Browsing by Author "Viljoen, Lario"

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    Community narratives about women and HIV risk in 21 high-burden communities in Zambia and South Africa
    (Dove Medical Press, 2017) Viljoen, Lario; Ndubani, Rhoda; Bond, Virginia; Seeley, Janet; Reynolds, Lindsey; Hoddinott, Graeme
    ENGLISH ABSTRACT: Public health researchers repeatedly represent women as a group vulnerable to ill health. This has been particularly true in the field of HIV research, where women are disproportionately affected by HIV in terms of disease burden and the social effects of the epidemic. Although women have been the focus of many prevention and treatment programs, structural barriers to implementation of these targeted programs persist. In this article we explore how high HIV-burden communities in South Africa and Zambia engage with the concepts of “woman” and “HIV risk”. The data are drawn from participatory storytelling activities completed with 604 participants across 78 group discussions between December 2012 and May 2013. During discussions we found that participants made use of the core archetypal caricatures of “goodness,” “badness,” and “vulnerability” when describing women’s HIV risk. Community members shifted between these categories in their characterizations of women, as they acknowledged the multiple roles women play, internalized different stories about women, and sometimes shifted register in the same stories. Findings suggest that health implementers, in consultation with community members, should consider the multiple positions women occupy and how this impacts the wider community’s understandings of women and “risk”. This approach of taking on board community understandings of the complexity of HIV risk can inform the design and implementation of HIV prevention and care programs by rendering programs more focused and in-line with community needs.
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    The effect of universal testing and treatment on HIV stigma in 21 communities in Zambia and South Africa
    (Wolters Kluwer Health, 2020-11) Stangl, Anne L.; Pliakas, Triantafyllos; Maingad, Tila; Steinhaus, Mara; Mubekapi-Musadaidzwae, Constance; Viljoen, Lario; Dunbare, Rory; Schaapd, Ab; Floyd, Sian; Mandla, Nomtha; Bond, Virginia; Hoddinott, Graeme; Fidler, Sarah; Hayes, Richard; Ayles, Helen; Bock, Peter; Donnell, Deborah; Hargreaves, James R.
    Objectives: To assess the impact of a combination HIV prevention intervention including universal testing and treatment (UTT) on HIV stigma among people living with HIV, and among community members and health workers not living with HIV. Design: This HIV stigma study was nested in the HPTN 071 (PopART) trial, a three-arm cluster randomised trial conducted between 2013 and 2018 in 21 urban/peri-urban communities (12 in Zambia and nine in South Africa). Methods: Using an adjusted two-stage cluster-level analysis, controlling for baseline imbalances, we compared multiple domains of stigma between the trial arms at 36 months. Different domains of stigma were measured among three cohorts recruited across all study communities: 4178 randomly sampled adults aged 18–44 who were living with HIV, and 3487 randomly sampled adults and 1224 health workers who did not self-report living with HIV. Results: Prevalence of any stigma reported by people living with HIV at 36 months was 20.2% in arm A, 26.1% in arm B, and 19.1% in arm C (adjusted prevalence ratio, A vs. C 1.01 95% CI 0.49–2.08, B vs. C 1.34 95% CI 0.65–2.75). There were no significant differences between arms in any other measures of stigma across all three cohorts. All measures of stigma reduced over time (0.2–4.1% reduction between rounds) with most reductions statistically significant. Conclusion: We found little evidence that UTT either increased or decreased HIV stigma measured among people living with HIV, or among community members or health workers not living with HIV. Stigma reduced over time, but slowly.
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    How place matters for addressing the HIV epidemic : evidence from the HPTN 071 (PopART) cluster-randomised controlled trial in Zambia and South Africa
    (BMC, 2021-04-06) Bond, Virginia; Hoddinott, Graeme; Viljoen, Lario; Ngwenya, Fredrick; Simuyaba, Melvin; Chiti, Bwalya; Ndubani, Rhoda; Makola, Nozizwe; Donnell, Deborah; Schaap, Ab; Floyd, Sian; Hargreaves, James; Shanaube, Kwame; Fidler, Sarah; Bock, Peter; Ayles, Helen; Hayes, Richard; Simwinga, Musonda; Seeley, Janet
    Background: In a cluster-randomised trial (CRT) of combination HIV prevention (HPTN 071 (PopART)) in 12 Zambian communities and nine South African communities, carried out from 2012 to 2018, the intervention arm A that offered HIV treatment irrespective of CD4 count did not have a significant impact on population level HIV incidence. Intervention arm B, where HIV incidence was reduced by 30%, followed national guidelines that mid trial (2016) changed from starting HIV treatment according to a CD4 threshold of 500 to universal treatment. Using social science data on the 21 communities, we consider how place (community context) might have influenced the primary outcome result. Methods: A social science component documented longitudinally the context of trial communities. Data were collected through rapid qualitative assessment, interviews, group discussions and observations. There were a total of 1547 participants and 1127 observations. Using these data, literature and a series of qualitative analysis steps, we identified key community characteristics of relevance to HIV and triangulated these with HIV community level incidence. Results: Two interdependent social factors were relevant to communities’ capability to manage HIV: stability/ instability and responsiveness/resistance. Key components of stability were social cohesion; limited social change; a vibrant local economy; better health, education and recreational services; strong institutional presence; established middle-class residents; predictable mobility; and less poverty and crime. Key components of responsiveness were community leadership being open to change, stronger history of HIV initiatives, willingness to take up HIV services, less HIV-related stigma and a supported and enterprising youth population. There was a clear pattern of social factors across arms. Intervention arm A communities were notably more resistant and unstable. Intervention arm B communities were overall more responsive and stable. Conclusions: In the specific case of the dissonant primary outcome results from the HPTN 071 (PopART) trial, the chance allocation of less stable, less responsive communities to arm A compared to arm B may explain some of the apparently smaller impact of the intervention in arm A. Stability and responsiveness appear to be two key social factors that may be relevant to secular trends in HIV incidence. We advocate for a systematic approach, using these factors as a framework, to community context in CRTs and monitoring HIV prevention efforts.
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    Linking love and health: Social narratives of sex, intimacy, and love in the context of universal testing and treatment of HIV
    (2021-03) Viljoen, Lario; Reynolds, Lindsey Jeanne; Thesis (PhD)--Stellenbosch University, 2021.; Stellenbosch University. Faculty of Arts and Social Sciences. Dept. of Sociology and Social Anthropology.
    ENGLISH ABSTRACT: Since the 1990s, HIV prevention efforts have evolved from a primary focus on sexual behavioural change to an increasing focus on treatment-based prevention modalities as scientific evidence about the preventive benefits of antiretroviral treatment (ART) has accumulated. As these new prevention technologies have been tested and implemented worldwide, new knowledge gaps have emerged about how the availability of HIV treatment as prevention (TasP) would fit into sexual experiences and shape relationship dynamics in high HIV burden contexts. In this thesis I aim to understand how women in South Africa experience sex, intimacy, and health in the context of a changing HIV prevention landscape. As women are disproportionately affected by the disease, the study of their sexual experiences and relationship dynamics in the context of treatment-based prevention is especially urgent. Furthermore, the dynamics of intimacy, care, and emotional connections in relation to sex in Africa remain underexplored. Historically, research on sex in Africa has positioned women as either fetishised or diseased, and the rise of the HIV epidemic did little to redirect this problematic narrative. I challenge these narratives and explore women’s conceptualisations of sex, focusing on how intimacy and emotional connections are prioritised. The study is nested in the HPTN 071 (PopART) HIV prevention trial, a community-randomised trial conducted in South Africa and Zambia from 2012-2018 that aimed to test the effectiveness of TasP at population-level through a strategy called universal test and treat (UTT). We conducted a qualitative cohort study with 89 households (n = ⁓300 participants, including 180 women) over 18-24 months to describe individual and community experiences of the trial. I analysed data from the cohort to explore women’s narratives of their sexual experiences. Working across theoretical constructs (scripting theory, performance theory, responsibilisation) and empirical findings, the central emerging theme relates to the ongoing tensions between idealised or expected conceptions of women’s sexual lives and their experienced realities. This is evident in the discord between women’s perception of HIV risk (assigned to ‘transgressive’ others) and how their own intimate relationships are described (trust, fidelity, respect, risk-free). Through focusing on idealised notions of romantic sex, HIV risk is dismissed, and idealised relationship values upheld, even when partners fail to live up to these expectations. An HIV diagnosis, or the possibility of HIV risk, is positioned as challenging to women’s conceptualisations of intimate relationships (safe, trustworthy) and to their conceptualisations of self (as morally ‘good’ women). As an early study of the effects of UTT on women’s sexual lives, the findings show that readily available HIV testing and treatment has not yet shaped the sexual narratives of women in South Africa. Despite fears related to behavioural disinhibition (where people engage in more risky sex), I did not find demonstrable differences in women’s narratives around their sexual experiences in places where treatment-based prevention strategies were implemented. These findings suggest that public health programmes must be responsive to women’s changing experiences and perceptions of their own HIV risk and consider presenting TasP as a partnered solution.
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    Understanding the time needed to link to care and start ART in seven HPTN 071 (PopART) study communities in Zambia and South Africa
    (Springer, 2019) Seeley, Janet; Bond, Virginia; Yang, Blia; Floyd, Sian; MacLeod, David; Viljoen, Lario; Phiri, Mwelwa; Simuyaba, Melvin; Hoddinott, Graeme; Shanaube, Kwame; Bwalya, Chiti; De Villiers, Laing; Jennings, Karen; Mwanza, Margaret; Schaap, Ab; Dunbar, Rory; Sabapathy, Kalpana; Ayles, Helen; Bock, Peter; Hayes, Richard; Fidler, Sarah
    To achieve UNAIDS 90:90:90 targets at population-level, knowledge of HIV status must be followed by timely linkage to care, initiation and maintenance of antiretroviral therapy (ART) for all people living with HIV (PLHIV). Interpreting quantitative patterns using qualitative data, we investigate time taken to link to care and initiate ART amongst individuals aware of their HIV-status in high HIV-prevalence urban communities in the HPTN 071 (PopART) study, a community-randomised trial of a combination HIV prevention package, including universal testing and treatment, in 21 communities in Zambia and South Africa. Data are drawn from the seven intervention communities where immediate ART irrespective if CD4 count was offered from the trial-start in 2014. Median time from HIV-diagnosis to ART initiation reduced after 2 years of delivering the intervention from 10 to 6 months in both countries but varied by gender and community of residence. Social and health system realities impact decisions made by PLHIV about ART initiation.