Articles tagged as "Stigma and social exclusion"

Rural schools in Zimbabwe provide less than optimal support of HIV-affected children

Children's representations of school support for HIV-affected peers in rural Zimbabwe.

Campbell C, Andersen L, Mutsikiwa A, Madanhire C, Skovdal M, Nyamukapa C, Gregson S. BMC Public Health. 2014 Apr 26;14(1):402. [Epub ahead of print]

Background: HIV has left many African children caring for sick relatives, orphaned or themselves HIV-positive, often facing immense challenges in the absence of significant support from adults. With reductions in development funding, public sector budgetary constraints, and a growing emphasis on the importance of indigenous resources in the HIV response, international policy allocates schools a key role in 'substituting for families' (Ansell, 2008) in supporting child health and well-being. We explore children's own accounts of the challenges facing their HIV-affected peers and the role of schools in providing such support.

Methods: Contextualised within a multi-method study of school support for HIV-affected children in rural Zimbabwe, and viewing children's views as a key resource for child-relevant intervention and policy, 128 school children (10-14) wrote a story about an HIV-affected peer and how school assisted them in tackling their problems.

Results: Children presented harrowing accounts of negative impacts of HIV on the social, physical and mental well-being of peers, and how these manifested in the school setting. Whilst relationships with fellow learners and teachers were said to provide a degree of support, this was patchy and minimal, generally limited to small-scale and often one-off acts of material help or kindness (e.g. teachers giving children pens and exercise books or peers sharing school lunches), with little potential to impact significantly on the wider social drivers of children's daily challenges. Despite having respect for the enormity of the challenges many HIV-affected peers were coping with, children tended to keep a distance from them. School was depicted as a source of the very bullying, stigma and social exclusion that undermined children's opportunities for well-being in their lives more generally.

Conclusions: Our findings challenge glib assumptions that schools can serve as a significant 'indigenous' supports of the health and well-being of HIV-affected children in the absence of a very significant increase in outside training, support and additional resources. Schools are an extension of communities, with members of school communities subject to many of the same deprivations, anxieties and prejudices that drive the health-limiting exclusion, impoverishment and stigmatisation of HIV-affected children in their households and wider communities.

Abstract  Full-text [free] access 

Editor’s notes: This is an important study exploring children’s narrative accounts of school support for HIV-affected children in a rural area in Zimbabwe. This research arose from an assumption that Zimbabwean schools and teachers may be supporting children in informal ways. The underlying assumptions of this research were that participation in community networks/schools can yield health and welfare benefits (social capital) but can also be a source of negative social norms, social exclusion and discrimination. This qualitative study took an interesting approach by asking 128 children aged 10 to 14 years old, to write stories and draw pictures over 90 minutes without a teacher present. This was to articulate their experiences, understandings and feelings about HIV-affected peers and their challenges and how they overcome them. The stories revealed children’s understandings of the lives of HIV-affected children. The key issues that arose were a lack of supportive adults in households living with HIV. Children were depicted as neglected and abused and carrying the burden of household responsibilities. There was a negative impact on school attendance and ability to pay for uniform and school equipment, as well as their poor physical and emotional health. HIV-affected children were depicted as experiencing bullying and social exclusion at school. However, HIV-affected children were seen to gain some guidance and material support provided by NGOs linked to the school and from teachers, as well as emotional support from peers. Finally, children described school as a place where HIV-affected children could forget about their HIV status. The authors conclude that the children’s stories emphasised both anti-social capital of the school environment including social isolation, bullying and HIV-stigma, with some support from teachers and peers as well as support from linked NGOs. The authors suggest that to enable schools to provide effective support, teachers should be allocated time and provided with external support, resources and training to support HIV-affected children. 

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Men at greater risk of not accessing antiretroviral treatment than women

Sex differentials in the uptake of antiretroviral treatment in Zambia.

Gari S, Martin-Hilber A, Malungo JR, Musheke M, Merten S. AIDS Care. 2014 Mar 25. [Epub ahead of print]

This study explores socio-structural factors that influence uptake of antiretroviral treatment (ART) in Zambia and assess differences between men and women. We conducted a case-control study nested in a community- and health facility-based survey, between September 2010 and February 2011. Cases were defined as HIV-positive individuals who, while eligible, never started ART and controls were HIV-positive individuals who were on ART. Cases and controls were matched by place of residence. We performed a conditional logistic regression analysis using a discrete logistic model stratified by sex. Overall, a significantly larger proportion of men (32.7%) than women (25.6%) did not uptake ART (Pearson chi2 = 5.9135; p = 0.015). In the crude analysis, poor health status and low self-efficacy were common factors associated with non-uptake in both sexes. After adjusting for covariates, men were more likely than women to refuse ART even though men's self-rated health was lower than women's. In general, the adjusted analysis suggests that HIV status disclosure affects uptake in both sexes but women's uptake of ART is largely hampered by poverty-related factors while for men, side effects and social pressure, probably associated with masculinity, are more important barriers. Alarmingly men's health seems to deteriorate until they start treatment, in contrast to women. Understanding gender differences in uptake and attitudes to ART is a crucial component to providing effective and appropriate health care to both men and women living with HIV/AIDS in Zambia.

Abstract access 

Editor’s notes: There have been observed differences in the uptake of antiretroviral therapy (ART) among men and women living with HIV, with men often at greater risk of not using ART than women. Previous research on this topic has suggested that this is due to the fact that women often have stronger links to community networks. Therefore, women have more information about the availability and accessibility of ART services. This study suggests that social and structural factors have different effects on men’s and women’s decisions to enrol in ART. The authors found that non-disclosure of HIV status was strongly associated with non-uptake of ART among both sexes.

Reasons for men not being on ART seemed to be related to ideas about masculinity while women were more likely to not enrol owing to financial factors. Women who participated in community activities and who were part of a cohesive network within their neighbourhoods, were at lower risk of not enrolling in ART than their counterparts. Conversely, men from discohesive neighbourhoods were at higher risk for non-uptake of ART. Anticipation of side effects and poor health status were associated with poor uptake among men. The authors suggest that this may be due to the fact that ill-health and spending time worrying about one’s health can be seen as signs of weakness among men. These findings are consistent with patterns of HIV treatment seeking behaviour as men usually tend to seek care when the disease is at a late stage, and when CD4 counts are particularly low.

The authors suggest that ART clinics and health centres are often seen as female spaces and so men might not feel comfortable accessing them. Strong social ties, especially in situations where poverty is persistent, appear to have a positive effect on uptake among women. On the other hand, this seems to have the opposite effect in men. This could be because of social pressures associated with masculinity. The authors conclude that HIV programming needs to reach out to men in order to avoid turning HIV into a ‘feminised epidemic’ and that programmes focusing on men need to be expanded. 

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Living with HIV in resource-constrained settings: recognising the challenge

Challenging the Paradigm: anthropological perspectives on HIV as a chronic disease.

McGrath JW, Winchester MS, Kaawa-Mafigiri D, Walakira E, Namutiibwa F, Birungi J, Ssendegye G, Nalwoga A, Kyarikunda E, Kisakye S, Ayebazibwe N, Rwabukwali CB. Med Anthropol. 2014 Mar 24. [Epub ahead of print]

Recently HIV has been framed as a 'manageable' chronic disease in contexts in which access to effective care is reliable. The chronic disease paradigm emphasizes self-care, biomedical disease management, social normalization, and uncertainty. Data from a longitudinal study of patients (N=949) in HIV care at two sites in Uganda, collected through semi-structured interviews and ethnographic data, permit examination of the salience of this model in a high burden, low resource context struggling to achieve the promise of a manageable HIV epidemic. Our data highlight the complexity of the emerging social reality of long-term survival with HIV. Participants struggle to manage stigma as well as to meet the costs involved in care seeking. In these settings, economic vulnerability leads to daily struggles for food and basic services. Reconceptualizing the chronic disease model to accommodate a 'social space', recognizing this new social reality will better capture the experience of long-term survival with HIV.

Abstract access 

Editor’s notes: Antiretroviral therapy (ART) is enabling many people living with HIV, who have access to the drugs, to live into older age. As a consequence there have been increasing calls for HIV-infection to be treated as a chronic condition, like diabetes or hypertension.  In this paper the authors remind us that many factors make living with HIV different from other conditions, particularly in resource-constrained settings. The persistence of stigma and discrimination can make seeking and sustaining treatment difficult. Worries over side-effects, problems with drug supplies and the economic burden of accessing treatment and adequate food can make living with HIV unmanageable.  The authors illustrate very clearly through their findings that the ‘normalisation’ of HIV in people’s lives can mean coming to terms with new and often difficult challenges as they manage the hardships and worries they face on a day to day basis.

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Masking diversity – the problems with labels for key populations

'Mobile men with money': HIV prevention and the erasure of difference.

Aggleton P, Bell SA, Kelly-Hanku A. Glob Public Health. 2014;9(3):257-70. doi: 10.1080/17441692.2014.889736. Epub 2014 Mar 4.

Mobile Men with Money is one of the latest risk categories to enter into HIV prevention discourse. Used in countries in Asia, the Pacific and Africa, it refers to diverse groups of men (e.g. businessmen, miners and itinerant wage labourers) who, in contexts of high population movement and economic disparity, find themselves at heightened risk of HIV as members of a 'most-at-risk population', or render others vulnerable to infection. How adequate is such a description? Does it make sense to develop HIV prevention programmes from such understandings? The history of the epidemic points to major weaknesses in the use of terminologies such as 'sex worker' and 'men who have sex with men' when characterising often diverse populations. Each of these terms carries negative connotations, portraying the individuals concerned as being apart from the 'general population', and posing a threat to it. This paper examines the diversity of men classified as mobile men with money, pointing to significant variations in mobility, wealth and sexual networking conducive to HIV transmission. It highlights the patriarchal, heteronormative and gendered assumptions frequently underpinning use of the category and suggests more useful ways of understanding men, masculinity, population movement, relative wealth in relation to HIV vulnerability and risk.

Abstract access 

Editor’s notes: Criticism of the use of labels to identify groups of people considered to be at high risk of HIV infection is not new, but this paper serves as a timely reminder of the dangers of such labels and abbreviations. The authors explain why a term that has entered common usage in recent years ‘mobile men with money’, is inappropriate. They argue that the label plays to stereotypes of men as powerful risk takers and, usually, women as their vulnerable victims. The use of the term hides the diversity of men who move around because of their work and other activities, who may be in very different professions and circumstances. It also suggests that mobility is a negative activity, overlooking the great economic and other benefits of migration. They argue that the term is not helpful for HIV programming or activities.  It is unhelpful because it fails to take account of the structural factors that influence and shape the risks many men and women, face. It is often tempting to make use of abbreviations and catchy phrases in our work. This paper helps to remind us why we need to think carefully about terminology and labelling.

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Urgent need to focus HIV prevention efforts on mobile men who have sex with men in India

The effect of mobility on sexual risk behaviour and HIV infection: a cross-sectional study of men who have sex with men in southern India.

Ramesh S, Mehrotra P, Mahapatra B, Ganju D, Nagarajan K, Saggurti N. Sex Transm Infect. 2014 Mar 26. doi: 10.1136/sextrans-2013-051350. [Epub ahead of print]

Objectives: Mobility is an important factor contributing to the spread of HIV among key population at risk for HIV; however, research linking this relationship among men who have sex men (MSM) is scarce in India. This study examines the association between mobility and sexual risk behaviour and HIV infection among MSM in southern India.

Methods: Data are drawn from a cross-sectional biobehavioural survey of 1 608 self-identified MSM from four districts of Andhra Pradesh in India, recruited through a probability-based sampling in 2009-2010. Logistic regression models were used to estimate odds ratios and 95% CIs for sexual risk behaviours (unprotected sex with any male partner) and HIV infection based on the mobility status (travelled and had sex in the past year) after adjusting for sociodemographics and risk behaviours.

Results: Of the 1 608 MSM, one-fourth (26%) were mobile. Of these, three-fourths had travelled across districts but within the state (56%), and one-fifth (20%) across states. As compared to non-mobile MSM, a higher proportion of MSM who were mobile across districts (adjusted (OR=1.42, 95% CI 1.04 to 1.95) or states (adjusted OR=3.20, 95% CI 1.65 to 6.17) reported having unprotected sex with any male sexual partner. Further, mobility across districts (adjusted OR=1.43, 95% CI 1.01 to 2.03) or states (adjusted OR=2.45, 95% CI 1.46 to 4.10) was significantly associated with HIV infection.

Conclusions: Mobile MSM have a higher likelihood of contracting HIV. Interventions extending the ways to reach out to MSM with greater mobility may augment ongoing efforts to reduce the spread of HIV/AIDS in India.

Abstract   Full-text [free] access 

Editor’s notes: Men who have sex with men are a key group for HIV prevention in India and many other settings. In India, MSM are a socially marginalised group, and people who tend to travel geographically are likely to have relatively little contact with prevention services. This study attempted to better understand the degree and pattern of mobility for this vulnerable group, in order to guide future programmes. The data, from a large cross-sectional survey in Andhra Pradesh, showed a high degree of mobility. It also showed that mobility was significantly associated with higher risk sexual behaviour and with HIV prevalence. The study highlights the need to renew efforts to focus prevention services on the hard-to-reach population of mobile men who have sex with men.

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Community-level behavioural programme increases access to HIV testing and counselling

NIMH Project Accept (HPTN 043): results from in-depth interviews with a longitudinal cohort of community members.

Maman S, van Rooyen H, Stankard P, Chingono A, Muravha T, Ntogwisangu J, Phakathi Z, Srirak N, F Morin S; NIMH Project Accept (HPTN 043) study team. PLoS One. 2014 Jan 29;9(1):e87091. doi: 10.1371/journal.pone.0087091. eCollection 2014.

Introduction: NIMH Project Accept (HPTN 043) is a community- randomized trial to test the safety and efficacy of a community-level intervention designed to increase testing and lower HIV incidence in Tanzania, Zimbabwe, South Africa and Thailand. The evaluation design included a longitudinal study with community members to assess attitudinal and behavioral changes in study outcomes including HIV testing norms, HIV-related discussions, and HIV-related stigma.

Methods: A cohort of 657 individuals across all sites was selected to participate in a qualitative study that involved 4 interviews during the study period. Baseline and 30-month data were summarized according to each outcome, and a qualitative assessment of changes was made at the community level over time.

Results: Members from intervention communities described fewer barriers and greater motivation for testing than those from comparison communities. HIV-related discussions in intervention communities were more grounded in personal testing experiences. A change in HIV-related stigma over time was most pronounced in Tanzania and Zimbabwe. Participants in the intervention communities from these two sites attributed community-level changes in attitudes to project specific activities.

Discussion: The Project Accept intervention was associated with more favorable social norms regarding HIV testing, more personal content in HIV discussions in all study sites, and qualitative changes in HIV-related stigma in two of five sites.

Abstract Full-text [free] access 

Editor’s notes: This paper describes a qualitative evaluation of the impact of NIMH Project Accept. The programme sought to determine the safety and efficacy of a community level behavioural intervention in reducing HIV incidence. The programme included: 1) increasing community knowledge about HIV; 2) increasing access to voluntary testing and counselling; and 3) providing post-test support services. Programme communities had higher rates of testing and improved social norms regarding HIV, than comparison communities. There was no impact on HIV-related stigma. The qualitative research collected in this evaluation describes how the quantitative changes found in the main trial happened. This paper highlights the importance of using a mixed methods approach when studying multi-level activities at the community level.  The study determined that programme community participants had fewer barriers and stronger motivation for testing than comparison communities. The qualitative analysis provided a narrative for how the programmes affected the communities. There were more favourable community norms regarding HIV testing in the programme communities. The primary goal of Project Accept was that HIV-related stigma would be reduced but there was little quantitative evidence to support this hypothesis in the study. Qualitative evidence did show some reduction in stigmatizing language over time across all study sites. No meaningful patterns of change in sexual risk behaviour were found across the programme and comparison communities. 

Africa, Asia
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Female sex workers in Iran require urgent support to combat HIV, other sexually transmitted infections, and drug use

The prevalence of human immunodeficiency virus and sexually transmitted infections among female sex workers in Shiraz, South of Iran: by respondent-driven sampling

Kazerooni PA, Motazedian N, Motamedifar M, Sayadi M, Sabet M, Lari MA, Kamali K. Int J STD AIDS. 2014 Feb;25(2):155-61. doi: 10.1177/0956462413496227. Epub 2013 Jul 19.

As a concentrated epidemic, human immunodeficiency virus (HIV) is spreading rapidly in one or more groups in Iran, but in the general population its prevalence is relatively low. Female sex workers (FSWs) and their partners are at greater risk for HIV infection. To determine the prevalence of HIV and sexually transmitted infections (STIs) including gonorrhoea, chlamydia, herpes simplex type 2 and syphilis among FSWs. We conducted a cross-sectional study of 278 FSWs in Shiraz, by using respondent-driven sampling, from June to March 2010. The recruitment chain started with 14 seeds, and FSWs were tested for HIV, syphilis, herpes simplex type 2, gonorrhoea and chlamydia. HIV prevalence was 4.7% (13/278); the most prevalent STI was herpes simplex type 2, 9.7% (27/278), followed by chlamydia 9% (25/278), gonorrhoea 1.4% (4/278) and syphilis (0/278). The FSWs reported drug use (69.9%) of which 16.4% had history of injecting drug use. Unprotected sex in the past month was reported by 24.4% of FSWs. Urgent education and risk reduction programmes are needed in this population.

Abstract access 

Editor’s notes: This paper describes the first cross-sectional study on HIV prevalence in female sex workers (FSWs) in Shiraz city in Iran. This city has some of the highest rates of HIV, sexually transmitted infections (STIs), and drug use in the country. The study was conducted using respondent driven sampling. Despite a fairly aggressive seeding strategy and a relatively long timeline, the study population was 278. The sample is reported to have reached equilibrium at this number; however it is unclear whether the seeds reflected the diversity of the population. FSWs are considered a hidden population in Iran, which could make it difficult to fully comprehend the depth of diversity within this group. Cultural, religious, and legal contexts in Iran make it difficult to reach populations such as FSWs, with health services and education. This can account for the growth in rates of HIV and other STIs in this population, and in Iran more generally. Overall, cases in HIV are estimated to rise in the country from 89 000 in 2009 to 106 000 in 2014. The HIV prevalence in this study was measured at 4.7%, with high rates of drug abuse at 69.9%. As expected, drug use was highly correlated with HIV prevalence. HSV-2 and gonorrhoea were the most prevalent STIs. FSWs reported fairly low rates of condom use overall, and as in other populations of FSWs, higher rates were seen with clients than with regular partners. Additionally, low rates of condom use were reported, especially for anal and oral sex. This important study sheds light on an otherwise hidden population and highlights the need for education and outreach of health services tailored to this population. 

Iran (Islamic Republic of)
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HIV positive women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men

Gender disparities in HIV treatment outcomes following release from jail: results from a multicenter study.

Meyer JP, Zelenev A, Wickersham JA, Williams CT, Teixeira PA, Altice FL. Am J Public Health 2014 Mar;104(3):434-41. doi: 10.2105/AJPH.2013.301553. Epub 2014 Jan 16.

Objectives: We assessed gender differences in longitudinal HIV treatment outcomes among HIV-infected jail detainees transitioning to the community.

Methods. Data were from the largest multisite prospective cohort study of HIV-infected released jail detainees (n = 1 270) the Enhancing Linkages to HIV Primary Care and Services in Jail Setting Initiative, January 2008 and March 2011, which had 10 sites in 9 states. We assessed baseline and 6-month HIV treatment outcomes, stratifying by gender.

Results: Of 867 evaluable participants, 277 (31.9%) were women. Compared with men, women were more likely to be younger, non-Hispanic White, married, homeless, and depressed, but were similar in recent alcohol and heroin use. By 6 months postrelease, women were significantly less likely than men to experience optimal HIV treatment outcomes, including (1) retention in care (50% vs 63%), (2) antiretroviral therapy prescription (39% vs 58%) or optimal antiretroviral therapy adherence (28% vs 44%), and (3) viral suppression (18% vs 30%). In multiple logistic regression models, women were half as likely as men to achieve viral suppression.

Conclusions: HIV-infected women transitioning from jail experience greater comorbidity and worse HIV treatment outcomes than men. Future interventions that transition people from jail to community-based HIV clinical care should be gender-specific.

Abstract  Full-text [free] access

Editor’s notes: In the United States of America, the HIV epidemic is highly concentrated among populations who interact with the criminal justice system. Similarly, attrition from HIV care is markedly higher among people living with HIV who interact with the criminal justice system. This attrition is for complex reasons, with this population being disproportionately comprised of those with socio-economic instability, psychiatric disorders, and substance use disorders. This study assessed whether there are gender differences in the longitudinal HIV treatment outcomes among HIV-positive jail detainees transitioning to the community. The study found that among 867 people living with HIV released from jail, women were less likely than men to engage in every point along an HIV treatment cascade. It was also found that women were half as likely as men to achieve viral load suppression (VLS) at six months, even after controlling for substance use, psychiatric disorders, and utilization of linkage support services. The findings are in contrast to evidence from community settings, where if anything, women tend to fare better than men in engagement along the HIV treatment cascade. The authors highlight the need for a more gender sensitive service provision that recognizes the increased prevalence of comorbid conditions, including depression, substance use, housing instability and homelessness among women.

Northern America
United States of America
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Intervention efforts needed to improve mental health status of young female sex workers in China

Age group differences in HIV risk and mental health problems among female sex workers in Southwest China.

Su S, Li X, Zhang L, Lin D, Zhang C, Zhou Y. AIDS Care 2014 Jan 13. [Epub ahead of print]

HIV risk and mental health problems are prevalent among female sex workers (FSWs) in China. The purpose of this research was to study age group differences in HIV risk and mental health problems in this population. In the current study, we divided a sample of 1 022 FSWs into three age groups (≤ 20 years, 21-34 years, and ≥ 35 years). Results showed that among the three groups (1) older FSWs (≥ 35 years) were likely to be socioeconomically disadvantaged (e.g., rural residency, little education, employment in low-paying venues, and low monthly income); (2) older FSWs reported the highest rates of inconsistent, ineffective condom use, and sexually transmitted diseases history; (3) younger FSWs (≤ 20 years) reported the highest level of depression, suicidal thoughts and suicide attempts, regular-partner violence, and substance use; (4) all health-related risks except casual-partner violence were more prevalent among older and younger FSWs than among FSWs aged 21-34 years; and (5) age had a significant effect on all health indicators except suicide attempts after controlling for several key demographic factors. These findings indicate the need for intervention efforts to address varying needs among FSWs in different age groups. Specific interventional efforts are needed to reduce older FSWs' exposure to HIV risk; meanwhile, more attention should be given to improve FSWs' mental health status, especially among younger FSWs.

Abstract access 

Editor’s notes: Previous research has shown that there are significant HIV risks persisting in the female sex worker (FSW) populations in China, including very low condom use, low HIV testing rates, and high rates of sexually transmitted infections. As with sex work populations in other parts of the world, research has also revealed high rates of substance use, depression, and violence among FSWs. In this study, conducted in two cities in south-western China, the research aimed to examine more closely the relationship between age, HIV risk, and mental health issues. The findings in this study reveal the older women (>35 years) tended towards more risky behaviour while the younger women (<20 years) expressed more issues around mental health. On first sight, this seems to contradict previous research; however, logically it makes sense that these two groups would tend towards more risky behaviour in order to gain and retain clients. The study has several implications for HIV and mental health interventions among FSWs in China. These include the need to provide knowledge, skills and counselling to improve coping strategies among FSWs, as well as extending health service coverage to women in sex work. 

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Time-space sampling can identify high-risk marginalised populations

Sampling methodologies for epidemiologic surveillance of men who have sex with men and transgender women in Latin America: an empiric comparison of convenience sampling, time space sampling, and respondent driven sampling

Clark JL, Konda KA, Silva-Santisteban A, Peinado J, Lama JR, Kusunoki L, Perez-Brumer A, Pun M, Cabello R, Sebastian JL, Suarez-Ognio L, Sanchez J. AIDS Behav. 2013 Dec 21. [Epub ahead of print]

Alternatives to convenience sampling (CS) are needed for HIV/STI surveillance of most-at-risk populations in Latin America. We compared CS, time space sampling (TSS), and respondent driven sampling (RDS) for recruitment of men who have sex with men (MSM) and transgender women (TW) in Lima, Peru. During concurrent 60-day periods from June-August, 2011, we recruited MSM/TW for epidemiologic surveillance using CS, TSS, and RDS. A total of 748 participants were recruited through CS, 233 through TSS, and 127 through RDS. The TSS sample included the largest proportion of TW (30.7 %) and the lowest percentage of subjects who had previously participated in HIV/STI research (14.9 %). The prevalence of newly diagnosed HIV infection, according to participants' self-reported previous HIV diagnosis, was highest among TSS recruits (17.9 %) compared with RDS (12.6 %) and CS (10.2 %). TSS identified diverse populations of MSM/TW with higher prevalences of HIV/STIs not accessed by other methods.

Abstract access 

Editor’s notes: This paper provides empirical data comparing three different strategies of epidemiological surveillance for men who have sex with men (MSM) and transgender women (TW) in Peru. All three samples identified a diverse sample of MSM/TW, with the time space sampling (TSS) method identifying the most diverse population with highest prevalence of HIV/STI. TSS is a location-based method that includes a preliminary ethnographic mapping process and randomly samples venue/date/time units which include a minimum number of potential participants. In this study, respondent driven sampling (RDS) performed less well, possibly due to the characteristics of seed participants, and geographical factors (urban sprawl), and a small number of recruitment waves. In contrast, TSS identified a large number of participants from previously undersampled populations – including the highest proportion of participants with undiagnosed HIV infection. It would be useful to conduct similar comparative studies in other settings.

Latin America
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