Articles tagged as "Sexual transmission and prevention"

Peer support benefits MSM in Malawi

Feasibility of a combination HIV prevention program for men who have sex with men in Blantyre, Malawi.

Wirtz AL, Trapence G, Jumbe V, Umar E, Ketende S, Kamba D, Berry M, Stromdahl S, Beyrer C, Muula AS, Baral S. J Acquir Immune Defic Syndr. 2015 Oct 1;70(2):155-62. doi: 10.1097/QAI.0000000000000693.

Introduction: The use of combination HIV prevention interventions (CHPI) now represent the standard of care to minimize HIV acquisition risks among men who have sex with men (MSM). There has been limited evaluation of these approaches in generalized HIV epidemics and/or where MSM are stigmatized. A peer-based CHPI program to target individual, social, and structural risks for HIV was developed for MSM in Blantyre, Malawi.

Methods: To test the feasibility of CHPI, adult MSM were followed prospectively from January 2012 to May 2013. Participants (N = 103) completed sociobehavioral surveys and HIV testing at each of the 3 follow-up study visits.

Results: Approximately 90% of participants attended each study visit and 93.2% (n = 96) completed the final visit. Participants met with peer educators a median of 3 times (range: 1-10) in the follow-up visits 2 and 3. Condom use at last sex improved from baseline through follow-up visit 3 with main (baseline: 62.5%, follow-up 3: 77.0%; P = 0.02) and casual male partners (baseline: 70.7%, follow-up 3: 86.3%; P = 0.01). Disclosure of sexual behaviors/orientation to family increased from 25% in follow-up 1 to 55% in follow-up 3 (P < 0.01).

Discussion: Participants maintained a high level of retention in the study highlighting the feasibility of leveraging community-based organizations to recruit and retain MSM in HIV prevention and treatment interventions in stigmatizing settings. Group-level changes in sexual behavior and disclosure in safe settings for MSM were noted. CHPI may represent a useful model to providing access to other HIV prevention for MSM and aiding retention in care and treatment services for MSM living with HIV in challenging environments.

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Editor’s notes: Gay men and other men who have sex with men are a key, difficult-to-reach population in many parts of sub-Saharan Africa. Stigma and criminalization of same-sex practices cause many challenges in improving access to HIV prevention and treatment services. This study tested the feasibility of a combination HIV prevention programme for gay men and other men who have sex with men in Malawi. The programme worked at three levels. At the individual level peer educators provided outreach to increase use of condoms, lubricants and other prevention methods. The health sector level provided training for doctors and nurses, to improve access to services. The community level built capacity to advocate in national HIV strategies and support decriminalisation of homosexuality. Study participants were identified by respondent-driven sampling. Retention was very high in the cohort, and over 16 months, participants reported improved behaviour-associated outcomes. This study was implemented by a community-based organisation and peer educators, and used several methods to protect participant confidentiality and privacy which can be adopted by others working in stigmatising settings. Overall, the study demonstrates that HIV prevention programmes for gay men and other men who have sex with men can be implemented if security measures and awareness of the social and political situation are well maintained.  

Africa
Malawi
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PEP is an unknown option for women at high risk in Nairobi

Barriers to the uptake of postexposure prophylaxis among Nairobi-based female sex workers.

Olsthoorn AV, Sivachandran N, Bogoch I, Kwantampora J, Kimani M, Kimani J, Kaul R. AIDS. 2015 Sep 13. [Epub ahead of print]

Introduction: Female sex workers (FSWs) in sub-Saharan Africa are at a particularly high risk for HIV infection. Postexposure prophylaxis (PEP) is available as part of an HIV care and prevention program through dedicated FSW clinics in Nairobi, Kenya, but is underutilized. We evaluated PEP knowledge, access, and adherence among clinic attendees.

Methods: An anonymous questionnaire was administered to unselected HIV-uninfected FSWs. Participants were dichotomized into high and low HIV risk categories based on self-reported sexual practices, and prior PEP use, knowledge, and adherence were then evaluated.

Results: One hundred thirty-four HIV-uninfected FSWs participated, with 64 (48%) categorized as being at high risk for HIV acquisition. High-risk FSWs were less likely to have heard of or accessed PEP than lower risk FSWs (37.5 vs. 58.6%, P = 0.014; and 21.9 vs. 40.6%, P = 0.019, respectively). Among higher risk FSWs, those who had accessed PEP were more likely to report treatment for a genital infection (71.4 vs. 42.0%, P = 0.049) or sex with an HIV-infected man (62.5 vs. 37.5%, P = 0.042) during the last 6 months. However, only 35.7% of high-risk women accessing PEP completed a full course of treatment, and noncompleters were more likely to report prior unprotected sex with an HIV-infected man (P = 0.023).

Conclusion: Despite freely available PEP for Nairobi-based FSWs, women at highest risk were less likely to have heard of PEP, access PEP, or complete the full course of therapy once initiated. Program delivery needs to be improved to ensure that FSW most at risk are able to benefit from this resource.

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Editor’s notes: There is currently in the field a strong buzz around antiretroviral (ARV)-based prevention following the results from recently completed oral pre-exposure prophylaxis studies (PrEP). This excitement is also driven by the new guidelines from the World Health Organization which recommend immediate treatment of any individual testing HIV positive at any CD4 count and initiation of PrEP for individuals at substantially high risk for acquiring HIV. On the other hand, post-exposure prophylaxis (PEP), involving giving a one month supply of daily ARVs to someone recently exposed or suspected to be exposed to HIV, has been in existence for almost two decades.  Yet despite new WHO guidelines released in 2014 it struggles to be successfully implemented in instances of suspected sexual exposure. This paper presents a case illustrating how despite support from national policy and availability in clinics, women at high risk do not know about PEP and do not access it as they could. This study was able to correlate association of risk and the need to care for children with accessing and completing PEP regimens. This is a valuable insight into how messaging and education around PEP could be constructed. PEP could be a powerful tool in the ARV-based prevention tool box, and the broader combination prevention strategies in countries. However it is clear that efforts to improve access and uptake will need directed attention and excitement along with support for the other prevention options coming on to the market.

Africa
Kenya
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Condoms or PrEP? Women’s decision-making for the prevention of HIV-transmission in Kenya and South Africa

Motivations for reducing other HIV risk-reduction practices if taking pre-exposure prophylaxis: findings from a qualitative study among women in Kenya and South Africa.

Corneli A, Namey E, Ahmed K, Agot K, Skhosana J, Odhiambo J, Guest G. AIDS Patient Care STDS. 2015 Sep;29(9):503-9. doi: 10.1089/apc.2015.0038. Epub 2015 Jul 21.

Findings from a survey conducted among women at high risk for HIV in Bondo, Kenya, and Pretoria, South Africa, demonstrated that a substantial proportion would be inclined to reduce their use of other HIV risk-reduction practices if they were taking pre-exposure prophylaxis (PrEP). To explore the motivations for their anticipated behavior change, we conducted qualitative interviews with 60 women whose survey responses suggested they would be more likely to reduce condom use or have sex with a new partner if they were taking PrEP compared to if they were not taking PrEP. Three interrelated themes were identified: (1) "PrEP protects"-PrEP was perceived as an effective HIV prevention method that replaced the need for condoms; (2) condoms were a source of conflict in relationships, and PrEP would provide an opportunity to resolve or avoid this conflict; and (3) having sex without a condom or having sex with a new partner was necessary for receiving material goods and financial assistance-PrEP would provide reassurance in these situations. Many believed that PrEP alone would be a sufficient HIV risk-reduction strategy. These findings suggest that participants' HIV risk-reduction intentions, if they were to use PrEP, were based predominately on their understanding of the high efficacy of PrEP and their experiences with the limitations of condoms. Enhanced counseling is needed to promote informed decision making and to ensure overall sexual health for women using PrEP for HIV prevention, particularly with respect to the prevention of pregnancy and other sexually transmitted infections when PrEP is used alone.

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Editor’s notes: New HIV-prevention methods and messages may be understood differently by different people. For example, the protection from HIV infection for men ‘at about 60%’ that is afforded by medical male circumcision is not always well understood. Some men assume higher protection levels. The authors of this paper describe women’s HIV-prevention method intentions, should pre-exposure prophylaxis (PrEP) be available.  The study is of women’s intention, not actual behaviour, but the findings provide useful insights into the way in which prevention messages are interpreted. In this case, the new method is seen to offer an alternative to using condoms. The authors describe the reasons women give for not using condoms based on their belief that PrEP would protect them from infection. The authors suggest that counselling to inform women of the other benefits of condoms, beyond HIV-infection, is necessary where PrEP is introduced as a HIV-prevention method. This may be so, but underlying the reasons the women gave for not wanting to use condoms was inequitable relationships with their partners. The decision to use condoms often rests mainly with the man. While some women actively disliked condoms because of a reduction in sexual pleasure, many saw not using condoms as a way to sustain their relationship. The authors note that prevention strategies not only need to support women’s choices; but they also need to engage with women who lack choice.  

Africa
Kenya, South Africa
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Male circumcision may reduce HIV transmission among MSM in China

Lower HIV risk among circumcised men who have sex with men in China: Interaction with anal sex role in a cross-sectional study.

Qian HZ, Ruan Y, Liu Y, Milam DF, HM LS, Yin L, Li D, Shepherd BE, Shao Y, Vermund SH. J Acquir Immune Defic Syndr. 2015 Sep 21. [Epub ahead of print]

Background: Voluntary medical male circumcision reduces the risk of HIV heterosexual transmission in men, but its effect on male-to-male sexual transmission is uncertain.

Methods: Circumcision status of men who have sex with men (MSM) in China was evaluated by genital examination and self-report; anal sexual role was assessed by questionnaire interview. Serostatus for HIV and syphilis was confirmed.

Results: Among 1155 participants (242 known seropositives and 913 with unknown HIV status at enrollment), the circumcision rate by self-report (10.4%) was higher than confirmed by genital examination (8.2%). Male circumcision (by exam) was associated with 47% lower odds of being HIV seropositive (adjusted odds ratio [aOR], 0.53; 95% confidence interval [CI], 0.27-1.02) after adjusting for demographic covariates, number of lifetime male sexual partners, and anal sex role. Among MSM who predominantly practiced insertive anal sex, circumcised men had 62% lower odds of HIV infection than those who were uncircumcised (aOR, 0.38, 95%CI, 0.09-1.64). Among those whose anal sex position was predominantly receptive or versatile, circumcised men have 46% lower odds of HIV infection than did men who were not circumcised (aOR, 0.54, 95%CI, 0.25-1.14). Compared to uncircumcised men reporting versatile or predominantly receptive anal sex positioning, those who were circumcised and reported practicing insertive sex had an 85% lower risk (aOR, 0.15; 95%CI, 0.04-0.65). Circumcision was not associated clearly with lower syphilis risk (aOR, 0.91; 95%CI, 0.51-1.61).

Conclusions: Circumcised MSM were less likely to have acquired HIV, most pronounced among men predominantly practicing insertive anal intercourse. A clinical trial is needed.

Abstract access

Editor’s notes: Randomised controlled trials in areas of high HIV prevalence in Africa have demonstrated that voluntary medical male circumcision (VMMC) can reduce heterosexual acquisition of HIV in men by around 60%.  However the evidence is less clear that the protection conferred by VMMC also applies to gay men and other men who have sex with men by reducing HIV acquisition through insertive anal sex. This cross-sectional study of gay men and other men who have sex with men in China suggests that, overall, the odds of being HIV positive among circumcised men were about half that in uncircumcised men, after adjusting for differences in demographic factors and sexual behaviour. Biologically, circumcision is likely to protect gay men and other men who have sex with men who are exclusively or mainly the insertive partner, and among men in this group, there was a slightly larger protective effect, although not statistically significant. This supports a meta-analysis which found a similar finding among gay men and other men who have sex with men who practiced insertive anal sex. There was no association of VMMC and syphilis infection in this population, in line with other studies. The authors note that HIV prevention strategies among gay men and other men who have sex with men are still limited in China, and suggest studies to assess the feasibility of a multicentre randomised controlled trial of the effect of VMMC on HIV acquisition among gay men and other men who have sex with men in this setting.

Asia
China
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Contraception for young girls living with HIV: barriers and facilitators to service provision in western Kenya

Barriers and facilitators adolescent females living with HIV face in accessing contraceptive services: a qualitative assessment of providers' perceptions in western Kenya.

Hagey JM, Akama E, Ayieko J, Bukusi EA, Cohen CR, Patel RC. J Int AIDS Soc. 2015 Sep 16;18(1):20123. doi: 10.7448/IAS.18.1.20123. eCollection 2015.

Introduction: Avoiding unintended pregnancies is important for the health of adolescents living with HIV and has the additional benefit of preventing potential vertical HIV transmission. Health facility providers represent an untapped resource in understanding the barriers and facilitators adolescents living with HIV face when accessing contraception. By understanding these barriers and facilitators to contraceptive use among adolescent females living with HIV, this study aimed to understand how best to promote contraception within this marginalized population.

Methods: We conducted structured in-depth interviews with 40 providers at 21 Family AIDS Care & Education Services - supported clinics in Homabay, Kisumu and Migori counties in western Kenya from July to August 2014. Our interview guide explored the providers' perspectives on contraceptive service provision to adolescent females living with HIV with the following specific domains: contraception screening and counselling, service provision, commodity security and clinic structure. Transcripts from the interviews were analyzed using inductive content analysis.

Results: According to providers, interpersonal factors dominated the barriers adolescent females living with HIV face in accessing contraception. Providers felt that adolescent females fear disclosing their sexual activity to parents, peers and providers, because of repercussions of perceived promiscuity. Furthermore, providers mentioned that adolescents find seeking contraceptive services without a male partner challenging, because some providers and community members view adolescents unaccompanied by their partners as not being serious about their relationships or having multiple concurrent relationships. On the other hand, providers noted that institutional factors best facilitated contraception for these adolescents. Integration of contraception and HIV care allows easier access to contraceptives by removing the stigma of coming to a clinic solely for contraceptive services. Youth-friendly services, including serving youth on days separate from adults, also create a more comfortable setting for adolescents seeking contraceptive services.

Conclusions: Providers at these facilities identified attitudes of equating seeking contraceptive services with promiscuity by parents, peers and providers as barriers preventing adolescent females living with HIV from accessing contraceptive services. Health facilities should provide services for adolescent females in a youth-friendly manner and integrate HIV and contraceptive services.

Abstract  Full-text [free] access

Editor’s notes: The article offers a clear picture of barriers and facilitators to access and uptake of contraceptive services for young girls living with HIV. It provides valuable evidence of providers’ views regarding integrated HIV and contraceptive services. The study was carried out with HIV care providers in different areas of western Kenya. The authors found that young girls find it difficult to access services, especially on their own, for fear of being seen as sexually active and/or promiscuous. Parental presence during consultations in HIV services can be a barrier to requesting contraceptives. But some parents are supportive and wish to prevent unintended pregnancies for their daughters. Young girls living with HIV might find it challenging to manage questions from their peers about their HIV medication and contraceptives. Providers’ themselves prioritise abstinence and condoms over offering hormonal contraceptives. Providers can feel protective towards the patients, whom they may see as ‘children’. The authors suggest that further involvement of parents, young boys and male partners can facilitate uptake of contraceptives for young girls living with HIV. The integration of HIV and contraceptive services for young girls can provide a crucial platform to reduce sexually transmitted infections, unintended pregnancies and vertical HIV transmission.

Africa
Kenya
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Antiretroviral therapy coverage associated with reduced HIV incidence in Kenya

Impact of community antiretroviral therapy coverage on HIV incidence in Kenyan female sex workers: a 15-year prospective cohort study.

McClelland RS, Richardson BA, Cherutich P, Mandaliya K, John-Stewart G, Miregwa B, Odem-Davis K, Jaoko W, Kimanga D, Overbaugh J. AIDS. 2015 Jul 31. [Epub ahead of print]

Objective: To test the hypothesis that increasing community antiretroviral therapy (ART) coverage would be associated with lower HIV incidence in female sex workers (FSWs) in Mombasa District, Kenya.

Design: Prospective cohort study.

Methods: From 1998 to 2012, HIV-negative FSWs were asked to return monthly for an interview regarding risk behavior and testing for sexually transmitted infections including HIV. We evaluated the association between community ART coverage and FSW's risk of becoming HIV infected using Cox proportional hazards models adjusted for potential confounding factors.

Results: One thousand four hundred four FSWs contributed 4335 woman-years of follow-up, with 145 acquiring HIV infection (incidence 3.35/100 woman-years). The ART rollout began in 2003. By 2012, an estimated 52% of HIV-positive individuals were receiving treatment. Community ART coverage was inversely associated with HIV incidence (adjusted hazard ratio 0.77; 95% confidence interval 0.61-0.98; P = 0.03), suggesting that each 10% increase in coverage was associated with a 23% reduction in FSWs' risk of HIV acquisition. Community ART coverage had no impact on herpes simplex virus type-2 incidence (adjusted hazard ratio 0.97; 95% confidence interval 0.79-1.20; P = 0.8).

Conclusion: Increasing general population ART coverage was associated with lower HIV incidence in FSWs. The association with HIV incidence, but not herpes simplex virus type-2 incidence, suggests that the effect of community ART coverage may be specific to HIV. Interventions such as preexposure prophylaxis and antiretroviral-containing microbicides have produced disappointing results in HIV prevention trials with FSWs. These results suggest that FSWs' risk of acquiring HIV infection might be reduced through the indirect approach of increasing ART coverage in the community.

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Editor’s notes: The individual-level benefit of antiretroviral therapy (ART) on reducing HIV transmission between serodiscordant partners is established, but less is known about a possible population-level effect of ART on key populations such as female sex workers. In this study of 1404 initially HIV-negative female sex workers in Mombasa, Kenya, increased community ART coverage was strongly associated with reduced HIV incidence. HIV incidence was 23% lower for every 10% increase in ART coverage, after adjusting for HIV prevalence and participants’ behavioural characteristics. However, the authors note that HIV incidence was already declining prior to the introduction of ART (from 11.4 cases/100 woman-years in 1998 to 7.6/100 woman-years in 2002), due to other factors including changes in risk behaviour and HIV-prevention efforts in the community. Despite this, the present study suggests that in the setting of ongoing high-quality HIV prevention services, the risk of HIV acquisition among female sex workers is likely to be reduced by increasing ART coverage in the community. Moves to increase coverage of ART in the community will potentially have a substantial HIV prevention benefit on this key population.

Africa
Kenya
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HIV and the relative perception of risk in a fishing site in Uganda

Risk denial and socio-economic factors related to high HIV transmission in a fishing community in Rakai, Uganda: a qualitative study.

Lubega M, Nakyaanjo N, Nansubuga S, Hiire E, Kigozi G, Nakigozi G, Lutalo T, Nalugoda F, Serwadda D, Gray R, Wawer M, Kennedy C, Reynolds SJ. PLoS One. 2015 Aug 26;10(8):e0132740. doi: 10.1371/journal.pone.0132740. eCollection 2015.

Background: In Kasensero fishing community, home of the first recorded case of HIV in Uganda, HIV transmission is still very high with an incidence of 4.3 and 3.1 per 100 person-years in women and men, respectively, and an HIV prevalence of 44%, reaching up to 74% among female sex workers. We explored drivers for the high HIV transmission at Kasensero from the perspective of fishermen and other community members to inform future policy and preventive interventions.

Methods: 20 in-depth interviews including both HIV positive and HIV negative respondents, and 12 focus-group discussions involving a total of 92 respondents from the Kasensero fishing community were conducted during April-September 2014. Content analysis was performed to identify recurrent themes.

Results: The socio-economic risk factors for high HIV transmission in Kasensero fishing community cited were multiple and cross-cutting and categorized into the following themes: power of money, risk denial, environmental triggers and a predisposing lifestyle and alcoholism and drug abuse. Others were: peer pressure, poor housing and the search for financial support for both the men and women which made them vulnerable to HIV exposure and or risk behavior.

Conclusions: There is a need for context specific combination prevention interventions in Kasensero that includes the fisher folk and other influential community leaders. Such groups could be empowered with the knowledge and social mobilization skills to fight the negative and risky behaviors, perceptions, beliefs, misconceptions and submission attitudes to fate that exposes the community to high HIV transmission. There is also need for government/partners to ensure effective policy implementation, life jackets for all fishermen, improve the poor housing at the community so as to reduce overcrowding and other housing related predispositions to high HIV rates at the community. Work place AIDS-competence teams have been successfully used to address high HIV transmission in similar settings.

Abstract  Full-text [free] access

Editor’s notes: In recent years policy makers and programme implementers have been urged to ‘know your epidemic’. This paper provides a striking illustration of the complexity of responding to the knowledge of a place with high prevalence and incidence. The authors describe the many factors which contribute to high HIV transmission rates. They illustrate why, for example, providing condoms and instruction on safer sex may have limited impact on a man who expresses concerns about drowning while fishing tomorrow. Drowning is a more immediate risk than dying because of AIDS-associated illnesses in the future. The information in this paper is not new. We have known about the different risk factors in fishing sites in Uganda for some time. There is also a considerable body of work on the relative perception of risk. However, what the authors do offer is a clear and well-grounded overview of the many different reasons why people in the study setting are at risk of HIV. They illustrate the vital importance of understanding the context of HIV-transmission; the value of looking beneath the prevalence and incidence figures.

Africa
Uganda
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Awareness of HIV status and risk among key populations in India

HIV care continuum among men who have sex with men and people who inject drugs in India: barriers to successful engagement.

Mehta SH, Lucas GM, Solomon S, Srikrishnan AS, McFall AM, Dhingra N, Nandagopal P, Kumar MS, Celentano DD, Solomon SS. Clin Infect Dis. 2015 Aug 6. pii: civ669. [Epub ahead of print]

Background: We characterize the HIV care continuum for men who have sex with men (MSM) and people who inject drugs (PWID) across India.

Methods: We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities using respondent-driven sampling (9/2012-12/2013). Participants were ≥18 years and either 1) self-identified as male and reported sex with a man in the prior year (MSM); or 2) reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV positive status were characterized using multi-level logistic regression.

Results: 1146 MSM were HIV-infected of whom a median 30% were aware of their HIV positive status, 23% were linked to care, 22% were retained pre-ART, 16% initiated ART, 16% were currently on ART, and 10% had suppressed VL. There was site variability (awareness range: 0-90%; suppressed VL range: 0-58%). 2906 PWID were HIV-infected of whom a median 41% were aware, 36% linked to care, 31% were retained pre-ART, 20% initiated ART, 18% were currently on ART, and 15% had suppressed VL. Similar site variability was observed (awareness range: 2-93%; suppressed VL range: 0-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), other service utilization (PWID), more lifetime sexual partners (MSM) and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol (MSM) were associated with lower awareness.

Conclusions: In this large sample, the major barrier to HIV care engagement was awareness of HIV positive status. Efforts should focus on linking HIV testing to other essential services.

Abstract access 

Editor’s notes: The UNAIDS target of 90-90-90 (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) applies to all people living with HIV, including people in key populations who can be hard to reach in some settings. In India, declines in HIV prevalence have been seen among women attending antenatal clinics, but not in the key populations of gay men and other men who have sex with men and people who inject drugs. In this large, community-based, study of gay men and other men who have sex with men and people who inject drugs across India, the majority of people living with HIV (70% of gay men and other men who have sex with men and 59% of people who inject drugs) were unaware of their HIV status. Of people who were aware of their status, the proportions receiving sustained ART were relatively low (68% of gay men and other men who have sex with men and 52% of people who inject drugs). Notably, among people on ART, levels of viral suppression were high and comparable to that in high-income settings. The study highlights awareness of HIV status as the primary barrier to HIV care in these populations, and the importance of integrating HIV testing across healthcare services for vulnerable populations, using same-day rapid tests to maximise linkage-to-care. However, to have a real impact on outcomes across the HIV care continuum, additional strategies will be necessary. These are needed together with large-scale public policy changes to modify the broader social environment – such as decriminalisation of same-sex behaviour.

Asia
India
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Risks and experiences of transgender women in Lebanon

Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon.

Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Health Care Women Int. 2015 Aug;36(8):917-35. doi: 10.1080/07399332.2014.896012. Epub 2014 Apr 9.

Using minority stress theory, the authors investigated risk behaviors of transgender women (trans women) in Lebanon. Using semistructured interviews, the authors explored six areas: relationships with family and friends; openness about gender and sexuality; experiences with stigma; sexual behavior; attitudes and behaviors regarding HIV testing; and perceived HIV-related norms among transgender peers. Participants voiced the importance of different forms of safety: social/emotional, physical, sexual, and financial. Strategies for obtaining safety were negotiated differently depending on social, behavioral, and structural factors in the environment. In this article, we provide study findings from the perspectives of trans women, their exposure to stigma, and the necessary navigation of environments characterized by transphobia

Abstract access                     

Editor’s notes: Transgender women have a high risk of HIV acquisition / transmission, due to experiences of stigma, discrimination and transphobia. However there is a dearth of studies on transgender women from North Africa or the Middle East.

Interviews with ten trans-women from Beirut were included in this qualitative study. The study findings highlight the extreme vulnerability of transgender women to stigma, discrimination, violence, mental ill-health, financial insecurity and HIV and STI risk. Social support and emotional security from family, friends, and the transgender community was frequently lacking. Mental ill-health (9/10) and suicide ideation / attempts was high (5/10). Stigma and discrimination by peers and teachers at school, and at the work-place were common. Many also reported verbal, physical and sexual abuse and violence in public spaces. Many participants were selling anal sex to reduce financial insecurity. Money was a key motivator for condom non-use. 

Programmes with transgender women should be multi-component to reflect the complexity of their needs. They should include HIV prevention, advocacy of laws to prevent discrimination, employment opportunities to enable economic independence, and treatment and support for mental ill-health.

Asia
Lebanon
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Longer secondary schooling reduces HIV transmission risk

Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.

De Neve JW, Fink G, Subramanian SV, Moyo S, Bor J. Lancet Glob Health. 2015 Aug;3(8):e470-7. doi: 10.1016/S2214-109X(15)00087-X. Epub 2015 Jun 28.

Background: An estimated 2.1 million individuals are newly infected with HIV every year. Cross-sectional and longitudinal studies have reported conflicting evidence for the association between education and HIV risk, and no randomised trial has identified a causal effect for education on HIV incidence. We aimed to use a policy reform in secondary schooling in Botswana to identify the causal effect of length of schooling on new HIV infection.

Methods: Data for HIV biomarkers and demographics were obtained from the nationally representative household 2004 and 2008 Botswana AIDS Impact Surveys (N=7018). In 1996, Botswana reformed the grade structure of secondary school, expanding access to grade ten and increasing educational attainment for affected cohorts. Using exposure to the policy reform as an instrumental variable, we used two-stage least squares to estimate the causal effect of years of schooling on the cumulative probability that an individual contracted HIV up to their age at the time of the survey. We also assessed the cost-effectiveness of secondary schooling as an HIV prevention intervention in comparison to other established interventions.

Findings: Each additional year of secondary schooling caused by the policy change led to an absolute reduction in the cumulative risk of HIV infection of 8.1 percentage points (p=0.008), relative to a baseline prevalence of 25.5% in the pre-reform 1980 birth cohort. Effects were particularly large in women (11.6 percentage points, p=0.046). Results were robust to a wide array of sensitivity analyses. Secondary school was cost effective as an HIV prevention intervention by standard metrics (cost per HIV infection averted was US$27 753).

Interpretation: Additional years of secondary schooling had a large protective effect against HIV risk in Botswana, particularly for women. Increasing progression through secondary school could be a cost-effective HIV prevention measure in HIV-endemic settings, in addition to yielding other societal benefits.

Abstract  Full-text [free] access

Editor’s notes: There is conflicting evidence on the association between education and HIV risk, and little causal evidence. Observational studies are limited by strong confounding by factors such as socioeconomic status and psychological traits, while previous randomised trials have been underpowered for HIV incidence. A policy reform in Botswana in 1996 provided a unique opportunity to assess this question. The policy affected specific birth cohorts and meant that the average number of years of schooling increased by nearly one year. The reform was unlikely to have affected HIV risk through mechanisms other than schooling itself. It therefore constitutes a natural experiment to estimate the causal effect of schooling on the risk of HIV infection, through comparison of birth cohorts exposed to the policy reform versus people unexposed. The authors found that, for each additional year of schooling induced by the reform, there was an 8.1 percentage point reduction in the risk of HIV infection. The effect was particularly strong among women, with an 11.6 percentage point reduction. These results translated to a cost of $27 753 per HIV infection averted. Secondary schooling is therefore more expensive than circumcision or treatment as prevention, but of similar cost-effectiveness to the upper range of estimates for pre-exposure prophylaxis. In addition, schooling offers other benefits beyond the reduction of HIV transmission.

Africa
Botswana
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