The associations of voluntary counseling and testing acceptance and the perceived likelihood of being HIV-infected among men with multiple sex partners in a South African township.
ABSTRACT This paper examines the socio-demographic factors and sexual risk behaviors (condom use, number of sexual partners, STI symptoms) associated with voluntary counselling and testing (VCT) acceptance and self-perceived risk of being HIV-infected among black men with multiple and younger sex partners in a South African township outside of Cape Town. Using respondent driven sampling, we interviewed 421 men, of whom 409 (97.3%) consented to provide a dried blood spot, 12.3% were HIVinfected (95% confidence intervals [CI.] 8.3, 16.9) and 47.2% (CI. 41.1, 53.6) accepted on site VCT. Twenty six percent (CI. 20.2, 30.7) reported having an HIV test in the past year. Few men perceived themselves as very likely to be infected with HIV (15.6%; CI. 10.4, 20.5). VCT acceptance was significantly associated with being older, married or living with a partner, having higher education, having four to six partners in the past three months and testing HIV positive. Self-perceived likelihood of being HIV infected was significantly associated with low condom use and having seven or more partners in the past three months, and testing HIV positive. These findings indicate that men correctly understand that engaging in certain HIV risk behaviors increases the likelihood of HIV-infection. However, those who perceive themselves at high risk of having HIV do not seek testing. Further investigation into the psychological and cultural barriers to reducing risky sexual behaviors and accessing VCT and other HIV services is recommended.
- SourceAvailable from: Alyona Mazhnaya[Show abstract] [Hide abstract]
ABSTRACT: Objective: To quantify potential bridging of HIV transmission between the injection drug using subpopulation to the non-injection drug using population through unprotected heterosexual sex.Design: Secondary analysis of cross-sectional data.Methods: A sub-sample of participants who reported having a permanent partner who are not injection drug users and have not injected drugs in the past (N=1379) was selected from a survey implemented in 26 Ukrainian cities in 2011. This study evaluates the association between consistent condom use and awareness of HIV status as measured by rapid testing during the study (known/unknown HIV+, known/unknown HIV- and undetermined) among a sub-sample of male injection drug users (IDUs) who have a non-injecting permanent partner. Poisson regression, with robust variance estimates, was utilized to identify associations while adjusting for other factors.Results: Reported consistent condom use varied between 15.5% (unknown HIV-) and 37.5% (known HIV+); average use was 19.3%. In multivariate analysis, males who were aware of their HIV+ status were more likely to report recent consistent condom use compared to those who were unaware of their HIV+ status. This association remains after adjustment for age, region, education level, years of injection, alcohol use, self-reported primary drug use and being an NGO client (prevalence ratio=1.65; 95% CI 1.03-2.64). No such association was found for those who were HIV-.Conclusions: Our results regarding HIV-positive male IDUs reinforce previous findings that HIV testing and counselling may be an effective means of secondary prevention. Further research is needed to understand how to effectively promote safer sex behaviours for IDUs who are currently HIV-.Journal of the International AIDS Society 02/2014; 17(1):18825. · 4.21 Impact Factor
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ABSTRACT: HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland. A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines. Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21(median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW(53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project(n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314)reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture(53.2%, n = 173/314) was prevalent. While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.PLoS ONE 12/2014; 9(12):e115465. · 3.53 Impact Factor
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ABSTRACT: Background: This study aimed to determine barriers to accessing human immunodeficiency virus (HIV) counseling and testing (HCT) services among a commuter population. Methods: A cross-sectional, venue-based intercept survey was conducted. Participants were recruited during a 2-day community campaign at the Noord Street taxi rank in Johannesburg, South Africa. Data were collected using a self-administered questionnaire loaded onto an electronic data collection system and analyzed using Stata software. Factors contributing to barriers for HCT were modeled using multivariate logistic regression. Results: A total of 1,146 (567 male and 579 female) individuals were interviewed; of these, 51.4% were females. The majority (59.5%) were aged 25–35 years. Significant factors were age group (15–19 years), marital status (married), educational level (high school), distance to the nearest clinic (.30 km), area of employment/residence (outside inner city), and numbers of sexual partners (more than one). Participants aged 15–19 years were more likely to report low-risk perception of HIV as a barrier to HCT (odds ratio [OR] 1.62; 95% confidence interval [CI] 1.01–2.59), the married were more likely to report low-risk perception of HIV as a barrier to HCT (OR 1.49; 95% CI 1.13–1.96), and those living outside the inner city were more likely to report lack of partner support as a potential barrier (OR 1.94; 95% CI 1.34–2.80), while those with a high school education more likely to report poor health worker attitude as a potential barrier to HIV testing (OR 2.17; 95% CI 1.36–3.45). Conclusion: Age, marital status, occupation, educational level, area of employment and residence, distance to the nearest clinic, and number of sexual partners were factors significantly associated with barriers to HIV testing in the study population. Future HIV intervention health services targeting this population need to be reinforced in order to enhance HIV testing while taking cognizance of these factors.HIV/AIDS - Research and Palliative Care 11/2014; 7(1):1-9.
The Associations of Voluntary Counseling and Testing Acceptance
and the Perceived Likelihood of Being HIV-Infected Among Men
with Multiple Sex Partners in a South African Township
Lisa Johnston Æ Æ Heidi O’Bra Æ Æ Mickey Chopra Æ Æ Cathy Mathews Æ Æ
Loraine Townsend Æ Æ Keith Sabin Æ Æ Mark Tomlinson Æ Æ Carl Kendall
? Springer Science+Business Media, LLC 2008
factors and sexual risk behaviors (condom use, number of
sexual partners, STI symptoms) associated with voluntary
counselling and testing (VCT) acceptance and self-per-
ceived risk of being HIV-infected among black men with
multiple and younger sex partners in a South African
township outside of Cape Town. Using respondent driven
sampling, we interviewed 421 men, of whom 409 (97.3%)
consented to provide a dried blood spot, 12.3% were
HIVinfected (95% confidence intervals [CI.] 8.3, 16.9) and
47.2% (CI. 41.1, 53.6) accepted on site VCT. Twenty six
This paper examines the socio-demographic
percent (CI. 20.2, 30.7) reported having an HIV test in the
past year. Few men perceived themselves as very likely to
be infected with HIV (15.6%; CI. 10.4, 20.5). VCT
acceptance was significantly associated with being older,
married or living with a partner, having higher education,
having four to six partners in the past three months and
testing HIV positive. Self-perceived likelihood of being
HIV infected was significantly associated with low condom
use and having seven or more partners in the past three
months, and testing HIV positive. These findings indicate
that men correctly understand that engaging in certain HIV
risk behaviors increases the likelihood of HIV-infection.
However, those who perceive themselves at high risk of
having HIV do not seek testing. Further investigation into
the psychological and cultural barriers to reducing risky
sexual behaviors and accessing VCT and other HIV ser-
vices is recommended.
Voluntary counseling and testing ?
Most at risk populations ? Respondent driven sampling
South Africa ? HIV/AIDS ?
In an effort to increase access to antiretroviral therapy
services, it is important to identify groups at high risk for
HIV-infection and scale-up HIV testing services to reach
these groups. Sexually active adolescents and adults living
in urban townships or informal settlements are among the
groups most at risk for HIV infection in South Africa
(Shisana et al. 2005). Within this group are men with
multiple concurrent partnerships, often with younger
female sexual partners, who are at high risk of contracting
HIV and also infecting this younger female population
L. Johnston ? C. Kendall
Department of International Health & Development, Center for
Global Health Equity, Tulane University School of Public Health
& Tropical Medicine, New Orleans, LA, USA
L. Johnston (&)
13 Via Plaza Nueva, Santa Fe, NM 87507, USA
HHS-Centers for Disease Control and Prevention/Global AIDS
Program, Pretoria, South Africa
HHS-Centers for Disease Control and Prevention/Global AIDS
Program, Atlanta, GA, USA
M. Chopra ? C. Mathews ? L. Townsend ? M. Tomlinson
Health Systems Research Unit, Medical Research Council,
Cape Town, South Africa
School of Public Health and Family Medicine, University
of Cape Town, Rondebosch, South Africa
(Dunkle et al. 2007; Hallett et al. 2007; Halperin and
Epstein 2004; Jewkes et al. 2003; Southern African
Development Community 2006).
Over the past several years, the South African govern-
ment and international donor organizations have been
strengthening and expanding voluntary counseling and
testing (VCT) services, and improving access to antiret-
roviral therapy in the country (Birdsall et al. 2004). First
established in South Africa at antenatal clinics, VCT ser-
vices have since been expanded to general primary care
services, including tuberculosis, family planning and sex-
ually transmitted infections (STIs) (MSF 2003). In just
2 years, (2002–2004) the number of clinics offering VCT
increased from 0.9 per 100,000 to 5.6 per 100,000 and
VCT acceptance has increased by 67% (Dorrington et al.
2004; WHO 2004). As of August 2007, there were 4,215
operational VCT centers in South Africa, 180 located in the
Cape Town area [South African National Department of
Health (personal communication) Pretoria, 2007].
Despite this progress, less than a third (&30%) of South
Africans have been tested for HIV (Shisana et al. 2005).
VCT programs are important entry points to access HIV
care and treatment services. VCT is also a key HIV pre-
vention tool because individuals who know their HIV
status may be less likely to practice high-risk sexual
behaviors compared with individuals who have not been
tested (Marks et al. 2005; Glick 2005). Given that a large
percentage (range: 14–40%) of South African men have
multiple concurrent sexual partners and practice unpro-
tected sex (Halperin and Epstein 2004; MSF 2004; Shisana
et al. 2005; Shisana and Simbayi 2002) it is important to
encourage this high-risk population to utilize VCT to learn
their HIV status and to access care and treatment if
There are numerous reasons why high-risk individuals,
particularly men, choose not to seek HIV testing and know
their HIV status. Some fear that being HIV-infected will
result in community and familial stigmatization (Kalich-
man and Simbayi 2003) and that testing positive for HIV
may lead to other undesirable outcomes, such as having to
disclose one’s status to sexual partners and potentially
having to change enjoyable, but risky, behaviors (IRIN
Plus News 2005; Levack 2005). Other barriers to accessing
VCT include the perceived lack of confidentiality, insuf-
unskilled staff, long waiting times and inconvenience
(Benatar 2004; Birdsall et al. 2004; Hutchinson and Mah-
lalela 2006; Kalichman and Simbay 2003; MSF 2003,
2004; Killewo et al. 1998; Mabunda 2006; Shisana et al.
2005). Of particular concern are individuals’ perceptions,
often inaccurate, that they are not at risk for HIV (MSF
2004). A recent national household HIV behavioral and
sero-prevalence survey in South Africa found that men who
perceived themselves as less likely to be HIV-infected
(self-perceived low risk of infection) were more likely to
test positive for HIV (Shisana et al. 2005). Inaccurate
perceptions of HIV risk may lead to increased risk
behaviors. On the other hand, individuals who accurately
recognize themselves at high risk, acknowledge their vul-
nerability to HIV infection and, in turn, may become more
receptive to HIV education and related services such as
VCT (Sethosa and Peltzer 2005; Zachariah et al. 2003).
Exposure to VCT leads some individuals to transition from
risky to safer behaviors (Coovadia 2000; De Zoysa et al.
1995; Glick 2005; Glick and Sahn 2004; UNAIDS 2004;
Voluntary HIV-1 Counseling and Testing Efficacy Study
Group 2000; Weinhardt et al. 1999). Determining linkages
between the self-perceived risk of being HIV-infected and
willingness to seek VCT could provide information about
why someone is more or less likely to access VCT (Akwara
et al. 2003; Cleland 1995).
This paper examines socio-demographic factors and
sexual risk behaviors (condom use, number of sexual
partners, STI symptoms) associated with VCT acceptance
and self-perceived risk of being HIV-infected among black
men with multiple and younger sex partners in a South
African township outside of Cape Town. It also explores
whether those who perceive themselves more likely to be
HIV-infected have sought testing in the past year, and
whether they chose to learn their HIV status when offered
testing as part of a survey to assess HIV prevalence and
behaviors. Findings from this survey can inform program
implementers and policy makers to bolster efforts to
encourage higher rates of VCT acceptance (Sweat et al.
2000; Voluntary HIV-1 Counseling and Testing Efficacy
Study Group 2000; WHO 2003).
In 2006, an HIV prevalence and risk behaviors survey was
conducted in a township outside of Cape Town, South
Africa. The survey location was selected based on an
assessment of the population’s vulnerability to HIV
infection by the Western Cape Department of Health
Working Group on HIV Prevention (Department of Health
2005; Shaikh et al. 2006; Statistics South Africa 2001).
The survey took place from August to December, and
used respondent-driven sampling (RDS). RDS is currently
used to gather HIV biological and behavioral data from
hard-to-reach, socially networked populations (Heckathorn
1997, 2002). RDS begins with a set of non-randomly
selected members of the survey population who, after
participating in the survey, are given a set number of
coupons with which to recruit eligible peers. Peers who
receive a coupon can choose to enroll in the survey by
redeeming their coupon at the interview location advertised
on the coupon. Participants are given an incentive for
completing the survey and for recruiting their peers who
complete the survey.
Eligible males were 18 years and older who had [1
female sexual partner in the previous 3 months who was
\24 years old or C3 years younger than the participant
and living in the sampled township. The age cut-off for
sexual partners (\24 years old or C3 years younger than
the male participant) was based on research that age dif-
ferences between young women and their older male
partners are a significant HIV risk factor for young women
by mixing populations with different sero-prevalence lev-
els (Dunkle et al. 2007; Kelly et al. 2003; Luke 2003,
2005; Shisana et al. 2005).
This survey used 15 non-randomly selected men who
met the eligibility criteria and were found through contacts
with ministry of health workers and a local nurse. These
initial recruits were selected based on their ability to recruit
other eligible males and on their differences in age, marital
status and occupation. Initial recruiters, as well as each
participant who completed the survey, received up to three
recruitment coupons with which to recruit other eligible
males. The coupons included a unique number for use in
linking recruiters to their recruits and in linking each par-
ticipant’s questionnaire to their biological specimen.
Males who presented a valid coupon to the interview
location were screened for eligibility, provided information
about the survey, and asked to consent to the survey. After
consenting, eligible participants were interviewed by
trained South African interviewers in IsiXhosa language
using a 106 item questionnaire developed by the Medical
Research Council and the Ministry of Health, Cape Town,
Upon completing the interview, participants were asked
to provide a dried blood spot (DBS) sample to a trained
nurse to test for HIV antibodies. Participants could receive
their test results on-site within 30 min of providing the
DBS along with anonymous HIV pre- and post-test coun-
seling with a trained counselor using VCT procedures
established by the Western Cape Department of Health.
Rapid tests were conducted with First Response?test kits
and those with reactive test results were re-tested using an
HIV-TriLine confirmatory test. All men with positive test
results received information about the nearest public health
clinics in order to receive follow-up care and treatment. All
DBS samples were transported to the Global Clinical and
Viral Laboratory in Durban and tested for HIV antibodies
with Vironostika?HIV-1 Microelisa System. Results from
lab tests were not given to participants but were used in the
final analysis of HIV status.
Eligible participants received an incentive of a cellular
phone recharge voucher worth R60 (±US$8) for com-
pleting the interview and providing a DBS. Those who
recruited eligible peers received another incentive worth
R20 (±US$2.75) for each recruit who presented a coupon,
fulfilled the eligibility criteria, and enrolled in the survey.
A sample size of 430 was calculated based on estimated
HIV prevalence of between 25 and 33% in the survey
township (MSF 2003; Shaikh et al. 2006) with a precision
of 25 ± 5% and a design effect of 1.5. Design effects are
used in sample size calculations to account for potential
biases introduced through sampling methodologies; at the
time of this survey a design effect of 1.5 was recommended
for surveys using RDS methods (D. Heckathorn, personal
The authors examined participants’ acceptance of on-site
VCT and the self-perceived likelihood (very likely,
somewhat likely or very unlikely) of being HIV-infected.
Participants were asked their age, marital status (single/
never married or ever married/living w/partner), education
(\grade 8, grade 8–12) and whether they currently earned
money from a job, rather than receiving financial support
from friends or family. Questions on behavioral risk factors
included reporting an STI symptom (dysuria, discharge
from penis, or sores on genital or anus) in the past
12 months, condom use with a casual or ‘‘one-off’’1partner
(categorized into never, sometimes and always) in the past
3 months, and number of sex partners (casual, ‘‘one-off’’
and main partners) in the past 3 months which was cate-
gorized into B3, 4–6, and C7. Participants were also asked
the number of males they knew who were 18 years and
older, had [1 female sexual partner \24 years old or
C3 years younger than the male participant in the previous
3 months, lived in the sampled township, and who they had
seen in the past 3 months. This question provides data on
the participants’ social network size which is essential to
weighting RDS data for analysis.
Proportion estimates and 95% confidence intervals (CI)
were calculated using the RDS Analysis Tool 5.6
(RDSAT), a software package specifically developed to
analyze data collected through RDS (www.respondent-
drivensampling.org). RDSAT was developed to minimize
1A ‘casual partner’ is a woman with whom the man has sexual
relations on an infrequent but ongoing basis; a ‘one-off’ partner is a
woman with whom the man had sex on one occasion only.
biases associated with chain referral sampling by weighting
participants’ social network sizes and controlling for
homophily and recruitment patterns (Salganik and Hecka-
purportedly representative of the population from which it
derives; males, 18 years and older, who had [1 female
sexual partner\24 years old or C3 years younger than the
male participant in the previous 3 months, and lived in the
sampled township (Salganik 2006; Salganik and Hecka-
thorn 2004; Heckathorn 1997, 2002).
We used cross tabulations and chi square tests (v2) to
assess the statistical significance of associations between
the acceptance of HIV counseling and test results (VCT
acceptance) and self-perceived likelihood of being HIV-
infected (HIV risk perception) and with specific categorical
variables. In the univariate and multivariate analyses,
RDSAT 5.6 generated sample weights were applied to
VCT acceptance and HIV risk perception to estimate odds
ratios (ORs) of each covariate. In the multivariate analysis,
adjusted odds ratios (AORs) were estimated with a full
model of all covariates for each of the two dependent
variables. Level of significance is based on p = 0.05.
Adjusted and unadjusted ORs and corresponding P-values
were calculated using STATA, version 9.0. Missing values
were omitted from the analyses.
Although no published data exists on logistic regression
analyses using RDS data, sample weights necessary to
conduct these analyses were recently added to the new
version of RDSAT 5.6. RDSAT-generated sample weights
take into account the variations in participants’ network
sizes (degree weight) and differential recruitment and
homophily (recruitment weight) (Heckathorn 2007). To
test the theory that RDSAT generated weights are valid for
conducting regression analyses, the authors compared the
output of a separate univariate analysis of two dependent
variables, VCT acceptance and HIV risk perception, from
RDSAT 5.6, of which the estimates and bootstrap gener-
ated CI have been validated as representative of the
sampled target population (Salganik 2006; Salganik and
Heckathorn 2004; Volz and Heckathorn 2007), and STA-
TA 9.0 with and without using RDSAT exported weights.
RDSAT generated estimates were more similar to that of
STATA with the RDSAT weights than to STATA without
the RDSAT weights. The same was found for the CI for
HIV risk perception but not for VCT acceptance. In the
latter, there were more similarities between STATA with
and without weights than either of the STATA groups and
RDSAT. We conclude that regression analyses using
RDSAT generated weights produced more accurate esti-
mates than without RDSAT generated weights. However,
the RDSAT weighting in STATA appear to overstate the
CI and p-values appear to overstate the true significance.
Until these processes using RDSAT are validated through
rigorous statistical methods, p-values should be interpreted
We were able to interview 421 men before the survey
completion date of December 10, 2006. Among those men
interviewed, 409 (97.3, CI. 95.4, 98.9) consented to pro-
vide and 200 (47.5%) accepted on-site VCT. The weighted
estimate for the population of interest suggests 47.2%
would have accepted VCT, if available (CI. 41.1, 53.6),
that 12.3% are HIV-infected (CI. 8.3, 16.9), and that 26.0%
(CI. 20.2, 30.7) had an HIV test in the past year.
Sampled men had a median age of 30 years (range 18–
62). The largest proportion of men in the population were
single/never married (n = 283; 80.5%, CI. 73.7, 85.9), had
some education (grades 8–12) (n = 343; 90.9%, CI. 86.6,
94.9) and earned money from work (n = 275; 71.0, 64.0,
77.5). Almost half reported always using condoms in the
previous 3 months with casual and ‘‘one-off’’ partners
(n = 169; 49.4%, CI. 41.0, 55.6) and had 4–6 sexual
partners during the previous 3 months (n = 155; 45.3%,
CI. 38.3, 51.3). The majority reported no past year STIs
(n = 226; 63.5%, CI. 56.8, 69.6).
Accepting On-Site VCT
Results of a regression analysis of socio-demographic
variables indicated that men C35 years were significantly
more likely (2.5 times) than younger men to accept on-site
VCT (and receive their test results offered at the RDS
interview site during the survey). Men who were ever
married or living with a partner versus those who were
single or never married were 1.8 times more likely to
accept on-site VCT. Men with higher education (C8th
grade) were significantly more likely to accept on-site VCT
than those with lower education (C8th grade) (Table 1).
Having 4–6 partners in the past 3 months (1.9 times
more likely than those who had B3 partners) was signifi-
cantly associated with accepting on-site VCT; those who
reported C7 partners were 1.2 times more likely (not sig-
nificant) than those who had B3 partners to accept on-site
VCT. Having had an HIV test in the past year (twice as
likely as those who had not had an HIV test in the past
year) was significantly associated with accepting on-site
Although these findings were not significant, those who
tested positive for HIV were 1.5 times as likely as those
who did not to accept on-site VCT; those who perceived
themselves most likely infected with HIV were less
likely to accept on-site VCT than those who perceived
themselves somewhat likely and very unlikely at risk for
HIV; those who self-reported STI symptoms in the past
12 months were no more likely to accept on-site VCT than
those who reported no STI symptoms; and those who
reported sometimes or never using condoms in the past
3 months with casual and ‘‘one-off’’ partners were less
likely to accept on-site VCT than those who reported
always using condoms.
Table 1 Estimates and 95% confidence intervalsa, odds ratios (OR)band adjusted odds ratios (AOR)cwith p-values for predictors of VCT
acceptance at study time among men in with multiple sexual partners, Cape Town, South Africa, 2006
VariableAccepted on-site VCT
Yes NoOR AOR
N = 200
N = 221
% 95% CI
% 95% CI
B2448 29.0 19.5, 38.890 43.6 33.8, 53.1Ref.d
25–3497 44.735.5, 54.1 108 46.137.4, 55.2 1.7 1.10.86
C35 5426.3 18.4, 35.4 21 10.25.3, 16.4 4.82.50.03
Single/never married 11976.7 68.2, 84.6162 83.1 73.9, 89.9 Ref.Ref.
Ever married/Live w/partner 5023.3 15.4, 31.83316.9 10.1, 26.12.1 1.80.05
Earn money from work
2113.96.7, 22.4868.259.3, 77.3Ref.Ref.
15386.1 15.8, 33.8 18831.8 92.2, 98.40.310.40.03
No 3676.166.2, 84.2 5868.2 59.3, 77.3Ref.Ref.
Yes137 23.9 15.8, 33.8 138 31.8 22.7, 40.81.1 1.10.78
Negative16085.3 77.7, 91.518889.584.4, 94 Ref. Ref.
Positive 37 14.7 8.5, 22.3 2210.5 5.8, 15.62.01.5 0.20
Past year HIV test
No115 71.2 65.3, 80.9154 77.769.6, 84.4 Ref. Ref.
Yes 58 28.819.1, 34.7 4122.3 15.6, 30.42.0 2.00.01
Likelihood of being HIV infected
Very unlikely42 31.7 22.0, 41.56138.5 27.9, 45.6 Ref. Ref.
Somewhat likely84 52.9 53.5, 64.085 45.538.2, 56.7 1.41.4 0.18
Very likely 43 15.48.6, 21.443 16.09.6, 18.104.22.168 0.09
STI symptoms (past 12 months)
No 10357.648.9, 67.6 122 68.258.6, 75.6 Ref.Ref.
Yes 7142.4 32.4, 52.174 31.824.2, 22.214.171.124 0.98
Condom Use with casual and ‘‘one-off’’ sexual partners (past 3 months)
Always85 52.339.9, 60.7 8245.1 34.6, 54.3Ref.d
Sometimes5231.7 23.7, 42.8 6833.825.7, 41.3 0.70.60.13
Never 3316.0 10.5, 23.58221.1 14.0, 31.1 0.70.70.34
Number of sex partners (past 3 months) including steady, casual and ‘‘one-off’’ partners
2–32719.2 11.4, 27.3 3622.0 14.1, 29.7Ref.d
4–6 7951.9 42.3, 60.6 7640.4 31.5, 126.96.36.199.05
7 or more 68 28.821.8, 37.9 8437.6 29.6, 47.4 188.8.131.52
aWeighted by social network size and recruitment patterns (Heckathorn 2002; Salganik and Heckathorn 2004)
bWeighted by degree and recruitment weight (Heckathorn 2007)
cWeighted by degree and recruitment weights and adjusted for all other characteristics listed in the table in a logistic regression model
dp-value provided for overall differences in variables with more than two levels: age p = 0.00; likelihood of being HIV infected p = 0.27;
condom use p = 0.34; number sex partners p = 0.42
Self-Perceived Likelihood of Being HIV-Infected
Few men perceived themselves as very likely infected with
HIV (15.6%;n = 87,CI: 10.4, 20.5). The largest proportion
of men perceived themselves as somewhat likely HIV
infected (48.3%, n = 169, CI: 43.2, 56.4), and 36.1%
(n = 104, CI: 28.4, 41.6) perceived themselves as very
unlikely HIV-infected. Men who had a past year HIV test
(26.0%) reported perceiving themselves as being very likely
to have HIV, 30% less often than those who did not have a
past year HIV test. In contrast, men who always used
condoms in the past 3 months with casual or ‘‘one-off’’
partners, and men who reported using condoms sometimes
and never were 3.2 and 7.8 times, respectively, more likely
to perceive themselves as very likely HIV-infected. Men
with C7 partners in the past 3 months reported perceiving
Table 2 Estimates and 95% confidence intervalsa, odds ratios (OR)band adjusted odds ratios (AOR)cwith p-values for predictors of likelihood
of being HIV-infected among men with multiple sexual partners, Cape Town, South Africa, 2006
Variable Self-perceived likelihood of being HIV-infected
Very unlikelySomewhat likelyVery likelyOR Adj. OR
N = 104
N = 169
N = 87
% 95% CI
% 95% CI
% 95% CI
B2441 38.928.6, 51.14929.219.0, 39.5 3141.721.2, 55.1Ref.d
25–34 4850.2 35.1, 60.5 9049.7 41.4, 58.74349.2 36.2, 184.108.40.206 .66
C35 1411.0 4.8, 21.7 3021.1 13.5, 30.4139.1 2.1, 220.127.116.11.85
Single/never married78 80.471.8, 89.5 127 79.070.8, 86.668 81.4 65.2, 91.4Ref.Ref.
Ever married/live w/partner 2319.6 10.5, 28.2 3921.0 13.4, 29.219 18.68.6, 34.8 1.0.8 .52
Earn money from work
8 6.81.7, 17.11510.1 4.8, 17.456.3 0.0, 14.4Ref.Ref.
9693.282.9, 98.315489.9 82.6, 95.2 82 93.785.6, 34.8 1.1 .9.86
No 3028.917.8, 38.5 4429.0 19.3, 40.8 1717.36.9, 25.3Ref.Ref.
Yes74 71.161.5, 82.212471.0 59.2, 80.770 82.774.7, 18.104.22.168 .50
Negative 9090.478.0, 96.9 143 88.681.6, 93.8 6580.2 65.1, 90.2Ref. Ref.
Positive7 9.63.1, 22.0 2411.4 6.2, 18.4 2119.89.8, 34.9 2.52.2.01
Past year HIV test
No7171.5 61.4, 82.6 11971.0 63.6, 79.97070.0 75.5, 93.7Ref.Ref.
Yes3328.5 17.4, 38.7 4929.0 20.1, 36.4 1616.06.3, 24.5 0.70.70.17
STI symptoms (past 12 months)
No6768.9 57.0, 79.7 10965.6 54.4, 72.84041.1 27.3, 55.0Ref.Ref.
Yes3731.1 20.3, 43.0 6033.3 27.2, 45.6 4758.9 45.0, 22.214.171.124.29
Condom use with casual and ‘‘one-off’’ sexual partners (past 3 months)
Always7268.1 55.8, 79.174 44.533.2, 55.3 1616.88.3, 28.0 Ref.d
Sometimes2122.012.7, 34.6 6842.3 32.4, 52.927 35.921.4, 48.43.0 3.20.00
Never11 18.155.8, 79.1 23 13.26.7, 21.0 4247.433.3, 62.3 7.47.80.00
Number of sex partners (past 3 months) including steady, casual and ‘‘one-off’’ partners
2–3 3132.2 19.3, 40.72218.4 11.2, 26.2910.72.6, 17.3Ref.d
4–65050.9 40.2, 63.3 7144.4 35.6, 54.4 27 33.521.0, 126.96.36.199.19
7 or more 2316.8 10.4, 27.97637.3 27.6, 46.6 5155.8 42.7, 71.24.8 3.4 0.00
aWeighted by social network size and recruitment patterns (Heckathorn 2002; Salganik and Heckathorn, 2004)
bWeighted by degree and recruitment weights (Heckathorn 2007)
cWeighted by degree and recruitment weights and adjusted for all other characteristics listed in the table in a logistic regression model
dp-value provided for overall differences in variables with more than two levels: Age p = 0.48; condom use p = 0.00; number sex partners
p = 0.00
themselves as very likely to be HIV-infected 3.4 times more
often than men who had B3 partners. There are significant
associations between self-reported STIs in the past year and
men’s self-perceived higher likelihood of being HIV-
infected (Table 2). There were no associations between
self-perceived levels of likelihood of being HIV-infected
and socio-demographic variables such as age, marital sta-
tus, education and earning income from a job.
Accepting On-Site VCT
We found no significant differences in accepting on-site
VCT for those with different levels of self-perceived HIV
risk perception (Table 1). We also found no significant
differences in accepting on-site VCT and some common
measures of high risk behaviors such as infrequent condom
use and having a higher number of sex partners (C7).
However, we did find that having 4–6 partners was sig-
nificantly associated with accepting on-site VCT. The
reason for these conflicting results is unclear. Other surveys
conducted in South Africa have found no significant
association between VCT acceptance and having multiple
sexual partners and low condom usage (Hutchinson and
Mahlalela 2006; Kalichman and Simbayi 2003).
One limitation of this survey is that participants who
refused the rapid test were not asked why they refused, nor
were participants who chose to learn their status asked why
they made that choice. It is difficult to conclude that those
who may have already known their HIV status were those
who refused on-site VCT. There was no significant differ-
ence in accepting on-site VCT based on HIV serostatus.
However, those who had received an HIV test in the past
year were more likely to accept on-site VCT. This could be
interpretedin acoupleof ways. Forexample,itcouldbethat
of getting tested and so they requested to be tested again. On
the other hand, it could also be an indication that these men
wanted to confirm their previous test results. Another limi-
tation was the inability to validate the eligibility criteria,
3yearagedifference.Thesample consisted ofhighriskmen
and it is unlikely that a directional bias would result from a
misreported age of sex partners.
Self-Perceived Likelihood of Being HIV-Infected
Few men in the sampled township perceived themselves as
being very likely to be HIV-infected. Low HIV risk per-
ception is consistent with findings in large-scale studies
conducted in South Africa (Pettifor et al. 2004; Shisana
et al. 2005; Shisana and Simbayi 2002). Men’s self-per-
ceived likelihood of being HIV-infected was not associated
with any of the selected socio-demographic variables. The
factors that were most associated with a higher HIV risk
perception included testing positive for HIV, sometimes or
never using condoms with casual and ‘‘one-off’’ partners
and having a higher number of sexual partners—An indi-
cation that these men accurately perceive their risk level
for being HIV infected.
The finding that men who never used condoms in the
past 3 months with a casual or ‘‘one-off’’ partner had a
higher HIV risk perception compared with those who
sometimes or always used condoms, could indicate that
these men understand the benefits of condom use for
reducing HIV transmission. However, this has not trans-
lated into risk reduction behaviors as just over half of the
respondents reported infrequent use or never using con-
doms. Furthermore, the finding that men who had C7
sexual partners in the past 3 months were more inclined to
perceive themselves very likely to be HIV-infected com-
pared with the men who had 4–6, and those who had B3
partners may indicate that these men have some awareness
that having multiple and concurrent sexual partners
increases their likelihood of HIV infection (Halperin and
Epstein 2004; Wellings et al. 2006). Despite this knowl-
edge, it is concerning that these men continue to engage in
such high-risk behavior.
Men who had an HIV test in the past year were less likely
than men who did not have a past year HIV test to perceive
themselves as very likely HIV-infected. However, respon-
dents who had a past year HIV test were more likely to have
also accepted an HIV test result during the survey. These
findings can have a couple of possible interpretations. First,
given that respondents were not asked whether they knew
their HIV status, it may be that those who were tested in the
past year may already have known that they were HIV
negative, resulting in a lower HIV risk perception. Second,
familiarity with VCT may encourage repeat testing.
This analysis investigates whether socio-demographic
characteristics, HIV status, having a past year HIV test
and HIV behavioral risk factors appear to exert inde-
pendent effects on VCT acceptance and HIV risk
perception among men with multiple sex partners in a
South African township outside of Cape Town. The
survey shows that high HIV risk perception was signifi-
cantly associated with being HIV-infected, but did not
significantly increase the person’s acceptance of on-site
It is interesting to note that in comparison to 97.3% who
consented to provide a DBS, 26% reported that they had a
past year HIV test and 47.2% accepted their HIV test
results as offered during the survey. Given that this town-
ship has numerous VCT centers (SA Census data 2005;
Statistics of South Africa 2005) and that sexually active
males in South Africa are extremely vulnerable to HIV
infection because of their sexual behaviors, it is unfortunate
that this population is not accessing available services.
One reason for the higher percentage of men accessing
HIV counseling and testing during this survey could be due
to the nature of the RDS methodology which relies on a
system of recruitment by trusted peers who themselves
have undergone the survey. Using the RDS recruitment
methodology could be effective in increasing VCT accep-
tance among this high-risk population. It is also possible
that these men chose to learn their test results during the
survey because VCT was proactively offered to them rather
than participants having to seek out HIV testing at a VCT
site or health care facility. This is in line with the provider-
initiated HIV testing guidelines recently released by the
World Health Organization (WHO 2007). Participants may
have also felt comfortable learning their status in an
environment where they felt at ease as there were no long
queues and testing was anonymous. In addition, the finding
that respondents who had an HIV test in the past year were
more likely to have also accepted an HIV test during the
survey, suggests that familiarity encourages (repeat) test-
ing. Interestingly, findings of a cross-sectional household
survey conducted in the same survey township suggested
that having a partner who had undergone VCT (and for
men, an acquaintance) was strongly associated with VCT
acceptance (MSF 2004), underscoring the link between
familiarity with the procedure and in this case (possibly)
However, since participants were not asked the reasons
for choosing to learn their results during the survey, further
investigation about barriers to HIV testing among this
population is recommended. Some of our findings (e.g., no
independent associations between infrequent condom use
and having C7 sex partners with VCT acceptance) are
difficult to interpret. A qualitative follow up on these
findings would be important to better understand these
Free condoms are widely available in the survey town-
ship at local health facilities and in local drinking
establishments, or are sold inexpensively in various loca-
tions in the township. Given that men who reported
infrequent condom use with casual or ‘‘one-off’’ partners
were more likely to have a higher self-perceived likelihood
of being HIV-infected, further investigation on reasons
men choose not to use condoms and how to design condom
promotion programs for this population is recommended.
We found that men correctly understand that engaging
in certain HIV risk behaviors increases the likelihood of
HIV-infection. However, those who perceive themselves at
high risk of having HIV do not seek testing. Further
investigation into the psychological and cultural barriers to
reducing risky sexual behaviors and accessing VCT and
other HIV services is recommended. Changing current
male social behaviors to delegitimize norms and accept-
ability of multiple sex partners and unprotected sex is a
complex and challenging task. Nonetheless, these key
issues must be addressed in order to have an impact on
reducing HIV transmission in South Africa.
and the Western Cape Department of Health, Cape Town, South
Africa conducted this survey. The University of Cape Town Institu-
tional Review Board, South Africa, granted ethical review and
approval. The Centers for Disease Control and Prevention (CDC)
Global AIDS Program provided technical assistance and funding
through the Tulane University Technical Assistance Project. The
findings and conclusions in this paper are those of the authors and do
not necessarily represent those of the Centers for Disease Control and
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