International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

Issue link:

Contents of this Issue


Page 83 of 153

584 W.M. Wechsberg et al. / International Journal of Drug Policy 25 (2014) 583–590 et al., 2010). Traditional gender expectations, gender-based vio- lence, and victimization as a result of AOD use further elevate women's vulnerability to HIV (Browne & Wechsberg, 2010; Jewkes, Dunkle, Nduna, & Shai, 2010; Sawyer-Kurian, Wechsberg, & Luseno, 2009; Wechsberg et al., 2013). Informal drinking venues (com- monly referred to as "shebeens") are widespread in townships with high HIV prevalence. Shebeens may serve as risk environments that facilitate HIV transmission as AOD use co-occurs with sexual risk taking. They provide opportunities for meeting new or casual sex partners, arranging transactional sex, and engaging in AOD use before sex, and unprotected sex (Kalichman, Simbayi, Jooste, Vermaak, & Cain, 2008; Kalichman et al., 2013; Meade et al., 2012; Scott-Sheldon et al., 2012). The relationship between social context, risk environment, individual behaviours, and HIV transmission among key affected populations such as people who inject drugs is well docu- mented in high income countries with concentrated epidemics. (e.g., Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005). The social determinants of HIV risk differ between high income countries and low-and-middle income countries with generalized epidemics (Rhodes et al., 2005). How the diversity of social con- texts contributes to variability in HIV prevalence in countries with generalized HIV epidemics, such as South Africa, is less under- stood. Compared to high income countries, in many low and middle income countries, the population density is high, a larger propor- tion of people live in abject poverty, and health care systems are inadequate (Zanakis, Alvarez, & Li, 2007). This paper investigates gender differences among couples with respect to substance use and HIV infection within neighbourhoods of Khayelitsha, the largest township in the Western Cape Province of South Africa. Methods Setting Khayelitsha was established in 1983 by South Africa's apartheid government; the residents are predominately Black African. In recent years, it has experienced explosive population growth exceeding 20% per year between 2002 and 2005 (Maverick 358 cc, 2006). According to official estimates, the population of Khayelitsha is approximately 400,000, but unofficial estimates place it at over 1-million (Brunn & Wilson, 2013). Khayelitsha occupies 38.7 km 2 , is bounded by major roads on all sides and bisected by a major railroad track. The roads and tracks do not interfere with pedes- trian travel. Taxis are available for people who can afford them. Access to resources and services such as piped water, sanitation, and electricity, and housing structures varies considerably across the township. It is divided into 12 wards, some of which consist almost entirely (i.e. 98%) of informal dwellings (e.g. shacks) while other wards have regular houses and relatively few (i.e. 16%) infor- mal dwellings (Maverick 358 cc, 2006). Since 1999 antenatal and perinatal health services have been available to women to prevent mother-to-child HIV transmission with antiretroviral therapy. As of 2009, there were nine clinics – three community health centres and six local authority clinics oper- ating in the township (Garone et al., 2011). Because of the rapid population growth and the uncertainty regarding the number of inhabitants, it is difficult to derive accurate estimates of service utilization and service needs. HIV prevalence among women pre- senting for antenatal care in Khayelitsha was 26% in 2010, while overall HIV prevalence was estimated at 16% (Garone et al., 2011). Study design The overall study, the Couples' Health CoOp, is a cluster- randomized field experiment that tested an intervention to decrease AOD use, promote safer sex practices, and reduce violence in sexual relationships. We recruited 300 couples from 30 neigh- bourhoods in Khayelitsha and followed them for six months to test an HIV risk-reduction intervention for AOD-using couples. Using only the baseline data, we present here a cross-sectional analysis to investigate gender differences of how the prevalence variables measured at the neighbourhood level relate to risk of HIV infec- tion while accounting for individual behaviours and partnership characteristics. Geospatial mapping and randomization Two study teams systematically drove and walked through Khayelitsha using handheld Global Positioning System (GPS) devices to geocode the locations of formal (taverns) and informal drinking establishments (shebeens). The geographic information system (GIS) files were uploaded and mapped using ArcGIS Spa- tial Analyst extension (ESRI, Redlands, CA) and Google Earth. Visual inspection of the maps indicated that shebeens were spatially clus- tered rather than evenly distributed across the township. Using ArcGIS, we identified geographic clusters (i.e., neighbourhoods) containing at least three drinking venues within 100 m of each other that were more than 200 m from the nearest drinking venue within another neighbourhood. Using this process, we identified 36 neighbourhoods, each of which contained between three to seven drinking venues clustered together and were separated from each other by at least 200 m. We randomly selected 30 of the 36 neigh- bourhoods for inclusion in the study. Drinking establishments in two of the originally selected neighbourhoods closed between the time they were mapped and when we began recruiting in them. These neighbourhoods were replaced by randomly selecting two new neighbourhoods from the six that were not selected originally. Participant recruitment and eligibility criteria RTI International's Institutional Review Board (IRB) in the United States and Stellenbosch University's Faculty of Health Sciences in South Africa approved the study protocol (Trial Registration Num- ber: R01-AA018076). Participant recruitment took place in the 30 selected neighbour- hoods in Khayelitsha between June 2010 and April 2012. Outreach workers used high-quality maps that showed locations of streets, drinking venues, and other visual characteristics of each neighbour- hood as well as GPS-enabled personal digital assistants (PDAs) to ensure that they were in the correct neighbourhoods. Outreach workers visited shebeens in each neighbourhood and met with their owners to build trust and rapport with community members to ensure that owners did not object to outreach workers speak- ing with their patrons about the study. The outreach staff spent time in shebeens, marketing the study to male patrons with fly- ers and talking to them. For men who were interested, study staff made arrangements for the couple to return to the shebeen (unless both partners were there together). After obtaining verbal permis- sion to administer a brief screening instrument to assess eligibility, a female staff person screened female partners while a male staff person simultaneously screened the male partner to ensure that men did not coerce their female partners to take part in the study. To be eligible for the study, men had to be 18–35 years of age, self-identify as Black African, live in Khayelitsha, report alcohol use in a tavern or shebeen in the past 90 days, spend time in a tav- ern or shebeen at least weekly, and report unprotected sex with their main partner in the past 90 days. In addition, both men and

Articles in this issue

view archives of International Journal of Drug Policy - 2014 - Volume 25 Issue 3 May 2014