Objective: As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout.

Methods: Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure.

Findings: Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family).

Discussion: Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

This study examines the relationship between wealth and HIV infection in Sub-Saharan Africa to determine whether and how this relationship has varied over time, within and across countries, by gender, and urban environment. The analysis draws on DHS and AIS data from 27 Sub-Saharan African countries, which spanned the 14 years between 2003 and 2016. We first use logistic regression analyses to assess the relationship between individual wealth, HIV infection and gender by country and year stratified on urban environment. We then use meta-regression analyses to assess the relationship between country level measures of wealth and the odds of HIV infection by gender and individual level wealth, stratified on urban environment. We find that there is a persistent and positive relationship between wealth and the odds of HIV infection across countries, but that the strength of this association has weakened over time. The rate of attenuation does not appear to differ between urban/rural strata. Likewise, we also find that these associations were most pronounced for women and that this relationship was persistent over the study period and across urban and rural strata. Overall, our findings suggest that the relationship between wealth and HIV infection is beginning to reverse and that in the coming years, the relationship between wealth and HIV infection in Sub-Saharan Africa may more clearly mirror the predominant global picture.

Life history calendars capture patterns of behavior over time, uncovering transitions and trajectories. Despite the growing numbers of older persons living with HIV in southern Africa, little is known about how HIV testing and risk unfold in this population. Operationalizing a life course approach with the use of an innovative Testing and Risk History Calendar [TRHC], we collected pilot data on older South Africans’ risk and HIV testing. We found older persons were able to provide (1) reference points to facilitate recall over a 10-year period, (2) specifics about HIV tests during that decade, and (3) details that contextualize the testing data, such as living arrangements, relationships, and health status. Interviewer debriefing sessions after each interview captured information on context and links across domains. On a larger scale, the TRHC has potential to reveal pathways between sexual behavior, HIV testing and risk perception, and health at older ages.

Understanding how sexual behaviors cluster in distinct population subgroups along the life course is critical for effective targeting and tailoring of HIV prevention messaging and intervention activities. We examined interrelatedness of sexual behaviors and variation between men and women across a wide age range in a rural South African setting with a high HIV burden. Data come from the Ha Nakekela population-based survey of people aged 15-85-plus drawn from the Agincourt Health and Socio-Demographic Surveillance System. We used latent class analysis of six sexual behavior indicators to identify distinct subgroup sexual behavior clusters. We then examined associations between class membership and sociodemographic and other behavioral risk factors and assessed the accuracy of a reduced set of sexual behavior indicators to classify individuals into latent classes. We identified three sexual behavior classes: (1) single with consistent protective behaviors; (2) risky behaviors; and (3) in union with lack of protective behaviors. Patterns of sexual behaviors varied by gender. Class membership was also associated with age, HIV status, nationality, and alcohol use. With only two sexual behavior indicators (union status and multiple sexual partners), individuals were accurately assigned to their most likely predicted class. There were distinct multidimensional sexual behavior clusters in population subgroups that varied by sex, age, and HIV status. In this population, only two brief questions were needed to classify individuals into risk classes. Replication in other situations is needed to confirm these findings.

The aim of the study was to investigate the relationship between counseling prior to starting antiretroviral treatment (ART) and adherence to treatment among women enrolled in Option B+ in Zambia. Using convenience sampling, 150 HIV+ women enrolled in an Option B+ treatment regimen in rural and urban districts were recruited. Four generalized Poisson regression models were built to assess the association between counseling and adherence to ART. In all, 75% of the participants reported adherence in the past 7 days. In adjusted analyses, there was a significant positive relationship between counseling and adherence in the rural district (prevalence ratio [PR] 2.52, 95% CI [1.19, 5.35], n = 81) but not in the urban district (PR = 0.77, 95% CI [0.15, 3.91], n = 69). Offering counseling prior to initiating antiretroviral treatment to HIV+ women is particularly important for promoting medication adherence in rural settings of low resourced countries.

In South Africa, evidence shows high HIV prevalence in older populations, with sexual behavior consistent with high HIV acquisition and transmission risk. However, there is a dearth of evidence on older people's HIV incidence.

 

Methods

We used a 2010-2011 cohort of HIV-negative adults in rural South Africa who were 40 years or older at retest in 2015-2016 to estimate HIV incidence over a 5-year period. We used Poisson regression to measure the association of HIV seroconversion with demographic and behavioral covariates. We used inverse probability sampling weights to adjust for nonresponse in 2015, based on a logistic regression with predictors of sex and age group at August 2010.

Results

HIV prevalence increased from 21% at baseline to 23% in the follow-up survey. From a cohort of 1360 individuals, 33 seroconverted from HIV negative at baseline, giving an overall HIV incidence rate of 0.39 per 100 person-years [95% confidence interval (CI): 0.28 to 0.57]. The rate for women was 0.44 (95% CI: 0.30 to 0.67), double than that for men, 0.21 (95% CI: 0.10 to 0.51). Incidence rate ratios (IRRs) again show women's risk of seroconverting double than that of men (IRR = 2.04, P value = 0.098). In past age 60, the IRR of seroconversion was significantly lower than that for those in their 40s (60-69, IRR = 0.09, P value = 0.002; 70-79, IRR = 0.14, P value = 0.010).

 

Conclusions

The risk of acquiring HIV is not zero for people older than 50 years, especially women. Our findings highlight the importance of acknowledging that older people are at high risk of HIV infection and that HIV prevention and treatment campaigns must take them into consideration.

 

The global HIV/AIDS scientific community has begun to hail the dawn of 'the End of AIDS' with widespread anti-retroviral therapy (ART) and dramatic declines in AIDS-related mortality. Drawing on community focus groups and in-depth individual interviews conducted in rural South Africa, we examine the complex unfolding of the end of AIDS in a hard-hit setting. We find that while widespread ART has led to declines in AIDS-related deaths, stigma persists and is now freshly motivated. We argue that the shifting landscape of illness in the community has produced a new interpretive lens through which to view living with HIV and dying from AIDS. Most adults have one or more chronic illnesses, and ART-managed HIV is now considered a preferred diagnosis because it is seen as easier to manage, more responsive to medication, and less dangerous compared to diseases like cancer, hypertension, and diabetes. Viewed through this comparative lens, dying from AIDS elicits stigmatising individual blame. We find that blame persists despite community acknowledgement of structural barriers to ART adherence. Setting the ending of AIDS within its wider health context sheds light on the complexities of the epidemiological and health transitions underway in much of the developing world.

Objective: The African HIV epidemic is aging, yet HIV testing behavior studies either exclude older persons or include too few to say much about age differences. Method: Strategically combining focus group interviews (participants in 40s/50s/60s-plus age groups) and survey data from rural South Africa (where HIV prevalence peaks in the late 30s, but continues to be over 10% into the late 60s), we examine gender and life course variation, motivations, and barriers in HIV testing. Results: We find significant gender differences—Women test at higher rates at younger ages, men at older ages. Our qualitative data not only highlight recognition of testing importance but also suggest gendered motivations and perceptions of testing. Men and women report similar barriers, however, including fear of finding out their (positive) HIV status, limited confidentiality, and partner nondisclosure. Discussion: We conclude with recommendations to increase HIV testing uptake among older adults including home testing, couples testing, and HIV testing concurrently with noncommunicable diseases.

Significant progress has been made in the African HIV pandemic; however, the pace of incidence decline has slowed or stalled in many East and Southern African countries, especially among young women. This stall is worrying because many countries have burgeoning youth populations. There is an important window of opportunity to halt the epidemic as well as the potential for millions more infections if primary prevention efforts are not strengthened.

Significant progress has been made in the African HIV pandemic; however, the pace of incidence decline has slowed or stalled in many East and Southern African countries, especially among young women. This stall is worrying because many countries have burgeoning youth populations. There is an important window of opportunity to halt the epidemic as well as the potential for millions more infections if primary prevention efforts are not strengthened.

Objective The objective of this study was to examine how young people in Nairobi, Kenya, are making sense of marriage, both in terms of their own lives and its social significance. Background In many sub-Saharan African communities, marriage has been a fundamental marker of the transition to adulthood. However, union formation is changing, particularly in urban areas-partnering is occurring later and nonmarital cohabitation is increasingly common with the pathways to union formation differing by gender. Young people's perspectives on marriage are valuable for a deeper understanding of these trends.

Few studies of the transition to adulthood in Africa analyse young people’s own definitions of the events that confer adult status, and how adulthood is actually attained. This paper examines the experience of transitioning to womanhood in rural Mpumalanga Province, South Africa, drawing on interviews with 18 women aged 18–39. Three primary experiences characterised this transition: puberty and emerging body awareness, spending time with boys, and having a child. More important than the timing of these experiences, however, was whether women ‘behaved well’ and maintained respectability as they transitioned to adulthood. Behavioural standards reinforcing ideal femininity were focused on dress, manner and talk, and were particularly stringent for mothers. Findings emphasise the value of emic models of adulthood for understanding how youth experience this transition and provide an important counter-narrative to the literature focused primarily on the risk African youth face during this period of change in the life course.

South Africa has the highest number of people living with HIV in the world (over 6 million) as well as a rapidly aging population, with 15% of the population aged 50 and over. High HIV prevalence in rural former apartheid homeland areas suggests substantial aging with HIV and acquisition of HIV at older ages. We develop a life course approach to HIV vulnerability, highlighting the rise and fall of risk and protection as people age, as well as the role of contextual density in shaping HIV vulnerability. Using this approach, we draw on an innovative multi-method data set collected within the Agincourt Health and Demographic Surveillance System in South Africa, combining survey data with 60 nested life history interviews and 9 community focus group interviews. We examine HIV risk and protective factors among adults aged 40-80, as well as how and why these factors vary among people at older ages.

In this paper, I use qualitative data to explore the practices engaged in by Kenyan schoolgirls to participate in modern consuming womanhood, as well as the contradictory implications of these practices for thinking about globalized mediated femininities and their enactment in resource-poor settings. The paper examines the centrality of consumption to valued modern femininity among young women around the world, as well as the structural reality of gendered access to income. I show how the cooptation of the materiality of romantic love and normative expectations of male provision in romantic relationships bridge the gap between consumption desires and economic realities among Kenyan schoolgirls in both powerful and problematic ways. The paper ends with a reflection of the implications of these findings for post-girl power, the post-feminist age and the re-inscription of patriarchy.

Several studies have demonstrated a link between young people’s sexual behavior and levels of parental monitoring, parent-child communication, and parental discipline in Western countries. However, little is known about this association in African settings, especially among young people living in high poverty settings such as urban slums. The objective of the study was to assess the influence of parental factors (monitoring, communication, and discipline) on the transition to first sexual intercourse among unmarried adolescents living in urban slums in Kenya.

This paper draws on ethnographic and interview based fieldwork to explore accounts of intimate relationships between widowed women and poor young men that emerged in the wake of economic crisis and a devastating HIV epidemic among the Luo ethnic group in Western Kenya. I show how the cooptation of widow inheritance practices in the wake of an overwhelming number of widows as well as economic crisis resulted in widows becoming providing women and poor young men becoming kept men. I illustrate how widows in this setting, by performing a set of practices central to what it meant to be a man in this society - pursuing and providing for their partners - were effectively doing masculinity. I will also show how young men, rather than being feminized by being kept, deployed other sets of practices to prove their masculinity and live in a manner congruent with cultural ideals. I argue that ultimately, women's practice of masculinity in large part seemed to serve patriarchal ends. It not only facilitated the fulfillment of patriarchal expectations of femininity - to being inherited - but also served, in the end, to provide a material base for young men's deployment of le

Past research provides strong evidence that adverse life events heighten the risk of delinquent behavior among adolescents. Urban informal (slum) settlements in sub-Saharan Africa are marked by extreme adversity. However, the prevalence and consequences of adverse life events as well as protective factors that can mitigate the effects of exposure to these events in slum settlements is largely understudied. We examine two research questions. First, are adverse life events experienced at the individual and household level associated with a higher likelihood of delinquent behavior among adolescents living in two slums in Nairobi, Kenya? Second, are parental monitoring, religiosity, and self-esteem protective against delinquency in a context of high adversity?

We explore the concerns, challenges, aspirations, and expectations of sub-Saharan African youth, and investigate how these youth cope with neighborhood constraints to aspiration achievement. We draw on cross-sectional survey data from 4033 12-22 year olds (50.3% males) from two Kenyan urban slums and subsequent in-depth interviews conducted with a subset of 75 youth when they were 13-24 years old (45.3% male). We observe that despite the challenges characteristic of urban slums, some youth maintain high aspirations and try to achieve them through education, delinquency, residential mobility, and religion. We note that others adjust their aspirations to account for limited opportunities. Overall, our findings highlight positive youth agency and underscore the need to improve the quality of life in urban slums.

This paper focuses on a neglected factor in literature on the HIV epidemic in sub-Saharan Africa: the role of the eco-social environment in shaping HIV risk. I argue that the changing ecological environment of Lake Victoria, Africa's largest freshwater lake, mapping onto a gendered economy, shaped fisherfolk's sexual relationships and sexual mixing patterns in ways that were consequential for their HIV risk. Specifically, I show how disrupted lake and fish ecology had an impact on fishermen's sexual, domestic and economic partnerships, as well as how it contributed to the "sex for fish" economy in Nyanza Province, Kenya. I also show the consequences of fishermen's relative wealth on transactional relationships with school girls and women in lakeside communities. The paper is based on ethnographic fieldwork over a seven month period among the Luo ethnic group, which has the highest HIV rates in Kenya. The study included 74 individual and focus group interviews in communities around Lake Victoria, as well as 20 key informant interviews. Additionally, literature reviews on fishing and sexual economies as well as on ecological research in Lake Victoria are employed. Exploring linkages between these literatures and fieldwork findings forms the basis of this paper. I argue that solely focusing on individual level HIV prevention strategies is limited without taking into account the eco-social context of individual sexual decision making.

Why are orphaned girls at particular risk of acquiring HIV infection? Using a transition-to-adulthood framework, this study employs qualitative data from Nyanza Province, Kenya, to explore pathways to HIV risk among orphaned and nonorphaned high-school girls. It shows how simultaneous processes such as leaving their parental home, negotiating financial access, and relationship transitions interact to produce disproportionate risk for orphaned girls. The role of financial provision and parental love in modifying girls' trajectories to risk are also explored. A testable theoretical model is proposed based on the qualitative findings, and policy implications are suggested.