!! ! ! ! ! ! Heterosexual!Penile/Anal!Intercourse!and!HIV!in! Five!Sub/Saharan!African!countries! ! ! n ! w o ! T ! e p Zoe$Duby$ a C ! ! f o $ $ y t i Thesis$Psresented$for$the$Degree$of$ r e DOCTOR$OF$PHILOSOPHY$ v i in$the$nSchool$of$Public$Health$and$Family$Medicine,$ U Faculty$of$Health$Sciences,$ UNIVERSITY$OF$CAPE$TOWN$ $ $ JUNE$2015$ ! ! $ ! n w The copyright of this thesis vests in the author. No o T quotation from it or information derived from it is to be published without full acknowledgeement of the source. p The thesis is to be used for private study or non- a C commercial research purposes only. f o Published by the Universit y of Cape Town (UCT) in terms y t of the non-exclusive license granted to UCT by the author. i s r e v i n U $ This$thesis$is$presented$in$fulfilment$of$the$requirements$for$the$degree$of$Doctor$of$ Philosophy$(PhD)$in$the$School$of$Public$Health$and$Family$Medicine,$at$the$Faculty$of$Health$ Sciences,$University$of$Cape$Town.$The$work$on$which$this$thesis$is$based$is$original$research$ and$has$not,$in$whole$or$in$part,$been$submitted$for$another$degree$at$this$or$any$other$ university.$The$contents$of$this$thesis$are$entirely$the$work$of$the$candidate,$or$in$the$case$of$ multiWauthored$published$papers,$constitute$work$for$which$the$candidate$was$the$lead$ author.$The$contribution$of$the$candidate$to$included$multiWauthored$papers$is$further$ detailed$in$Appendix$2.$$$ $ $ ! ! Declaration! $ I,$Zoe$Duby,$hereby$declare$that$the$work$on$which$this$thesis$is$based$is$my$original$work$ (except$where$acknowledgements$indicate$otherwise)$and$that$neither$the$whole$work$nor$ any$part$of$it$has$been,$is$being,$or$is$to$be$submitted$for$another$degree$in$this$or$any$other$ university.$I$authorise$the$University$to$reproduce$for$the$purpose$of$research$either$the$ whole$or$any$portion$of$the$contents$in$any$manner$whatsoever.$ $ Signature:$$……………………………………………….$$Date:$$……………………………………….$ $ $ ! $ ! $ Page$2$of$275$ CONTENTS' ! List%of%Tables% 4! List%of%Figures% 4! Acronyms% 5! Acknowledgements% 6! ABSTRACT'............................................................................................................'10! SYNOPSIS'.............................................................................................................'11! CHAPTER'1'Introduction'.......................................................................................'14! CHAPTER'2'Patience’s'Story'.................................................................................'28! CHAPTER'3'Methods'............................................................................................'43! CHAPTER'4'Defining'sex,'virginity'and'abstinence:'where'does'anal'sex'fit'in'and' what'are'the'implications'for'HIV'prevention?'.....................................................'80! CHAPTER'5''Talking'about'sex'and'virginity'with'young'people'in'Masiphumelele '..........................................................................................................................'100! CHAPTER'6'Conceptualizations'of'Heterosexual'Anal'Sex'and'HIV'Risk'in'Five'East' African'Communities'..........................................................................................'119! PREFACE'TO'CHAPTERS'7,'8'and'9'The'VOICEZD'Study'........................................'141! CHAPTER'7'Lost'in'translation:'Language,'Terminology'and'Understanding'of' PenileZAnal'Intercourse'in'an'HIV'prevention'Trial'in'South'Africa,'Uganda'and' Zimbabwe'..........................................................................................................'144! CHAPTER'8'Sexual'Scripting'of'Heterosexual'PenileZAnal'Intercourse'amongst' participants'in'an'HIV'prevention'trial'in'South'Africa,'Uganda'and'Zimbabwe'..'164! CHAPTER'9'Condoms,'lubricants'and'rectal'cleansing:'Practices'associated'with' Heterosexual'PenileZAnal'Intercourse'amongst'participants'in'an'HIV'prevention' trial'in'South'Africa,'Uganda'and'Zimbabwe'.......................................................'184! CHAPTER'10'Discussion'......................................................................................'201! APPENDICES'.......................................................................................................'236! Appendix%1:%%Note%on%language%&%terminology%used%in%this%thesis% 236! Appendix%2:%%Overview%of%My%Role%in%Each%Study% 238! Appendix%3:%Table%12:%Terminology%in%socioLbehavioural%studies%on%sexual%behaviour%(Chapter%4)%240! Appendix%4:%%Example%of%body%maps%(see%Chapter%5)% 243! Appendix%5:%%Support%letter%from%Doctoral%Degrees%Board%for%including%publications%in%thesis% 245! Appendix%6:%%Statement%from%coLauthors%(VOICELD%papers)% 247! Appendix%7:%%VOICELD%Interview%Guide%Excerpt% 248! Appendix%8:%%Informed%Consent%Form%for%VOICELD% 250! Appendix%9:%%Masiphumelele%study%FGD%guide% 254! Appendix%10:%%Informed%Consent%Form%for%Masiphumelele%FGDs% 255! Appendix%11:%%Informed%Consent%Form%for%case%study% 258! Appendix%12:%%Ethics%approval%letters% 261! REFERENCES'.......................................................................................................'263! ' ! Page!3!of!275! List!of!Tables! $ Table& Title& Page&number& number& Table!1! Countries$covered$in$this$research$(Data$from$UNAIDS,$2013)$ 16$ Table!2! Comparing$the$physiology$/$histology$of$the$rectum$and$vagina$ 18$ Table!3! Overall$sample$population$ 50$ Table!4! Demographic$characteristics$of$FGD$sample$ 104$ Table!5! Heterosexual$anal$sex$prevalence$data$from$Africa$ 124$ Table!6! Data$collection$sample$for$East$Africa$study$ 126$ Table!7! Translations$of$ACASI$PAI$question$ 149$ Table!8! Demographic$characteristics$of$and$PAI$reporting$by$VOICEWD$sample$ 152$ Table!9! Demographic$characteristics$of$VOICEWD$sample$ 169$ Table!10! Demographic$characteristics$of$VOICE$D$sample,$sexual$behaviour,$ 189$ and$practices$associated$with$PAI$ Table!11! Overall$roles$&$responsibilities$in$the$studies$presented$in$this$thesis$ 238$ Table!12! Terminology$in$socioWbehavioural$studies$on$sexual$behaviour$ 240W242$ (Chapter$4)$ & $ $ List!of!Figures! ! Figure& Title& Page&number& number& Figure!1! Data$collection$site$map$ 51$ Figure!2! Body$map$template$used$in$VOICEWD$ 151$ Figure!3! Theoretical$Model$1$ 225$ Figure!4! Theoretical$Model$2$ 227$ Figure!5! Theoretical$Model$3$ 230$ Figure!6! Theoretical$Model$4$ 232$ ! & ! ! $ Page$4$of$275$ Acronyms! ACASI! Audio$ComputerWAssisted$SelfWInterviewing$ AI! Anal$Intercourse$ AIDS! Acquired$immune$deficiency$syndrome$ CAQDA! Computer$assisted$qualitative$data$analysis$ DHS! Demographic$and$Health$Surveys$ DoH! Department$of$Health$ DTHF! Desmond$Tutu$HIV$Foundation$ FGD! Focus$Group$Discussion$ FTFI! Face$to$face$interview$ HIV! Human$immunodeficiency$virus$ HPAI! Heterosexual$penileWanal$intercourse$ HPV! Human$Papilloma$Virus$ IDI! InWdepth$interview$ MSM! Men$who$have$sex$with$men$ MTN! Microbicide$Trials$Network$ NIMH! National$Institute$of$Mental$Health$(US$Government$Funded)$ PAI! PenileWanal$intercourse$ PrEP! PreWExposure$Prophylaxis$ PVI! PenileWvaginal$intercourse$ QC! Quality$control$ RD! Rectal$douching$ RTI! RTI$International$ STI! Sexually$transmitted$infection$ VOICE!(MTN/003)! The$Vaginal$and$Oral$Interventions$to$Control$the$Epidemic$ VOICE/D!(MTN/003D)! An$Exploratory$Study$of$Potential$Sources$of$Efficacy$Dilution$ in$the$VOICE$Trial$ UCT! University$of$Cape$Town$ UNAIDS! Joint$United$Nations$Programme$on$HIV/AIDS$ WHO! World$Health$Organisation$ ZD! Zoe$Duby$ $ Page$5$of$275$ Acknowledgements! ! $ First$and$foremost,$I$must$thank$my$mother,$Fiona$Duby,$who$throughout$my$life$has$been$a$ constant$source$of$inspiration,$and$a$deep$well$of$unconditional$love.$From$my$early$days$as$ baby$accompanying$my$mother$to$her$work$in$family$planning$clinics$in$Swaziland,$with$a$ diaphragm$as$a$teething$ring$and$coloured$condoms$for$birthday$balloons,$I$was$off$to$a$ good$start.$This$was$followed$by$a$childhood$in$Bangladesh$where$my$Barbies$had$hairbands$ made$of$condom$rings,$and$I$entertained$myself$at$Mum’s$office$by$inserting$intraWuterine$ devices$into$plastic$models.$TeenageWyears$in$Nigeria$were$also$formative;$my$brother$and$I$ occasionally$took$Mum$to$our$favourite$Lagos$drinking$hole,$a$rickety$brothelWbar$on$stilts$ over$the$lagoon.$It$seemed$I$was$destined$to$follow$in$my$mother’s$footsteps$into$the$world$ of$sexual$and$reproductive$health.$$ $ I$have$always$been$drawn$to$topics$that$are$tabooed$and$silenced,$especially$those$for$which$ the$silences$exacerbate$the$associated$health$risks.$It$was$as$an$intern$in$Nairobi,$that$I$first$ stumbled$upon$the$topic$of$heterosexual$penileWanal$intercourse$and$HIV.$While$conducting$ a$literature$review$on$men$who$have$sex$with$men$in$Kenya,$I$came$across$anecdotal$reports$ of$young$girls$in$coastalWKenya$practising$anal$sex$to$maintain$their$virginity.$This$sparked$my$ interest,$and$after$delving$further$I$noticed$a$glaring$gap$in$the$literature.$Thus$I$arrived$at$ UCT$with$a$topic$in$hand$for$my$Masters$dissertation.$After$completing$my$Masters$I$felt$that$ I$had$only$begun$to$scrape$the$surface$of$this$complex$and$neglected$topic,$which$has$ potentially$critical$implications$for$HIV$transmission$in$Africa.$ $ Having$decided$that$it$was$necessary$to$pursue$this$topic$as$a$PhD,$I$was$pointed$in$the$ direction$of$Chris$Colvin,$a$medical$anthropologist$at$UCT’s$School$of$Public$Health.$My$ gratitude$goes$to$Chris$for$enduring$five$years$of$reading$about$a$topic$I’m$sure$he$never$ imagined$having$to$think$about$in$such$depth.$Chris$has$helped$me$to$engage$critically$with$ my$study$topic,$giving$me$the$freedom$to$pursue$the$research$in$various$directions,$while$ supporting$ my$ learning$ through$ the$ process,$ championing$ my$ cause,$ and$ guiding$ me$ through$the$requirements$of$academic$study$at$this$level.$ $ I$must$also$thank$the$Desmond$Tutu$HIV$Foundation$for$giving$me$the$opportunity$to$gain$ valuable$work$experience$while$studying;$special$thanks$goes$to$Ben$Brown$for$giving$me$the$ freedom$and$support$I$needed$to$attain$a$manageable$workWstudy$balance.$Thanks$to$LindaW $ Page$6$of$275$ Gail$Bekker$for$her$support,$and$for$connecting$me$to$the$Microbicide$Trial$Network.$It$is$ through$her$incomparable$networking$and$connections$that$I$became$involved$in$the$VOICEW D$study,$which$formed$a$large$part$of$my$data.$My$gratitude$goes$to$Ariane$van$der$Straten,$ Barbara$Mensch$and$the$rest$of$the$VOICEWD$team$for$their$permission$and$support$in$using$ VOICEWD$data$as$part$of$my$doctoral$thesis,$and$for$their$valuable$input$in$honing$the$three$ VOICEWD$papers.$During$my$involvement$in$VOICEWD,$I$have$grown$as$a$researcher$and$ developed$invaluable$skills$and$expertise$that$will$stand$me$in$good$stead$for$the$rest$of$my$ research$career.$ $ Lastly,$I$must$thank$my$partner$Jamie,$for$his$companionship$and$love,$and$for$being$one$of$ the$most$openWminded$people$I$have$had$the$pleasure$of$knowing.$Jamie$has$not$once$ batted$so$much$as$an$eyelid$in$conversations$about$the$graphic$details$of$my$work$over$our$ evening$meal.$$ $ This$doctoral$project$has$been$a$long,$but$fascinating$journey.$There$are$many$others$not$ mentioned$by$name$here$–$friends,$family,$and$colleagues$–$you$know$who$you$are$–$who$ have$played$a$part$in$this$journey$over$the$past$five$years,$and$to$whom$I$extend$my$ gratitude.$My$hope$is$that$I$have$contributed$something$useful$to$the$domain$of$HIV$ research,$enriching$our$understanding$of$sexual$behaviour$and$HIV$transmission$in$subW Saharan$Africa.$Perhaps$now$I$can$pursue$research$topics$that$make$for$less$startling$dinner$ table$conversation…$perhaps$not.$$ $ ! Zoe$Duby,$Cape$Town,$February$2015 $ Page$7$of$275$ INCLUSION!OF!PAPERS!IN!THE!THESIS! $ This$doctoral$thesis$includes$four$papers$written$for$publication,$as$per$provision$6.7$in$the$ General$Rules$for$the$Degree$of$Doctor$of$Philosophy$(PhD)$of$the$University$of$Cape$Town,$ and$with$approval$in$2015$from$the$University$Doctoral$Degrees$Board.$The$manuscripts$are$ currently$in$various$stages$of$the$publication$process,$as$detailed$at$the$beginning$of$each$ chapter.$The$data$collection,$data$analysis$and$drafting$of$these$papers$were$carried$out$ during$the$period$of$doctoral$degree$registration.$I$was$the$lead$author$on$each$manuscript,$ under$the$supervision$of$her$doctoral$academic$supervisor.$I$have$given$further$details$of$my$ specific$contributions$and$the$role$I$played$in$each$study$in$Appendix$XX.$All$coWauthors$ reviewed$and$approved$the$submitted$manuscripts,$and$gave$permission$for$their$inclusion$ in$this$doctoral$thesis.$ $ In$addition$to$the$four$papers$written$for$journal$publication$that$are$included$as$selfW contained$chapters$in$this$theses,$three$findings$chapters$take$the$form$of$monographs.$The$ monograph$chapters$have$been$written$in$a$similar$style$to$the$papers;$the$rationale$for$this$ was$to$enable$consistent$formatting$across$the$findings$chapters,$and$so$that$the$methods$ chapter$could$be$more$general,$with$study$specific$methods$presented$in$each$chapter.$$ $ The$decision$to$include$publications$in$this$thesis$was$influenced$by$various$factors.$Firstly$ having$drawn$data$from$multiple$studies$and$data$sets,$all$with$the$focus$of$heterosexual$ penileWanal$intercourse$in$subWSaharan$Africa,$it$made$sense$that$the$findings$from$each$ study$would$form$a$discrete$paper.$Additionally$the$method$of$including$publications$in$this$ thesis$enables$me$to$contribute$to$research$in$the$field$at$the$earliest$possible$opportunity,$ and$ allows$ an$ engaged$ approach$ to$ dissemination$ of$ the$ findings.$ The$ field$ of$ HIV$ prevention$is$fast$moving,$particularly$in$the$realm$of$biomedical$prevention$products$such$ as$microbicides,$and$the$publication$approach$enables$me$to$make$progressive$contributions$ to$the$field$during$the$course$of$the$project,$without$having$to$wait$for$the$entire$thesis$to$ be$completed,$by$which$time$some$of$the$findings$may$be$out$of$date$and$no$longer$as$ useful$as$they$might$have$been.$By$presenting$my$research$findings$at$conferences,$and$by$ publishing$articles$in$peerWreviewed$journals,$my$findings$have$been$more$immediate$and$ accessible$to$other$researchers$in$the$field.$Additionally,$working$with$coWauthors$who$are$ experienced$in$the$field,$has$strengthened$my$own$work$by$engaging$in$peer$review$as$part$ of$the$writing$and$publication$process.$Throughout$the$course$of$the$thesis$I$have$been$able$ to$ participate$ in$ a$ multiWdisciplinary$ international$ team,$ and$ have$ learned$ from$ the$ $ Page$8$of$275$ experience$and$mentorship$of$my$coWauthors,$which$has$served$to$strengthen$the$value$of$ the$research$findings$and$the$quality$of$my$writing.$The$method$of$including$publications$in$ my$PhD$thesis$therefore$has$enabled$me$to$make$a$more$significant$contribution$to$the$field$ of$HIV$prevention$than$the$thesis$alone.$ $ This$research$project$has$thus$far$resulted$in$the$following$articles:$ $ Articles!already!published!in!peer/reviewed!journals! 1. Zoe!Duby$&$Christopher$J.$Colvin$(2014).$Conceptualizations&of&Heterosexual&Anal&Sex& and&HIV&Risk&in&Five&East&African&Communities.$The$Journal$of$Sex$Research,$51$(8).$ & Articles!submitted!to!peer!reviewed!journals,!currently!under!review!! $ 1. Zoe!Duby,$Miriam$Hartmann,$Elizabeth$T.$Montgomery,$Christopher$J.$Colvin,$Barbara$ Mensch$and$Ariane$van$der$Straten.$Condoms,&lubricants&and&rectal&cleansing:& Practices&associated&with&Heterosexual&PenileGAnal&Intercourse&amongst&participants& in&an&HIV&prevention&trial&in&South&Africa,&Uganda&and&Zimbabwe! W Submitted$to$AIDS$&$Behavior$ 2. Zoe!Duby,$Miriam$Hartmann,$Imelda$Mahaka,$Otillia$Munaiwa,$Josephine$Nabukeera,$ Nozipho$Vilakazi,$Funeka$Mthembu,$Christopher$Colvin,$Barbara$Mensch,$Ariane$van$ der$Straten.$Lost&in&translation:&Language,&Terminology&and&Understanding&of&PenileG Anal&Intercourse&in&an&HIV&prevention&Trial&in&South&Africa,&Uganda&and&Zimbabwe& W Submitted$to$The$Journal$of$Sex$Research$ $ 3. Zoe!Duby,$Miriam$Hartmann,$Elizabeth$T.$Montgomery,$Christopher$J.$Colvin,$Barbara$ Mensch$and$Ariane$van$der$Straten.$Sexual!Scripting!of!Heterosexual!Penile/Anal! Intercourse!amongst!participants!in!an!HIV!prevention!trial!in!South!Africa,!Uganda! and!Zimbabwe!$ W Submitted$to$Culture,$Health$and$Sexuality$ $ $ $ $ Page$9$of$275$