High risk injection drug use and uptake of HIV prevention and treatment services among people who inject drugs in KwaZulu-Natal, South Africa.

We conducted a mixed-methods study to understand current drug use practices and access to healthcare services for people who use injection drugs in KwaZulu-Natal, South Africa. We used respondent-driven sampling to recruit 45 people who used injection drugs within the past 6 months from KwaZulu-Natal, South Africa. We found high rates of practices that increase HIV/viral hepatitis risk including the use of shared needles (43%) and direct blood injections (bluetoothing) (18%). Despite 35% living with HIV, only 40% accessed antiretroviral therapy within the past year, and one accessed PrEP. None of the participants ever tested for Hepatitis C.

"I am scared, I do not want to lie": exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa.

BACKGROUND: COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. METHODS: A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. RESULTS: Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. CONCLUSIONS: About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.

High risk injection drug use and uptake of HIV prevention and treatment services among people who inject drugs in KwaZulu-Natal, South Africa.

The use of injection drugs in South Africa is increasing. HIV prevention, treatment and addiction services for people who inject drugs (PWID) in South Africa are not well documented. We conducted a mixed-methods study to understand current drug use practices and access to HIV prevention and treatment services for PWID in KwaZulu-Natal, South Africa. We used respondent-driven sampling to recruit 45 people who reported injecting opiates within the past 6 months from Durban, KwaZulu-Natal, South Africa. We found high rates of practices that increase HIV/viral hepatitis risk including the use of shared needles (43%) and direct blood injections (bluetoothing) (18%). Despite 35% of participants living with HIV, only 40% accessed antiretroviral therapy within the past year, and one accessed PrEP. None of the participants reported ever testing for Hepatitis C.

"I am scared, I do not want to lie": Exploring the impacts of COVID-19 on engagement in care, perceived health, relationship dynamics, and parenting among postpartum women with HIV in South Africa.

Background COVID-19 and efforts to manage widespread infection may compromise HIV care engagement. The COVID-19-related factors linked to reduced HIV engagement have not been assessed among postpartum women with HIV, who are at heightened risk of attrition under non-pandemic circumstances. To mitigate the effects of the pandemic on care engagement and to prepare for future public health crises, it is critical to understand how COVID-19 has impacted (1) engagement in care and (2) factors that may act as barriers to care engagement. Methods A quantitative assessment of COVID-19-related experiences was added to a longitudinal cohort study assessing predictors of postpartum attrition from HIV care among women in South Africa. Participants (N = 266) completed the assessment at 6, 12, 18, or 24 months postpartum between June and November of 2020. Those who endorsed one or more challenge related to engagement in care (making or keeping HIV care appointments, procuring HIV medications, procuring contraception, and/or accessing immunization services for infants; n = 55) were invited to complete a brief qualitative interview, which explored the specific factors driving these challenges, as well as other impacts of COVID-19 on care engagement. Within this subset, 53 participants completed an interview; qualitative data were analyzed via rapid analysis. Results Participants described key challenges that reduced their engagement in HIV care and identified four other domains of COVID-19-related impacts: physical health, mental health, relationship with a partner or with the father of the baby, and motherhood/caring for the new baby. Within these domains, specific themes and subthemes emerged, with some positive impacts of COVID-19 also reported (e.g., increased quality time, improved communication with partner, HIV disclosure). Coping strategies for COVID-19-related challenges (e.g., acceptance, spirituality, distraction) were also discussed. Conclusions About one in five participants reported challenges accessing HIV care, medications, or services, and they faced complex, multilayered barriers to remaining engaged. Physical health, mental health, relationships with partners, and ability to care for their infant were also affected. Given the dynamic nature of the pandemic and general uncertainty about its course, ongoing assessment of pandemic-related challenges among postpartum women is needed to avoid HIV care disruptions and to support wellbeing.

Optimizing PMTCT Adherence by Treating Depression in Perinatal Women with HIV in South Africa: A Pilot Randomized Controlled Trial.

BACKGROUND: South Africa (SA) has the greatest HIV prevalence in the world, with rates as high as 40% among pregnant women. Depression is a robust predictor of nonadherence to antiretroviral therapy (ART) and engagement in HIV care; perinatal depression may affect upwards of 47% of women in SA. Evidence-based, scalable approaches for depression treatment and ART adherence in this setting are lacking. METHOD: Twenty-three pregnant women with HIV (WWH), ages 18-45 and receiving ART, were randomized to a psychosocial depression and adherence intervention or treatment as usual (TAU) to evaluate intervention feasibility, acceptability, and preliminary effect on depressive symptoms and ART adherence. Assessments were conducted pre-, immediately post-, and 3 months post-treatment, and included a qualitative exit interview. RESULTS: Most (67.6%) eligible individuals enrolled; 71% completed at least 75% of sessions. Compared to TAU, intervention participants had significantly greater improvements in depressive symptoms at post-treatment, ß = - 11.1, t(24) = - 3.1, p < 0.005, 95% CI [- 18.41, - 3.83], and 3 months, ß = - 13.8, t(24) = - 3.3, p < 0.005, 95% CI [- 22.50, - 5.17]. No significant differences in ART adherence, social support, or stigma were found. Qualitatively, perceived improvements in social support, self-esteem, and problem-solving adherence barriers emerged as key benefits of the intervention; additional sessions were desired. CONCLUSION: A combined depression and ART adherence intervention appears feasible and acceptable, and demonstrated preliminary evidence of efficacy in a high-need population. Additional research is needed to confirm efficacy and identify dissemination strategies to optimize the health of WWH and their children. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03069417. Protocol available at https://clinicaltrials.gov/ct2/show/NCT03069417.

Demonstration and Acceptability of a Safer Conception Intervention for Men With HIV in South Africa: Pilot Cohort Study.

BACKGROUND: Many men with HIV (MWH) want to have children. HIV viral suppression minimizes sexual HIV transmission risks while allowing for conception and optimization of the health of men, their partners, and their infants. OBJECTIVE: This study developed and evaluated the feasibility and acceptability of an intervention to promote serostatus disclosure, antiretroviral therapy (ART) uptake and adherence, and viral suppression among MWH who want to have children in South Africa. METHODS: We developed a safer conception intervention (Sinikithemba Kwabesilisa or We give hope to men) to promote viral suppression via ART uptake and adherence, HIV serostatus disclosure, and other safer conception strategies for MWH in South Africa. Through 3 counseling and 2 booster sessions over 12 weeks, we offered education on safer conception strategies and aided participants in developing a safer conception plan. We recruited MWH (HIV diagnosis known for >1 month), not yet accessing ART or accessing ART for <3 months, in a stable partnership with an HIV-negative or unknown-serostatus woman, and wanting to have a child in the following year. We conducted an open pilot study to evaluate acceptability based on patient participation and exit interviews and feasibility based on recruitment and retention. In-depth exit interviews were conducted with men to explore intervention acceptability. Questionnaires collected at baseline and exit assessed disclosure outcomes; CD4 and HIV-RNA data were used to evaluate preliminary impacts on clinical outcomes of interest. RESULTS: Among 31 eligible men, 16 (52%) enrolled in the study with a median age of 29 (range 27-44) years and a median time-since-diagnosis of 7 months (range 1 month to 9 years). All identified as Black South African, with 56% (9/16) reporting secondary school completion and 44% (7/16) reporting full-time employment. Approximately 44% (7/16) of participants reported an HIV-negative (vs unknown-serostatus) partner. Approximately 88% (14/16) of men completed the 3 primary counseling sessions. In 11 exit interviews, men reported personal satisfaction with session content and structure while also suggesting that they would refer their peers to the program. They also described the perceived effectiveness of the intervention and self-efficacy to benefit. Although significance testing was not conducted, 81% (13/16) of men were taking ART at the exit, and 100% (13/13) of those on ART were virally suppressed at 12 weeks. Of the 16 men, 12 (75%) reported disclosure to pregnancy partners. CONCLUSIONS: These preliminary data suggest that safer conception care is acceptable to men and has the potential to reduce HIV incidence among women and their children while supporting men's health. Approximately half of the men who met the screening eligibility criteria were enrolled. Accordingly, refinement to optimize uptake is needed. Providing safer conception care and peer support at the community level may help reach men. TRIAL REGISTRATION: ClinicalTrials.gov NCT03818984; https://clinicaltrials.gov/ct2/show/NCT03818984. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-https://doi.org/10.1007/s10461-017-1719-4.

Acceptability of an Intervention to Promote Viral Suppression and Serostatus Disclosure for Men Living with HIV in South Africa: Qualitative Findings.

Men living with HIV (MLWH) often have reproductive goals that can increase HIV-transmission risks to their pregnancy partners. We developed a safer conception intervention for MLWH in South Africa employing cognitive behavioral skills to promote serostatus disclosure, ART uptake, and viral suppression. MLWH were recruited from an HIV clinic near Durban, South Africa, and encouraged to include partners in follow-up visits. Exit in-depth interviews were conducted with eleven men and one female partner. The emerging over-arching theme is that safer conception care mitigates internalized and community-level HIV-stigma among MLWH. Additional related sub-themes include: (1) safer conception care acceptability is high but structural barriers challenge participation; (2) communication skills trainings helped overcome barriers to disclose serostatus; (3) feasibility and perceived effectiveness of strategies informed safer conception method selection. Our findings suggest that offering safer conception care to MLWH is a novel stigma-reducing strategy for motivating HIV prevention and treatment and serostatus disclosure to partners.

"I did not plan that is what hurts": Pregnancy intentions and contraceptive use among pregnant young women in KwaZulu-Natal, South Africa.

Unintended pregnancy impacts many young women in South Africa, and rates of consistent contraceptive use among this population are suboptimal. Limited empirical work has investigated reasons for inconsistency between pregnancy intention and contraceptive use behaviour with data collected during pregnancy. We explored pregnancy intentions and discordance between intentions and contraceptive use prior to conception among young pregnant women in KwaZulu-Natal, South Africa. In-depth qualitative interviews were conducted with 35 women during pregnancy (mean age = 19.3; range = 18-21) in 2011 and 2012. Data were analysed using content analysis. All participants reported unintended pregnancies; almost half were not using contraception near conception. Reasons for not intending to become pregnant spanned personal, social, health, and economic domains. Participants living with HIV (n = 13) expressed specific concerns related to impacts of pregnancy on HIV disease management and fear of transmission of HIV to the infant. Discordance between pregnancy intentions and contraceptive use prior to conception was attributed to personal, social, health and structural domains. Findings indicate a need for interventions that address barriers to contraceptive use in order to minimise unintended pregnancy and support safe, desired pregnancies among young women.

Overcoming Ethical Challenges to Engaging Men Who Have Sex with Women in HIV Research.

Men who have sex with women are understudied in HIV research despite the extent to which they experience HIV-related mortality and contribute to the epidemic among women. During our experience of developing and piloting an HIV prevention intervention for men living with HIV in South Africa, and planning to have a child with an HIV-negative woman, ethical questions were posed regarding implementation of a male-centered intervention that did not require female partner participation. Two overarching ethical issues were the potential for (1) compromising women's reproductive and sexual autonomy and (2) increasing HIV-acquisition risks for the woman because the intervention efficacy was unknown. We describe here how these concerns were addressed to facilitate development of a male-centered HIV-prevention intervention. We hope this process manuscript will support researchers, clinicians, and reviewers to engage men who have sex with women in HIV prevention and care.

Trajectories of initiation for the heroin-based drug whoonga - qualitative evidence from South Africa.

BACKGROUND: Whoonga is a smoked heroin-based street drug that first emerged in South Africa a decade ago. While previous scientific reports suggest that use is growing and youth are particularly vulnerable, trajectories of initiation are not well characterized. METHODS: In 2015, 30 men undergoing residential addiction treatment for this smoked heroin drug in KwaZulu-Natal, South Africa participated in semi-structured interviews about their experiences using the drug. Interview data were coded using qualitative content analysis. RESULTS: Participant trajectories to initiating smoked heroin were "vertical" in the context of marijuana use or "horizontal" in the context of other hard drug use. Participants reporting vertical trajectories began smoking heroin as youth at school or in other settings where people were smoking marijuana. Several participants with horizontal trajectories started smoking heroin to address symptoms of other drug or alcohol addiction. Social influences on initiation emerged as an overarching theme. Members of participants' social networks who were smoking or distributing heroin figured prominently in initiation narratives. Surprisingly, references to injection drug use were absent from initiation narratives. Participants reported people who smoke heroin differ from those who inject heroin by race. CONCLUSION: Consistent with theories implicating social and structural influences on substance use initiation, people who started smoking heroin had social contacts who smoked heroin and frequented places where substance use was common. Smoked heroin initiation for several participants with horizontal trajectories may have been averted if they accessed evidence-based treatments for stimulant or alcohol use disorders. With increasing reports of heroin use across Africa, a coordinated approach to address this growing epidemic is needed. However, because smoked heroin and injection heroin use occur in distinct risk environments, interventions tailored to people who use smoked heroin will be needed to prevent smoked heroin use, prevent transition to injection use, and mitigate other social harms.

PMTCT Adherence in Pregnant South African Women: The Role of Depression, Social Support, Stigma, and Structural Barriers to Care.

BACKGROUND: Depression is a robust predictor of nonadherence to antiretroviral (ARV) therapy, which is essential to prevention of mother-to-child transmission (PMTCT). Women in resource-limited settings face additional barriers to PMTCT adherence. Although structural barriers may be minimized by social support, depression and stigma may impede access to this support. PURPOSE: To better understand modifiable factors that contribute to PMTCT adherence and inform intervention development. METHODS: We tested an ARV adherence model using data from 200 pregnant women enrolled in PMTCT (median age 28), who completed a third-trimester interview. Adherence scores were created using principal components analysis based on four questions assessing 30-day adherence. We used path analysis to assess (i) depression and stigma as predictors of social support and then (ii) the combined associations of depression, stigma, social support, and structural barriers with adherence. RESULTS: Elevated depressive symptoms were directly associated with significantly lower adherence (est = -8.60, 95% confidence interval [-15.02, -2.18], p < .01). Individuals with increased stigma and depression were significantly less likely to utilize social support (p < .01, for both), and higher social support was associated with increased adherence (est = 7.42, 95% confidence interval [2.29, 12.58], p < .01). Structural barriers, defined by income (p = .55) and time spent traveling to clinic (p = .31), did not predict adherence. CONCLUSIONS: Depression and social support may play an important role in adherence to PMTCT care. Pregnant women living with HIV with elevated depressive symptoms and high levels of stigma may suffer from low social support. In PMTCT programs, maximizing adherence may require effective identification and treatment of depression and stigma, as well as enhancing social support.

Protocol for a prospective evaluation of postpartum engagement in HIV care among women living with HIV in South Africa.

INTRODUCTION: KwaZulu-Natal (KZN), South Africa (SA) has the highest prevalence of pregnant women living with HIV in the world. Pregnancy and the postpartum period offer opportunities to engage women in HIV care, to prevent perinatal transmission and to optimise maternal and infant well-being. However, research suggests that remaining engaged in HIV care during this time can be challenging. METHODS AND ANALYSIS: We are conducting a 5-year prospective cohort study among pregnant women living with HIV in KZN to estimate the rates and factors associated with attrition from HIV care during this critical period. To determine who is most likely to fall out of care, we are examining a range of relevant variables informed by a socioecological model of HIV care, including individual, relational, community and healthcare system variables. We are enrolling 18-45-year-old women, at 28 weeks or more of pregnancy, who are living with HIV and currently taking antiretroviral therapies. Participants complete quantitative assessments at baseline (pregnancy) and at 6, 12, 18 and 24 months postpartum. A subset of women and their partners are invited to complete qualitative interviews to further explore their experiences in HIV care. The main study outcomes are suppressed HIV RNA and retention in care at each study assessment. Our understanding of the factors that drive postpartum attrition from HIV care will ultimately inform the development of interventions to facilitate continued engagement in postpartum HIV care. ETHICS AND DISSEMINATION: This protocol has been approved by the Human Research Ethics Committee (Medical) at The University of the Witwatersrand (Johannesburg, SA) and the Partners Human Research Committee at Partners HealthCare (Boston, Massachusetts, USA). Site support and approval were obtained from the District Hospital and the KZN Provincial Department of Health. Results will be disseminated through peer-reviewed manuscripts, reports and both local and international presentations (Ethics Registration #170 212).

Sexual Relationship Power and Periconception HIV-Risk Behavior Among HIV-Infected Men in Serodifferent Relationships.

Gender norms affect HIV risk within serodifferent partnerships. We assessed how the sexual relationship power described by men living with HIV (MLWH) associates with periconception HIV-transmission risk behavior. Quantitative surveys were conducted with 82 MLWH reporting a recent pregnancy with an HIV-negative or unknown-serostatus partner in KwaZulu-Natal, South Africa. Surveys assessed decision-making dominance (DMD) using the Pulerwitz et al. sexual relationship power scale; partnership characteristics; and HIV-risk behaviors. Multivariable logistic regression models evaluated associations between DMD score and HIV-risk behaviors. Higher male decision-making dominance was associated with non-disclosure of HIV-serostatus to pregnancy partner (aRR 2.00, 95% CI 1.52, 2.64), not knowing partner's HIV-serostatus (aRR 1.64, 95% CI 1.27, 2.13), condomless sex since pregnancy (aRR 1.92, 95% CI 1.08, 3.43), and concurrent relationships (aRR 1.50, 95% CI 1.20, 1.88). Efforts to minimize periconception HIV-risk behavior must address gender norms and power inequities.

Breastfeeding Practices Among Women Living with HIV in KwaZulu-Natal, South Africa: An Observational Study.

INTRODUCTION: Exclusive breastfeeding (EBF) is the safest infant feeding option in resource-limited settings, though women living with HIV have the lowest rates of EBF. Barriers to EBF in the absences of a formal intervention in women living with HIV in KwaZulu-Natal, where the prevalence of HIV among pregnant women is among the highest in the world, are understudied. Thus, this study sought to describe barriers to EBF and examine differences in social support, disclosure status, mood, and HIV-related stigma among women with different feeding methods. METHODS: Women living with HIV enrolled in preventing mother-to-child transmission treatment (n = 156) were interviewed postpartum (M = 13.1 weeks) at a district hospital and self-reported infant feeding method, reasons not breastfeeding (if applicable), and HIV disclosure status. Mood, HIV-related stigma, functional social support, and HIV-related social support were also assessed. RESULTS: No participants reported mixed feeding, 30% reported EBF, and 70% reported exclusive formula feeding. Commonly reported reasons for not breastfeeding included fear of HIV transmission to the infant and being away from the infant for extended periods of time. Social support (p = 0.02) and HIV-related social support (p < 0.01) were significantly higher in women who had attempted breastfeeding compared to women who never attempted breastfeeding. DISCUSSION: Rates of EBF in this sample are lower than in other recent studies, suggesting this sample experiences multiple barriers to EBF. Healthcare providers should seek to correct misconceptions regarding HIV transmission and breastfeeding practices. Social and logistical support for EBF may be important considerations for future interventions.

"As we have gathered with a common problem, so we seek a solution": exploring the dynamics of a community dialogue process to encourage community participation in family planning/contraceptive programmes.

BACKGROUND: Community dialogues have been widely used as a method for community engagement and participation to cover a broad range of areas. However, there has been limited documentation and evaluation of the process, particularly as a method towards achieving family planning and contraception (FP/C) programme goals. As part of the development of an intervention package aimed at increasing community and health care provider (HCP) participation in the provision of FP/C, feasibility testing of the intervention approach (a community dialogue between communities and health facilities) was carried out. Our findings offer a systematic description and evaluation of the community dialogue process, with key recommendations towards future implementation. METHODS: The dialogue was evaluated in three ways: 1) through participant observation during the community dialogue, 2) via a standardised feasibility testing tick-list for all observers of the dialogue, and 3) through three focus group discussions (FGDs) consisting of different groups of stakeholders who participated in the community dialogue. In total, 28 community members, HCPs, and key stakeholders attended the community dialogue (22 females, 6 males). Twenty-seven of the community dialogue participants participated in one of 3 FGDs held after the dialogue. Six evaluators assessed feasibility of the dialogue process. RESULTS: There was good attendance, representation and participation amongst community and provider sectors based on the participant observations using the standardized feasibility check-list. The community dialogue process received positive feedback in the FGDs and was demonstrated to be feasible and acceptable. Key factors contributing to the success of the community dialogue included a skilled facilitator, good representation of participants, establishing ground rules, good timekeeping, and using a Theory of Change to facilitate goal identification and dialogue. Issues to consider are the underlying power differentials related to age, profession and gender which caused initial feelings of anxiety amongst some participants. CONCLUSIONS: Our formative findings offer a systematic description and evaluation of a community dialogue process with key recommendations that may be considered when constituting similar community dialogues in the future.

Mapping a Syndemic of Psychosocial Risks During Pregnancy Using Network Analysis.

BACKGROUND: Psychosocial risks during pregnancy impact maternal health in resource-limited settings, and HIV-positive women often bear a heavy burden of these factors. This study sought to use network modeling to characterize co-occurring psychosocial risks to maternal and child health among at-risk pregnant women. METHODS: Two hundred pregnant HIV-positive women attending antenatal care in South Africa were enrolled. Measured risk factors included younger age, low income, low education, unemployment, unintended pregnancy, distress about pregnancy, antenatal depression, internalized HIV stigma, violence exposure, and lack of social support. Network analysis between risk factors was conducted in R using mixed graphical modeling. Centrality statistics were examined for each risk node in the network. RESULTS: In the resulting network, unintended pregnancy was strongly tied to distress about pregnancy. Distress about pregnancy was most central in the network and was connected to antenatal depression and HIV stigma. Unintended pregnancy was also associated with lack of social support, which was itself linked to antenatal depression, HIV stigma, and low income. Finally, antenatal depression was connected to violence exposure. CONCLUSIONS: Our results characterize a network of psychosocial risks among pregnant HIV-positive women. Distress about pregnancy emerged as central to this network, suggesting that unintended pregnancy is particularly distressing in this population and may contribute to further risks to maternal health, such as depression. Prevention of unintended pregnancies and interventions for coping with unplanned pregnancies may be particularly useful where multiple risks intersect. Efforts addressing single risk factors should consider an integrated, multilevel approach to support women during pregnancy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03069417.

HIV Prevention Among Young Women in South Africa: Understanding Multiple Layers of Risk.

Despite concerted prevention efforts, young South African women remain at the epicenter of the HIV epidemic. Although these women have grown up in a community powerfully affected by HIV, systematic investigation into how this "second generation" of HIV-affected youth navigates HIV risk is lacking. This study qualitatively explored a complex interplay of factors influencing HIV risk among young pregnant women in KwaZulu-Natal, South Africa. We conducted in-depth interviews with 35 pregnant women (22 HIV-uninfected and 13 HIV-infected) aged 18-21, 18 healthcare providers, and focus groups with 19 community stakeholders. Among the young women, HIV knowledge was high, and many reported taking some action to prevent pregnancy or HIV; however, these efforts were not routinely implemented. Themes related to HIV acquisition risk from all participants were organized using a socioecological framework and revolved around individual and developmental experiences (personal experience with HIV, perceived invincibility), family barriers (lack of adult supervision, pressure to leave school), relational barriers (lack of disclosure and partner communication, "burn out" around attempts to discuss condom use with partners, overdependence on partners), community-level barriers (township environment, lack of structured activities), and social barriers (poverty, HIV-related stigma). Some novel concepts emerged from the data, including an understanding of how overdependence on the romantic relationship may develop. Current HIV prevention efforts, including traditional HIV counseling and testing, condom distribution, and biomedical agents for HIV prevention, are unlikely to be effective without a broader, ecological up-to-date understanding of the evolving, intertwined, and complex constellation of factors that drive HIV risk behavior in this high-risk population.

Choice in HIV testing: the acceptability and anticipated use of a self-administered at-home oral HIV test among South Africans.

Combination HIV prevention is being widely promoted by funders. This strategy aims to offer HIV prevention choices that can be selected and combined to decrease HIV risk in ways that fit with each individual's situation. Treatment as prevention and pre-exposure prophylaxis are two new evidence-based strategies to decrease HIV incidence, both of which require high HIV testing rates to be effective, and the Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a goal of 90% of HIV-positive individuals knowing their status by 2030. However, HIV testing rates in many countries remain suboptimal. Just as no single HIV prevention method is ideal for all people in all situations, no single HIV testing modality is likely to be acceptable to everyone. By offering HIV testing choices, we may be able to increase testing rates. However, many low-resourced countries have been slow to take up new HIV testing options such as the self-administered at-home oral HIV test that is currently available in the United States. In this paper, we present findings from 20 in-depth interviews, conducted in 2010, documenting opinions about self-administered at-home oral HIV testing, a testing modality still largely unavailable in Africa. Participants were clients of three primary healthcare clinics in South Africa. Self-testing was seen as enabling confidentiality/privacy, saving time, and facilitating testing together with partners. However, concerns were raised about psychological distress when testing at home without a counsellor. Some suggested this concern could be minimised by having experienced clinic-based HIV testing and counselling before getting self-testing kits for home use. Thus, self-administered HIV testing could be an option added to the current testing modalities to address some important barriers to testing.

Healthcare providers' knowledge, attitudes and practices towards medical male circumcision and their understandings of its partial efficacy in HIV prevention: Qualitative research in KwaZulu-Natal, South Africa.

BACKGROUND: Medical male circumcision has been shown to reduce HIV transmission to an uninfected male partner. In South Africa, medical male circumcision programs were rolled-out in 2010. OBJECTIVES: Prior to roll-out, we explored healthcare providers' knowledge, attitudes and practices about medical male circumcision and their understandings of partial efficacy for HIV prevention. DESIGN: We conducted qualitative research, using in-depth interviews. SETTING: Participants were from three rural and three urban primary healthcare clinics, randomly selected in eThekwini District, KwaZulu-Natal. PARTICIPANTS: 25 healthcare providers (including nurse managers, nurses and counselors) were purposively selected from the clinics. METHODS: In-depth interviews were recorded, transcribed and translated. Independent researchers reviewed the transcripts and developed a codebook based on emergent themes, using thematic analysis. NVivo 8 was used to facilitate data management, coding and analysis. RESULTS: Although most providers had heard that medical male circumcision can reduce risk of HIV acquisition in men, most did not have accurate scientific understandings of this. Some providers had misperceptions about the limited/partial protection medical male circumcision offers. Many had concerns that their communities would misunderstand it, causing increased risky sexual behavior. CONCLUSIONS: These data provide a baseline of providers' understandings of medical male circumcision prior to roll-out, and can be used to compare current data and ensure accurate messaging to clients. Healthcare provider messaging should build client understandings of the meaning of partially efficacious technologies.

Inkwari: an emerging high-risk place potentiating hiv spread among young adults in a hyper-endemic South African setting.

Young adults in South Africa are at the epicenter of the HIV epidemic. The prevalence of HIV among young people in the province of KwaZulu-Natal (KZN) is particularly high. This study characterizes inkwari (Zulu word for raves or weekend-long parties) in eThekwini District, KZN and explored how these place-based dynamics shape the risk environment for the young adult attendees. In 2011, 13 qualitative interviews were conducted with men and women between 18 and 30 years-old who reported unprotected sex with at least one casual partner in the prior 3 months and attended an inkwari in the same time period. Interviews were analyzed using qualitative content analysis. Nine key informant interviews helped to triangulate these data. Five women and eight men were interviewed and the mean age was 25 years (SD 3.24). Ten reported meeting a sexual partner at an inkwari. Inkwari were characterized as sexualized settings with limited adult supervision. Participants attended inkwari to socialize with peers, use drugs and alcohol, and meet sexual partners. Sexual and physical violence also occurred at inkwari. Given the convergence of social, sexual, and substance-using networks at inkwari, further inquiry is needed to determine how this place may potentiate HIV transmission risk in an endemic setting.