A research report submitted to the School of Public Health, University of the Witwatersrand in partial fulfillment of the requirements for the degree of Master of Public Health. June 2018. / Introduction Southern Africa forms the epicentre of the HIV epidemic and young people commonly get diagnosed long after infection. Despite the evidence that HIV Counselling and Testing (HCT) can reduce risky sexual behaviors and prevent HIV, uptake of testing in young people remains limited and this is especially true in Southern Africa. In the last few years, effective interventions for HIV prevention have been implemented, including treatment as prevention and pre-exposure prophylaxis. In the context of very high prevalence of HIV among young people in Southern Africa, it is critical that countries attain higher levels of HCT. Demand creation is one of the means to increase uptake of HCT. This study investigated the relationship between exposure to a mass media campaign and uptake of HIV counselling and testing among young people in five countries of Southern Africa (Lesotho, Mozambique, South Africa, Swaziland and Zambia) for the period 2008 to 2012. A secondary data analysis from a multi-country study was undertaken. Methods: Secondary data on young people aged 15-24 years from a post-only cross-sectional observational multi-country study that was undertaken in 2012 to evaluate the One Love Campaign, a regional behavior change media campaign coordinated by Soul City Institute for Development Communication was undertaken. The exposure variable was exposure to One Love campaign (in the form of television film series; locally produced radio drama series, television public service announcements and a television series in South Africa. In other participating countries the programme also comprised talk shows broadcast by national- and community broadcasters; booklets, billboards used to trigger discussion during community dialogues and community outreach events) with the outcome of interest being HIV testing, with a number of covariates such as socio-demographic characteristics (e.g age, education level, nationality, sex, marital status, socio-economic status (defined as wealth quintile), whether respondent had children or not, and country of residence. Bivariate and multivariate analysis was conducted to establish the relationship between exposure to One Love campaign and HIV testing among the study population. Results: A total of eight-thousand-six-hundred and thirteen young people (n=8613) participated in the study. There was nearly equal distribution of respondents between those that had had an HIV test (52.0%) and those that had not (48.0%). Exposure to One Love through multiple media, was positively associated with HIV testing (aOR=2.34, 95% CI 1.94-2.81), and there was a dose response. Other factors associated with having an HIV test included being female (aOR= 1.95, 95% CI 1.75 - 2.18); having living child (aOR=4.23, 95% CI 3.57-5.01); being the aged 18-20 years (aOR=2.24, 95% CI 1.95 - 2.58) or group 20-24 years (aOR=4.14, 95% CI 3.57 - 4.81) and having secondary or tertiary education ( aOR= 2.67, 95% CI 1.92 - 3.68). Increased wealth until quintile 4 was negatively associated with having an HIV test, (aOR= 0.93, 95% CI 0.77 - 1.12). Conclusion: Overall the findings of this study show that exposure to more than one medium in the campaign has greater odds of testing. The results of this study provide important information on the relationship between exposure to a media campaign and HIV testing among young people. Social and behaviour change communication strategies that use multi-media are necessary to achieve improved HIV testing among young people. / LG2018

Background: By 2005 an estimated 5. 5 million South Africans were living with HIV and the peak prevalence of HIV/AIDS occurs in young people aged 15-24 years. In order to develop prevention strategies aimed at young people, it is important to determine risk behaviours for HIV in this age group. As VCT has been shown to impact on risk behaviours, it is important to determine the accessibility of these services to youth. Aim: This study assessed the knowledge, attitudes, beliefs and practises (KABP) of young adults, 15-24 years of age attending a private general practise, regarding risks for HIV and accessibility of HIV Voluntary Counselling and Testing (VCT) services. Methods: This was a cross-sectional study. A self-administered questionnaire was completed by a sample of 100 patients attending a general practice located in Athlone. Results: Thirty-six of respondents were male and 64 were female. The age range was 15 to 24 years, with a mean age of 20.2 years. The demographic profile of the study population was typical of a formal urban settlement in a traditionally coloured area. Sixty four percent of respondents reported current or previous sexually activity, of which 89% reported that they had one sexual partner over the preceding three months and 58%, reported not using a condom at their last sexual encounter. The mean age of sexual debut was 16 years. Most respondents could identify safer sexual practices. While 97% of respondents had heard of HIV, only 33% knew someone who had died of HIV/AIDS. Most respondents knew how HIV was transmitted and 74% felt that they had never put themselves at risk of contracting HIV. Seventy five percent of respondents had heard of VCT, and 60% had considered having a test. Knowledge regarding the location of VCT testing sites, methods of testing and waiting period for results was generally poor. Most respondents had a favourable impression of staff in the clinic/CHC setting and would return to these facilities for HIV VCT. However, 71 % reported that they were prepared to pay for a HIV test. Respondents reported that having an HIV test would have a positive effect on sexual behaviour; however, only a third would disclose their HIV test result. Discussion: Respondents had high levels of awareness of HIV prevention strategies but these did not always translate into the adoption of appropriate behaviours. This disparity between awareness of HIV prevention strategies and actual risk taking sexual behaviour could reflect inadequacies in current HIV education programmes. Knowledge regarding most aspects of HIV VCT was inadequate, but there was a high willingness to test for HIV. Respondents indicated that they were prepared to pay for VCT. VCT could be used to engage with young adults and impact on behaviour changes. Further studies may be useful to illustrate the potential of VCT as a prevention strategy and to promote the allocation of more resources for this purpose.

MSc (Med), Faculty of Health Sciences, University of the Witwatersrand, 2006

Philosophiae Doctor - PhD / HIV counselling and testing (HCT) is an essential element in the response to the HIV epidemic. There are still major gaps in research about the best ways to provide HCT, especially to young people. School-based HCT is a model which has been suggested for providing HCT to young people in a youth friendly manner. This study was aimed at producing recommendations for providing a youth friendly school-based HCT service using the World Health Organisation (WHO) framework for youth friendly health services. It was conducted in six secondary schools in Cape Town, where a mobile HCT service is provided by a nongovernmental organisation (NGO). It was an exploratory descriptive study, using a mixed-methods approach. Twelve focus group discussions (FGDs) were held with learners to explore their needs with regards to school-based HCT. An evaluation (which consisted of observation of the HCT site, service provider interviews and direct observation of the HCT counselling process) was done to determine whether the mobile school-based HCT service was youth friendly. A learner survey was conducted with 529 learners to investigate the factors that influence the uptake of HCT and to explore learners’ behaviours and experiences under test conditions. In the FGDs, learners said that they wanted HCT to be provided in schools on condition that their fears and expressed needs were taken into account. They wanted their concerns regarding privacy and confidentiality addressed; they wanted to be provided with information regarding the benefits and procedure of HCT before testing took place; they wanted service providers to be competent to work with young people, and they wanted to be assured that those who tested positive were followed up and supported. On evaluation of the mobile school-based HCT service, it was evident that the service did not meet all the needs of the learners nor did it have all the characteristics of a youth friendly health service. The model of ‘mass testing’ used by the NGO did not fulfil learners’ expressed need for privacy with regards to HCT. Service providers were friendly and non-judgemental but had not been trained to work with young people (especially marginalised groups e.g. young men who have sex with men). The information needs of learners were not addressed, and learners were not involved in the provision of the HCT service. Learners who tested positive were not assisted in accessing care and support. The learner survey revealed a high uptake of HCT (71% of learners) at schools with learners who do not identify themselves as Black, with female learners and older learners being more likely to have had an HIV test. Factors that influenced uptake of HCT were complex, with learners reporting many different motivators and barriers to testing. Of concern was the low risk perception of leaners with regards to HIV infection and the fact that learners who tested HIV positive were not being linked up with treatment and care. Based on the findings of the study, recommendations were made for providing youth friendly school based HCT. A multisectoral approach, with learner and community involvement, was suggested in order to provide a service which is equitable, accessible, acceptable, appropriate and effective.

Magister Public Health - MPH / High HIV incidence among young women is a global public health concern with the potential for a huge impact on their lives. Several interventions have been identified to help reduce HIV incidence among young women, including HIV Counselling and Testing (HCT). Lack of knowledge of HIV status is a major barrier to HIV prevention, care and treatment efforts. Therefore, HCT uptake among young women needs to be up-scaled. Early detection and treatment can help cushion the impact of AIDS on the lives of young women. There are various factors that negatively influence young women’s HCT uptake, including psychosocial characteristics. Studies have linked self-esteem to HCT and high levels of HIV risk behaviour practices among young women. The aim of this study was to assess the relationship between self-esteem and HCT uptake among young women (16 to 24 years) in South Africa using data from the 2012, Third National HIV Communication Survey (NCS). This was a quantitative secondary data analysis of cross-sectional data from the 2012 NCS. The participants of this study were young women (n =1922) from all provinces in South Africa. The independent variable was self-esteem and the dependent variable was ever testing for HIV and testing in the last 12 months, with a number of socio-demographic characteristics as covariates. Data was analysed using STATA statistical software (version 13.0, STATA Corp., College Station Texas, USA). Socio-demographic characteristics were described through descriptive statistics. The relationship between independent variables and HIV testing was analysed with Chi-squared tests of association. Logistic regression models were used to examine the relationship between self-esteem and HCT uptake when controlling for confounders.

Thesis (M.Cur.) --University of Limpopo, 2013 / All pregnant women who seek antenatal health care at the public clinics are offered HIV counselling and testing. Those who agree to test and who test positive, often fail to bring their infants for polymerase chain reaction (PCR) HIV testing after delivery, despite the fact that they have been advised to do so during delivery. There are very few studies which have assessed the women’s knowledge with regard to the PCR HIV testing of infants. In this study; a qualitative, exploratory, and descriptive methodology was applied to explore and describe the knowledge of pregnant women with regard to PCR HIV testing of infants in the Molemole Municipality of the Limpopo Province, Capricorn District. Purposive sampling was used and semi-structured interviews were conducted until saturation of data was reached. Qualitative data analysis design of Marshall and Rossman was used. The study indicated that the participants had knowledge with regard to the PCR HIV testing of infants. The nurse and lay counsellors knew about the different modes of prevention of mother-to-child transmission (PMTCT) and they used every contact opportunity with pregnant women to share its benefits. Mother to mother support groups for HIV positive pregnant and lactating women should be established for continuous support and counselling with the purpose of achieving an HIV-free generation.

Philosophiae Doctor - PhD / HIV counselling and testing (HCT) is an essential element in the response to the HIV epidemic. Thereare still major gaps in research about the best ways to provide HCT, especially to young people. School-based HCT is a model which has been suggested for providing HCT to young people in a youth friendly manner. This study was aimed at producing recommendations for providing a youth friendly school-based HCT service using the World Health Organisation (WHO) framework for youth friendly health services. It was conducted in six secondary schools in Cape Town, where a mobile HCT service is provided by a nongovernmental organisation (NGO). It was an exploratory descriptive study, using a mixed-methods approach. Twelve focus group discussions (FGDs) were held with learners to explore their needs with regards to school-based HCT. An evaluation (which consisted of observation of the HCT site, service provider interviews and direct observation of the HCT counselling process) was done to determine whether the mobile school-based HCT service was youth friendly. A learner survey was conducted with 529 learners to investigate the factors that influence the uptake of HCT and to explore learners’ behaviours and experiences under test conditions. In the FGDs, learners said that they wanted HCT to be provided in schools on condition that their fears and expressed needs were taken into account. They wanted their concerns regarding privacy and confidentiality addressed; they wanted to be provided with information regarding the benefits and procedure of HCT before testing took place; they wanted service providers to be competent to work with young people, and they wanted to be assured that those who tested positive were followed up and supported. On evaluation of the mobile school-based HCT service, it was evident that the service did not meet all the needs of the learners nor did it have all the characteristics of a youth friendly health service. The model of ‘mass testing’ used by the NGO did not fulfil learners’ expressed need for privacy with regards to HCT. Service providers were friendly and on-judgemental but had not been trained to work with young people (especially marginalised groups e.g. young men who have sex with men). The information needs of learners were not addressed, and learners were not involved in the provision of the HCT service. Learners who tested positive were not assisted in accessing care and support. The learner survey revealed a high uptake of HCT (71% of learners) at schools with learners who do not identify themselves as Black, with female learners and older learners being more likely to have had an HIV test. Factors that influenced uptake of HCT were complex, with learners reporting many different motivators and barriers to testing. Of concern was the low risk perception of learners with regards to HIV infection and the fact that learners who tested HIV positive were not being linked up with treatment and care. Based on the findings of the study, recommendations were made for proving youth friendly school based HCT. A multisectoral approach, with learner and community involvement, was suggested in order to provide a service which is equitable, accessible, acceptable, appropriate and effective.

Background Globally, external HIV-related stigma is a major threat to all HIV prevention, care and treatment interventions including the recently launched Universal Test and Treat (UTT) strategy in South Africa and the 90-90-90 targets set by UNAIDS for the global response by 2020. The 90-90-90 targets are put in place to track the progression from HIV testing to durable viral load suppression among people living with HIV. The targets guide HIV programmes to achieve 90% known HIV status, to access 90% antiretroviral therapy and to suppress 90% viral loads (UNAIDS, 2017). Achievement of the 90-90-90 targets has since become a part of South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022. External HIV-related stigma in this study was defined as the presence of one or more of the following attitudes and behaviours: rejection, avoidance, intolerance, stereotyping, discrimination, and physical violence towards people living or perceived as having HIV. There have not been many efforts to attenuate HIV-related stigma in South Africa, as it continues to exist. There has been a scale up of other HIV responses, such as HIV Counselling and Testing (HCT) and treatment, with the argument made that in scaling up these biomedical approaches, stigma would disappear. Furthermore, its exact magnitude, trends over the years and correlates have not been explored fully at national level, hence the present study known as Stigma Assessment Study in South Africa (SASSA). SASSA is based on the Institutional Social Construction theory framework. It explores the external HIV-related stigma magnitude and its trends between 2005 and 2012, as well as the associated factors which influence its prevalence in South Africa at a national level. The study further explores the mediating and moderating factors of external HIV-related stigma and tries to explore external HIV-related stigma by viewing individuals with HIV living in families, societies and structures, with the hope of contributing to the development of new systematic HIV-related stigma interventions in South Africa as well as, strengthening existing ones. Methodology The project used secondary data obtained from three South African national population HIV surveys which were conducted in 2005, 2008 and 2012 by a research consortium led by the Human Sciences Research Council. Sub-samples of the original surveys consisting of respondents aged 15 years and older who had responded to the stigma questions in the three surveys were extracted and included in the SASSA analysis. A nationally representative sample of a total of 16 140 individual respondents from the 2005 survey, 13 134 from the 2008 survey and 30 748 from the 2012 survey was used in the study. Two different measures of external HIV stigma are used in this analysis, one is a summary measure from the latest survey data, i.e. 2012, which was used to do a regression analysis. The summary measure was regarded as reliable to use for the regression analysis as it provides crude effect of the exposure factors on external HIV stigma. However, this summary measure was not included in the previous surveys, i.e. 2005 and 2008, and therefore could not be used for trends analysis. We therefore used 4 individual stigma items for the trends analysis as these were included in all 3 surveys. The use of 4 individual stigma items was important because when data from a variety of sources or categories have been joined together, the meaning of the data can be difficult to see. It was therefore considered ideal to assess the performance of the individual constructs on their individual contribution to the impact on HIV external stigma. Furthermore, analysis using individual constructs provided an opportunity to see specific patterns which could have remained obscure in crude analysis. The first measure of external HIV-related stigma used in the regression analysis was measured by five individual items which elicited attitudes towards people living with HIV (PLHIV). The five items were based on a 9-item scale that was originally developed and tested in a South African population, and the 9-item scale was found to be internally consistent (alpha = 0.75) and reliable (r = 0.67). The 5 items were (1) People who have AIDS are dirty; (2) People who have AIDS are cursed; (3) People who have AIDS should be ashamed; (4) People with AIDS must expect some restrictions on their freedom; (5) A person with AIDS must have done something wrong and deserves to be punished. As explained above, the specific external HIV stigma patterns second measure, which was utilized to explore stigma trends over the years 2005, 2008 and 2012, consists of four individual stigma items which elicited attitudes towards PLHIV. The four individual stigma items included: (1) If you knew that a shopkeeper or food seller had HIV, would you buy food from them? (2) Would you be willing to care for a family member with AIDS? (3) Is it a waste of money to train or give a promotion to someone with HIV/AIDS? (4) Would you want to keep the HIV positive status of a family member a secret? Findings Overall, external HIV-related stigma was found to exist among 38.3% of adult South Africans in 2012. Multiple regression analysis showed that predictors of external HIV-related stigma were race, sex, education level, self-perceived risk of HIV infection and HIV knowledge (p< 0.01). Females were less likely to report external HIV-stigma than males (AOR = 0.9, P< 0.001). Those who perceived themselves to be at high risk of HIV infection were less likely to display some stigma than those who believed they were at low risk (AOR = 0.89, p < 0.01). The study did not find any significant associations between HIV testing or awareness of HIV status, with external HIV-related stigma in this study. Looking at the individual external HIV stigma items used to measure trends, the study reveals a slight decrease in the reporting of stigma over the three time periods (2005 vs 2008 vs 2012) on responses for two of the stigma items (Q1: If you knew that a shopkeeper or food seller had HIV, would you buy food from them, and Q2: Would you be willing to care for a family member with AIDS). While an increase was observed in the reporting of stigma over the three years on responses for two of the stigma items (Q3: Is it a waste of money to train or give a promotion to someone with HIV/AIDS, and Q4: Would you want to keep the HIV positive status of a family member a secret). The structural equation modelling (SEM) showed likelihood ratio test results with a p-value greater than 0.05, a root mean square error of approximation (RMSE) of 0.008 and Tucker–Lewis index (TLI) value of 0.985. The model fit assessment results allow us to accept that an hypothesized model of the study is not far from a perfect model. The SEM results also showed a direct effect of sex on HIV knowledge statistically significant at p < 0.001, with race having an effect of 3.3% and education a direct effect of 9.5%, and both of these showed a statistically significant effect (p < 0.001) respectively. HIV knowledge showed to have a statistically significant inverse relationship on external HIV stigma of -10.4% (95% CI: -12.3-0.09) p< 0.001. Awareness of HIV status had the highest positive direct effect on external stigma of 10% (95% CI: 4.41-15.67%) p<0.001. With regard to indirect effects, sex, race, and education had minimal negative indirect effects on external stigma, which was statistically significant for all the three covariates. With the said effects of external HIV-related stigma, it was found that HIV knowledge independently mediates the relationship between Level of Education, Awareness of HIV status, Race, HIV testing history, and Sex, with External HIV-related stigma. Conclusion External HIV-related stigma still exists in South Africa despite previous success in massive ART rollout, HTC campaigns, and most recently test-and-treat programmes, which were arguably thought to have a parallel effect in the decrease of HIV related stigma. The focus on individualistic health structural approaches that do not generally have stigma-reduction as a specific aim, as discussed, is likely to undermine the successes achieved in the fight against HIV thus far. There is a need to develop innovative holistic interventions which are specifically intended for HIV stigma reduction. These should be inclusive of both social institutional elements and health structural elements to address the challenge of external HIV-related stigma.

Magister Artium (Development Studies) - MA(DVS) / Malawi had an estimated HIV prevalence of 9.6% with about 9.2% of its adult population living with HIV/AIDS in 2018. HIV Counselling and Testing (HCT) is essential to the prevention of HIV infection, HIV treatment and access to care and support services. However, despite the availability of free HCT services, the uptake of HCT services has been low among men in Malawi. This study assessed barriers and enablers of HCT uptake among men aged 18-49 in Chileka Health Area in Lilongwe District.

Thesis (M.A. (Clinical Psychology)) --University of Limpopo, 2013 / Studies have indicated that help-seeking behaviour of people living with HIV is not predictable and linear and may entail the utilization of western medicine, traditional medicine and/or complementary medicine. The aim of this study was to explore pre- and post- HIV diagnosis help-seeking behaviour by patients receiving antiretroviral treatment at Witbank Hospital in Mpumalanga Province (South Africa).A qualitative, descriptive phenomenological approach was utilized in the study. Ten participants (male = 5; female = 5, and aged between 30 and 50 years)diagnosed with HIV and who came to the hospital to collect their treatment and for medical review were interviewed using semi-structured interviews. Interpretive analysis method was used to analyse the data. The results suggest the preference for western medicine pre-and post-HIV diagnosis. The results further suggest that help-seeking behaviour is a dynamic process embedded mainly in the conceptualization of the health problem, perception of its severity, the treatment given, and social support experienced.