NATIONAL INSTITUTES OF HEALTH:National Institute of Allergy and Infectious Diseases

National Institute of Mental HealthNational Institute on Drug Abuse

Graeme Hoddinott, Lario Viljoen, Jabulile Mantantana, Kelly Abrahams, Helen Ayles, Nulda Beyers, Peter Bock, Sarah Fidler, Richard Hayes, James Hargreaves, Maurice Musheke, Musonda Simwinga, &

Virginia Bond ON BEHALF OF THE HPTN 071 STUDY PROTOCOL TEAM

20TH IAS WORLD AIDS CONFERENCE, MELBOURNE, 2014

When your life is threatened, HIV is a peripheral concern; qualitative perceptions of crime/violence in 9 HPTN 071 (PopART)

community sites in South Africa

The HPTN 071 Study Team, led by:Dr. Richard Hayes

Dr. Sarah FidlerDr. Helen Ayles

Dr. Nulda Beyers

PEPFAR Implementing Partners:

Government Agencies:

• All research participants and their families

• The 21 research communities and their religious, traditional, secular and civil leadership structures

• Volunteers in the community advisory board structures

With thanks to:

• Community randomised controlled trial 21 community sites (12 Zambia; 9 South Africa) 3-Arms Evaluation: a cohort of ±52,500 adults Outcome: HIV incidence

• A complex, multi-component intervention Home-based HCT, linkage to care, MMC, condoms, TB & STI-

screening, PMTCT; Community HIV-care providers (CHiPs) Earlier ART (Arm A only) Delivered to: ±600,000 individuals

• Cori A, et al. (2014). • Hayes R, et al. (2014).

HPTN 071 (PopART) – an overview

1. Violence as a direct threat to health E.g. “Injuries were the second-leading cause of loss of healthy life

… 14.3% of all DALYs in South Africa in 2000.” (Norman, et al. 2007)

2. Violence in health; ‘structural violence’ Social arrangements where people or groups and their health is

reduced/threatened (see Farmer, 1999)

How do people living in communities where interpersonal violence is an ever-present threat think about health (personal/community)?

Violence and health

Study context• 9 study ‘community sites’

(clinic-catchment areas) • 6 within the City of Cape

Town, 3 ‘rural’• Adult HIV prevalence ±10%• High unemployment• Large wealth disparity • Mostly small, formal housing

with semi-formal attachments and informal areas

• Highly accessible (but expensive) road transit system

South Africa

Western Cape

Lesotho

Swaziland

Namibia

Botswana

Zimbabwe

Indian Ocean

Atlantic Ocean

Data collection process• Broad Brush Surveys (BBS)

Group of mixed-methods Rapid assessment of community and HIV landscape See poster (abstract number: THPE214)

• Nov 2012 – May 2013• ±12 days spent in each community• A total of (purposive, diversity sampling):

48 group discussions (232 participants) 30 key informant interviews 63 structured observation activities

• Findings draw on all of above data, in particular: ‘What kind of place is this’ activity (35 groups; 153 participants) ‘Wealth, poverty, and risk ranking’ activity (35 groups; 153 participants)

Data collection tools

‘What kind of place is this?’ Wealth, poverty, and risk ranking

Data analysis

• Phase 1:Rapid, pragmatic (for the trial)Field notes, routine debriefingSummary reports (matrices, narrative, technical

report)• Phase 2:

Further investigation of core, ‘emergent’ themesDiscursive analysis (see Billig, 1999; Potter, 2000)

Findings

Poverty

Opportunity

EmploymentAlcoholism

Community members’ priorities

HIV

Crime

Versus:Inequity

1. Living under threat, not HIV (1)

1. Living under threat, not HIV (2)

“People … cower behind their doors, because they think, ‘when is the bullet coming for them? … Everyone’s life was in danger in this place. You weren’t allowed to go out, you had to stay in the house the whole day.” (Group Discussion, younger women, 10 Apr 2013, S21)

Findings

Poverty

Opportunity

EmploymentAlcoholism

Community members’ priorities

HIV

Crime

Versus:Inequity

HIV as a by-product

Crime

HIV

Poverty

HIV

InequityHIV

AlcoholismHIV

OpportunityHIV

Employment

HIV

2. HIV as a violence by-product (1)

• Sello is a gangster• He depends on his

grandmother’s pension money

• He rapes and robs houses

• One day he fought with his ‘friends’

• That put his grandmother’s life at risk, she was raped

(Group Discussion, younger men, 12 Mar 2013, S16)

2. HIV as a violence by-product (2)

“If we come from clinic to fetch our pills, they take our pills. … This happens here. A lady was robbed of her pills last week.” (Group Discussion, PLWH, 13 Apr 2013, S20)

Conclusions• Crime and violence represent serious challenges in some

South African contexts• Some violent crimes place individuals at direct risk of HIV

infection• Crime and violence are also structural barriers to HIV

prevention uptake: HIV prevention resources are a potential target for crime Fear of violence can be a stronger priority than health Violence is indiscriminate (and pervasive), HIV is also an ever-

present risk, but at least it is preventable and treatable• Crime and violence are a challenge to conducting research

in these contexts (see Poster: TUPDD0105)

Billig M. (1999). Arguing and thinking: a rhetorical approach to social psychology; new edition. Cambridge: Cambridge University Press

Cori A, et al. (2014). HPTN 071 (PopART): a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment: mathematical model. PloS ONE 9(1): e84511. doi:10.1371/journal.pone.0084511

Farmer P. (1999). Pathologies of power: rethinking health and human rights. American Journal of Public Health; 89(10), 1486-96

Hayes R, et al. (2014). Rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment – a study protocol for a cluster-randomised trial. Trials 15(47):doi:10.1186/1745-6215-15-57

Norman R, Matzopoulos R, Groenewald P, & Bradshaw D. (2007). The high burden of injuries in South Africa. Bulletin of the World Health Organisation; 85(9), 695-702

Potter J. (2000). Representing reality: discourse reality and social construction. London: Sage

References

ACKNOWLEDGEMENTS

• Sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) under Cooperative Agreements # UM1 AI068619, UM1-AI068617, and UM1-AI068613

• Funded by:

– The U.S. President's Emergency Plan for AIDS Relief (PEPFAR)

– The International Initiative for Impact Evaluation (3ie) with support from the Bill & Melinda Gates Foundation

– NIAID, the National Institute of Mental Health (NIMH), and the National Institute on Drug Abuse (NIDA) all part of the U.S. National Institutes of Health (NIH)