Behavioral interventions to reduce the transmission of HIV infection among sex workers and their clients in low- and middle-income countries

Impact of COVID-19 on human immunodeficiency virus tests, new diagnoses, and healthcare visits in the Republic of Korea: a retrospective study from 2016 to 2021

BACKGROUND

Public health workers have been at the forefront of treating patients with coronavirus disease 2019 (COVID-19) and managing the pandemic. The redeployment of this workforce has limited or interrupted other public health services, including testing for human immunodeficiency virus (HIV). This study aims to examine the impact of COVID-19 on HIV testing and diagnosis in the Republic of Korea from 2016 to 2021, comparing data before and after the onset of COVID-19.

METHODS

Annual HIV testing data were collected from each institution through direct communication or from open-source databases. The annual number of new HIV cases was obtained from the official report of the Korea Disease Control and Prevention Agency. Data on healthcare visits for HIV diagnosis or treatment were extracted from the open-source database of the National Insurance Health Service of Korea. Interrupted time series regression was conducted, stratified by institution type.

RESULTS

In 2020, HIV tests, diagnoses, and visits decreased. Notably, public health centers experienced a substantial reduction in 2020-2021 compared to previous years. The annual percentage change in HIV tests was -53.0%, while for HIV diagnoses, it was -31.6%. The decrease in visits for HIV was also most pronounced for public facilities: -33.3% in 2020 and -45.6% in 2021 relative to 2019.

CONCLUSION

The numbers of tests, diagnoses, and healthcare visits for HIV at public health centers in the Republic of Korea substantially decreased in 2020 and 2021. The impacts of these changes on the early diagnosis and treatment of HIV necessitate further monitoring.

Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review

BACKGROUND

Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups.

AIM

To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations.

METHODS

A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively.

RESULTS

A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations.

CONCLUSION

Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.

Examining HIV Knowledge and Sexually Risky Behaviors among Female Sex Workers in Kampala, Uganda

HIV incidence remains alarmingly high among female sex workers (FSWs) in Uganda, necessitating targeted interventions. This study aimed to identify individual and provider-level barriers and facilitators to primary HIV prevention among FSWs in an urban setting. Focus groups involving FSWs and healthcare providers (HCPs) were conducted to inform the development of tailored prevention interventions. Results revealed that all participants had mobile phones, recent sexual activity, and a history of HIV testing, with high rates of sexually transmitted infections and varying HIV test results. FSWs displayed a well-informed awareness of HIV transmission risks, emphasizing the threat for those not testing positive. They unanimously recognized the crucial role of HIV testing in informing, mitigating risks, promoting ART use, and endorsing consistent condom usage. Despite heightened awareness, HCPs noted potential underestimation of vulnerability. Various challenges, including inadequate condom usage, substance abuse, and client dynamics, underscored the complexity of safeguarding against HIV transmission among FSWs. Widespread alcohol and drug use, including marijuana, kuber, and khat, served as coping mechanisms and social facilitators. Some FSWs successfully reduced alcohol intake, highlighting challenges in addressing substance use. FSWs preferred group discussions in health education programs, emphasizing peer interactions and the effectiveness of visual aids in HIV prevention education. This study provides comprehensive insights to guide the development of targeted interventions addressing the multi-faceted challenges FSWs face in HIV prevention.

Quantitative Methods Used to Evaluate Impact of Combination HIV Prevention Intervention: A Methodological Systematic Review

Combination HIV prevention aims to provide the right mix of biomedical, behavioral and structural interventions, and is considered the best approach to curb the HIV pandemic. The impact evaluation of combined HIV prevention intervention (CHPI) provides critical information for decision making. We conducted a systematic review of the literature to map the designs and methods used in these studies. We searched original articles indexed in Web of Science, Scopus and PubMed. Fifty-eight studies assessing the impact of CHPI on HIV transmission were included. Most of the studies took place in Asia or sub-Saharan Africa and were published from 2000 onward. We identified 36 (62.1%) quasi-experimental studies (posttest, pretest-posttest and nonequivalent group designs) and 22 (37.9%) experimental studies (randomized designs). The findings suggest that diverse methods are already rooted in CHPI impact evaluation practices as recommended but should be better reported. CHPI impact evaluation would benefit from more comprehensive approaches.

Modelling the impact of HIV and HCV prevention and treatment interventions for people who inject drugs in Dar es Salaam, Tanzania

Introduction

People who inject drugs (PWID) in Dar es Salaam, Tanzania, have a high prevalence of HIV and hepatitis C virus (HCV). While needle and syringe programmes (NSP), opioid agonist therapy (OAT) and anti‐retroviral therapy (ART) are available in Tanzania, their coverage is sub‐optimal. We assess the impact of existing and scaled up harm reduction (HR) interventions on HIV and HCV transmission among PWID in Dar es Salaam.

Methods

An HIV and HCV transmission model among PWID in Tanzania was calibrated to data over 2006–2018 on HIV (∼30% and ∼67% prevalence in males and females in 2011) and HCV prevalence (∼16% in 2017), numbers on HR interventions (5254 ever on OAT in 2018, 766–1479 accessing NSP in 2017) and ART coverage (63.1% in 2015). We evaluated the impact of existing interventions in 2019 and impact by 2030 of scaling‐up the coverage of OAT (to 50% of PWID), NSP (75%, both combined termed “full HR”) and ART (81% with 90% virally suppressed) from 2019, reducing sexual HIV transmission by 50%, and/or HCV‐treating 10% of PWID infected with HCV annually.

Results

The model projects HIV and HCV prevalence of 19.0% (95% credibility interval: 16.4–21.2%) and 41.0% (24.4–49.0%) in 2019, respectively. For HIV, 24.6% (13.6–32.6%) and 70.3% (59.3–77.1%) of incident infections among male and female PWID are sexually transmitted, respectively. Due to their low coverage (22.8% for OAT, 16.3% for NSP in 2019), OAT and NSP averted 20.4% (12.9–24.7%) of HIV infections and 21.7% (17.0–25.2%) of HCV infections in 2019. Existing ART (68.5% coverage by 2019) averted 48.1% (29.7–64.3%) of HIV infections in 2019. Scaling up to full HR will reduce HIV and HCV incidence by 62.6% (52.5–74.0%) and 81.4% (56.7–81.4%), respectively, over 2019–2030; scaled up ART alongside full HR will decrease HIV incidence by 66.8% (55.6–77.5%), increasing to 81.5% (73.7–87.5%) when sexual risk is also reduced. HCV‐treatment alongside full HR will decrease HCV incidence by 92.4% (80.7–95.8%) by 2030.

Conclusions

Combination interventions, including sexual risk reduction and HCV treatment, are needed to eliminate HCV and HIV among PWID in Tanzania.

Web-Based Multifaceted Approach for Community-Based HIV Self-Testing Among Female Sex Workers in Indonesia: Protocol for a Randomized Community Trial

BACKGROUND

New HIV infections in Indonesia continue to be concentrated among key populations, including female sex workers (FSWs). However, increasing HIV testing among this subpopulation remains a challenge, necessitating exploration into alternative testing modalities.

OBJECTIVE

This study aims to assess whether the addition of an oral fluid testing option in community settings would increase the rate of HIV case identification among FSWs. Because the study was implemented early in the outbreak of COVID-19 in Indonesia, a secondary objective is to assess approaches and tools for implementing both community outreach and community HIV screening for FSWs during pandemic conditions.

METHODS

We undertook a community-based randomized trial in 23 national priority districts in which community outreach services were being provided. Community-based screening using an oral fluid-based rapid test was added to the community outreach standard of care in intervention districts with clients having the option of performing the test themselves or being assisted by outreach workers. A web-based system was created to screen for eligibility and collect participant data and test results, facilitating the process for both unassisted and assisted participants. Participants with reactive screening results were encouraged to undergo HIV testing at a health facility to confirm their diagnosis and initiate antiretroviral treatment as needed. Multiple means of recruitment were deployed including through outreach workers and social media campaigns.

RESULTS

Of the 1907 FSWs who registered, met the eligibility criteria, and gave consent to participate, 1545 undertook community oral fluid test (OFT) screening. Most (1516/1545, 98.1%) opted for assisted screening. Recruitment via social media fell far short of expectations as many who registered independently for the OFT because of the social media campaign did not identify as FSWs. They were eventually not eligible to participate, but their interest points to the possibility of implementing HIV self-testing in the general population. The successful recruitment through outreach workers, facilitated by social media, indicates that their roles remain crucial in accessing FSW networks and improving HIV testing uptake.

CONCLUSIONS

The addition of HIV self-testing to the standard of care supported by a web-based data collection system was able to increase HIV case identification among FSWs in intervention districts. The high satisfaction of OFT users and the interest of the general population toward this alternative testing modality are promising for scaling up community HIV screening nationally.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04578145; https://clinicaltrials.gov/ct2/show/NCT04578145.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/27168.

Mujeres Unidas: Addressing Substance Use, Violence, and HIV Risk through Asset-Based Community Development for Women in the Sex Trade

This paper examines the prevalence of and potential for community mobilization (CM) and its association with HIV/STI risk, substance use, and violence victimization among women, particularly those using substances, in the sex trade in Tijuana, Mexico.

METHODS

195 women participated in Mujeres Unidas (K01DA036439 Urada) under a longitudinal survey study, "Proyecto Mapa de Salud" (R01DA028692, PI: Brouwer). Local health/social service providers (N = 16) were also interviewed.

RESULTS

39% of women who participated in community mobilization activities used substances. In adjusted analyses (n = 135), participation in CM activities (n = 26) was more likely among women who did not report substance use (AOR: 4.36, CI: 1.11-17.16), perceived a right to a life free from violence (AOR: 9.28, CI: 2.03-59.26), talked/worked with peers in the sex trade to change a situation (AOR: 7.87, CI: 2.03-30.57), witnessed violence where they worked (AOR: 4.45, CI: 1.24-15.96), and accessed free condoms (AOR: 1.54, CI: 1.01-2.35). Forty-five of the women using substances demonstrated their potential for engaging in asset-based community development (ABCD) with service providers in Mujeres Unidas meetings.

CONCLUSION

Women using substances, vs. those who did not, demonstrated their potential to engage in ABCD strategies. Women's empowerment, safety, and health could be enhanced by communities engaging in ABCD strategies that build and bridge social capital for marginalized women who otherwise have few exit and recovery options.

Incidence and time-varying predictors of HIV and sexually transmitted infections among male sex workers in Mexico City

Background

Male sex workers are at high-risk for acquisition of sexually transmitted infections (STIs), including human immunodeficiency virus (HIV). We quantified incidence rates of STIs and identified their time-varying predictors among male sex workers in Mexico City.

Methods

From January 2012 to May 2014, male sex workers recruited from the largest HIV clinic and community sites in Mexico City were tested for chlamydia, gonorrhea, syphilis, hepatitis, and HIV at baseline, 6-months, and 12-months. Incidence rates with 95% bootstrapped confidence limits were calculated. We examined potential time-varying predictors using generalized estimating equations for a population averaged model.

Results

Among 227 male sex workers, median age was 24 and baseline HIV prevalence was 32%. Incidence rates (per 100 person-years) were as follows: HIV [5.23; 95% confidence interval (CI): 2.15–10.31], chlamydia (5.15; 95% CI: 2.58–9.34), gonorrhea (3.93; 95% CI: 1.88–7.83), syphilis (13.04; 95% CI: 8.24–19.94), hepatitis B (2.11; 95% CI: 0.53–4.89), hepatitis C (0.95; 95% CI: 0.00–3.16), any STI except HIV (30.99; 95% CI: 21.73–40.26), and any STI including HIV (50.08; 95% CI: 37.60–62.55). In the multivariable-adjusted model, incident STI (excluding HIV) were lower among those who reported consistently using condoms during anal and vaginal intercourse (odds ratio = 0.03, 95% CI: 0.00–0.68) compared to those who reported inconsistently using condoms during anal and vaginal intercourse.

Conclusions

Incidence of STIs is high among male sex workers in Mexico City. Consistent condom use is an important protective factor for STIs, and should be an important component of interventions to prevent incident infections.

Systematic Review of Interventions to Reduce HIV Risk Among Men Who Purchase Sex in Low- and Middle-Income Countries: Outcomes, Lessons Learned, and Opportunities for Future Interventions

Along with other partners of key population groups, men who purchase sex (MWPS) contributed to around 18% of new reported HIV cases in 2018 among people aged 15-49 years worldwide. A systematic review was performed to evaluate interventions conducted to reduce HIV risk among MWPS in low- and middle-income countries (LMICs). A comprehensive search of studies published in Embase, Medline, Global Health, Scopus, and Cinahl was performed. Among 32,115 studies found, 21 studies met the review's inclusion criteria. Only four studies recruited MWPS, while the rest recruited groups often used as proxy populations for MWPS. The interventions were made primarily to increase HIV-related knowledge or perceptions through education and to improve condom usage rates through promotion and distribution. Few studies evaluated the impact of interventions on HIV testing rates and none looked at HIV treatment. Given the important role of testing as a prevention gate, together with UNAIDS' 90-90-90 testing and treatment coverage goals for people infected with HIV, more studies which evaluate the impact of HIV testing and treatment provision among this group are needed.

Factors associated to inconsistent condom use among sex workers

OBJECTIVE

to analyze the factors associated to the inconsistent condom use among sex workers.

METHOD

a transversal study, carried out in prostitution area, using the Respondent Drive Sampling. The sample was calculated based on the information by the Sex Workers Association: 600 female sex workers. The study selected seven women with different characteristics regarding color, age, and place of work, who were called seeds. After the participation, they received three coupons to recruit other participants in order to obtain a representative sample. The definition of inconsistent condom use was determined as occasional use or never using it. Univariate analyses and a multivariate logistic regression were performed.

RESULTS

416 female sex workers participated in the study. The associated factors were having studied for less than eight years (Odds Ratio = 27.28), not having a permanent partner (Odds Ratio = 2.79), high alcohol use (Odds Ratio = 5.07), and being black (Odds Ratio = 2.21).

CONCLUSION

the factors associated to inconsistent condom use were: lower education levels, not having a permanent partner, high alcohol use, and being black.

A community-based comprehensive intervention to reduce syphilis infection among low-fee female sex workers in China: a matched-pair, community-based randomized study

Background

Low-fee female sex workers (FSWs) are at high risk of acquiring and spreading human immunodeficiency virus (HIV)/sexually transmitted diseases (STDs) in China. There is an urgent need to develop comprehensive intervention measures targeted towards low-fee FSWs to reduce HIV/STD infections. Thus, this study aimed to reduce HIV/STD infections among low-fee FSW through a matched-pair, community-based randomized intervention trial carried out in 12 cities in three provinces in China.

Methods

Four cities from Guangxi Zhuang Autonomous Region, four from Yunnan Province, and four from Hunan Province were paired and participants received either the intervention package (including condom promotion, HIV and syphilis testing, reimbursement for syphilis treatment costs, and free anti-retroviral therapy or the current standard of care. Venue-based, convenience sampling was used to recruit FSWs. A face-to-face interview and HIV and syphilis blood testing was conducted at baseline and follow-up intervals of 24 months. Generalized linear mixed models (GLMM) were used to evaluate the effect of the intervention package on reducing HIV/STD infection in the FSWs.

Results

A total of 1024 eligible FSWs were enrolled in the baseline survey and 843 in the follow-up. GLMM results showed that syphilis infection was reduced by 49% in the intervention group compared to the current standard of care group (P = 0.0378, OR = 0.51, 95% CI: 0.27–0.96). FSWs aged 35 years or older were 2.38 times more likely to get syphilis infection compared to those younger than 35 years old (P <  0.0001, OR = 2.38, 95% CI: 1.55–3.65). The risk of syphilis infection among more educated FSWs was 0.43 times less than those with lower levels of education (P <  0.05, OR = 0.43, 95% CI: 0.63–0.93).

Conclusions

This study demonstrates that comprehensive interventions can lead to significant declines in syphilis infection amongst low-tier FSWs. Integrating both behavioral and biomedical intervention measures should be considered when developing programs for low-fee FSWs.

Trial registration

CHiCTR-TRC-12002655.

Strength-based interventions for HIV prevention and sexual risk reduction among girls and young women: A resilience-focused systematic review

Despite significant public health efforts, girls and young women still face gender-specific barriers to achieving optimal physical and mental health. Public health interventions have historically addressed the health needs of girls and young women using risk-focused, or deficit-based, approaches. Emerging research in public health and prevention provides an alternative approach, focusing instead on strengths and resilience. However, evidence remains limited regarding strength-based interventions to improve health outcomes for young women, including outcomes within the critically important areas of sexual and reproductive health. To address this gap in evidence, this review analyses the evidence base for intervention research using a strength-based resilience-focused approach to reduce HIV and sexual risk for girls and young women globally. A systematic search of published literature identified 35 articles, representing 25 unique interventions (N = 25). These interventions employed in-person, and other engaging methods, to deliver intervention content aimed at fostering resilience and changing sexual risk behaviours. Results also highlight gaps in measurement and study design, as well as variation in geographic setting and level of behaviour change. This review draws attention to the potential growth of strength-based intervention research, and offers future directions for developing and expanding research on resilience as an urgent global public health priority.

Effects of a computerized psychological inoculation intervention on condom use tendencies in sub Saharan and Caucasian students: two feasibility trials

Objective: An effective method for preventing the Human Immunodeficiency Virus (HIV) is condom use. Yet, research shows limited effects of education on increasing condom use. This research examined the effects of psychological inoculation (PI) versus education on condom use -barriers and -tendencies, using a fully automatized online system. Design: Two randomized controlled trials. In Study 1, 59 Sub-Saharan students were included while Study 2 20 European students were included. In both studies, participants were randomly assigned to PI or control conditions. In Study 2, we additionally matched pairs on gender and condom barriers. In the PI, participants received challenging sentences they had to refute. Main outcome measures: An indirect condom use test (I-CUTE) and a condom use barriers questionnaire, assessed at baseline and a month later. Results: In Study 1, a significant increase in I-CUTE scores and no change in barriers was found in the PI condition. Controls did not change on either outcome. In Study 2, two sub-scales of condom barriers (concerning partner and satisfaction) were significantly decreased in the PI group, while in controls, barriers significantly increased over time. In both groups, I-CUTE scores tended to increase. Conclusions: These results replicate previous studies and extend them to a fully automatized system without counselors.

Informing HIV Prevention Programs for Adolescent Girls and Young Women: A Modified Approach to Programmatic Mapping and Key Population Size Estimation

BACKGROUND

Standard programmatic mapping involves identifying locations where key populations meet, profiling of these locations (hotspots), and estimating the key population size. Information gained from this method has been used for HIV programming-resource allocation, program planning, service delivery, and monitoring and evaluation-for people who inject drugs, men who have sex with men, and female sex workers (FSWs). With an increasing focus on adolescent girls and young women (AGYW) as a priority population for HIV prevention, programs need to know the location of and how to effectively reach individuals who are at increased risk for HIV but were conventionally considered part of the general population. We hypothesize that AGYW who engage in transactional and casual sex also congregate at sex work hotspots to meet sex partners. Therefore, we adapted the standard programmatic mapping approach to understand the geographic distribution and population size of AGYW at increased HIV risk in Mombasa County, Kenya.

OBJECTIVES

The objectives are several-fold: (1) detail and compare the modified programmatic mapping approach used in this study to the standard approach, (2) estimate the number of young FSWs, (3) estimate the number of AGYW who congregate in sex work hotspots to meet sex partners other than clients, (4) estimate the overlap in sexual network in hotspots, (5) describe the distribution of sex work hotspots across Mombasa and its four subcounties, and (6) compare the distribution of hotspots that were known to the local HIV prevention program prior to this study and those newly identified.

METHODS

The standard programmatic mapping approach was modified to estimate the population of young women aged 14 to 24 years who visit sex work hotspots in Mombasa to meet partners for commercial, transactional, and casual sex.

RESULTS

We estimated that there were 11,777 FSWs (range 9265 to 14,290) in Mombasa in 2014 among whom 6127 (52.02%) were 14 to 24 years old. The population estimates for women aged 14 to 24 years who engaged in transactional and casual sex and congregated at the hotspots were 5348 (range 4185 to 6510) and 4160 (range 3194 to 5125), respectively. Of the 1025 validated sex work hotspots, 870 (84.88%) were locations also visited by women engaged in transactional and casual sex. Only 47 (4.58%) hotspots were exclusive sex work locations. The geographic and typological distribution of hotspots were significantly different between the four subcounties (P<.001). Of the 1025 hotspots, 419 (40.88%) were already known to the local HIV prevention program and 606 (59.12%) were newly identified.

CONCLUSIONS

Using the adapted programmatic mapping approach detailed in this study, our results show that HIV prevention programs tailored to AGYW can focus delivery of their interventions to sex work hotspots to reach subgroups that may be at increased risk for HIV.

HIV Testing and Counseling Among Female Sex Workers: A Systematic Literature Review

HIV testing uptake continues to be low among Female Sex Workers (FSWs). We synthesizes evidence on barriers and facilitators to HIV testing among FSW as well as frequencies of testing, willingness to test, and return rates to collect results. We systematically searched the MEDLINE/PubMed, EMBASE, SCOPUS databases for articles published in English between January 2000 and November 2017. Out of 5036 references screened, we retained 36 papers. The two barriers to HIV testing most commonly reported were financial and time costs—including low income, transportation costs, time constraints, and formal/informal payments—as well as the stigma and discrimination ascribed to HIV positive people and sex workers. Social support facilitated testing with consistently higher uptake amongst married FSWs and women who were encouraged to test by peers and managers. The consistent finding that social support facilitated HIV testing calls for its inclusion into current HIV testing strategies addressed at FSW.

Symptom-Based Versus Laboratory-Based Diagnosis of Five Sexually Transmitted Infections in Female Sex Workers in Iran

Among 1337 Iranian adult female sex workers in 2015, we assessed the diagnostic value of 4 self-reported sexually transmitted infection (STIs) symptoms for detecting laboratory-confirmed gonorrhea, chlamydia, trichomoniasis, human papillomavirus (HPV), and syphilis. While 37.7% reported vaginal discharge (VD), 25.9% reported pain or burning (P/B), 3.0% reported genital ulcers (GU), and 1.4% reported genital warts (GW), the prevalence of laboratory-confirmed syphilis, gonorrhea, chlamydia, trichomoniasis, and HPV was 0.4, 1.3, 6.0, 11.9, and 41.9%, respectively. The sensitivity of VD was 40.3% for detecting tricomoniasis, 37.5% for chlamydia, and 37.5% for gonorrhea. The sensitivity of P/B ranged from 12.5% for gonorrhea to 25.2% for trichomoniasis. The sensitivity of GU and GW was very low for 5 STIs. The sensitivity of all symptoms combined was also lower than 50%. Among asymptomatic participants, 41.2% tested positive for HPV, 11.8% for trichomoniasis, and less than 6.6% for other STIs. Symptom-based case management and surveillance of STIs can lead to misclassification of a large proportion of cases.

Development of risk reduction behavioral counseling for Ebola virus disease survivors enrolled in the Sierra Leone Ebola Virus Persistence Study, 2015-2016

Background

During the 2014–2016 West Africa Ebola Virus Disease (EVD) epidemic, the public health community had concerns that sexual transmission of the Ebola virus (EBOV) from EVD survivors was a risk, due to EBOV persistence in body fluids of EVD survivors, particularly semen. The Sierra Leone Ebola Virus Persistence Study was initiated to investigate this risk by assessing EBOV persistence in numerous body fluids of EVD survivors and providing risk reduction counseling based on test results for semen, vaginal fluid, menstrual blood, urine, rectal fluid, sweat, tears, saliva, and breast milk. This publication describes implementation of the counseling protocol and the key lessons learned.

Methodology/Principal findings

The Ebola Virus Persistence Risk Reduction Behavioral Counseling Protocol was developed from a framework used to prevent transmission of HIV and other sexually transmitted infections. The framework helped to identify barriers to risk reduction and facilitated the development of a personalized risk-reduction plan, particularly around condom use and abstinence. Pre-test and post-test counseling sessions included risk reduction guidance, and post-test counseling was based on the participants’ individual test results. The behavioral counseling protocol enabled study staff to translate the study’s body fluid test results into individualized information for study participants.

Conclusions/Significance

The Ebola Virus Persistence Risk Reduction Behavioral Counseling Protocol provided guidance to mitigate the risk of EBOV transmission from EVD survivors. It has since been shared with and adapted by other EVD survivor body fluid testing programs and studies in Ebola-affected countries.

The 2014–2016 West Africa Ebola Virus Disease (EVD) epidemic was large and widespread, affecting thousands of people across Guinea, Liberia, and Sierra Leone. Prior to this epidemic, there were limited data on persistence of Ebola virus in body fluids of EVD survivors and the potential risk that viral persistence may pose for Ebola virus transmission, including possible sexual transmission. This paper documents the development and implementation of a behavioral counseling protocol to facilitate adoption of risk reduction behaviors among male and female EVD survivors enrolled in the Sierra Leone Ebola Virus Persistence Study. This behavioral counseling protocol, composed of pre-test, delivery of results, and post-test counseling, enabled study staff to translate the study’s body fluid test results into individualized information and preventive action for study participants. Risk reduction behavioral counseling became an important EVD epidemic control measure.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Prevention Interventions Targeting Female Entertainment Workers: A Systematic Review and Meta-analysis

Female entertainment workers (FEWs) working in karaoke lounges, bars, pubs, nightclubs, discotheques, dance halls, massage parlours, restaurants (as hostesses or singers) and beer gardens are at high risk for human immunodeficiency virus (HIV)/sexually transmitted infection (STI). The aim of the systematic review and meta-analysis is to evaluate the efficacy of HIV/STI intervention programmes targeting FEWs. Among the 14 included studies, majority were in Asia and targeted native FEWs. Most studies were quasi-experimental and the overall quality was relatively low. While most studies employed only behavioural strategies, structural interventions were the least common. In studies with structural interventions, there was a preference for behavioural and biomedical-based outcome measurements rather than structural-related indicators. FEWs in the intervention group were significantly more likely to report condom use with paying (odds ratio OR 1.7; 95% CI 1.0-2.9, p 0.04), but not with regular (OR 1.0; 95% CI 0.8-1.3, p 0.84) partner than the control/comparison group post-intervention.

Buffering Syndemic Effects in a Sexual Risk-Reduction Intervention for Male Clients of Female Sex Workers: Results From a Randomized Controlled Trial

OBJECTIVES

We sought to test the efficacy of a sexual risk intervention for male clients of female sex workers (FSWs) and examine whether efficacy was moderated by syndemic risk.

METHODS

From 2010 to 2014, we conducted a 2-arm randomized controlled trial (60-minute, theory-based, safer sex intervention versus a didactic time-equivalent attention control) that included 400 male clients of FSWs on the US-Mexico border with follow-up at 4, 8, and 12 months. We measured 5 syndemic risk factors, including substance use and depression. Primary outcomes were sexually transmitted infections incidence and total unprotected sex with FSWs.

RESULTS

Although participants in both groups became safer, there was no significant difference in behavior change between groups. However, baseline syndemic risk moderated intervention efficacy. At baseline, there was a positive association between syndemic risk and unprotected sex. Then at 12 months, longitudinal analyses showed the association depended on intervention participation (B = -0.71; 95% confidence interval [CI] = -1.22, -0.20; P = .007). Among control participants there still existed this modest association (B = 0.36; 95% CI = -0.49, 1.22; P = .09); among intervention participants there was a significant negative association (B = -0.35; 95% CI = -0.63, -0.06; P = .02).

CONCLUSION

A brief intervention might attenuate syndemic risks among clients of FSWs. Other populations experiencing syndemic problems may also benefit from such programs.

Determinants of consistent condom use among female sex workers in Savannakhet, Lao PDR

Background

Female sex workers (FSWs) are a high-risk population for HIV. Correct and consistent use of condoms is the most effective measure for reducing transmission of HIV. Lao PDR is a low HIV-prevalence country, but FSWs have a relatively high HIV prevalence. To be able to make recommendations for condom promotion interventions in Lao PDR it is important to know more about the context specific situation. This study looked at reasons for and associated factors of consistent condom use among FSWs.

Methods

A cross-sectional survey among 258 FSWs in Kaysone Phomvihan district in Savannakhet province was performed.

Results

Almost all FSWs had enough condoms (94 %), condoms always available (100 %) and could always afford condoms (92 %). Consistent condom use was 97% with non-regular partners and 60% with regular partners. Almost all respondents (95 %) had received information about condoms from the drop-in centre. Stated reasons for consistent condom use were prevention of HIV (94 %), STIs (88 %) and pregnancy (87 %). Most reasons for inconsistent condom use were related to partners not wanting to use condoms because of reduced sexual pleasure. Some FSWs reported that they were physically abused and forced not to use condoms. Shorter time in sex work, higher education and FSW not having regular partners were significantly associated with consistent condom use.

Conclusions

Consistent condom use was very high with non-regular partners, but less frequent with regular partners. The main reason for inconsistent condom use was that the partner did not want to use a condom. Associated factors for consistent condom use were not having regular partners, higher education and shorter time in sex work. Condom promotion programs should include both FSWs and their partners and female condoms should be included in condom intervention efforts. Future studies should investigate the validity of self-reported sexual practices, partners’ reasons for inconsistent condom use, risk of violence in sex work and why shorter time in sex work is associated with consistent condom use.

HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs

There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection "Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers" highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.

Risk behaviours among female sex workers in China: a systematic review and data synthesis

BACKGROUND

Commercial sex is one of the major modes of HIV transmission in China. Understanding HIV risk behaviours in female sex workers (FSW) is of great importance for prevention. This study aims to assess the magnitude and temporal changes of risk behaviours in Chinese FSW.

METHOD

Five electronic databases were searched to identify peer-reviewed English and Chinese language articles published between January 2000 and December 2012 that reported risk behaviours among FSW in China, including condom use, HIV testing, and drug use. Linear regression and Spearman's rank correlation were used to examine temporal trends in these risk factors. The study followed PRISMA guidelines for meta-analyses and was registered in the PROSPERO database for systematic reviews.

RESULTS

A total of 583 articles (44 English, 539 Chinese) investigating 594,583 Chinese FSW were included in this review. At last sex, condom use was highest with commercial partners (clients), increasing from 53.7% in 2000 to 84.9% in 2011. During this same time period, condom use increased with regular partners from 15.2% to 40.4% and with unspecified partners from 38.6% to 82.5%. Increasing trends were also found in the proportion of sampled FSW who reported testing for HIV in the past 12 months (from 3.2% in 2000 to 48.0% in 2011), while drug use behaviours decreased significantly from 10.9% to 2.6%.

CONCLUSION

During the first decade of 2000, Chinese FSWs' self-reported risk behaviours have decreased significantly while HIV testing has increased. Further outreach and intervention efforts are needed to encourage condom use with regular partners, continue promotion of HIV testing, and provide resources for the most vulnerable FSW, particularly low tier FSW, who may have limited access to sexual health and prevention programs.

Prevalence of HIV, sexually transmitted infections, and risk behaviours among female sex workers in Nairobi, Kenya: results of a respondent driven sampling study

We conducted a respondent driven sampling survey to estimate HIV prevalence and risk behavior among female sex workers (FSWs) in Nairobi, Kenya. Women aged 18 years and older who reported selling sex to a man at least once in the past 3 months were eligible to participate. Consenting FSWs completed a behavioral questionnaire and were tested for HIV and sexually transmitted infections (STIs). Adjusted population-based prevalence and 95 % confidence intervals (CI) were estimated using RDS analysis tool. Factors significantly associated with HIV infection were assessed using log-binomial regression analysis. A total of 596 eligible participants were included in the analysis. Overall HIV prevalence was 29.5 % (95 % CI 24.7-34.9). Median age was 30 years (IQR 25-38 years); median duration of sex work was 12 years (IQR 8-17 years). The most frequent client-seeking venues were bars (76.6 %) and roadsides (29.3 %). The median number of clients per week was seven (IQR 4-18 clients). HIV testing was high with 86.6 % reported ever been tested for HIV and, of these, 63.1 % testing within the past 12 months. Of all women, 59.7 % perceived themselves at 'great risk' for HIV infection. Of HIV-positive women, 51.0 % were aware of their infection. In multivariable analysis, increasing age, inconsistent condom use with paying clients, and use of a male condom as a method of contraception were independently associated with unrecognized HIV infection. Prevalence among STIs was low, ranging from 0.9 % for syphilis, 1.1 % for gonorrhea, and 3.1 % for Chlamydia. The data suggest high prevalence of HIV among FSWs in Nairobi. Targeted and routine HIV and STI combination prevention strategies need to be scaled up or established to meet the needs of this population.

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes

Background

Many adults with type 1 diabetes cannot self-manage their diabetes effectively and die prematurely with diabetic complications as a result of poor glucose control. Following the positive results obtained from a randomised controlled trial (RCT) by the Dose Adjustment For Normal Eating (DAFNE) group, published in 2002, structured training is recommended for all adults with type 1 diabetes in the UK.

Aim

With evidence that blood glucose control is not always improved or sustained, we sought to determine factors explaining why some patients benefit from training more than other patients, identifying barriers to successful self-management, while developing other models to make skills training more accessible and effective.

Findings

We confirmed that glycaemic outcomes are not always improved or sustained when the DAFNE programme is delivered routinely, although improvements in psychosocial outcomes are maintained. DAFNE courses and follow-up support is needed to help participants instil and habituate key self-management practices such as regular diary/record keeping. DAFNE graduates need structured professional support following training. This is currently either unavailable or provided ad hoc without a supporting evidence base. Demographic and psychosocial characteristics had minimal explanatory power in predicting glycaemic control but good explanatory power in predicting diabetes-specific quality of life over the following year. We developed a DAFNE course delivered for 1 day per week over 5 weeks. There were no major differences in outcomes between this and a standard 1-week DAFNE course; in both arms of a RCT, glycaemic control improved by less than in the original DAFNE trial. We piloted a course delivering both the DAFNE programme and pump training. The pilot demonstrated the feasibility of a full multicentre RCT and resulted in us obtaining subsequent Health Technology Assessment programme funding. In collaboration with the National Institute for Health Research (NIHR) Diabetes Research Programme at King’s College Hospital (RG-PG-0606-1142), London, an intervention for patients with hypoglycaemic problems, DAFNE HART (Dose Adjustment for Normal Eating Hypoglycaemia Awareness Restoration Training), improved impaired hypoglycaemia awareness and is worthy of a formal trial. The health economic work developed a new type 1 diabetes model and confirmed that the DAFNE programme is cost-effective compared with no structured education; indeed, it is cost-saving in the majority of our analyses despite limited glycated haemoglobin benefit. Users made important contributions but this could have been maximised by involving them with grant writing, delaying training until the group was established and funding users’ time off work to maximise attendance. Collecting routine clinical data to conduct continuing evaluated roll-out is possible but to do this effectively requires additional administrator support and/or routine electronic data capture.

Conclusions

We propose that, in future work, we should modify the current DAFNE curricula to incorporate emerging understanding of behaviour change principles to instil and habituate key self-management behaviours that include key DAFNE competencies. An assessment of numeracy, critical for insulin dose adjustment, may help to determine whether or not additional input/support is required both before and after training. Models of structured support involving professionals should be developed and evaluated, incorporating technological interventions to help overcome the barriers identified above and enable participants to build effective self-management behaviours into their everyday lives.

Trial registration

ClinicalTrials.gov NCT01069393.

Funding

The NIHR Programme Grants for Applied Research programme.

An epidemiological study of Mycoplasma genitalium infections among males attending a sexually transmitted disease clinic in Guangxi, China

The objective of this study was to determine the prevalence of urethral Mycoplasma genitalium infections among male patients attending a sexually transmitted disease (STD) clinic in China and identify risk factors associated with this disease. A total of 423 patients were recruited in Hezhou City, Guangxi Province, China, and each was requested to complete a questionnaire regarding sociological and sexual behaviors. First-void urine samples were collected for M. genitalium analysis by polymerase chain reaction. Of the 406 urine samples collected, 114 were M. genitalium-positive, giving a prevalence rate of 28.1%. Univariate logistic regression analysis showed that M. genitalium infection was associated with younger age, having received at least senior high school education, and single marital status. In both univariate and multivariate logistic regression analyses, M. genitalium infection was found to be associated with lack of symptoms for STD in the past year (adjusted odds ratio [AOR] = 2.839; 95% CI = 1.495-5.392; P = 0.001), no use of condoms with steady partners in the past year (AOR = 2.830; 95% CI = 1.468-5.455; P = 0.002), and having sexual encounters with female sexual workers within the past 3 months (AOR = 2.955; 95% CI = 1.637-5.336; P < 0.0003). The observed high rate of M. genitalium infection among male STD patients in Hezhou City indicates an M. genitalium epidemic in the study population; thus, the national surveillance program and clinical health providers in China should more closely monitor this disease.

Effects of behavioral intervention content on HIV prevention outcomes: a meta-review of meta-analyses

OBJECTIVE

Numerous meta-analyses have examined the success of trials of interventions to reduce the behavioral risk of acquiring or transmitting HIV. Yet, to date, meta-reviews have not systematically examined which type of intervention content is more likely to lead to successful HIV outcomes. The current study addresses this gap.

METHODS

Published meta-analyses on HIV prevention (k = 56) were retrieved, then coded, and analyzed in terms of the intervention content.

RESULTS

Past meta-analyses have examined relatively few dimensions of intervention content. Larger meta-analyses were more likely to find that information content dimensions, especially skill provision and motivational enhancement, relate to risk reduction.

CONCLUSIONS

Fully incorporating behavior change technique (BCT) taxonomies into both intervention research and systematic reviews of this research offers considerable potential. It can improve the precision of conclusions about which specific types of content best promote HIV prevention behaviors and help to lower the cost of interventions. International efforts to improve reporting standards and generate the scholarly expertise necessary to discern BCTs reliably and validly help to address some of the challenges to including BCTs in study reports. Contextualizing research on effective strategies for HIV prevention by reporting and including in analyses community, social, and sample factors is also recommended. Together, such efforts can help refocus the field of HIV prevention on improved research strategies to further improve future interventions by discerning the content design factors related to success for particular populations, rather than merely to assess whether interventions have been successful.

Prevalence and correlates of HIV and sexually transmitted infections among female sex workers and their non-commercial male partners in two Mexico-USA border cities

Female sex workers (FSWs) acquire HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and non-commercial (intimate) male partners. Little research has focused on FSWs' intimate relationships, within which condom use is rare. We sought to determine the prevalence and correlates of HIV/STIs within FSWs' intimate relationships in Northern Mexico. From 2010 to 2011, we conducted a cross-sectional survey of FSWs and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico. Eligible FSWs and their verified male partners were aged ≥18 years; FSWs reported lifetime use of heroin, cocaine, crack, or methamphetamine and recently exchanged sex (past month). Participants completed baseline questionnaires and testing for HIV, chlamydia, gonorrhea, and syphilis. We determined the prevalence and correlates of individuals' HIV/STI positivity using bivariate probit regression. Among 212 couples (n = 424), prevalence of HIV was 2.6 % (n = 11). Forty-two (9.9 %) tested positive for any HIV/STIs, which was more prevalent among women than men (12.7 % vs. 7.1 %, p < 0.05). FSWs with regular sex work clients were less likely to test positive for HIV/STIs than those without regular clients. Similarly, male partners of FSWs who had regular clients were 9 % less likely to have HIV/STIs. Higher sexual decision-making power was protective against HIV/STIs for women. Men who recently used methamphetamine or reported perpetrating any conflict within steady relationships were more likely to test positive for HIV/STIs. Within FSWs' intimate relationships in two Mexican-US border cities, nearly one in ten partners tested positive for HIV/STIs. Couple-based prevention interventions should recognize how intimate relationship factors and social contexts influence HIV/STI vulnerability.

HIV infection: epidemiology, pathogenesis, treatment, and prevention

HIV prevalence is increasing worldwide because people on antiretroviral therapy are living longer, although new infections decreased from 3.3 million in 2002, to 2.3 million in 2012. Global AIDS-related deaths peaked at 2.3 million in 2005, and decreased to 1.6 million by 2012. An estimated 9.7 million people in low-income and middle-income countries had started antiretroviral therapy by 2012. New insights into the mechanisms of latent infection and the importance of reservoirs of infection might eventually lead to a cure. The role of immune activation in the pathogenesis of non-AIDS clinical events (major causes of morbidity and mortality in people on antiretroviral therapy) is receiving increased recognition. Breakthroughs in the prevention of HIV important to public health include male medical circumcision, antiretrovirals to prevent mother-to-child transmission, antiretroviral therapy in people with HIV to prevent transmission, and antiretrovirals for pre-exposure prophylaxis. Research into other prevention interventions, notably vaccines and vaginal microbicides, is in progress.

HIV behavioural interventions targeted towards older adults: a systematic review

Background

The increasing number of people living with HIV aged 50 years and older has been recognised around the world yet non-pharmacologic HIV behavioural and cognitive interventions specifically targeted to older adults are limited. Evidence is needed to guide the response to this affected group.

Methods

We conducted a systematic review of the available published literature in MEDLINE, Embase and the Education Resources Information Center. A search strategy was defined with high sensitivity but low specificity to identify behavioural interventions with outcomes in the areas of treatment adherence, HIV testing uptake, increased HIV knowledge and uptake of prevention measures. Data from relevant articles were extracted into excel.

Results

Twelve articles were identified all of which originated from the Americas. Eight of the interventions were conducted among older adults living with HIV and four for HIV-negative older adults. Five studies included control groups. Of the included studies, four focused on general knowledge of HIV, three emphasised mental health and coping, two focused on reduced sexual risk behaviour, two on physical status and one on referral for care. Only four of the studies were randomised controlled trials and seven – including all of the studies among HIV-negative older adults – did not include controls at all. A few of the studies conducted statistical testing on small samples of 16 or 11 older adults making inference based on the results difficult. The most relevant study demonstrated that using telephone-based interventions can reduce risky sexual behaviour among older adults with control reporting 3.24 times (95% CI 1.79-5.85) as many occasions of unprotected sex at follow-up as participants. Overall however, few of the articles are sufficiently rigorous to suggest broad replication or to be considered representative and applicable in other settings.

Conclusions

More evidence is needed on what interventions work among older adults to support prevention, adherence and testing. More methodological rigourised needed in the studies targeting older adults. Specifically, including control groups in all studies is needed as well as sufficient sample size to allow for statistical testing. Addition of specific bio-marker or validated behavioural or cognitive outcomes would also strengthen the studies.

Outcomes of a behavioral intervention to reduce HIV risk among drug-involved female sex workers

Although street-based female sex workers (FSWs) are highly vulnerable to HIV, they often lack access to needed health services and medical care. This paper reports the results of a recently completed randomized intervention trial for FSWs in Miami, Florida, which tested the relative efficacy of two case management interventions that aimed to link underserved FSWs with health services and to reduce risk behaviors for HIV. Participants were recruited using targeted sampling strategies and were randomly assigned to: a Strengths-Based/Professional Only (PO) or a Strengths-Based/Professional-Peer condition (PP). Follow-up data were collected 3 and 6 months post-baseline. Outcome analyses indicated that both intervention groups displayed significant reductions in HIV risk behaviors and significant increases in services utilization; the Professional-Peer condition provided no added benefit. HIV seropositive FSWs responded particularly well to the interventions, suggesting the utility of brief strengths-based case management interventions for this population in future initiatives.

The rise and fall of HIV in high-prevalence countries: a challenge for mathematical modeling

Several countries with generalized, high-prevalence HIV epidemics, mostly in sub-Saharan Africa, have experienced rapid declines in transmission. These HIV epidemics, often with rapid onsets, have generally been attributed to a combination of factors related to high-risk sexual behavior. The subsequent declines in these countries began prior to widespread therapy or implementation of any other major biomedical prevention. This change has been construed as evidence of behavior change, often on the basis of mathematical models, but direct evidence for behavior changes that would explain these declines is limited. Here, we look at the structure of current models and argue that the common “fixed risk per sexual contact" assumption favors the conclusion of substantial behavior changes. We argue that this assumption ignores reported non-linearities between exposure and risk. Taking this into account, we propose that some of the decline in HIV transmission may be part of the natural dynamics of the epidemic, and that several factors that have traditionally been ignored by modelers for lack of precise quantitative estimates may well hold the key to understanding epidemiologic trends.

Abriendo Puertas: baseline findings from an integrated intervention to promote prevention, treatment and care among FSW living with HIV in the Dominican Republic

Female sex workers (FSW) are often the focus of primary HIV prevention efforts. However, little attention has been paid to the prevention, treatment, and care needs of FSW living with HIV. Based on formative research, we developed an integrated model to promote prevention and care for FSW living with HIV in Santo Domingo, Dominican Republic, including (1) individual counseling and education; (2) peer navigation; (3) clinical provider training; and (4) community mobilization. We enrolled 268 FSW living with HIV into the intervention and conducted socio-behavioral surveys, sexually transmitted infection (STI) testing, and viral load (VL) assessments. We used multivariate logistic regression to identify behavioral and socio-demographic factors associated with detectable VL (>50 copies/mL) and STI prevalence. Over half of all participants (51.9%) had a detectable VL, even though most received HIV-related care in the last 6 months (85.1%) and were currently on anti-retroviral treatment (ART) (72.4%). Factors positively associated with a detectable VL included being 18-35 years of age (Adjusted Odds Ratio [AOR] 2.46, 95% CI 1.31-4.60), having ever used drugs (AOR 2.34, 95% CI 1.14-4.79), and having ever interrupted ART (AOR 3.09, 95% CI 1.44-6.59). Factors protective against having a detectable VL included being single (AOR 0.45, 95% 0.20-0.98) and being currently on ART (AOR 0.17, 95% CI 0.07-0.41). Nearly one-quarter (23.1%) had an STI, which was associated with being single (AOR 3.21, 95% CI 1.27-8.11) and using drugs in the last 6 months (AOR 3.54, 95% CI 1.32-9.45). Being on ART was protective against STI (AOR 0.51, 95% CI 0.26-1.00). Baseline findings indicate significant barriers to VL suppression and STI prevention among FSW living with HIV and highlight gaps in the continuum of HIV care and treatment. These findings have important implications for both the individual health of FSW and population-level HIV transmission dynamics.

Prevalence of HIV, syphilis, and HCV infection and associated risk factors among male clients of low-paying female sex workers in a rural county of Guangxi, China: a cross-sectional study

BACKGROUND

The purpose of this study was to examine prevalence of HIV, syphilis and hepatitis C virus (HCV) infection as well as related risk factors among a group of male clients of low-paying female sex workers (FSW) (eg, women who usually encounter their clients on the street or small establishments in rural or less developed areas, or who charge low fees for each sexual service) in a rural county of China.

METHOD

Cross-sectional study conducted in 2011 in a rural county of Guangxi in China. A total of 102 clients who reported information on demographics and HIV risks (eg, inconsistent condom use) and provided blood sample to test for HIV, HCV and syphilis were included in the data analysis. Both bivariate and multivariate analyses were employed to explore risk factors of HIV, HCV and syphilis infection.

RESULTS

Most of participants were of Han ethnicity with a mean age of 61.8 years. The majority of them lived in rural areas and worked as farmers with limited disposable cash incomes. The sample reported a high rate of unprotected sex with FSW in the last sex episode (83.7%) and inconsistent condom use in the last 6 months (95.9%). The overall prevalence of HIV, HCV and syphilis was 1.9%, 1.0% and 18.4%, respectively.

CONCLUSIONS

Findings suggest that male clients, especially the elderly ones, are at a high risk of HIV infection given prevalent unprotected sex and high prevalence of syphilis. Culturally-appropriate, age-specific interventions are urgently needed to curb the HIV/sexually transmitted infection epidemic among this at-risk population in China.

Willingness-to-accept reductions in HIV risks: conditional economic incentives in Mexico

The objective of this study was to measure willingness-to-accept (WTA) reductions in risks for HIV and other sexually transmitted infections (STI) using conditional economic incentives (CEI) among men who have sex with men (MSM), including male sex workers (MSW) in Mexico City. A survey experiment was conducted with 1,745 MSM and MSW (18-25 years of age) who received incentive offers to decide first whether to accept monthly prevention talks and STI testing; and then a second set of offers to accept to stay free of STIs (verified by quarterly biological testing). The survey used random-starting-point and iterative offers. WTA was estimated with a maximum likelihood double-bounded dichotomous choice model. The average acceptance probabilities were: 73.9 % for the monthly model, and 80.4 % for the quarterly model. The incentive-elasticity of participation in the monthly model was 0.222, and 0.515 in the quarterly model. For a combination program with monthly prevention talks, and staying free of curable STI, the implied WTA was USD$ 288 per person per year, but it was lower for MSW: USD$ 156 per person per year. Thus, some of the populations at highest risk of HIV infection (MSM and MSW) seem well disposed to participate in a CEI program for HIV and STI prevention in Mexico. The average WTA estimate is within the range of feasible allocations for prevention in the local context. Given the potential impact, Mexico, a leader in conditional cash transfers for human development and poverty reduction, could extend that successful model to targeted HIV/STI prevention.

Reduction in STIs in an empowerment intervention programme for female sex workers in Bangalore, India: the Pragati programme

Background/Objective

The Pragati programme is an on-going empowerment programme for female sex workers (FSWs) working and living in Bangalore, India. Pragati aims to reduce transmission of HIV and sexually transmitted infections (STIs) among FSWs. This study describes the STI incidence rate, contact rate, and condom use during follow-up years.

Design

Between April 2005 and November 2010, 20,330 FSWs participated in the programme. Outcome measures were programme exposure (number of contacts per person-year), STI incidence rate, and condom use. All analyses were stratified by year of follow-up. STIs were diagnosed by syndromic case management in either programme or referral clinics. We restricted our analyses to the period between April 2005 and July 2008 (when the majority of STIs were diagnosed in programme clinics), in order to minimise the possible influence of differences in STI diagnosis between clinic types.

Results

Results showed a significant increase of programme exposure (p-value for trend < 0.001) and a significant decrease in the STI incidence rate (p-value for trend < 0.001) over the follow-up time (between April 2005 and July 2008). Reported condom use at last paid sex increased from 77.6% in year 1 to 100% in year 4 of follow-up (p-value for trend < 0.001).

Conclusion

Our data seem to suggest that the Pragati programme had a positive effect on the STI incidence rate and condom use, possibly as a result of increased programme exposure. We recommend for future studies to invest more in the study design, type of data collection, and recording mechanisms before starting with an intervention. Incorporation of empowerment strategies as an approach in HIV prevention programmes can have a beneficial effect on the lives and livelihoods of FSWs.

Behavioral interventions for improving condom use for dual protection

BACKGROUND

Unprotected sex is a major risk factor for disease, disability, and mortality in many areas of the world due to the prevalence and incidence of sexually transmitted infections (STI) including HIV. The male condom is one of the oldest contraceptive methods and the earliest method for preventing the spread of HIV. When used correctly and consistently, condoms can provide dual protection, i.e., against both pregnancy and HIV/STI.

OBJECTIVES

We examined comparative studies of behavioral interventions for improving condom use. We were interested in identifying interventions associated with effective condom use as measured with biological assessments, which can provide objective evidence of protection.

SEARCH METHODS

Through September 2013, we searched computerized databases for comparative studies of behavioral interventions for improving condom use: MEDLINE, POPLINE, CENTRAL, EMBASE, LILACS, OpenGrey, COPAC, ClinicalTrials.gov, and ICTRP. We wrote to investigators for missing data.

SELECTION CRITERIA

Studies could be either randomized or nonrandomized. They examined a behavioral intervention for improving condom use. The comparison could be another behavioral intervention, usual care, or no intervention. The experimental intervention had an educational or counseling component to encourage or improve condom use. It addressed preventing pregnancy as well as the transmission of HIV/STI. The focus could be on male or female condoms and targeted to individuals, couples, or communities. Potential participants included heterosexual women and heterosexual men.Studies had to provide data from test results or records on a biological outcome: pregnancy, HIV/STI, or presence of semen as assessed with a biological marker, e.g., prostate-specific antigen. We did not include self-reported data on protected or unprotected sex, due to the limitations of recall and social desirability bias. Outcomes were measured at least three months after the behavioral intervention started.

DATA COLLECTION AND ANALYSIS

Two authors evaluated abstracts for eligibility and extracted data from included studies. For the dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model. Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. No meta-analysis was conducted due to differences in interventions and outcome measures.

MAIN RESULTS

Seven studies met our eligibility criteria. All were randomized controlled trials; six assigned clusters and one randomized individuals. Sample sizes for the cluster-randomized trials ranged from 2157 to 15,614; the number of clusters ranged from 18 to 70. Four trials took place in African countries, two in the USA, and one in England. Three were based mainly in schools, two were in community settings, one took place during military training, and one was clinic-based.Five studies provided data on pregnancy, either from pregnancy tests or national records of abortions and live births. Four trials assessed the incidence or prevalence of HIV and HSV-2. Three trials examined other STI. The trials showed or reported no significant difference between study groups for pregnancy or HIV, but favorable effects were evident for some STI. Two showed a lower incidence of HSV-2 for the behavioral-intervention group compared to the usual-care group, with reported adjusted rate ratios (ARR) of 0.65 (95% CI 0.43 to 0.97) and 0.67 (95% CI 0.47 to 0.97), while HIV did not differ significantly. One also reported lower syphilis incidence and gonorrhea prevalence for the behavioral intervention plus STI management compared to the usual-care group. The reported ARR were 0.58 (95% CI 0.35 to 0.96) and 0.28 (95% CI 0.11 to 0.70), respectively. Another study reported a negative effect on gonorrhea for young women in the intervention group versus the control group (ARR 1.93; 95% CI 1.01 to 3.71). The difference occurred among those with only one year of the intervention.

AUTHORS' CONCLUSIONS

We found few studies and little clinical evidence of effectiveness for interventions promoting condom use for dual protection. We did not find favorable results for pregnancy or HIV, and only found some for other STI. The overall quality of evidence was moderate to low; losses to follow up were high. Effective interventions for improving condom use are needed to prevent pregnancy and HIV/STI transmission. Interventions should be feasible for resource-limited settings and tested using valid and reliable outcome measures.

Combination prevention: new hope for stopping the epidemic

HIV research has identified approaches that can be combined to be more effective in transmission reduction than any 1 modality alone: delayed adolescent sexual debut, mutual monogamy or sexual partner reduction, correct and consistent condom use, pre-exposure prophylaxis with oral antiretroviral drugs or vaginal microbicides, voluntary medical male circumcision, antiretroviral therapy (ART) for prevention (including prevention of mother to child HIV transmission [PMTCT]), treatment of sexually transmitted infections, use of clean needles for all injections, blood screening prior to donation, a future HIV prime/boost vaccine, and the female condom. The extent to which evidence-based modalities can be combined to prevent substantial HIV transmission is largely unknown, but combination approaches that are truly implementable in field conditions are likely to be far more effective than single interventions alone. Analogous to PMTCT, "treatment as prevention" for adult-to-adult transmission reduction includes expanded HIV testing, linkage to care, antiretroviral coverage, retention in care, adherence to therapy, and management of key co-morbidities such as depression and substance use. With successful viral suppression, persons with HIV are far less infectious to others, as we see in the fields of sexually transmitted infection control and mycobacterial disease control (tuberculosis and leprosy). Combination approaches are complex, may involve high program costs, and require substantial global commitments. We present a rationale for such investments and cite an ongoing research agenda that seeks to determine how feasible and cost-effective a combination prevention approach would be in a variety of epidemic contexts, notably that in a sub-Saharan Africa.

Telephone delivered interventions for preventing HIV infection in HIV-negative persons

BACKGROUND

This is one of the three Cochrane reviews that examine the role of the telephone in HIV/AIDS services. Although HIV infection can be prevented, still a large number of new infections occur. More effective HIV prevention interventions are needed to reduce the number of people newly infected with HIV. Phone calls can be used to potentially more effectively deliver HIV prevention interventions. They have the potential to save time, reduce costs and facilitate easier access.

OBJECTIVES

To assess the effectiveness of voice landline and mobile telephone delivered HIV prevention interventions in HIV-negative persons.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed Central, EMBASE, PsycINFO, Web of Science, Cumulative Index to Nursing & Allied Health, the World Health Organization's Global Health Library and Current Controlled Trials from 1980 to June 2011. We searched the following grey literature sources: Dissertation Abstracts International and the Centre for Agricultural Bioscience International Direct Global Health database, the System for Information on Grey Literature Europe, The Healthcare Management Information Consortium, Google Scholar, Conference on Retroviruses and Opportunistic Infections database, International AIDS Society conference database, AIDS Education Global Information System and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs), quasi-randomised controlled trials, controlled before and after studies, and interrupted time series studies comparing the effectiveness of delivering HIV prevention by phone calls to usual care in HIV-negative people regardless of their demographic characteristics and in all settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched databases, screened citations, assessed study quality and extracted data. A third reviewer resolved any disagreement. Primary outcomes were knowledge about the causes and consequences of HIV/AIDS, change in behaviour, healthcare uptake and clinical outcomes. Secondary outcomes were users' and providers' views on the intervention, economic outcomes and adverse outcomes.

MAIN RESULTS

Out of 14,717 citations, only one study met the inclusion criteria. The included RCT recruited women and girl children who received post-exposure prophylaxis (PEP) after rape from sexual assault services in South Africa between August 2007 and May 2008.Participants (n (number) =274) were randomised into a telephone support (n=136) and control (n=138) group. Control group participants received usual care (an interactive information session) from the sexual assault service during the 28 days in which they had to take PEP, with no further contact from the study staff. Telephone support group participants received standard care and phone calls from a counsellor throughout the 28 days when they had to take PEP.Overall, adherence to PEP was not significantly (P=0.13) different between the intervention (38.2%) and control (31.9 %) groups. Also, the proportion of participants who read a pamphlet, did not return to collect medication or with a depression were not significantly different between the intervention and control groups (P=0.006, P=0.42, P=0.72 respectively). The proportion of participants who used a diary was significantly (P=0.001) higher in the intervention group (78.8%) versus the control group (69.9%). The study authors reported that there were no recorded adverse events. The RCT did not provide information about participants' and providers' evaluation outcomes, or economic outcomes. The study had a moderate risk of bias.

AUTHORS' CONCLUSIONS

We found only one RCT, with a moderate risk of bias, which showed that providing PEP support by phone calls did not result in higher adherence to PEP. However, the RCT was conducted in an upper-middle-income country with high HIV prevalence, on a high-risk population and the applicability of its results on other settings and contexts is unclear. There is a need for robust evidence from various settings on the effectiveness of using phone calls for providing PEP support and for other HIV prevention interventions.

HIV due to female sex work: regional and global estimates

INTRODUCTION

Female sex workers (FSWs) are at high risk of HIV infection. Our objective was to determine the proportion of HIV prevalence in the general female adult population that is attributable to the occupational exposure of female sex work, due to unprotected sexual intercourse.

METHODS

Population attributable fractions of HIV prevalence due to female sex work were estimated for 2011. A systematic search was conducted to retrieve required input data from available sources. Data gaps of HIV prevalence in FSWs for 2011 were filled using multilevel modeling and multivariate linear regression. The fraction of HIV attributable to female sex work was estimated as the excess HIV burden in FSWs deducting the HIV burden in FSWs due to injecting drug use.

RESULTS

An estimated fifteen percent of HIV in the general female adult population is attributable to (unsafe) female sex work. The region with the highest attributable fraction is Sub Saharan Africa, but the burden is also substantial for the Caribbean, Latin America and South and Southeast Asia. We estimate 106,000 deaths from HIV are a result of female sex work globally, 98,000 of which occur in Sub-Saharan Africa. If HIV prevalence in other population groups originating from sexual contact with FSWs had been considered, the overall attributable burden would probably be much larger.

DISCUSSION

Female sex work is an important contributor to HIV transmission and the global HIV burden. Effective HIV prevention measures exist and have been successfully targeted at key populations in many settings. These must be scaled up.

CONCLUSION

FSWs suffer from high HIV burden and are a crucial core population for HIV transmission. Surveillance, prevention and treatment of HIV in FSWs should benefit both this often neglected vulnerable group and the general population.

Social support and recovery among Mexican female sex workers who inject drugs

This qualitative study describes social support that female sex workers who inject drugs (FSW-IDUs) receive and recovery efforts in the context of relationships with family and intimate partners. We conducted thematic analysis of in-depth interviews with 47 FSW-IDUs enrolled in an intervention study to reduce injection/sexual risk behaviors in Tijuana, Mexico. FSW-IDUs received instrumental and emotional social support, which positively and negatively influenced recovery efforts. Participants reported how some intimate partners provided conflicting positive and negative support during recovery attempts. Problematic support (i.e., well-intended support with unintended consequences) occurred in strained family relationships, limiting the positive effects of support. Mexican drug treatment programs should consider addressing social support in recovery curricula through evidence-based interventions that engage intimate partners, children and family to better reflect socio-cultural and contextual determinants of substance abuse.

Enumeration of sex workers in the central business district of Nairobi, Kenya

Accurate program planning for populations most at risk for HIV/STI acquisition requires knowledge of the size and location where these populations can best be reached. To obtain this information for sex workers operating at 137 hotspots in the central business district (CBD) in Nairobi, Kenya, we utilized a combined mapping and capture-recapture enumeration exercise. The majority of identified hotspots in this study were bars. Based on this exercise, we estimate that 6,904 male and female sex workers (95% confidence intervals, 6690 and 7118) were working nightly in the Nairobi CBD in April 2009. Wide ranges of captures per spot were obtained, suggesting that relatively few hot spots (18%) contain a relatively high proportion of the area's sex workers (65%). We provide geographic data including relatively short distances from hotspots to our dedicated sex worker outreach program in the CBD (mean<1 km), and clustering of hotspots within a relatively small area. Given the size covered and areas where sex work is likely taking place in Nairobi, the estimate is several times lower than what would be obtained if the entire metropolitan area was enumerated. These results have important practical and policy implications for enhancing HIV/STI prevention efforts.

Pragati: an empowerment programme for female sex workers in Bangalore, India

Objectives

To describe the effects of a broad empowerment programme among female sex workers (FSWs) in Bangalore, India, which seeks to develop the capacities of these women to address the issues that threaten their lives and livelihoods.

Design

This study is based on a comprehensive, on-going HIV-prevention and empowering programme, known as Pragati, which reaches out to approximately 10,000–12,000 FSWs in Bangalore each year. The programme has been designed in collaboration with the sex worker community and provides a personalised set of services, which include STI prevention and treatment services, crisis-response facilities, de-addiction services, and microfinance support all of which have been tailored to adequately fulfil each woman's needs. During the period examined by this study, the programme reached out to 20,330 individual FSWs [median (IQR) age 28 (24–35) years]. The programme's personal records of the participating FSWs were used for this descriptive study.

Results

Between 2005 and 2010, the number of participating FSWs increased from 2,307 to 13,392. These women intensified their contact with the programme over time: the number of programme contacts increased from 10,351 in 2005 to 167,709 in 2010. Furthermore, data on the effects of crisis-response facilities, de-addiction and microfinance services, condom distribution schemes, and STI diagnosis and treatment showed an accumulating involvement of the participating FSWs in these programme services.

Conclusion

This programme, which focuses on social and economic empowerment among FSWs, is successful in reaching and involving the target population.