The male factor: Outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township.
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SUBMITTER: Wechsberg WM
PROVIDER: S-EPMC5645020 | biostudies-literature | 2016 Apr
REPOSITORIES: biostudies-literature
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The male factor: Outcomes from a cluster randomized field experiment with a couples-based HIV prevention intervention in a South African township.
Wechsberg Wendee M WM Zule William A WA El-Bassel Nabila N Doherty Irene A IA Minnis Alexandra M AM Novak Scott D SD Myers Bronwyn B Carney Tara T
Drug and alcohol dependence 20160218
<h4>Background</h4>This study examined the effects of the Couples Health CoOp intervention on heavy drinking, condom use, and HIV incidence.<h4>Methods</h4>Thirty neighborhoods from one South African township were cluster randomized into three intervention arms: Couples Health CoOp (CHC), Women's Health CoOp/Men's Health CoOp (WHC/MHC), or a comparison arm. We recruited 290 men from informal drinking establishments who reported drinking alcohol regularly. We also recruited their main heterosexua ...[more]
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Project description:In South Africa, heterosexual couples are at risk for HIV infection and transmission through substance use, gender-based violence and traditional gender roles, and sex risk behaviors such as having multiple partners and unsafe sex.To address these interconnected HIV risks among heterosexual couples, we used the ADAPT framework to modify an existing, efficacious women's HIV prevention intervention (the Western Cape Women's Health CoOp) to include components of an evidence-based couple's intervention from the United States (Project Connect) and components from the Men as Partners program that has been used successfully in South Africa. We conducted focus groups with men, women and couples, and obtained feedback from a long-standing Community Collaborative Board (CCB) to guide the synthesis of elements of these three interventions into a new intervention. We then piloted the adapted intervention for feasibility and acceptability.The new intervention is called the Couples' Health CoOp. This intervention targets men who use alcohol and other drugs and engage in unprotected sex, and their main female sex partners. The intervention addresses substance use, sex risk, HIV and other sexually transmitted infections, gender roles, gender-based violence, communication skills, and goal-setting activities to increase sexy (eroticize) safe-sex behaviors. The Couples' Health CoOp also includes "voices" from the focus group members to ground the intervention in the experiences of these at-risk couples. In addition, it utilizes a participant handbook that reiterates workshop content and includes homework assignments for couples to complete together to increase problem-solving skills within their relationship, and to improve their sexual relationship and help sustain HIV risk-reduction strategies. All of these adaptations were based on participants' suggestions made during formative work and pilot testing.The Couples' Health CoOp is a couple-based HIV prevention intervention that targets alcohol and other drug use to reduce sexual risk, reduce gender-based violence and offer alternatives for conflict resolution, promote healthy relationships, and modify traditional gender roles in South Africa.NCT01121692 .
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Project description:Human immunodeficiency virus (HIV) has disproportionately affected African Americans. Couple-level interventions may be a promising intervention strategy.To determine if a behavioral intervention can reduce HIV/sexually transmitted disease (STD) risk behaviors among African American HIV serodiscordant couples, a cluster randomized controlled trial (Eban) was conducted in Atlanta, Georgia; Los Angeles, California; New York, New York; and Philadelphia, Pennsylvania; with African American HIV serodiscordant heterosexual couples who were eligible if both partners were at least 18 years old and reported unprotected intercourse in the previous 90 days and awareness of each other's serostatus. One thousand seventy participants were enrolled (mean age, 43 years; 40% of male participants were HIV positive). Couples were randomized to 1 of 2 interventions: couple-focused Eban HIV/STD risk-reduction intervention or attention-matched individual-focused health promotion comparison. The primary outcomes were the proportion of condom-protected intercourse acts and cumulative incidence of STDs (chlamydia, gonorrhea, or trichomonas). Data were collected preintervention and postintervention, and at 6- and 12-month follow-ups.Data were analyzed for 535 randomized couples: 260 in the intervention group and 275 in the comparison group; 81.9% were retained at the 12-month follow-up. Generalized estimating equation analyses revealed that the proportion of condom-protected intercourse acts was larger among couples in the intervention group (0.77) than in the comparison group (0.47; risk ratio, 1.24; 95% confidence interval [CI], 1.09 to 1.41; P = .006) when adjusted for the baseline criterion measure. The adjusted percentage of couples using condoms consistently was higher in the intervention group (63%) than in the comparison group (48%; risk ratio, 1.45; 95% CI, 1.24 to 1.70; P < .001). The adjusted mean number of (log)unprotected intercourse acts was lower in the intervention group than in the comparison group (mean difference, -1.52; 95% CI, -2.07 to -0.98; P < .001). The cumulative STD incidence over the 12-month follow-up did not differ between couples in the intervention and comparison groups. The overall HIV seroconversion at the 12-month follow-up was 5 (2 in the intervention group, 3 in the comparison group) of 535 individuals, which translates to 935 per 100,000 population.To our knowledge, this is the first randomized controlled intervention trial to report significant reductions in HIV/STD risk behaviors among African American HIV serodiscordant couples.clinicaltrials.gov Identifier: NCT00644163.
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Project description:Despite recent emphasis on couples-based HIV prevention interventions, efficacious interventions for Latino male couples have yet to be tested. The study examined the feasibility and acceptability of the Connecting Latinos en Pareja (CLP) intervention, a couples-based HIV prevention intervention for Latino male couples. This pilot demonstrated high feasibility, meeting targets for recruitment, retention, and intervention completion. We recruited a diverse cohort of 46 individuals/23 couples with a retention rate of 80% over 6 months and a 100% intervention completion rate in both conditions (four structured couple sessions in each condition). This pilot RCT was not powered to detect significant intervention impact on the primary outcome; however, there was a significant increase in relationship functioning among couples in the intervention group relative to controls and promising trends in changes in several key outcome and mediating variables. Secondary analysis documented trends in the expected directions for several other key hypothesized mechanisms of action (stimulant use, psychological symptoms, quality of life) as well as the primary outcome of proportion of protected sex acts (overall and broken out by main vs. outside partners). Qualitative exit interviews revealed high levels of acceptability of the CLP intervention. Participants highlighted affective component of the intervention and perceived effectiveness in improving dyadic communication skills and safer sex practices. Our findings show that a pilot trial of CLP is highly feasible and acceptable, with CLP demonstrating promising evidence of changes in key intervention mechanisms.
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Project description:BackgroundConsistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa.Methods and findingsCost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189-428) infections over 20 years. The cost is 181 dollars (80% CI 117-306 dollars) per HIA, and net savings are 2.4 million dollars (80% CI 1.3 million to 3.6 million dollars). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is 551 dollars (80% CI 344-1,071 dollars) and net savings are 753,000 (80% CI 0.3 million to 1.2 million dollars). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage.ConclusionsIn settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.
| S-EPMC1716193 | biostudies-literature
Project description:We investigated alcohol-related sexual risk behavior from the perspective of social norms theory. Adults (N = 895, 62% men) residing in a South African township completed street-intercept surveys that assessed risk and protective behaviors (e.g., multiple partners, drinking before sex, meeting sex partners in shebeens, condom use) and corresponding norms. Men consistently overestimated the actual frequency of risky behaviors, as reported by the sample, and underestimated the frequency of condom use. Relative to actual attitudes, men believed that other men were more approving of risk behavior and less approving of condom use. Both behavioral and attitudinal norms predicted the respondents' self-reported risk behavior. These findings indicate that correcting inaccurate norms in HIV-risk reduction efforts is worthwhile.
| S-EPMC3015007 | biostudies-literature
Project description:INTRODUCTION:The goals of scale-up of antiretroviral therapy (ART) have expanded from prevention of morbidity and death to include prevention of transmission. Morbidity and mortality risk are associated with CD4 count; transmission risk depends on plasma viral load (VL). This study aimed to describe CD4 count and VL distributions among HIV-infected individuals in a South African township to gain insights into the potential impact of ART scale-up on community HIV transmission risk. METHODS:A random sample of 10% of the adult population was invited to attend an HIV testing service. Study procedures included a questionnaire, HIV testing, CD4 count, and VL testing. RESULTS:One thousand one hundred forty-four (88.0%) of 1300 randomly selected individuals participated in the study. Two hundred sixty tested positive, giving an HIV prevalence of 22.7% [95% confidence interval (CI): 20.3 to 25.3]. A third of all HIV-infected individuals (33.5%, 95% CI: 27.8 to 39.6) reported taking ART. The median CD4 count was 417 cells per microliter (interquartile range, 285-627); 33 (12.7%, 95% CI: 8.9 to 17.4) had a CD4 count of ?200 cells per microliter. VL measurements were available for 219 individuals (84.2%) and were undetectable in 72 (33.9%), >1500 copies per milliliter in 127 (58.0%) and >10,000 copies per milliliter in 96 (43.8%). Of those reporting they were receiving ART, 30.4% had a VL >1500 copies per milliliter compared with 58.0% of those reporting they were not receiving ART. CONCLUSIONS:A small proportion of those living with HIV in this community had a CD4 count of <200 cells per microliter; more than half had a VL high enough to be associated with considerable transmission risk. A substantial proportion of HIV-infected individuals remained at risk of transmitting HIV even after starting ART.
| S-EPMC4233323 | biostudies-literature
Project description:IntroductionThe burden of type 2 diabetes is growing rapidly in sub-Saharan Africa. Healthy eating has been shown to prevent the disease but is challenging to maintain. Self-determination theory offers a motivational framework for maintaining a healthy diet based on evidence from western settings. This study aims to assess whether self-determination theory can explain healthy diet behavior in a disadvantaged urban South African population.MethodsCross-sectional data from a South African township population (N = 585; pre-diabetes = 292, diabetes = 293, age 30-75) were analyzed using structural equation modeling, while controlling for socio-demographic factors. Measures included self-reported autonomous and controlled motivation, perceived competence (measured through barrier self-efficacy), perceived relatedness (measured through perceived participation of significant others) and, as indicator for healthy diet, frequency of fruit, vegetable, and non-refined starch intake.ResultsHealthy eating was positively associated (β = 0.26) with autonomous motivation, and negatively associated (β = -0.09) with controlled motivation. Perceived competence and relatedness were positively associated with healthy eating (β = 0.49 and 0.37) and autonomous motivation (β = 0.65 and 0.35), and negatively associated with controlled motivation (β = -0.26 and -0.15). Autonomous motivation mediated the effect of perceived competence and relatedness on healthy eating. The model supported a negative association between controlled and autonomous motivation.ConclusionThis is the first study providing evidence for self-determination theory explaining healthy eating in a disadvantaged sub-Saharan African setting among people at risk of or with diabetes type two. Our findings suggest that individuals who experience support from friends or family and who feel competent in adopting a healthy diet are more likely to become more motivated through identifying the health benefits of healthy eating as their goal. This type of autonomous motivation was associated with a healthier diet compared to individuals whose motivation originated in pressure from others or feelings of guilt or shame. Our recommendations for public health interventions include: focus on the promotion of diet-related health benefits people can identify with; encourage social support by friends or family; reinforce people's sense of competence and skills; and avoid triggering perceived social pressure or feelings of guilt.
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Project description:In rural South Africa, only two-thirds of HIV-positive pregnant women seeking antenatal care at community health centers took full advantage of 'prevention of mother-to-child transmission' (PMTCT) services in 2010. Studies generally support male involvement to promote PMTCT, but the nature and impact of that involvement is unclear and untested. Additionally, stigma, disclosure and intimate partner violence pose significant barriers to PMTCT uptake and retention in care, suggesting that male involvement may be 'necessary, but not sufficient' to reduce infant HIV incidence. This study expands on a successful United States President's Emergency Plan for AIDS Relief (PEPFAR)-supported PMTCT couples intervention pilot study conducted in the Mpumalanga province, targeting HIV-positive pregnant women and their partners, the primary objective being to determine whether male partner involvement plus a behavioral intervention will significantly reduce infant HIV incidence.The study follows a cluster randomized controlled design enrolling two cohorts of HIV-positive pregnant women recruited from 12 randomly assigned Community Health Centers (CHC) (six experimental, six control). The two cohorts will consist of women attending without their male partners (n = 720) and women attending with their male partners (n = 720 couples), in order to determine whether the influence of male participation itself, or combined with a behavioral PMTCT intervention, can significantly reduce infant HIV infection ante-, peri- and postnatally.It is our intention to significantly increase PMTCT participation from current levels (69%) in the Mpumalanga province to between 90 and 95% through engaging women and couples in a controlled, six session ante- and postnatal risk-reducing and PMTCT promotion intervention addressing barriers to PMTCT (such as stigma, disclosure, intimate partner violence, communication, infant feeding practices and safer conception) that prevent women and men from utilizing treatment opportunities available to them and their infants. Based upon the encouraging preliminary results from our pilot study, successful CHC adoption of the program could have major public health policy implications for containing the epidemic among the most vulnerable populations in rural South Africa: HIV-positive pregnant women and their infants.ClinicalTrials.gov NCT02085356 (registration date: 10 March 2014).
| S-EPMC4219009 | biostudies-literature
Project description:We hypothesized that in South Africa, with a generalized tuberculosis (TB) epidemic, TB infection is predominantly acquired indoors and transmission potential is determined by the number and duration of social contacts made in locations that are conducive to TB transmission. We therefore quantified time spent and contacts met in indoor locations and public transport by residents of a South African township with a very high TB burden.A diary-based community social mixing survey was performed in 2010. Randomly selected participants (n?=?571) prospectively recorded numbers of contacts and time spent in specified locations over 24-hour periods. To better characterize age-related social networks, participants were stratified into ten 5-year age strata and locations were classified into 11 types.Five location types (own-household, other-households, transport, crèche/school, and work) contributed 97.2% of total indoor time and 80.4% of total indoor contacts. Median time spent indoors was 19.1 hours/day (IQR:14.3-22.7), which was consistent across age strata. Median daily contacts increased from 16 (IQR:9-40) in 0-4 year-olds to 40 (IQR:18-60) in 15-19 year-olds and declined to 18 (IQR:10-41) in ?45 year-olds. Mean daily own-household contacts was 8.8 (95%CI:8.2-9.4), which decreased with increasing age. Mean crèche/school contacts increased from 6.2/day (95%CI:2.7-9.7) in 0-4 year-olds to 28.1/day (95%CI:8.1-48.1) in 15-19 year-olds. Mean transport contacts increased from 4.9/day (95%CI:1.6-8.2) in 0-4 year-olds to 25.5/day (95%CI:12.1-38.9) in 25-29 year-olds.A limited number of location types contributed the majority of indoor social contacts in this community. Increasing numbers of social contacts occurred throughout childhood, adolescence, and young adulthood, predominantly in school and public transport. This rapid increase in non-home socialization parallels the increasing TB infection rates during childhood and young adulthood reported in this community. Further studies of the environmental conditions in schools and public transport, as potentially important locations for ongoing TB infection, are indicated.
| S-EPMC3387133 | biostudies-literature
Project description:BackgroundPopulation models of tuberculosis transmission have not accounted for social contact structure and the role of the environment in which tuberculosis is transmitted.MethodsWe utilized extensions to the Wells-Riley model of tuberculosis transmission, using exhaled carbon dioxide as a tracer gas, to describe transmission patterns in an endemic community. Drawing upon social interaction data and carbon dioxide measurements from a South African township, we created an age-structured model of tuberculosis transmission in households, public transit, schools, and workplaces. We fit the model to local data on latent tuberculosis prevalence by age.ResultsMost tuberculosis infections (84%) were estimated to occur outside of one's own household. Fifty percent of infections among young adults (ages 15-19) occurred in schools, due to high contact rates and poor ventilation. Despite lower numbers of contacts in workplaces, assortative mixing among adults with high rates of smear-positive tuberculosis contributed to transmission in this environment. Households and public transit were important sites of transmission between age groups.ConclusionsConsistent with molecular epidemiologic estimates, a minority of tuberculosis transmission was estimated to occur within households, which may limit the impact of contact investigations. Further work is needed to investigate the role of schools in tuberculosis transmission.
| S-EPMC4133578 | biostudies-literature