NATIONAL INSTITUTES OF HEALTH: National Institute of Allergy and Infectious Diseases National Institute of Mental Health National 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 20 TH 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 Fidler Dr. 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 debriefing  Summary reports (matrices, narrative, technical report) Phase 2:  Further investigation of core, ‘emergent’ themes  Discursive analysis (see Billig, 1999; Potter, 2000)

Findings Poverty Opportunity Employment Alcoholism 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 Employment Alcoholism Community members’ priorities HIV Crime Versus: Inequity HIV as a by-product Crime HIV Poverty HIV Inequity HIV Alcoholism HIV Opportunity HIV 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): e doi: /journal.pone Farmer P. (1999). Pathologies of power: rethinking health and human rights. American Journal of Public Health; 89(10), 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: / 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), 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-AI 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)