Reconsidering the impact of conflict on HIV infection among women in the era of antiretroviral treatment scale-up in sub-Saharan Africa: a gender lens

Sexually transmitted infections among pregnant Syrian refugee women seeking antenatal care in Lebanon

The prevalence of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis was determined among 431 pregnant Syrian refugee women seeking antenatal care in Lebanon. Low prevalence at 0.5% for chlamydia, 0.2% for trichomoniasis and 0.0% for gonorrhoeae was detected, suggesting a low burden of sexually transmitted infection in this population.

The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine

This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.

"Stigma and HIV Are Like Brother and Sister!": The Experience of African-Born Persons Living with HIV in the US

Minnesota has seen an increase in the number of immigrants from Africa, notably in the mid-1990s, making up around 2% of Minnesota’s total population. This population also faces many impediments that cause important difficulties not only for HIV prevention but also for treatment and care options. The objectives of this study were to capture the experiences of Persons Living with HIV (PLWH) in Minnesota (US) and to elicit their stories about their diagnosis news and what management strategies they use for coping with the stigma associated with the disease. Participants were recruited via fliers in pharmacies, clinics, and HIV service centers located in Minnesota. Recruitment continued until thematic saturation was obtained. Fourteen subjects participated in audio-recorded, semi-structured interviews that were transcribed verbatim into written text. The transcriptions were analyzed using Thematic Analysis. Three themes emerged from the data. Theme 1: Cruel News: “HIV-Oooooo! I wish I was dead”, Theme 2: This is My Secret! and Theme 3: “Stigma and HIV are brother and sister”. The results demonstrate that stigma is an ever-present problem in African-born PLWH living in the US. Participants perceived the stigma associated with HIV status to affect their lives and culture at individual, familial, and societal levels.

What drives mortality among HIV patients in a conflict setting? A prospective cohort study in the Central African Republic

Background

Provision of antiretroviral therapy (ART) during conflict settings is rarely attempted and little is known about the expected patterns of mortality. The Central African Republic (CAR) continues to have a low coverage of ART despite an estimated 110,000 people living with HIV and 5000 AIDS-related deaths in 2018. We present results from a cohort in Zemio, Haut-Mboumou prefecture. This region had the highest prevalence of HIV nationally (14.8% in a 2010 survey), and was subject to repeated attacks by armed groups on civilians during the observed period.

Methods

Conflict from armed groups can impact cohort mortality rates i) directly if HIV patients are victims of armed conflict, or ii) indirectly if population displacement or fear of movement reduces access to ART. Using monthly counts of civilian deaths, injuries and abductions, we estimated the impact of the conflict on patient mortality. We also determined patient-level risk factors for mortality and how the risk of mortality varies with time spent in the cohort. Model-fitting was performed in a Bayesian framework, using logistic regression with terms accounting for temporal autocorrelation.

Results

Patients were recruited and observed in the HIV treatment program from October 2011 to May 2017. Overall 1631 patients were enrolled and 1628 were included in the analysis giving 48,430 person-months at risk and 145 deaths. The crude mortality rate after 12 months was 0.92 (95% CI 0.90, 0.93). Our model showed that patient mortality did not increase during periods of heightened conflict; the odds ratios (OR) 95% credible interval (CrI) for i) civilian fatalities and injuries, and ii) civilian abductions on patient mortality both spanned unity. The risk of mortality for individual patients was highest in the second month after entering the cohort, and declined seven-fold over the first 12 months. Male sex was associated with a higher mortality (odds ratio 1.70 [95% CrI 1.20, 2.33]) along with the severity of opportunistic infections (OIs) at baseline (OR 2.52; 95% CrI 2.01, 3.23 for stage 2 OIs compared with stage 1).

Conclusions

Our results show that chronic conflict did not appear to adversely affect rates of mortality in this cohort, and that mortality was driven predominantly by patient-specific risk factors. The risk of mortality and recovery of CD4 T-cell counts observed in this conflict setting are comparable to those in stable resource poor settings, suggesting that conflict should not be a barrier in access to ART.

High burden of previously undiagnosed HIV infections and gaps in HIV care cascade for conflict-affected female sex workers in northern Uganda

Given the disproportionate HIV burden faced by female sex workers FSWs and limited data regarding their engagement in the HIV cascade of care in conflict-affected settings, we characterized the cascade of care and examined associations with new HIV diagnoses and antiretroviral therapy (ART) use in a community-based cohort of FSWs in conflict-affected Northern Uganda. Data were collected via FSW/peer-led time-location sampling and outreach, interview-administered questionnaires, and voluntary HIV testing. Of 400 FSWs, 33.5% were living with HIV, of whom 33.6% were new/previously undiagnosed infections and 32.8% were on ART. Unstable housing and heavy alcohol/drug use were independently associated with increased odds of new HIV diagnoses, whereas exposure to condom demonstrations and number of lifetime pregnancies were negatively associated. In subanalysis among known HIV-positive women, age and time since diagnosis were associated with ART use, whereas sexually transmitted infections were negatively associated. Findings suggest the need for FSW-tailored, peer-based, and integrated HIV and sexual and reproductive health programs to address gaps in HIV testing and treatment for FSWs in conflict-affected communities.

A comprehensive review of HIV/STI prevention and sexual and reproductive health services among sex Workers in Conflict-Affected Settings: call for an evidence- and rights-based approach in the humanitarian response

Background

While the conditions in emergency humanitarian and conflict-affected settings often result in significant sex work economies, there is limited information on the social and structural conditions of sex work in these settings, and the impacts on HIV/STI prevention and access to sexual and reproductive health (SRH) services for sex workers. Our objective was to comprehensively review existing evidence on HIV/STI prevention and access to SRH services for sex workers in conflict-affected settings globally.

Methods

We conducted a comprehensive review of all peer review (both epidemiological and qualitative) and grey literature published in the last 15 years (2000–2015), focusing on 1) HIV/STI vulnerability or prevention, and/or 2) access to SRH services for sex workers in conflict-affected settings. Five databases were searched, using combinations of sex work, conflict/mobility, HIV/STI, and SRH service terms. Relevant peer-reviewed and grey literature were also hand-searched, and key papers were cross-referenced for additional material.

Results

Five hundred fifty one records were screened and 416 records reviewed. Of 33 records describing HIV/STI prevention and/or access to SRH services among sex workers in conflict-affected settings, 24 were from sub-Saharan Africa; 18 studies described the results of primary research (13 quantitative, 3 qualitative, 2 mixed-methods) and 15 were non-primary research (e.g., commentaries, policy reports, programmatic manuals). Available evidence indicated that within conflict-affected settings, SWs’ capacity to engage in HIV/STI prevention and access SRH services is severely undermined by social and structural determinants including widespread violence and human rights violations, the collapse of livelihoods and traditional social structures, high levels of displacement, and difficulties accessing already scant health services due to stigma, discrimination and criminalization.

Discussion/Conclusions

This review identified significant gaps in HIV/STI and SRH research, policy, and programming for conflict-affected sex workers, highlighting a critical gap in the humanitarian response. Sex worker-informed policies and interventions to promote HIV/STI prevention and access to HIV and SRH services using a rights-based approach are recommended, and further research on the degree to which conflict-affected sex workers are accessing HIV/STI and SRH services is recommended.

A paradigm shift from the behavioural and biomedical approach to a human rights-based approach to HIV/STI prevention and SRH is strongly recommended.

War-Related Abduction and History of Incarceration Linked to High Burden of HIV Among Female Sex Workers in Conflict-Affected Northern Uganda

OBJECTIVE

Sex workers (SWs) in sub-Saharan Africa face a disproportionate HIV burden and growing concerns of severe human rights violations. Given the dearth of evidence on the burden and correlates of HIV among SWs in sub-Saharan Africa, particularly within conflict-affected settings, we examined the relationship between structural determinants (eg, war-related abduction, incarceration) and HIV infection among conflict-affected SWs in Northern Uganda.

DESIGN

Cross-sectional community-based research study among female SWs in conflict-affected Gulu, Northern Uganda.

METHODS

Interview questionnaires and voluntary HIV testing were conducted with participants recruited through SW/peer-led outreach and time-location sampling from 2011 to 2012. HIV prevalence was calculated, and bivariable and multivariable logistic regression was used to identify independent associations with HIV seroprevalence.

RESULTS

Of 400 SWs, 135 (33.75%) were HIV seropositive; of whom one-third were new/previously undiagnosed HIV infections. In multivariable analysis, after adjusting for age of sex work entry and education, lifetime incarceration (adjusted odds ratio: 1.93, 95% confidence interval: 1.17 to -3.20) was independently associated with HIV seroprevalence, and history of wartime abduction (adjusted odds ratio: 1.62, 95% confidence interval: 1.00 to 2.63) was marginally associated (P = 0.051).

CONCLUSIONS

This study documented a high rate of undiagnosed HIV infections and associations between war-related human rights violations, incarceration, and a heavy HIV burden among SWs in conflict-affected Northern Uganda. These findings highlight the serious harms of conflict and criminalization of marginalized women in sub-Saharan African contexts. SW-led interventions that address conflict experiences and policy shifts to promote a rights-based approach to HIV prevention and care remain critically needed.

"The Cango Lyec Project - Healing the Elephant": HIV related vulnerabilities of post-conflict affected populations aged 13-49 years living in three Mid-Northern Uganda districts

BACKGROUND

The protracted war between the Government of Uganda and the Lord's Resistance Army in Northern Uganda (1996-2006) resulted in widespread atrocities, destruction of health infrastructure and services, weakening the social and economic fabric of the affected populations, internal displacement and death. Despite grave concerns that increased spread of HIV/AIDS may be devastating to post conflict Northern Uganda, empirical epidemiological data describing the legacy of the war on HIV infection are scarce.

METHODS

The 'Cango Lyec' Project is an open cohort study involving conflict-affected populations living in three districts of Gulu, Nwoya and Amuru in mid-northern Uganda. Between November 2011 and July 2012, 8 study communities randomly selected out of 32, were mapped and house-to-house census conducted to enumerate the entire community population. Consenting participants aged 13-49 years were enrolled and interviewer-administered data were collected on trauma, depression and socio-demographic-behavioural characteristics, in the local Luo language. Venous blood was taken for HIV and syphilis serology. Multivariable logistic regression was used to determine factors associated with HIV prevalence at baseline.

RESULTS

A total of 2954 participants were eligible, of whom 2449 were enrolled. Among 2388 participants with known HIV status, HIV prevalence was 12.2% (95%CI: 10.8-13.8), higher in females (14.6%) than males (8.5%, p < 0.001), higher in Gulu (15.2%) than Nwoya (11.6%, p < 0.001) and Amuru (7.5%, p = 0.006) districts. In this post-conflict period, HIV infection was significantly associated with war trauma experiences (Adj. OR = 2.50; 95%CI: 1.31-4.79), the psychiatric problems of PTSD (Adj. OR = 1.44; 95%CI: 1.06-1.96), Major Depressive Disorder (Adj. OR = 1.89; 95%CI: 1.28-2.80) and suicidal ideation (Adj. OR = 1.87; 95%CI: 1.34-2.61). Other HIV related vulnerabilities included older age, being married, separated, divorced or widowed, residing in an urban district, ulcerative sexually transmitted infections, and staying in a female headed household. There was no evidence in this study to suggest that people with a history of abduction were more likely to be HIV positive.

CONCLUSIONS

HIV prevalence in this post conflict-affected population is high and is significantly associated with age, trauma, depression, history of ulcerative STIs, and residing in more urban districts. Evidence-based HIV/STI prevention programs and culturally safe, gender and trauma-informed are urgently needed.

Pre-incarceration police harassment, drug addiction and HIV risk behaviours among prisoners in Kyrgyzstan and Azerbaijan: results from a nationally representative cross-sectional study

Introduction

The expanding HIV epidemic in Azerbaijan and Kyrgyzstan is concentrated among people who inject drugs (PWID), who comprise a third of prisoners there. Detention of PWID is common but its impact on health has not been previously studied in the region. We aimed to understand the relationship between official and unofficial (police harassment) detention of PWID and HIV risk behaviours.

Methods

In a nationally representative cross-sectional study, soon-to-be released prisoners in Kyrgyzstan (N=368) and Azerbaijan (N=510) completed standardized health assessment surveys. After identifying correlated variables through bivariate testing, we built multi-group path models with pre-incarceration official and unofficial detention as exogenous variables and pre-incarceration composite HIV risk as an endogenous variable, controlling for potential confounders and estimating indirect effects.

Results

Overall, 463 (51%) prisoners reported at least one detention in the year before incarceration with an average of 1.3 detentions in that period. Unofficial detentions (13%) were less common than official detentions (41%). Optimal model fit was achieved (X²=5.83, p=0.44; Goodness of Fit Index (GFI) GFI=0.99; Comparative Fit Index (CFI) CFI=1.00; Root Mean Square Error of Approximation (RMSEA) RMSEA=0.00; PCLOSE=0.98) when unofficial detention had an indirect effect on HIV risk, mediated by drug addiction severity, with more detentions associated with higher addiction severity, which in turn correlated with increased HIV risk. The final model explained 35% of the variance in the outcome. The effect was maintained for both countries, but stronger for Kyrgyzstan. The model also holds for Kyrgyzstan using unique data on within-prison drug injection as the outcome, which was frequent in prisoners there.

Conclusions

Detention by police is a strong correlate of addiction severity, which mediates its effect on HIV risk behaviour. This pattern suggests that police may target drug users and that such harassment may result in an increase in HIV risk-taking behaviours, primarily because of the continued drug use within prisons. These findings highlight the important negative role that police play in the HIV epidemic response and point to the urgent need for interventions to reduce police harassment, in parallel with interventions to reduce HIV transmission within and outside of prison.

HIV, drugs and the legal environment

A large body of scientific evidence indicates that policies based solely on law enforcement without taking into account public health and human rights considerations increase the health risks of people who inject drugs (PWIDs) and their communities. Although formal laws are an important component of the legal environment supporting harm reduction, it is the enforcement of the law that affects PWIDs' behavior and attitudes most acutely. This commentary focuses primarily on drug policies and policing practices that increase PWIDs' risk of acquiring HIV and viral hepatitis, and avenues for intervention. Policy and legal reforms that promote public health over the criminalization of drug use and PWID are urgently needed. This should include alternative regulatory frameworks for illicit drug possession and use. Changing legal norms and improving law enforcement responses to drug-related harms requires partnerships that are broader than the necessary bridges between criminal justice and public health sectors. HIV prevention efforts must partner with wider initiatives that seek to improve police professionalism, accountability, and transparency and boost the rule of law. Public health and criminal justice professionals can work synergistically to shift the legal environment away from one that exacerbates HIV risks to one that promotes safe and healthy communities.

Molecular epidemiology of HIV type 1 subtypes in Rwanda

HIV-1 infection is characterized by genetic diversity, with multiple subtypes and recombinant variants circulating, particularly in sub-Saharan Africa. During the Rwandan genocide, many women experienced multiple rapes and some became HIV-1 infected. We studied plasma and peripheral blood mononuclear cells (PBMCs) from 30 infected women comprising two exposure groups: those with numerous contacts, raped multiple times, and women with one lifetime sexual partner and no history of rape. Population-based sequences from gag, pol, and env genes were analyzed to determine HIV-1 subtypes and intersubtype recombination. Individual plasma-derived variants from 12 women were also analyzed. Subtype A was found in 24/30 (80%), intersubtype recombination (AC and AD) in 4/30 (13%), and subtypes C and D in 1/30 each. In two subjects, the pattern of HIV-1 recombination differed between plasma and PBMC-derived sequences. Intersubtype recombination was common, although there were no significant differences in subtype or recombination rates between exposure groups.

Reproductive health for refugees by refugees in Guinea IV: Peer education and HIV knowledge, attitudes, and reported practices

BACKGROUND

Both conflict and HIV affect sub-Saharan Africa, and supportive approaches for HIV prevention among refugees are crucial. Peer education has been associated with improved HIV outcomes, though relatively little research has been published on refugee settings. The primary objective of this study was to assess whether exposure to refugee peer education was associated with improved HIV knowledge, attitudes, or practice outcomes among refugees in Guinea. Secondary objectives were to assess whether gender, age, or formal education were more strongly associated than peer education with improved HIV outcomes.

METHODS

Data was collected by cross-sectional survey from 889 reproductive-age men and women in 23 camps in the Forest Region of Guinea. Selected exposures (i.e. peer education, gender, formal education, age) were analysed for associations with HIV outcomes using logistic regression odds ratios (OR).

RESULTS

Most participants (88%) had heard of HIV, particularly those exposed to peer or formal education. Most correctly identified ways to protect themselves, while maintaining misconceptions about HIV transmission. Women and those exposed to either peer or formal education had significantly fewer misconceptions. Half of participants considered themselves at risk of HIV, women with 52% higher odds than men (adjusted OR 1.52, 95%CI 1.01-2.29). Participants exposed to peer education had more than twice the odds of reporting having made HIV-avoidant behavioural changes than unexposed participants (72% versus 58%; adjusted OR 2.49, 95%CI 1.52-4.08). While women had 57% lower odds than men of reporting HIV-avoidant behavioural changes (OR 0.43, 95%CI 0.31-0.60), women exposed to peer education had greater odds than exposed men of reporting HIV-avoidant changes (OR 2.70 versus OR 1.95). Staying faithful (66%) was the most frequent behavioural change reported.

CONCLUSIONS

Peer education was most strongly associated with reported HIV-avoidant behaviour change. Gender was most associated with HIV knowledge and risk perception. Refugee women had fewer misconceptions than men had, but were more likely to report HIV risk and less likely to report making behavioural changes. Peer education appears promising for HIV interventions in chronic-emergency settings, if gender disparities and related barriers to condom usage are also addressed.

Provision of antiretroviral treatment in conflict settings: the experience of Médecins Sans Frontières

INTRODUCTION

Many countries ravaged by conflict have substantial morbidity and mortality attributed to HIV/AIDS yet HIV treatment is uncommonly available. Universal access to HIV care cannot be achieved unless the needs of populations in conflict-affected areas are addressed.

METHODS

From 2003 Médecins Sans Frontières introduced HIV care, including antiretroviral therapy, into 24 programmes in conflict or post-conflict settings, mainly in sub-Saharan Africa. HIV care and treatment activities were usually integrated within other medical activities. Project data collected in the Fuchia software system were analysed and outcomes compared with ART-LINC data. Programme reports and other relevant documents and interviews with local and headquarters staff were used to develop lessons learned.

RESULTS

In the 22 programmes where ART was initiated, more than 10,500 people were diagnosed with HIV and received medical care, and 4555 commenced antiretroviral therapy, including 348 children. Complete data were available for adults in 20 programmes (n = 4145). At analysis, 2645 (64%) remained on ART, 422 (10%) had died, 466 (11%) lost to follow-up, 417 (10%) transferred to another programme, and 195 (5%) had an unclear outcome. Median 12-month mortality and loss to follow-up were 9% and 11% respectively, and median 6-month CD4 gain was 129 cells/mm 3.Patient outcomes on treatment were comparable to those in stable resource-limited settings, and individuals and communities obtained significant benefits from access to HIV treatment. Programme disruption through instability was uncommon with only one program experiencing interruption to services, and programs were adapted to allow for disruption and population movements. Integration of HIV activities strengthened other health activities contributing to health benefits for all victims of conflict and increasing the potential sustainability for implemented activities.

CONCLUSIONS

With commitment, simplified treatment and monitoring, and adaptations for potential instability, HIV treatment can be feasibly and effectively provided in conflict or post-conflict settings.

Providing antiretroviral care in conflict settings

There has been an historic expectation that delivering combination antiretroviral therapy (cART) to populations affected by violent conflict is untenable due to population movement and separation of drug supplies. There is now emerging evidence that cART provision can be successful in these populations. Using examples from Médecins Sans Frontières experience in a variety of African settings and also local nongovernmental organizations' experiences in northern Uganda, we examine novel approaches that have ensured retention in programs and adequate adherence. Emerging guidelines from United Nations bodies now support the expansion of cART in settings of conflict.