Abstract
BackgroundRecent evidence highlighting high HIV incidence and prevalence in informal settlements suggests that they are environments that foster HIV risk. Given growing urbanization in sub-Saharan Africa, there is a critical need to assess the successes and challenges of implementing HIV testing, prevention and treatment interventions in these contexts.MethodsWe randomly selected a household-based sample of 1528 adult men (18–35) and women (18–24) living in 18 randomly selected communities in KZN, South Africa. After the baseline interview, communities were randomized to one of three intervention rollout arms in a stepped wedge design. At approximately 8-month intervals, the Asibonisane Community Responses Program (and in particular the implementation of Stepping Stones, a participatory HIV prevention program focused on strengthening relationships and communication) was rolled at by intervention phase. Using data from this evaluation, we describe levels and trends in HIV testing and treatment during follow-up, and we use fixed effects models to estimate the effects of participation in the program on testing.ResultsStudy respondents reported high levels of economic insecurity and mobility, and men report various HIV risk behaviors including about 50% reporting multiple partnerships. About two-thirds of respondents (73% of women, 63% of men) had been tested for HIV in the last six months. Among those living with HIV, treatment levels were high at baseline, and almost universal by endline in 2019. Program participation led to a 17% increase in the probability of testing for women (p<0.05) but had no effect on testing for men due, in part, to the fact that the program did not reach men who were least likely to be tested, including those who had migrated recently, and those who had never been tested at baseline.ConclusionsNear universal HIV treatment use demonstrates positive trends in access to some HIV services (including treatment as prevention) in these communities. Stepping Stones had positive effects on HIV testing for women, yet barriers to HIV testing remain, especially for men. Redoubled efforts to reach men with testing are vital for improving HIV outcomes for both men and their partners.
Highlights
Informal settlements, where communities are formed of ad hoc and improvised housing as residents seek opportunities for employment in the surrounding area, are increasingly a major part of the African landscape, as African cities continue to grow
Program participation led to a 17% increase in the probability of testing for women (p
HIV testing in informal settlements in South Africa of this paper are the sole responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID, or the United States Government
Summary
Informal settlements, where communities are formed of ad hoc and improvised housing as residents seek opportunities for employment in the surrounding area, are increasingly a major part of the African landscape, as African cities continue to grow. South Africa is one of the most urbanized countries in sub-Saharan Africa, with a substantial and growing population living in informal settlements [2]. KwaZuluNatal (KZN) province, a major epicenter of the South African HIV epidemic, where approximately 37% of adult women and 19% of adult men are living with HIV [3, 4], has large informal settlements. According to the most recent census, about 12% of the population of South Africa was living in informal settlements [5]. Since the settlements are unplanned, they are often underserved by municipal services, are under-represented politically, and lack accessible healthcare and economic opportunities [7]. This environment can translate into unique challenges and barriers in terms of accessing HIV services and care. Given growing urbanization in subSaharan Africa, there is a critical need to assess the successes and challenges of implementing HIV testing, prevention and treatment interventions in these contexts
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