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Hendrickson ZM, De Jesus M, Barrington C, Cole SW, Kennedy CE, Sisson LN, Uzzi M, Donastorg Y, Perez M, Gomez H, Mbwambo J, Likindikoki S, Kerrigan DL. "You know that we travel a lot": Mobility narratives among female sex workers living with HIV in Tanzania and the Dominican Republic. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003355. [PMID: 38968203 PMCID: PMC11226099 DOI: 10.1371/journal.pgph.0003355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 05/22/2024] [Indexed: 07/07/2024]
Abstract
Female sex workers (FSW) are highly mobile, which may result in reduced access to and use of health services and increased risk for poor health outcomes, particularly for those living with HIV. Mobility includes spatial, temporal, and social elements that are not fully captured by quantitative measures. We conducted two rounds of in-depth interviews with FSW living with HIV in Iringa, Tanzania (n = 20), and Santo Domingo, Dominican Republic (n = 20), to describe mobility experiences and compare mobility narratives across settings. We integrated a thematic analysis of all interviews with a narrative analysis of a subset of 10 information-rich interviews (five in each country) with women who had recently traveled, for sex work or another reason, outside of their hometown. Across narratives, FSW living with HIV traveled locally or to seasonal destinations, for short and long periods. Social factors influencing mobility included economic drivers; risk of arrest, harassment, or violence; anonymity and/or familiarity; social relationships; and clients' mobility. Spatial, temporal, and social factors intersected in unique ways in FSW's mobility experiences, yet distinct mobility typologies were evident across settings and destinations. Together, mobility narratives of FSW living with HIV can inform quantitative research on mobility typologies in Tanzania, the Dominican Republic, and elsewhere. With the potential for economic circumstances, climate change, and other emergencies to increase people's mobility around the world, researchers and practitioners can learn from the lived experiences of FSW to inform whether and how to tailor and improve the accessibility of HIV care and treatment interventions based on spatial, temporal, and social characteristics of mobility.
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Affiliation(s)
- Zoé M. Hendrickson
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, United States of America
| | - Maria De Jesus
- School of International Service, American University, Washington, DC, United States of America
| | - Clare Barrington
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, United States of America
| | - S. Wilson Cole
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Caitlin E. Kennedy
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Laura Nicole Sisson
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Mudia Uzzi
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Yeycy Donastorg
- Instituto Dermatologico y Cirugia de la Piel, Santo Domingo, Dominican Republic
| | - Martha Perez
- Instituto Dermatologico y Cirugia de la Piel, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Instituto Dermatologico y Cirugia de la Piel, Santo Domingo, Dominican Republic
| | - Jessie Mbwambo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Samuel Likindikoki
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Deanna L. Kerrigan
- Prevention and Community Health Department, Milken Institute School of Public Health, the George Washington University, Washington, DC, United States of America
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Tun W, Conserve DF, Bunga C, Jeremiah K, Apicella L, Vu L. Quality of Care is Perceived to be High with Community-based Antiretroviral Therapy (ART) Services for Female Sex Workers in Tanzania: Qualitative Findings from a Pilot Implementation Science Study. AIDS Behav 2024; 28:1-11. [PMID: 37632605 PMCID: PMC10803559 DOI: 10.1007/s10461-023-04155-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 08/28/2023]
Abstract
This qualitative study reports on female sex workers' (FSWs) perceptions of the quality of antiretroviral therapy (ART) services they received as part of a community-based ART distribution intervention compared to services received by FSWs in the standard of care (SOC) arm. In-depth interviews were conducted with 24 participants to explore their perceptions of the quality of ART services. Data was analyzed using a quality-of-care framework that included but was not limited to, domains of accessibility, effective organization of care, package of services, and patient-centered care. Overall, FSWs in the intervention arm reported community-based ART services to be highly accessible, organized, and effective, and they highly valued the patient-centered care and high level of privacy. Community-based ART programs for FSWs can have high quality-of-care, which can have a positive effect on HIV treatment outcomes for FSWs.
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Affiliation(s)
- Waimar Tun
- Population Council, Social and Behavioral Sciences Research, 4301 Connecticut Ave., NW, Suite 280, Washington, DC, 20008, USA.
| | - Donaldson F Conserve
- Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Catherine Bunga
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | - Kidola Jeremiah
- Mwanza Research Centre, National Institute for Medical Research, Mwanza, Tanzania
| | - Louis Apicella
- Population Council, Social and Behavioral Sciences Research, 4301 Connecticut Ave., NW, Suite 280, Washington, DC, 20008, USA
| | - Lung Vu
- The World Bank, Washington, DC, USA
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Kerrigan D, Barrington C, Donastorg Y, Perez M, Gomez H, Davis W, Beckham SW, Karver TS, Mantsios A, Galai N. Individual and Collective Forms of Stigma Resistance: Pathways Between HIV and Sex Work Stigma and Viral Suppression Among Female Sex Workers in the Dominican Republic. AIDS Behav 2024; 28:357-366. [PMID: 37725235 DOI: 10.1007/s10461-023-04169-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 09/21/2023]
Abstract
Intersecting forms of stigma including both HIV and sex work stigma have been known to impede HIV prevention and optimal treatment outcomes among FSW. Recent research has indicated that intersectional stigma can be resisted at the community and individual level. We assessed pathways between HIV stigma, sex work stigma, social cohesion and viral suppression among a cohort of 210 FSW living with HIV in the Dominican Republic. Through Poisson regression we explored the relationship between HIV outcomes and internalized, anticipated and enacted HIV and sex work stigma, and resisted sex work stigma. We employed structural equation modeling to explore the direct effect of various forms of stigma on HIV outcomes, and the mediating effects of multi-level stigma resistance including social cohesion at the community level and occupational dignity at the individual level. 76.2% of FSW were virally suppressed and 28.1% had stopped ART at least once in the last 6 months. ART interruption had a significant negative direct effect on viral suppression (OR = 0.26, p < 0.001, 95% CI: 0.13-0.51). Social cohesion had a significant positive direct effect on viral suppression (OR = 2.07, p = 0.046, 95% CI: 1.01-4.25). Anticipated HIV stigma had a significant negative effect on viral suppression (OR = 0.34, p = 0.055, 95% CI: 0.11-1.02). This effect was mediated by the interaction between cohesion and dignity which rendered the impact of HIV stigma on viral suppression not significant. Findings demonstrate that while HIV stigma has a negative impact on viral suppression among FSW, it can be resisted through individual and collective means. Results reinforce the importance of community-driven, multi-level interventions.
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Affiliation(s)
- Deanna Kerrigan
- George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - Clare Barrington
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugía de Piel Dr. Huberto Bogaert Díaz, Santo Domingo, Dominican Republic
| | - Martha Perez
- Instituto Dermatológico y Cirugía de Piel Dr. Huberto Bogaert Díaz, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Instituto Dermatológico y Cirugía de Piel Dr. Huberto Bogaert Díaz, Santo Domingo, Dominican Republic
| | - Wendy Davis
- George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - S Wilson Beckham
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Noya Galai
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Hinman K, Amon JJ. Human rights and HIV: rhetoric or determinants? BMJ Glob Health 2023; 8:e013571. [PMID: 37827727 PMCID: PMC10583038 DOI: 10.1136/bmjgh-2023-013571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
International donors and UN agencies emphasise the importance of human rights as a key determinant of HIV vulnerability and of access, uptake and retention in HIV prevention and treatment services. Yet, the extent to which HIV researchers are incorporating rights into their research, the specific rights being examined and the frequency of research assessing rights-based approaches, is unknown. METHODS We examined all articles published in the five highest impact-factor HIV journals: (1) Lancet HIV; (2) AIDS and Behavior; (3) AIDS; (4) Journal of the International AIDS Society (JIAS); and (5) Journal of Acquired Immune Deficiency Syndromes (JAIDS), between 1 January 2017 and 31 December 2022, for reference to 'human right(s)' or 'right(s)'. We analysed articles to assess: (1) what populations were identified in relation to specific human rights concerns; (2) what specific rights were mentioned; (3) whether researchers cited specific legal frameworks; and (4) if and what types of rights-based interventions were examined. RESULTS Overall, 2.8% (n=224) of the 8080 articles reviewed included a mention of 'human right(s)' or 'right(s)'. Forty-two per cent of these (n=94) were original research articles. The most common key population discussed was men who have sex with men (33 articles), followed by sex workers (21 articles) and transgender people (14 articles). Of the 94 articles, 11 mentioned the right to health and nine referenced reproductive rights. Few articles identified a specific authority-whether in national, regional or international law-for the basis of the rights cited. Fourteen articles discussed rights-based interventions. CONCLUSION Despite global recognition of the importance of human rights to HIV outcomes, few HIV researchers publishing in the top five cited HIV journals include attention to human rights, or rights-based interventions, in their research. When rights are mentioned, it is often without specificity or recognition of the legal basis for human rights.
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Affiliation(s)
- Kati Hinman
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, USA
| | - Joseph J Amon
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania, USA
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Maclin BJ, Wang Y, Rodriguez-Diaz C, Donastorg Y, Perez M, Gomez H, Barrington C, Kerrigan D. Comparing typologies of violence exposure and associations with syndemic health outcomes among cisgender and transgender female sex workers living with HIV in the Dominican Republic. PLoS One 2023; 18:e0291314. [PMID: 37695770 PMCID: PMC10495030 DOI: 10.1371/journal.pone.0291314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 08/22/2023] [Indexed: 09/13/2023] Open
Abstract
Violence against women research largely excludes transgender women's experiences and violence from perpetrators other than intimate partners. This study compares patterns of violence exposure among cisgender and transgender female sex workers (FSWs) and the associations with syndemic health outcomes. We used cross-sectional surveys from samples of cisgender and transgender FSWs living with HIV in the Dominican Republic (N = 211 and 100, respectively). We used latent class analysis to identify patterns of emotional, physical, and sexual violence and harassment by partners, clients, and police. We assessed sociodemographic and occupational predictors in relation to class membership, and class membership in relation to health (HIV continuum of care outcomes, mental health, substance use), using logistic regression. Two classes were identified in cisgender sample: Low Reported Violence Exposure (Class 1) and Sex Work-related Police Harassment (Class 2). Class 2 participants had greater odds of scoring abnormal or borderline abnormal anxiety on the Hospital Anxiety and Depression Scale (HADS-A) (adjusted OR = 3.97, p<0.01), moderate-to-severe depression per the Patient Health Questionnaire-9 (PHQ-9) (aOR = 5.74, p<0.01), and any illicit drug use in the past six months (aOR = 3.06, p<0.05), compared to Class 1. The transgender sample produced three classes: Low Reported Violence Exposure (Class 1); Sex Work-related Police Harassment (Class 2); and Sex Work-related Violence and Harassment (Class 3). Class 3 participants had greater odds of having anxiety (aOR = 6.65, p<0.01) and depression (aOR = 4.45, p<0.05), while Class 2 participants had greater odds of perfect ART adherence during the previous four days (aOR = 2.78, p<0.05), compared to Class 1. The more diverse and extreme violence patterns uncovered for the transgender sample show this group's heightened risk, while similar patterns across groups regarding police abuse highlight a need for police-focused violence prevention interventions. Each sample's highest violence class was associated with poor mental health, underscoring the need for mental health interventions for all FSWs.
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Affiliation(s)
- Beth J. Maclin
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Yan Wang
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Carlos Rodriguez-Diaz
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Yeycy Donastorg
- HIV Vaccine Trials Research Unit, Instituto Dermatológico y Cirugía de la Piel, Santo Domingo, Dominican Republic
| | - Martha Perez
- HIV Vaccine Trials Research Unit, Instituto Dermatológico y Cirugía de la Piel, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- HIV Vaccine Trials Research Unit, Instituto Dermatológico y Cirugía de la Piel, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
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Maclin BJ, Wang Y, Rodriguez-Diaz C, Donastorg Y, Perez M, Gomez H, Barrington C, Kerrigan D. Beyond a deficit-based approach: Characterizing typologies of assets for cisgender and transgender female sex workers and their relationship with syndemic health outcomes. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002314. [PMID: 37647289 PMCID: PMC10468052 DOI: 10.1371/journal.pgph.0002314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 07/26/2023] [Indexed: 09/01/2023]
Abstract
Female sex workers (FSWs) live and work at the intersection of multiple marginalized identities that place them at greater risk for various negative health outcomes. Resilience theory asserts that an individual or community needs assets from which they can draw in response to stressors, such as chronic discrimination and abuse. This study characterizes and compares patterns of assets among cisgender and transgender FSWs living with HIV in the Dominican Republic and their relations with syndemic health outcomes. With Latent Class Analysis, we used companion cross-sectional datasets comprised of cisgender and transgender FSWs (N = 211 and 100, respectively) to estimate typologies of interpersonal, community, and institutional assets. We used multivariate logistic regression to model the relationship between class membership and HIV care and treatment, mental health, violence exposure, and substance use outcomes, respectively. Among cisgender FSWs, we identified three classes: Internal and External Multilevel Assets (Class 1); External Institutional Assets (Class 2); and Low Reported Assets (Class 3). Compared to Class 3, Class 1 membership among cisgender FSWs was significantly associated with ART adherence and marginally associated with viral suppression, and Class 2 membership was marginally associated with currently taking ART. We identified two classes in the transgender sample: Internal and External Multilevel Assets (Class 1) and External Institutional Assets (Class 2). Class 1 membership among transgender FSWs was significantly associated with ART adherence and marginally associated with current ART use and physical or sexual violence, compared to Class 2. Having a variety of assets may explain the ability of some FSWs to more effectively engage with healthcare and maintain their HIV medication regimen. Future interventions should seek to expand FSWs' interpersonal and community assets, both from within and outside of the sex worker community, to bolster their ability to care for themselves and their community.
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Affiliation(s)
- Beth J. Maclin
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
- Behavioral & Community Health Sciences, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Yan Wang
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Carlos Rodriguez-Diaz
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugía de la Piel, HIV Vaccine Trials Research Unit, Santo Domingo, Dominican Republic
| | - Martha Perez
- Instituto Dermatológico y Cirugía de la Piel, HIV Vaccine Trials Research Unit, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Instituto Dermatológico y Cirugía de la Piel, HIV Vaccine Trials Research Unit, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, United States of America
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Beckham S, Karver TS, Mantsios A, Shembilu C, Donastorg Y, Perez M, Gomez H, Barrington C, Mwampashi A, Davis W, Likindikoki S, Mbwambo JK, Kerrigan D. Acceptability and perceptions of HIV oral self-testing across settings: A comparative qualitative study among Dominican and Tanzanian female sex workers. Glob Public Health 2022; 17:870-884. [PMID: 33736565 PMCID: PMC8449797 DOI: 10.1080/17441692.2021.1901129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/24/2021] [Indexed: 10/21/2022]
Abstract
Rapid oral HIV self-tests (HIVST) have potential to increase the proportion of people who know their HIV status, especially among stigmatised populations. This study was embedded in two cohorts of female sex workers (FSW) in the Dominican Republic (DR) and Tanzania. Qualitative interviews with 40 FSW were conducted to explore perceived acceptability of HIVST. Interviews were analysed using inductive and deductive thematic coding. Emergent themes were organised by socio-ecological framework levels. FSW in both settings responded positively to the ease of use of HIVST but questioned test accuracy due to the use of saliva rather than blood. FSW in the DR had a more cautious response, while women in Tanzania had favourable perceptions expressing eagerness to use it. At the individual level, themes shaping participants' interest included autonomy, HIV risk perception, and emotional well-being for those with reactive test results, and self-efficacy. At the interpersonal level, privacy, confidentiality, sex work and HIV stigma and social support were salient. Structural level themes focused on health systems including linkages to HIV treatment, provider roles, and access (cost, travel, distribution). Understanding FSW's perceptions and acceptability of HIVST is essential to its integration into health systems and programmes using a community-driven approach.
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Affiliation(s)
- S.Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Tahilin S. Karver
- Department of Health, Behavior and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Catherine Shembilu
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Yeycy Donastorg
- Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Maria Perez
- Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Instituto Dominicano de Dermatologia y Cirugia de Piel, Santo Domingo, Dominican Republic
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Ardi Mwampashi
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Wendy Davis
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington DC, USA
| | - Samuel Likindikoki
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Jessie K. Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington DC, USA
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Access to Social Protection by People Living with, at Risk of, or Affected by HIV in Eswatini, Malawi, Tanzania, and Zambia: Results from Population-Based HIV Impact Assessments. AIDS Behav 2022; 26:3068-3078. [PMID: 35316470 PMCID: PMC8938650 DOI: 10.1007/s10461-022-03645-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/03/2022]
Abstract
We aimed to measure social protection coverage among the general population, women and men living with HIV (WLHIV, MLHV), female and male sex workers (FSW, MSW), men who have sex with men (MSM), adolescent girls young women (AGYW), and orphans vulnerable children (OVC) in Eswatini, Malawi, Tanzania, and Zambia. We used Population-Based HIV Impact Assessment data. We operationalised social protection benefits as external economic support from private and public sources to the household in the last three or 12 months. We estimated survey-weighted proportions and 95% confidence intervals (CI) for each population receiving social protection benefits. The sample size ranged from 10,233 adults ages 15-59 years in Eswatini to 29,638 in Tanzania. In the surveyed countries, social protection coverage among the general population was lower than the global average of 45%, ranging from 7.7% (95% CI 6.7%-8.8%) in Zambia to 39.6% (95% CI 36.8%-42.5%) in Eswatini. In Malawi and Zambia, social protection coverage among OVC, AGYW, SW, MSM, and people living with HIV (PLHIV) was similar to the general population. In Eswatini, more AGWY reported receiving social projection benefits than older women and more men not living with HIV reported receiving social protection benefits than MLHIV. In Tanzania, more WLHIV than women not living with HIV, MLHIV than men not living with HIV, and FSW than women who were not sex workers reported receiving social protection benefits. More data on access to social protection benefits by PLHIV or affected by HIV are needed to estimate better their social protection coverage.
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Pearson J, Shannon K, McBride B, Krüsi A, Machat S, Braschel M, Goldenberg S. Sex work community participation in criminalized environments: a community-based cohort study of occupational health impacts in Vancouver, Canada: 2010-2019. Int J Equity Health 2022; 21:18. [PMID: 35139867 PMCID: PMC8826666 DOI: 10.1186/s12939-022-01621-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/29/2021] [Indexed: 11/20/2022] Open
Abstract
Background Sex work criminalization and occupational stigma pose barriers to sex workers’ access to support services, including community participation — engagement with sex work specific community organizing at both formalized and grassroots capacities. In light of gaps in evidence regarding impacts of community participation on sex workers’ occupational health in higher-income settings, we evaluated engagement in community participation and associations with occupational sexual health outcomes among sex workers in Vancouver, Canada. Methods Prospective data from a community-based cohort of 943 women sex workers in Vancouver, British Columbia (2010–2019). We used logistic regression with generalised estimating equations (GEE) to model correlates of community participation, and a confounder modeling approach to examine the association of community participation on sexually transmitted infection (STI) seropositivity. Results Among participants, 38.1% were Indigenous, 31.4% identified as women of colour (e.g., East Asian, Southeast Asian, Black) and 29.3% were im/migrants to Canada. Over a quarter (28.3%, n = 267) serviced in informal indoor spaces, while 38.0% (n = 358) serviced clients in outdoor/public and 31.4% (n = 296) in formal in-call spaces. 8.9% of participants reported sex work community participation at least once over the 9-year study. In multivariable GEE analysis, Indigenous (adjusted odds ratio(aOR) 1.71, 95% confidence interval (CI) 0.88–3.32) and trans women (aOR 4.69, 95%CI 2.43–9.06) had higher odds of community participation; women of colour had lower odds (aOR 0.18, 95%CI 0.06–0.57). In a multivariable GEE confounder model, community participation was independently associated with lower odds of STI seropositivity (aOR 0.66, 95% CI0.45–0.96). Conclusion Sex workers who engaged in sex work community participation faced reduced odds of STI seropositivity. Building off reserach evaluating community interventions in low and middle income contexts, our study provides some of the first quantitative evidence on community participation among sex workers in Canada, and is the first to examine this in relation to sexual health outcomes. This research demonstrates the need to scale up community participation access for sex workers, via linguistically diverse community spaces, anti-stigma initiatives, and decriminalization to reduce barriers faced by racialized sex workers and support occupational health and rights for all sex workers.
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Affiliation(s)
- Jennie Pearson
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada
| | - Kate Shannon
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Bronwyn McBride
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada
| | - Andrea Krüsi
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Sylvia Machat
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada
| | - Melissa Braschel
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada
| | - Shira Goldenberg
- Centre for Gender and Sexual Health Equity, St. Paul's Hospital, 1081 Burrard Street, Vancouver, B.C., V6Z 1Y6, Canada. .,Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6, Canada. .,Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, USA.
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Ruegsegger LM, Stockton M, Go VF, Piscalko H, Davis D, Hoffman IF, Hosseinipour MC, Zalira E, Lungu T, Bula A, Lancaster KE. Stigma, Social Support, and Sexual Behavior Among Female Sex Workers at Risk for HIV in Malawi. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2021; 33:290-302. [PMID: 34370569 PMCID: PMC8408828 DOI: 10.1521/aeap.2021.33.4.290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Lack of social support and sex work stigma may hinder STI/HIV prevention for female sex workers (FSW). We explored the associations between sex work stigma and social support with sexual behaviors in Malawi. In 2017, 150 HIV-negative, venue-based FSW completed a behavioral survey containing sex work stigma items and social support. Linear binomial regression models were used to estimate prevalence differences of inconsistent condom use and substance use before sex by social support and stigma. A majority (93%) reported sex work-related internalized stigma. About 50% reported family or friend isolation. Social support was high (mean index: 86.53). Inconsistent condom use and substance use before sex had little to no association with stigma and social support. Malawian FSW largely internalize stigma and experience isolation from family and friends yet have high levels of social support. Large-scale evaluations should investigate the role of stigma and social support in STI/HIV prevention for FSW.
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Affiliation(s)
- Laura M. Ruegsegger
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melissa Stockton
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F. Go
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hannah Piscalko
- Division of Epidemiology, College of Public Health, The Ohio State University, 334 Cunz Hall, 1841 Neil Ave, Columbus, OH, USA
| | - Dylane Davis
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Irving F. Hoffman
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mina C. Hosseinipour
- Division of Infectious Diseases, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Thandie Lungu
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Agatha Bula
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Kathryn E. Lancaster
- Division of Epidemiology, College of Public Health, The Ohio State University, 334 Cunz Hall, 1841 Neil Ave, Columbus, OH, USA
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Beckham SW, Stockton M, Galai N, Davis W, Mwambo J, Likindikoki S, Kerrigan D. Family planning use and correlates among female sex workers in a community empowerment HIV prevention intervention in Iringa, Tanzania: a case for tailored programming. BMC Public Health 2021; 21:1377. [PMID: 34247614 PMCID: PMC8274018 DOI: 10.1186/s12889-021-11426-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 06/30/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Female sex workers in sub-Saharan Africa face high unmet need for family planning and higher risk for unintended pregnancy. Community empowerment HIV prevention approaches have the potential to increase family planning uptake and present an opportunity to integrate HIV, reproductive health, and contraception. This article describes family planning use and pregnancy among female sex workers in Iringa, Tanzania and evaluates whether engagement in a community empowerment HIV prevention program is associated with contraceptive use. METHODS This study consists of secondary analysis from a two-community randomized controlled trial following a longitudinal cohort over 18 months. We implemented a year-long community empowerment intervention consisting of 1) a community-led drop-in-center; 2) venue-based peer education, condom distribution, and HIV testing; 3) peer service navigation; 4) sensitivity trainings for providers and police; and 5) text messages to promote engagement. Additionally, monthly seminars were held at the drop-in-center, one of which focused on family planning. Modified Poisson regression models were used to estimate the association between program exposure and family planning use in the intervention arm. (Trials Registration NCT02281578, Nov 2, 2014.) RESULTS: Among the 339 participants with follow-up data on family planning, 60% reported current family planning use; 6% reported dual use of modern contraception and condoms; over 90% had living children; and 85% sought antenatal care at their most recent pregnancy. Among the 185 participants in the intervention arm, the adjusted relative risk (aRR) of family planning use among female sex workers who reported ever attending the Shikamana drop-in-center and among female sex workers who reported attending a family planning-related workshop was respectively 26% (aRR 1.26 [95% Confidence Interval (CI): 1.02-1.56]) and 36% (aRR 1.36 [95%CI: 1.13-1.64) higher than among those who had not attended. CONCLUSION There is a clear need for family planning among this population. General program exposure and exposure to a family planning workshop were associated with higher family planning use, which suggests that community empowerment models have potential to increase family planning uptake for this vulnerable group.
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Affiliation(s)
- S. Wilson Beckham
- grid.21107.350000 0001 2171 9311Johns Hopkins School of Public Health; Department of Health, Behavior and Society, 624 N Broadway HH 757, Baltimore, MD 21205 USA
| | - Melissa Stockton
- grid.10698.360000000122483208Gillings School of Global Public Health, Department of Epidemiology, 135 Dauer Dr., University of North Carolina—Chapel Hill, Chapel Hill, NC 27599 USA
| | - Noya Galai
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
| | - Wendy Davis
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205 USA
| | - Jessie Mwambo
- grid.25867.3e0000 0001 1481 7466Department of Psychiatry, Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania
| | - Samuel Likindikoki
- grid.25867.3e0000 0001 1481 7466Department of Psychiatry, Muhimbili University of Health and Allied Sciences, PO Box 65001, Dar es Salaam, Tanzania
| | - Deanna Kerrigan
- grid.21107.350000 0001 2171 9311Johns Hopkins School of Public Health; Department of Health, Behavior and Society, 624 N Broadway HH 757, Baltimore, MD 21205 USA
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12
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Hendrickson ZM, Leddy AM, Galai N, Beckham SW, Davis W, Mbwambo JK, Likindikoki S, Kerrigan DL. Mobility for sex work and recent experiences of gender-based violence among female sex workers in Iringa, Tanzania: A longitudinal analysis. PLoS One 2021; 16:e0252728. [PMID: 34081739 PMCID: PMC8174717 DOI: 10.1371/journal.pone.0252728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/20/2021] [Indexed: 11/25/2022] Open
Abstract
Female sex workers are highly mobile, which may influence their risk of experiencing physical and sexual violence. However, there remains a paucity of research, particularly longitudinal, from Sub-Saharan Africa exploring mobility and gender-based violence among female sex workers. To address this gap, this study examined the longitudinal relationship between work-related mobility and recent experience of physical or sexual gender-based violence from a client or partner among female sex workers in Iringa, Tanzania. A secondary data analysis was conducted using baseline and 18-month follow-up data from Project Shikamana, a community empowerment-based combination HIV prevention intervention. Responses from 387 female sex workers aged 18 years and older participating in both baseline and follow-up were analyzed. Unadjusted and adjusted Poisson regression models with robust variance estimations, accounting for clustering of female sex workers' responses over time, were fit. Final models adjusted for socio-demographic characteristics and aspects of participants' living situations and work environments. Recent physical or sexual violence from a client or partner was common (baseline: 40%; follow-up: 29%). Twenty-six percent of female sex workers at baseline, and 11% at follow-up, had recently traveled outside of Iringa for sex work. In the final adjusted longitudinal model, female sex workers recently mobile for sex work had a 25% increased risk of any recent experience of physical or sexual gender-based violence when compared with their non-mobile counterparts (adjusted incidence rate ratio: 1.25; 95% CI: 1.03-1.53; p<0.05). Interventions must identify ways-such as mobile support services, linkages and referrals to health and other social services while traveling, or the use of mobile or digital technology-to address mobile female sex workers' unique needs while traveling. Future quantitative and qualitative research is needed to understand the context of female sex workers' mobility and how and why mobility influences risk environments and experiences of gender-based violence.
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Affiliation(s)
- Zoé Mistrale Hendrickson
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Anna M. Leddy
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Noya Galai
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Statistics, University of Haifa, Mt Carmel, Haifa, Israel
| | - S. Wilson Beckham
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Wendy Davis
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America
| | - Jessie K. Mbwambo
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Samuel Likindikoki
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Deanna L. Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America
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13
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Yang LS, Witte SS, Vélez-Grau C, McCrimmon T, Terlikbayeva A, Primbetova S, Mergenova G, El-Bassel N. The Financial Lives and Capabilities of Women Engaged in Sex Work: Can Paradoxical Autonomy Inform Intervention Strategies? Glob J Health Sci 2021; 13:69-80. [PMID: 37163144 PMCID: PMC10165725 DOI: 10.5539/gjhs.v13n6p69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction Despite growing attention to structural approaches to HIV prevention, including economic empowerment interventions for key populations, few studies examine the financial lives of women engaged in sex work (WESW) and even fewer examine the financial lives of those who also use drugs. The purpose of this paper is to examine the financial status, sex work involvement, and individual and structural vulnerabilities of women involved in sex work and drug use in Kazakhstan. Methods We used baseline data from Project Nova, a cluster-randomized controlled trial that tested the efficacy of a combined HIV risk reduction and microfinance intervention for WESW in two cities in Kazakhstan. We collected data on income, savings, debt, sex work, drug use, homelessness, food insecurity, HIV status, attitudes towards safety, and financial knowledge from 400 participants through computer-assisted self-interview techniques. Descriptive statistics were utilized to describe and characterize the sample and aforementioned measures. Results Findings illustrate the paradoxical nature of sex work, wherein women may achieve economic independence despite the great adversities they encounter in their daily lives and work. The majority of women (65%) in this study reported being the highest income earner in the household, caring for up to 3 dependents, and demonstrated entrepreneurial characteristics and aspirations for the future. However, many were still living below the poverty line (72.5%), as well as experiencing high levels of homelessness (58%) and food insecurity (89.5%). Conclusion Study findings underscore the need for better understanding of the existing capabilities of WESW and those who use drugs, including financial autonomy and community supports, that may guide the design of programs that most effectively promote women's economic well-being and ensure that it is not at the expense of wellness and safety. Designing such programs requires incorporating a social justice lens into social work and public health interventions, including HIV prevention, and attention to the human rights of the most marginalized and highest risk populations, including WESW and those who use drugs.
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Affiliation(s)
- Lyla S Yang
- Columbia University, School of Social Work, New York, NY
| | - Susan S Witte
- Columbia University, School of Social Work, New York, NY
- Social Intervention Group, Columbia University School of Social Work, New York, NY
| | | | - Tara McCrimmon
- Social Intervention Group, Columbia University School of Social Work, New York, NY
| | | | | | | | - Nabila El-Bassel
- Columbia University, School of Social Work, New York, NY
- Social Intervention Group, Columbia University School of Social Work, New York, NY
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14
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Assessing and Addressing Social Determinants of HIV among Female Sex Workers in the Dominican Republic and Tanzania through Community Empowerment-Based Responses. Curr HIV/AIDS Rep 2020; 17:88-96. [PMID: 32072467 DOI: 10.1007/s11904-020-00485-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW This review describes social determinants of HIV in two geographic and epidemic settings, the Dominican Republic (DR) and Tanzania, among female sex workers (FSW), their influence on HIV outcomes including 90-90-90 goals, and the development and impact of tailored, context driven, community empowerment-based responses in each setting. RECENT FINDINGS Our review documents the significance of social determinants of HIV including sex work-related stigma, discrimination, and violence and the impact of community empowerment-based approaches on HIV incidence in Tanzania and other HIV prevention, treatment, and care outcomes, including care engagement and adherence, in the DR and Tanzania. Community empowerment approaches where FSW drive the response to HIV and strategically engage partners to target socio-structural and environmental factors can have a demonstrable impact on HIV prevention, treatment, and care outcomes. Such approaches can also support further gains towards reaching the 90-90-90 across geographies and types of epidemics.
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15
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Liu C, Meyers K. Beyond clinical trials: social outcomes of structured stakeholder engagement in biomedical HIV prevention trials in China. CULTURE, HEALTH & SEXUALITY 2020; 22:1365-1381. [PMID: 31702447 PMCID: PMC7205565 DOI: 10.1080/13691058.2019.1683230] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 10/17/2019] [Indexed: 05/31/2023]
Abstract
Stakeholder engagement is increasingly recognised and institutionalised as an essential component of HIV-related biomedical research. However, we know little about stakeholder engagement's social outcomes, such as its influence on the community it engages with, in authoritarian regimes and beyond high-income countries. This study evaluates a multi-site structured stakeholder engagement programme conducted in parallel with two HIV prevention studies among men who have sex with men in China. We conducted a one-month ethnographic study and 41 semi-structured interviews with participants of a structured stakeholder engagement programme in six Chinese cities. We found that the structured stakeholder engagement programme offered community stakeholders additional and flexible funding, networking opportunities, increased clinical research literacy, and strengthened their connections with the community. However, the structured stakeholder programme generated unintended consequences in some cases. It caused community stakeholders to expend their social capital, introduced moral conflicts and created tension between stakeholders' 'community representative' and 'research assistant' identities. Our findings suggest that despite these unintended consequences, structured stakeholder engagement could effectively mitigate negative outcomes generated by such engagement if such programmes are more sensitive and responsive to the broader socio-political structure in which trials are embedded.
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Affiliation(s)
- Chuncheng Liu
- Department of Sociology, University of California San Diego, La Jolla, CA, USA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center, The Rockefeller University, New York, NY, USA
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16
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Brault MA, Spiegelman D, Abdool Karim SS, Vermund SH. Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials. Curr HIV/AIDS Rep 2020; 17:249-258. [PMID: 32297219 DOI: 10.1007/s11904-020-00492-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA.
| | - Donna Spiegelman
- Department of Biostatistics; Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Salim S Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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17
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Fielding-Miller R, Hatcher AM, Wagman J, Swendeman D, Upadhyay UD. Gender, justice and empowerment: creating the world we want to see. CULTURE, HEALTH & SEXUALITY 2020; 22:1-12. [PMID: 32723225 PMCID: PMC8155812 DOI: 10.1080/13691058.2020.1736843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
| | - Abigail M. Hatcher
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Jennifer Wagman
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, USA
- Women’s Health, Gender and Empowerment Center of Expertise, University of California Global Health Institute, San Francisco, CA, USA
| | - Dallas Swendeman
- Women’s Health, Gender and Empowerment Center of Expertise, University of California Global Health Institute, San Francisco, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Ushma D. Upadhyay
- Women’s Health, Gender and Empowerment Center of Expertise, University of California Global Health Institute, San Francisco, CA, USA
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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