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Manguro GO, Kioko UM, Githinji G, Owira P, Langat L, Okoro D, Temmerman M, Luchters S. Costs and cost drivers of comprehensive sexual reproductive health services to female sex workers in Kenya. BMC Health Serv Res 2024; 24:822. [PMID: 39014381 PMCID: PMC11253356 DOI: 10.1186/s12913-024-11293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 07/08/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Comprehensive sexual reproductive health (SRH) programs for female sex workers (FSW) offering clinical, behavioural, and structural interventions have contributed to declining rates of HIV in this population. However, data on costs and cost drivers is needed to support programs and their donors to better allocate resources, make an investment case for continued funding, and to identify areas of improvement in program design and implementation. We aimed to estimate the annual per-FSW costs of comprehensive services for a standalone FSW program in Kenya. METHODS We implemented a top-bottom and activity-based costing study of comprehensive FSW services at two drop-in centres (DICs), Mtwapa and Kilifi town, in Kilifi County, Kenya. Service costs were obtained from routinely collected patient data during FSW scheduled and unscheduled visits using Kenyan Ministry of Health records. Costing data were from the program and organization's expenditure reports, cross checked against bank documents and supported by information from in-depth interviews. Data were collected retrospectively for the fiscal year 2019. We obtained approval from the AMREF Research Ethics Committee (AMREF-ESRC P862/2020). RESULTS In 2019, the unit cost of comprehensive services was 105.93 USD per FSW per year, roughly equivalent to 10,593 Kenya shillings. Costs were higher at Mtwapa DICs compared to Kilifi town DIC; 121.90 USD and 89.90 USD respectively. HIV counselling and testing cost 63.90 USD per person, PrEP was 34.20 USD and family planning was 9.93 USD. Of the total costs, staff salaries accounted for about 60%. Adjusted for inflation, costs in 2024 would be approximately 146.60. CONCLUSION Programs should strive to maximize the number of FSW served to benefit from economies of scale. Given that personnel costs contribute most to the unit costs, programs should consider alternative designs which reduce personnel and other costs.
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Affiliation(s)
- Griffins O Manguro
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
| | | | - Gerald Githinji
- Monitoring and Evaluation, International Centre for Reproductive Health Kenya, Mombasa, Kenya
| | - Patricia Owira
- Monitoring and Evaluation, International Centre for Reproductive Health Kenya, Mombasa, Kenya
| | | | | | - Marleen Temmerman
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Monitoring and Evaluation, International Centre for Reproductive Health Kenya, Mombasa, Kenya
- Aga Khan University Centre for Excellence in Women and Child Health, Nairobi, Kenya
| | - Stanley Luchters
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
- Centre for Sexual Health and, HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe
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Becker M, Mishra S, Bhattacharjee P, Musyoki H, Tennakoon A, Leung S, Cheuk E, Lorway R, Isac S, Ma H, Cholette F, Sandstrom P, Gichangi P, Mwatelah R, Mckinnon L, Blanchard J, Pickles M. Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya. J Acquir Immune Defic Syndr 2024; 96:121-129. [PMID: 38771751 DOI: 10.1097/qai.0000000000003412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 02/02/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk. SETTING This study took place in Mombasa, Kenya. METHODS We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors. RESULTS Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW. CONCLUSION AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.
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Affiliation(s)
- Marissa Becker
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Parinita Bhattacharjee
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Aruni Tennakoon
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Stella Leung
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Eve Cheuk
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Rob Lorway
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Shajy Isac
- India Health Action Trust, New Delhi, India
| | - Huiting Ma
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Francois Cholette
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- National HIV and Retrovirology Laboratories, J.C. Wilt Infectious Diseases Research Centre at the National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Canada
| | - Paul Sandstrom
- National HIV and Retrovirology Laboratories, J.C. Wilt Infectious Diseases Research Centre at the National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Canada
| | | | - Ruth Mwatelah
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Lyle Mckinnon
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Microbiology and Immunology, University of Nairobi, Nairobi, Kenya; and
| | - James Blanchard
- Department of Community Health Sciences, Institute for Global Public Health, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
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Mody A, Sohn AH, Iwuji C, Tan RKJ, Venter F, Geng EH. HIV epidemiology, prevention, treatment, and implementation strategies for public health. Lancet 2024; 403:471-492. [PMID: 38043552 DOI: 10.1016/s0140-6736(23)01381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 12/05/2023]
Abstract
The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care.
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Affiliation(s)
- Aaloke Mody
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
| | - Annette H Sohn
- TREAT Asia, amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Collins Iwuji
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Rayner K J Tan
- University of North Carolina Project-China, Guangzhou, China; Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Francois Venter
- Ezintsha, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Elvin H Geng
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
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Babirye S, Michielsen K, Ssengooba F. The unwritten rules and HIV: a qualitative study of informal institutions and HIV vulnerability among workers at social venues in Uganda. Front Public Health 2023; 11:1288058. [PMID: 38155895 PMCID: PMC10752962 DOI: 10.3389/fpubh.2023.1288058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/14/2023] [Indexed: 12/30/2023] Open
Abstract
Introduction There is increasing appreciation of the need to understand how social and structural factors shape HIV risk. The unwritten rules, also known as informal institutions or social norms, are increasingly recognized as important determinants of HIV transmission. Unfortunately, these informal institutions, especially among high-risk environments for HIV, such as social venues like bars, lodges, remain poorly understood. This study explored the informal institutions at social venues, and how these institutions influenced vulnerability for HIV for venue workers in Uganda. Methods We conducted a qualitative study in two districts of Kyotera and Rakai in Central Uganda. We purposively selected and interviewed 44 workers including, cleaners, waiters, and waitresses and 22 venue managers at 22 social venues to explore the informal institutions at these establishments and how the institutions shaped HIV vulnerabilities among the workers. 31.8% (14) of the participants were males, and 68.2% (30) females. Data were analyzed using thematic content analysis. Results We found that the informal institutions at the venues were both officially and socially created, communicated, and sanctioned. The most common institutions operated through; selective hiring, rigid reporting structures, and informal job contracting procedures. Meager salaries, varying and delayed payments as well as attractive benefits and bonuses from customers were also important forms of informal institutions at the venues. Drinking alcohol, and offering sexual services at the venues were acceptable, although excessive drinking, and committed sexual relationships with customers were disapproved. These informal institutions shaped a risk environment at the venues by creating risk exposure opportunities that influenced workers' engagement into sexual risk behaviors. Conclusion The risk environment at social venues is shaped by the informal institutions at these venues. Thus, the need for venue-based HIV programs that integrate social norms interventions to better address the contextual determinants of HIV risk behaviors at the venues.
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Affiliation(s)
- Susan Babirye
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Health Policy, Planning, and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Research and Evaluation, Afrislum Uganda, Kampala, Uganda
| | - Kristien Michielsen
- International Centre for Reproductive Health, Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Freddie Ssengooba
- Department of Health Policy, Planning, and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Center for Policy and Management Science, Kampala, Uganda
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Bhattacharjee P, Isac S, Musyoki H, Gichangi P, Ma H, Becker M, Hontelez J, Mishra S. Changes in context, typology and programme outcomes between early and recent periods of sex work among young female sex workers in Mombasa, Kenya: A cross-sectional study. PLoS One 2023; 18:e0288717. [PMID: 37490512 PMCID: PMC10368250 DOI: 10.1371/journal.pone.0288717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 07/04/2023] [Indexed: 07/27/2023] Open
Abstract
INTRODUCTION The sex work context and typology change continuously and influence HIV related risk and vulnerability for young female sex workers (YFSW). We sought to describe changes in the context and typology of sex work between the first (early) and past month (recent) of sex work among YFSW to inform HIV prevention programming for sex workers. METHODS We used data from a cross-sectional survey (April-November 2015), administered using physical location-based sampling to 408 cis-women, aged 14-24 years, who self-identified as sex workers, in Mombasa, Kenya. We collected self-reported data on the early and recent month of sex work. The analysis focused on changes in a) sex work context and typology (defined by setting where sex workers practice sex work) where YFSW operated, b) primary typology of sex work, and c) HIV programme outcomes among YFSW who changed primary typology, within the early and recent month of sex work. We analysed the data using a) SPSS27.0 and excel; b) bivariate analysis and χ2 test; and c) bivariate logistic regression models. RESULTS Overall, the median age of respondents was 20 years and median duration in sex work was 2 years. Higher proportion of respondents in the recent period managed their clients on their own (98.0% vs. 91.2%), had sex with >5 clients per week (39.3% vs.16.5%); were able to meet > 50% of living expenses through sex work income (46.8% vs. 18.8%); and experienced police violence in the past month (16.4% vs. 6.5%). YFSW reported multiple sex work typology in early and recent periods. Overall, 37.2% reported changing their primary typology. A higher proportion among those who used street/ bus stop typology, experienced police violence, or initiated sex work after 19 years of age in the early period reported a change. There was no difference in HIV programme outcomes among YFSW who changed typology vs. those who did not. CONCLUSIONS The sex work context changes even in a short duration of two years. Hence, understanding these changes in the early period of sex work can allow for development of tailored strategies that are responsive to the specific needs and vulnerabilities of YFSW.
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Affiliation(s)
- Parinita Bhattacharjee
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Shajy Isac
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Peter Gichangi
- International Centre for Reproductive Health- Kenya, Mombasa, Kenya
| | - Huiting Ma
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Marissa Becker
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Jan Hontelez
- Department of Public Health, Erasmus MC, Rotterdam, Netherlands
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Sharmistha Mishra
- St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Institute of Health Policy Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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6
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Neufeld B, Cholette F, Sandstrom P, Musyoki H, Ma H, Kaosa S, Kioko J, Isac S, Bhattacharjee P, Cheuk E, Pickles M, Mwatelah R, Capiña R, Daniuk C, Mckinnon LR, Blanchard J, Mishra S, Becker M. HIV acquisition prior to entry into formal sex work: inference from next-generation viral sequencing. AIDS 2023; 37:987-992. [PMID: 36727844 PMCID: PMC10090304 DOI: 10.1097/qad.0000000000003484] [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: 10/20/2022] [Revised: 12/15/2022] [Accepted: 01/04/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To infer the timing of HIV acquisition in relation to self-reported events in the sexual life course of adolescent girls and young women (AGYW) who self-identify as female sex workers (FSW) in Mombasa, Kenya. DESIGN Next-generation viral sequencing of samples of AGYW living with HIV in the Transitions study, a cross-sectional bio-behavioural survey of AGYW aged 14-24 years in Mombasa, Kenya. METHOD Dried blood spot specimens were collected from study participants ( n = 37, all FSW). A portion of the HIV pol gene was sequenced using an in-house next-generation sequencing assay for HIV drug resistance mutation genotyping. Estimated time since infection (ETI) was inferred using the HIV EVO web-based tool ( https://hiv.biozentrum.unibas.ch/ETI/ ), and data on self-reported events were obtained from the survey. RESULTS The median ETI among FSW was 3.4 (interquartile range = 1.7, 6.3) years, with a median ETI of 1.5 years prior to entry into formal sex work. We estimated that 74.1% (95% confidence interval = 53.7-88.9%) of participants living with HIV and who self-identified as FSW likely acquired HIV prior to self-identification as a sex worker. CONCLUSIONS Findings suggest a large fraction of prevalent HIV infection among AGYW engaged in sex work stems from acquisition prior to entry into formal sex work. Current HIV prevention programs tailored for sex workers may miss key opportunities for HIV prevention as they are designed to reach women after entry into formal sex work, signaling a need for tailored programs to reach high-risk AGYW earlier on in their sexual life course.
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Affiliation(s)
- Bronwyn Neufeld
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
| | - François Cholette
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Paul Sandstrom
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Helgar Musyoki
- National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya
| | - Huiting Ma
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
| | - Shem Kaosa
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Japheth Kioko
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Shajy Isac
- India Health Action Trust, New Delhi, India
| | - Parinita Bhattacharjee
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
- Partners for Health and Development in Africa, Nairobi, Kenya
| | - Eve Cheuk
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
| | - Michael Pickles
- Medical Research Council Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Ruth Mwatelah
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Rupert Capiña
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
| | - Christina Daniuk
- National HIV and Retrovirology Laboratories, National Microbiology Laboratory at the JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada
| | - Lyle R. Mckinnon
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - James Blanchard
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, Canada
- Department of Medicine
- Institute of Medical Sciences
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Marissa Becker
- Institute for Global Public Health, Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba
- Department of Medical Microbiology and Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
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Cholette F, Lazarus L, Macharia P, Thompson LH, Githaiga S, Mathenge J, Walimbwa J, Kuria I, Okoth S, Wambua S, Albert H, Mwangi P, Adhiambo J, Kasiba R, Juma E, Battacharjee P, Kimani J, Sandstrom P, Meyers AFA, Joy JB, Thomann M, McLaren PJ, Shaw S, Mishra S, Becker ML, McKinnon L, Lorway R. Community Insights in Phylogenetic HIV Research: The CIPHR Project Protocol. Glob Public Health 2023; 18:2269435. [PMID: 37851872 DOI: 10.1080/17441692.2023.2269435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
Inferring HIV transmission networks from HIV sequences is gaining popularity in the field of HIV molecular epidemiology. However, HIV sequences are often analyzed at distance from those affected by HIV epidemics, namely without the involvement of communities most affected by HIV. These remote analyses often mean that knowledge is generated in absence of lived experiences and socio-economic realities that could inform the ethical application of network-derived information in 'real world' programmes. Procedures to engage communities are noticeably absent from the HIV molecular epidemiology literature. Here we present our team's protocol for engaging community activists living in Nairobi, Kenya in a knowledge exchange process - The CIPHR Project (Community Insights in Phylogenetic HIV Research). Drawing upon a community-based participatory approach, our team will (1) explore the possibilities and limitations of HIV molecular epidemiology for key population programmes, (2) pilot a community-based HIV molecular study, and (3) co-develop policy guidelines on conducting ethically safe HIV molecular epidemiology. Critical dialogue with activist communities will offer insight into the potential uses and abuses of using such information to sharpen HIV prevention programmes. The outcome of this process holds importance to the development of policy frameworks that will guide the next generation of the global response.
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Affiliation(s)
- François Cholette
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Sexually Transmitted and Blood-Borne Infections, National Microbiology Laboratory at JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, Canada
| | - Lisa Lazarus
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Pascal Macharia
- Health Options for Young Men on HIV/AIDS and STIs (HOYMAS), Nairobi, Kenya
| | - Laura H Thompson
- Sexually Transmitted and Blood-Borne Infections Surveillance Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada
| | - Samuel Githaiga
- Health Options for Young Men on HIV/AIDS and STIs (HOYMAS), Nairobi, Kenya
| | - John Mathenge
- Health Options for Young Men on HIV/AIDS and STIs (HOYMAS), Nairobi, Kenya
| | | | - Irene Kuria
- Key Population Consortium of Kenya, Nairobi, Kenya
| | - Silvia Okoth
- Bar Hostess Empowerment and Support Programme, Nairobi, Kenya
| | | | - Harrison Albert
- Health Options for Young Men on HIV/AIDS and STIs (HOYMAS), Nairobi, Kenya
| | - Peninah Mwangi
- Bar Hostess Empowerment and Support Programme, Nairobi, Kenya
| | - Joyce Adhiambo
- Partners for Health Development in Africa (PHDA), Nairobi, Kenya
- Sex Worker Outreach Programme (SWOP), Nairobi, Kenya
| | | | - Esther Juma
- Sex Worker Outreach Programme (SWOP), Nairobi, Kenya
| | | | - Joshua Kimani
- Sex Worker Outreach Programme (SWOP), Nairobi, Kenya
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Paul Sandstrom
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Sexually Transmitted and Blood-Borne Infections, National Microbiology Laboratory at JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, Canada
| | - Adrienne F A Meyers
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Sexually Transmitted and Blood-Borne Infections, National Microbiology Laboratory at JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, Canada
| | - Jeffrey B Joy
- British Columbia Centre for Excellence in HIV/AIDS (BCCfE), St. Paul's Hospital, Vancouver, Canada
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, Canada
- Bioinformatics Programme, University of British Columbia, Vancouver, Canada
| | - Matthew Thomann
- Department of Anthropology, University of Maryland, College Park, MD, USA
| | - Paul J McLaren
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Sexually Transmitted and Blood-Borne Infections, National Microbiology Laboratory at JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, Canada
| | - Souradet Shaw
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Marissa L Becker
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Lyle McKinnon
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
| | - Robert Lorway
- Institute for Global Public Health, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
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Bossard C, Chihana M, Nicholas S, Mauambeta D, Weinstein D, Conan N, Nicco E, Suzi J, OConnell L, Poulet E, Ellman T. HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study. PLoS One 2022; 17:e0279692. [PMID: 36584132 PMCID: PMC9803093 DOI: 10.1371/journal.pone.0279692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13-19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3-57.6] and increased with age: from 14.7% (13-19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3-97.4], ART coverage was 98.8% [95.3-99.7], and VL suppression 83.2% [77.1-88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3-43.5], gonorrhea 9.5% [6.9-12.9], and chlamydia 12.5% [9.3-16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5-52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.
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Affiliation(s)
- Claire Bossard
- Epicentre, Médecins Sans Frontières, Paris, France
- * E-mail:
| | | | | | | | | | | | - Elena Nicco
- OCB, Médecins Sans Frontières, Blantyre, Malawi
| | - Joel Suzi
- The Malawi National Aids Commission, Lilongwe, Malawi
| | - Lucy OConnell
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - Tom Ellman
- Southern African Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Lindsay BR, Mwango L, Toeque M, Malupande SL, Nkhuwa E, Moonga CN, Chilambe A, Sakala H, Kafunda I, Olowski P, Olufunso A, Okuku J, Kancheya N, Mumba D, Hachaambwa L, Sheneberger R, Blanco N, Lavoie M, Claassen CW. Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z-CHECK project, 2019-2020. J Int AIDS Soc 2022; 25:e26030. [PMID: 36317821 PMCID: PMC9624072 DOI: 10.1002/jia2.26030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Zambia has made tremendous progress towards HIV epidemic control; however, gaps remain among key populations (KPs), such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and people in prisons and enclosed settings due to cultural, social and legal barriers. The University of Maryland, Baltimore Zambia Community HIV Epidemic Control for Key Populations (Z-CHECK) project aimed to improve HIV case-finding, linkage and treatment adherence at the community level for KPs in Zambia. We describe Z-CHECK strategies and examine HIV positivity yield and antiretroviral therapy (ART) linkage among KPs to inform ongoing programme improvement. METHODS Z-CHECK recruited, trained and deployed peer community health workers (CHWs) for KP groups, with ongoing mentorship in community engagement. CHWs offered HIV testing in safe spaces and escorted newly HIV-diagnosed clients for same-day ART initiation. Z-CHECK also reached out to KP community leaders and gatekeepers for KP mobilization and trained healthcare workers (HCWs) on KP services and sensitivity. We conducted a retrospective observational review of routinely collected aggregate data for KPs aged ≥15 years at high risk for HIV transmission across five districts in Zambia from January 2019 to December 2020. RESULTS Z-CHECK provided HIV testing for 9211 KPs, of whom 2227 were HIV positive (positivity yield, 24%). Among these, 1901 (85%) were linked to ART; linkage for MSM, FSW, PWID and people in prisons and enclosed settings was 95%, 89%, 86% and 65%, respectively. Programme strategies that contributed to high positivity yield and linkage included the use of peer KP CHWs, social network testing strategies and opportunities for same-day ART initiation. Challenges to programme implementation included stigma and discrimination among HCWs, as well as KP CHW attrition, which may be explained by high mobility. CONCLUSIONS Peer CHWs were highly effective at reaching KP communities, identifying persons living with HIV and linking them to care. Engaging KP community gatekeepers resulted in high diffusion of health messages and increased access to health resources. The mobility of CHWs and HCWs is a challenge for programme implementation. Innovative interventions are needed to support PWID and people in prisons and enclosed settings.
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Affiliation(s)
- Brianna R. Lindsay
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia,Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | | | - Mona‐Gekanju Toeque
- Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | | | | | | | | | - Henry Sakala
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia
| | - Ina Kafunda
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia
| | - Pawel Olowski
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia
| | - Adebayo Olufunso
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia
| | - Jackson Okuku
- U.S. Centers for Disease Control and Prevention ZambiaLusakaZambia
| | - Nzali Kancheya
- U.S. Centers for Disease Control and Prevention ZambiaLusakaZambia
| | | | - Lottie Hachaambwa
- Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA,Ciheb ZambiaLusakaZambia
| | - Robb Sheneberger
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia,Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Natalia Blanco
- Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Marie‐Claude Lavoie
- Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
| | - Cassidy W. Claassen
- Center for International Health Education and BiosecurityMGIC‐an affiliate of the University of Maryland BaltimoreLusakaZambia,Center for International HealthEducation, and BiosecurityUniversity of Maryland School of MedicineBaltimoreMarylandUSA
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Factors associated with adherence to HIV testing guidelines among HIV-negative female sex workers in Kampala, Uganda. IJID REGIONS 2022; 4:25-32. [PMID: 36093368 PMCID: PMC9453214 DOI: 10.1016/j.ijregi.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/23/2022]
Abstract
The adherence of human immunodeficiency virus (HIV)-negative female sex worker to the testing guidelines was investigated. Uneducated female sex workers are less likely to adhere to HIV testing guidelines. HIV testing in drop-in centres for female sex workers needs to be expanded. The provision of an integrated package of health services improves access to HIV testing.
Background Frequent human immunodeficiency virus (HIV) testing is recommended among female sex workers. This study examined the extent to which HIV-negative female sex workers (FSWs) in Kampala adhere to the HIV testing guidelines, and identified associated factors. Methods This cross-sectional study used a simple random sampling method to select 12 sex work hotspots. Two hundred participants were allocated proportionally in each hotspot. Frequencies were used to describe categorical characteristics of FSWs, and a multivariable logistic regression model was used to determine the factors associated with adherence to the HIV testing guidelines. Results Eighty-eight percent of the 200 study participants reported their HIV testing status; of these, 56% had tested three or more times in the 12 months preceding the survey. Attaining a secondary education was associated with adherence to the HIV testing guidelines [odds ratio (OR) 1.86, 95% confidence interval (CI) 1.01–3.44; P=0.047]. Sexually transmitted infection testing in the preceding 3 months (OR 2.13, 95% CI 0.95–4.74; P=0.065) and accessing HIV testing at a drop-in centre (OR 5.90, 95% CI 0.71–49.1; P=0.101) were associated with higher odds of adherence to the HIV testing guidelines. Conclusion Adherence to the HIV testing guidelines was suboptimal, indicating the need to scale up interventions to improve access to HIV testing, including rigorous behaviour change communication.
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11
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Knight J, Kaul R, Mishra S. Risk heterogeneity in compartmental HIV transmission models of ART as prevention in Sub-Saharan Africa: A scoping review. Epidemics 2022; 40:100608. [PMID: 35843152 DOI: 10.1016/j.epidem.2022.100608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/11/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Transmission models provide complementary evidence to clinical trials about the potential population-level incidence reduction attributable to ART (ART prevention impact). Different modelling assumptions about risk heterogeneity may influence projected ART prevention impacts. We sought to review representations of risk heterogeneity in compartmental HIV transmission models applied to project ART prevention impacts in Sub-Saharan Africa. METHODS We systematically reviewed studies published before January 2020 that used non-linear compartmental models of sexual HIV transmission to simulate ART prevention impacts in Sub-Saharan Africa. We summarized data on model structure/assumptions (factors) related to risk and intervention heterogeneity, and explored multivariate ecological associations of ART prevention impacts with modelled factors. RESULTS Of 1384 search hits, 94 studies were included. 64 studies considered sexual activity stratification and 39 modelled at least one key population. 21 studies modelled faster/slower ART cascade transitions (HIV diagnosis, ART initiation, or cessation) by risk group, including 8 with faster and 4 with slower cascade transitions among key populations versus the wider population. In ecological analysis of 125 scenarios from 40 studies (subset without combination intervention), scenarios with risk heterogeneity that included turnover of higher risk groups were associated with smaller ART prevention benefits. Modelled differences in ART cascade across risk groups also influenced the projected ART benefits, including: ART prioritized to key populations was associated with larger ART prevention benefits. Of note, zero of these 125 scenarios considered lower ART coverage among key populations. CONCLUSION Among compartmental transmission models applied to project ART prevention impacts in Sub-Saharan Africa, representations of risk heterogeneity and projected impacts varied considerably. Inclusion/exclusion of risk heterogeneity with turnover, and intervention heterogeneity across risk groups could influence the projected impacts of ART scale-up. These findings highlight a need to capture risk heterogeneity with turnover and cascade heterogeneity when projecting ART prevention impacts.
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Affiliation(s)
- Jesse Knight
- Institute of Medical Science, University of Toronto, Toronto, Canada.
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Sharmistha Mishra
- Institute of Medical Science, University of Toronto, Toronto, Canada; MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada; Division of Infectious Disease, Department of Medicine, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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12
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Chamie G, Napierala S, Agot K, Thirumurthy H. HIV testing approaches to reach the first UNAIDS 95% target in sub-Saharan Africa. Lancet HIV 2021; 8:e225-e236. [PMID: 33794183 DOI: 10.1016/s2352-3018(21)00023-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/20/2021] [Accepted: 01/26/2021] [Indexed: 02/06/2023]
Abstract
HIV testing is a crucial first step to accessing HIV prevention and treatment services and to achieving the UNAIDS target of 95% of people living with HIV being aware of their status by 2030. Combined implementation of facility-based and community-based approaches has helped to achieve high levels of HIV testing coverage in many countries including those in sub-Saharan Africa. Approaches such as index testing and self-testing help to reach individuals at higher risk of acquiring HIV, men, and those less likely to use health facilities or community-based services. However, as the proportion of people living with HIV who are aware of their HIV status has risen, the challenge of reaching those who remain undiagnosed or those who are at high risk of acquiring HIV has grown. Demand generation and novel testing approaches will be necessary to reach undiagnosed people living with HIV and to promote frequent retesting among key and priority populations.
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Affiliation(s)
- Gabriel Chamie
- Division of HIV, Infectious Diseases & Global Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Sue Napierala
- RTI International, Women's Global Health Imperative, Berkeley, CA, USA
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Harsha Thirumurthy
- Perelman School of Medicine and Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
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13
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Roberts E, Ma H, Bhattacharjee P, Musyoki HK, Gichangi P, Avery L, Musimbi J, Tsang J, Kaosa S, Kioko J, Becker ML, Mishra S. Low program access despite high burden of sexual, structural, and reproductive health vulnerabilities among young women who sell sex in Mombasa, Kenya. BMC Public Health 2020; 20:806. [PMID: 32471410 PMCID: PMC7257181 DOI: 10.1186/s12889-020-08872-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/07/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Across Sub-Saharan Africa, young women who sell sex (YSW) face institutional barriers in accessing sexual health and HIV prevention programs designed for female sex workers. In 2018, Kenya developed a national framework to guide service provision for YSW aged 14-24 years. To help inform the implementation of the framework, we estimated the burden of vulnerabilities related to the Sustainable Development Goals (SDGs related to health and gender equality) and program contact among YSW. METHODS We used data from Transitions, a 2015 bio-behavioural cross-sectional survey of 408 YSW aged 14-24 years in Mombasa, Kenya. We estimated the prevalence of sexual (inconsistent condom use), structural (financial, violence), and reproductive health vulnerabilities; and characterized engagement with local HIV programs tailored to sex workers. We then compared the prevalence of vulnerabilities by age group (14-18 years, N = 117; 19-24 years, N = 291) and by program contact (ever contacted by local program for sex workers). RESULTS 47.3% reported inconsistent condom use with any partner in the previous week (no difference by age-group, p = 1.00). Structural vulnerabilities were common and did not vary by age: 83.6% did not have a regular source of income; 29.9 and 29.2% had experienced physical and sexual violence, respectively. 26.5% reported at least one pregnancy before age 18, and 18.5% used a non-reliable form of contraception with little variability by age. 25.7% were aware of at least one program, and only 13.7% of YSW had ever been contacted by a program (8.5% of those aged 14-18 years; and 15.8% of those aged 19-24 years, p = 0.06). Sexual, structural, and reproductive health vulnerabilities did not vary by program contact. CONCLUSIONS SDG-related vulnerabilities begin early in the lives of YSW who are not currently reached by programs designed for female sex workers.
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Affiliation(s)
- Elizabeth Roberts
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Huiting Ma
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Parinita Bhattacharjee
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
- Technical Support Unit, Partnership for Health and Development in Africa, Nairobi, Kenya
| | | | - Peter Gichangi
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
| | - Lisa Avery
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Janet Musimbi
- Technical Support Unit, Partnership for Health and Development in Africa, Nairobi, Kenya
| | - Jenkin Tsang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Canada
| | - Shem Kaosa
- Technical Support Unit, Partnership for Health and Development in Africa, Nairobi, Kenya
| | - Japheth Kioko
- Technical Support Unit, Partnership for Health and Development in Africa, Nairobi, Kenya
| | - Marissa L. Becker
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Sharmistha Mishra
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Infectious Disease, University of Toronto, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - on behalf of the Transitions Study Team
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University of Toronto, Toronto, Canada
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
- Technical Support Unit, Partnership for Health and Development in Africa, Nairobi, Kenya
- National AIDS and STI Control Programme, Nairobi, Kenya
- International Centre for Reproductive Health-Kenya, Mombasa, Kenya
- Department of Medicine, Division of Infectious Disease, University of Toronto, Toronto, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
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