Injecting behaviour and service use among young injectors in Albania, Moldova, Romania and Serbia

Hepatitis co-infection in paediatric HIV: progressing treatment and prevention

PURPOSE OF REVIEW

To analyse the main evidence and recommendations for the management of hepatitis co-infection in children living with HIV.

RECENT FINDINGS

We analysed available data pertaining to the natural history of liver disease and treatment of co-infected children.

SUMMARY

Viral hepatitis co-infection in people living with HIV (PLHIV) is a global problem owing to the shared routes of transmission, particularly in areas of high endemicity for the three viruses. Viral hepatitis co-infection can accelerate liver disease progression and increase morbidity and mortality, even in patients on suppressive antiretroviral treatment (ART). Viral hepatitis should be routinely screened in PLHIV and, once diagnosed with viral hepatitis, PLHIV should be closely monitored for liver disease progression and complications. Children living with HIV-HBV co-infection should be treated with ART containing agents which are active against both viruses. Children living with HIV-HCV co-infection should receive directly acting antivirals (DAA) to eradicate HCV infection. Prevention measures to reduce vertical and horizontal transmission of HBV and HCV (anti-HBV vaccination and immunoglobulins, anti-HBV treatment in pregnancy, anti-HCV DAAs in people of childbearing age, avoiding blood contact, sexual barrier precautions) should be adopted and encouraged, particularly in high endemicity countries.

Legal Minors Who Inject: Differences in Socio-Demographics and Treatment Needs Compared to Adults in a Swedish National Sample of People with Injecting Drug Use

BACKGROUND

Injection drug use among legal minors is under-researched. Although the population may be small in absolute terms, treatment needs may be greater than for those who began injecting as adults. Such knowledge may help tailor services more effectively. Previous research tends to use selective samples or focuses solely on medical indicators. The present study uses a larger sample drawn from national register data in Sweden over a 9-year period (2013-2021) to analyze differences in medical and social treatment needs between people who began injecting as legal minors and their older counterparts.

METHOD

Data on first-time visitors to needle and syringe programmes (n = 8225, mean age 37.6, 26% women) were used. Historical socio-demographics and presenting treatment needs were compared between those with a debut injecting age under 18, and those who began injecting as adults.

RESULTS

The prevalence of injecting before 18 years was 29%. This group had more negative social circumstances, such as leaving school early, worse health, and greater service consumption, compared to those who began injecting as adults. In particular, they had been subjected to a greater level of control measures, such as arrest and compulsory care.

CONCLUSIONS

The present study shows that there are important health and social differences between those who inject prior to 18 and those who begin injecting as adults. This raises important questions for both child protection services and harm reduction approaches for legal minors who inject, who still qualify as 'children' in a legal and policy sense.

Costs and impact on HIV transmission of a switch from a criminalisation to a public health approach to injecting drug use in eastern Europe and central Asia: a modelling analysis

BACKGROUND

HIV incidence is increasing in eastern Europe and central Asia, primarily driven by injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy are suboptimal, with many people who inject drugs (PWID) being incarcerated. We aimed to assess whether use of monies saved as a result of decriminalisation of drug use or possession to scale up ART and opioid agonist therapy could control HIV transmission among PWID in eastern Europe and central Asia.

METHODS

A dynamic HIV transmission model among PWID incorporating incarceration, ART, and opioid agonist therapy was calibrated to Belarus, Kazakhstan, Kyrgyzstan, and St Petersburg (Russia). Country-specific costs for opioid agonist therapy, ART, and incarceration were collated or estimated. Compared with baseline, the model prospectively projected the life-years gained, incremental costs (2018 euros), and infections prevented over 2020-40 for three scenarios. The decriminalisation scenario removed incarceration resulting from drug use or possession for personal use, reducing incarceration among PWID by 24·8% in Belarus, Kazakhstan, and Kyrgyzstan and 46·4% in St Petersburg; the public health approach scenario used savings from decriminalisation to scale up ART and opioid agonist therapy; and the full scale-up scenario included the decriminalisation scenario plus investment of additional resources to scale up ART to the UNAIDS 90-90-90 target of 81% coverage and opioid agonist therapy to the WHO target of 40% coverage. The incremental cost-effectiveness ratios per life-year gained for each scenario were calculated and compared with country-specific gross domestic product per-capita willingness-to-pay thresholds. Costs and life-years gained were discounted 3% annually.

FINDINGS

Current levels of incarceration, opioid agonist therapy, and ART were estimated to cost from €198 million (95% credibility interval 173-224) in Kyrgyzstan to €4129 million (3897-4358) in Kazakhstan over 2020-40; 74·8-95·8% of these total costs were incarceration costs. Decriminalisation resulted in cost savings (€38-773 million due to reduced prison costs; 16·9-26·1% reduction in overall costs) but modest life-years gained (745-1694). The public health approach was cost saving, allowing each setting to reach 81% ART coverage and 29·7-41·8% coverage of opioid agonist therapy, resulting in 17 768-148 464 life-years gained and 58·9-83·7% of infections prevented. Results were similar for the full scale-up scenario.

INTERPRETATION

Cost savings from decriminalisation of drug use could greatly reduce HIV transmission through increased coverage of opioid agonist therapy and ART among PWID in eastern Europe and central Asia.

FUNDING

Alliance for Public Health, US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse, and Economist Intelligence Unit.

Young and invisible: a qualitative study of service engagement by people who inject drugs in India

OBJECTIVES

The HIV epidemic in India is concentrated in key populations such as people who inject drugs (PWID). New HIV infections are high among young PWID (≤30 years of age), who are hard to engage in services. We assessed perspectives of young PWID to guide development of youth-specific services.

SETTING

We conducted focus group discussions (FGDs) with PWID and staff at venues offering services to PWID in three Indian cities representing historical and emerging drug use epidemics.

PARTICIPANTS

PWID were eligible to participate if they were between 18 and 35 years, had initiated injection as adolescents or young adults and knew adolescent PWID in their networks. 43 PWID (81% male, 19% female) and 10 staff members participated in FGDs. A semistructured interview guide was used to elicit participants' narratives on injection initiation experiences, barriers to seeking harm reduction services, service delivery gaps and recommendations to promote engagement. Thematic analysis was used to develop an explanatory model for service engagement in each temporal stage across the injection continuum.

RESULTS

Injection initiation followed non-injection opioid dependence. Lack of services for non-injection opioid dependence was a key gap in the preinjection initiation phase. Lack of knowledge and reliance on informal sources for injecting equipment were key reasons for non-engagement in the peri-injection phase. Additionally, low-risk perception resulted in low motivation to seek services. Psychosocial and structural factors shaped engagement after established injection. Housing and food insecurity, and stigma disproportionately affected female PWID while lack of confidential adolescent friendly services impeded engagement by adolescent PWID.

CONCLUSIONS

Development of youth-specific services for young PWID in India will need to address unique vulnerabilities and service gaps along each stage of the injection continuum. Scaling-up of tailored services is needed for young female PWID and adolescents, including interventions that prevent injection initiation and provision of confidential harm reduction services.

"Drugs are a taboo": a qualitative and retrospective study on the role of education and harm reduction strategies associated with the use of psychoactive substances under the age of 18

Background

The use of psychoactive substances frequently starts at a younger age than adulthood. Considering the perspective of young people, this retrospective study tried to provide them with a role in identifying their own needs regarding drug use and interventions focused on it; the obstacles in accessing both general health and harm reduction services; the changes needed for a more effective, congruent and empowering response to the use of psychoactive substances before the age of 18.

Methods

The study was divided into two parts having both parts a qualitative focus. In the first part of the study, an online questionnaire was sent to all harm reduction teams and two focus groups were carried out with eight harm reduction professionals and six people who use(d) drugs. The second part used an online questionnaire applied to 143 participants aged between the age of 18 and 25 complemented by two semi-structured interviews.

Results

The need for education about psychoactive substances, namely in the educational context; the lack of information about available services; and the need for confidentiality were the most mentioned issues by the young people. Also, the informal network played a significant role in the participants relationship with psychoactive substances.

Conclusions

The lack of information was the most highlighted obstacle. Also, there is a confluence of various vulnerabilities such as being under 18, using drugs and the different social situations that they live in. To improve policy and practice regarding drug use among young people, harm reduction interventions must be scaled-up as well as intentionally driven to empower youth to deal with. School environment was chosen by participants as one of the elected environments to implement harm reduction services.

Injecting risk behaviours amongst people who inject drugs: A global multi-stage systematic review and meta-analysis

BACKGROUND

Injecting risk behaviour, such as receptive sharing of injecting equipment and/or re-using one's equipment, is associated with bloodborne virus transmission and infections in people who inject drugs (PWID). We aimed to estimate prevalence and correlates of injecting risk behaviours amongst PWID.

METHODS

We conducted a systematic review and meta-analyses to estimate country, regional, and global prevalences of injecting risk behaviours (including sharing or re-using needle/syringe and sharing other injecting equipment). Using meta-regression analyses, we determined associations between study- and country-level characteristics and receptive needle/syringe sharing.

RESULTS

From 61,077 identified papers and reports and 61 studies from expert consutation, evidence on injecting risk behaviours was available for 464 studies from 88 countries. Globally, it is estimated that 17.9% (95%CI: 16.2-19.6%) of PWID engaged in receptive needle/syringe sharing at last injection, 23.9% (95%CI: 21.2-26.5%) in the past month, and 32.8% (95%CI: 28.6-37.0%) in the past 6-12 months. Receptive sharing of other injecting equipment was common. Higher prevalence of receptive needle/syringe sharing in the previous month was associated with samples of PWID with a lower proportion of females, shorter average injecting duration, a higher proportion with ≥daily injecting, and older studies. Countries with lower development index, higher gender inequality and lower NSP coverage had higher proportions reporting receptive needle/syringe sharing.

CONCLUSIONS

High levels of injecting risk behaviours were observed amongst PWID globally, although estimates were only available for half of the countries with evidence of injecting drug use. There is a need for better capturing of injecting risk behaviours in these countries to inform implementation of harm reduction services and evaluate potential impacts of interventions to reduce risk.

HIV- and hepatitis C-related risk behaviors among people who inject drugs in Uganda: implications for policy and programming

BACKGROUND

There is a dearth of evidence on injecting drug use and associated HIV and hepatitis C virus (HCV) infections in Uganda. As such, policy and programming for people who inject drugs (PWID) is limited due to scarcity of epidemiological data. We therefore conducted this study to assess the injecting drug and sexual practices among PWID in Kampala Capital City and Mbale Municipality.

METHODS

Using a rapid situation assessment framework, we conducted semi-structured interviews among 125 PWID (102 males and 23 females)-recruited through outreach and snowball sampling. We assessed their injecting drug and sexual practices. We also conducted 12 focus group discussions among PWID and 30 in-depth interviews among key informants.

RESULTS

A total of 125 PWID (81.6% males and 18.4% females) were recruited into the study. Approximately three quarters of PWID started injecting before the age of 25. More females (21.7%) compared to males (13.7%) started injecting by the age of 17. Fifty-seven percent of the PWID in Kampala and 50% in Mbale shared injecting equipment in the last 3 months prior to the study. There was an emerging practice of mixing drugs with blood and sharing it among different PWID as a sign of oneness. Heroin was being injected by 72% of the participants. Less than one half of the PWID had used a condom during the last casual sex, and 42.7% did not use a condom the last time they engaged in sex work. Seventy-six percent of the PWID had undertaken an HIV test in the last 12 months, and 9.2% self-reported to be HIV positive.

CONCLUSIONS

This study highlights the need for introducing harm reduction policies and services including increased access to sterile injecting equipment and education around safer injecting and sexual practices. Programs for PWID should also address the specific needs of female sex workers who inject drugs.

Coinfection with HIV and hepatitis C virus in 229 children and young adults living in Europe

OBJECTIVE

To characterize children, adolescents and young adults infected with HIV/hepatitis C virus (HCV) vertically or before age of 18 years and living in Europe regarding mode of acquisition, HCV genotype, clinical status and treatment.

DESIGN

Retrospective, cross-sectional study using pooled data from 11 European paediatric HIV cohorts.

METHODS

Patients aged more than 18 months and less than 25 years, with HIV/HCV acquired vertically or in childhood, were included. Anonymized individual patient data were collected using a standard protocol and modified HIV Cohorts Data Exchange Protocol.

RESULTS

Of 229 patients included, 142 (62%) had vertically acquired infection. Median age at last follow-up was 16.2 years. Most children had HCV genotype 1 (101/184, 55%) or 3 (57/184, 31%). One-fifth (46/214) had a previous AIDS diagnosis (data missing on prior AIDS diagnoses for 15). At their last clinic visit, 70% (145/208) had no/mild immunosuppression (Centers for Disease Control and Prevention stage 1), and 131 of 179 on antiretroviral therapy had undetectable HIV RNA (assay thresholds varied from <20 to <150 copies/ml). Overall, 42% (86/204) had hepatomegaly in the previous year, and 55% (116/213) had alanine aminotransferase more than 40 IU/l at their last test. Of 97 patients with transient elastography, 12 had results more than 9 kPa; this was associated with duration of HCV infection (P = 0.033), but not with CD4 cell count, antiretroviral therapy use or sex in univariable analysis. Of 17 patients with liver biopsies, six had bridging fibrosis and one had cirrhosis. Twenty-five (11%) had been treated successfully for HCV.

CONCLUSION

The high proportion of patients with progressive liver disease underscores the need for close monitoring and earlier and more effective HCV treatment.

A Systematic Review of Published Respondent-Driven Sampling Surveys Collecting Behavioral and Biologic Data

Reporting key details of respondent-driven sampling (RDS) survey implementation and analysis is essential for assessing the quality of RDS surveys. RDS is both a recruitment and analytic method and, as such, it is important to adequately describe both aspects in publications. We extracted data from peer-reviewed literature published through September, 2013 that reported collected biological specimens using RDS. We identified 151 eligible peer-reviewed articles describing 222 surveys conducted in seven regions throughout the world. Most published surveys reported basic implementation information such as survey city, country, year, population sampled, interview method, and final sample size. However, many surveys did not report essential methodological and analytical information for assessing RDS survey quality, including number of recruitment sites, seeds at start and end, maximum number of waves, and whether data were adjusted for network size. Understanding the quality of data collection and analysis in RDS is useful for effectively planning public health service delivery and funding priorities.

How can we better serve adolescent key populations? Strategies to encourage and inform future data collection, analysis, and use

Young key populations (ages 10-24) (YKPs) are uniquely vulnerable to HIV infection. Yet they are often underserved, due in part to a limited understanding of their needs. Many successful approaches to understanding YKPs exist but are not widely used. To identify the most useful approaches and encourage their uptake, we reviewed strategic information on YKPs and experiences collecting, analysing, and utilising it from countries in Africa, Asia, and Central and Eastern Europe. As a result, we recommend one central guiding principle - any effort to understand and serve YKPs should include a specific focus on adolescent key populations (AKPs) (ages 10-19) - and three strategies to inform data collection, analysis, and use: tailor recruitment practices to ensure young people's representation, select indicators and research methods based on their ability to inform responsive programming for and give a voice to YKPs, and thoroughly disaggregate data. We demonstrate the utility of each strategy in YKP research and programmes, and in doing so note the particular importance for AKPs. We hope that this paper encourages additional research on YKPs and helps bridge the gap between research and effective programmes to serve the youngest and most vulnerable members of key populations.

A cross-sectional study of the feasibility of pharmacy-delivered harm reduction services among people who inject drugs in Xichang, China

Background

HIV prevalence is high in Liangshan, China (1.1 %). In 2012, people who inject drugs (PWID) in Xichang, the capital city, contributed to 60.0 % of the HIV infections. The goal of the current study was to examine the feasibility of implementing pharmacy-delivered harm reduction services (PDHRS) for PWID.

Methods

Face-to-face structured interviews with 403 PWID included questions on PWID’s experiences of syringe services and their specific experiences, acceptance, and potential usage of PDHRS.

Results

There were some reports of harassment/bad treatment from pharmacists (12.2 %) and police (17.6 %). Non-prescription syringe sales (NPSS) from pharmacies in single piece were the main source (82.1 %) of syringes. 72.5 % of PWID reported visiting 31.5 % of the identified pharmacies. Most (74.7 %) PWID disposed of their used syringes by throwing them away. Only one PWID brought used syringes back to a pharmacy in the past 30 days. Half of the PDHRS, such as printed materials about HIV, Hepatitis C and STIs; risk reduction services; (16.9 %) and sharps container to dispose of syringes (0.2 %) were offered by a few pharmacies (<20 % for each service). The acceptance rates among PWID toward currently offered services were high (≥91.1 %). All potential PDHRS were acceptable by most (68–95.3 %) PWID, and correspondingly 67–94.5 % of PWID reported they would use each service if offered.

Conclusions

NPSS from pharmacies provided many PWID in Liangshan with new syringes. However, disposal of used syringes was problematic. At the time of investigation, half of 16 assessed PDHRS were already available in pharmacies in Xichang. PWID were ready to use all the potential PDHRS and14 of 16 PDHRS were feasible to provide. HIV testing kits may be available in pharmacies in the future. Many pharmacy-delivered harm reduction services are feasible and acceptable among PWID in Xichang, China.

Trust and people who inject drugs: The perspectives of clients and staff of Needle Syringe Programs

AIMS

Interest in health-care related trust is growing with the recognition that trust is essential for effective therapeutic encounters. While most trust-related research has been conducted with general patient groups, the experiences of people who inject drugs cannot be understood without acknowledging the critical role social stigma plays in shaping (mis)trust, both generally and in regards to health services specifically. This study examined the experiences of trust among clients and staff of Needle and Syringe Programs (NSPs) in one area of Sydney, Australia.

METHOD

In-depth interviews with 12 NSP staff and 31 NSP clients were conducted. Analysis was informed by a five component model of trust, with particular emphasis on the notion of "global trust" as encompassing experiences of stigma and other negative social processes related to injecting drug use. Participant experiences of trust in NSPs were compared with those within other drug-related health services. Particular attention was paid to understanding the relationship between 'identity' (as a drug user) and 'legitimacy' (as a service user) and the centrality of this relationship to the experience of global trust for PWID.

RESULTS

Notions of identity and legitimacy were inextricably bound up with the stigmatisation of drug use, shaping participants' experiences and accounts of trust in NSPs and drug treatment services. Client participants reported high levels of trust in NSPs, especially when compared with drug treatment services, describing being treated like "any other person" even when negotiating 'sensitive' issues. NSP staff participants described the establishment of trust as not only underpinning their work with clients but as something that required ongoing renewal and demonstration.

CONCLUSION

"Global trust" assists us to better understand the complex experiences shaping PWID decisions to engage with and trust health services. The high levels of trust reported between client and NSP need to be recognised as a valuable resource for the delivery of effective health care for people who inject drugs, including encouraging behaviours to support the prevention of blood-borne viruses.

Global Epidemiology of HIV Among Women and Girls Who Use or Inject Drugs: Current Knowledge and Limitations of Existing Data

BACKGROUND

Women and girls who use and inject drugs are a critical population at risk of HIV. In this article, we review data on the epidemiology of drug use and injection among women globally and HIV prevalence among women and girls who use and inject drugs.

RESULTS

Women and girls comprise one-third of people who use and inject drugs globally. There is substantial variation in HIV prevalence in this population, between and within countries. There is a pronounced lack of data examining HIV risk among particularly vulnerable subpopulations of women who use and inject drugs, including women who have sex with women, transgender women, racial and ethnic minority women, and young women. Women who use and inject drugs experience stigma and discrimination that affect access to services, and high levels of sexual risk exposures.

CONCLUSIONS

There are significant gaps in our understanding of the epidemiology of drug use and injecting among women and girls and HIV risk and prevalence in this population. Women are frequently underrepresented in studies of drug use and HIV risk and prevalence among people who inject drugs, limiting our understanding of possible sex differences in this population. Most research originates from developed countries and may not be generalizable to other settings. A great deal of work is needed to improve understanding of HIV among particularly vulnerable subpopulations, such as transgender women who use drugs. Better data are critical to efforts to advocate for the needs of women and girls who use and inject drugs.

Reality and feasibility for pharmacy-delivered services for people who inject drugs in Xichang, China: Comparisons between pharmacy staff and people who inject drugs

BACKGROUND

In 2010, the reported overall HIV prevalence in Liangshan China (1.14%) was 19.7 times of the overall estimated prevalence in China (0.058%), and injection drug use contributed to 60.0% of overall HIV infections in Xichang, the Capital city of Liangshan. With one national methadone clinic and three outpatient service sites, and three NEP sites, the HIV prevalence among people who inject drugs (PWID) in Xichang was estimated as 18.0% (2.8 times of national HIV prevalence among PWID) in 2012.

METHODS

Face-to-face questionnaire interviews were used in a cross-sectional study to assess experience, attitudes, possibility and acceptability of implementing 8 pharmacy-delivered services among PWID (n=403). The concordance of attitudes, possibility and acceptability between PWID and pharmacy staff (n=50) was examined.

RESULTS

Rather than medical facility (23.1%), and NEP (8.9%), pharmacies were the main source of syringes for PWID in the last 12 months (82.1%), PWID (63.5%) reported syringes could be bought in single piece and at the price of $0.16 USD (59.3%). In the last 30 days, only 1 PWID brought used syringes back to a pharmacy. Pharmacy staff's attitudes were generally negative but nearly neutral (average score -0.18), discrimination/business concerns against pharmacy-delivered services existed, and 4 of 5 compared attitude questions between PWID and pharmacy staff were statistically different (p<0.01). 5 of 8 pharmacy-delivered services were available for PWID at low level (≤16.9%). Pharmacy staff's supportive perception for pharmacy-delivered services focused on pharmacies' initiate roles targeting on general population more than on PWID. PWID were more supportive and optimistic than pharmacy staff toward potential usage of pharmacy-delivered services (p<0.05).

CONCLUSION

Pharmacy-delivered services for PWID in Xichang were partly in reality, and could be feasible. It is urgently needed to address the legal requirements and remuneration for pharmacies. Pharmacy staff should receive additional training on services related knowledge and skills, cultural sensitivity toward PWID. Successful pharmacy-delivered services would benefit from identifying mutual interest and benefit between pharmacies and PWID.

"We don't need services. We have no problems": exploring the experiences of young people who inject drugs in accessing harm reduction services

Introduction

Evidence suggests that people who inject drugs often begin their drug use and injecting practices in adolescence, yet there are limited data available on the HIV epidemic and the responses for this population. The comprehensive package of interventions for the prevention, treatment and care of HIV infection among people who inject drugs first laid out in 2009 (revised in 2012) by World Health Organization, United Nations Office of Drugs and Crime and Joint United Nations Programme on HIV/AIDS, does not consider the unique needs of adolescent and young people. In order to better understand the values and preferences of young people who inject drugs in accessing harm reduction services and support, we undertook a series of community consultations with young people with experience of injecting drugs during adolescence.

Methods

Community consultations (4–14 persons) were held in 14 countries. Participants were recruited using a combined criterion and maximum variation sampling strategy. Data were analyzed using collaborative qualitative data analysis. Frequency analysis of themes was conducted.

Results

Nineteen community consultations were organized with a total of 132 participants. All participants had experienced injecting drugs before the age of 18. They had the following age distribution: 18–20 (37%), 21–25 (48%) and 26–30 (15%). Of the participants, 73.5% were male while 25.7% were female, with one transgender participant. Barriers to accessing the comprehensive package included: lack of information and knowledge of services, age restrictions on services, belief that services were not needed, fear of law enforcement, fear of stigma, lack of concern, high cost, lack of outreach, lack of knowledge of HCV/TB and lack of youth friendly services.

Conclusions

The consultations provide a rare insight into the lived experiences of adolescents who inject drugs and highlight the dissonance between their reality and current policy and programmatic approaches. Findings suggest that harm reduction and HIV policies and programmes should adapt the comprehensive package to reach young people and explore linkages to other sectors such as education and employment to ensure they are fully supported and protected. Continued participation of the community of young people who inject drugs can help ensure policy and programmes respond to the social exclusion and denial of rights and prevent HIV infection among adolescents who inject drugs.

Providing comprehensive health services for young key populations: needs, barriers and gaps

INTRODUCTION

Adolescence is a time of physical, emotional and social transitions that have implications for health. In addition to being at high risk for HIV, young key populations (YKP) may experience other health problems attributable to high-risk behaviour or their developmental stage, or a combination of both.

METHODS

We reviewed the needs, barriers and gaps for other non-HIV health services for YKP. We searched PubMed and Google Scholar for articles that provided specific age-related data on sexual and reproductive health; mental health; violence; and substance use problems for adolescent, youth or young sex workers, men who have sex with men, transgender people, and people who inject drugs.

RESULTS

YKP experience more unprotected sex, sexually transmitted infections including HIV, unintended pregnancy, violence, mental health disorders and substance use compared to older members of key populations and youth among the general population. YKP experience significant barriers to accessing care; coverage of services is low, largely because of stigma and discrimination experienced at both the health system and policy levels.

DISCUSSION

YKP require comprehensive, integrated services that respond to their specific developmental needs, including health, educational and social services within the context of a human rights-based approach. The recent WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations are an important first step for a more comprehensive approach to HIV programming for YKP, but there are limited data on the effective delivery of combined interventions for YKP. Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care.

Is violence associated with increased risk behavior among MSM? Evidence from a population-based survey conducted across nine cities in Central America

Background/Objective

There is a dearth of research examining the linkages between violence and HIV risk behavior among men who have sex with men (MSM), including those who identify as transgender women (TW), particularly in Central America where violence is widespread. In this paper, we use population-based survey results to independently examine the correlations between physical, emotional and sexual violence and HIV risk behavior among MSM populations in five countries in Central America.

Design

As part of USAID's Combination Prevention for HIV program in Central America, PASMO conducted population based surveys using respondent-driven sampling (RDS) in nine cities in Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama. Initial seeds were recruited using the following criteria: individuals who represented subgroups of MSM by self-identification (homosexual vs. heterosexual or bisexual vs. transgender), social economic strata, and by sex work practices. This study examines the association between violence and 1) HIV risk behaviors relevant to the study populations; 2) protective behaviors; and 3) reported STIs. Individualized RDS estimator weights for each outcome variable were calculated using RDSAT software, and logistic regression analysis was used to determine associations between different forms of violence and the outcome variables.

Results

MSM who experienced physical violence were more likely to be engaged in transactional sex (OR: 1.76 [1.42–2.18]), have multiple partners in the past 30 days (OR: 1.37 [1.09–1.71]), and have engaged in sex under the influence of alcohol or drugs (OR: 1.51 [1.24–1.83]). Both physical violence and psychological/verbal violence were also associated with reporting STI symptoms or diagnosis within the past 12 months (OR: 1.72 [1.34–2.21] and 1.80 [1.45–2.23]). The effects of violence on the outcomes were observed after controlling for other risk factors. Transgender women were 3.9 times more likely to report engaging in transactional sex. Respondents who were heterosexual, bisexual, or transgender were also more likely to both report multiple partnerships (OR: 1.44 [1.07–1.96], 1.99 [1.67–2.38], 1.79 [1.37–2.33], respectively) and more likely to report engaging in sex under the influence of alcohol or drugs (OR: 1.52 [1.15–2.01], 1.38 [1.17–1.63], 1.47 [1.16–1.87], respectively), as compared to those identifying as homosexual.

Conclusion

Violence experienced by MSM and TW is widespread in Central America. The experience of violence is shown in this study to be independently associated with risk behaviors for HIV infections. Further research and studies are needed to identify the effects violence has on HIV risk behavior among this under-researched population to improve targeted HIV prevention interventions.

Epidemiology of HIV and AIDS among adolescents: current status, inequities, and data gaps

OBJECTIVES

To examine levels and patterns of HIV prevalence, knowledge, sexual behavior, and coverage of selected HIV services among adolescents aged 10-19 years and highlight data gaps and challenges.

METHODS

Data were reviewed from Joint United Nations Programme on HIV/AIDS HIV estimates, nationally representative household surveys, behavioral surveillance surveys, and published literature.

RESULTS

A number of gaps exist for adolescent-specific HIV-related data; however, important implications for programming can be drawn. Eighty-two percent of the estimated 2.1 million adolescents aged 10-19 years living with HIV in 2012 were in sub-Saharan Africa, and the majority of these (58%) were females. Comprehensive accurate knowledge about HIV, condom use, HIV testing, and antiretroviral treatment coverage remain low in most countries. Early sexual debut (sex before 15 years of age) is more common among adolescent girls than boys in low- and middle-income countries, consistent with early marriage and early childbirth in these countries. In low and concentrated epidemic countries, HIV prevalence is highest among key populations.

CONCLUSIONS

Although the available HIV-related data on adolescents are limited, increased HIV vulnerability in the second decade of life is evident in the data. Improving data gathering, analysis, and reporting systems specific to adolescents is essential to monitoring progress and improving health outcomes for adolescents. More systematic and better quality disaggregated data are needed to understand differences by sex, age, geography, and socioeconomic factors and to address equity and human rights obligations, especially for key populations.