Browsing by Author "Nuala McGrath"

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    Antiretroviral therapy based HIV prevention targeting young women who sell sex: A mixed method approach to understand the implementation of PrEP in a rural area of KwaZulu-Natal, South Africa
    (2022-02) Natsayi Chimbindi; Nondumiso Mthiyane; Thembelihle Zuma; Kathy Baisley; Deenan Pillay; Nuala McGrath; Guy Harling; Lorraine Sherr; Isolde Birdthistle; Sian Floyd; Jaco Dreyer; Sarah Nakasone; Janet Seeley; Maryam Shahmanesh§
    Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13-22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15-24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%-15.7%) reported transactional sex and 10.6% (95%CI: 8.85-12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS.
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    Home-Based Intervention to Test and Start (HITS): a community-randomized controlled trial to increase HIV testing uptake among men in rural South Africa
    (2020-12-23) Frank C Tanser; Hae-Young Kim; Thulile Mathenjwa; Maryam Shahmanesh; Janet Seeley; Phillippa Matthews; Sally Wyke; Nuala McGrath; Oluwafemi Adeagbo; Benn Sartorius; Handurugamage Manisha Yapa; Thembelihle Zuma; Anya Zeitlin; Ann Blandford; Adrian Dobra; Till B€arnighausen
    Introduction: The uptake of HIV testing and linkage to care remains low among men, contributing to high HIV incidence in women in South Africa. We conducted the “Home-Based Intervention to Test and Start” (HITS) in a 2x2 factorial cluster randomized controlled trial in one of the World’s largest ongoing HIV cohorts in rural South Africa aimed at enhancing both intrinsic and extrinsic motivations for HIV testing. Methods: Between February and December 2018, in the uMkhanyakude district of KwaZulu-Natal, we randomly assigned 45 communities (clusters) (n = 13,838 residents) to one of the four arms: (i) financial incentives for home-based HIV testing and linkage to care (R50 [$3] food voucher each); (ii) male-targeted HIV-specific decision support application, called EPIC-HIV; (iii) both financial incentives and male-targeted HIV-specific decision support application and (iv) standard of care (SoC). EPIC-HIV was developed to encourage and serve as an intrinsic motivator for HIV testing and linkage to care, and individually offered to men via a tablet device. Financial incentives were offered to both men and women. Here we report the effect of the interventions on uptake of home-based HIV testing among men. Intention-to-treat (ITT) analysis was performed using modified Poisson regression with adjustment for clustering of standard errors at the cluster levels. Results: Among all 13,838 men ≥ 15 years living in the 45 communities, the overall population coverage during a single round of home-based HIV testing was 20.7%. The uptake of HIV testing was 27.5% (683/2481) in the financial incentives arm, 17.1% (433/2534) in the EPIC-HIV arm, 26.8% (568/2120) in the arm receiving both interventions and 17.8% in the SoC arm. The probability of HIV testing increased substantially by 55% in the financial incentives arm (risk ratio (RR)=1.55, 95% CI: 1.31 to 1.82, p < 0.001) and 51% in the arm receiving both interventions (RR = 1.51, 95% CI: 1.21 to 1.87 p < 0.001), compared to men in the SoC arm. The probability of HIV testing did not significantly differ in the EPIC-HIV arm (RR = 0.96, 95% CI: 0.76 to 1.20, p = 0.70). Conclusions: The provision of a small financial incentive acted as a powerful extrinsic motivator substantially increasing the uptake of home-based HIV testing among men in rural South Africa. In contrast, the counselling and testing application which was designed to encourage and serve as an intrinsic motivator to test for HIV did not increase the uptake of home-based testing.
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    Isisekelo Sempilo study protocol for the efectiveness of HIV prevention embedded in sexual health with or without peer navigator support (Thetha Nami) to reduce prevalence of transmissible HIV amongst adolescents and young adults in rural KwaZulu-Natal: a 2×2 factorial randomised controlled trial
    (2022) Glory Chidumwa; Natsayi Chimbindi; Carina Herbst; Nonhlanhla Okeselo; Jaco Dreyer; Thembelihle Zuma; Theresa Smith; Jean‑Michel Molina; Thandeka Khoza; Nuala McGrath; Janet Seeley; Deenan Pillay; Frank Tanser; Guy Harling; Lorraine Sherr; Andrew Copas; Kathy Baisley; Maryam Shahmanesh
    Background: Antiretroviral therapy (ART) through universal test and treat (UTT) and HIV pre-exposure prophylaxis (PrEP) substantially reduces HIV-related mortality, morbidity and incidence. Efective individual-level prevention modalities have not translated into population-level impact in southern Africa due to sub-optimal coverage among adolescents and youth who are hard to engage. We aim to investigate the feasibility, acceptability, and preliminary population level efectiveness of HIV prevention services with or without peer support to reduce prevalence of trans‑ missible HIV amongst adolescents and young adults in KwaZulu-Natal. Methods: We are conducting a 2×2 factorial trial among young men and women aged 16–29 years, randomly selected from the Africa Health Research Institute demographic surveillance area. Participants are randomly allocated to one of four intervention combinations: 1) Standard of Care (SOC): nurse-led services for HIV testing plus ART if posi‑ tive or PrEP for those eligible and negative; 2) Sexual and Reproductive Health (SRH): Baseline self-collected vaginal and urine samples with study-organized clinic appointments for results, treatment and delivery of HIV testing, ART and PrEP integrated with SRH services; 3) Peer-support: Study referral of participants to a peer navigator to assess their health, social and educational needs and provide risk-informed HIV prevention, including facilitating clinic attendance; or 4) SRH+peer-support. The primary outcomes for efectiveness are: (1) the proportion of individuals with infectious HIV at 12 months and (2) uptake of risk-informed comprehensive HIV prevention services within 60 days of enrolment. At 12 months, all participants will be contacted at home and the study team will collect a dried blood spot for HIV ELISA and HIV viral load testing. Discussion: This trial will enable us to understand the relative importance of SRH and peer support in creating demand for efective and risk informed biomedical HIV prevention and preliminary data on their efectiveness on reducing the prevalence of transmissible HIV amongst all adolescents and youth. Trial registration: Trial Registry: clincialtrials.gov. ClinicalTrials.gov Identifer NCT04532307. Registered: March 2020. Keywords: Peer navigator, HIV prevention, Community-based care, Contraception, Pre-Exposure prophylaxis
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    Process evaluation of peer-to-peer delivery of HIV self-testing and sexual health information to support HIV prevention among youth in rural KwaZulu-Natal, South Africa: qualitative analysis
    (2022-01-19) Oluwafemi Atanda Adeagbo; Janet Seeley; Dumsani Gumede; Sibongiseni Xulu; Nondumiso Dlamini; Manono Luthuli; Jaco Dreyer; Carina Herbst; F Cowan; Natsayi Chimbindi; Karin Hatzold; Nonhlanhla Okesola; Cheryl Johnson; Guy Harling; Hasina Subedar; Lorraine Sherr; Nuala McGrath; Liz Corbett; Maryam Shahmanesh
    Objective: Peer-to-peer (PTP) HIV self-testing (HIVST) distribution models can increase uptake of HIV testing and potentially create demand for HIV treatment and pre-exposure prophylaxis (PrEP). We describe the acceptability and experiences of young women and men participating in a cluster randomised trial of PTP HIVST distribution and antiretroviral/PrEP promotion in rural KwaZulu-Natal. Methods: Between March and September 2019, 24 pairs of trained peer navigators were randomised to two approaches to distribute HIVST packs (kits+HIV prevention information): incentivised-peer-networks where peer-age friends distributed packs within their social network for a small incentive, or direct distribution where peer navigators distributed HIVST packs directly. Standard-of-care peer navigators distributed information without HIVST kits. For the process evaluation, we conducted semi-structured interviews with purposively sampled young women (n=30) and men (n=15) aged 18-29 years from all arms. Qualitative data were transcribed, translated, coded manually and thematically analysed using an interpretivist approach. Results: Overall, PTP approaches were acceptable and valued by young people. Participants were comfortable sharing sexual health issues they would not share with adults. Coupled with HIVST, peer (friends) support facilitated HIV testing and solidarity for HIV status disclosure and treatment. However, some young people showed limited interest in other sexual health information provided. Some young people were wary of receiving health information from friends perceived as non-professionals while others avoided sharing personal issues with peer navigators from their community. Referral slips and youth-friendly clinics were facilitators to PrEP uptake. Family disapproval, limited information, daily pills and perceived risks were major barriers to PrEP uptake. Conclusion: Both professional (peer navigators) and social network (friends) approaches were acceptable methods to receive HIVST and sexual health information. Doubts about the professionalism of friends and overly exclusive focus on HIVST information materials may in part explain why HIVST kits, without peer navigators support, did not create demand for PrEP.
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    Protocol: Mapping social networks, social influence and sexual health among youth in rural KwaZulu-Natal, the Sixhumene cohort study
    (2022-05-26) Vuyiswa Nxumalo; Siyabonga Nxumalo; Theresa Smit; Thandeka Khoza; Fikile Mdaba; Thulile Khumalo; Beniamino Cislaghi; Nuala McGrath; Janet Seeley; Maryam Shahmanesh; Guy Harling
    Background: Sexual behaviour and sexually transmitted infections are strongly affected by social connections, and interventions are often adapted more readily when diffused through social networks. However, evidence on how young people acquire ideas and change behaviour through the influence of important social contacts is not well understood in high-HIV-prevalence settings, with the result that past peer-led HIV-prevention interventions have had limited success. Methods: We therefore designed a cohort study (named Sixhumene or ‘we are connected’) to follow young people in three rural and small-town communities in uMkhanyakude district, KwaZulu-Natal, South Africa, and the people that these youth identify as important in their lives. We will interview them five times over three years, at each visit collecting information on their socioeconomic, social and sexual health lives, and testing them for HIV and herpes simplex virus 2 (HSV-2). We will use this information to understand how these young people’s sexual health decisions are formed. This will include evaluating how poor sexual health outcomes are correlated across social networks, how youth mimic the attitudes and behaviours of those around them, who is at greatest risk of acquiring HIV and HSV-2, and who might be most influential within communities and thus best able to promote protective interventions. Discussion: The information gathered through this study will allow us to describe social connection and influence spread through these real-world social networks, and how this leads to sexual health outcomes. Sixhumene will provide vital inputs for mathematical models of communities and spreading processes, as well as inform the development of effective interventions to protect the sexual health of community members through appropriate targeting with optimised messaging requiring fewer resources.
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    The association of exposure to DREAMS on sexually acquiring or transmitting HIV amongst adolescent girls and young women living in rural South Africa: A cohort study
    (2024-06-15) Nondumiso Mthiyane; Kathy Baisley; Natsayi Chimbindi; Thembelihle Zuma; Nonhlanhla Okesola; Jaco Dreyer; Carina Herbst; Theresa Smit; Siva Danaviah; Nuala McGrath; Guy Harling; Lorraine Sherr; Janet Seeley; Sian Floyd; Isolde Birdthistle; Maryam Shahmanesh
    Objective: We investigate how risk of sexually acquiring or transmitting HIV in adolescent girls and young women (AGYW) changed following the real-world implementation of DREAMS (Determined, Resilient, Empowered, AIDS free, Mentored and Safe) HIV prevention programme. Design: A representative population-based prospective cohort study of AGYW living in rural KwaZulu-Natal. Methods: Between 2017–2019 we interviewed a random sample of AGYW aged 13–22 annually. We measured exposure to DREAMS as self-reported receipt of an invitation to participate and/or participation in DREAMS activities that were provided by DREAMS implementing organizations. HIV and Herpes Simplex Virus type 2 (HSV-2) statuses were ascertained through blood tests on Dried Blood Spot (DBS). We used multivariable regression analysis to assess the association between exposure to DREAMS and risk of acquiring HIV: measured as incident HSV-2 (a proxy of sexual risk) and incident HIV; and the risk of sexually transmitting HIV: measured as being HIV positive with a detectable HIV viral load (>=50 copies per millitre (mL)) on the last available DBS. We adjusted for socio-demographic, sexual relationship, and migration. Results: 2184 (86.4%) of those eligible agreed to participate and 2016 (92.3%) provided data for at least one follow-up time-point. 1030 (54%) were exposed to DREAMS; HIV and HSV-2 incidence were 2.2/100 person-years (95% Confidence Interval [CI]: 1.66–2.86) and 17.3/100 person-years (95%CI: 15.5–19.4) respectively. There was no evidence that HSV-2 and HIV incidence were lower in those exposed to DREAMS: adjusted rate ratio (aRR) 0.96 (95%CI: 0.76–1.23 and 0.83 (95%CI: 0.46–1.52) respectively. HIV viral load was detectable for 169 (8.9%) respondents; there was no evidence this was lower in those exposed to DREAMS with an adjusted risk difference, compared to those not exposed to DREAMS, of 0.99% [95%CI: −1.52–3.82]. Participants who lived in peri-urban/urban setting were more likely to have incident HIV and transmissible HIV. Both HSV-2 incidence and the transmissible HIV were associated with older age and ever having sex. Findings did not differ substantively by respondent age group. Conclusions: DREAMS exposure was not associated with measurable reductions in risk of sexually acquiring or transmitting HIV amongst a representative cohort of AGYW in rural South Africa.