1. Socio-behavioral Determinants: A Necessary Element Of HIV Surveillance Experience of South Africa Olive Shisana, Sc.D CEO Human Sciences Research Council (HSRC)

2. Presentation Format Introduction • Bio-markers • Prevalence • Incidence • ARV testing • Themes not usually included in population survey questionnaire • Present question/item and give example of how socio-behavioral item was linked to HIV status • Conclusion

3. Introduction • Survey of 15 000 HH is done every 3 years; now on third wave using multi-stage cluster sampling • Four people selected per household (<2, 2-14, 15-24, 25+) & return to HH maximum 4 times • Preceded by qualitative study in two waves • Collect socio-behavioral. communication and HIV biomarkers • Collect contextual questions like geotype, marital status, employment status, social grants, poverty • Generate socio-behavioral, epidemiological curve, identify high risk groups • Perform detailed response analysis

4. Eg of Qualitative research:AIDS Stigma • “How do you question your partner?… Your wife…yes… your husband. …"Honey! Use a condom because I don't trust you. You know because you might have AIDS! … How do you put that? … How do you ask your partner that?”- Muslim man

5. HIV Prevalence By Age And Sex, South Africa, 2005

6. HIV Prevalence By Geotype, South Africa, 2005

7. ARVs • Do you currently have any of the following illnesses (diagnosed; if yes are you currently taking medicine? If yes, names of medicines • ARV data is collected to help interpretation of HIV prevalence and prevent BED incidence misclassification

8. Themes Not Usually Included In Population Survey Questionnaire • HIV risk perception • Alcohol and substance use • Perceptions of government policies and • Perception of health care system • Violence in households • Media and communication • PMTCT (children under 2)

9. HIV Risk Perception On a scale of 1 to 4 (with 1 being low and 4 being high), how would you rate yourself in terms of risk of becoming infected with HIV?

10. Low risk 30 23.1 High risk 20.8 25 17.4 20 HIV Prevalence (%) 12.8 15 10.1 7.5 10 5 0 Male Female Total Self Perceived Risk Of HIV Among Respondents Aged 15 Years And Older By Sex And HIV Prevalence, South Africa 2005

11. Alcohol Use 1

12. Alcohol Use 2

13. Alcohol Use 3 Have you or someone else been injured as a result of your drinking? Has a concerned relative, friend, doctor or other health worker ever suggested that you should cut down on your drinking?

14. Alcohol Risk Status And HIV Status, South Africa 2005 Chi-square:17.6, p <0.01)

15. Binge Drinking And HIV Status, South Africa 2005 Chi-square:12.5, p <0.05

16. Use Of Other Substances Have you ever used one of the following substances in the past three months?

17. General Perceptions About Government Policies And Programs

18. Public Perception Regarding Political Commitment

19. Health Questions From what you know or have heard, please indicate for each of the items below to show whether you think the health system in your area is in need of improvement or satisfactory?

20. Violence In The Household 1 Who was assaulted and who committed the assault?

21. Violence In The Household 2 Do you think the government has provided enough services for female victims of physical and sexual violence? Based on what you have heard in your own community are women and children who have been raped able to access medication to prevent HIV infection at all times or some of the time at their local government hospital or clinic?

22. Services For Female Victims Of Physical And Sexual Violence

23. Media And Communication 1

24. Media And CommunicatIon 2

25. Receiving Useful HIV/AIDS Information

26. HIV positive child under 2 given cotrimoxazol PMTCT noted on the road to health card/growth chart Child previously tested for HIV Where child was born (hospital, clinic, home) Attendant at birth (doctor, midwife, etc) Breastfeeding: length and by whom Supplementary food: what and when Where child was seen: hospital, clinic, doctor (public/private) Mother’s ANC visits and trimester for first care and number of visits Mother offered HIV test during ANC visits Child previously tested for HIV Child scarified Vaccinations PMTCT items

27. 4. Conclusion 1 • It is critical to measure HIV prevalence and incidence in all age groups to assess adequacy of response to the epidemic • Linking socio-behavioral items with HIV helps in understanding the dynamics of the epidemic • Measuring ARV use is important to interpret prevalence figures and also to correct for HIV incidence • Health questions help in understanding the ability of the health care system to cope with HIV/AIDS burden

28. Conclusion 2 • Assessing public perceptions on government’s response is an important advocacy tool. • Collecting information on communication help to identify program reach and source of information • Can track PMTCT program implementation • Data are used for surveillance, program evaluation and also for research purposes

29. Acknowledgement • Co-authors • Leickness Simbayi and • Thomas Rehle • Data analysis • Alicia Davis • Sean Jooste