BackgroundThe South African national HIV program has increased antiretroviral therapy (ART) coverage over the last decade, supported by policy changes allowing for earlier ART initiation. However, many patients still enter care with advanced (<200 cells/μL) and very advanced (<100 cells/μL) HIV disease. We assessed disease progression at entry to care using nationwide laboratory data.MethodsWe constructed a national HIV cohort using laboratory records containing HIV RNA loads and CD4 counts from 2004 to 2016 to determine entry into care. We estimated numbers and proportions of adults with the first CD4 count <100 cells/ μL or 100–199 cells/μL. We calculated relative risks of presenting with advanced disease associated with male sex.Results8.04 million first CD4 results were identified. From 2005 to 2011, the proportion of patients entering into care with CD4 count <200 cells/μL declined from 46.8% to 35.6%. From 2011 onward, the proportion of patients entering ART with advanced HIV disease has remained relatively unchanged. In 2016, we estimated that of 654 868 patients entering care, 32.9% had advanced HIV disease, and 16.8% had very advanced HIV disease. Men were almost twice as likely as women (23.1% vs 12.6% ) to enter care with very advanced HIV disease.ConclusionsThe proportion of patients presenting with advanced HIV disease in South Africa remains consistently high despite ART scale-up, representing a large and avoidable burden of morbidity. Early HIV diagnosis, rapid linkage to ART and approaches to attract men into early ART initiation should be prioritized.

a b s t r a c tStigma is a recognised problem for effective prevention, treatment, and care of HIV/AIDS. However, few studies have measured changes in the magnitude and character of stigma over time. This paper provides the first quantitative evaluation in Africa of the changing nature of stigma and the potential determinants of these changes. More specifically, it evaluates the dynamic relationship between stigma and (1) increased personal contact with people living with HIV/AIDS and (2) knowing people who died of AIDS. Panel survey data collected in Cape town 2003 and 2006 for 1074 young adults aged 14-22 years were used to evaluate changes in three distinct dimensions of stigma: behavioural intentions towards people living with HIV/AIDS; instrumental stigma; and symbolic stigma. Individual fixed effects regression models are used to evaluate factors that influence stigma over time. Each dimension of stigma increased in the population as a whole, and for all racial and gender sub-groups. Symbolic stigma increased the most, followed by instrumental stigma, while negative behavioural intentions showed a modest increase. Knowing someone who died of AIDS was significantly associated with an increase in instrumental stigma and symbolic stigma, while increased personal contact with people living with HIV/AIDS was not significantly associated with any changes in stigma. Despite interventions, such as public-sector provision of antiretroviral treatment (which some hoped would have reduced stigma), stigma increased among a sample highly targeted with HIV-prevention messages. These findings emphasise that changes in stigma are difficult to predict and thus important to monitor. They also indicate the imperative for renewed efforts to reduce stigma, perhaps through interventions to weaken the association between HIV/AIDS and death, to reduce fear of HIV/AIDS, and to recast HIV as a chronic manageable disease.

Partner-age difference is an HIV-risk factor among young women in Africa, but the underlying mechanisms are poorly understood. We used nationally representative data among black South Africans (men: 3530; women: 3946) to examine the proportion of women in partnerships involving male partner concurrency by age of female partners and by age-disparate (≥5 years) partnerships. Of all partners reported by men, 35% of young (16–24) women were in partnerships involving male partner concurrency of four weeks or longer during the past 12 months. Young women in age-disparate partnerships were more likely to be in partnerships with men who had other concurrent partners (9%; OR 1.88 p<0.01) and more likely to be connected to an older sexual network. Our results suggest that the relationship between male concurrency and age-disparate relationships may increase HIV risk for young women by connecting them to larger and older sexual networks.

BackgroundAge-disparate partnerships are hypothesized to increase HIV-risk for young women. However, the evidence base remains mixed. Most studies have focused only on unprotected sex among women in the partnership. Consequently, little is known about other risky behaviours, such as transactional sex, alcohol use, and concurrency, as well as the behaviours of the men who partner with young women. We therefore examined differences in various sexual behaviours of both young women and their male partners by partnership age difference.MethodsWe used nationally representative data from South Africa (2012) on partnerships reported by 16–24 year old black African women (n = 818) and by black African men in partnerships with 16–24 year old women (n = 985). We compared sexual behaviours in age-disparate partnerships and age-similar partnerships, using multiple logistic regression to control for potential confounders and to assess rural/urban differences.ResultsYoung women in age-disparate partnerships were more likely to report unprotected sex than young women in similar-aged partnerships (aOR:1.51; p = 0.014; 95%CI:1.09–2.11). Men in partnerships with young women were more likely to report unprotected sex (aOR:1.92; p<0.01; 95%CI:1.31–2.81), transactional sex (aOR:2.73; p<0.01; 95%CI:1.64–4.56), drinking alcohol before sex (aOR:1.60; p = 0.062; 95%CI:0.98–2.61), and concurrency (aOR:1.39; p = 0.097; 95%CI:0.94–2.07) when their partners were five or more years younger. The association between age-disparate partnerships and transactional sex (aOR:4.14; p<0.01; 95%CI: 2.03–8.46) and alcohol use (aOR:2.24; p<0.013; 95%CI:1.20–4.19) was only found in urban areas.ConclusionsResults provide evidence that young women’s age-disparate partnerships involve greater sexual risk, particularly through the risky behaviours of their male partners, with the risk amplified for young women in urban areas.

Introduction: Age-disparate sex has long been considered a factor that increases HIV risk for young women in South Africa. However, recent studies from specific regions in South Africa have found conflicting evidence. Few studies have assessed the association between age-disparate partnerships (those involving an age gap of 5 years or more) and HIV risk at the national level. This study investigates the relationship between age-disparate sex and HIV status among young women aged 15–24 in South Africa. Methods: Nationally representative weighted data from the 2002, 2005, 2008, and 2012 South African National HIV Surveys were analysed for young women aged 15–24 years using bivariate analyses and multiple logistic regressions. Results: After conducting multiple logistic regression analyses and controlling for confounders, young women with age-disparate partners had greater odds of being HIV positive in every survey year: 2002 (aOR = 1.74, 95%CI: 0.81–3.76, p = 0.16); 2005 (aOR = 2.11, 95%CI: 1.22–3.66, p < 0.01); 2008 (aOR = 2.02, 95%CI: 1.24–3.29, p < 0.01); 2012 (aOR = 1.53, 95%CI: 0.92–2.54, p < 0.1). The odds of being HIV positive increased for each year increase in their male partner’s age in 2002 (aOR = 1.10, 95%CI: 0.98–1.22, p = 0.11), 2005 (aOR = 1.10, 95%CI: 1.03–1.17, p < 0.01), 2008 (aOR = 1.08, 95%CI: 1.01–1.15, p < 0.05), and 2012 (aOR = 1.08, 95%CI: 1.01–1.16, p < 0.05). Findings were statistically significant (p < 0.1) for the years 2005, 2008, and 2012. Conclusions: Our findings suggest that age-disparate sex continues to be a risk factor for young women aged 15–24 in South Africa at a national level. These results may reflect variation in HIV risk at the national level compared to the differing results from recent studies in a demographic surveillance system and trial contexts. In light of recent contradictory study results, further research is required on the relationship between age-disparate sex and HIV for a more nuanced understanding of young women’s HIV risk.

International Family Planning Perspectives, 2007, 33(3):98-105

BackgroundHIV risk perceptions are a key determinant of HIV testing. The success of efforts to achieve an AIDS-free generation – including reaching the UNAIDS 90–90-90 target – thus depends critically on the content of these perceptions. We examined the accuracy of HIV-risk perceptions and their correlates among young black women in South Africa, a group with one of the highest HIV incidence rates worldwide.MethodsWe used individual-level longitudinal data from the Cape Area Panel Study (CAPS) from 2005 to 2009 on black African women (20–30 years old in 2009) to assess the association between perceived HIV-risk in 2005 and the probability of testing HIV-positive four years later. We then estimated multivariable logistic regressions using cross-sectional data from the 2009 CAPS wave to assess the relationship between risk perceptions and a wide range of demographic, sexual behaviour and psychosocial covariates of perceived HIV-risk.ResultsWe found that the proportion testing HIV-positive in 2009 was almost identical across perceived risk categories in 2005 (no, small, moderate, great) (χ 2 = 1.43, p = 0.85). Consistent with epidemiologic risk factors, the likelihood of reporting moderate or great HIV-risk perceptions was associated with condom-use (aOR: 0.57; 95% CI: 0.36, 0.89; p < 0.01); having ≥3 lifetime partners (aOR: 2.38, 95% CI: 1.53, 3.73; p < 0.01); knowledge of one’s partner’s HIV status (aOR: 0.67; 95% CI: 0.43, 1.07; p = 0.09); and being in an age-disparate partnerships (aOR: 1.73; 95% CI: 1.09, 2.76; p = 0.02). However, the likelihood of reporting moderate or great self-perceived risk did not vary with sexually transmitted disease history and respondent age, both strong predictors of HIV risk in the study setting. Risk perceptions were associated with stigmatising attitudes (aOR: 0.53; 95% CI: 0.26, 1.09; p = 0.09); prior HIV testing (aOR: 0.21; 95% CI: 0.13, 0.35; p < 0.01); and having heard that male circumcision is protective (aOR: 0.38; 95% CI: 0.22, 0.64; p < 0.01).ConclusionsResults indicate that HIV-risk perceptions are inaccurate. Our findings suggest that this inaccuracy stems from HIV-risk perceptions being driven by an incomplete understanding of epidemiological risk and being influenced by a range of psycho-social factors not directly related to sexual behaviour. Consequently, new interventions are needed to align perceived and actual HIV risk.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-017-4593-0) contains supplementary material, which is available to authorized users.

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