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Murray SM, Wiginton JM, Xue QL, Dibble K, Sanchez T, Kane JC, Augustinavicius J, Nowak RG, Crowell TA, Njindam IM, Tamoufe U, Charurat M, Turpin G, Sithole B, Mothopeng T, Nemande S, Simplice A, Kouanda S, Diouf D, Lyons C, Baral S. Measuring sexual behavior stigma among cisgender men who have sex with men: an assessment of cross-country measurement invariance. STIGMA AND HEALTH 2024; 9:349-361. [PMID: 39185350 PMCID: PMC11343079 DOI: 10.1037/sah0000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Objectives Globally, cisgender men who have sex with men experience sexual stigma, but limited investigation of cross-population scale performance hinder comparisons. As measurement invariance is a necessary but seldom-established criterion of valid cross-cultural comparisons, we assessed invariance in scales of stigma related to sexual behavior across 9 countries. Methods This secondary analysis used data collected from adult (mean age=29.6, standard deviation=12.5) cisgender men who have sex with men (n=8,669) in studies from 6 West African, 2 Southern African, and 1 North American country from 2012-2016. A common item set assessed 2 sexual behavior stigma domains. A sequential process was used to test the factor structure and measurement invariance, which included multigroup confirmatory factor analyses (CFA). Individual countries, items, living with HIV, and disclosure were explored as possible sources of noninvariance. Results Goodness-of-fit statistics indicated adequate fit of the same 2-factor model in 7 of the 9 countries. The chi2 difference test comparing a constrained and unconstrained 7-country model in which loadings and thresholds were freely estimated was significant (p<0.001), indicating metric and scalar noninvariance, but removing the US provided evidence of invariance and freeing certain items led to a finding of partial invariance. Sexuality disclosure exhibited a direct relationship with select stigma items in several countries. Conclusions Our findings point to the utility of the two stigma scale dimensions in making cross-country comparisons, but also to the necessity of assessing invariance with explicit attention to several factors including differential disclosure of sexuality across contexts to ensure valid comparisons.
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Affiliation(s)
- Sarah M. Murray
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - John Mark Wiginton
- School of Social Work, San Diego State University; Department of Medicine, University of California-San Diego, San Diego, CA, USA
| | - Qian Li Xue
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kate Dibble
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Travis Sanchez
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jeremy C. Kane
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Jura Augustinavicius
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca G. Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Trevor A. Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | | | | | - Man Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
- Center for International Health Education and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gnilane Turpin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
- Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | | | - Carrie Lyons
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Jessani A, Berry-Moreau T, Parmar R, Athanasakos A, Prodger JL, Mujugira A. Healthcare access and barriers to utilization among transgender and gender diverse people in Africa: a systematic review. BMC GLOBAL AND PUBLIC HEALTH 2024; 2:44. [PMID: 38948028 PMCID: PMC11208260 DOI: 10.1186/s44263-024-00073-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024]
Abstract
Background Transgender and gender diverse (TGD) people face significant challenges in accessing timely, culturally competent, and adequate healthcare due to structural and systemic barriers, yet there is a lack of research exploring the access and utilization of healthcare services within African TGD communities. To address this gap, this systematic review explored: (1) barriers to accessing healthcare services and gender-affirming hormone therapy (GAHT) faced by TGD people, (2) demographic and societal factors correlated with the utilization of healthcare services and GAHT, (3) common healthcare and support services utilized by TGD people, and (4) patterns of accessing healthcare services and GAHT within TGD communities. Methods A systematic literature search was conducted in PubMed, Embase, and Scopus in September 2023. Eligible studies included peer-reviewed original research, reports, and summaries published in the English language assessing health service accessibility and utilization of TGD people in Africa between January 2016 and December 2023. Results From 2072 potentially relevant articles, 159 were assessed for eligibility following duplicate removal, and 49 were included for analysis. Forty-five articles addressed barriers to accessing healthcare services and GAHT, seven focused on demographic and societal factors correlated with the utilization of healthcare services and GAHT, 16 covered common healthcare and support services utilized by TGD people, and seven examined patterns of accessing healthcare services and GAHT. Findings suggested a limited availability of health services, inadequate knowledge of TGD healthcare needs among healthcare providers, a lack of recognition of TGD people in healthcare settings, healthcare-related stigma, and financial constraints within African TGD communities. An absence of studies conducted in Northern and Central Africa was identified. Conclusions TGD people in Africa encounter significant barriers when seeking healthcare services, leading to disparity in the utilization of healthcare and resulting in a disproportionate burden of health risks. The implications of these barriers highlight the urgent need for more high-quality evidence to promote health equity for African TGD people. Trial registration PROSPERO CRD42024532405. Supplementary Information The online version contains supplementary material available at 10.1186/s44263-024-00073-2.
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Affiliation(s)
- Abbas Jessani
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Teagan Berry-Moreau
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Reeya Parmar
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Alexia Athanasakos
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Jessica L. Prodger
- Department of Dentistry, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON Canada
| | - Andrew Mujugira
- Department of Global Health, University of Washington, Seattle, WA USA
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Shamrock OW, Abu-Ba'are GR, Zigah EY, Dakpui HD, Adjaka G, LeBlanc NM, Alio AP, Nelson L. Community stigma, victimization, and coping strategies among gay, bisexual, and other cis-gender men who have sex with men in slum communities in Ghana. BSGH-003. BMC Public Health 2024; 24:966. [PMID: 38580970 PMCID: PMC10998418 DOI: 10.1186/s12889-024-18242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/01/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Gay, bisexual, and cis-gender men who have sex with men (GBMSM) face severe consequences, especially within stigmatized environments. However, very little is known about the experiences of GBMSM living in slums in SSA and Ghana. This study investigates the experiences of stigma, victimization, and coping strategies and proposes some interventional approaches for combating stigma facing GBMSM in slum communities. METHODS We engaged GBMSM living in slums in two major Ghanaian cities. We used a time-location sampling and collected data through in-depth individual interviews. Two major themes emerged from the study: (1) insecurities and criminalization of GBMSM activity, and (2) GBMSM coping strategies. RESULTS Findings show GBMSM experienced negative attitudes from the community due to their sexual behavior/orientation. GBMSM also developed coping strategies to avert negative experiences, such as hiding their identities/behavior, avoiding gender non-conforming men, and having relationships with persons outside their communities. CONCLUSION We propose interventions such as HIV Education, Empathy, Empowerment, Acceptance, and Commitment Therapy as possible measures to improve the experiences of GBMSM living in Ghanaian slum communities.
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Affiliation(s)
- Osman Wumpini Shamrock
- School of Nursing, University of Rochester, Rochester, USA
- Behavioral, Sexual and Gender Health Lab, Accra, Ghana
- Behavioral, Sexual and Gender Health Lab, University of Rochester, New Haven, Connecticut, USA
| | - Gamji Rabiu Abu-Ba'are
- School of Nursing, University of Rochester, Rochester, USA
- Behavioral, Sexual and Gender Health Lab, Accra, Ghana
- School of Public Health, University of Rochester, Rochester, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, Connecticut, USA
- Behavioral, Sexual and Gender Health Lab, University of Rochester, New Haven, Connecticut, USA
| | | | | | - Gideon Adjaka
- Hope Alliance Foundation, Non-profit Organization, Accra, Ghana
| | - Natalie M LeBlanc
- School of Nursing, University of Rochester, Rochester, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, Connecticut, USA
| | - Amina P Alio
- School of Public Health, University of Rochester, Rochester, USA
| | - LaRon Nelson
- School of Nursing, Yale University, West Haven, USA
- Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, Connecticut, USA
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Dada D, Abu-Ba'are GR, Turner D, Mashoud IW, Owusu-Dampare F, Apreku A, Ni Z, Djiadeu P, Aidoo-Frimpong G, Zigah EY, Nyhan K, Nyblade L, Nelson LE. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. BMJ Open 2024; 14:e078794. [PMID: 38346887 PMCID: PMC10862343 DOI: 10.1136/bmjopen-2023-078794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/09/2024] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations. DESIGN Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. DATA SOURCES Public health and regional databases were searched in 2020 and 2022. ELIGIBILITY CRITERIA Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA. DATA EXTRACTION AND SYNTHESIS Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed. RESULTS Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors. CONCLUSION Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.
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Affiliation(s)
- Debbie Dada
- School of Nursing, Yale University, New Haven, Connecticut, USA
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
| | - Gamji R Abu-Ba'are
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, USA
- Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, USA
| | | | | | | | | | - Zhao Ni
- School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Pascal Djiadeu
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
- School of Public Health, University of Toronto Dalla Lana, Toronto, Ontario, Canada
| | - Gloria Aidoo-Frimpong
- Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, USA
| | - Edem Yaw Zigah
- Behavioral, Sexual, and Global Health Lab, University of Rochester, Rochester, New York, USA
| | - Kate Nyhan
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut, USA
| | - Laura Nyblade
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
| | - LaRon E Nelson
- School of Nursing, Yale University, New Haven, Connecticut, USA
- St Michael's Hospital Centre for Urban Health Solutions, Toronto, Ontario, Canada
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Mwaniki SW, Kaberia PM, Mugo PM, Palanee-Phillips T. "What if I get sick, where shall I go?": a qualitative investigation of healthcare engagement among young gay and bisexual men in Nairobi, Kenya. BMC Public Health 2024; 24:52. [PMID: 38166989 PMCID: PMC10763282 DOI: 10.1186/s12889-023-17555-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/21/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Globally, young gay, bisexual and other men who have sex with men (YMSM) experience a disproportionate burden of disease compared to young heterosexual men and older MSM. However, YMSM experience major inequities in access and use of health services. We sought to gain a detailed understanding of YMSM's healthcare engagement experiences across public, private, tertiary institution-based and MSM-friendly health facilities in Nairobi, Kenya, to inform development of interventions to improve access and use of health services by YMSM. METHODS In September 2021, in-person qualitative in-depths interviews were conducted among 22 YMSM purposively sampled from 248 YMSM who had previously participated in a respondent-driven sampling integrated bio-behavioral survey. Interviews were done in English, transcribed verbatim and analyzed descriptively using NVivo version 12. RESULTS Participants were 18-24 years old, all identified as cisgender male, three-quarters as gay and a quarter as bisexual. Themes that were defined from the analysis included: YMSM's experiences during healthcare seeking in various clinical settings, priority health needs, desired healthcare provider (HCP) characteristics, and the potential role of digital health interventions in improving access and use of health services. Participants relayed experiences of prejudice, stigma and discrimination when seeking services in public and institution-based health facilities, unlike in community pharmacies, private and MSM-friendly health facilities where they felt they were handled with dignity. Health needs prioritized by YMSM centered on prevention and control of HIV, sexually transmitted infections (STIs), depression and substance abuse. Participants desired HCPs who were empathetic, non-judgmental and knowledgeable about their unique health needs such as management of anorectal STIs. Participants highlighted the usefulness of digital media in offering telehealth consultations and health education on subjects such as HIV/STIs prevention. CONCLUSION During engagement with healthcare, YMSM experience various barriers that may cause them to postpone or avoid seeking care hence resulting in poor health outcomes. There is need to equip HCPs with knowledge, skills and cultural competencies to enable them offer equitable services to YMSM. Considerations should also be made for use of digital health interventions that may help YMSM circumvent some of the aforementioned barriers to service access and use.
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Affiliation(s)
- Samuel Waweru Mwaniki
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Health Services, Administration and Campus Support Services, University of Nairobi, Nairobi, Kenya.
| | - Peter Mwenda Kaberia
- Department of Mathematics, Faculty of Science and Technology, University of Nairobi, Nairobi, Kenya
| | - Peter Mwangi Mugo
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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Iroezindu MO, Crowell TA, Ogoina D, Yinka-Ogunleye A. Human Mpox in People Living with HIV: Epidemiologic and Clinical Perspectives from Nigeria. AIDS Res Hum Retroviruses 2023; 39:593-600. [PMID: 37646422 DOI: 10.1089/aid.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
Sub-Saharan Africa (SSA) is disproportionately affected by mpox and HIV. We described epidemiologic trends and clinical experiences in the management of mpox in people living with HIV (PLWH) in Nigeria and further examined how the rapidly accumulating body of knowledge from the 2022 global mpox outbreak might be explored to improve mpox care in PLWH in SSA. During the 2017/2018 Nigerian mpox outbreak, we reported that 9/40 (22.5%) hospitalized mpox patients with known HIV status were PLWH. In the 2022 global mpox outbreak, 52% of confirmed mpox cases with known HIV status were PLWH, predominantly sexual and gender minority groups. However, substantial missing data on HIV status of confirmed mpox cases highlights a critical gap in HIV testing as a component of mpox management. Before 2022, sexual activity was not commonly linked to mpox transmission, but this was identified as a major driver of transmission during the 2022 mpox outbreak. Notable sexual history observed in Nigerian mpox patients in 2017/2018 suggests that the contribution of sexual activity in human-to-human mpox transmission might have been underappreciated for years. Our cohort of PLWH with mpox, predominantly individuals with advanced or uncontrolled HIV, were significantly more likely to experience severe mpox manifestations and prolonged disease compared with those without HIV. This contrasts with the generally less remarkable differences in mpox presentation between people with and without HIV in Western countries, an observation that can be at least partially explained by more stable HIV disease. The unavailability of mpox antiviral drugs and vaccines in SSA highlights global inequity in mpox response, which requires an urgent attention. As mpox countermeasures become available in SSA, lessons learned from their use in Western countries could provide important guidance for care providers in SSA. Public health measures to mitigate stigmatization in PLWH with mpox is also critical.
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Affiliation(s)
- Michael O Iroezindu
- Clinical Research Center, HJF Medical Research International, Abuja, Nigeria
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Dimie Ogoina
- Infectious Disease Unit, Niger Delta University Teaching Hospital, Okolobiri, Nigeria
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Mwaniki SW, Kaberia PM, Mugo PM, Palanee-Phillips T. "We must help them despite who they are…": healthcare providers' attitudes and perspectives on care for young gay, bisexual and other men who have sex with men in Nairobi, Kenya. BMC Health Serv Res 2023; 23:1055. [PMID: 37789339 PMCID: PMC10546658 DOI: 10.1186/s12913-023-10026-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 09/12/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Compared to young heterosexual men, young gay, bisexual and other men who have sex with men (YMSM) face a disproportionate burden of sexual health conditions. This disparity is occasioned by factors such as criminalization and stigmatization of same-sex practices, YMSM's limited access to non-judgmental and non-discriminatory health services, and challenges associated with healthcare delivery. We explored the attitudes and perspectives of tertiary academic institution-based healthcare providers (HCPs) toward provision of services to YMSM in Nairobi, Kenya. METHODS In September 2021, six in-person focus group discussions (FGDs) were held with 36 HCPs drawn from six public tertiary academic institutions within the Nairobi metropolis. HCPs were drawn from six cadres: front office staff, nurses, clinicians, counsellors, laboratory technologists, and pharmaceutical technologists. Discussions were conducted in English, transcribed verbatim and analyzed thematically using NVivo version 12. RESULTS Analysis showed that despite expressing disapproval of same-sex practices, HCPs recognized their professional duty to provide care to YMSM, voiced challenges they experienced when providing care to YMSM, and suggested possible strategies for improving care for YMSM. Disapproval of same-sex practices mainly stemmed from HCPs' personal values, societal norms and religious beliefs, though some HCPs identified religious principles such as the golden rule of "treating others as one would want to be treated" as motivation to providing care to YMSM. HCPs did not perceive criminalization of same-sex practices as a barrier to providing care to YMSM. Healthcare delivery challenges included inadequate knowledge and skills, a desire to "convert" YMSM's perceived deviant homosexual to the normative heterosexual orientation, secondary stigma from other HCPs, and healthcare settings that did not support YMSM to disclose same-sex practices. Suggestions for improving care comprised sensitization and training of HCPs, encouraging more HCP-YMSM interaction, providing YMSM-friendly and inclusive services, and advocacy for YMSM services. CONCLUSION There is need for interventions to improve HCPs' knowledge of YMSM's health needs, build skills to respond to these needs, and foster affirming attitudes toward same-sex practices. By so doing, YMSM can hopefully be able to access services that meet their needs, and are non-discriminatory, non-stigmatizing and non-judgmental.
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Affiliation(s)
- Samuel Waweru Mwaniki
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
- Department of Health Services, Administration and Campus Support Services, University of Nairobi, Nairobi, Kenya.
| | - Peter Mwenda Kaberia
- Department of Mathematics, Faculty of Science and Technology, University of Nairobi, Nairobi, Kenya
| | - Peter Mwangi Mugo
- Kenya Medical Research Institute - Wellcome Trust Research Programme, Nairobi, Kenya
| | - Thesla Palanee-Phillips
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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Folayan MO, Yakusik A, Enemo A, Sunday A, Muhammad A, Nyako HY, Abdullah RM, Okiwu H, Lamontagne E. Socioeconomic inequality, health inequity and well-being of transgender people during the COVID-19 pandemic in Nigeria. BMC Public Health 2023; 23:1539. [PMID: 37573293 PMCID: PMC10422710 DOI: 10.1186/s12889-023-16482-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 08/08/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND We aimed to explore socioeconomic inequality, health inequity, and the well-being of transgender people during the COVID-19 crisis in Nigeria. METHODS Between June and December 2021, a cross-sectional survey was conducted collaboratively with community-based organisations in Nigeria. Participants living with or at risk of HIV were recruited voluntarily, online and face-to-face, using a combination of venue-based and snowball sampling. We assessed the association between gender identity (transgender and vulnerable cisgender women), and (i) socioeconomic inequality measured with socioeconomic status, social status, economic vulnerability, macrosocial vulnerability; (ii) health inequity measured with self-assessment of health, recency of HIV test, access to HIV and sexual and reproductive health services, gender-affirming care, financial and non-financial barriers to accessing health services; and (iii) well-being, measured with gender-based violence, mental health, psychoeconomic preferences. We used multivariable logistic regressions and controlled for interactions and confounders. RESULTS There were 4072 participants; 62% were under 30, and 47% reported living with HIV. One in ten (11.9%; n = 485) was transgender, and 56.5% reported living with HIV. Compared to vulnerable cisgender women, the results showed significantly higher odds (aOR:3.80) of disruption in accessing HIV services in transgender participants; gender-based violence (aOR:2.63); severe (aOR:2.28) symptoms of anxiety and depression. Among the barriers to accessing health and HIV services, transgender had three-time higher odds of reporting additional non-official fees compared to vulnerable cisgender women. The disclosure of their gender identity or sexual orientation was the most important non-financial barrier to accessing health services (aOR:3.16). Transgender participants faced higher housing insecurity (aOR: 1.35) and lower odds of using drugs (aOR:0.48). Importantly, they are more likely to have performed a recent HIV test and less likely to not know their HIV status (aOR:0.38) compared to vulnerable cisgender women. CONCLUSIONS Socioeconomic inequality, health and well-being inequity in transgender people appear to be exacerbated by the COVID-19 pandemic in Nigeria. Interventions are necessary to mitigate socioeconomic challenges, address structural inequality, and ensure equitable access to health services to meet the Sustainable Development Goals for transgender people.
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Affiliation(s)
- Morenike Oluwatoyin Folayan
- Department of Child Dental Health, Obafemi Awolowo University, Ile-Ife, Nigeria.
- Nigeria Institute of Medical Research, Yaba, Lagos State, Nigeria.
| | - Anna Yakusik
- Joint United Nations Programme on HIV/AIDS, CH, Geneva, Switzerland
| | - Amaka Enemo
- Nigeria Sex Workers Association, Kubwa, Nigeria
| | - Aaron Sunday
- African Network of Adolescent and Young Persons Development, Barnawa, Nigeria
| | - Amira Muhammad
- Northern Nigerian Transgender Initiative, Abuja, Nigeria
| | | | | | | | - Erik Lamontagne
- Joint United Nations Programme on HIV/AIDS, CH, Geneva, Switzerland
- School of Economics, Aix-Marseille University, Marseille, France
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Kittle K, Boerner K, Kim K, Fredriksen-Goldsen K. The Role of Contextual Factors in the Health Care Utilization of Aging LGBT Adults. THE GERONTOLOGIST 2023; 63:741-750. [PMID: 36048185 PMCID: PMC10167762 DOI: 10.1093/geront/gnac137] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Research suggests lesbian, gay, bisexual, and transgender (LGBT) populations have unique health care challenges. The purpose of this study was to understand contextual factors, including minority stress and social resources, associated with the health care utilization of LGBT middle-aged and older adults. RESEARCH DESIGN AND METHODS Using data from the Caring and Aging With Pride: National Health, Aging, and Sexuality/Gender Study (N = 2,560), multiple logistic regression investigated associations between minority stress (i.e., internalized stigma and LGBT identity disclosure) and health care utilization (i.e., health screenings, emergency room use, routine checkups, and regular provider). We also examined the moderating effect of social resources (i.e., social network size, social support, and LGBT community belonging) in these associations. RESULTS Internalized stigma was negatively associated with having a routine checkup in the previous year. LGBT identity disclosure was positively associated with having a health screening within the past 3 years. Social support moderated the association between LGBT identity disclosure and health screenings. DISCUSSION AND IMPLICATIONS Health and human service professionals and their clients should be educated about the ways that LGBT identity disclosure can affect health care utilization. Providers should consistently assess the social support of their aging LGBT clients and inform them about the potential risk of low social support in health care utilization.
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Affiliation(s)
- Krystal R Kittle
- Department of Social and Behavioral Health Program, School of Public Health, University of Nevada, Las Vegas, Nevada, USA
| | - Kathrin Boerner
- Department of Gerontology, University of Massachusetts, Boston, Massachusetts, USA
| | - Kyungmin Kim
- Department of Child Development and Family Studies, Research Institute of Human Ecology, Seoul National University, Seoul, Republic of Korea
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Lyons CE, Twahirwa Rwema JO, Makofane K, Diouf D, Mfochive Njindam I, Ba I, Kouame A, Tamoufe U, Cham B, Aliu Djaló M, Obodou EP, Karita E, Simplice A, Nowak RG, Crowell TA, Matse S, Kouanda S, Enama JP, Kavanagh M, Millett GA, Beyrer C, Murray S, Baral S. Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey. Lancet HIV 2023; 10:e186-e194. [PMID: 36623537 PMCID: PMC10288909 DOI: 10.1016/s2352-3018(22)00336-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/27/2022] [Accepted: 11/08/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments. METHODS This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs. FINDINGS Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings. INTERPRETATION Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV. FUNDING National Institutes of Health. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Carrie E Lyons
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | | | - Keletso Makofane
- FXB Health and Human Rights, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Abo Kouame
- Ministère de la Santé et de l'Hygiène Publique, Abidjan, Côte d'Ivoire
| | - Ubald Tamoufe
- Johns Hopkins Cameroon Program/Metabiota, Yaoundé, Cameroon
| | | | | | | | | | | | - Rebecca G Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Trevor A Crowell
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA; US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Sindy Matse
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso; Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | | | - Matthew Kavanagh
- Department of International Health and Neill Institute for National and Global Health Law, Georgetown University, Washington, DC, USA
| | | | - Chris Beyrer
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA; Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Sarah Murray
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Adeyemi OA, Nowak RG, Marzinke M, Morgan D, Sam-Agudu N, Craddock J, Zhan M, Crowell TA, Baral S, Ndembi N, Adebajo S, Charurat ME. Correlates of self-reported and biomarker based adherence to daily oral HIV pre-exposure prophylaxis among a cohort of predominantly men who have sex with men in Nigeria. PLoS One 2023; 18:e0282999. [PMID: 36928630 PMCID: PMC10019705 DOI: 10.1371/journal.pone.0282999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/28/2023] [Indexed: 03/17/2023] Open
Abstract
INTRODUCTION HIV pre-exposure prophylaxis (PrEP) significantly reduces the risk of HIV acquisition. However, studies have demonstrated discordance between self-reported measures and biomedical benchmarks of PrEP adherence. We estimated the correlation between self-reported PrEP adherence and PrEP biomarkers and explored factors associated with adherence among men who have sex with men (MSM) in Nigeria. METHODS TRUST-PrEP, an open-label, prospective study; conducted in Abuja between April 2018 and May 2019. MSM ≥ 18 years with substantial HIV risk were enrolled. Participants reported PrEP adherence in the last month using a 4-point scale from "poor" to "perfect" and serum samples for PrEP biomarkers were collected at months 3 and 9. Serum tenofovir concentration was measured by liquid chromatography-tandem mass spectrometry and considered protective for adherence if ≥ 4.2 ng/ml. Spearman's rank correlation was used to estimate correlation between self-reported adherence and measured tenofovir levels. Generalized estimating equations with a logit link was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between self-reported adherence and laboratory-measured adherence. RESULTS A total of 219 MSM with median age 23 (interquartile range 20-27) years had at least one PrEP biomarker assay. Only 66/219 (30%) had at least one record of protective tenofovir concentration. Correlation between tenofovir and self-reported adherence at 3 and 9 months were 0.1 and 0.02 respectively. Furthermore, 17/219 (8%,) and 49/219 (22%) had serum tenofovir of 4.2-35.4 ng/mL and ≥ 35.5 ng/mL, corresponding to at least 4 and 7 days' PrEP use in a week, respectively. PrEP adherence was higher among participants introduced to PrEP in the clinics compared with communities (aOR: 8.35, 95%CI: [3.24, 21.5]) and those with same-sex practices family disclosure (aOR: 3.60 95% CI: [1.73, 7.51]). CONCLUSION Self-reported PrEP adherence poorly correlated with biomarkers. Facilitating clinic-based PrEP introduction and disclosure of same-sex practices to family among MSM may improve PrEP adherence.
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Affiliation(s)
- Olusegun A. Adeyemi
- Department of Public Health and Epidemiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- International Research Center of Excellence, Institute of Human Virology, Abuja, Nigeria
- * E-mail:
| | - Rebecca G. Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Mark Marzinke
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Daniel Morgan
- Department of Public Health and Epidemiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Nadia Sam-Agudu
- International Research Center of Excellence, Institute of Human Virology, Abuja, Nigeria
| | - Jaih Craddock
- School of Social Work, University of Maryland, Baltimore, MD, United States of America
| | - Min Zhan
- Division of Biostatistics and Bioinformatics, Department of Public Health and Epidemiology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Trevor A. Crowell
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States of America
- U.S Military HIV Research Program, Silver Spring, Maryland, United States of America
| | - Stefan Baral
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Nicaise Ndembi
- International Research Center of Excellence, Institute of Human Virology, Abuja, Nigeria
| | - Sylvia Adebajo
- Center for International Health, Education, and Biosecurity, Abuja, Nigeria
| | - Manhattan E. Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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12
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Tun W, Pulerwitz J, Shoyemi E, Fernandez A, Adeniran A, Ejiogu F, Sangowawa O, Granger K, Dirisu O, Adedimeji AA. A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria. J Int AIDS Soc 2022; 25 Suppl 1:e25933. [PMID: 35818868 PMCID: PMC9274359 DOI: 10.1002/jia2.25933] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 05/05/2022] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria. METHODS In-depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services. RESULTS AND DISCUSSION Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender-inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender-inclusive and gender-affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender-inclusive CSO clinics. CONCLUSIONS This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender-inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender-affirming HIV services.
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Affiliation(s)
- Waimar Tun
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | - Julie Pulerwitz
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | | | | | | | | | | | - Krista Granger
- Social and Behavioral Science Research, Population Council, Washington, DC, USA
| | - Osasuyi Dirisu
- Policy Innovation Unit, Nigerian Economic Summit Group, Lagos, Nigeria
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13
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LeeVan E, Hu F, Mitchell AB, Kokogho A, Adebajo S, Garges EC, Qian H, Ake JA, Robb ML, Charurat ME, Baral SD, Nowak RG, Crowell TA. Associations of gender identity with sexual behaviours, social stigma and sexually transmitted infections among adults who have sex with men in Abuja and Lagos, Nigeria. J Int AIDS Soc 2022; 25:e25956. [PMID: 35794838 PMCID: PMC9259961 DOI: 10.1002/jia2.25956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Sexual and gender minority populations are disproportionately affected by the global syndemic of HIV and other sexually transmitted infections (STIs). We hypothesized that transgender women (TGW) and non‐binary individuals in Nigeria have more STIs than cis‐gender men who have sex with men (cis‐MSM), and that experiences of stigma and sexual practices differ between these three groups. Methods From 2013 to 2020, TRUST/RV368 enrolled adults assigned male sex at birth who reported anal sex with men in Abuja and Lagos, Nigeria. Participants were tested for STIs and completed questionnaires about sexual behaviours and social stigma every 3 months. Participants were categorized as cis‐MSM, TGW or non‐binary/other based on self‐reported gender identity. Gender group comparisons were made of HIV, gonorrhoea and chlamydia prevalence and incidence; stigma indicators; and condom use during anal sex. Results Among 2795 participants, there were 2260 (80.8%) cis‐MSM, 284 (10.2%) TGW and 251 (9.0%) non‐binary/other individuals with median age of 23 years (interquartile range 20–27). HIV prevalence among cis‐MSM, TGW and non‐binary/other participants was 40.8%, 51.5% and 47.6%, respectively (p = 0.002). HIV incidence was 8.7 cases per 100 person‐years (PY) (95% confidence interval [CI] 6.9–10.8), 13.1 cases/100 PY (95% CI 6.5–23.4) and 17.6 cases/100 PY (95% CI 9.8–29.0, p = 0.025), respectively. Anorectal gonorrhoea incidence was lower in cis‐MSM than TGW (22.2 [95% CI 19.6–25.0] vs. 35.9 [95% CI 27.3–46.3]). TGW were more likely than cis‐MSM to report being affected by stigma, including assault (47.2% vs. 32.3%), fear of walking around (32.4% vs. 19.2%) and healthcare avoidance (25.0% vs. 19.1%; all p < 0.05). TGW were more likely to report always using condoms than non‐binary/other individuals (35.3% vs. 26.2%, p = 0.041) during receptive anal sex. Conclusions Sexual and gender minorities in Nigeria have heterogeneous sexual behaviours and experiences of social stigma that may influence the vulnerability to HIV and other STIs. There is a need for tailored interventions that acknowledge and are informed by gender. Further research is needed, particularly among understudied non‐binary individuals, to better understand disparities and inform tailored interventions to improve outcomes among these communities.
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Affiliation(s)
- Elyse LeeVan
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Fengming Hu
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | | | | | - Sylvia Adebajo
- Center for International Health and Biosecurity (Ciheb)AbujaNigeria
| | - Eric C. Garges
- Department of Preventive Medicine and BiostaticsUniformed Services UniversityBethesdaMarylandUSA
| | - Haoyu Qian
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Julie A. Ake
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
| | - Merlin L. Robb
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | | | - Stefan D. Baral
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Rebecca G. Nowak
- Institute of Human VirologyUniversity of MarylandBaltimoreMarylandUSA
| | - Trevor A. Crowell
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
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14
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Rucinski K, Masankha Banda L, Olawore O, Akolo C, Zakaliya A, Chilongozi D, Schwartz S, Wilcher R, Persaud N, Ruberintwari M, Baral S. HIV Testing Approaches to Optimize Prevention and Treatment for Key and Priority Populations in Malawi. Open Forum Infect Dis 2022; 9:ofac038. [PMID: 35265725 PMCID: PMC8900928 DOI: 10.1093/ofid/ofac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/28/2022] [Indexed: 12/04/2022] Open
Abstract
Background Despite progress in improving antiretroviral therapy (ART) for people with HIV in Malawi, the burden of HIV infections and HIV treatment outcomes among key populations is suboptimal. Client-centered differentiated service delivery approaches may facilitate addressing HIV prevention and treatment needs of key populations in Malawi. Methods De-identified program data routinely collected as part of the LINKAGES project–Malawi were assembled from October 2017 to September 2019. HIV case finding was compared across different testing modalities for each population. Poisson regression was used to estimate the association between testing modalities and ART initiation. Results Of the 18 397 people included in analyses, 10 627 (58%) were female sex workers (FSWs), 2219 (12%) were men who have sex with men (MSM), and 4970 (27%) were clients of FSWs. HIV case finding varied by modality and population, with index testing and enhanced peer outreach demonstrating high yield despite reaching relatively few individuals. FSWs who tested positive through risk network referral testing were more likely to initiate ART within 30 days compared with those who tested positive through clinic-based testing (adjusted risk ratio [aRR], 1.50; 95% CI, 1.23–1.82). For MSM, index testing (aRR, 1.45; 95% CI, 1.06–2.00) and testing through a drop-in center (aRR, 1.82; 95% CI, 1.19–2.78) were associated with 30-day ART initiation. Conclusions These data suggest that differentiated HIV testing and outreach approaches tailored to the needs of different key populations may facilitate improved ART initiation in Malawi. Achieving 0 new infections by 2030 suggests the need to adapt treatment strategies given individual and structural barriers to treatment for key populations with HIV in high-prevalence settings.
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Affiliation(s)
- Katherine Rucinski
- Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Oluwasolape Olawore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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15
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Wiginton JM, Murray SM, Poku O, Augustinavicius J, Jackman KMP, Kane J, Billong SC, Diouf D, Ba I, Mothopeng T, Njindam IM, Turpin G, Tamoufe U, Sithole B, Zlotorzynska M, Sanchez TH, Baral SD. Disclosure of same-sex practices and experiences of healthcare stigma among cisgender men who have sex with men in five sub-Saharan African countries. BMC Public Health 2021; 21:2206. [PMID: 34861835 PMCID: PMC8641177 DOI: 10.1186/s12889-021-12151-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/28/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma. METHODS We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d'Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data. RESULTS Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations. CONCLUSIONS Research to determine the factors driving disclosure's differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA.
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Affiliation(s)
- John Mark Wiginton
- grid.21107.350000 0001 2171 9311Department of Health, Behavior & Society, Johns Hopkins University Bloomberg School of Public Health, 624 N Broadway Street, Baltimore, MD 21205 USA
| | - Sarah M. Murray
- grid.21107.350000 0001 2171 9311Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Ohemaa Poku
- grid.21107.350000 0001 2171 9311Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Jura Augustinavicius
- grid.21107.350000 0001 2171 9311Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Kevon-Mark Phillip Jackman
- grid.21107.350000 0001 2171 9311Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
| | - Jeremy Kane
- grid.21729.3f0000000419368729Department of Epidemiology, Columbia University Mailman School of Public Health, New York City, NY USA
| | - Serge C. Billong
- grid.412661.60000 0001 2173 8504Department of Public Health, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon; Central Technical Group, National AIDS Control Committee, Yaoundé, Cameroon
| | | | | | | | - Iliassou Mfochive Njindam
- grid.21107.350000 0001 2171 9311Center for Public Health & Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA ,grid.452492.cMetabiota, Yaounde, Cameroon, Johns Hopkins Cameroon Program, Yaounde, Cameroon
| | - Gnilane Turpin
- grid.21107.350000 0001 2171 9311Center for Public Health & Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA ,grid.452492.cMetabiota, Yaounde, Cameroon, Johns Hopkins Cameroon Program, Yaounde, Cameroon
| | - Ubald Tamoufe
- grid.452492.cMetabiota, Yaounde, Cameroon, Johns Hopkins Cameroon Program, Yaounde, Cameroon
| | | | - Maria Zlotorzynska
- grid.189967.80000 0001 0941 6502Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Travis H. Sanchez
- grid.189967.80000 0001 0941 6502Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA USA
| | - Stefan D. Baral
- grid.21107.350000 0001 2171 9311Center for Public Health & Human Rights, Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD USA
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Sekoni AO, Jolly K, Gale NK. Hidden healthcare populations: using intersectionality to theorise the experiences of LGBT+ people in Nigeria, Africa. Glob Public Health 2020; 17:134-149. [PMID: 33287671 DOI: 10.1080/17441692.2020.1849351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Minority population groups are often excluded or marginalised within health systems and in health research and policy. This article argues that theories of intersectionality can help us to understand these issues and develops the concept of 'hidden healthcare populations' - using the case of people who identify as Lesbian, Gay, Bisexual, Transgender Plus (LGBT+) in Nigeria, in sub-Saharan Africa. The findings present original qualitative data from a seldom heard population group about instances of abuse, rejection and marginalisation by healthcare providers working in public and private healthcare facilities, and the attempts of LGBT+ people to resist and survive in that context. We extend theoretical understandings of intersectionality in global public health and explore how the concept relates to the social determinants of health. The article has significant implications for policy and healthcare education and responds to a call from the World Health Organisation to generate context-specific data to guide interventions targeted at minority population groups. Additionally, our discussion has wider significance because it highlights the Western-centric nature of much theory in health policy - and offers analysis and reinterpretation that incorporates queer, postcolonial, African perspectives.
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Affiliation(s)
| | - Kate Jolly
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Nicola Kay Gale
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
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17
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Kayode BO, Mitchell A, Ndembi N, Kokogho A, Ramadhani HO, Adebajo S, Robb ML, Baral SD, Ake JA, Charurat ME, Crowell TA, Nowak RG. Retention of a cohort of men who have sex with men and transgender women at risk for and living with HIV in Abuja and Lagos, Nigeria: a longitudinal analysis. J Int AIDS Soc 2020; 23 Suppl 6:e25592. [PMID: 33000914 PMCID: PMC7527765 DOI: 10.1002/jia2.25592] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/08/2020] [Accepted: 07/15/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Men who have sex with men (MSM), and transgender women (TGW), face specific obstacles to retention in care, particularly in settings with stigmatization such as sub-Saharan Africa. We evaluated the impacts of HIV status and other factors on loss-to-follow-up (LTFU) and visit adherence among MSM and TGW in Abuja and Lagos, Nigeria. METHODS TRUST/RV368 is an open cohort that provides comprehensive and integrated prevention and treatment services for HIV and sexually transmitted infections (STIs) at community venues supportive of sexual and gender minorities. Recruitment began in March 2013 and participants were followed every three months for up to 18 months. LTFU was defined as not presenting for an expected visit in the past 180 days. Visit adherence was calculated as a rate of completed visits adjusted by the number of three-month intervals elapsed since enrolment. HIV and other factors predictive of LTFU and visit adherence were evaluated using Cox proportional hazards and Poisson regression models, respectively. RESULTS A total of 1447 participants who completed enrolment evaluations over two visits as of November 2018 were included in these analyses. Their median age was 24 years (interquartile range [IQR]: 21 to 28) and 53% (n = 766) were living with HIV. LTFU occurred in 56% (n = 808) and visit adherence was 0.62 (95% confidence interval: 0.61 to 0.64) visits per three-month interval. Participants at risk and living with HIV had median follow-up times of 12 months (IQR: 6 to 22), and 21 months (IQR: 12 to 30), respectively (p < 0.01). After controlling for other factors, LTFU was less common among participants living with HIV or other STIs and more common among those who did not own a cell phone, sold sex and had never undergone HIV testing prior to enrolment. These factors had parallel associations with visit adherence. CONCLUSIONS Retention was suboptimal in Nigerian clinics designed to serve MSM and TGW. Particularly high LTFU and low visit adherence among participants at risk for HIV could complicate deployment of HIV prevention interventions. Marketing the benefits of testing, improving access to cell phones and nurturing more trust with clients may improve retention among marginalized communities in Nigeria.
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Affiliation(s)
| | - Andrew Mitchell
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Afoke Kokogho
- HJF Medical Research International, Abuja, Nigeria
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Habib O Ramadhani
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sylvia Adebajo
- Maryland Global Initiatives Corporation- A University of Maryland Baltimore Affiliate, Abuja, Nigeria
| | - Merlin L Robb
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Stefan D Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Julie A Ake
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Manhattan E Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Rebecca G Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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Makofane K, van der Elst EM, Walimbwa J, Nemande S, Baral SD. From general to specific: moving past the general population in the HIV response across sub-Saharan Africa. J Int AIDS Soc 2020; 23 Suppl 6:e25605. [PMID: 33000913 PMCID: PMC7527769 DOI: 10.1002/jia2.25605] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/14/2020] [Accepted: 07/21/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION As the HIV field evolves to better serve populations which are diverse in risk and access to services, it is crucial to understand and adapt the conceptual tools used to make sense of the HIV pandemic. In this commentary, we discuss the concept of general population. Using a synthetic and historical review, we reflect on the genesis and usage of the general population in HIV research and programme literature, pointing to its moral connotations and its impact on epidemiologic reasoning. DISCUSSION From the early days of the HIV pandemic, the category of general population has carried implicit normative meanings. General population represented those people considered to be undeserving of HIV acquisition, and therefore deserving of a response. Framing the HIV epidemic in sub-Saharan Africa as a generalized epidemic primarily affecting the general population has contributed to the exclusion of men who have sex with men from epidemic responses. The usage of this category has also masked heterogeneity among those it includes; the increasing focus on the use of interventions such as circumcision and HIV treatment as general population HIV prevention approaches has been marked by a lack of attention to heterogeneity among beneficiaries. CONCLUSIONS We recommend that the term general population be retired from the field's lexicon. HIV programmes should strengthen their capacity to describe the heterogeneity of those they serve and plan their interventions accordingly. To increase the efficiency and impact of the HIV response, it is urgent to stratify the category of general population by risk. Sexual networks are a promising basis for this stratification.
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Affiliation(s)
- Keletso Makofane
- FXB Center for Health and Human RightsHarvard UniversityBostonMAUSA
| | | | | | | | - Stefan D Baral
- Center for Public Health and Human RightsDepartment of EpidemiologyJohns Hopkins School of Public HealthBaltimoreUSA
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HIV status disclosure by Nigerian men who have sex with men and transgender women living with HIV: a cross-sectional analysis at enrollment into an observational cohort. BMC Public Health 2020; 20:1282. [PMID: 32842997 PMCID: PMC7448976 DOI: 10.1186/s12889-020-09315-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Men who have sex with men (MSM) and transgender women (TGW) are disproportionately impacted by HIV and may face barriers to HIV status disclosure with negative ramifications for HIV prevention and care. We evaluated HIV status disclosure to sexual partners, HIV treatment outcomes, and stigma patterns of MSM and TGW in Abuja and Lagos, Nigeria. Methods Previously-diagnosed MSM and TGW living with HIV who enrolled in the TRUST/RV368 cohort from March 2013 to August 2018 were asked, “Have you told your (male/female) sexual partners (MSP/FSP) that you are living with HIV?” In separate analyses, robust Poisson regression models were used to estimate risk ratios (RRs) and 95% confidence intervals (95% CIs) for characteristics associated with HIV status disclosure to MSP and FSP. Self-reported stigma indicators were compared between groups. Results Of 493 participants living with HIV, 153 (31.0%) had disclosed their HIV status to some or all MSP since being diagnosed. Among 222 with FSP, 34 (15.3%) had disclosed to some or all FSP. Factors independently associated with disclosure to MSP included living in Lagos (RR 1.58 [95% CI 1.14–2.20]) and having viral load < 50 copies/mL (RR 1.67 [95% CI 1.24–2.25]). Disclosure to FSP was more common among participants who were working in entertainment industries (RR 6.25 [95% CI 1.06–36.84]) or as drivers/laborers (RR 6.66 [95% CI 1.10–40.36], as compared to unemployed) and also among those married/cohabiting (RR 3.95 [95% CI 1.97–7.91], as compared to single) and prescribed ART (RR 2.27 [95% CI 1.07–4.83]). No differences in self-reported stigma indicators were observed by disclosure status to MSP but disclosure to FSP was associated with a lower likelihood of ever having been assaulted (26.5% versus 45.2%, p = 0.042). Conclusions HIV status disclosure to sexual partners was uncommon among Nigerian MSM and TGW living with HIV but was associated with improved HIV care outcomes. Disclosure was not associated with substantially increased experiences of stigma. Strategies to encourage HIV status disclosure may improve HIV management outcomes in these highly-marginalized populations with a high burden of HIV infection.
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