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Background. Young South Africans experience high rates of HIV infection. While nationally scaled medical male circumcision (MMC) can help to curb HIV infection rates in countries such as South Africa (SA), MMC uptake has not been consistent or universal, suggesting variable acceptability among men. Both MMC and traditional male circumcision (TMC) are practised in SA. For male circumcision to be most effective for HIV prevention, it should be performed prior to sexual debut with complete removal of the foreskin. Objectives. The MACHO (Male Adolescent Choices for HIV Prevention Options) study investigated uptake of and preference for MMC v. TMC in two culturally distinct settings in SA. Methods. This observational, longitudinal, cohort study investigated circumcision preferences and uptake in 100 males (aged 14 - 17 years) and their legal guardians in Cape Town (Western Cape Province) and Soweto (Gauteng Province). Data were collected via surveys administered every 4 months over a 24-month period. Results. A total of 100 uncircumcised adolescent boys (Cape Town n =50, Soweto n =50; mean (interquartile range) age 15 (14 - 16) years) and their guardians were enrolled. At baseline, 42 boys from Soweto (84%) and none from Cape Town expressed a preference for MMC over TMC. Sowetan participants were more likely to elect circumcision (MMC n =11 (22%), TMC n =1 (2%)) than those from Cape Town (TMC n =1 (2%), MMC n =0) over 13.6 months of follow-up (hazard ratio 18.9; 95% confidence interval 2.37 - 150.71; p =0.006). Conclusions. MMC was the preferred option for young men in Soweto compared with those in Cape Town, and this translated into practice. Despite knowledge of the benefits of early MMC, many participants delayed uptake, potentially reducing the MMC benefits before sexual debut. Programmes promoting circumcision should consider the influence of local practices. To realise full HIV prevention benefits, efforts should be made to ensure that circumcision is promoted, and that all circumcision is safe, performed prior to sexual debut, and contextually responsive.

Worldwide, 780 million people do not have access to improved drinking water supplies and 88% of deaths from diarrheal diseases are attributable to unsafe water, inadequate sanitation, and insufficient hygiene. Access to safe water and practice of low cost home based treatments are generally at lower level in people living with human immunodeficiency virus (HIV) in Ethiopia. The aim of this study was to assess the water handling and treatment practice of peoples living with HIV in Southern Ethiopia. A cross sectional descriptive study was carried out among 414 study participants in February 2016 at Arba Minch town, Southern Ethiopia. The study participants were selected randomly from all the associations found in Arba Minch town who have HIV/acquired immunodeficiency syndromes (AIDS) infected people with proportional allocation to sample size. Data was collected using structured questionnaire and prepared checklists by trained data collectors. After checking for the completeness and consistency, the data were entered into Epi Info Version 7 software. Finally, descriptive analysis was done using SPSS Version 21 software, and the results were presented and discussed. The majority of clients 403 (97.6%) reported their drinking water source is tap water. Most households 382 (92.5%) had covered their stored water. Most of the respondents practiced pouring method to withdraw water from the stored container. The water status served for the clients showed that 84.5% (349) of households have improved water status. Majority (83.9%) of the households had access to water within a distance of up to 200 m or less. The majority (82.4%) of households had access to water within a time of 30 min or less. About 56% of the households treated drinking water at home. The water handling practice of the participants is not as recommended, and much effort is needed to alleviate this problem. Key words: Water handling, water treatment, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

Background. Young people in sub-Saharan Africa (SSA) are disproportionately affected by HIV, sexually transmitted infections and unplanned pregnancies. The provision of accessible sexual and reproductive health services (SRHS) for young people in SSA is vital to reduce this burden. Objectives. To examine the needs of South African (SA) adolescents with regard to differentiated, accessible and adolescent-responsive SRHS. Methods. Data were drawn from a larger project examining the feasibility of conducting HIV vaccine trials in adolescents. Fifteen focus group discussions were conducted across five research sites in four SA provinces with 120 male and female adolescent human papillomavirus vaccine trial participants aged 12 - 19 years from low-income areas with a high incidence of HIV. Transcribed data were double-coded using framework analysis. Results. Three main themes emerged on how best to improve SRHS for adolescents in resource-limited settings: adolescent-friendly services, availability of developmentally appropriate and tailored information, and improved relationships between healthcare workers and clinic attendees. Participants wanted more flexible opening hours at SRHS to account for travel time to clinics from school and home. They suggested that services include contraception, counselling, educational materials, links to adoption services, emergency vehicles, pre- and postnatal care, and improved service quality from clinic staff. Conclusions. While dedicated adolescent SRHS might best meet the needs of young people in SA, the study suggests that failing this, existing SRHS should be more responsive to adolescent use. Innovations such as mobile outreach services, self-testing and flexible hours will help SRHS respond to adolescents’ needs.S Afr Med J 2018;108(8):677-681.

The Human Research Council’s National HIV Prevalence, Incidence and Behavior Survey ranks South Africa first in HIV incidence in the world with 400,000 new infections in 2012 and found the HIV incidence rate among female youth aged 15 to 24 years to be 2.5% that year. The objective of this study was to compare the pattern and predictability of sexual activity between HIV-infected and HIV- uninfected young South African women. Sexually active young women between the ages of 16 and 21 years old completed a study survey between October 2012 and 2014 at two Desmond Tutu HIV Foundation centers. 100 young women with a mean age of 19.04 years responded to the survey. 51 women (51%) were HIV- infected and 49 were HIV-uninfected (49%). HIV-infected young women were found to be statistically less likely to have a temporal pattern to their sexual activity as compared to HIV-uninfected young women (56.9 vs. 95.9%, p

OBJECTIVES In VOICE, a phase IIB trial of daily oral and vaginal tenofovir for HIV prevention, at least 50% of women receiving active products had undetectable tenofovir in all plasma samples tested. MTN-003D, an ancillary study using in-depth interviews (IDIs) and focus group discussions (FGDs), together with retrospective disclosure of plasma tenofovir pharmacokinetic results, explored adherence challenges during VOICE. METHODS We systematically recruited participants with pharmacokinetic data (median six plasma samples), categorized as low (0%, N = 79), inconsistent (1-74%, N = 28) or high (≥75%; N = 20) on the basis of frequency of tenofovir detection. Following disclosure of pharmacokinetic results, reactions were captured and adherence challenges systematically elicited; IDIs and FGDs were audio-recorded, transcribed, coded and thematically analysed. RESULTS We interviewed 127 participants from South Africa, Uganda and Zimbabwe. The most common reactions to pharmacokinetic results included surprise (41%; low pharmacokinetic), acceptance (39%; inconsistent pharmacokinetic) and happiness (65%; high pharmacokinetic). On the basis of participants' explanations, we developed a typology of adherence patterns: noninitiation, discontinuation, misimplementation (resulting from visit-driven use, variable taking, modified dosing or regimen) and adherence. Fear of product side effects/harm was a frequent concern, fuelled by stories shared among participants. Although women with high pharmacokinetic levels reported similar concerns, several described strategies to overcome challenges. Women at all pharmacokinetic levels suggested real-time drug monitoring and feedback to improve adherence and reporting. CONCLUSION Retrospective provision of pharmacokinetic results seemingly promoted candid discussions around nonadherence and study participation. The effect of real-time drug monitoring and feedback on adherence and accuracy of reporting should be evaluated in trials.

Women of reproductive age account for nearly half of all HIV-infected people worldwide. Childbearing intention among HIV-infected women is complicated by social and reproductive concerns related to their HIV status. We conducted a cross-sectional study of HIV-infected and HIV-uninfected sexually active South African women aged 17 to 21 in order to compare their childbearing intentions and to identify predictors of the desire to have children among women with HIV. We found the rate of childbearing intention to be similarly high among both HIV-infected and HIV-uninfected study participants (80 and 79% respectively, p=0.81). History of previous parity was found to be associated with decreased intention to have children. No difference in childbearing intention was found between HIV-infected women on anti-retroviral therapy (ART) and women not on ART. High rates of childbearing intention among HIV-infected women require integration of reproductive health services with comprehensive HIV/AIDS care in order to mitigate the risks of sexual and vertical transmission of HIV.

Despite high HIV prevalence the uptake of HIV counseling and testing (HCT) has been low in South African adolescents, in particular among boys. We designed and implemented an integrated Youth Centre (YC), which included a health clinic and a points based rewards program to incentivize YC services, adjacent to a peri-urban community in Cape Town. We compared 12 month age and gender specific HCT rates for 12–22 year olds between the YC and the single local community clinic in the adjacent community prospectively and for the 12 months prior to YC implementation. Local clinic data were collected through the HCT register. At the YC demographic, attendance, incentives and HIV testing data were prospectively collected via a biometric data collection system. 1187 12–22 year olds attended the YC in the 12 month period. Within the 12–15 year old age group, 12.7% more individuals tested at the YC compared to the clinic in 2011–2012; this difference was greater in males than females. In the 16–22 year category, significantly more individuals tested at the clinic compared to the YC. The use of the YC reward program was associated with undergoing an HIV test. Understanding the specific programmatic factors that led to increased testing behaviour including the role of incentives at the YC warrants further attention.

Background.HIV-infected adolescents may be at higher risk for high-grade cervical lesions than HIV-uninfected adolescents. The purpose of this study was to compare the prevalence of high-risk HPV (HR-HPV) infections and Pap smear abnormalities between these two groups.Methods.In this cross-sectional study, we compared the HPV DNA and Pap smear results between 35 HIV-infected and 50 HIV-uninfected adolescents in order to determine the prevalence of HR-HPV genotypes and cervical cytological abnormalities. Comparisons were made using Pearsonχ2and independent-samplest-tests analyses, and associations between demographic and behavioral characteristics and HPV infections were examined.Results.HIV-infected participants were more likely to be infected with any HPV (88.6% versus 48.0%;P<0.001) and with at least one HR-HPV (60.0% versus 24.0%;P=0.001), and to have multiple concurrent HPV infections (68.6% versus 22.0%;P<0.001). HPV 16 and 18 were relatively underrepresented among HR-HPV infections. Abnormal Pap test results were more common among HIV-infected participants (28.8% versus 12.0%;P=0.054). A history of smoking was associated with HR-HPV infection.Conclusions.HIV-infected adolescents have an increased risk of infection with HR-HPV and of Pap test abnormalities. The majority of HR-HPV infections among our participants would not be prevented by the currently available vaccinations against HPV.

Infection with HIV is known to increase the risk of cervical cancer. In addition, evidence suggests that concurrent infection with multiple human papillomavirus (HPV) genotypes increases the risk of cervical dysplasia more than infection with a single HPV genotype. However, the impact of the combination of HIV coinfection and presence of multiple concurrent HPV infections on the risk of cervical dysplasia is uncertain. We compared the results of HPV testing and Pap smears between HIV-infected and HIV-uninfected young women to assess the cumulative impact of these two conditions. We found that both HIV and the presence of multiple concurrent HPV infections are associated with increased risk of associated Pap smear abnormality and that the impact of these two risk factors may be additive.

The high prevalence of HIV among young people in African countries underscores a pressing need for effective prevention interventions. Adapting school-based prevention programs developed in the United States for use in African schools may present an alternative to the time-consuming process of developing home-grown programs. The researchers report the results of a pretest-posttest field trial of an alcohol/HIV prevention curriculum adapted from an American model and delivered to ninth-grade students in five South African township schools. The revised intervention was based primarily on the Project Northland alcohol prevention and Reducing the Risk safer sex programs. The researchers found significant differences in change from baseline to follow-up between students in intervention and comparison groups on intentions to use a condom; drinking before or during sex; and, among females, sex refusal self-efficacy. The results of the field trial suggest that behavioral interventions developed in Western countries may be rapidly adapted to work in other cultural contexts.

Knowledge of HPV among HIV-Infected and HIV-Uninfected Adolescent Women in South Africa Objective: The aim of this study is to examine the knowledge of human papillomavirus (HPV) and cervical cancer among HIVinfected and HIV-uninfected female adolescents in South Africa. Methods: Subjects were recruited from a parent study of HPV infection comprised of females ages 16-21 in Masiphumelele, Cape Town, South Africa. A total of 30 subjects, 15 HIV-infected and 15 HIV-uninfected, were selected via randomization and completed a measure of HPV knowledge, based on a previously validated instrument. The study took place in May 2013. Results: The overall mean score on the measure for all subjects was 43.3% (S.D. 10.9). There was no significant difference in HPV knowledge between the HIV-infected and HIV-uninfected groups. Based on results from a previous large-scale study using the same validated measure, this sample scored significantly worse on general HPV knowledge than samples from the US, UK, and Australia. Conclusion: Given the limited knowledge of HPV in this sample, there is greater need for education about the prevention of cervical cancer, specifically among high-risk adolescent women.

Bacterial vaginosis (BV) is a widely prevalent infection that is associated with a range of adverse outcomes. We compared the rates of incidentally identified BV and other cervico-vaginal infections on Papanicolaou (Pap) smears of HIV-infected and HIV-uninfected adolescent females in South Africa. Cervical specimens from 50 HIV-uninfected and 32 HIV-infected sexually active South African adolescent females age 17-21 were collected and analyzed in accordance with the Bethesda system. We found a high overall prevalence of BV (54.9%) in our cohort. While previous research has found an increased prevalence of BV among HIV-infected women, the difference in the prevalence of BV between our HIV-infected group (62.5%) and HIV-uninfected group (50.0%) was not found to be statistically significant. The high rate of BV in both of these groups has significant implications for their risk of HIV acquisition and/or transmission in addition to other associated risks of BV. Given that the Pap smear is specific in incidentally diagnosing BV, it may be utilized as a screening method for BV in the adolescent population.

01CD002 Studying pulmonary function in HIV positive tanzanian youth A. August; Geisel School of Medicine at Dartmouth, Hanover, NH/US Program/Project Purpose: Survival into childhood with an untreated HIV infection was once considered unusual, but has increased in recent years. This has spurred further interest in studying the health of adolescents living with HIV. There have been two major reports from Zimbabwe (Ferrand et al., 2007) and Malawi (Zverez et al., 2001) of a decrease in pulmonary function in HIV positive youth, especially if they had delayed onset of treatment. The purpose of this study is to investigate the pulmonary function of HIV positive Tanzanian children. This study will help determine the importance of monitoring lung function in HIV patients and if a pulmonary treatment regimen should be instituted. Structure/Method/Design: A cohort of 250 Tanzanian children between the ages of 8 and 18 with a diagnosis of HIV currently being treated at the DarDar Pediatric Program in Dar es Salaam, Tanzania will take part in the study. Pulmonary function (PFT) was assessed using spirometry to measure forced expiratory volume at one second (FEV1), forced vital capacity (FVC), FVC/FEV1 ratio, and forced expiratory flow 25% to 75% (FEF25-75) as well as pulse oximetry. Each participant was evaluated at rest. If recorded values for FVC and FEV 1 were > 70% of predicted, they were re-evaluated after moderate exercise and after administration of a bronchodilator. Normative data from healthy Malawian youth were used. The PFT data were analyzed in correlation with age of diagnosis and age at initiation of antiretroviral therapy. Outcomes & Evaluation: A preliminary analysis of the first 50 subjects has not shown any significant degree of pulmonary dysfunction nor any correlation with a delayed ART regimen. Of the 50 subjects, three were excluded for inconsistent PFT efforts. The remaining 47 subjects consisted of 17 females/30 males. Only 3 subjects had FEV 1 Going Forward: Ongoing challenges include obtaining consistent data from younger subjects as well as timely patient acquisition. We anticipate meeting our goal of 250 subjects by late spring 2015. Funding: This project is supported by internal funds available through the Medical Schools at Muhimbili University and Dartmouth. Funding for the author’s participation was provided by the DIHG-DICKEY International Health Fellowship and Helen’s Fund for pediatric research at the Children’s Hospital at Dartmouth.