently with noncommunicable diseases.

Sexual behavior and HIV risk across the life course in rural South Africa: trends and comparisons.

There is limited information about sexual behavior among older Africans, which is problematic given high HIV rates among older adults. We use a population-based survey among people aged 15-80+ to examine the prevalence of sexual risk and protective behaviors in the context of a severe HIV epidemic. We focus on variation across the life course, gender and HIV serostatus to compare the similarities and differences of young, middle aged, and older adults. Younger adults continue to be at risk of HIV, with potential partners being more likely to have been diagnosed with an STI and more likely to have HIV, partner change is high, and condom use is low. Middle aged and older adults engage in sexual behavior that makes them vulnerable at older ages, including extramarital sex, low condom use, and cross-generational sex with people in age groups with the highest rates of HIV. We find insignificant differences between HIV positive and negative adults' reports of recent sexual activity. This study provides new information on sexual behavior and HIV risk across the life course in rural South Africa to inform HIV prevention and treatment programing.

'Taking care' in the age of AIDS: older rural South Africans' strategies for surviving the HIV epidemic.

Older adults have been largely overlooked in community studies of HIV in highly endemic African countries. In our rural study site in Mpumalanga Province, South Africa, HIV prevalence among those aged 50 and older is 16.5%, suggesting that older adults are at risk of both acquiring and transmitting HIV. This paper utilises community-based focus-group interviews with older rural South African men and women to better understand the normative environment in which they come to understand and make decisions about their health as they age in an HIV endemic setting. We analyse the dimensions of an inductively emerging theme: ku ti hlayisa (to take care of yourself). For older adults, 'taking care' in an age of AIDS represented: (1) an individualised pathway to achieving old-age respectability through the taking up of responsibilities and behaviours that characterise being an older person, (2) a set of gendered norms and strategies for reducing one's HIV risk, and (3) a shared responsibility for attenuating the impact of the HIV epidemic in the local community. Findings reflect the individual, interdependent and communal ways in which older rural South Africans understand HIV risk and prevention, ways that also map onto current epidemiological thinking for improving HIV-related outcomes in high-prevalence settings.

Fieldworker effects on substance use reporting in a rural South African setting.

AIMS: Fieldworkers capturing reports of sensitive behaviors, such as substance use, may influence survey responses and represent an important factor in response validity. We explored the effects and interaction of fieldworker and respondent characteristics (age and gender) in substance (tobacco and alcohol) use reporting. We aim to further the literature on conditional social attribution effects on substance use reporting in the context of South Africa, where accurate estimates of modifiable risk factors are critical for medical and public health practitioners and policy-makers in efforts to reduce chronic disease burden and mortality. DESIGN: We modeled substance use reporting using binary logistic regression. We also tested if fieldworker effects remained, allowing for correlation in reporting for respondents with the same fieldworker using multi-level logistic regression. SETTING: Agincourt Health and Socio-Demographic Surveillance System site, rural South Africa. PARTICIPANTS: We used data from a 2010-2011 study on HIV and cardiometabolic risk, ages 15+ (N = 4,684). MEASURES: Lifetime and current alcohol and tobacco use. FINDINGS: Respondents reported higher lifetime smoking use to older fieldworkers. Male respondents reported higher lifetime alcohol use to older fieldworkers. No fieldworker effects were significant on reports of current smoking. An older, male fieldworker increased the probability of reports of current alcohol use. Adjusting for intra-fieldworker correlation explained many of the observed fieldworker effects. CONCLUSIONS: Our results highlight the importance of adjusting for interviewer characteristics to improve the accuracy of chronic disease risk factor estimates and validity of inferred associations. We recommend that surveys collecting information that may be subject to response bias routinely include anonymized fieldworker identifiers and demographic information. Analysts can then use these additional fieldworker data as a tool in evaluating probable bias in respondent reporting.

"They are looking just the same": Antiretroviral treatment as social danger in rural Malawi.

Research on the social impact of ART pivots on questions of individual adherence and community acceptability of treatment programmes. In this paper we examine unexpected and unintended consequences of the scale-up of treatment in rural Malawi, using a unique dataset of more than 150 observational journals from three sites, spanning 2010 to 2013, focusing on men's everyday conversations. Through thematic content analysis, we explore the emerging perception that the widespread availability of ART constitutes a form of social danger, as treatment makes it difficult to tell who does or does not have AIDS. This ambiguity introduced through ART is interpreted as putting individuals at risk, because it is no longer possible to tell who might be infected - indeed, the sick now look healthier and "plumper" than the well. This ambivalence over the social impact of ART co-exists with individual demand for and appreciation of the benefits of treatment.

Reconsidering gendered sexualities in a generalized AIDS epidemic.

Using the threat of a severe AIDS epidemic in a collection of rural villages in South Africa, we illustrate how men and women reconsider gendered sexualities through conversations and interactions in everyday life. We draw from data collected by local ethnographers and focus on the processes through which men and women collectively respond to the threat posed by AIDS to relationships, families, and communities. Whereas previous research has shown that individuals often reaffirm hegemonic norms about gender and sexuality in response to disruptions to heteronormative gender relations, we find that the threat of AIDS provokes reconsideration of gendered sexualities at the community level. That is, our data demonstrate how men and women-through the interactions and exchanges that make up their daily lives-debate, challenge, make sense of, and attempt to come to terms with social norms circumscribing gendered sexual practices in a context where the threat of a fatal disease transmitted through sex looms large. We argue that ethnographic data are particularly useful for capturing communal responses to events that threaten heteronormative gender relations and reflect on how our findings inform theories of gender relations and processes.

Let's Talk about Sex, Maybe: Interviewers, Respondents, and Sexual Behavior Reporting in Rural South Africa.

Researchers are often skeptical of sexual behavior surveys: respondents may lie or forget details of their intimate lives, and interviewers may exercise authority in how they capture responses. We use data from a 2010-2011 cross-sectional sexual behavior survey in rural South Africa to explore who says what to whom about their sexual lives. Results show an effect of fieldworker age across outcomes -- respondents report "safer", more "responsible" sexual behavior to older fieldworkers; and an effect of fieldworker sex -- men report more sexual partners to female fieldworkers. Understanding fieldworker effects on the production of sexual behavior survey data serves methodological and analytical goals.