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L'Engle K.L.,Social and Behavioral Health science | Mwarogo P.,FHI 360 | Kingola N.,International Center for Reproductive Health | Sinkele W.,Support for Addiction Prevention and Treatment in Africa SAPTA | Weiner D.H.,Biostatistics
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Objective: We assessed whether a brief alcohol intervention would lead to reduced alcohol use and sexually transmitted infection (STI)/HIV incidence and related sexual risk behaviors among moderate drinking female sex workers. Methods: A randomized controlled intervention trial was conducted with 818 female sex workers affiliated with the AIDS, Population, Health, and Integrated Assistance II project in Mombasa, Kenya. Eligible women were hazardous or harmful drinkers who scored between 7 and 19 (full range, 1-40) on the Alcohol Use Disorders Identification Test. Intervention participants received 6 counseling sessions approximately monthly. The equal-attention control group received 6 nutrition sessions. Participants were followed for 6 and 12 months after the intervention, with at least 86% retention at both time points. We used general linear models in intention-to-treat analyses, adjusting for recruitment setting and HIV status at enrollment. Results: There was a statistically significant reduction in alcohol use and binge drinking at 6 and 12 months, with intervention participants reporting less than one third of the odds of higher levels of drinking than the control group. The intervention did not impact laboratory-confirmed STI/HIV incidence, self-reported condom use, or sexual violence from nonpaying partners. However, the odds of reporting sexual violence from clients was significantly lower among intervention than control participants at both 6 and 12 months. Conclusions: We found that a brief alcohol intervention can reduce self-reported alcohol consumption among a nondependent and non-treatment-seeking population most at risk for HIV. More attention is needed to understand the pathway from drinking to sexual behavior and STI/HIV acquisition. Copyright © 2014 by Lippincott Williams & Wilkins.


Mack N.,Social and Behavioral Health science | Evens E.M.,Health Services Research | Tolley E.E.,Social and Behavioral Health science | Brelsford K.,Duke University | And 4 more authors.
Journal of the International AIDS Society | Year: 2014

Introduction: Stakeholders continue to discuss the appropriateness of antiretroviral-based pre-exposure prophylaxis (PrEP) for HIV prevention among sub-Saharan African and other women. In particular, women need formulations they can adhere to given that effectiveness has been found to correlate with adherence. Evidence from family planning shows that contraceptive use, continuation and adherence may be increased by expanding choices. To explore the potential role of choice in women's use of HIV prevention methods, we conducted a secondary analysis of research with female sex workers (FSWs) and men and women in serodiscordant couples (SDCs) in Kenya, and adolescent and young women in South Africa. Our objective here is to present their interest in and preferences for PrEP formulations-pills, gel and injectable.Methods: In this qualitative study, in Kenya we conducted three focus groups with FSWs, and three with SDCs. In South Africa, we conducted two focus groups with adolescent girls, and two with young women. All focus groups were audio-recorded, transcribed and translated into English as needed. We structurally and thematically coded transcripts using a codebook and QSR NVivo 9.0; generated code reports; and conducted inductive thematic analysis to identify major trends and themes. Results: All groups expressed strong interest in PrEP products. In Kenya, FSWs said the products might help them earn more money, because they would feel safer accepting more clients or having sex without condoms for a higher price. SDCs said the products might replace condoms and reanimate couples' sex lives. Most sex workers and SDCs preferred an injectable because it would last longer, required little intervention and was private. In South Africa, adolescent girls believed it would be possible to obtain the products more privately than condoms. Young women were excited about PrEP but concerned about interactions with alcohol and drug use, which often precede sex. Adolescents did not prefer a particular formulation but noted benefits and limitations of each; young women's preferences also varied.Conclusions: The circumstances and preferences of sub-Saharan African women are likely to vary within and across groups and to change over time, highlighting the importance of choice in HIV prevention methods. Copyright: © 2014 Mack N et al.


Corneli A.,Social and Behavioral Health science | Wang M.,Quantitative science | Agot K.,Impact Research and Development Organization | Ahmed K.,Setshaba Research Center | And 3 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2014

Background: FEM-PrEP was unable to demonstrate the effectiveness of oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) as preexposure prophylaxis for HIV prevention because of low adherence. We hypothesized that one reason for the poor adherence was low perceived HIV risk. Methods: At enrollment and at quarterly follow-up visits, we assessed participants' perceived HIV risk for the subsequent 4 weeks. We used logistic regression to assess factors associated with some (small, moderate, or high) perceived HIV risk. We also used logistic regression with robust variance estimation to assess the association between risk perceptions (none versus some) reported at enrollment and at weeks 12, 24, and 36 and good adherence based on drug concentrations of plasma tenofovir and intracellular tenofovir diphosphate in specimens collected 4 weeks later (at weeks 4, 16, 28, and 40) among 150 randomly selected participants assigned FTC/TDF. Results: Multiple factors were statistically associated with having some perceived risk, including having sex without a condom, having multiple partners, and not knowing if a partner has HIV. We observed a significant association between having some risk perception and good adherence (odds ratio: 2.0; 95% confidence interval: 1.1 to 3.5; P = 0.016). Conclusions: Data suggest that participants are likely knowledgeable about factors that increase their HIV risk. Perceived risk seemed to have influenced some participants' decisions to adhere to the study pill within the context of a placebo-controlled clinical trial. Future research can explore the role of risk perception in the uptake of and adherence to pre-exposure prophylaxis, now that FTC/TDF has been shown efficacious. Copyright © 2014 by Lippincott Williams & Wilkins.


Corneli A.L.,Social and Behavioral Health science | McKenna K.,Social and Behavioral Health science | Perry B.,Social and Behavioral Health science | Ahmed K.,Setshaba Research Center | And 6 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2015

Background: FEM-PrEP was unable to determine whether once-daily, oral emtricitabine/tenofovir disoproxil fumarate reduces the risk of HIV acquisition among women because of low adherence. Self-reported adherence was high, and pill-count data suggested good adherence. Yet, drug concentrations revealed limited pill use. We conducted a follow-up study with former participants in Bondo, Kenya, and Pretoria, South Africa, to understand factors that had influenced overreporting of adherence and to learn the whereabouts of unused pills. Methods: Qualitative, semistructured interviews were conducted with 88 participants, and quantitative, audio computer-assisted self-interviews were conducted with 224 participants. We used thematic analysis and descriptive statistics to analyze the qualitative and quantitative data, respectively. Results: In audio computer-assisted self-interviews, 31% (n 70) said they had overreported adherence; the main reason was the belief that nonadherence would result in trial termination (69%, n 48). A considerable percentage (35%, n 78) acknowledged discarding unused pills. Few acknowledged giving their pills to someone else (4%, n 10), and even fewer acknowledged giving them to someone with HIV (2%, n 5). Many participants in the semistructured interviews said other participants had counted and removed pills from their bottles to appear adherent. Conclusions: Despite repeated messages that nonadherence would not upset staff, participants acknowledged several perceived negative consequences of reporting nonadherence, which made it difficult to report accurately. Uneasiness continued in the follow-up study, as many said they had not overreported during the trial. Efforts to improve self-reported measures should include identifying alternative methods for creating supportive environments that allow participants to feel comfortable reporting actual adherence. © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Lanham M.,Social and Behavioral Health science | Wilcher R.,Research Utilization | Montgomery E.T.,Rti International | Pool R.,University of Amsterdam | And 3 more authors.
Journal of the International AIDS Society | Year: 2014

Introduction: Constructively engaging male partners in women-centred health programs such as family planning and prevention of mother-to-child HIV transmission has resulted in both improved health outcomes and stronger relationships. Concerted efforts to engage men in microbicide use could make it easier for women to access and use microbicides in the future.This paper synthesizes findings from studies that investigated men's role in their partners' microbicide use during clinical trials to inform recommendations for male engagement in women's microbicide use.Methods: We conducted primary and secondary analyses of data from six qualitative studies implemented in conjunction with microbicide clinical trials in South Africa, Kenya, and Tanzania. The analyses included data from 535 interviews and 107 focus groups with trial participants, male partners, and community members to answer research questions on partner communication about microbicides, men's role in women's microbicide use, and potential strategies for engaging men in future microbicide introduction. We synthesized the findings across the studies and developed recommendations.Results: The majority of women in steady partnerships wanted agreement from their partners to use microbicides. Women used various strategies to obtain their agreement, including using the product for a while before telling their partners, giving men information gradually, and continuing to bring up microbicides until resistant partners acquiesced. Among men who were aware their partners were participating in a trial and using microbicides, involvement ranged from opposition to agreement/noninterference to active support. Both men and women expressed a desire for men to have access to information about microbicides and to be able to talk with a healthcare provider about microbicides.Conclusions: We recommend counselling women on whether and how to involve their partners including strategies for gaining partner approval; providing couples' counselling on microbicides so men have the opportunity to talk with providers; and targeting men with community education and mass media to increase their awareness and acceptance of microbicides. These strategies should be tested in microbicide trials, open-label studies, and demonstration projects to identify effective male engagement approaches to include in eventual microbicide introduction. Efforts to engage men must take care not to diminish women's agency to decide whether to use the product and inform their partners. Copyright: © 2014 Lanham M et al; licensee International AIDS Society.


Baumgartner J.N.,Social and Behavioral Health science | Burns J.K.,University of KwaZulu - Natal
International Journal of Epidemiology | Year: 2014

Background: Social inclusion is increasingly recognized as a key outcome for evaluating global mental health programmes and interventions. Whereas social inclusion as an outcome is not a new concept in the field of mental health, its measurement has been hampered by varying definitions, concepts and instruments. To move the field forward, this paper reviews the currently available instrumentswhich measure social inclusion and are reported in the literature, realizing that no single measure will be appropriate for all studies or contexts.Methods: A systematic literature search of English language peer-reviewed articles published through February 2013 was undertaken to identify scales specifically developed to measure social inclusion or social/community integration among populations with mental disorders.Results: Five instruments were identified through the search criteria. The scales are discussed in terms of their theoretical underpinnings, domains and/or key items and their potential for use in global settings. Whereas numerous reviewed abstracts discussed mental health and social inclusion or social integration, very few were concerned with direct measurement of the construct. All identified scales were developed in high-income countries with limited attention paid to how the scale could be adapted for cross-cultural use.Conclusions: Social inclusion is increasingly highlighted as a key outcome for global mental health policies and programmes, yet its measurement is underdeveloped. There is need for a global cross-cultural measure that has been developed and tested in diverse settings. However, until that need is met, some of the scales presented here may be amenable to adaptation. © The Author 2013; all rights reserved.


Mack N.,Social and Behavioral Health science | Odhiambo J.,Impact Research and Development Organization | Wong C.M.,Social and Behavioral Health science | Agot K.,Impact Research and Development Organization
BMC Health Services Research | Year: 2014

Background: As pre-exposure prophylaxis (PrEP) moves closer to availability in developing countries, practical considerations for implementation become important. We conducted a consultation with district-level community stakeholders experienced in HIV-prevention interventions with at-risk populations in Bondo and Rarieda, Kenya to generate locally grounded approaches to the future rollout of oral PrEP to four populations: fishermen, widows, female sex workers, and serodiscordant couples. Methods. The 20 consultation participants represented the Ministry of Health, faith- and community-based organizations, health facilities, community groups, and nongovernmental organizations. Participants divided into breakout groups and followed a structured discussion guide asking them to identify barriers to implementing HIV-prevention interventions (including PrEP) with each population. Questions also solicited solutions for addressing these barriers, as well as other facilitators for PrEP implementation. In particular, questions focused on how to encourage people to screen for PrEP eligibility by having HIV and other blood tests and how to encourage compliance with ongoing HIV testing. Results: The barriers and facilitators/solutions discussants provided were frequently population-specific, but there were also broad-level similarities across populations. Service delivery barriers to HIV-prevention interventions concerned the need for staff trained to address the needs of particular populations. Service delivery facilitators to provision of ongoing HIV testing consisted of offering testing options besides facility-based testing. Stigma was the main community-level barrier for all groups, whereas barriers at the level of target populations included mobility; lifestyle and life circumstances, especially cultural norms among fishermen and widows; and fears, lack of awareness, and misinformation. Proposed facilitators and strategies for addressing community- and population-level barriers included topic-specific education within the populations and community, involvement of partners and family members, mass HIV testing, and peer educators. Barriers to PrEP uptake included non-adherence to pill taking and missing clinic visits. For drug adherence, facilitators were counselling and involving family members. Discussants suggested that client reminders, e.g., home visits, were needed to encourage clients to keep their clinic appointments. Conclusions: Strategies for encouraging eligibility screening and ongoing HIV testing will have local and population-specific aspects. Our results nonetheless apply to similar populations throughout sub-Saharan Africa and reach beyond oral PrEP to other ARV-based PrEP formulations. © 2014 Mack et al.; licensee BioMed Central Ltd.


L'Engle K.,Social and Behavioral Health science | Lanham M.,Social and Behavioral Health science | Loolpapit M.,Male Circumcision Consortium Project | Oguma I.,Male Circumcision Consortium Project
Health Education Research | Year: 2014

In the midst of scaling up voluntary medical male circumcision (VMMC) in Kenya, there is concern that men do not adequately understand that circumcision provides only partial protection against HIV. The study goal was to determine men's understanding of partial protection, perceptions of HIV risk before and after VMMC and use of protective measures following VMMC. In-depth interviews with 44 men aged 18-39 years recently circumcised or planning to undergo VMMC were conducted in two urban and rural districts in Nyanza Province, Kenya. Participants described partial protection as the need to continue using other HIV protective measures such as condoms, with numbers such as a '60 percent protection' or 'not 100 percent protection', and described how circumcision reduces HIV transmission such as reduced penile bruising or bleeding. Most said their HIV risk before VMMC was high and that VMMC would reduce their risk moderately. Participants demonstrated good understanding of partial protection and there was little suggestion of risk compensation following VMMC. © The Author 2013. Published by Oxford University Press. All rights reserved.


Corneli A.L.,Social and Behavioral Health science | McKenna K.,Social and Behavioral Health science | Headley J.,Social and Behavioral Health science | Ahmed K.,Social and Behavioral Health science | And 4 more authors.
Journal of the International AIDS Society | Year: 2014

Introduction: Risk perception is a core construct in many behaviour change theories in public health. Individuals who believe they are at risk of acquiring an illness may be more likely to engage in behaviours to reduce that risk; those who do not feel at risk may be unlikely to engage in risk reduction behaviours. Among participants who seroconverted in two FEM-PrEP sites - Bondo, Kenya, and Pretoria, South Africa - we explored perceived HIV risk and worry about acquiring HIV prior to HIV infection. Methods: FEM-PrEP was a phase III clinical trial of once-daily, oral emtricitabine and tenofovir disoproxil fumarate for HIV prevention among women in sub-Saharan Africa. We asked all participants about their perceived HIV risk in the next four weeks, prior to HIV testing, during a quantitative face-to-face interview at enrolment and at quarterly follow-up visits. Among participants who seroconverted, we calculated the frequencies of their responses from the visit conducted closest to, but before, HIV acquisition. Also among women who seroconverted, we conducted qualitative, semi-structured interviews (SSIs) at weeks 1, 4 and 8 after participants' HIV diagnosis visit to retrospectively explore feelings of HIV worry. Applied thematic analysis was used to analyse the SSI data. Results: Among participants who seroconverted in Bondo and Pretoria, 52% reported in the quantitative interview that they had no chance of acquiring HIV in the next four weeks. We identified four processes of risk rationalization from the SSI narratives. In ''protective behaviour,'' participants described at least one risk reduction behaviour they used to reduce their HIV risk; these actions made them feel not vulnerable to HIV, and therefore they did not worry about acquiring the virus. In ''protective reasoning,'' participants considered their HIV risk but rationalized, based on certain events or beliefs, that they were not vulnerable and therefore did not worry about getting HIV. In ''recognition of vulnerability,'' participants described reasons for being worried about getting HIV but said no or limited action was taken to reduce their perceived vulnerability. Participants with ''no rationalization or action'' did not describe any HIV worry or did not engage in HIV risk reduction behaviours. Conclusions: Women who are at substantial risk of acquiring HIV may underestimate their actual risk. Yet, others who accurately understand their HIV risk may be unable to act on their concerns. Perceived HIV risk and risk rationalization are important concepts to explore in risk reduction counselling to increase the use of HIV prevention strategies among women at risk of HIV. ©2014 Corneli AL et al.


Lanham M.,Social and Behavioral Health science | L'Engle K.L.,Social and Behavioral Health science | Loolpapit M.,Male Circumcision Consortium Project | Oguma I.O.,Male Circumcision Consortium Project
PLoS ONE | Year: 2012

Women are an important audience for voluntary medical male circumcision (VMMC) communication messages so that they know that VMMC provides only partial protection against HIV. They may also be able to influence their male partners to get circumcised and practice other HIV protective measures after VMMC. This study was conducted in two phases of qualitative data collection. Phase 1 used in-depth interviews to explore women's understanding of partial protection and their role in VMMC. Phase 2 built on the findings from the Phase 1, using focus groups to test VMMC communication messages currently used in Nyanza Province and to further explore women's roles in VMMC. Sixty-four sexually active women between the ages of 18 and 35 participated. In Phase 1, all women said they had heard of partial protection, though some were not able to elaborate on what the concept means. When women in Phase 2 were exposed to messages about partial protection, however, participants understood the messages well and were able to identify the main points. In Phases 1 and 2, many participants said that they had discussed VMMC with their partner, and for several, it was a joint decision for the man to go for VMMC. These findings suggest that current VMMC messaging is reaching women, though communications could more effectively target women to increase their ability to communicate about partial HIV protection from VMMC. Also, women seem to be playing an important role in encouraging men to get circumcised, so reaching out to women could be a valuable intervention strategy for increasing VMMC uptake and promoting use of other HIV protective measures after VMMC. © 2012 Lanham et al.

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