Second-generation surveillance for HIV/AIDS in Pakistan: results from the 4th round of Integrated Behavior and Biological Survey 2011-2012

The story of female sex workers in the shadow of sex work coercion: A qualitative study

Background:

What has been less considered in the literature of the sex work research, especially in Iran, is to look at the causes of sex work from the perspective of women. The present study sought to understand the causes of the problem and the experience of female sex workers.

Methods:

The present study was conducted by using qualitative method. Twenty-eight sex workers participated in the study voluntarily and with informed consent. The researcher conducted deep semistructured interviews. Purposive sampling continued until data saturation was reached. Conventional content analysis of the transcribed interviews and field notes were performed to identify key themes, first by each of researchers separately and then in joint discussions.

Results:

The main theme of the study, according to the participants, was the sense of “what pushed me into sex worker” which included the five main categories of “despair, psychic restlessness, getting drunk by alcohol and drug, incomplete families, not to be left behind by the sudden social changes.”

Conclusions:

Social and health consequences, especially reproductive health of female sex, workers are affected by several factors. However, to deal with this social and health problems, specific attention should be paid to social factors affecting health. Accordingly, each of the influential variables known in this study could be a target for the country's intervention programs, especially in public health centers and even charities related to the healthcare counseling of sex workers.

Elucidating Drivers for Variations in the Explosive Human Immunodeficiency Virus Epidemic Among People Who Inject Drugs in Pakistan

BACKGROUND

Pakistan's explosive human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) varies widely across cities. We evaluated possible drivers for these variations.

METHODS

Multivariable regression analyses were undertaken using data from 5 national surveys among PWID (n = 18 467; 2005-2017) to determine risk factors associated with variations in city-level HIV prevalence. A dynamic HIV model was used to estimate the population-attributable fraction (PAF; proportion of HIV infections prevented over 10 years when that risk factor is removed) of these risk factors to HIV transmission and impact on HIV incidence of reducing their prevalence.

RESULTS

Regression analyses suggested that city-level HIV prevalence is strongly associated with the prevalence of using professional injectors at last injection, heroin use in last month, and injecting ≥4 times per day. Through calibrating a model to these associations, we estimate that the 10-year PAFs of using professional injectors, heroin use, and frequent injecting are 45.3% (95% uncertainty interval [UI], 4.3%-79.7%), 45.9% (95% UI, 8.1%-78.4%), and 22.2% (95% UI, 2.0%-58.4%), respectively. Reducing to lowest city-level prevalences of using professional injectors (2.8%; median 89.9% reduction), heroin use (0.9%; median 91.2% reduction), and frequent injecting (0.1%; median 91.8% reduction) in 2020 reduces overall HIV incidence by 52.7% (95% UI, 6.1%-82.0%), 53.0% (95% UI, 11.3%-80.2%), and 28.1% (95% UI, 2.7%-66.6%), respectively, over 10 years.

CONCLUSIONS

Interventions should focus on these risk factors to control Pakistan's explosive HIV epidemic among PWID, including a concomitant expansion of high-coverage needle/syringe provision, opioid substitution therapy, and antiretroviral therapy.

Prevalence of HIV and HCV among injecting drug users in three selected WHO-EMRO countries: a meta-analysis

BACKGROUND

HIV and Hepatitis C Virus (HCV) infections are responsible for a significant burden of mortality and morbidity, particularly in developing countries. This study sought to determine the prevalence of HIV and Hepatitis C among injecting drug users in Afghanistan, Iran, and Pakistan.

METHODS

This review conforms to the Preferred Reporting Guidelines for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases including PubMed, Scopus, Web of Science/Knowledge, SID.ir, and MAGIRAN were searched. Studies that were published from 2003 up to 2018 were considered for analysis. Studies were screened for inclusion in duplicate, and also, that data were narratively synthesized.

RESULTS

We report on data from 79 articles. The total number of participants in studies that assessed the prevalence of HIV among injecting drug users included 68,926 participants, while those from studies that assessed HCV prevalence were 23,016 participants. Overall HIV and HCV prevalence among injecting drug users in the three selected countries were 9.1% (95% CI 6.9-12.0%) and 48.3% (95% CI 43.9-52.7%), respectively. Iran had the highest HIV prevalence of 11.0% among injectable drug users (95% CI 8.4-14.2%), while Afghanistan had the lowest HIV prevalence of 3.1% (95% CI 1.5-6.3%) among three selected countries. In Pakistan, the prevalence of HIV was 8.6% (95% CI 4.8-15.0%). Regarding HCV prevalence, Pakistan had the highest while Afghanistan had the lowest, 54.4% (95% CI 33.5-73.9%) and 37.3% (95% CI 35.2-39.4%), respectively. HCV prevalence in Iran was 47.7% (95% CI 43.4-52.0%).

CONCLUSION

Injecting drug users form a special cohort of persons at risk of HIV and Hepatitis C infections. The prevalence of HIV and Hepatitis noted from our findings is significantly high. Awareness of the grave risk of spreading HIV and Hepatitis C associated with sharing needles is recommended among this sub-group of drug users.

Frequency and reasons for delayed treatment initiation after HIV diagnosis: cross-sectional study in Lahore, Pakistan

Background

Well-timed initiation of HIV therapy enhances life expectancy, decreases mortality and morbidity, and inhibits the transmission of HIV and complications related to it. The purpose of the present survey is to investigate the frequency and reasons for delayed initiation of anti-retroviral therapy (ART) and to determine its relationship with various socio-demographic variables and HIV-related characteristics.

Methods

The analysis is based on a cross-sectional study involving 355 people living with HIV (diagnosed by PCR) who were more than 18 years of age and not receiving HIV therapy before enrolment at the HIV clinics of two selected tertiary-care teaching hospitals in Lahore, Pakistan. In this study, delayed initiation of ART was defined as not attending the HIV management centre or a clinic for ART within 3 months of a confirmed diagnosis. The participants were selected using a systematic probability sampling technique. Bivariate logistic regression was performed using a backward stepwise technique to establish the variables related to delayed onset of HIV therapy. Factors significant at p ≤ 0.20 were considered for multivariate analysis, which was used to describe the association between independent factors and delayed initiation of treatment.

Results

Delayed onset of ART was observed in 28.5% of individuals. Factors such as no schooling (AOR = 5.92; 95% CI: 1.38–25.41; p = 0.017) and occasional household income (AOR = 3.88; 95% CI: 1.01–14.89; p = 0.048) were significantly associated with late onset of ART. Our research findings also indicated that the main reasons for late beginning of HIV therapy were: feeling healthy (45.5%), did not have time to go to the HIV treatment centre (42.6%), did not want to discuss HIV test result (37.6%), and fear of stigma and discrimination within their community (35.6%).

Conclusions

Late commencement of HIV therapy in Pakistan is common, and an improved connection is needed between identification of HIV and beginning of therapy. HIV management centres should counsel and monitor patients from the time of a positive HIV test result until they initiate therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11031-0.

Prevalence and factors associated with HIV epidemic among female sex workers in Pakistan: results of the fifth round of integrated biological and behavioural surveillance

OBJECTIVES

We examined data collected as part of the fifth round of integrated biological and behavioural surveillance to determine the prevalence and factors associated with HIV infection among female sex workers (FSWs) in Pakistan.

METHODS

FSWs were defined as 'all females, age 13 years and above, who receive money or goods in exchange for sexual services, regardless of the site of operation'. Data were collected between October 2016 and January 2017 in 18 cities using multistage sampling techniques to randomly select FSWs from spots facilitated by peers. Behavioural data were collected by interviewers using structured questionnaires, which was followed by obtaining finger prick blood samples tested for HIV using two rapid tests. Multivariate logistic regression analysis was done to assess independent associations of potential correlates using HIV status as dependent variable.

RESULTS

We invited 5728 FSWs to participate, of which 68 refused to participate (refusal rate=1.2%). Of the 5660 FSWs who participated, 121 were HIV seropositive (weighted HIV prevalence 2.3%; 95% CI 1.9% to 2.7%) mostly concentrated within cities in Sindh. Multivariate analysis showed being uneducated/illiterate (adjusted OR (aOR) 2.1; 95% CI 1.4 to 3.4), directly dealing with clients without a pimp (aOR 1.8; 95% CI 1.1 to 2.8), non-use of condom with clients (aOR 1.8; 95% CI 1.1 to 2.8), having sexual contact with people who inject drugs (PWID) (aOR 2.2; 95% CI 1.3 to 3.7) and non-participation in HIV programmes (aOR 1.7; 95% CI 1.0 to 3.1) as factors independently associated with HIV seropositivity.

CONCLUSIONS

We found a weighted national HIV prevalence of 2.3% and identified factors independently associated with HIV in FSWs. The country needs to scale up HIV prevention programmes to improve coverage, prioritising FSWs who are illiterate, work independently and have PWID as sex partners. Emphasis should be laid on strategies to improve condom use with both regular and non-regular partners.

Genetic Diversity of Human Immunodeficiency Virus Type 1 in Asymptomatic Blood Donors in Islamabad, Pakistan

Objective  The serological testing of human immunodeficiency virus (HIV) is mandatory under the blood safety legislation of Pakistan; hence, data exist on the prevalence of HIV in blood donors. However, little is known about the molecular epidemiology of HIV in the blood donor population. Therefore, the current study was designed to study the genetic diversity of HIV-1 infection in a population of apparently healthy treatment-naive blood donors in Islamabad, Pakistan.

Material and Methods  A total of 85,736 blood donors were tested for HIV by the chemiluminescence immunoassay. All positive donor samples were analyzed for the presence of various HIV genotypes (types and subtypes). Viral ribonucleic acid was extracted from blood samples of HIV positive donors and reverse transcribed into complementary deoxyribonucleic acid (cDNA). The cDNA of all positive donors was then analyzed for the presence of various HIV genotypes (types and subtypes) by employing subtype-specific primers in a nested polymerase chain reaction. The amplified products were run on ethidium bromide-stained 2% agarose gel and visualized using a ultraviolet transilluminator. A particular subtype was assigned to a sample if the subtype-specific reaction made a band 20% highly intense compared with the band made by the subtype-independent reaction.

Results  A total of 85,736 blood donors were screened for the presence of antibodies to HIV. Out of them, 114 were initially found reactive for HIV. The repeat testing resulted in 112 (0.13%) positive donors, 95% confidence interval 0.0014 (0.0011–0.0018). These 112 samples were analyzed for molecular typing of HIV-1. The predominant HIV-1 subtype was A ( n = 101) (90.1%) followed by subtype B ( n = 11) (9.9%).

Conclusion  These findings are key to understand the diversified HIV epidemic at the molecular level and should assist public health workers in implementing measures to lessen the further dissemination of these viruses in the country.

Rising HIV seroconversion rates & associated risks among employees of organization 'X': A case control study, Pakistan, 2017

Background and Objectives:

In 2004 Pakistan escalated from ‘low-prevalence’ to ‘concentrated’ phase of HIV epidemic. Despite global decline in HIV incidence since 1997, rate of HIV infections in Pakistan is persistently rising since 1990. Available literature focusses on key populations or localized outbreaks limited by short study duration and regional applicability of results. We studied HIV seroconversion trends over a period of 8 years in a geographically diverse population and evaluated associated risk factors.

Methods:

A desk review of HIV surveillance data from 2010 to 2017 was carried out at Armed Forces Institute of Pathology. A case was defined as any adult employed in organization ‘X’, initially screened for HIV but later seroconverted on ELISA and western blot. Case-control study was conducted on cases diagnosed in 2017. Age and sex matched controls were identified from same population sub-group. Structured telephonic interviews were conducted and statistical analysis done at 5% margin of error.

Results:

The annual HIV diagnosis rate remained relatively stable till 2015 (< 40 /100,000/yr) after which it rose sharply to 60/100,000/yr in 2016 .Upward trend continued in 2017 to reach 125/100,000/yr (>200% increase from baseline). Acquisition of HIV was significantly associated with commercial sex activities (OR=9; 95% CI: 1.25-395).

Conclusion:

HIV seroconversion rates among employees of organization X have increased significantly in the past two years. Unlike HIV outbreaks previously reported from Pakistan, sexual route seems to be the predominant mode of transmission. Focus is mandated on prevention of sexual transmission of HIV at national level as well for all vulnerable populations.

The Effect of Theory-Based HIV/AIDS Educational Program on Preventive Behaviors Among Female Adolescents in Tehran: A Randomized Controlled Trial

BACKGROUND

Adolescents are increasingly at risks of HIV infection through high-risk sexual behaviors. This paper aimed to assess the effectiveness of a HIV/AIDS educational intervention among female adolescents in Tehran.

METHODS

A randomized controlled trial was conducted among high school girls aged 12-16 years studying in Tehran in 2016-17. The sample was selected using multistage random cluster sampling. Four schools per district were randomly selected using probability-proportional to size. Adolescents were randomly assigned to the experimental (n=289) and the control (n=289) groups. The theory of planned behavior (TPB) was the basis of both the intervention and the evaluation phase. Both experimental and control groups completed a questionnaire designed for HIV related behaviors for female adolescents (HBQFA) at baseline and after six months follow up. A theory-based educational program was implemented for the experimental group.

RESULTS

The mean age of participants was 14.1 years (SD=0.96). In the experimental group, significant improvements were shown in adolescents' HIV knowledge (31.9%, 95% CI: 28.8-35.0), attitudes towards HIV (16.6%, 95% CI=14.4-18.8), subjective norm (16.8%, 95% CI=12.9-20.6) and perceived behavioral control (19.1%, 95% CI=16.2-22.1), perceived parental support (17%, 95% CI=13.8-20.2), behavioral intention to prevent HIV (19%, 95% CI=16.3-21.6), and HIV preventive behavior (17.3%, 95% CI=13.9-20.6) (p<0.001).

CONCLUSION

Theory-based educational intervention on HIV/AIDS prevention can significantly protect adolescents from misconceptions, wrong attitudes and risky behaviors and unsupportive social environment that expose them to greater HIV risk. Health policy -makers are advised to consider effective training programs related to HIV/AIDS prevention behaviors in the school system.

Programmatic Mapping: Providing Evidence for High Impact HIV Prevention Programs for Female Sex Workers

Programmatic mapping (PM) is a rapid and efficient mechanism to develop size estimates of key populations including female sex workers (FSWs) and geolocate them at physical locations in a systematic and scientific manner. At the macro level, this information forms the basis for allocating program resources, setting performance targets, and assess coverage. At a micro level, PM data provide specific information on hot spots, estimates of FSWs at those spots, and hot spot typology and days and times of operation, all of which provides targeted service delivery strategies. This information can provide a reliable platform to plan HIV prevention and treatment services to considerable scale and intensity. Above all, the entire PM process requires deep involvement of FSWs, which increases community ownership of the data and can lead to an increased uptake of services. Despite a few limitations, the approach is versatile and can be used in varied country contexts to generate important information about sex work and its dynamics. In this paper, we describe experiences and lessons learned from using evidence generated from PM of FSWs in multiple countries to develop HIV prevention programs at scale.

Political and Governance Challenges to Achieving Global HIV Goals with Injecting Drug Users: The Case of Pakistan

Background: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently set the ambitious "90-90-90 target" of having 90% of people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve viral suppression by 2020. This ambitious new goal is occurring in a context of global "scale-down" following nearly a decade of heightened investment in HIV prevention and treatment efforts. Arguably international goals spur action, however, setting unrealistic goals that do not take weak health systems and variations in the nature of the epidemic across countries into consideration may set them up for failure in unproductive ways that lead to a decline in confidence in global governance institutions. This study explores how policy actors tasked with implementing HIV programs navigate the competing demands placed upon them by development targets and national politics, particularly in the current context of waning international investments towards HIV.

Methods: To examine these questions, we interviewed 29 key informants comprising health experts in donor organizations and government employees in HIV programs in Pakistan, a country where HIV programs must compete with other issues for attention. Themes were identified inductively through an iterative process and findings were triangulated with various data sources and existing literature.

Results: We found both political and governance challenges to achieving the target, particularly in the context of the global HIV scale-down. Political challenges included, low and heterogeneous political commitment for HIV and a conservative legal environment that contributed towards a ban on opiate substitution therapy, creating low treatment coverage. Governance challenges includedstrained state and non-governmental organization (NGO) relations creating a hostile service delivery environment, weak bureaucratic and civil society capacity contributing to poor regulation of the health infrastructure, and resource mismanagement on both the part of the government and NGOs.

Conclusion: Our findings suggest that in a context of waning international attention to HIV, policy actors on the ground face a number of practical hurdles to achieving the ambitious targets set out by international agencies. Greater attention to the political and governance challenges of implementing HIV programs in low- and middle-income countries (LMICs) could help technical assistance agencies to develop more realistic implementation plans.

Barriers to Access to Sterile Syringes as Perceived by Pharmacists and Injecting Drug Users: Implications for Harm Reduction in Lebanon

BACKGROUND

Access to sterile syringes to injecting drug users (IDU) reduces sharing behavior and prevents the transmission of HIV.

OBJECTIVES

To describe the barriers to access to sterile syringes for IDUs in Lebanon from the perspectives of pharmacists and IDUs.

METHODS

in this qualitative study conducted in Lebanon, data were collected from 72 syringe purchase tests at pharmacies, 64 interviewees with pharmacists and 2 focus groups with injecting drug users. Two independent researchers analyzed the verbatim transcripts.

RESULTS

Results revealed that pharmacists often deny access to sterile syringes to IDUs who are frequently stigmatized and intimidated at pharmacies. While no large gender differences in pharmacists' attitudes and practices were observed, inequalities in syringe access were noticed with men IDUs more often denied purchase. Pharmacists had several barriers to sell syringes to IDUs including fear of disease spread, increased drug use, inappropriately discarded syringes, staff and customer safety, and business concerns. IDUs had several challenges to purchase syringes including stigmatization, intimidation, physical harassment, concern to reveal identity, fear of arrest and syringe price abuse.

CONCLUSIONS

Identifying the barriers to and facilitators of access to sterile syringes to IDUs is important to guide the development of efficient policies. Findings implicate the importance of empowering IDUs to purchase syringes at pharmacies through reducing the negative attitude towards IDUs and strengthening pharmacists' role in the promotion of health of IDUs. Findings also suggest that the habit of syringe sharing would decrease if the legal and cultural barriers to access are reduced.

HIV/AIDS: trends in the Middle East and North Africa region

OBJECTIVES

To give an overview of the HIV epidemic in the Middle East and North Africa (MENA) region.

METHODS

Articles on the MENA region were reviewed.

RESULTS

The MENA region comprises a geographically defined group of countries including both high-income, well-developed nations and low- and middle-income countries. While the annual number of new HIV infections in Sub-Saharan Africa has declined by 33% since 2005, new HIV infections in the MENA region have increased by 31% since 2001, which is the highest increase among all regions in the world. Moreover, the number of AIDS-related deaths in 2013 was estimated to be 15000, representing a 66% increase since 2005. However, the current prevalence of 0.1% is still among the lowest rates globally. There is substantial heterogeneity in HIV epidemic dynamics across MENA, and different risk contexts are present throughout the region. Despite unfavorable conditions, many countries in the region have put significant effort into scaling up their response to this growing epidemic, while in others the response to HIV is proving slower due to denial, stigma, and reluctance to address sensitive issues.

CONCLUSIONS

The HIV epidemic in the MENA region is still at a controllable level, and this opportunity should not be missed.

Effects of In-country and Cross-Border Mobility on Condom Use Among Transgender Women (hijras) in Bangladesh: A Cross-Sectional Study

In Bangladesh transgender women (hijras) are thought to be highly mobile that may be an impediment to condom use. This cross-sectional study was conducted to determine the extent of mobility of hijras, in-country and cross-border, and whether mobility affects condom use in anal intercourse. Hijras ≥15 years of age, receiving services from the Global Fund supported HIV prevention program were enrolled. A behavioral questionnaire was administered and blood was tested for antibodies to HIV and syphilis. Of 889 hijras sampled, 41.3 % never traveled, 26.4 % traveled in-country and 32.3 % crossed the border in the last year. HIV and active syphilis was at 0.8 and 1.8 % respectively. Among hijras who crossed the border condom use was less likely in last anal intercourse (AOR 0.68; 95 % CI 0.48-0.96), and consistently with new (AOR 0.59; 95 % CI 0.34-1.01) and regular clients (AOR 0.45; 95 % CI 0.27-0.76) in the last week. This study concludes that in Bangladesh hijras are highly mobile and cross-border mobility negatively affects condom use.

Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People

INTRODUCTION

Transgender populations have been underrepresented in HIV epidemiologic studies and consequently in HIV prevention, care, and treatment programs. Since 2012, there has been a dramatic increase in research focused on transgender people. Studies highlight the burden of HIV and risk determinants, including intersecting stigmas, as drivers of syndemics among transgender populations. This review synthesizes the most recent global epidemiology of HIV infection and describes current gaps in research and interventions to inform prioritization of HIV research for transgender populations.

METHODS

A systematic review was conducted of the medical literature published between January 1, 2012 and November 30, 2015. The data focused on HIV prevalence, determinants of risk, and syndemics among transgender populations.

RESULTS

Estimates varied dramatically by location and subpopulation. Transfeminine individuals have some of the highest concentrated HIV epidemics in the world with laboratory-confirmed prevalence up to 40%. Data were sparse among trans masculine individuals; however, they suggest potential increased risk for trans masculine men who have sex with men (MSM). No prevalence data were available for transgender people across Sub-Saharan Africa or Eastern Europe/Central Asia. Emerging data consistently support the association of syndemic conditions with HIV risk in transgender populations.

DISCUSSION

Addressing syndemic conditions and gender-specific challenges is critical to ensure engagement and retention in HIV prevention by transgender populations. Future research should prioritize: filling knowledge gaps in HIV epidemiology; elucidating how stigma shapes syndemic factors to produce HIV and other deleterious effects on transgender health; and understanding how to effectively implement HIV interventions for transgender people.

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Status of HIV and hepatitis C virus infections among prisoners in the Middle East and North Africa: review and synthesis

INTRODUCTION

The status of HIV and hepatitis C virus (HCV) infections among incarcerated populations in the Middle East and North Africa (MENA) and the links between prisons and the HIV epidemic are poorly understood. This review synthesized available HIV and HCV data in prisons in MENA and highlighted opportunities for action.

METHODS

The review was based on data generated through the systematic searches of the MENA HIV/AIDS Epidemiology Synthesis Project (2003 to December 15, 2015) and the MENA HCV Epidemiology Synthesis Project (2011 to December 15, 2015). Sources of data included peer-reviewed publications and country-level reports and databases.

RESULTS AND DISCUSSION

We estimated a population of 496,000 prisoners in MENA, with drug-related offences being a major cause for incarceration. Twenty countries had data on HIV among incarcerated populations with a median prevalence of 0.6% in Afghanistan, 6.1% in Djibouti, 0.01% in Egypt, 2.5% in Iran, 0% in Iraq, 0.1% in Jordan, 0.05% in Kuwait, 0.7% in Lebanon, 18.0% in Libya, 0.7% in Morocco, 0.3% in Oman, 1.1% in Pakistan, 0% in Palestine, 1.2% in Saudi Arabia, 0% in Somalia, 5.3% in Sudan and South Sudan, 0.04% in Syria, 0.05% in Tunisia, and 3.5% in Yemen. Seven countries had data on HCV, with a median prevalence of 1.7% in Afghanistan, 23.6% in Egypt, 28.1% in Lebanon, 15.6% in Pakistan, and 37.8% in Iran. Syria and Libya had only one HCV prevalence measure each at 1.5% and 23.7%, respectively. There was strong evidence for injecting drug use and the use of non-sterile injecting-equipment in prisons. Incarceration and injecting drugs, use of non-sterile injecting-equipment, and tattooing in prisons were found to be independent risk factors for HIV or HCV infections. High levels of sexual risk behaviour, tattooing and use of non-sterile razors among prisoners were documented.

CONCLUSIONS

Prisons play an important role in HIV and HCV dynamics in MENA and have facilitated the emergence of large HIV epidemics in at least two countries, Iran and Pakistan. There is evidence for substantial but variable HIV and HCV prevalence, as well as risk behaviour including injecting drug use and unprotected sex among prisoners across countries. These findings highlight the need for comprehensive harm-reduction strategies in prisons.

Global Epidemiology of HIV Among Women and Girls Who Use or Inject Drugs: Current Knowledge and Limitations of Existing Data

BACKGROUND

Women and girls who use and inject drugs are a critical population at risk of HIV. In this article, we review data on the epidemiology of drug use and injection among women globally and HIV prevalence among women and girls who use and inject drugs.

RESULTS

Women and girls comprise one-third of people who use and inject drugs globally. There is substantial variation in HIV prevalence in this population, between and within countries. There is a pronounced lack of data examining HIV risk among particularly vulnerable subpopulations of women who use and inject drugs, including women who have sex with women, transgender women, racial and ethnic minority women, and young women. Women who use and inject drugs experience stigma and discrimination that affect access to services, and high levels of sexual risk exposures.

CONCLUSIONS

There are significant gaps in our understanding of the epidemiology of drug use and injecting among women and girls and HIV risk and prevalence in this population. Women are frequently underrepresented in studies of drug use and HIV risk and prevalence among people who inject drugs, limiting our understanding of possible sex differences in this population. Most research originates from developed countries and may not be generalizable to other settings. A great deal of work is needed to improve understanding of HIV among particularly vulnerable subpopulations, such as transgender women who use drugs. Better data are critical to efforts to advocate for the needs of women and girls who use and inject drugs.

Epidemiological challenges to the assessment of HIV burdens among key populations: respondent-driven sampling, time-location sampling and demographic and health surveys

PURPOSE OF REVIEW

Measuring the burden of HIV among key populations is subject to many challenges. Sufficient quantities of valid HIV prevalence and programme coverage data are required to effectively respond to the epidemic.

RECENT FINDINGS

Ability to validate exposure to unprotected sex through the innovative use of prostate-specific antigen provides confirmation of condom use. A new weighting scheme based on frequency of venue attendance for time location samples should improve validity of data obtained with this method. Two new proportion estimators, new diagnostic methods, a new population size estimator and new analysis software will provide more robust results from respondent-driven sampling (RDS).

SUMMARY

Analytical advances have improved the potential quality of results from surveys using time location and RDS. However, data from sufficient numbers of sites over sufficient number of years are still needed to provide clear national pictures of distribution and trends of HIV infection.

The emerging face of the HIV epidemic in the Middle East and North Africa

PURPOSE OF REVIEW

A volume of quality HIV data has materialized recently in the Middle East and North Africa (MENA). This review provides a thematic narrative of the patterns of HIV infection transmission in this region in light of these data.

RECENT FINDINGS

Tens of integrated bio-behavioral surveillance surveys among hard-to-reach key populations at higher risk have been conducted in MENA in the recent years. Many of the studies reported appreciable and growing HIV prevalence. A few studies found alarming prevalence of as much as 87.2% HIV prevalence among people who inject drugs in Tripoli, Libya. The discovery of these hitherto hidden epidemics was unsettling to some authorities after years in which the importance of a focus on HIV prevention among key populations was not recognized.

SUMMARY

The new data from MENA indicate growing HIV epidemics among key populations across the region. There is heterogeneity, however, as to which key populations are affected and in what proportions in different countries. In a few countries, HIV appears to affect only one key population and often there is substantial geographical heterogeneity in HIV transmission. Data are indicative of a growing HIV disease burden in this part of the globe, in contrast with the declining epidemics in most other regions.

Epidemiology of HIV and AIDS among adolescents: current status, inequities, and data gaps

OBJECTIVES

To examine levels and patterns of HIV prevalence, knowledge, sexual behavior, and coverage of selected HIV services among adolescents aged 10-19 years and highlight data gaps and challenges.

METHODS

Data were reviewed from Joint United Nations Programme on HIV/AIDS HIV estimates, nationally representative household surveys, behavioral surveillance surveys, and published literature.

RESULTS

A number of gaps exist for adolescent-specific HIV-related data; however, important implications for programming can be drawn. Eighty-two percent of the estimated 2.1 million adolescents aged 10-19 years living with HIV in 2012 were in sub-Saharan Africa, and the majority of these (58%) were females. Comprehensive accurate knowledge about HIV, condom use, HIV testing, and antiretroviral treatment coverage remain low in most countries. Early sexual debut (sex before 15 years of age) is more common among adolescent girls than boys in low- and middle-income countries, consistent with early marriage and early childbirth in these countries. In low and concentrated epidemic countries, HIV prevalence is highest among key populations.

CONCLUSIONS

Although the available HIV-related data on adolescents are limited, increased HIV vulnerability in the second decade of life is evident in the data. Improving data gathering, analysis, and reporting systems specific to adolescents is essential to monitoring progress and improving health outcomes for adolescents. More systematic and better quality disaggregated data are needed to understand differences by sex, age, geography, and socioeconomic factors and to address equity and human rights obligations, especially for key populations.

Does knowledge about bloodborne pathogens influence the reuse of medical injection syringes among women in Pakistan?

Injections with re-used syringes have been identified as a major risk factor for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in Pakistan. We analyzed data from the 2006-2007 Pakistan Demographic Health Survey (PDHS) to describe the distribution of injections administered with newly opened syringes and assessed the association of knowledge about bloodborne pathogens with syringe reuse in Pakistan. In the PDHS, women aged 12-49 years were enrolled through a multistage stratified cluster-sampling strategy across Pakistan. Approximately 10,000 women were interviewed to collect information regarding receiving injections, the use of syringes taken out of new unopened packages for their last injections, and knowledge regarding the transmission of Human Immunodeficiency Virus (HIV), HBV and HCV through the re-use of syringes and transfusion of unscreened blood. Of the 5126/10,023 women who provided information concerning their last injection, 4342 (86%) received this injection with a new syringe taken out of an unopened package. The proportion of injections received with a new syringe increased with the education level, wealth, HIV knowledge and knowledge about HCV/HBV transmission through the re-use of syringes. In the multivariable model, respondents in the 4th (adjusted odds ratio (AOR): 2.1, 95%CI: 1.4-3.0) and 5th (AOR: 2.4, 95%CI: 1.6-3.5) wealth quintiles, with some education (AOR: 1.4, 95%CI: 1.1-1.9), those in the 4th quartile of the HIV knowledge score (AOR: 1.5, 95%CI: 1.1-2.0), and those with the knowledge that a new syringe protects against HCV/HBV and HIV (AOR: 2.3, 95%CI: 1.5-3.5) were more likely to receive injections with a newly opened syringe. The patients' knowledge regarding the transmission of bloodborne pathogens is an important factor in receiving injections with a new syringe.

'Part of the job': male-to-male sexual experiences and abuse of young men working as 'truck cleaners' along the highways of Pakistan

As part of a study on the sexual health and social protection needs of men who have sex with men in Pakistan, 11 young men employed as assistants to truckers ('truck cleaners') who acknowledged having had sexual experiences with men, were interviewed and their social background and sexual initiation and their subsequent sexual lives were explored. For most truck cleaners, the first instance of sexual contact between the truck cleaner and the driver was forced and happened at an early age. Sex with other men, as well as with women (including sex workers) was widely reported. Drug and alcohol use was common. There is strong potential for HIV and STIs to spread through these sexual networks. Measures to prevent young men from entering into a career as truck helpers should be considered, as well as interventions to improve the health and social situation of those already employed.

HIV prevalence and risk behaviours among people who inject drugs in Iran: the 2010 National Surveillance Survey

OBJECTIVES

To assess the prevalence of HIV and related risk behaviours among people who inject drugs (PWID) in Iran.

METHODS

We conducted a national cross-sectional bio-behavioural surveillance survey between March and July 2010, interviewing male PWID from a geographically dispersed sample through a facility-based sampling method.

RESULTS

We recruited 2480, and tested 2290 PWID. The overall prevalence of HIV was 15.2% (95% CI 9.7% to 23.1%). Among those who had injected drugs over the last month, 36.9% had used a non-sterile needle, and 12.6% had practiced shared injection. Over the past 12 months preceding the interview, 30.4% had sold sex for money, drugs, goods or a favour. In the multivariate analysis, the prevalence of HIV had a positive association with age, while having above high school education, and permanent job were protective.

CONCLUSIONS

Unsafe injection, and sexual risk behaviours are still frequent and the prevalence of HIV among PWID remains high. Intensified efforts are needed to prevent the further spread of HIV among Iranian PWID and their sexual partners.