HIV and Sexual Risk in African MSM in South African Township
PI: Theo Sandfort
National Institute of Mental Health R01; 2008 - 2012
South African men who have sex with men (MSM) are an understudied population in HIV/AIDS epidemiological and social science research. However, evolving evidence indicates that sexual risk behavior among these men is common, and strongly associated with the use of alcohol. Self-report data suggest that HIV prevalence in this population is as high as or higher than the overall high rate of infection among the general South African population. Due to the association of HIV/AIDS with poverty, African MSM in townships seem to be at particular risk for HIV infection. As a result of these gaps in our knowledge, there is a lack of targeted, culturally appropriate, evidence-based interventions addressing HIV risk in this population and the resources for effective prevention are limited.
The aims of the proposed study are (1) to assess the prevalence of HIV among African MSM living in South African townships and identify which behavioral, psychosocial, and network characteristics distinguish infected MSM from non-infected MSM; (2) to identify the structural and psychosocial correlates of sexual risk behavior in these men, with a particular focus on the role of alcohol use; and (3) to describe the social organization of same-sex sexual practices of these men and identify structural and psychosocial factors that affect how these practices are experienced.
To accomplish these aims, the proposed study combines HIV testing, a survey, and ethnography. Using ethnographic observations, ethnographic mapping, in-depth interviewing and of 20 key informants and 80 members from the target population, we will first study the lives of African MSM in four townships that are part of the Tshwane Municipality (the greater metropolitan area that includes Pretoria). Ethnography will elucidate how male same-sex sexuality and risk is structured in terms of practices, identities, networks, and communities, and inform future development or adaptation of prevention strategies. Building on the ethnographic phase, we will survey 500 men residing in Tshwane who engage in same-sex sexual practices with men (either exclusively of or in conjunction with sexual interactions with women) recruited via Respondent-Driven Sampling. The survey will identify structural and psychosocial correlates, particularly the role of the use of alcohol and other substances in sexual risk behavior. HIV testing of survey participants will allow us to identify risk factors of HIV infection, enabling us to target HIV prevention efforts to specific behaviors, subgroups of MSM, or their female partners, and to determine the correspondence between the study participant’s presumed and actual serostatus.
In the final phase of the proposed study and based on the study’s outcomes, the research team will in collaboration with community partners design an intervention; feasibility and effectiveness of this intervention will be tested in a subsequent study.
Rakai Adolescent Project (RAP)
PI: John Santelli
National Institute of Child Health and Human Development R01; 2009 - 2014
The Rakai Youth Project will use an innovative combination of quantitative and qualitative methods to examine risk for HIV infection among adolescents and young adults within the Rakai Community Cohort Study (RCCS), part of the Rakai Health Sciences Program (RHSP). Most previous studies of youth and HIV/STIs have been limited by a cross-sectional design and have been unable to use biological outcomes such as HIV incident infections as study outcomes. Using longitudinal data from the RCCS, the study has the opportunity not only to examine risk factors over time, but also to study HIV-incidence as an outcome. It includes longitudinal analysis of the rich Rakai Cohort data set and provides a unique opportunity to assess a continuum of biopsychosocial risk factors for new HIV infections from 1994 through 2012. The complementary use of qualitative methods, including an innovative ethnographic case-control study design allows an improved understanding of how social and developmental processes specifically shape HIV risk over time in a cohort of Ugandan youth.
The project will also explore the impact of changing HIV prevention and care policies, employing a generational change model to understand people's interpretations of the shifting dynamics of Uganda’s HIV policies and programs, including the recent introduction of antiretroviral therapies and male circumcision. The Rakai Community Cohort Study has, for the past 12 years, conducted annual surveillance on a total population of ~14,000 persons aged 15-49, of whom ~ 2,300 are adolescents aged 15-19 and ~2,500 are young adults aged 20-24. The population consists of all consenting residents of 50 communities currently in the sample area, and has achieved over 85% coverage among all residents. It enrolls newly age-eligible and in-migrants each year (~14%) which offsets losses to follow up that result from temporary or long-term absence, death, or refusal to participate. The cumulative sample size available for analysis of enrollment data from the available data for 1994-2006 is ~6020 youth 15-19 years and ~6545 youth 20-24 years. Sociodemographic information in the RCCS includes but is not limited to age, occupation, schooling, religious affiliation, marital status including polygamy, mobility and migration. RCCS behavioral and reproductive health information includes the use of VCT, behaviors to avoid sexually transmitted diseases, pregnancy and health history, sexual behavior, and relationships.
Qualitative interviews will be conducted with 80 HIV+ and HIV- young people over the course of two to three meetings, with each interview lasting between an hour and 1.5 hours. Participants will also be asked about their understanding of HIV prevention, behavioral reactions to this knowledge, and the landscape of Uganda's HIV-prevention policies, programs, and technologies. In addition, we will conduct 20 focus group discussions, and 40 individual interviews with youth and adults to explore how the evolving focus of HIV policies and programs in Uganda have influenced HIV risk factors and protective factors among youth in Rakai District.
Participants are asked to provide voluntary consent for interviewing and other research activities and are assured that their own data will not be divulged to any third party, including partners, without their written permission, as required by Ugandan policy. Adolescents under the age of 18 who reside with a parent or guardian are asked to provide assent and parental consent is also obtained.