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Author: search.filters.author.Audrey PettiforAuthor: search.filters.author.Kathleen Kahn

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    Evaluating the Validity and Reliability of the Gender Equitable Men’s Scale Using a Longitudinal Cohort of Adolescent Girls and Young Women in South Africa
    (2022-03) Paul D Wesson; Sheri A Lippman; Torsten B Neilands; Jennifer Ahern; Kathleen Kahn; Audrey Pettifor
    Inequitable gender norms and beliefs contribute to increased sexual risk behavior, and, among adolescent girls and young women (AGYW), risk of HIV acquisition. We investigated the longitudinal measurement properties of the Gender Equitable Men's Scale (GEMS) when applied to a cohort of AGYW in rural South Africa (2011-2015). We used item response theory [Person-Item maps, Differential Item Functioning (DIF)] and measurement invariance confirmatory factor analysis models to assess the validity and reliability of the GEMS instrument. Item difficulty and endorsement of gender equitable beliefs both shifted over time. DIF analysis identified item bias for over half of the items; influenced by age, pregnancy, sexual debut, and intimate partner violence. Measurement invariance models revealed strong longitudinal invariance properties. GEMS is a reliable longitudinal measurement of gender equitable beliefs, with notable bias for specific items when administered to subgroups. Additional items specific to the adolescent experience are warranted for a more stable assessment of gender equitable beliefs in a population facing shifting norms as they mature.
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    Effect of quality of caregiver-adolescent relationship on sexual debut, transactional sex and on age-disparate relationships among young women in rural South Africa enrolled in HPTN 068
    (2022-04-01) Nosipho Shangase; Jess Edwards; Brian Pence; Allison Aiello; Andrea Hussong; Xavier Gómez-Olivé; Kathleen Kahn; Marie Stoner; Audrey Pettifor
    Background: Adolescent girls and young women (AGYW) remain burdened by the HIV epidemic. Positive caregiver-child relationships are associated with safe sexual behaviors in young people; yet, this literature often highlights the role of parent-child communication and parental monitoring, neglecting the importance of emotional relationships between a caregiver and adolescent. Setting: We used longitudinal data from HIV Prevention Trial Network 068-conducted among 2533 AGYW (13-20 years) over a period of 5 years in Agincourt, South Africa. Method: Kaplan-Meier and Cox models were used to estimate the effect of quality of caregiver-adolescent relationships (caring and closeness) on sexual debut, and log-binomial models with generalized estimating equations were used to examine the relationship between our exposures and transactional sex and age-disparate relationships. Results: Sexual debut was delayed among those who reported high levels of caregiver caring [hazard ratio: 0.80, 95% confidence interval (CI): 0.69 to 0.93] and caregiver closeness (hazard ratio: 0.80, 95% CI: 0.68 to 0.95). AGYW who reported high quality caregiver-adolescent relationships had a lower risk of transactional sex [caring: risk ratio (RR): 0.67, 95% CI: 0.58 to 0.78; closeness: RR: 0.58; 95% CI: 0.50 to 0.67]. Similarly, those with high-quality caregiver-adolescent relationships were less likely to be in an age-disparate relationship (caring: RR: 0.68, 95% CI: 0.58 to 0.79; closeness: RR: 0.77, 95% CI: 0.66 to 0.90). Conclusions: Findings indicate high-quality caregiver-adolescent relationships are associated with delayed sexual debut, a lower risk of transactional sex, and having an older partner. Family-centered interventions are needed to improve relationships between AGYW and caregivers.
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    The impact of conditional cash transfers for HIV prevention on peer relationships: perspectives from female recipients and non‑recipients in HPTN 068
    (2022) Makhosazane Nomhle Ndimande‑Khoza; Fiona Scorgie; Sinead Delany‑Moretlwe; Amanda Selin; Rhian Twine; Kathleen Kahn; Audrey Pettifor; Catherine MacPhail
    CCTs are currently being explored for HIV prevention among adolescent girls and young women (AGYW) in South‑ ern Africa. However, little is known about how CCT geared towards adolescents’ infuence peer relationships, despite evidence that peer relationships form a critical part of development in adolescence. This article presents fndings from a qualitative study that explored CCT recipients’ and non-recipients’ perspectives on the impact of CCTs paid to AGYW on peer relationships. HPTN 068 was a randomised controlled trial that assessed whether providing CCT to AGYW and their households reduces AGYW’s risk of acquiring HIV. As part of this trial, we conducted interviews and focus group discussions with sub-samples of AGYW (n=39), who were both cash recipients and non-recipients. Through content analysis, we explored ways in which the CCT positively or negatively impacted on peer relationships. From the recipients’ viewpoint, the CCT improved their social standing within their peer groups. It facilitated peer identity and promoted social connectedness among AGYW receiving the CCT. Receipt of the CCT enabled AGYW to resemble and behave like their peers who had money, allowing their poverty to become “invisible”. The CCT facilitated social interactions, information sharing, and instrumental social support among AGYW. CCT recipients experienced an increase in their social capital, evident in their ability to network, share, and reciprocate with others. However, the CCT also evoked negative emotions such as jealousy, anxiety, and resentment among non-recipients and led to a deterio‑ ration of personal relationships. CCTs have enormous benefts for AGYW, but they may also have a negative impact on peer relationships. The imple‑ mentation of HIV prevention interventions focused on structural drivers needs to be conscious of these dynamics and ensure that the negative consequences do not outweigh benefts.
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    Emotional Violence is Associated with Increased HIV Risk Behavior Among South African Adolescent Girls and Young Women in the HPTN 068 Cohort
    (2021-11-06) Anna M. Leddy; Amanda Selin; Sheri A. Lippman; Linda J. Kimaru; Rhian Twine; Xavier Gómez‑Olivé; Kathleen Kahn; Audrey Pettifor
    Limited research has explored how emotional intimate partner violence (IPV) shapes HIV risk behaviors. Using crosssectional data from the HPTN 068 post-trial visit (N=1942), we assessed the association between emotional IPV and its sub-domains (verbal abuse and threats) with condomless sex, transactional sex, and frequent alcohol use among young women in South Africa. In adjusted multivariable logistic regression models, any emotional IPV and verbal IPV were associated with increased odds of condomless sex (aOR: 1.47; 95% CI: 1.15, 1.87; and aOR: 1.48; 95% CI: 1.15, 1.89), transactional sex (aOR: 2.32; 95% CI: 1.74, 3.08; and aOR: 2.02; 95% CI: 1.51, 2.71) and alcohol use (aOR: 1.88; 95% CI: 1.39, 2.53; and aOR: 1.87; 95% CI: 1.37, 2.55). Threats were associated with transactional sex (aOR: 3.67; 95% CI: 2.62, 5.14). Future research should examine this relationship over-time and HIV prevention programs should consider and address emotional IPV.
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    Examining Mediators of the Relationship Between Community Mobilization and HIV Incidence Among Young South African Women Participating in the HPTN 068 Study Cohort
    (2021-10-07) Anna M. Leddy; Torsten B. Neilands; Rhian Twine; Kathleen Kahn; Jennifer Ahern; Audrey Pettifor; Sheri A. Lippman
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    A community mobilization intervention to improve engagement in HIV testing, linkage to care, and retention in care in South Africa: a cluster-randomized controlled trial
    (2022-09) Sheri A. Lippman; Audrey Pettifor; Mi-Suk Kang Dufour; Chodziwadziwa Whiteson Kabudula; Rhian Twine; Dean Peacock; Rhandzekile Mathebula; Aimée Julien; Rebecca West; Torsten B. Neilands; Ryan Wagner; Ann Gottert; F. Xavier Gómez Olivé; Dumisani Rebombo; Nicole Haberland; Julie Pulerwitz; Louis Pappie Majuba; Stephen Tollman; Kathleen Kahn
    Background: Community Mobilization (CM), engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. We assessed whether CM increased HIV testing, linkage to, and retention in care over time in intervention relative to control communities. Methods: Fifteen communities in Mpumalanga, South Africa were randomized to either a CM intervention engaging residents to address social barriers to HIV testing and treatment or to control. Implementation occurred from August 2015-July 2018. Outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among 18-49 year-old residents of intervention and control communities over the three years of study. Intention-to-treat analyses employed generalized estimating equations stratified by sex. ClinicalTrials.gov number NCT02197793. Findings: Residents in eight intervention communities (N=20,544) and seven control communities (N=17,848) contributed data. Among men, HIV testing increased quarterly by 12·1% (Relative Change (RC):1·121, 95%CI:1·099-1·143) in intervention communities and 9·5% (RC:1·095, 95%CI:1·075-1·114) in control communities; differences by arm were marginally significant (exponentiated interaction coefficient:1·024, 95%CI:0·997-1·052, p-value=0·078). Among women, HIV testing increased quarterly by 10·6% (RC:1·106, 95%CI:1·097-1·114) in intervention and 9·3% (RC:1·093, 95%CI:1·084-1·102) in control communities; increases were greater in intervention communities (exponentiated interaction coefficient:1·012, 95%CI:1·001-1·023, p-value=0·043). Quarterly linkage increased significantly among intervention community women (RC:1·013, 95%CI:1·002-1·023) only. Quarterly retention fell among women in both arms; however, reductions were tempered among intervention women (exponentiated interaction coefficient:1·003, 95%CI:<1·000-1·006, p-value=0·062). No significant differences were detected in linkage or retention among men. Interpretation: CM was associated with modest improvements in select trial outcomes. The sum of these incremental, quarterly improvements achieved by addressing social barriers to HIV care engagement can impact epidemic control. However, achieving optimal impacts will likely require integrated efforts addressing both social barriers through CM and provision of improved service delivery.
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    COVID-19 vaccine hesitancy in rural South Africa: Deepening understanding to increase uptake and access
    (2022-05-22) Kathleen Kahn; Audrey Pettifor; Palesa Mataboge; Nicole K Kelly; Duduzile P Mashinini; Harish Nair; Harry Campbell; Cheryl Cohen; F Xavier Gómez-Olivé; Stephen Tollman
    Background: To date, COVID-19 vaccine coverage in the African region falls far too short of global goals. Increasing vaccination rates requires understanding barriers to vaccination so that effective interventions that sensitively and effectively address barriers to vaccination can be implemented. Methods: To assess COVID-19 vaccination levels and identify major barriers to vaccine uptake we conducted a population-based, cross-sectional survey among 1662 adults 18 and older from August 25 to October 29 2021 in the Agincourt Health and Socio-Demographic Surveillance System (AHDSS) area, Mpumalanga, South Africa. Results: Half of participants reported receiving a COVID-19 vaccine (50.4%) with 41.1% being fully vaccinated and 9.3% being partially vaccinated; 49.6% were unvaccinated. More women than men were vaccinated (55.5% vs 42.8%, P < 0.001), and older age groups were more likely to be vaccinated than younger age groups (P < 0.001). Among the unvaccinated, 69.0% planned to get vaccinated as soon as possible, while 14.7% reported definitely not wanting the vaccine. Major barriers to vaccination included lacking information on eligibility (12.3%) or where to get vaccinated (13.0%), concerns about side effects (12.5%), and inconvenient hours and locations for vaccination (11.0%). Confidence in the safety and efficacy of COVID-19 vaccines was higher among those vaccinated than unvaccinated (75.3% vs 51.2%, 75.8% vs 51.0%, both P < 0.001, respectively). Conclusions: Increasing vaccination in South Africa beyond current levels will require a concerted effort to address concerns around vaccine safety and increase confidence in vaccine efficacy. Clarifying eligibility and ensuring access to vaccines at times and places that are convenient to younger populations, men, and other vulnerable groups is necessary.
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    Associations between WASH-related violence and depressive symptoms in adolescent girls and young women in South Africa (HPTN 068): a cross-sectional analysis
    (2022-07-05) Ruvani T Jayaweera; Dana Goin; Rhian Twine; Torsten B Neilands; Ryan G Wagner; Sheri A Lippman; Kathleen Kahn; Audrey Pettifor; Jennifer Ahern
    Objective: There is a lack of research on experiences of WASH-related violence. This study aims to quantify the association between experience or worry of violence when using the toilet or collecting water and depressive symptoms among a cohort of young women in South Africa. Methods: Data are from visit 3 of the HPTN 068 cohort of adolescent girls in rural Mpumalanga Province, South Africa. Participants (n=1798) included in this analysis were aged 13-21 at baseline. Lifetime experience of violence or fear of violence when using the toilet and collecting water was collected by self-report; depressive symptoms in the past week were measured using the Center for Epidemiological Studies Depression Scale (CES-D). We used G-computation to calculate the prevalence difference (PD) and prevalence ratio of depression (CES-D score >15) associated with each domain of violence, controlling for baseline covariates. Findings: A total of 15.1% of respondents reported experiencing violence when using the toilet; 17.1% reported experiencing violence when collecting water and 26.7% reported depression. In adjusted models, those who reported experiencing violence when using the toilet had an 18.1% higher prevalence of depression (95% CI: 11.6% to 24.4%) than those who did not experience violence when using the toilet. Adjusted prevalence of depression was also higher among those who reported violence when collecting water (PD 11.9%, 95% CI: 6.7% to 17.2%), and who worried about violence when using the toilet (PD 12.8%, 95% CI: 7.9% to 19.8%), as compared with those who did not report these experiences. Worrying about violence when collecting water was not associated with depression after adjusting for covariates. Conclusion: Experience of WASH-related violence is common among young women in rural South Africa, and experience or worry of experiencing violence is associated with higher prevalence of depressive symptoms.
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    The Sky is the Limit; I am Going There”: Experiences of Hope Among Young Women Receiving a Conditional Cash Transfer in Rural South Africa
    (2021-05-05) Kaitlyn Atkins; Catherine MacPhail; Suzanne Maman; Nomhle Khoza; Rhian Twine; F Xavier Gomez-Olive; Audrey Pettifor; Kathleen Kahn
    Young women in South Africa face elevated risk of HIV infection compared to male peers. Cash transfers may mitigate their risk for HIV; however, there is limited understanding of mechanisms of impact. We explored hope as one potential mechanism. Longitudinal qualitative analysis was used to explore how cash transfer recipients in the HPTN 068 study conceptualised hope and how the intervention influenced their hope over time. We found the intervention increased confidence, alleviated financial stressors and instilled in young women the belief that a better life, defined as being educated, independent and supportive to family, was attainable. Findings support hope as a critical outcome of cash transfer and other economic strengthening interventions.
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    Built Environment and HIV Linkage to Care in Rural South Africa
    (2023-01) Nosipho Shangase; Brian Pence; Sheri A. Lippman; Mi-Suk Kang Dufour; Chodziwadziwa Whiteson Kabudula; F. Xavier Gomez-Olive; Kathleen Kahn; Audrey Pettifor
    Background: We assessed built environment (residential density, landuse mix and aesthetics) and HIV linkage to care (LTC) among 1,681 (18–49 years-old) residents of 15 Mpumalanga villages, South Africa. Methods: Multilevel models (linear-binomial) were used for the association between built environment, measured using NEWS for Africa, and LTC from a clinical database of 9 facilities (2015–2018). Additionally, we assessed effect-measure modification by universal test-and-treat policy (UTT). Results: We observed, a significant association in the adjusted 3-month probability of LTC for residential density (risk difference (RD)%: 5.6, 95%CI: 1.2–10.1), however, no association for land-use mix (RD%: 2.4, 95%CI: 0.4, 5.2) and aesthetics (RD%: 1.2, 95% CI: 4.5–2.2). Among those diagnosed after UTT, residents of high land-use villages were more likely to link-to-care than those of low land-use villages at 12 months (RD%: 4.6, 95%CI: 1.1–8.1, p < 0.04), however, not at 3 months (RD%: 3.0, 95%CI: 2.1–8.0, p > 0.10). Conclusion: Findings suggest, better built environment conditions (adequate infrastructure, proximity to services etc.) help facilitate LTC. Moreover, UTT appears to have a protective effect on LTC.