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Gender-based violence and violence against children are significant problems in South Africa. Community mobilisation and gender-transformative programming are promising approaches to address and reduce violence. A quantitative evaluation of One Man Can, a gender-transformative community mobilisation programme in South Africa, found mixed results in increasing gender-equitable behaviours and reducing violence. To better understand these findings, we analyse longitudinal qualitative data from community mobilisers, community members and community action teams, exploring individual and community-level factors that facilitate and hinder change. Interviews and focus groups were transcribed and analysed. Participants self-reported changes in their gender-equitable attitudes and use of violence as a result of participation in the programme, although some participants also reported opposition to shifting to a more gender-equitable culture. Facilitators to change included the internalisation of gender-transformative messaging and supportive social networks, which was buoyed by a shared vocabulary in their community generated by One Man Can. Because the programme targeted a critical mass of community members with gender-transformative programming, mobilisers and community action teams were held accountable by community members to model non-violent behaviour. Results reinforce the importance of addressing facilitators and barriers to change at both individual and community levels.

Despite the large interest in economic interventions to reduce HIV risk, little research has been done to show whether there are economic gains of these interventions for younger women and what intermediary role economic resources play in changing participants’ sexual behavior. This paper contributes to this gap by examining the impacts of a conditional cash transfer (CCT) for young women in South Africa on young women’s economic resources and the extent to which they play a role in young women’s health and behavior. We used data from HIV Prevention Trials Network 068 study, which provided transfers to young women (in addition to their parents) conditional on the young woman attending at least 80% of school days in the previous month. We found that the CCT increased young women’s economic wellbeing in terms of having savings, spending money, being unindebted, and food secure. We also investigated heterogeneous effects of the program by household economic status at baseline because the program was not specifically poverty targeted and found that the results were driven by young women from the poorest families. From these results, we examined heterogeneity by baseline poverty for other outcomes related to HIV risk including sexual behavior and psychosocial well-being. We found psychosocial well-being benefits in young women from the poorest families and that economic wellbeing gains explained much these impacts.

Purpose: Schooling is associated with a lower risk of Herpes simplex virus type 2 (HSV-2) in adolescent girls and young women, but there is little understanding of the pathways underlying this relationship. Methods: We used data from adolescent girls and young women in South Africa enrolled in the HIV Prevention Trials Network 068 study. We tested a structural equation model where individual household and community education measures were associated directly and indirectly with incident HSV-2 through HIV knowledge, future aspirations, age-disparate partnerships, sex in the last 12 months, and condomless sex. Results: Community, household, and individual measures of schooling were all associated with incident HSV-2 infection through mediated pathways that increased the likelihood of having sex. Low school attendance (

We combined behavioral survey data from the human immunodeficiency virus (HIV) Prevention Trials Network 068 study with phylogenetic information to determine if cluster membership was associated with characteristics of young women and their partners. Clusters were more likely to involve young women from specific villages and schools, indicating some localized transmission. Supplemental digital content is available in the text.

Evidence on cash transfer interventions for HIV prevention in adolescent girls and young women is unclear and indicates that they may not work uniformly in all settings. Qualitative interviews were conducted with 22 girls and young women post-intervention to determine how a cash transfer study (HPTN 068) in South Africa was perceived to influence sexual behaviours and to explore mechanisms for these changes. Participants described how the intervention motivated them to increase condom use, have fewer partners, end risky relationships and access HIV testing services at local primary health clinics. Changes were attributed to receipt of the cash transfer, in addition to HIV testing and sexual health information. Processes of change included improved communication with partners and increased negotiation power in sexual decision-making. Economic empowerment interventions increase confidence in negotiating behaviours with sexual partners and are complementary to sexual health information and health services that provide young women with a foundation on which to make informed decisions about how to protect themselves.

Friends could be influential on young women’s sexual health via influences on sexual behaviours and as connections to sexual partners, but are understudied in sub-Saharan Africa. We cross-sectionally surveyed 2326 13–20 year-old young women eligible for grades 8–11 in rural South Africa about their sexual behaviour and up to three sexual partners. Participants each described five specific but unidentified friends and the relationships between them in an ‘egocentric’ network analysis design. We used logistic regression to investigate associations between friendship characteristics and participants’ reports of ever having had sex (n = 2326) and recent condom use (n = 457). We used linear regression with random effects by participant to investigate friendship characteristics and age differences with sexual partners (n = 633 participants, 1051 partners). We found that it was common for friends to introduce young women to those who later became sexual partners, and having older friends was associated with having older sexual partners, (increase of 0.37 years per friend at least 1 year older, 95% CI 0.21–0.52, adjusted). Young women were more likely to report ever having had sex when more friends were perceived to be sexually active (adjusted OR 1.85, 95% CI 1.72–2.01 per friend) and when they discussed sex, condoms and HIV with friends. Perception of friends’ condom use was not associated with participants’ reported condom use. While this study is preliminary and unique in this population and further research should be conducted, social connections between friends and sexual partners and perceptions of friend sexual behaviours could be considered in the design of sexual health interventions for young women in South Africa.

Men's gender role conflict and stress (GRC/S), the psychological strain they experience around fulfilling expectations of themselves as men, has been largely unexplored in HIV prevention research. We examined associations between both men's gender norms and GRC/S and three HIV risk behaviors using data from a population-based survey of 579 18-35year-old men in rural northeast South Africa. Prevalence of sexual partner concurrency and intimate partner violence (IPV) perpetration in the last 12months were 38.0 and 13.4%, respectively; 19.9% abused alcohol. More inequitable gender norms and higher GRC/S were each significantly associated with an increased odds of concurrency (p=0.01; p&nbsp

Background: Antiretroviral (ARV) drugs are used for HIV treatment and prevention. We analyzed ARV drug use and HIV drug resistance in a cohort of young women in rural South Africa enrolled in the HIV Prevention Trials Network (HPTN) 068 study, which evaluated the use of a cash transfer conditional on school attendance to reduce HIV incidence. Methods: ARV drug testing was performed using plasma samples from 2526 young women. This included 2526 enrollment samples (80 HIV-infected and 2446 HIV-uninfected) and 162 seroconversion samples (first HIV-positive study visit). Testing was performed using a qualitative assay that detects 20 ARV drugs from 5 drug classes. HIV drug resistance testing was performed with the ViroSeq HIV-1 Genotyping System for samples that had HIV viral loads ≥400 copies per milliliter. Results: At enrollment, ARV drugs were detected in 10 (12.5%) of 80 HIV-infected young women. None of 2446 HIV-uninfected young women had ARV drugs detected at enrollment. ARV drugs were also detected in 16 (9.9%) of 162 seroconverters. At enrollment, 9 (13.4%) of 67 young women with genotyping results had HIV drug resistance; resistance was also detected in 9 (6.9%) of 131 seroconverters with genotyping results. Conclusions: Most of the HIV-infected young women in this cohort from rural South Africa were not taking ARV drugs, suggesting they were unaware of their HIV status or were not in care. HIV drug resistance was detected in young women with both prevalent and new HIV infection.

Background: Some individuals control HIV replication without antiretroviral (ARV) therapy. Objective: To analyze viral suppression in young women in rural South Africa enrolled in a trial evaluating a behavioral intervention for HIV prevention. Methods: Plasma samples were obtained from women ages 13–24 (81 infected at enrollment, 164 seroconverters). ARV testing was performed using an assay that detects 20 ARV drugs. Women were classified as viremic controllers if they were virally suppressed for ≥12 months with no ARV drug use. Results: Samples from 216/245 (88.2%) women had no ARV drugs detected at their first HIV-positive visit. Thirty-four (15.7%) of the 216 women had a viral load

Objective: School attendance prevents HIV and herpes simplex virus-2 (HSV-2) in adolescent girls and young women, but the mechanisms to explain this relationship remain unclear. Our study assesses the extent to which characteristics of sex partners, partner age, and number mediate the relationship between attendance and risk of infection in adolescent girls and young women in South Africa. Design: We use longitudinal data from the HIV Prevention Trials Network 068 randomized controlled trial in rural South Africa, where girls were enrolled in early adolescence and followed in the main trial for more than 3 years. We examined older partners and the number of partners as possible mediators. Methods: We used the parametric g-formula to estimate 4-year risk differences for the effect of school attendance on the cumulative incidence of HIV/HSV-2 overall and the controlled direct effect (CDE) for mediation. We examined mediation separately and jointly for the mediators of interest. Results: We found that young women with high attendance in school had a lower cumulative incidence of HIV compared with those with low attendance (risk difference =-1.6%). Partner age difference (CDE =-1.2%) and the number of partners (CDE =-0.4%) mediated a large portion of this effect. In fact, when we accounted for the mediators jointly, the effect of schooling on HIV was almost removed, showing full mediation (CDE =-0.3%). The same patterns were observed for the relationship between school attendance and cumulative incidence of HSV-2 infection. Conclusion: Increasing school attendance reduces the risk of acquiring HIV and HSV-2. Our results indicate the importance of school attendance in reducing partner number and partner age difference in this relationship.

The limiting antigen (LAg)-avidity assay is a serologic assay used for cross-sectional HIV incidence testing. We compared the results obtained with the LAg-avidity assay using dried blood spot (DBS) samples stored at room temperature (18°C-25°C) or stored frozen at -80°C with results obtained from matched plasma samples. Matched DBS and plasma samples (306 paired samples) were collected in the HIV Prevention Trials Network (HPTN) 068 trial in South Africa (2012-2014). The DBS were stored at room temperature before testing. Matched DBS and plasma samples (100 paired samples) from the Consortium for the Evaluation and Performance of HIV Incidence Assays (CEPHIA) were collected in 2016 and were stored at -80°C. All DBS testing was performed in 2017. Differences in normalized optical density (ODn) were compared between matched DBS and plasma samples. For DBS samples stored at room temperature (HPTN 068), the average difference in ODn values for plasma versus DBS was 1.49 (95% confidence intervals [CI]: 1.36-1.62). In contrast, when DBS samples were stored at -80°C (CEPHIA), the average difference in ODn values for plasma versus DBS was -0.22 (95% CI: -0.32 to -0.13). DBS samples stored at room temperature should not be used for cross-sectional HIV incidence testing with the LAg-avidity assay.

Introduction: Evidence has shown that the experience of violence by a partner has important influences on women's risk of HIV acquisition. Using a randomized experiment in northeast South Africa, we found that a conditional cash transfer (CCT) targeted to poor girls in high school reduced the risk of physical intimate partner violence (IPV) in the past 12 months by 34%. The purpose of this analysis is to understand the pathways through which the CCT affects IPV. Methods: HPTN 068 was a phase 3, randomized controlled trial in rural Mpumalanga province, South Africa. Eligible young women (aged 13-20) and their parents or guardians were randomly assigned (1:1) to either receive a monthly cash transfer conditional on monthly high school attendance or no cash transfer. Between 2011 and 2015, participants (N = 2,448) were interviewed at baseline, then at annual follow-up visits at 12, 24 and 36 months. The total effect of the CCT on IPV was estimated using a GEE log-binomial regression model. We then estimated controlled direct effects to examine mediation of direct effects through intermediate pathways. Mediators include sexual partnership measures, the sexual relationship power scale, and household consumption measures. Results: We found evidence that the CCT works in part through delaying sexual debut or reducing the number of sexual partners. The intervention interacts with these mediators leading to larger reductions in IPV risk compared to the total effect of the CCT on any physical IPV [RR 0.66, CI(95%):0.59-0.74]. The largest reductions are seen when we estimate the controlled direct effect under no sexual debut [RR 0.57, CI(95%):0.48-0.65] or under no sexual partner in the last 12 months [RR 0.53, CI(95%):0.46-0.60]. Conclusions: Results indicate that a CCT for high school girls has protective effects on their experience of IPV and that the effect is due in part to girls choosing not to engage in sexual partnerships, thereby reducing the opportunity for IPV. As a lower exposure to IPV and safer sexual behaviours also protect against HIV acquisition, this study adds to the growing body of evidence on how cash transfers may reduce young women's HIV risk.

Skilled attendance at birth is widely recognized as a single most effective strategy for reducing maternal mortality and morbidity and this is being used as an indicator to measure progress toward the fifth Millennium Development Goal of improving maternal health (MDG 5). However around half of the deliveries in the developing world are not attended by skilled professionals. The situation is worse in some regions such as South Asia where only less than one-third of deliveries are attended by skilled professionals. Safe motherhood still remains a distant dream for many around the world especially in developing countries leading to most of the maternal deaths in poor countries suggesting that most of these can be attributed to low level of supply and utilization of skilled maternal health services. Research studies have documented a range of social economic and geographic factors that act as barriers to low use of skilled maternity care during childbirth around the world. As far as India is concerned maternal education economic status of household caste and religion; availability of and accessibility to a health facility presence of a lady medical doctor availability of drugs; community attributes and programme-related factors play a critical role in the utilization of facility-based maternity care. Though costs - both direct and indirect-have also been shown to be an important barrier to womens use of facility-based maternity care there are a limited number of studies that have explored the issue in detail at regional level unlike at national level. India has avoided significant maternal and neonatal deaths in j:he last two decades. The Maternal Mortality Ratio (MMR) has declined from 398 (per 100 000 live births) in 1997-98 to 212 in 2007-09 and the neonatal mortality has declined from 45 (per 1000 live births) to 34 during the same period. Despite this recent achievement India still is one of the countries having high MMR in the world accounting for 19 percent of maternal deaths worldwide. Findings of a study report on MDGs progress in Bangladesh suggest that utilization of maternal health care is less in rural and poorest household as compared to their counterpart. Unlike developed countries in India more than 70 percent of the health care expenditure is paid by individuals and the government bears only 20 percent the rest is from businesses and external flows. In many situations health care expenditure which also includes maternal and neonatal care is catastrophic; this in tum can push the households into poverty. Especially rural households the less educated slum dwellers and poor households because these households in India are more likely to finance health care through borrowing and sale of assets than well off population groups. The District Level Household Survey DLHS4 has pointed out that at the public health facilities on an average a household has to spend INR 3130 for each delivery and it is INR 3000 in rural areas of Karnataka. Hence in this background using information from a baseline survey the present article aims to examine household expenses incurred for availing maternal healthcare services by rural women in North Kamataka.

Globally the HIV epidemic is aging due to the success of life-prolonging antiretroviral treatment. Historically, UNAIDS data reporting stopped at age 49. But the UNAIDS’ 2014 Gap Report identified older adults with HIV (OPH) as a group left behind. Challenges faced by this population include multimorbidity management, sexual health, stigma, and access to social care. Referencing three parallel studies in Uganda, South Africa and the U.S., this paper will examine similarities and differences in the complex challenges facing OPH across resource settings. For example, differences in the average number of comorbidities are evident (5.3, 1.2, and 3.2, respectively). In Africa, friends and neighbors provide much greater IADL assistance and emotional support than is observed in the U.S., but OPH in all settings report needing more support. The challenges in implementing policy and programmatic responses to the ageing of HIV in the context of available resources across settings will be discussed.

BACKGROUND: The transmission of Kaposi's sarcoma herpes virus (KSHV) in men who have sex with men is clearly associated with sexual risk factors, but evidence of heterosexual transmission of KSHV is conflicting. METHODS: Sera were obtained from 2103 South African individuals (862 miners, 95 sex workers, 731 female and 415 male township residents; mean age 33.2 years; +/- 10.1). All sera were tested for antibodies to KSHV lytic K8.1 and latent Orf73, HIV, gonococcus, herpes simplex virus type 2 (HSV-2), syphilis and chlamydia. Information on social, demographic and high-risk sexual behavior was linked to laboratory data, to evaluate risk factors, expressed as odds ratios (95% confidence interval) for KSHV. RESULTS: Overall KSHV and HIV prevalences were 47.5 and 40%, respectively (P = 0.43). The risk of HIV infection was highest in sex workers then female residents and miners, compared with male residents (P < 0.001). HSV-2 infection was highly prevalent (66%) and lower, but still substantial, prevalences (6-8%) were observed for other sexually transmitted infections (STI). No significant difference in KSHV infection was observed among the residential groups (P > 0.05). KSHV was not associated with any of the STI or any measures of sexual behavior (P > 0.05). CONCLUSION: The pattern of HIV and STI in sex workers suggests high rates of high-risk sexual behavior in this population. The lack of association with high-risk sexual behavior, particularly in sex workers, and with any markers of STI strongly suggest that the sexual mode does not play a significant role in KSHV transmission in this South African population

Objective To characterise perceived household support for female education and the associations between educational support and HIV prevalence, HSV-2 prevalence and sexual risk behaviours. Methods This cross-sectional study used baseline survey data from the Swa Koteka HPTN 068 trial undertaken in Mpumalanga, South Africa. The study included 2533 young women aged 13–20, in grades 8–11 at baseline. HIV and HSV-2 status were determined at baseline. Information about patterns of sexual behaviour and household support for education was collected during the baseline survey. Linear regression and binary logistic regression were used to determine associations between household support for education and both biological and behavioural outcomes. Results High levels of educational support were reported across all measures. HIV prevalence was 3.2% and HSV-2 prevalence was 4.7%, both increasing significantly with age. Over a quarter (26.6%) of young women reported vaginal sex, with 60% reporting condom use at last sex. The median age of sexual debut was 16 years. Household educational support was not significantly associated with HIV or HSV-2; however, the odds of having had vaginal sex were significantly lower in those who reported greater homework supervision (OR 0.82, 95%CI: 0.72–0.94), those who engaged in regular discussion of school marks with a caregiver (OR 0.82, 95%CI: 0.71–0.95) and when caregivers had greater educational goals for the young woman (OR 0.82, 95%CI: 0.71–0.96). In contrast, greater caregiver disappointment at dropout was significantly associated with reported vaginal sex (OR 1.29, 95%CI: 1.14–1.46). Conclusion Young women in rural South Africa report experiencing high levels of household educational support. This study suggests that greater household educational support is associated with lower odds of having vaginal sex and engaging in risky sexual behaviour, though not with HIV or HSV-2 prevalence.

Stigma remains a significant barrier to HIV testing in South Africa. Despite being a social construct, most HIV-stigma research focuses on individuals; further the intersection of gender, testing and stigma is yet to be fully explored. We examined the relationship between anticipated stigma at individual and community levels and recent testing using a population-based sample (n = 1126) in Mpumalanga, South Africa. We used multi-level regression to estimate the potential effect of reducing community-level stigma on testing uptake using the g-computation algorithm. Men tested less frequently (OR 0.22, 95% CI 0.14–0.33) and reported more anticipated stigma (OR 5.1, 95% CI 2.6–10.1) than women. For men only, testing was higher among those reporting no stigma versus some (OR 1.40, 95% CI 0.97–2.03; p = 0.07). For women only, each percentage point reduction in community-level stigma, the likelihood of testing increased by 3% (p < 0.01). Programming should consider stigma reduction in the context of social norms and gender to tailor activities appropriately.

Introduction: Adolescent girls and young women (AGYW) in South Africa bear a disproportionate burden of HIV. Community mobilization (CM), defined as community members taking collective action to achieve a common goal related to health, equity and rights, has been associated with increased HIV testing and condom use and has been called a ‘critical enabler’ for addressing the HIV epidemic. However, limited research has examined whether CM is associated with HIV incidence among AGYW. Methods: We examine the association of CM with incident HIV among AGYW (ages 13 to 21) enrolled in the HPTN 068 cohort in the Agincourt Health and socio-Demographic Surveillance System, South Africa. This analysis includes 2292 participants residing in 26 villages where cross-sectional, population-based surveys were conducted to measure CM among 18- to 35-year-old residents in 2012 and 2014. HPTN 068 participants completed up to five annual visits that included an HIV test (2011 to 2016). Household-level data were collected from AGYW parents/guardians and census data is updated annually. Mean village-level CM scores were created using a validated community mobilization measure with seven components (social cohesion, social control, critical consciousness, shared concerns, organizations and networks, leadership and collective action). We used pooled generalized estimating equation regression with a Poisson distribution to estimate risk ratios (RR) for the association of village-level CM score and CM components with incident HIV infection, accounting for village-level clustering and adjusting for key covariates. Results: There were 194 incident infections over the follow-up period. For every additional standard deviation of village-level CM there was 12% lower HIV incidence (RR: 0.88, 95% CI: 0.79, 0.98) after adjusting for individual, household and community characteristics. CM components associated with lower HIV incidence included critical consciousness (RR: 0.88; CI: 0.79, 0.97) and leadership (RR: 0.87; CI: 0.79, 0.95); while not statistically significant, social cohesion (RR: 0.91; CI: 0.81, 1.01), shared concerns (RR: 0.90; CI: 0.81, 1.00), and organizations and networks (RR: 0.91; CI: 0.79, 1.03) may also play a protective role. Conclusions: These results suggest that having strong community social resources will reduce AGYW's risk of HIV acquisition. Work to mobilize communities, focusing on building social cohesion, shared concerns, critical consciousness, and effective and accountable leadership, can fortify prevention programming for AGYW.

Background. Prevention of both school dropout and teen pregnancy represent clear public health priorities for South Africa, yet their complex and potentially cyclical relationship has not been fully explored. Objective. To further understand how this relationship operates, we analyzed data from a randomized trial of young women aged 13 to 20 years enrolled in school in rural South Africa to estimate the association between pregnancy and subsequent dropout and between dropout and subsequent pregnancy. Method. We examined inverse probability (IP) of exposure-weighted survival curves for school dropout by pregnancy and for pregnancy by school dropout. We used weighted curves to calculate 1-, 2-, and 3-year risk differences and risk ratios. Additionally, we used an IP-weighted marginal structural cox model to estimate a hazard ratio (HR) for each relationship. Results. Dropout from school was associated with subsequent pregnancy (HR 3.58; 95% confidence interval [CI] [2.04, 6.28]) and pregnancy was associated with subsequent school dropout (HR 2.36; 95% CI [1.29, 4.31]). Young women who attended school but attended fewer days had a higher hazard of pregnancy than those who attended more school (HR 3.64; 95% CI [2.27, 5.84]). Conclusion. Pregnancy is both a cause and a consequence of school dropout. Consideration of school attendance and academic performance could ultimately enhance pregnancy prevention efforts in this population. Programs should be tailored differently for (1) girls who have dropped out of school, (2) those who are in school and at risk for pregnancy, and (3) those who are in school and become pregnant.