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McDermid J, Pearson J, Braschel M, Moreheart S, Marck R, Shannon K, Krüsi A, Goldenberg SM. Increases in housing rules and surveillance during COVID-19: impacts on overdose and overdose response in a community-based cohort of sex workers who use drugs in Vancouver, BC. Harm Reduct J 2024; 21:153. [PMID: 39175071 PMCID: PMC11342539 DOI: 10.1186/s12954-024-01030-w] [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: 02/13/2023] [Accepted: 05/29/2024] [Indexed: 08/24/2024] Open
Abstract
INTRODUCTION Since the beginning of the COVID-19 pandemic, COVID-19 risk mitigation measures have expanded to include increased rules and surveillance in supportive housing. Yet, in the context of the dual public health emergencies of COVID-19 and the unregulated drug toxicity crisis, we have not evaluated the unintended health and social consequences of such measures, especially on criminalized women. In order to address this dearth of evidence, our aim was to assess the association between increased housing rules and surveillance during COVID-19 and (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal among women sex workers who use drugs in Vancouver, BC. METHODS This study is nested within An Evaluation of Sex Workers Health Access (AESHA), a community-based prospective cohort of women sex workers in Metro Vancouver (2010-present). Using cross-sectional data collected during the first year of COVID-19 (April 2020-2021), we developed separate multivariable logistic regression confounder models to examine the independent associations between experiencing increased housing rules and surveillance during COVID-19 on (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal in the last 6 months. RESULTS Amongst 166 participants, 10.8% reported experiencing a recent non-fatal overdose and 31.3% recently administered naloxone for overdose reversal. 56.6% reported experiencing increased rules and surveillance within their housing during COVID-19. The prevalence of non-fatal overdose and administering naloxone was significantly elevated among those exposed to increased housing rules and surveillance during COVID-19 versus those who were unexposed (83.3% vs. 52.1%; 75.0% vs. 48.2%, respectively). In separate multivariate confounder models, exposure to increased housing rules and surveillance during COVID-19 was independently associated with increased odds of administering naloxone [AOR: 3.66, CI: 1.63-8.21], and marginally associated with non-fatal overdose [AOR: 3.49, CI: 0.92-13.27]. CONCLUSION Efforts to prioritize the right to safe, adequate and affordable housing must avoid reinforcing an overly coercive reliance on surveillance measures which, while often well-intended, can negatively shape residents' well-being. Furthermore, public health responses to pandemics must include criminalized populations so that measures do not exacerbate overdose risk. Implementation of a regulated drug supply is recommended, alongside housing policies that promote residents' rights, safety, and health.
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Affiliation(s)
- Jenn McDermid
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- School of Public Policy, Simon Fraser University, Burnaby, BC, Canada
| | - Jennie Pearson
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Melissa Braschel
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Sarah Moreheart
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Rory Marck
- Community Scholars Program, Simon Fraser University, Burnaby, BC, Canada
| | - Kate Shannon
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Krüsi
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shira M Goldenberg
- Centre for Gender and Sexual Health Equity [CGSHE], University of British Columbia Faculty of Medicine, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
- SDSU/UCSD Joint Doctoral Program in Public Health (Epidemiology), Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University (SDSU), San Diego, CA, USA.
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Logie CH, Kinitz DJ, Gittings L, Lalor P, MacKenzie F, Newman PA, Baral SD, Mbuagbaw L, Shuper P, Levermore K. Intersecting Stigma and the HIV Care Cascade: Qualitative Insights from Sex Workers, Men who have Sex with Men, and Transgender Women Living with HIV in Jamaica. AIDS Behav 2024:10.1007/s10461-024-04460-6. [PMID: 39098884 DOI: 10.1007/s10461-024-04460-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/06/2024]
Abstract
In Jamaica, stigma experiences of sex workers (SW), gay men and other men who have sex with men (MSM), and transgender women living with HIV remain understudied. To address this gap, we explored experiences of stigma and linkages with the HIV care cascade among key populations living with HIV in Jamaica, including cisgender women SW, MSM, and transgender women. This qualitative study involved n = 9 focus groups (FG), n = 1 FG per population living with HIV (SW, MSM, transgender women) in each of three sites (Kingston, St. Ann, Montego Bay). We also conducted key informant (KI) interviews. We applied thematic analysis informed by the Health Stigma and Discrimination (HSD) Framework. FG participants (n = 67) included SW (n = 18), MSM (n = 28), and trans women (n = 21); we interviewed n = 10 KI (n = 5 cisgender women, n = 5 cisgender men). Participant discussions revealed that stigma drivers included low HIV treatment literacy, notably misinformation about antiretroviral therapy (ART) benefits and HIV acquisition risks, and a lack of legal protection from discrimination. Stigma targets health (HIV) and intersecting social identities (sex work, LGBTQ identities, gender non-conformity, low socio-economic status). Stigma manifestations included enacted stigma in communities and families, and internalized stigma-including lateral violence. HIV care cascade impacts included reduced and/or delayed HIV care engagement and ART adherence challenges/disruptions. Participants discussed strategies to live positively with HIV, including ART adherence as stigma resistance; social support and solidarity; and accessing affirming institutional support. In addition to addressing intersecting stigma, future research and programing should bolster multi-level stigma-resistance strategies to live positively with HIV.
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Affiliation(s)
- Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Room 504, Toronto, ON, M5S 1V4, Canada.
- United Nations University Institute for Water, Environment, and Health, Richmond Hill, Canada.
- Centre for Gender & Sexual Health Equity, Vancouver, Canada.
- Women's College Research Institute, Women's College Hospital, Toronto, Canada.
| | - David J Kinitz
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lesley Gittings
- Faculty of Health Sciences, Western University, London, ON, Canada
| | - Patrick Lalor
- Jamaica AIDS Support for Life (JASL), Kingston, Jamaica
| | - Frannie MacKenzie
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Room 504, Toronto, ON, M5S 1V4, Canada
| | - Peter A Newman
- Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Room 504, Toronto, ON, M5S 1V4, Canada
| | - Stefan D Baral
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
- Centre for Development of Best Practices in Health (CDBPH), Yaoundé Central Hospital, Yaoundé, Cameroon
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - Paul Shuper
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, ON, M5S 2S1, Canada
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McClarty LM, Green K, Leung S, Ejeckam C, Adesina A, Shaw SY, Neufeld B, Isac S, Emmanuel F, Blanchard JF, Aliyu G. Advancing Programme Science approaches to understand gaps in HIV prevention programme coverage for key populations in 12 Nigerian states: findings from the 2020 Integrated Biological and Behavioural Surveillance Survey. J Int AIDS Soc 2024; 27 Suppl 2:e26269. [PMID: 38988042 PMCID: PMC11236907 DOI: 10.1002/jia2.26269] [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: 11/24/2023] [Accepted: 04/29/2024] [Indexed: 07/12/2024] Open
Abstract
INTRODUCTION Effective HIV prevention programme coverage is necessary to achieve Nigeria's goal of ending the epidemic by 2030. Recent evidence highlights gaps in service coverage and utilization across the country. The Effective Programme Coverage framework is a Programme Science tool to optimize a programme's population-level impact by examining gaps in programme coverage using data generated through programme-embedded research and learning. We apply the framework using Integrated Biological and Behavioural Surveillance Survey (IBBSS) data from Nigeria to examine coverage of four prevention interventions-condoms, HIV testing, and needle and syringe programmes (NSP)-among four key population groups-female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID) and transgender people. METHODS Data from Nigeria's 2020 IBBSS, implemented in 12 states, were analysed to examine HIV prevention programme coverage among key populations. For each key population group and prevention intervention of interest, weighted IBBSS data were used to retrospectively generate coverage cascades that identify and quantify coverage gaps. Required coverage targets were informed by targets articulated in Nigeria's National HIV/AIDS Strategic Framework or, in their absence, by guidelines from policy normative bodies. Availability-, outreach- and utilization coverage proxy indicators were defined using variables from IBBSS data collection tools. Sankey diagrams are presented to visualize pathways followed by participants between coverage cascade steps. RESULTS Required coverage targets were missed for HIV testing and NSP among all key population groups. Condom availability coverage surpassed required coverage targets among FSW and MSM, while utilization coverage only among FSW exceeded the 90% required coverage target. Outreach coverage was low for all key population groups, falling below all required coverage targets. CONCLUSIONS Our findings identify critical gaps in HIV prevention programme coverage for key populations in Nigeria and demonstrate non-linear movement across coverage cascades, signalling the need for innovative solutions to optimize coverage of prevention services. Programme-embedded research is required to better understand how key population groups in Nigeria access and use different HIV prevention services so that programmes, policies and resource allocation decisions can be optimized to achieve effective programme coverage and population-level impact.
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Affiliation(s)
- Leigh M. McClarty
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
| | - Kalada Green
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
- West African Centre for Public Health and DevelopmentAbujaNigeria
| | - Stella Leung
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
| | | | - Adediran Adesina
- West African Centre for Public Health and DevelopmentAbujaNigeria
| | - Souradet Y. Shaw
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
| | - Bronwyn Neufeld
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
- National Sexually Transmitted and Blood Borne Infection LaboratoryPublic Health Agency of CanadaWinnipegManitobaCanada
| | - Shajy Isac
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
- India Health Action TrustDelhiIndia
| | - Faran Emmanuel
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
| | - James F. Blanchard
- Institute for Global Public HealthUniversity of ManitobaWinnipegManitobaCanada
| | - Gambo Aliyu
- National Agency for the Control of AIDSAbujaNigeria
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Mujugira A, Muwonge T, Aliganyira B, Okoboi S. Uganda's Anti-Homosexuality Act undermines public health. J Int AIDS Soc 2024; 27:e26259. [PMID: 38712671 DOI: 10.1002/jia2.26259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/18/2024] [Indexed: 05/08/2024] Open
Affiliation(s)
- Andrew Mujugira
- The Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Timothy Muwonge
- The Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | | | - Stephen Okoboi
- The Infectious Diseases Institute, Makerere University, Kampala, Uganda
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Mahmoud M, Ballouz T, Lahoud C, Adnan J, Habib PA, Saab R, Farhat H, Hussein ME, Rizk N. Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon. Sci Rep 2024; 14:8296. [PMID: 38594292 PMCID: PMC11004126 DOI: 10.1038/s41598-024-55277-1] [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: 09/04/2023] [Accepted: 02/22/2024] [Indexed: 04/11/2024] Open
Abstract
Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/μL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers' attitudes and competencies.
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Affiliation(s)
- Maya Mahmoud
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Tala Ballouz
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich (UZH), Zurich, Switzerland
| | - Chloe Lahoud
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jana Adnan
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Paola Abi Habib
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Reem Saab
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Haya Farhat
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammad El Hussein
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nesrine Rizk
- Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut, 1107 2020, Lebanon.
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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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Decriminalisation and the end of AIDS: keep the promise, follow the science, and fulfill human rights. Sex Reprod Health Matters 2023; 31:2194188. [PMID: 37351922 PMCID: PMC10291907 DOI: 10.1080/26410397.2023.2194188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023] Open
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Hinman K, Sun N, Amon JJ. Ensuring access to justice: the need for community paralegals to end AIDS by 2030. J Int AIDS Soc 2023; 26:e26146. [PMID: 37535441 PMCID: PMC10399720 DOI: 10.1002/jia2.26146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023] Open
Abstract
INTRODUCTION The HIV response has long recognized that certain "key populations" such as individuals in detention, adolescent girls and young women, sex workers, people who use drugs, LGBTQ individuals, migrants and others face higher barriers to access to, uptake of, and retention in HIV prevention and treatment services. One approach to addressing these barriers is the training of community paralegals to advocate for the rights of individuals and to address discrimination in health settings. DISCUSSION Community paralegal programmes have been able to successfully address rights violations that impact access to health services and underlying determinants of health across a range of countries and populations, focusing upon issues such as discrimination and the denial of health services; unlawful detention of outreach workers, sex workers, persons who use drugs and men who have sex with men; and harmful traditional practices and gender-based violence. In addition to resolving specific cases, evaluations of paralegal programmes have found that these programmes increased legal literacy among key populations at risk of HIV and increased understanding of human rights among healthcare providers, resulting in improved access to HIV services. Some evaluations have noted challenges related to the sustainability of paralegal programmes similar to those raised with community health worker programmes more broadly. CONCLUSIONS To achieve global HIV goals, funding for legal literacy and paralegal programmes should be increased and interventions should be rigorously evaluated. Efforts should target discrimination in access to HIV prevention and treatment and criminalization of key populations, two key barriers to ensuring access to HIV prevention and treatment services.
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Affiliation(s)
- Kati Hinman
- Office of Global HealthDornsife School of Public HealthDrexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Nina Sun
- Office of Global HealthDornsife School of Public HealthDrexel UniversityPhiladelphiaPennsylvaniaUSA
| | - Joseph J. Amon
- Office of Global HealthDornsife School of Public HealthDrexel UniversityPhiladelphiaPennsylvaniaUSA
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Nchinda N, Elangovan R, Yun J, Dickson-Tetteh L, Kirtley S, Hemelaar J. Global associations of key populations with HIV-1 recombinants: a systematic review, global survey, and individual participant data meta-analysis. Front Public Health 2023; 11:1153638. [PMID: 37575094 PMCID: PMC10420084 DOI: 10.3389/fpubh.2023.1153638] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction Global HIV infections due to HIV-1 recombinants are increasing and impede prevention and treatment efforts. Key populations suffer most new HIV infections, but their role in the spread of HIV-1 recombinants is unknown. We conducted a global analysis of the associations between key populations and HIV-1 recombinants. Methods We searched PubMed, EMBASE, CINAHL, and Global Health for HIV-1 subtyping studies published from 1/1/1990 to 31/12/2015. Unpublished data was collected through a global survey. We included studies with HIV-1 subtyping data of key populations collected during 1990-2015. Key populations assessed were heterosexual people (HET), men who have sex with men (MSM), people who inject drugs (PWID), vertical transmissions (VERT), commercial sex workers (CSW), and transfusion-associated infections (BLOOD). Logistic regression was used to determine associations of key populations with HIV-1 recombinants. Subgroup analyses were performed for circulating recombinant forms (CRFs), unique recombinant forms (URFs), regions, and time periods. Results Eight hundred and eighty five datasets including 77,284 participants from 83 countries were included. Globally, PWID were associated with the greatest odds of recombinants and CRFs (OR 2.6 [95% CI 2.46-2.74] and 2.99 [2.83-3.16]), compared to HET. CSW were associated with increased odds of recombinants and URFs (1.59 [1.44-1.75] and 3.61 [3.15-4.13]). VERT and BLOOD were associated with decreased odds of recombinants (0.58 [0.54-0.63] and 0.43 [0.33-0.56]). MSM were associated with increased odds of recombinants in 2010-2015 (1.43 [1.35-1.51]). Subgroup analyses supported our main findings. Discussion As PWID, CSW, and MSM are associated with HIV-1 recombinants, increased preventative measures and HIV-1 molecular surveillance are crucial within these key populations. Systematic review registration PROSPERO [CRD42017067164].
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Affiliation(s)
- Nkazi Nchinda
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Ramyiadarsini Elangovan
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Jason Yun
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Leslie Dickson-Tetteh
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Shona Kirtley
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, United Kingdom
| | - Joris Hemelaar
- Nuffield Department of Population Health, Infectious Disease Epidemiology Unit, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
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Jamrozik E, Munung NS, Abeler-Dorner L, Parker M. Public health use of HIV phylogenetic data in sub-Saharan Africa: ethical issues. BMJ Glob Health 2023; 8:e011884. [PMID: 37407228 DOI: 10.1136/bmjgh-2023-011884] [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: 02/15/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Phylogenetic analyses of HIV are an increasingly accurate method of clarifying population-level patterns of transmission and linking individuals or groups with transmission events. Viral genetic data may be used by public health agencies to guide policy interventions focused on clusters of transmission or segments of the population in which transmission is concentrated. Analyses of HIV phylogenetics in high-income countries have often found that clusters of transmission play a significant role in HIV epidemics. In sub-Saharan Africa, HIV phylogenetic analyses to date suggest that clusters of transmission play a relatively minor role in local epidemics. Such analyses could nevertheless be used to guide priority setting and HIV public health programme design in Africa for sub-populations in which transmission events are more concentrated. Phylogenetic analysis raises ethical issues, in part due to the range of potential benefits and potential harms (ie, risks). Potential benefits include (1) improving knowledge of transmission patterns, (2) informing the design of focused public health interventions for subpopulations in which transmission is concentrated, (3) identifying and responding to clusters of transmission, (4) reducing stigma (in some cases) and (5) informing estimates of the (cost-)effectiveness of HIV treatment programmes. Potential harms include (1) privacy infringements, (2) increasing stigma (in some cases), (3) reducing trust in public health programmes, and (4) increased prosecution of legal cases where HIV transmission, homosexuality or sex work is criminalised. This paper provides analysis of relevant issues with a focus on sub-Saharan Africa in order to inform consultations regarding ethical best practice for HIV phylogenetics.
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Affiliation(s)
- Euzebiusz Jamrozik
- Ethox and the Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Monash Bioethics Centre, Monash University, Melbourne, Victoria, Australia
| | | | | | - Michael Parker
- Ethox and the Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
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Opuni M, Figueroa JL, Sanchez-Morales JE, Salas-Ortiz A, Ochoa-Sanchez LE, Morales-Vazquez M, Banda LM, Olawo A, Munthali S, Korir J, DiCarlo M, Persaud N, Bautista-Arredondo S. The Cost of Providing Comprehensive HIV Services to Key Populations: An Analysis of the LINKAGES Program in Kenya and Malawi. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200538. [PMID: 37348941 PMCID: PMC10285728 DOI: 10.9745/ghsp-d-22-00538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/03/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Timely data on HIV service costs are critical for estimating resource needs and allocating funding, but few data exist on the cost of HIV services for key populations (KPs) at higher risk of HIV infection in low- and middle-income countries. We aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs to inform planning and budgeting decisions. METHODS We collected cost data from the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi serving female and male sex workers, men who have sex with men, and transgender women. Data were collected prospectively for fiscal year (FY) 2019 and retrospectively for start-up activities conducted in FY2015 and FY2016. Data to estimate economic costs from the provider's perspective were collected from LINKAGES headquarters, country offices, implementing partners (IPs), and drop-in centers (DICs). We used top-down and bottom-up cost estimation approaches. RESULTS Total economic costs for FY2019 were US$6,175,960 in Kenya and US$4,261,207 in Malawi. The proportion of costs incurred in IPs and DICs was 66% in Kenya and 42% in Malawi. The costliest program areas were clinical services, management, peer outreach, and monitoring and data use. Mean cost per contact was US$127 in Kenya and US$279 in Malawi, with a mean cost per contact in DICs and IPs of US$63 in Kenya and US$104 in Malawi. CONCLUSION Actions undertaken above the service level in headquarters and country offices along with those conducted below the service level in communities, comprised important proportions of KP HIV service costs. The costs of pre-service population mapping and size estimation activities were not negligible. Costing studies that focus on the service level alone are likely to underestimate the costs of delivering HIV services to KPs.
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Affiliation(s)
| | - Jose Luis Figueroa
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health, Cuernavaca, Mexico
| | - Jorge Eduardo Sanchez-Morales
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health, Cuernavaca, Mexico
| | | | - Luz Edith Ochoa-Sanchez
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health, Cuernavaca, Mexico
| | - Mariana Morales-Vazquez
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health, Cuernavaca, Mexico
| | | | | | | | | | | | | | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health, Cuernavaca, Mexico.
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Opuni M, Sanchez-Morales JE, Figueroa JL, Salas-Ortiz A, Banda LM, Olawo A, Munthali S, Korir J, DiCarlo M, Bautista-Arredondo S. Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi. BMC Health Serv Res 2023; 23:337. [PMID: 37016402 PMCID: PMC10071702 DOI: 10.1186/s12913-023-09279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 03/13/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program. METHODS Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$). RESULTS The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred. CONCLUSIONS A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.
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Affiliation(s)
| | - Jorge Eduardo Sanchez-Morales
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Jose Luis Figueroa
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Andrea Salas-Ortiz
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | | | | | | | | | | | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico.
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Lyons CE, Twahirwa Rwema JO, Makofane K, Diouf D, Mfochive Njindam I, Ba I, Kouame A, Tamoufe U, Cham B, Aliu Djaló M, Obodou EP, Karita E, Simplice A, Nowak RG, Crowell TA, Matse S, Kouanda S, Enama JP, Kavanagh M, Millett GA, Beyrer C, Murray S, Baral S. Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey. Lancet HIV 2023; 10:e186-e194. [PMID: 36623537 PMCID: PMC10288909 DOI: 10.1016/s2352-3018(22)00336-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/27/2022] [Accepted: 11/08/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments. METHODS This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs. FINDINGS Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings. INTERPRETATION Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV. FUNDING National Institutes of Health. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Carrie E Lyons
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.
| | | | - Keletso Makofane
- FXB Health and Human Rights, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | | | | | - Abo Kouame
- Ministère de la Santé et de l'Hygiène Publique, Abidjan, Côte d'Ivoire
| | - Ubald Tamoufe
- Johns Hopkins Cameroon Program/Metabiota, Yaoundé, Cameroon
| | | | | | | | | | | | - Rebecca G Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Trevor A Crowell
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA; US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Sindy Matse
- Eswatini Ministry of Health, Mbabane, Eswatini
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso; Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | | | - Matthew Kavanagh
- Department of International Health and Neill Institute for National and Global Health Law, Georgetown University, Washington, DC, USA
| | | | - Chris Beyrer
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA; Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Sarah Murray
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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14
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Affiliation(s)
- Kent Buse
- Healthier Societies Program, The George Institute for Global Health, Imperial College London
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15
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Byanyima W, Kavanagh MM. Equalizing the response to AIDS and other pandemics. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001370. [PMID: 36962851 PMCID: PMC10021569 DOI: 10.1371/journal.pgph.0001370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
- Winnie Byanyima
- United Nations Joint Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Matthew M. Kavanagh
- United Nations Joint Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
- Georgetown University, Washington, D.C., United States of America
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Dhaliwal M. Making the law work for HIV responses. BMJ 2022; 376:o660. [PMID: 35277385 DOI: 10.1136/bmj.o660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Mandeep Dhaliwal
- HIV, Health and Development at the United Nations Development Programme
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17
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Sun N, Christie E, Cabal L, Amon JJ. Human rights in pandemics: criminal and punitive approaches to COVID-19. BMJ Glob Health 2022; 7:bmjgh-2021-008232. [PMID: 35185015 PMCID: PMC8889439 DOI: 10.1136/bmjgh-2021-008232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/01/2022] [Indexed: 11/30/2022] Open
Abstract
In the early years of the HIV epidemic, many countries passed laws criminalising HIV non-disclosure, exposure and/or transmission. These responses, intended to limit transmission and punish those viewed as ‘irresponsible’, have since been found to undermine effective HIV responses by driving people away from diagnosis and increasing stigma towards those living with HIV. With the emergence of COVID-19, human rights and public health advocates raised concerns that countries might again respond with criminal and punitive approaches. To assess the degree to which countries adopted such strategies, 51 English-language emergency orders from 39 countries, representing seven world regions, were selected from the COVID-19 Law Lab, a database of COVID-19 related laws from over 190 countries. Emergency orders were reviewed to assess the type of restrictions identified, enforcement mechanisms and compliance with principles outlined in the Siracusa Principles on the Limitation and Derogation Provisions in the International Covenant on Civil and Political Rights, including legality, legitimate aim, proportionality, non-discrimination, limited duration and subject to review. Approximately half of all orders examined included criminal sanctions related to violations of lockdowns. Few orders fully complied with the legal requirements for the limitation of, or derogation from, human rights obligations in public health emergencies. In future pandemics, policymakers should carefully assess the need for criminal and punitive responses and ensure that emergency orders comply with countries’ human rights obligations.
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Affiliation(s)
- Nina Sun
- Department of Community Health, Drexel University, Philadelphia, Pennsylvania, USA
| | - Emily Christie
- Department of Community Support Social Justice and Inclusion, UNAIDS, Geneva, Switzerland
| | - Luisa Cabal
- Department of Community Support Social Justice and Inclusion, UNAIDS, Geneva, Switzerland
| | - Joseph J Amon
- Department of Community Health, Drexel University, Philadelphia, Pennsylvania, USA
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Kavanagh MM, Nygren-Krug H. Ending AIDS and stopping pandemics through closing inequalities. Am J Physiol Lung Cell Mol Physiol 2021; 321:L1055-L1056. [PMID: 34786993 PMCID: PMC8783638 DOI: 10.1152/ajplung.00463.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Matthew M Kavanagh
- United Nations Joint Programme on HIV/AIDS, Geneva, Switzerland.,Department of International Health, Georgetown University, Washington, District of Columbia
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Choi JP, Seo BK. HIV-Related Stigma Reduction in the Era of Undetectable Equals Untransmittable: The South Korean Perspective. Infect Chemother 2021; 53:661-675. [PMID: 34979602 PMCID: PMC8731251 DOI: 10.3947/ic.2021.0127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/15/2021] [Indexed: 11/24/2022] Open
Abstract
Since the introduction of effective antiretroviral therapy (ART) in the late 1990s, the prognosis for people living with human immunodeficiency virus (HIV) (PLWH) has dramatically improved. High-income countries like South Korea have had rapid declines in HIV-related deaths. Scientific advancements including pre-exposure prophylaxis (PrEP) and “undetectable equals untransmittable (U = U)” knowledge have contributed progress towards the goal of ending the acquired immune deficiency syndrome epidemic by 2030. However, the application of these advancements has been limited in South Korea. Evidence shows that HIV-related stigma and discrimination in healthcare settings remain strong in this region. We review key principles for stigma reduction and people-centered approaches in the era of U = U and identify three priorities: 1) immediate intervention in HIV stigma drivers in healthcare settings; 2) social stigma reduction on multiple levels; and 3) collaboration with key populations.
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Affiliation(s)
- Jae-Phil Choi
- Division of infectious diseases, Seoul Medical Center, Seoul, Korea
| | - Bo Kyeong Seo
- Department of Cultural Anthropology, College of Social Sciences, Yonsei University, Seoul, Korea
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