From personal survival to public health: community leadership by men who have sex with men in the response to HIV

The Sexual Health Clinic Role in Vaccine and Treatment Access During the 2022 Mpox Outbreak in King County, Washington

BACKGROUND

Sexual health clinics (SHCs) were frontline providers in the 2022 US mpox public health response, although data on clinic-based mpox vaccine scale-up, diagnoses, and treatment are limited. We describe the role of a public health SHC in King County's mpox response between May 23, 2022, and October 31, 2022.

METHODS

In July 2022, the SHC implemented a dedicated vaccine clinic and presumptive tecovirimat treatment (before laboratory confirmation) with on-site dispensation. We describe SHC's vaccine scale-up and contribution to clinical care by calculating the weekly number of vaccines administered by SHC and the total number of patients diagnosed and treated for mpox within SHC, and by comparing with countywide data. We calculated time from symptom onset to testing and time from testing to treatment, and assessed temporal changes in these metrics using linear regression.

RESULTS

The SHC provided ≥1 vaccine doses to 7442 individuals (10,295 doses), administering 42% of the 24,409 vaccine doses provided countywide, with the greatest contribution in the first week of August (n = 1562, 58% of countywide vaccinations that week). Of 598 patients evaluated for mpox and tested, 178 (30%) tested positive (37% of countywide cases), and 152 (85% of SHC patients with mpox) received tecovirimat (46% of treatment countywide). Median time from symptom onset to testing decreased from 12 to 6 days ( P = 0.045); time from testing to treatment decreased from 4.5 to 0 days ( P < 0.001).

CONCLUSIONS

The SHC was central to mpox vaccination and treatment scale-up, particularly in the first months of the 2022 epidemic.

Implementation strategies to improve HIV care cascade outcomes in low- and middle-income countries: a systematic review from 2014 to 2021

INTRODUCTION

In low- and middle-income countries (LMICs), which are disproportionately affected by the HIV epidemic and manage limited resources, optimized implementation strategies are needed to enhance the efficiency of the HIV response. Assessing strategy usage to date could identify research gaps and inform future implementation efforts. We conducted a systematic review to describe the features and distributions of published implementation strategies attempting to improve HIV treatment service delivery and outcomes.

METHODS

We searched PubMed, Embase, and CINAHL and screened abstracts and full texts published between 1 January 2014 and 27 August 2021, for English-language studies conducted in LMICs that described the implementation of HIV intervention and reported at least one HIV care cascade outcome, ranging from HIV testing to viral suppression. Implementation strategies were inductively specified, characterized by unique combinations of actor, action and action target, and summarized based on existing implementation strategy taxonomies. All strategies included in this study were independently reviewed to ensure accuracy and consistency.

RESULTS

We identified 44,126 abstracts and reviewed 1504 full-text manuscripts. Among 485 included studies, 83% were conducted in sub-Saharan Africa; the rest were conducted in South-East Asia and Western Pacific (12%), and the Americas (8%). A total of 7253 unique implementation strategies were identified, including changing health service delivery (48%) and providing capacity building and support strategies (34%). Healthcare providers and researchers led 59% and 28% of the strategies, respectively. People living with HIV and their communities (62%) and healthcare providers (38%) were common strategy targets. Strategies attempting to change governance, financial arrangements and implementation processes were rarely reported.

DISCUSSION

We identified a range of published implementation strategies that addressed HIV cascade outcomes, though some key gaps exist. We may need to expand the application of implementation strategies to ensure that all stakeholders are meaningfully involved to support equitable implementation efforts across the geographic regions and target populations, and to optimize implementation outcomes.

CONCLUSIONS

Some health service delivery and capacity building and support strategies have been most commonly used to date. Future research and implementation may incorporate a more diverse range of strategies and detailed reporting on their usage to inform improved HIV responses globally.

LGBQ-affirming clinical recommendations for compulsive sexual behavior disorder

Background and aims

Since the inclusion of Compulsive Sexual Behavior Disorder (CSBD) in the International Classification of Diseases (11th ed.), there has been little effort placed into developing clinical recommendations for lesbian, gay, bisexual, and queer (LGBQ) clients with this condition. Thus, we develop preliminary clinical recommendations for mental health professionals working with LGBQ clients who may be struggling with CSBD.

Methods

The present paper synthesizes the CSBD literature with advances in LGBQ-affirming care to develop assessment and treatment recommendations. These recommendations are discussed within the context of minority stress theory, which provides an empirically supported explanation for how anti-LGBQ stigma may contribute to the development of mental health conditions in LGBQ populations.

Results

Assessment recommendations are designed to assist mental health professionals in distinguishing aspects of an LGBQ client's sociocultural context from CSBD symptomology, given recent concerns that these constructs may be wrongly conflated and result in misdiagnosis. The treatment recommendations consist of broadly applicable, evidence-based principles that can be leveraged by mental health professionals of various theoretical orientations to provide LGBQ-affirming treatment for CSBD.

Discussion and Conclusions

The present article provides theoretically and empirically supported recommendations for mental health professionals who want to provide LGBQ-affirming care for CSBD. Given the preliminary nature of these recommendations, future research is needed to investigate their clinical applicability and efficacy.

Overcoming Stigma: The Human Side of Monkeypox Virus

Monkeypox (Mpox) virus is a zoonotic disease that was recently declared a public health emergency of international concern (PHEIC) by the World Health Organization (WHO). Symptoms of Mpox include fever, headache, muscle pain, and a rash which starts on the face and spreads to the rest of the body. The stigma surrounding the Mpox virus has been one of the greatest challenges in dealing with the disease. People with Mpox have been often shunned by their communities, and many are afraid to seek medical care for fear of ostracism. For those affected by the virus, this stigma can significantly impact their mental health and quality of life. It is further fueled by misinformation and societal norms. Hence, a multifaceted approach that includes education, awareness campaigns, and community engagement is needed to overcome the stigma associated with Mpox. Effective communication strategies are critical to the dispelling of rumors and the reduction of fear. Interventional measures need to be shaped according to the needs of those affected.

Sexual Behaviors and Aggression in Gay Pornography

Previous studies have suggested a substantial number of men who have sex with men (MSM) have consumed and used pornography to learn about same-sex sexual behaviors. Yet, past research has focused almost exclusively on condom-use in the category of Gay pornography and ignored the types of sexual behaviors and aggression depicted within the content. This study examined aggression and sexual behaviors depicted in Gay online pornography (N = 415). We found fellatio and anal sex were the most common behaviors, occurring in roughly two-thirds of scenes, while kissing occurred in less than a third of scenes. Additionally, sexual aggression occurred in 31% of scenes, with spanking being the most common, occurring in 20% of scenes. Anal sex and forced fellatio were found to be predictors of physical aggression. These findings point to normalization of aggression and narrow sexual behaviors in Gay pornography, which may have implications for MSM's norm perceptions related to sexuality.

Ensuring access to justice: the need for community paralegals to end AIDS by 2030

INTRODUCTION

The HIV response has long recognized that certain "key populations" such as individuals in detention, adolescent girls and young women, sex workers, people who use drugs, LGBTQ individuals, migrants and others face higher barriers to access to, uptake of, and retention in HIV prevention and treatment services. One approach to addressing these barriers is the training of community paralegals to advocate for the rights of individuals and to address discrimination in health settings.

DISCUSSION

Community paralegal programmes have been able to successfully address rights violations that impact access to health services and underlying determinants of health across a range of countries and populations, focusing upon issues such as discrimination and the denial of health services; unlawful detention of outreach workers, sex workers, persons who use drugs and men who have sex with men; and harmful traditional practices and gender-based violence. In addition to resolving specific cases, evaluations of paralegal programmes have found that these programmes increased legal literacy among key populations at risk of HIV and increased understanding of human rights among healthcare providers, resulting in improved access to HIV services. Some evaluations have noted challenges related to the sustainability of paralegal programmes similar to those raised with community health worker programmes more broadly.

CONCLUSIONS

To achieve global HIV goals, funding for legal literacy and paralegal programmes should be increased and interventions should be rigorously evaluated. Efforts should target discrimination in access to HIV prevention and treatment and criminalization of key populations, two key barriers to ensuring access to HIV prevention and treatment services.

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

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.

Leveraging the HIV response to strengthen pandemic preparedness

The COVID-19 pandemic and the expectation of future pandemic threats have generated a global dialogue on strengthening pandemic preparedness and response (PPR). Thus far, this dialogue has largely failed to fully consider the critical role that established, disease-specific programs played in national and regional COVID-19 responses, and the potential for these programs to contribute to stronger pandemic preparedness for the future. The HIV response is an important example of a global health initiative that is already making substantial contributions to PPR. Both the infrastructure and core principles of the HIV response have much to contribute towards pandemic preparedness that is more effective and equitable than seen in the response to COVID-19. This review examines how HIV-related resources and principles can support communities and countries in being better prepared for emerging disease threats, with a specific focus on evidence from the COVID-19 pandemic. Drawing on the current literature, the review explores the clear, multi-faceted intersection between the HIV response and the central elements of pandemic preparedness in areas including surveillance; supply chain; primary care; health care workforce; community engagement; biomedical research; universal access without discrimination; political leadership; governance; and financing. There are many opportunities to be more strategic and purposeful in leveraging HIV programs and approaches for preparedness. Avoiding the longstanding temptation in global health to create new siloes, PPR initiatives, including the new Pandemic Fund at the World Bank, should invest in and build out from existing programs that are already making health systems more inclusive and resilient, including the global response to HIV.

HIV Care Continuum Interventions for Transgender Women: A Topical Review

Transgender women experience a disproportionate prevalence of HIV and barriers to linkage to care, retention in care, medication adherence, and viral suppression. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature from January 1, 2010, through June 1, 2020, for English-language articles on interventions designed to improve at least 1 HIV care continuum outcome or address 1 barrier to achieving HIV care continuum outcomes among transgender women diagnosed with HIV in the United States. To be included, articles needed to identify transgender women as a priority population for the intervention. We found 22 interventions, of which 15 reported quantitative or qualitative outcomes and 7 reported study protocols. Recent interventions have incorporated a range of strategies that show promise for addressing pervasive structural and individual barriers rooted in societal and cultural stigma and discrimination against transgender people. Cross-cutting themes found among the interventions included meaningful community participation in the design and implementation of the interventions; culturally affirming programs that serve as a gateway to HIV care and combine gender-affirming care and social services with HIV care; interventions to improve behavioral health outcomes; peer-led counseling, education, and navigation; and technology-based interventions to increase access to care management and online social support. Ongoing studies will further elucidate the efficacy and effectiveness of these interventions, with the goal of reducing disparities in the HIV care continuum and bringing us closer to ending the HIV epidemic among transgender women in the United States.

Changing Levels of Social Engagement with Gay Men Is Associated with HIV Related Outcomes and Behaviors: Trends in Australian Behavioral Surveillance 1998-2020

Changes to how gay, bisexual, and other men who have sex with men (GBM) connect with each other and with their communities have implications for HIV prevention. Social engagement with gay men (defined as having friends who are gay men and spending time with them) has been associated with HIV related outcomes over time among Australian GBM. Using data collected in national, repeated, cross-sectional surveys of GBM between 1998 and 2020 (N = 161,117), analyses of trends in the prevalence of gay social engagement (GSE) in Australia were conducted using linear regression. To assess changing associations with GSE at different time points in the HIV epidemic, three cross-sectional analyses were conducted on factors associated with high and low GSE in 1999/2000, 2009/2010, and 2019/2020 using bivariate and multivariable logistic regression. GSE (scored from 0 to 7) declined among all participants from 4.76 in 1998 to 4.04 in 2020 (p < 0.001) with a steeper decline among GBM aged under 25 years from 4.63 in 1998 to 3.40 in 2020 (p < 0.001). In all timepoints, high GSE was associated with older age, being university educated, full time employment, identifying as gay, recent HIV testing, and PrEP uptake. While mostly associated with protective behaviors, high GSE was also associated with some practices that may put GBM at risk of HIV infection such as drug-enhanced sex and group sex in the most recent timepoint. Changing levels of GSE have implications for health promotion among GBM, particularly how to engage GBM less connected to gay social networks.

Peer- and community-led responses to HIV: A scoping review

INTRODUCTION

In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track.

METHODS

We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research.

FINDINGS

Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices.

CONCLUSIONS AND RECOMMENDATIONS

Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

Protective Factors That Foster Resilience to HIV/AIDS: Insights and Lived Experiences of Older Gay, Bisexual, and Other Men Who Have Sex with Men

Since the beginning of the HIV/AIDS epidemic, gay, bisexual, and other men who have sex with men (gbMSM) have been disproportionately impacted by HIV/AIDS health disparities. Research showed that resilience to HIV/AIDS is associated with increased use of relevant health services, lower sexual health risks, and improved mental health outcomes among racially and ethnically diverse gbMSM. As the subpopulation that has historically been impacted by HIV/AIDS the longest, older gbMSM living with HIV/AIDS have inarguably exhibited resilience to HIV/AIDS the most. The qualitative study described in this paper sought to identify and examine protective factors that fostered resilience to HIV/AIDS based on the insights and lived experiences of racially and ethnically diverse, older gbMSM. Applying a community-based participatory research approach that included the meaningful involvement of older gbMSM living with HIV/AIDS in different roles (i.e., advisory committee member, collaborator, peer researcher, and participant), the study recruited and included forty-one older gbMSM living with HIV/AIDS from Ontario, Canada, in confidential, semi-structured interviews. Utilizing thematic analysis, we identified three major themes from the participant interviews as factors that fostered the resilience of older gbMSM to HIV/AIDS and helped to address HIV/AIDS health disparities: (1) established protective factors, (2) behavioral protective factors, and (3) controversial protective factors. This paper argues for the importance of valuing and capitalizing on these protective factors in the conceptualization and development of interventions, services, and programs that are dedicated to fostering resilience to HIV/AIDS.

Law, criminalisation and HIV in the world: have countries that criminalise achieved more or less successful pandemic response?

How do choices in criminal law and rights protections affect disease-fighting efforts? This long-standing question facing governments around the world is acute in the context of pandemics like HIV and COVID-19. The Global AIDS Strategy of the last 5 years sought to prevent mortality and HIV transmission in part through ensuring people living with HIV (PLHIV) knew their HIV status and could suppress the HIV virus through antiretroviral treatment. This article presents a cross-national ecological analysis of the relative success of national AIDS responses under this strategy, where laws were characterised by more or less criminalisation and with varying rights protections. In countries where same-sex sexual acts were criminalised, the portion of PLHIV who knew their HIV status was 11% lower and viral suppression levels 8% lower. Sex work criminalisation was associated with 10% lower knowledge of status and 6% lower viral suppression. Drug use criminalisation was associated with 14% lower levels of both. Criminalising all three of these areas was associated with approximately 18%-24% worse outcomes. Meanwhile, national laws on non-discrimination, independent human rights institutions and gender-based violence were associated with significantly higher knowledge of HIV status and higher viral suppression among PLHIV. Since most countries did not achieve 2020 HIV goals, this ecological evidence suggests that law reform may be an important tool in speeding momentum to halt the pandemic.

Barriers and Facilitators to Promoting Resilience to HIV/AIDS: A Qualitative Study on the Lived Experiences of HIV-Positive, Racial and Ethnic Minority, Middle-Aged and Older Men Who Have Sex with Men from Ontario, Canada

Evidence-based research has highlighted the need for exploring factors that support the mental health of men who have sex with men living with HIV/AIDS (MSMLWH), and environmental influences that promote their resilience to HIV/AIDS. This exploratory study utilized a community-based participatory research approach to investigate barriers and facilitators to promoting resilience to HIV/AIDS, specifically among racial and ethnic minority, middle-aged and older MSMLWH, a population that continues to be significantly impacted by HIV/AIDS today. This collaborative, qualitative study recruited participants who identified as racial or ethnic minority MSMLWH, were aged 40 or older, and resided in Ontario, Canada. Participants (n = 24) discussed in their interviews barriers and facilitators to promoting resilience to HIV/AIDS, which they recognized from their lived experiences. Utilizing thematic analysis, themes related to barriers and facilitators to promoting resilience to HIV/AIDS were identified. Themes related to identified barriers included: (1) language proficiency, (2) racism, (3) pernicious norms in North American gay culture, and (4) HIV stigma. Themes related to identified facilitators included: (1) compartmentalization, (2) perseverance, and (3) community-based health and social services. This article discusses the implications of the study’s findings, particularly on how they may influence the development of future services for racial and ethnic minority, middle-aged and older MSMLWH.

Messaging matters: achieving equity in the HIV response through public health communication

Public health messages shape how the world understands the HIV epidemic. Considerable inequalities remain in HIV care continuum indicators by subpopulation and geography (eg, highest infection and mortality burden among men who have sex with men and people who live in sub-Saharan Africa). Health equity-focused approaches are necessary in this next decade to close gaps in the HIV epidemic. Between 1981 and 1989, HIV messages triggered fear and victim blaming, and highlighted behaviours of a few marginalised groups as deviant. Between 1990 and 1999, messages signalled that HIV was a growing challenge for the world and required multisector approaches that addressed structural drivers of inequality. Between 2000 and 2009, messages highlighted universal testing, while advances in HIV testing made these messages easier for individuals to respond to than in previous decades. Currently, messages signal that ending HIV is possible, people can live productive lives with HIV, and transmission to people without HIV can be eliminated. Public health messaging about the HIV epidemic has evolved substantially over the past 40 years. Future HIV messaging should be driven by health equity principles that include an increased representation of key populations in message design and dissemination, transparency of funding, and communicating any impact that campaigns have had on closing health inequalities.

Understanding patient motivations for HIV pre-exposure prophylaxis initiation and adherence

Consistent dosing of tenofovir/emtricitabine-based HIV pre-exposure prophylaxis (PrEP) can reduce HIV infection risk by up to 92%. However, clinical trials have shown low PrEP adherence (34-71%), resulting in reduced effectiveness. To improve PrEP's effectiveness, adherence to a daily PrEP regimen is essential. This report explores patients' patterns of PrEP initiation and use and their PrEP-related perceptions to provide greater understanding of patient motivations for beginning and adhering to PrEP. At two urban primary care clinics, individual coaching sessions that included semistructured interviews were offered to 10 PrEP patients. Regarding PrEP initiation, 30% of patients were advised to use PrEP by their nurse practitioners (NPs), while the remaining patients requested PrEP themselves. Before they initiated PrEP, all patients were familiar with it through social contacts or internet-based research. Patients' PrEP-related perceptions were identified, including perceived pros and cons of PrEP use, and degrees of PrEP knowledge, uncertainty, and fear. Primary care NPs should take detailed sexual histories to avoid overlooking PrEP candidates. In addition, primary care NPs should introduce easy-to-access, Internet-based resources to reinforce patient education. Last, PrEP promotional campaigns should be focused at the community level in gay, bisexual, transgender and queer populations.

Sexual health literacy among gay, bisexual and other men who have sex with men: a conceptual framework for future research

Good sexual health requires navigating intimate relationships within diverse power dynamics and sexual cultures, coupled with the complexities of increasing biomedicalisation of sexual health. Understanding this is important for the implementation of biomedical HIV prevention. We propose a socially nuanced conceptual framework for sexual health literacy developed through a consensus building workshop with experts in the field. We use rigorous qualitative data analysis to illustrate the functionality of the framework by reference to two complementary studies. The first collected data from five focus groups (FGs) in 2012 (n = 22), with gay, bisexual and other men who have sex with men aged 18-75 years and 20 in-depth interviews in 2013 with men aged 19-60 years. The second included 12 FGs in 2014/15 with 55 patients/service providers involved in the use/implementation of HIV self-testing or HIV prevention/care. Sexual health literacy goes well beyond individual health literacy and is enabled through complex community practices and multi-sectoral services. It is affected by emerging (and older) technologies and demands tailored approaches for specific groups and needs. The framework serves as a starting point for how sexual health literacy should be understood in the evaluation of sustainable and equitable implementation of biomedical sexual healthcare and prevention internationally.

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

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.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

Implementation opportunities and challenges identified by key stakeholders in scaling up HIV Treatment as Prevention in British Columbia, Canada: a qualitative study

Background

The province of British Columbia (BC), Canada, was among the first jurisdictions to scale up HIV Treatment as Prevention (TasP) to the population level, including funding and policy commitments that enhanced HIV testing efforts (e.g., expansion of routine, opt-out testing), while also making antiretroviral therapy universally available to all people living with HIV. As such, BC represents a critical context within which to identify factors that influenced the scalability of TasP (e.g., acceptability, adoption, fidelity, equitable reach, sustainability), including key opportunities and challenges.

Methods

We draw on in-depth, semi-structured interviews with 10 key stakeholders, comprised policymakers at the local and provincial levels and representatives from community-based organizations. Using the Consolidated Framework for Implementation Research (CFIR) to guide data collection, coding, and analysis, we identified key factors that influenced practice transformation and scale up.

Results

Key factors that contributed to the successful scale up of TasP included: (i) opportunities that enhanced stakeholder buy-in based on features of the intervention characteristics, including with regard to assessments about the quality and strength of evidence supporting TasP; (ii) an inner setting implementation climate that was, in part, shaped by the large and highly symbolic government investments into TasP; (iii) features of the outer setting such as external policies (e.g., harm reduction) that cultivated opportunities to implement new "systems-level" approaches to HIV intervention; (iv) the personal attributes of some "middle-level" influencers, including a team that was comprised of some highly motivated and social justice-oriented individuals (e.g., folks who were deeply committed to serving marginalized populations); and (v) the capacity to develop various implementation processes that could maintain "nimble and evidence-informed" adaptations across a highly decentralized service delivery system, while also creating opportunities to adapt features of TasP programming based on "real time" program data.

Conclusion

Constructs across all five domains of CFIR (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) were identified to influence the success of TasP in BC. Our findings provide important insights into how BC can successfully implement and scale up other systems-level interventions that have demonstrated efficacy, while also offering insights for other jurisdictions that are currently or planning to scale up TasP.

A Secondary Mixed Methods Analysis of a Pay-it-Forward Gonorrhea/Chlamydia Testing Program Among Men Who Have Sex With Men in China

BACKGROUND

Gonorrhea and chlamydia are common among Chinese men who have sex with men (MSM), but testing rates are low. We developed a pay-it-forward program where men receive a free gonorrhea/chlamydia test and can then donate toward future participants' tests. This study aims to investigate drivers of testing uptake and donation using a mixed methods approach.

METHODS

We used a sequential explanatory design to explore drivers of testing uptake and donation unique to pay-it-forward through a quantitative cross-sectional survey and a qualitative thematic analysis of semistructured interviews. We collected data on sociodemographics and perceived benefits of pay-it-forward among men offered the pay-it-forward interventionand analyzed testing uptake and donations using descriptive statistics and logistic regression. We then conducted 30 semistructured interviews with men and coded interview data to identify themes.

RESULTS

Three hundred and one MSM were offered pay-it-forward and 55% (165/301) received gonorrhea/chlamydia testing. Ninety-one percent (150 of 165) donated any amount with a mean of 58.31 ± 53.39 RMB (US $8.61 ± 7.88), or 39% of the standard price of gonorrhea/chlamydia testing. Getting tested was not associated with income, but donations were higher in the highest income bracket (adjusted odds ratio, 7.12; 95% confidence interval, 1.61-31.52). Fifty-eight percent (94 of 162) selected "more MSM can get tested," and 54% (88 of 162) selected "I can help someone else" as benefits of pay-it-forward. Qualitative themes for drivers of testing and donation included flexible pricing, generosity and reciprocity, and MSM community identity.

CONCLUSIONS

Quantitative and qualitative results suggest that this pay-it-forward program may increase gonorrhea/chlamydia testing by reducing cost barriers, leveraging generosity and reciprocity, and mobilizing community altruism.

Pay-it-forward strategy to enhance uptake of dual gonorrhea and chlamydia testing among men who have sex with men in China: a pragmatic, quasi-experimental study

BACKGROUND

Chinese men who have sex with men (MSM) rarely receive gonorrhoea and chlamydia testing. The purpose of this pilot study was to evaluate a pay-it-forward strategy to increase uptake of gonorrhoea and chlamydia testing among MSM.

METHODS

We performed a quasi-experimental pragmatic study to compare a pay-it-forward model with standard of care at two HIV testing sites for MSM in Guangzhou, China: an STD clinic for MSM and a local MSM community-based organisation. All men who arrived at the STD clinic or the community-based organisation were invited to participate. In the pay-it-forward programme, men were offered free gonorrhoea and chlamydia testing and given the option of donating money toward testing for future participants. In the standard-of-care group, men were offered gonorrhoea and chlamydia testing at the standard patient price of ¥150 (about US$21·50). The pay-it-forward programme was implemented for 3 months, after which both sites switched to standard of care offering dual testing for 3 months. The primary outcome for this study was uptake of dual gonorrhoea and chlamydia testing, which we compared using χ² test and logistic regression, reported as crude odds ratios (cOR) and adjusted odds ratios (aOR), by adjusting for nationality, marital status, income, and site of testing.

FINDINGS

The pay-it-forward programme took place from Dec 2, 2017, to Feb 3, 2018, and the standard-of-care control took place from March 11, 2018, to May 1, 2018. 408 men were included in this study. 203 men were offered pay-it-forward, and 205 were offered standard of care. Overall, 109 (54%) of 203 men in the pay-it-forward group and 12 (6%) of 205 men in the standard-of-care group received gonorrhoea and chlamydia testing (cOR 18·65, 9·78-35·54; p<0·0001; aOR 19·73, 95% CI 10·02-38·85; p<0·0001). Of all 121 men who tested, this was the first gonorrhoea test for 97 (80%) men and the first chlamydia test for 104 (86%) men. Five (4%) of these 121 men were diagnosed with gonorrhoea and 15 (12%) were diagnosed with chlamydia. 97 (89%) of 109 men who received testing in the pay-it-forward group donated some money toward testing for future participants.

INTERPRETATION

Pay-it-forward might be a sustainable model for expanding integrated HIV testing services among MSM in China.

FUNDING

National Institutes of Health, Southern Medical University Dermatology Hospital, Doris Duke Charitable Foundation.

Demographic characteristics associated with the use of HIV pre-exposure prophylaxis (PrEP) in an urban, community health center

Individuals who are at high risk of contracting HIV should have equitable access to preventive measures, such as pre-exposure prophylaxis (PrEP). We conducted a retrospective data extract from the electronic medical records of federally-qualified health centers in New York City from 2016 to 2018. Descriptive statistics are presented, stratified by those who have been prescribed PrEP and those who have not. We created a variable called "ever-female" which includes individuals assigned female at birth or who have ever identified as female. A chi-square test was performed to determine the statistical significance between variables as p < .05. A total of 9659 patients met inclusion criteria for the study. Patients who were prescribed PrEP were significantly associated with being white and never-female, with 38.2% of those prescribed PrEP identifying as white and 83.8% of those prescribed PrEP categorized as never-female. Patients of trans experience were 9.6% of the PrEP cohort and 1.5% of the never PrEP cohort (p < .001). Patients identifying as Black/African American made up 19.8% of patients prescribed PrEP and 49.8% of those never prescribed PrEP (p < .001). Patients with the lowest reported income composed 48.4% of those prescribed PrEP compared to 69.3% of patients who were never prescribed PrEP (p < .001). These findings indicate that key demographic categories may not be accessing PrEP as much as would be expected for their level of risk. Barriers to access of PrEP for women and other at-risk, under-represented populations should be further studied.

Changes in risky sexual behaviours among West African MSM enrolled in a quarterly HIV testing and counselling prevention programme (CohMSM ANRS 12324 - Expertise France)

OBJECTIVES

Whether regular HIV testing and counselling reduce risky sexual behaviours in African men who have sex with men (MSM) is still a matter for debate. We aimed to identify behavioural trajectories based on HIV risk exposure (HRE) and factors affecting their evolution.

METHODS

Data were collected from 621 HIV-negative West African MSM (Mali, Cote d'Ivoire, Burkina Faso and Togo) included in a community-based cohort providing quarterly HIV testing and counselling. Sociobehavioural data were collected every 6 months. HRE was defined as reporting inconsistent condom use during receptive anal sex with male partners of unknown HIV status in the previous 6 months. Using 18-month follow-up data, group-based trajectory modelling helped identify behavioural trajectories and determine the factors associated with their evolution. HIV seroconversions (n=67) were specified in each group trajectory.

RESULTS

Two distinct group trajectories were identified: medium-risk exposure MSM (ME-MSM) (61%, 6.4% of whom having seroconverted) and high-risk exposure MSM (HE-MSM) (39%, 17.5% of whom having seroconverted). A significant declining trend in the probability of reporting HRE over time ((95% CI)) was observed for HE-MSM (from 0.59 (0.48 to 0.70) at M0 to 0.31 (0.22 to 0.41) at M18), while it remained constant for ME-MSM (0.034 (0.0 to 0.079)). This can be explained by a progressive use of risk reduction strategies (less receptive anal sex, better knowledge of their partners' status and increasing condom use). Being younger, living in Burkina Faso, self-considering both a man and a woman and reporting a higher level of depression were all associated with HE membership. Among HE-MSM, HRE was higher in those practising transactional or group sex and those experiencing psychological harassment.

CONCLUSIONS

Quarterly HIV testing and counselling seem to reduce risky sexual behaviours in HIV-negative MSM at greatest risk of infection. Specific support for young MSM, focusing on identity and mental health, is needed to strengthen HIV prevention in West African MSM.

Healthcare providers' attitudes towards care for men who have sex with men (MSM) in Malawi

BACKGROUND

Men who have sex with men (MSM) are a priority group in Malawi's national response to Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). There are limited data on service providers' acceptability to deliver appropriate sexual health services in relation to HIV prevention, care and treatment targeting the MSM. We assessed attitudes of healthcare providers already working, health professions students and faculty at health professions training institutions regarding the provision of MSM focused HIV related health services.

METHODS

We conducted a qualitative study between April and May 2017 in Lilongwe, Malawi. We purposively recruited 15 participants (5 health service providers, 5 health professions students and 5 faculty of tertiary health training institutions) among whom individual in-depth interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically.

RESULTS

Participants recognized MSM as having health needs and rights. Participants generally expressed willingness to deliver appropriate healthcare because they perceived this as their professional responsibility. Participants suggested that it was the responsibility for MSM to disclose their sexual orientation and or preferences when they access care such that healthcare providers better anticipate their care needs. They suggested a need to increase the availability of MSM-centered and friendly health services as well as trained providers that are non-judgmental, non-discriminatory and have respect for people's right to health care access.

CONCLUSION

Despite widespread poor attitudes against MSM in Malawi, health service providers and health professions students and faculty accepted and were willing to provide MSM-focused health services. The acceptability and willingness of health service providers, health professions students and faculty to provide health services to MSM offer hope and scope for efforts to strengthen the delivery of health services and quality of care to MSM in Malawi.

A systematic review of selected human rights programs to improve HIV-related outcomes from 2003 to 2015: what do we know?

Background

Repressive legal environments and widespread human rights violations act as structural impediments to efforts to engage key populations at risk of HIV infection in HIV prevention, care, and treatment efforts. The identification and scale-up of human rights programs and rights-based interventions that enable coverage of and retention in evidence-based HIV prevention and treatment approaches is crucial for halting the epidemic.

Methods

We conducted a systematic review of studies that assessed the effectiveness of human rights interventions on improving HIV-related outcomes between 1/1/2003–28/3/2015 per PRISMA guidelines. Studies of any design that sought to evaluate an intervention falling into one of the following UNAIDS’ key human rights program areas were included: HIV-related legal services; monitoring and reforming laws, policies, and regulations; legal literacy programs; sensitization of lawmakers and law enforcement agents; and training for health care providers on human rights and medical ethics related to HIV.

Results

Of 31,861 peer-reviewed articles and reports identified, 23 were included in our review representing 15 different populations across 11 countries. Most studies (83%) reported a positive influence of human rights interventions on HIV-related outcomes. The majority incorporated two or more principles of the human rights-based approach, typically non-discrimination and accountability, and sought to influence two or more elements of the right to health, namely availability and acceptability. Outcome measures varied considerably, making comparisons between studies difficult.

Conclusion

Our review revealed encouraging evidence of human rights interventions enabling a comprehensive HIV response, yet critical gaps remain. The development of a research framework with standardized indicators is needed to advance the field. Promising interventions should be implemented on a larger scale and rigorously evaluated. Funding for methodologically sound evaluations of human rights interventions should match the demand for human rights-based and structural approaches to protect those most vulnerable from HIV infection.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3692-1) contains supplementary material, which is available to authorized users.

Taking empowerment into account: the response of community-based organisations to the HIV care needs of men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France)

Empowerment is an ongoing process through which individuals and communities appropriate power and acquire the capability to function autonomously. Research on empowerment in men who have sex with men (MSM) is lacking in community-based contexts. We investigated the relationship between willingness to be empowered and HIV care needs in West African MSM accessing community-based organisations' (CBO) services. Fifty-three interviews were administered to HIV-negative MSM participating in the CohMSM study (Mali, Burkina Faso, Côte d'Ivoire, Togo). Five indicators of empowerment were identified from a discourse analysis: (i) motivation to access HIV services, (ii) willingness to improve HIV services, (iii) desire to be involved in new activities, (iv) desire to participate in such services, (v) willingness to collaborate in decision making. Based on these indicators, participants were classified into two profiles: high (19/53, 36%) and low (34/53, 64%) level of willingness to be empowered (HWE, LWE). Using a thematic analysis, HWE participants were focused on collective benefit (preventive follow-up, questions about MSM identity), while LWE participants were centred on individual benefit (medical care). CBOs should consider empowerment as a tool to advance collective health benefits for MSM. To improve empowerment in MSM, specific training on issues regarding sexual identity and stigma is needed for CBO providers.

Simbayi L, Barré I, Dovidio JF. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas

Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.

"In transition: ensuring the sexual and reproductive health and rights of transgender populations." A roundtable discussion

This roundtable discussion is the result of a research symposium entitled In Transition: Gender [Identity], Law & Global Health where participants took up the challenge to engage with the question: What will it take to ensure the sexual and reproductive health and rights (SRHR) of transgender populations across the globe? The barriers to overcome are fierce, and include not only lack of access to health services and insurance but also stigma and discrimination, harassment, violence, and violations of rights at every turn. Transgender people must of course lead any sort of initiatives to improve their lives, even as partnerships are needed to build capacity, translate lived experience into usable data, and to make strategic decisions. The SRHR of transgender people can only be addressed with attention to the social, cultural, legal, historical, and political contexts in which people are situated, with social, psychological, medical, and legal gender affirmation as a key priority shaping any intervention. Bringing together nine diverse yet complementary perspectives, our intent is to jumpstart a global and multigenerational conversation among transgender activists, lawyers, policy-makers, programmers, epidemiologists, economists, social workers, clinicians and all other stakeholders to help think through priority areas of focus that will support the needs, rights, and health of transgender populations. Making the changes envisioned here is possible but it will require not only the advocacy, policy, programmatic and research directions presented here but also struggle and action locally, nationally, and globally.

Acceptability of Peer-Delivered HIV Testing and Counselling Among Men Who Have Sex with Men (MSM) and Transgender Women (TW) in Myanmar

Men who have sex with men (MSM) and transgender women (TW) are a priority population for HIV prevention in Myanmar but report sub-optimal HIV testing frequency. Previous studies have shown that peer involvement in HIV testing can normalize stigmatized sexualities and reduce barriers to testing. We explored the acceptability of peer-delivered HIV testing among 425 undiagnosed MSM and TW in Yangon and Mandalay. An overwhelming majority of participants (86%) reported being 'comfortable/very comfortable' with peer-delivered HIV testing. Logistic regression identified reporting sexual identity as Apone [adjusted odds ratio (aOR) 3.8; 95% CI 1.2-11.7], recent HIV testing (aOR 3.1; 95% CI 1.4-6.5), reporting a high likelihood of HIV acquisition (aOR 3.6; 95% CI 1.7-7.6), and reporting ≥ 5 casual partners in the past 3 months (aOR 0.2; 95% CI 0.1-0.6) as associated with peer-delivered HIV testing acceptability. Given ongoing HIV vulnerability among MSM and TW in Myanmar, peer-delivered testing may offer prevention benefits by increasing testing rates and identifying undiagnosed infection earlier.

The Interplay between Stigma, Collective Efficacy, and Advocacy Communication among Men Who Have Sex with Men and Transgender Females

Stigma and discrimination are primary drivers of health disparities among marginalized communities. Drawing on stigma management, minority stress model, and social cognitive theories, this article tests the interplay between dimensions of stigma, collective efficacy, and advocacy communication among men who have sex with men (MSM) and transgender females. Using data from a cross-sectional survey conducted in south India (N = 225), five distinct dimensions of stigma were identified using factor analysis: experienced stigma, self-stigma, felt normative stigma, and two new dimensions-HIV-related vicarious stigma and media stigma. Respondents reported highest levels of media stigma. While most of the dimensions of stigma were negatively associated with both collective efficacy and advocacy communication, collective efficacy mediated the relationship between stigma and advocacy. Implications for public health campaigns among MSM groups are discussed.

Community-Engaged Research as an Approach to Expedite Advances in HIV Prevention, Care, and Treatment: A Call to Action

Throughout the world, we continue to face profound challenges to reducing the impact of the HIV epidemic. Community-engaged research has emerged as an approach to increase our understanding of HIV and reduce health disparities, increase health equity, and promote community and population health. Our partnership has conducted more than 25 community-engaged research studies in the U.S. and Guatemala, and members have identified nine themes to facilitate community-engaged research and expedite advances in HIV prevention, care, and treatment. These themes include the inclusion of multisectoral partners, trust building and maintenance, the alignment of partner priorities, a can-do attitude, capacity and desire to move beyond service and conduct research, flexibility, power sharing, empowerment, an assets orientation, the shared and timely use of findings, and a stepwise approach. To reduce HIV disparities, community-engaged research is as critical now as ever, and we desperately need to reinvigorate our commitment to and support of it.

Wisdom of the Crowds: Crowd-Based Development of a Logo for a Conference Using a Crowdsourcing Contest

BACKGROUND

Crowdsourcing methods have been widely used in business, but rarely in sexual health research. We evaluated a crowdsourced logo contest as part of an international human immunodeficiency virus conference.

METHODS

A logo crowdsourcing contest was conducted for the 20th International Acquired Immunodeficiency Syndrome Conference. Crowdsourcing has a group of individuals solve a task, often as part of an open contest. Semistructured interviews were conducted with key informants including contest organizers, contest contributors, and conference attendees. Interviews were transcribed verbatim and analysed using a content analysis approach.

RESULTS

In total, 22 interviews were conducted with 3 contest organizers, 7 contest contributors, and 12 conference attendees. All individuals reported that the crowdsourced logo provided benefits beyond branding the conference, including creating a shared sense of purpose among diverse conference participants and explicitly demonstrating the strong community orientation of the conference. Conference organizers and attendees all reported deeper engagement because of the story of the Tanzanian artist who won the contest. Most conference attendees (11/12) preferred the crowdsourced logo compared with the previous company-organized logo, and all (22/22) supported the logo contest continuing. Implementing a logo contest was simple and relatively inexpensive. Stakeholders identified several ways to enhance crowdsourcing logo contest methods including wider promotion of the contest to encourage broader participation, greater transparency in the selection process, and a different prize structure which acknowledges the contribution of more contestants.

CONCLUSIONS

We found that a crowdsourcing contest helped engage local and global communities in the lead-up before and during an international conference. Similar participatory events may be useful for sexual health conferences and research projects.

An Assessment of Health Interventions Required to Prevent the Transmission of HIV Infection Among Men Having Sex with Men in Bujumbura, Burundi

Data regarding HIV among men having sex with men (MSM) in Burundi are scarce. In a context where same-sex practices are illegal, national recommendations including MSM have been issued in 2012. However, no study has been conducted to evaluate MSM's health needs, which would be useful to adapt recommendations and implement evidence-based interventions. This study aimed at identifying health needs expressed by MSM. A cross-sectional study was conducted in Bujumbura in 2014, in collaboration with the National Association for HIV positive people and AIDS patients. Fifty-one MSM, recruited during HIV prevention activities, self-completed a questionnaire. A descriptive analysis was conducted. Participants had a median age of 23 years, over 60 % declared being a member of an LGBT organisation and 76 % lived their homosexuality secretly or discretely. Over the last month, 67 % declared having had sex with a man and 32 % with a woman. In the previous 6 months, 40 % declared having systematically used a condom during sexual intercourse. In terms of health needs, 22 % did not use the services offered by HIV providers. Participants expressed needs in terms of prevention (access to rapid HIV tests, in a confidential setting, with counselling) and care (listening centre, free treatment, confidentiality). Medical expertise and being a good listener were the predominant healthcare staff qualities desired by participants. Results suggest that Burundian MSM represent an at-risk population, with low access to HIV services, in need of a comprehensive approach for HIV prevention, with community-based activities (HIV testing, counselling, prevention tools), psychological and social support.

Stigma as a barrier to health care utilization among female sex workers and men who have sex with men in Burkina Faso

PURPOSE

The aim of this study is to examine the prevalence and correlates of perceived health care stigma among female sex workers (FSWs) and men who have sex with men (MSM), including other stigma types, suicidal ideation, and participation in social activities.

METHODS

FSWs (N = 350) and MSM (N = 330) aged ≥18 were recruited in Bobo-Dioulasso, Burkina Faso. Perceived health care stigma was defined as either ever being afraid of or avoiding health care services because someone might find out the participant has sex with men (for MSM) or sells sex (for FSW). Correlates of perceived health care stigma were examined using multivariable logistic regression.

RESULTS

The prevalence of perceived health care stigma was 14.9% (52/350) and 24.5% (81/330) in FSWs and MSM, respectively. Among FSWs, experienced or social stigma, including verbal harassment (adjusted odds ratio [aOR] = 3.59, 95% confidence interval [CI] 1.48-8.71), feeling rejected by friends (aOR = 2.30, 95% CI 1.14-4.64), and feeling police refused to protect them (aOR = 2.58, 95% CI 1.27-5.25), was associated with perceived health care stigma. Among MSM, experiencing verbal harassment (aOR = 1.95, 95% CI 1.09-3.50) and feeling scared to walk in public (aOR = 2.93, 95% CI 1.47-5.86) were associated with perceived health care stigma.

CONCLUSIONS

In these key populations, perceived health care stigma was prevalent and associated with experienced and social stigmas. To increase coverage of effective HIV services, interventions should incorporate approaches to comprehensively mitigate stigma.

Measuring stigma affecting sex workers (SW) and men who have sex with men (MSM): A systematic review

Background

Stigma involves discrediting a person or group based on a perceived attribute, behaviour or reputation associated with them. Sex workers (SW) and men who have sex with men (MSM) are key populations who are often at increased risk for the acquisition and transmission of HIV and who are affected by stigma that can negatively impact their health and well-being. Although stigma was included as an indicator in the US National HIV/AIDS Strategic Plan and there have been consultations focused on adding a stigma indicator within PEPFAR and the Global Fund in relation to potentiating HIV risks among key populations, there remains limited consensus on the appropriate measurement of SW- or MSM-associated stigma. Consequently, this systematic review summarizes studies using quantitative, qualitative, or mixed methods approaches to measure stigma affecting sex workers and men who have sex with men.

Methods and findings

This systematic review included English, French, and Spanish peer-reviewed research of any study design measuring SW- or MSM-associated stigma. Articles were published from January 1, 2004 to March 26, 2014 in PsycINFO, PubMed, EMBASE, CINAHL Plus, Global Health, and World Health Organization Global Health Library Regional Indexes.

Of the 541 articles reviewed, the majority measured stigma toward MSM (over 97%), were conducted in North America, used quantitative methods, and focused on internalized stigma.

Conclusions

With the inclusion of addressing stigma in several domestic and international HIV strategies, there is a need to ensure the use of validated metrics for stigma. The field to date has completed limited measurement of stigma affecting sex workers, and limited measurement of stigma affecting MSM outside of higher income settings. Moving forward requires a concerted effort integrating validated metrics of stigma into health-related surveys and programs for key populations.

Changing hearts and minds: Results from a multi-country gender and sexual diversity training

Engaging key populations, including gender and sexual minorities, is essential to meeting global targets for reducing new HIV infections and improving the HIV continuum of care. Negative attitudes toward gender and sexual minorities serve as a barrier to political will and effective programming for HIV health services. The President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003, provided Gender and Sexual Diversity Trainings for 2,825 participants including PEPFAR staff and program implementers, U.S. government staff, and local stakeholders in 38 countries. The outcomes of these one-day trainings were evaluated among a subset of participants using a mixed methods pre- and post-training study design. Findings suggest that sustainable decreases in negative attitudes toward gender and sexual minorities are achievable with a one-day training.

Community engagement in sexual health and uptake of HIV testing and syphilis testing among MSM in China: a cross-sectional online survey

INTRODUCTION

HIV and syphilis testing rates remain low among men who have sex with men (MSM) in low- and middle-income countries (LMICs). Community engagement has been increasingly used to promote HIV testing among key populations in high-income countries, often in settings with stronger civil society. This study aimed to assess socio-demographic, behavioural, and community engagement factors associated with HIV and syphilis testing among MSM in China.

METHODS

MSM ≥16 years old who had condomless sex in the past three months were recruited nationwide to complete a cross-sectional online survey in November 2015. Data were collected on socio-demographics, sexual behaviours, HIV testing, syphilis testing, and community engagement in sexual health. We defined community engagement in sexual health using six items assessing awareness and advocacy of sexual health programmes. The underlying factor structure of a 6-item community engagement scale was determined through exploratory factor analysis. Univariate and multivariable logistic regressions identified correlates of HIV and syphilis testing.

RESULTS

1189 MSM were recruited. 54% (647/1189) of men had ever tested for HIV and 30% (354/1189) had ever tested for syphilis. Factor analysis suggested three levels of community engagement (minimal, moderate, and substantial) and this model explained 79.5% of observed variance. A quarter (26%, 312/1189) reported none to minimal engagement, over one half (54%, 644/1189) reported moderate engagement, and a fifth (20%, 233/1189) reported substantial engagement. Multivariable logistic regression showed that MSM with greater community engagement in sexual health were more likely to have ever tested for HIV (substantial vs. no engagement: aOR 7.91, 95% CI 4.98-12.57) and for syphilis (substantial vs. no engagement: aOR 5.35, 95% CI 3.16-9.04).

CONCLUSION

HIV and syphilis testing are suboptimal among MSM in China. Community engagement may be useful for promoting testing in China and should be considered in intervention development and delivery. Further research is needed to better understand the role of LMIC community engagement in HIV interventions.

Community engagement in sexual health and uptake of HIV testing and syphilis testing among MSM in China: a cross-sectional online survey

INTRODUCTION

HIV and syphilis testing rates remain low among men who have sex with men (MSM) in low- and middle-income countries (LMICs). Community engagement has been increasingly used to promote HIV testing among key populations in high-income countries, often in settings with stronger civil society. This study aimed to assess socio-demographic, behavioural, and community engagement factors associated with HIV and syphilis testing among MSM in China.

METHODS

MSM ≥16 years old who had condomless sex in the past three months were recruited nationwide to complete a cross-sectional online survey in November 2015. Data were collected on socio-demographics, sexual behaviours, HIV testing, syphilis testing, and community engagement in sexual health. We defined community engagement in sexual health using six items assessing awareness and advocacy of sexual health programmes. The underlying factor structure of a 6-item community engagement scale was determined through exploratory factor analysis. Univariate and multivariable logistic regressions identified correlates of HIV and syphilis testing.

RESULTS

1189 MSM were recruited. 54% (647/1189) of men had ever tested for HIV and 30% (354/1189) had ever tested for syphilis. Factor analysis suggested three levels of community engagement (minimal, moderate, and substantial) and this model explained 79.5% of observed variance. A quarter (26%, 312/1189) reported none to minimal engagement, over one half (54%, 644/1189) reported moderate engagement, and a fifth (20%, 233/1189) reported substantial engagement. Multivariable logistic regression showed that MSM with greater community engagement in sexual health were more likely to have ever tested for HIV (substantial vs. no engagement: aOR 7.91, 95% CI 4.98-12.57) and for syphilis (substantial vs. no engagement: aOR 5.35, 95% CI 3.16-9.04).

CONCLUSION

HIV and syphilis testing are suboptimal among MSM in China. Community engagement may be useful for promoting testing in China and should be considered in intervention development and delivery. Further research is needed to better understand the role of LMIC community engagement in HIV interventions.

Prevalence of condomless anal intercourse and recent HIV testing and their associated factors among men who have sex with men in Hangzhou, China: A respondent-driven sampling survey

Men who have sex with men (MSM) are a large high-risk population for HIV infection in recent years in China. A cross-sectional survey was conducted in Hangzhou, China, to determine rates of condomless anal intercourse (CAI), recent HIV testing (in the recent year) and associated factors using respondent-driven sampling. Questionnaires using face-to-face interviews were employed to collect data on sexual risk behaviors and HIV testing. Five hundred eleven MSM were recruited, of which 459 (89.8%) had anal intercourse in the past 6 months. Of these 459 participants, 457 (99.6%) answered whether they had taken an HIV test in the recent year, so only their data were analyzed. Weighted data were analyzed using bivariate and multivariate logistic regression analysis. The CAI rate with male partners in the past 6 months was 43.7% (95% confidence interval [CI], 34.0-51.5%), while the rate of condomless vaginal intercourse (CVI) was 21.6% (95% CI, 15.6-32.3%). The prevalence of recent HIV testing was 56.8% (95% CI, 48.7-66.5%), while the prevalence of HIV and syphilis were 8.8% and 6.5%, respectively. Multivariate analysis indicated that CAI was associated with earlier homosexual debut, suicidal inclinations, childhood sexual abuse, HIV testing in the recent year, and lower estimate of HIV prevalence. Recent HIV testing was associated with homosexual debut age, engaging in CAI with male partners in the past 6 months, having oral sex in the past 6 months, self-perceived higher likelihood of HIV infection, knowing about antiretroviral therapy for HIV/AIDS, receiving AIDS/sexually transmitted infection (STI) interventions in the past year, and syphilis infection. Given high prevalence of HIV and syphilis, high levels of CAI and CVI, and low HIV testing rate, the results indicated high risk of HIV infection and transmission among MSM. HIV prevention interventions should target MSM with early homosexual debut and psychosocial health problems, while HIV/AIDS education among MSM should focus on increasing knowledge of HIV risk, estimated HIV prevalence and antiretroviral therapy, and improving risk perception of HIV acquisition.

Pursuing Social Justice through Public Health: Gender and Sexual Diversity Activism in Malawi

African lesbian, gay, bisexual, transgender, intersex, and queer (LGBTIQ) organizations face various strategic dilemmas in contexts characterized by political hostility to gender and sexual dissidents. In Malawi, one such context, we examine how an LGBTIQ social movement organization (SMO) in Malawi, the Centre for the Development of People (CEDEP), navigated one particular strategic dilemma-the dilemma of whether to adopt a less politicized public-health approach or a more nimble, grassroots-oriented, and social-justice approach to their advocacy work-and the consequences of the organization's strategic decisions. Scholars interpret these approaches as signifying differential political engagement among organizations, with the social-justice approach indicating political engagement and the public-health approach signaling political disengagement. This difference has led critics to argue that a public-health approach is poorly suited to generating social and legal reform because it de-politicizes LGBTIQ issues over time, while a social-justice approach exerts constant pressure on political and religious elites. Drawing on qualitative interview data with Malawian LGBTIQ activists and news media data reflecting public debate around homosexuality in the country, we illuminate how this SMO metamorphosed from an organization ostensibly focused only on public health and HIV/AIDS to one that advances social justice for gender and sexual dissidents. We argue for an understanding of the indigenous development of a hybrid strategy integrating the public-health and social-justice approaches.

Knowledge and preferences concerning acute HIV testing programs among both Peruvian men who have sex with men and transgender women

Immediate antiretroviral therapy (ART) for acute HIV infection (AHI) may decrease HIV transmission in high-risk populations. This study evaluated knowledge of AHI and AHI testing program preferences in Lima, Peru through four semi-structured focus groups with high-risk men who have sex with men (MSM) ( n = 20) and transgender women (TW) ( n = 16). Using content analysis, emergent themes included knowledge of AHI symptoms, AHI transmission potential, and the HIV testing window period, and preferences concerning point of care results. Participants demonstrated low familiarity with the term AHI, but many correctly identified AHI symptoms. However, these symptoms may not motivate testing because they overlap with common viral illnesses and AIDS. Some were aware that infectiousness is highest during AHI, and believe this knowledge would facilitate HIV testing. The shortened window period with AHI testing would encourage testing following high-risk sex. Delayed result notification would not decrease AHI testing demand among MSM, although it might for some TW.

Healthcare Provider Contact and Pre-exposure Prophylaxis in Baltimore Men Who Have Sex With Men

INTRODUCTION

Pre-exposure prophylaxis (PrEP) safely and effectively prevents HIV in populations at high risk, including men who have sex with men (MSM). PrEP scale-up depends upon primary care providers and community-based organizations (CBOs) sharing PrEP information. This study aimed to determine whether healthcare provider or CBO contact was associated with PrEP awareness among Baltimore MSM.

METHODS

This study used 2014 Baltimore MSM National HIV Behavioral Surveillance data, which included data on health care, HIV and sexually transmitted infection testing, and receipt of condoms from CBOs. In 2015, associations were estimated between healthcare contacts and PrEP awareness through logistic regression models controlling for age, race, and education and clustering by venue. Comparative analyses were conducted with HIV testing as outcome.

RESULTS

There were 401 HIV-negative participants, of whom 168 (42%) were aware of PrEP. Visiting a healthcare provider in the past 12 months, receiving an HIV test from a provider, and having a sexually transmitted infection test in the past 12 months were not significantly associated with PrEP awareness. PrEP awareness was associated with being out to a healthcare provider (OR=2.97, 95% CI=1.78, 4.96, p<0.001); being tested for HIV (OR=1.50, 95% CI=1.06, 2.13, p=0.023); and receiving condoms from an HIV/AIDS CBO (OR=2.59, 95% CI=1.43, 4.64, p=0.001). By contrast, HIV testing was significantly associated with most forms of healthcare contact.

CONCLUSIONS

PrEP awareness is not associated with most forms of healthcare contact, highlighting the need for guidelines and trainings to support provider discussion of PrEP with MSM.

Engagement of Gay Men and Other Men Who Have Sex with Men (MSM) in the Response to HIV: A Critical Step in Achieving an AIDS-Free Generation

Men who have sex with men (MSM) continue to be at elevated risk for HIV acquisition and transmission secondary to biological and behavioral characteristics, social and sexual network characteristics, community environmental factors, and structural factors. HIV incidence rates remain high among MSM in both low- and high-income settings, and in both concentrated and more generalized HIV epidemic settings. While data quality tends to be poorer, the best estimates collectively suggest that MSM have up to 20 times the odds of living with HIV as compared to other reproductive aged adults across low- and middle-income countries. Recent prevention strategies to lower biological HIV transmission and acquisition risks, including the early use of antiretrovirals to decrease infectiousness for those living with HIV, and pre-exposure prophylaxis for those at significant risk of HIV acquisition, have demonstrated the potential to change the trajectory of the HIV epidemics among MSM. However, the coverage and effectiveness of these approaches is limited by structural factors including the punitive legal frameworks and institutional discrimination that contribute to limited uptake, challenges to adherence, and suboptimal health-seeking behaviors among MSM. More intensive efforts will be required to reach MSM who do not currently have access to relevant and effective prevention and treatment services or elect not to access these services given enacted and/or perceived stigma. Respect for human rights, including efforts to aggressively confront and combat the forms of stigma that are preventing us from achieving an AIDS-Free generation, are needed for all people including gay men and other MSM.

The immediate eff ect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort

BACKGROUND

In January, 2014, the Same-Sex Marriage Prohibition Act was signed into law in Nigeria, further criminalising same-sex sexual relationships. We aimed to assess the immediate effect of this prohibition act on stigma, discrimination, and engagement in HIV prevention and treatment services in men who have sex with men (MSM) in Nigeria.

METHODS

The TRUST cohort study uses respondent-driven sampling to assess the feasibility and effectiveness of engagement of MSM in HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community. TRUST is a prospective implementation research cohort of MSM (≥16 years) in Abuja, Nigeria. We compared HIV clinical outcomes and stigma, including fear and avoidance of health care, across baseline and quarterly visits before and after implementation of the the Same-Sex Marriage Prohibition Act. Outcomes assessed were measures of stigma and discrimination, loss to follow-up, antiretroviral therapy status, and viral load. We compared outcomes before and after the legislation with χ2 statistics, and estimated incident stigma-related events and loss to follow-up with Poisson regression.

FINDINGS

Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures, contributing to 756 before legislation (prelaw) and 420 after legislation (postlaw) visits. Reported history of fear of seeking health care was significantly higher in postlaw visits than in prelaw visits (n=161 [38%] vs n=187 [25%]; p<0・0001), as was avoidance of health care (n=118 [28%] vs n=151 [20%]; p=0・001). In incidence analyses, of 192 MSM with follow-up data and no history of an event at baseline, reported fear of seeking health care was higher in the postlaw than the prelaw period (n=144; incidence rate ratio 2・57, 95% CI 1・29–5・10; p=0・007); loss to follow-up and incident healthcare avoidance were similar across periods. Of the 161 (89%) of 181 HIV-infected MSM with HIV viral loads available, those who had disclosed sexual behaviour with a health-care provider were more often virally suppressed at baseline than those with no previous disclosure (18 [29%] of 62 vs 13 [13%] of 99 men; p=0・013).

INTERPRETATION

These analyses represent individual-level, quantitative, real-time prospective data for the health-related effects resulting from the enactment of legislation further criminalising same-sex practices. The negative effects of HIV treatment and care in MSM reinforce the unintended consequences of such legislation on global goals of HIV eradication. Strategies to reach MSM less likely to engage in HIV testing and care in highly stigmatised environments are needed to reduce time to HIV diagnosis and treatment.

FUNDING

National Institutes of Health.