Articles tagged as "Kazakhstan"

Stigma and sex work

Editor’s notes: Two interesting studies this month looked at aspects of stigma.  There are big methodological challenges to the study of stigma.  Stigma comprises several different domains and few studies use standardized approaches to measurement that can be translated easily into other contexts.  A systematic review and meta-analysis concludes that people who feel more stigmatized are twice as likely to delay presenting for HIV care.  Gesesew HA and colleagues found only ten studies that met their pre-specified inclusion criteria, and five of these came from Ethiopia.  They acknowledge many of the challenges in combining the results of these ten studies into a single conclusion.  They recommend engagement of health care workers to try to reduce perceived stigma among people living with HIV.

The Nyblade L et al. study from Kenya emphasizes the perception of stigma among sex workers.  In a large sample of 497 females and 232 males, most reported experiencing stigma both verbal and measured from health care workers. For female sex workers, the anticipation of such stigma led to avoidance of health services for both HIV and non-HIV related conditions. In order to provide effective services for key populations, health care workers must be trained to be non-judgemental.  HIV services need to be provided in the context of an overall package of health care.

A study from Europe used ecological data to explore structural risks for HIV among sex workers.  Reeves A and colleagues used regression modelling with data on sex work policies from 27 countries.  They showed a strong correlation between criminalisation of sex work and higher prevalence of HIV among sex workers.  Although they included other factors such as the level of economic development and using drugs, the relatively small number of data points does mean that there may be other confounding factors that could not be measured or adjusted for.

Significant association between perceived HIV related stigma and late presentation for HIV/AIDS care in low and middle-income countries: A systematic review and meta-analysis.

Gesesew HA, Tesfay Gebremedhin A, Demissie TD, Kerie MW, Sudhakar M, Mwanri L. PLoS One. 2017 Mar 30;12(3):e0173928. doi: 10.1371/journal.pone.0173928.eCollection 2017.

Background: Late presentation for human immunodeficiency virus (HIV) care is a major impediment for the success of antiretroviral therapy (ART) outcomes. The role that stigma plays as a potential barrier to timely diagnosis and treatment of HIV among people living with HIV/AIDS (acquired immunodeficiency syndrome) is ambivalent. This review aimed to assess the best available evidence regarding the association between perceived HIV related stigma and time to present for HIV/AIDS care.

Methods: Quantitative studies conducted in English language between 2002 and 2016 that evaluated the association between HIV related stigma and late presentation for HIV care were sought across four major databases. This review considered studies that included the following outcome: 'late HIV testing', 'late HIV diagnosis' and 'late presentation for HIV care after testing'. Data were extracted using a standardized Joanna Briggs Institute (JBI) data extraction tool. Meta- analysis was undertaken using Revman-5 software. I2 and chi-square test were used to assess heterogeneity. Summary statistics were expressed as pooled odds ratio with 95% confidence intervals and corresponding p-value.

Results: Ten studies from low- and middle- income countries met the search criteria, including six (6) and four (4) case control studies and cross-sectional studies respectively. The total sample size in the included studies was 3788 participants. Half (5) of the studies reported a significant association between stigma and late presentation for HIV care. The meta-analytical association showed that people who perceived high HIV related stigma had two times more probability of late presentation for HIV care than who perceived low stigma (pooled odds ratio = 2.4; 95%CI: 1.6-3.6, I2 = 79%).

Conclusions: High perceptions of HIV related stigma influenced timely presentation for HIV care. In order to avoid late HIV care presentation due the fear of stigma among patients, health professionals should play a key role in informing and counselling patients on the benefits of early HIV testing or early entry to HIV care. Additionally, linking the systems and positive case tracing after HIV testing should be strengthened.

Abstract  Full-text [free] access

The relationship between health worker stigma and uptake of HIV counseling and testing and utilization of non-HIV health services: the experience of male and female sex workers in Kenya.

Nyblade L, Reddy A, Mbote D, Kraemer J, Stockton M, Kemunto C, Krotki K, Morla J, Njuguna S, Dutta A, Barker C. AIDS Care. 2017 Mar 22:1-9. doi: 10.1080/09540121.2017.1307922. [Epub ahead of print]

The barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.

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National sex work policy and HIV prevalence among sex workers: an ecological regression analysis of 27 European countries.

Reeves A, Steele S, Stuckler D, McKee M, Amato-Gauci A, Semenza JC. Lancet HIV. 2017 Mar;4(3):e134-e140. doi: 10.1016/S2352-3018(16)30217-X. Epub2017 Jan 25.

Background: Sex workers are disproportionately affected by HIV compared with the general population. Most studies of HIV risk among sex workers have focused on individual-level risk factors, with few studies assessing potential structural determinants of HIV risk. In this Article, we examine whether criminal laws around sex work are associated with HIV prevalence among female sex workers.

Method: We estimate cross-sectional, ecological regression models with data from 27 European countries on HIV prevalence among sex workers from the European Centre for Disease Control; sex-work legislation from the US State Department's Country Reports on Human Rights Practices and country-specific legal documents; the rule of law and gross-domestic product per capita, adjusted for purchasing power, from the World Bank; and the prevalence of injecting drug use among sex workers. Although data from two countries include male sex workers, the numbers are so small that the findings here essentially pertain to prevalence in female sex workers.

Findings: Countries that have legalised some aspects of sex work (n=17) have significantly lower HIV prevalence among sex workers than countries that criminalise all aspects of sex work (n=10; β=-2·09, 95% CI -0·80 to -3·37;p=0·003), even after controlling for the level of economic development (β=-1·86; p=0·038) and the proportion of sex workers who are injecting drug users (-1·93;p=0·026). We found that the relation between sex work policy and HIV among sex workers might be partly moderated by the effectiveness and fairness of enforcement, suggesting legalisation of some aspects of sex work could reduce HIV among sex workers to the greatest extent in countries where enforcement is fair and effective.

Interpretation: Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair.

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Pulling out: how to make it work for Kazakhstan

Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies.

Shattock AJ, Benedikt C, Bokazhanova A, Duric P, Petrenko I, Ganina L, Kelly SL, Stuart RM, Kerr CC, Vinichenko T, Zhang S, Hamelmann C, Manova M, Masaki E, Wilson DP, Gray RT. PLoS One. 2017 Feb 16;12(2):e0169530. doi: 10.1371/journal.pone.0169530. eCollection 2017.

Background: Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels.

Methodology: We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure-two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment.

Findings: Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%-39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%-58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%-27%] reduction in management costs, and allocating resources optimally.

Significance: With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.

Abstract  Full-text [free] access 

Editor’s notes: The HIV epidemic in Kazakhstan is concentrated around key populations (such as people who inject drugs, female sex workers and their partners, gay men and other men who have sex with men). Unlike in other settings, incidence has not decreased in recent years. However, as Kazakhstan continues to boom economically, international donors are expected to withdraw from the country in the near future and the responsibility for funding HIV-associated programmes will shift towards the state. This article attempts to explore how different kinds of efficiencies in the distribution of resources could strengthen the national HIV response in the coming years.  

The authors modelled future scenarios of the epidemic in Kazakhstan. They looked at whether and how the country could achieve certain targets by 2020 given its budgetary restrictions. They found that the country could achieve its national targets by either securing a 35% reduction in antiretroviral therapy or reducing management costs by 44%.

The topic this paper covers raises a number of important issues. As national governments move towards covering the totality of spending on HIV prevention and treatment, they will be confronted with the need to fund (using national tax revenues) prevention mechanisms. Their mechanisms are aimed at key populations who are often marginalized. Although funding these types of programmes through donor funding may have not caused political challenges, doing so using the state’s funding may. Government budget allocation is often a highly contentious exercise. Potential shifts in national priority setting following donor withdrawal should not be ignored.

Secondly, focussing on key populations is more costly than focussing on the general population. As prevention programmes cover people in key populations who are easier to reach, efforts should shift towards making prevention available to the harder-to-reach sections of key populations. However, this will further increase unit costs per person reached, and probably per infection averted. Given the decrease in external funding for Kazakhstan, it is important for the national response to budget for these additional costs.  This is a necessity to ensure equity in the access to the HIV response.

Asia
Kazakhstan
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Mobility, migration, and HIV: not always what you assume

The Silk Road health project: how mobility and migration status influence HIV risks among male migrant workers in central Asia. 

El-Bassel N, Gilbert L, Shaw SA, Mergenova G, Terlikbayeva A, Primbetova S, Ma X, Chang M, Ismayilova L, Hunt T, West B, Wu E, Beyrer C. PLoS One. 2016 Mar 11;11(3):e0151278. doi: 10.1371/journal.pone.0151278. eCollection 2016.

Objectives: We examined whether mobility, migrant status, and risk environments are associated with sexually transmitted infections (STIs) and HIV risk behaviors (e.g. sex trading, multiple partners, and unprotected sex).

Methods: We used Respondent Driven Sampling (RDS) to recruit external male migrant market vendors from Kyrgyzstan, Uzbekistan, and Tajikistan as well internal migrant and non-migrant market vendors from Kazakhstan. We conducted multivariate logistic regressions to examine the effects of mobility combined with the interaction between mobility and migration status on STIs and sexual risk behaviors, when controlling for risk environment characteristics.

Results: Mobility was associated with increased risk for biologically-confirmed STIs, sex trading, and unprotected sex among non-migrants, but not among internal or external migrants. Condom use rates were low among all three groups, particularly external migrants. Risk environment factors of low-income status, debt, homelessness, and limited access to medical care were associated with unprotected sex among external migrants.

Conclusion: Study findings underscore the role mobility and risk environments play in shaping HIV/STI risks. They highlight the need to consider mobility in the context of migration status and other risk environment factors in developing effective prevention strategies for this population.

Abstract  Full-text [free] access 

Editor’s notes: The 14 participants selected as seeds in this respondent driven sampling (RDS) strategy generated two large chains that made up 90% of the recruited study sample of 1324 male labour market workers at the Baraholka Market in Almaty, Kazakhstan. An estimated one million labour migrants enter Kazakhstan each year from neighbouring Central Asian countries that lack employment opportunities. However they face stigma, discrimination, police harassment, and lack of access to services. Finding out whether they are resilient to risk of exposure to HIV and other sexually transmitted infections (STIs) or are more likely to acquire HIV/STIs is key to designing effective HIV prevention strategies in a country that saw HIV incidence rise 25% between 2001 and 2009. This study looked at associations between HIV and STI risk and mobility – defined as having travelled outside Almaty in the last 90 days. The study was among three groups at the market: external migrants, internal migrants, and non-migrants. The analysis adjusted for both sociodemographic and-structural risk environment factors (legal status, income, debt, policing, homelessness, loneliness, social support, access to medical care, and alcohol use). Overall, 5.2% were positive for any STI. These included 2.1% of external migrants, 7.5% of internal migrants, and 8.8% of non-migrants. The authors hypothesise that mobility was not associated with increased STIs and a range of risk behaviours in external and internal migrants because these men travel primarily to visit their families and because they are goal-oriented and focused on fulfilling their roles as major wage earners for their families. These findings are in contrast to those of other studies that suggest that migrants are at higher HIV risk and challenge perceptions of migrants as a source of disease transmission within host countries. They underscore the importance of prevention strategies in unique venues such as markets, including peer-led prevention messaging, mobile clinics, and confidential HIV/STI testing. However, to address the factors that put migrants at risk for HIV, the authors argue for labour agreements, a legal registration process, and other measures to sustain their rights, prevent violence against migrants, and reduce marginalisation. 

Asia
Kazakhstan
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Violence experience of women living with HIV: a global study

Violence. Enough already: findings from a global participatory survey among women living with HIV.

Orza L, Bewley S, Chung C, Crone ET, Nagadya H, Vazquez M, Welbourn A. J Int AIDS Soc. 2015 Dec 1;18(6 Suppl 5):20285. doi: 10.7448/IAS.18.6.20285. eCollection 2015.

Introduction: Women living with HIV are vulnerable to gender-based violence (GBV) before and after diagnosis, in multiple settings. This study's aim was to explore how GBV is experienced by women living with HIV, how this affects women's sexual and reproductive health (SRH) and human rights (HR), and the implications for policymakers.

Methods: A community-based, participatory, user-led, mixed-methods study was conducted, with women living with HIV from key affected populations. Simple descriptive frequencies were used for quantitative data. Thematic coding of open qualitative responses was performed and validated with key respondents.

Results: In total, 945 women living with HIV from 94 countries participated in the study. Eighty-nine percent of 480 respondents to an optional section on GBV reported having experienced or feared violence, either before, since and/or because of their HIV diagnosis. GBV reporting was higher after HIV diagnosis (intimate partner, family/neighbours, community and health settings). Women described a complex and iterative relationship between GBV and HIV occurring throughout their lives, including breaches of confidentiality and lack of SRH choice in healthcare settings, forced/coerced treatments, HR abuses, moralistic and judgemental attitudes (including towards women from key populations), and fear of losing child custody. Respondents recommended healthcare practitioners and policymakers address stigma and discrimination, training, awareness-raising, and HR abuses in healthcare settings.

Conclusions: Respondents reported increased GBV with partners and in families, communities and healthcare settings after their HIV diagnosis and across the life-cycle. Measures of GBV must be sought and monitored, particularly within healthcare settings that should be safe. Respondents offered policymakers a comprehensive range of recommendations to achieve their SRH and HR goals. Global guidance documents and policies are more likely to succeed for the end-users if lived experiences are used.

Abstract  Full-text [free] access

Editor’s notes: Violence against women who are living with HIV is common globally. This paper reports on a study of 832 women living with HIV from 94 countries who participated in an online survey, recruited through a non-random snowball sampling model. The survey comprised quantitative and qualitative (free text) components. Participants included women who had ever or were currently using injection drugs (14%), who had ever or were currently selling sex (14%), and who had ever or were currently homeless (14%). Lifetime experience of violence among respondents was high (86%). Perpetrators included: intimate partner (59%), family member / neighbour (45%), community member (53%), health care workers (53%) and police, military, prison or detention services (17%). Findings suggest that violence is not a one off occurrence and cannot easily be packaged as a cause or a consequence of HIV. Instead violence occurs throughout women’s lives, takes multiple forms, and has a complex and iterative relationship with HIV.

The study population did not represent all women living with HIV, and was biased towards women with internet access who have an activist interest. Nonetheless, the study provides further evidence of the breadth and frequency of gender based violence experienced by women living with HIV. Key recommendations for policy makers include training of health care workers working in sexual and reproductive services to offer non-discriminatory services to women living with HIV and to effectively respond to disclosures of gender based violence (such as intimate partner violence) as part of the package of care.

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Expanding ART access: increasing costs

The HIV treatment gap: estimates of the financial resources needed versus available for scale-up of antiretroviral therapy in 97 countries from 2015 to 2020.

Dutta A, Barker C, Kallarakal A. PLoS Med. 2015 Nov 24;12(11):e1001907. doi: 10.1371/journal.pmed.1001907. eCollection 2015.

Background: The World Health Organization (WHO) released revised guidelines in 2015 recommending that all people living with HIV, regardless of CD4 count, initiate antiretroviral therapy (ART) upon diagnosis. However, few studies have projected the global resources needed for rapid scale-up of ART. Under the Health Policy Project, we conducted modeling analyses for 97 countries to estimate eligibility for and numbers on ART from 2015 to 2020, along with the facility-level financial resources required. We compared the estimated financial requirements to estimated funding available.

Methods and findings: Current coverage levels and future need for treatment were based on country-specific epidemiological and demographic data. Simulated annual numbers of individuals on treatment were derived from three scenarios: (1) continuation of countries' current policies of eligibility for ART, (2) universal adoption of aspects of the WHO 2013 eligibility guidelines, and (3) expanded eligibility as per the WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS "90-90-90" ART targets. We modeled uncertainty in the annual resource requirements for antiretroviral drugs, laboratory tests, and facility-level personnel and overhead.

We estimate that 25.7 (95% CI 25.5, 26.0) million adults and 1.57 (95% CI 1.55, 1.60) million children could receive ART by 2020 if countries maintain current eligibility plans and increase coverage based on historical rates, which may be ambitious. If countries uniformly adopt aspects of the WHO 2013 guidelines, 26.5 (95% CI 26.0 27.0) million adults and 1.53 (95% CI 1.52, 1.55) million children could be on ART by 2020. Under the 90-90-90 scenario, 30.4 (95% CI 30.1, 30.7) million adults and 1.68 (95% CI 1.63, 1.73) million children could receive treatment by 2020. The facility-level financial resources needed for scaling up ART in these countries from 2015 to 2020 are estimated to be US$45.8 (95% CI 45.4, 46.2) billion under the current scenario, US$48.7 (95% CI 47.8, 49.6) billion under the WHO 2013 scenario, and US$52.5 (95% CI 51.4, 53.6) billion under the 90-90-90 scenario. After projecting recent external and domestic funding trends, the estimated 6-y financing gap ranges from US$19.8 billion to US$25.0 billion, depending on the costing scenario and the U.S. President's Emergency Plan for AIDS Relief contribution level, with the gap for ART commodities alone ranging from US$14.0 to US$16.8 billion. The study is limited by excluding above-facility and other costs essential to ART service delivery and by the availability and quality of country- and region-specific data.

Conclusions: The projected number of people receiving ART across three scenarios suggests that countries are unlikely to meet the 90-90-90 treatment target (81% of people living with HIV on ART by 2020) unless they adopt a test-and-offer approach and increase ART coverage. Our results suggest that future resource needs for ART scale-up are smaller than stated elsewhere but still significantly threaten the sustainability of the global HIV response without additional resource mobilization from domestic or innovative financing sources or efficiency gains. As the world moves towards adopting the WHO 2015 guidelines, advances in technology, including the introduction of lower-cost, highly effective antiretroviral regimens, whose value are assessed here, may prove to be "game changers" that allow more people to be on ART with the resources available.

Abstract Full-text [free] access

Editor’s notes: This is a complex and important paper that seeks to understand the financial requirements necessary to: a) continue countries’ current policies of eligibility for ART, b) roll out universal adoption of certain aspects of WHO 2013 eligibility guidelines, and c) expand eligibility as per WHO 2015 guidelines and meeting the Joint United Nations Programme on HIV/AIDS ‘90-90-90’ targets.

The authors estimated the number of adults and children eligible for and receiving HIV treatment, as well as the cost of providing ART in 97 countries across six regions, covering different income levels. They estimated that 25.7 million adults and 1.57 million children could receive ART by 2020 if countries maintain the current eligibility strategies. If countries adopted WHO 2013 eligibility guidelines, 26.5 million adults and 1.53 million children would be on ART by 2020, and if they adopted the 90-90-90 scenario, 30.4 million adults and 1.68 million children could receive treatment by then. The financial resources necessary for this scale up are estimated to be US$ 45.8 billion under current eligibility, US$ 48.7 billion under WHO 2013 scenario and US$ 52.5 billion under the 90-90-90 scenario. The estimated funding gap for the six year period ranges between US$ 20 and US$ 25 billion. In this study, the costs of commodities were taken directly from data collated by other organisations.  No empirical cost estimates of service delivery were made.  Nor was there an attempt to understand the cost implications of the development synergies and social and programme enablers that may be needed to increase the number of people living with HIV knowing their status.  The new WHO recommendations need to be actively pursued if we are to meet targets, rather than passively continuing with “business as usual”. 

Nonetheless, the findings of this study highlight the gap between guidelines written by WHO and very real programmatic obstacles on the ground. There is evidence to suggest that universal test-and-treat strategies could lead to substantially improved health outcomes at the population level, as well as potentially being cost-saving in the long-term. However, as the authors have illustrated, it would require increased levels of funding. What needs to be explored further now is how to overcome the logistical hurdles of rolling out such an initiative. Changing systems and practices is costly and takes time. Health workers will have to be retrained, data collection strategies will have to be revised. Expanding treatment may also mean increasing the number of health staff working on this initiative, which has an opportunity cost that may reverberate in other parts of the health system. Substantially altering health service provision, particularly in weak health systems, may have knock-on effects with unexpected and unintended consequences.

WHO guidelines serve a vital purpose of giving us a goal to aim for. But studies like this one help us know if and how we can get there. 

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Female migrants may be more at risk of HIV in Kazakhstan

Migrant workers in Kazakhstan: gender differences in HIV knowledge and sexual risk behaviors.

Zhussupov B, McNutt LA, Gilbert L, Terlikbayeva A, El-Bassel N. AIDS Behav. 2015 Jul;19(7):1298-304. doi: 10.1007/s10461-014-0914-9. AIDS Behav. 2015 Jul;19(7):1298-304. doi: 10.1007/s10461-014-0914-9.

This study compares sexual risk behaviors among male and female migrant market vendors in Almaty, Kazakhstan. From the Barakholka Market, 209 male and 213 female market vendors were randomly recruited. Self-reported data were collected through standardized face-to-face interviews. Dry blood spot was used as specimen for syphilis testing. Propensity score stratification was used to estimate adjusted prevalence or rate ratios by gender. Compared to male migrant workers, females had lower HIV knowledge and were less likely to have multiple sexual partners. There was no evidence of a gender difference for prevalence of syphilis, condom use with unsteady partners, and safe sex communication between couples. Associations between mobility patterns and engagement in multiple sexual partnerships were stronger among women than men. Efforts should be made to mitigate the gender differential in HIV knowledge among migrants, especially women. Such efforts need to be implemented in both home and host countries.

Abstract  Full-text [free] access

Editor’s notes: Migration and mobility have been shown to be contributing factors to increased risk of HIV around the world. This is due to a number of factors, but most common are lack of social support, little or no access to services, and language and legal issues. Depending on socio-economic contexts, women and men will often leave their homes for periods of time to trade or work in agriculture or construction in other domestic or international locations. This paper examines the relationship between gender and sexual risk behaviours in Almaty, the financial capital of Kazakhstan. Kazakhstan, and Almaty in particular, is a hub for trade migrants from all over Central Asia. The paper notes the lack of accurate statistics for gender distribution among migrants, but estimates indicate ahigh proportion are women. Overall, the study found that the migrant population surveyed was more likely to have multiple sexual partners than the general population, although the data used as the general population comparison was somewhat dated. Women were less likely to be educated about HIV than men, and while also less likely to have multiple sexual partners than men, the partnerships they did have were closely linked to their mobility and the time spent at market. This study provides important insights into the HIV and sexual risk contexts in this region, and highlights the importance of continuing research there in order to inform HIV prevention and care programmes which can better support population needs. 

Asia
Kazakhstan
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Combination harm reduction may be more effective and cost-effective than partial approaches alone

The cost-effectiveness of harm reduction.

Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. Int J Drug Policy. 2015 Feb;26 Suppl 1:S5-11. doi: 10.1016/j.drugpo.2014.11.007. Epub 2014 Dec 1.

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

Abstract   Full-text [free] access

Editor’s notes: The spread of HIV among people who inject drugs has driven epidemics throughout regions of eastern Europe, and central and South-East Asia. In eastern Europe and central Asia, the majority of HIV infections have been attributed to injecting drug use. Some countries in the Middle East and North Africa region have also been experiencing rapidly emerging HIV epidemics among people who inject drugs. Harm reduction refers to methods of reducing health risks when eliminating them may not be possible. This paper provides a comprehensive review of evidence on the effectiveness and cost-effectiveness of different harm reduction approaches. These include needle- syringe programmes, opioid substitution therapy (OST), and antiretroviral therapy (ART), when implemented in different settings. Importantly, alongside considering the potential benefits of each approach separately, it makes the case that combination  prevention strategies are synergistic, and may achieve multiple impacts. Sadly still however, the coverage of harm reduction remains very low across the world. An estimated 90% of people who inject drugs worldwide are not accessing needle-syringe programmes, despite this being a highly effective and cost-effective programme. Along with the need for a greater investment in harm reduction, there are socio-political and legislative reasons for poor coverage of harm reduction. This cannot be improved without first addressing the stigma, discrimination and intolerance that restricts the expansion of harm reduction programmes in many settings. Addressing these barriers remains of paramount importance for facilitating effective harm reduction programmes. Encouragingly however, high OST coverage has been reported in Iran, Czech Republic and western Europe, and several countries in Asia and the Middle East have begun to scale-up their programmes. China has recently had the largest OST scale-up programme in the world. Uptake of ART by people living with HIV who inject drugs illustrates the largest disparities with what is required or deemed to be appropriate access. Only 14% of people living with HIV who inject drugs globally, have access to ART, with the largest gaps in ART provision in eastern Europe and central Asia. The further expansion of harm reduction is urgently needed, both to meet WHO targets, and to achieve the UNAIDS 90-90-90 target.

Asia, Europe, Oceania
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Increasing transmitted resistance to antiretroviral therapy in low/middle-income countries - highest prevalence in MSM

Global burden of transmitted HIV drug resistance and HIV-exposure categories: a systematic review and meta-analysis.

Pham QD, Wilson DP, Law MG, Kelleher AD, Zhang L. AIDS. 2014 Nov 28;28(18):2751-62. doi: 10.1097/QAD.0000000000000494.

Objectives: Our aim was to review the global disparities of transmitted HIV drug resistance (TDR) in antiretroviral-naive MSM, people who inject drugs (PWID) and heterosexual populations in both high-income and low/middle-income countries.

Design/methods: We undertook a systematic review of the peer-reviewed English literature on TDR (1999-2013). Random-effects meta-analyses were performed to pool TDR prevalence and compare the odds of TDR across at-risk groups.

Results: A total of 212 studies were included in this review. Areas with greatest TDR prevalence were North America (MSM: 13.7%, PWID: 9.1%, heterosexuals: 10.5%); followed by western Europe (MSM: 11.0%, PWID: 5.7%, heterosexuals: 6.9%) and South America (MSM: 8.3%, PWID: 13.5%, heterosexuals: 7.5%). Our data indicated disproportionately high TDR burdens in MSM in Oceania (Australia 15.5%), eastern Europe/central Asia (10.2%) and east Asia (7.8%). TDR epidemics have stabilized in high-income countries, with a higher prevalence (range 10.9-12.6%) in MSM than in PWID (5.2-8.3%) and heterosexuals (6.4-9.0%) over 1999-2013. In low/middle-income countries, TDR prevalence in all at-risk groups in 2009-2013 almost doubled than that in 2004-2008 (MSM: 7.8 vs. 4.2%, P = 0.011; heterosexuals: 4.1 vs. 2.6%, P < 0.001; PWID: 4.8 vs. 2.4%, P = 0.265, respectively). The risk of TDR infection was significantly greater in MSM than that in heterosexuals and PWID. We observed increasing trends of resistance to non-nucleoside reverse transcriptase and protease inhibitors among MSM.

Conclusion: TDR prevalence is stabilizing in high-income countries, but increasing in low/middle-income countries. This is likely due to the low, but increasing, coverage of antiretroviral therapy in these settings. Transmission of TDR is most prevalent among MSM worldwide.

Abstract access 

Editor’s notes: HIV mutates very rapidly, and many early antiretroviral agents had a low genetic barrier to the development of resistance. Thus the emergence of virus resistant to antiretroviral agents, particularly to early drug classes, was inevitable. Surveillance for drug-resistant virus among people with no prior history of taking antiretroviral drugs (transmitted drug resistance) is essential to monitor the spread of drug resistance at population level.

This systematic review aimed to compare transmitted drug resistance in different geographical regions and between subpopulations of HIV-positive people by likely route of transmission. Transmitted resistance was most prevalent in high income settings. This is not surprising given wide use of suboptimal drug regimens before effective triple therapy was available. Reassuringly, the prevalence of transmitted resistance seems to have stabilised in high-income settings. The increase in transmitted resistance in low and middle income countries is of more concern. It is not surprising, given that first-line regimens comprising two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor are vulnerable to the development of resistance if the drug supply is interrupted or adherence is suboptimal. In addition, if viral load monitoring is not available, people remain on failing drug regimens for longer, and thus have more risk of transmitting resistant virus.

Within the subpopulations examined in this review, transmitted resistance was consistently higher in men who have sex with men, suggesting that resistance testing prior to treatment is particularly valuable for this population.

Limitations of the review include exclusion of studies that did not compare transmitted resistance between the specified subpopulations, and small sample size in many subgroups.

Continued surveillance for transmitted drug resistance is critical. This is most important in settings where individualised resistance testing is not available. This will ensure that people starting antiretroviral therapy receive treatment that will suppress their viral load effectively. Wider use of viral load monitoring, combined with access to effective second and third line regimens, will also help limit spread of drug resistance.

HIV Treatment
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Counting and classifying global deaths

Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

Murray CJ, Ortblad KF, Guinovart C, et al. Lancet. 2014 Sep 13;384(9947):1005-70. doi: 10.1016/S0140-6736(14)60844-8. Epub 2014 Jul 22.

Background: The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occurred since the Millennium Declaration.

Methods: To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.

Findings: Globally in 2013, there were 1.8 million new HIV infections (95% uncertainty interval 1.7 million to 2.1 million), 29.2 million prevalent HIV cases (28.1 to 31.7), and 1.3 million HIV deaths (1.3 to 1.5). At the peak of the epidemic in 2005, HIV caused 1.7 million deaths (1.6 million to 1.9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19.1 million life-years (16.6 million to 21.5 million) have been saved, 70.3% (65.4 to 76.1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$ 4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7.5 million (7.4 million to 7.7 million), prevalence was 11.9 million (11.6 million to 12.2 million), and number of deaths was 1.4 million (1.3 million to 1.5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7.1 million (6.9 million to 7.3 million), prevalence was 11.2 million (10.8 million to 11.6 million), and number of deaths was 1.3 million (1.2 million to 1.4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64.0% of cases (63.6 to 64.3) and 64.7% of deaths (60.8 to 70.3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1.2 million deaths (1.1 million to 1.4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31.5% (15.7 to 44.1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.

Interpretation: Our estimates of the number of people living with HIV are 18.7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.

Abstract  Full-text [free] access

Editor’s notes: The Global Burden of Disease (GBD) study uses standard methods to compare and track over time national distributions of deaths by cause, and the prevalence of disease and disability.  This detailed report focuses on HIV, TB and Malaria. It presents regional summaries of incidence, prevalence and mortality rates, and national estimates of the number of male and female deaths and new infections. Point estimates are shown for 2013, and annualised rates of change for 1990-2000 and 2000-2013. These highlight the contrasting trends in disease impact before and after the formulation of the Millennium Development Goal to combat these diseases.  The global peak of HIV mortality occurred in 2005, but regional annualised rates of change for 2000-2013 indicate that HIV deaths are still increasing significantly in east Asia, southern Africa, and most rapidly in eastern Europe.

The GBD 2013 global estimates of new infections and deaths agree closely with the corresponding estimates made by UNAIDS. But there are significant differences in the respective estimates of the number of people currently living with HIV (UNAIDS estimates are some 18% higher), and historical trends in AIDS deaths, with UNAIDS judging that the recent fall has been steeper. These differences are attributed primarily to methods used in the GBD study to ensure that the sum of deaths from specific causes fits the estimated all cause total, and to varying assumptions about historical survival patterns following HIV infection. 

It may be worthwhile to look at a comment by Michel Sidibé, Mark Dybul, and Deborah Birx in the Lancet on MDG 6 and beyond: from halting and reversing AIDS to ending the epidemic which refers to this study.

Epidemiology
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Female sex work in Central Asia: a neglected population for research and intervention

HIV among female sex workers in the Central Asian Republics, Afghanistan, and Mongolia: contexts and convergence with drug use.

Baral S, Todd CS, Aumakhan B, Lloyd J, Delegchoimbol A, Sabin K. Drug Alcohol Depend. 2013 Nov;132 Suppl 1:S13-6. doi: 10.1016/j.drugalcdep.2013.07.004. Epub 2013 Aug 14.

Background: Central Asia is culturally and demographically diverse, both between and within its respective countries. That diversity is represented in the range of individual, network, community, and structural risks for female sex workers (FSWs) regionally. FSWs have several risk factors for HIV acquisition and transmission including behavioral, biological, and structural risk factors. Across Central Asia, sexual risks have become conflated with risks associated with injection and non-injection illicit drug use.

Methods: Peer-reviewed literature databases and gray literature were searched for articles on sex work in Central Asia. The medical subject heading (MeSH) of "sex work" was cross-referenced with terms associated with Uzbekistan, Tajikistan, Turkmenistan, Kazakhstan, Kyrgyzstan, Mongolia, and Afghanistan.

Results: HIV prevalence data for FSWs suggest sustained or increasing prevalence in the region. There are increasing data directly linking HIV among FSWs to injection drug use; odds of HIV are up to 20 times higher among FSWs reporting injecting drug use. Though injecting drug use among FSWs is rare in some settings, recreational drugs and alcohol use limits other risk reduction behaviors, such as condom use.

Conclusions: The Central Asian HIV epidemic has traditionally been assumed to be driven nearly exclusively by drug use, resulting in surveillance systems focused on parenteral transmission. The reviewed data highlight limited attention to characterizing the burden of HIV and risk factors for HIV acquisition and transmission among FSWs who use drugs. Moving forward will require enhanced HIV surveillance and research to inform HIV prevention approaches to address all levels of HIV risks affecting FSWs in Central Asia.

Abstract access 

Editor’s notes: This paper summarises available data on HIV prevalence among female sex workers in Central Asia. The many gaps in information are striking – with data on HIV prevalence being available for only three of the seven countries reviewed, data on HIV among injecting female sex workers (FSW) available from three countries, and data on HIV among non-injecting female sex workers being available from one country only. The most detailed data came from Kyrgyzstan, where, as would be expected, injecting female sex workers were at greatest risk of HIV, and also had very high levels of hepatitis C infection. The findings highlight the need to expand surveillance systems in the region. Doing so will lead to better geographical coverage, and also to obtain more routinely compiled information on the extent of sex work and the prevalence of HIV infection among injecting and non-injecting sex workers. The high risk of HIV and hepatitis C infection among injecting FSW highlight also the importance of programmes for sex workers who inject drugs.   

Asia
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