Migrant men: a priority for HIV control in Pakistan?

An exploratory study of knowledge, attitudes, and practices toward HPV associated anal cancer among Pakistani population

Background

Anal cancer, mainly attributed to human papillomavirus (HPV) infection, is rising in prevalence among the general population in Pakistan. This study aimed to examine the knowledge, attitudes, and practices (KAP) towards anal cancer screening and HPV of the general population in Pakistan.

Method

We surveyed anal cancer KAP using social media and snowball sampling from December 2022 to May 2023. The questionnaire had 16 knowledge, 12 attitudes, 6 practice questions, and socio-demographic variables. We applied validity criteria for inclusion and exclusion and used cutoffs ≥50% for each KAP category. We analyzed data in R with Guttman's λ2 for reliability, did univariate and bivariate analysis, and reported frequencies, percentages, p-values, coefficients, odds ratios, and 95% confidence intervals.

Results

We surveyed 1620 people and discovered low awareness of HPV and anal cancer causes prevention, and screening (11%-24%), high stigma and embarrassment for screening (54%-70%), strong moral beliefs (89%), condom nonuse (91%), and low engagement in health services and programs (9.1%-14%). Knowledge (75.23%, OR = 1.0984, p = 0.05) was shaped by socio-demographic factors, attitude, and practice, with higher education enhancing knowledge (OR = 1.0984, p = 0.05). Attitude (78.45%, OR = 6.6052, p< 0.001) was influenced by socio-demographic factors, practice, and knowledge as well. Younger females, single, unemployed, students, living with more family members, earning more income, and residing in Islamabad had a more positive attitude (ORs from 1.0115 to 6.6052, p< 0.05), while religion did not affect attitude (p = 0.51). Practice (9.16%, OR = 0.1820, p< 0.001) was determined by socio-demographic factors, knowledge, and attitude. Older males, employed teachers, living with more family members, earning less income, and residing in Islamabad had better practice (ORs from 0.1323 to 3.8431, p< 0.05), but marital status and religion did not influence practice (p > 0.05).

Conclusion

Pakistani young adults need more education, awareness, health services, and programs on HPV and anal cancer, as they have low awareness, high stigma, and socio-cultural challenges. In addition, it is recommended for more research and policy initiatives are needed to address socio-cultural factors and increase anal Pap to overcome anal cancer.

Epidemiology of Chlamydia trachomatis in the Middle East and north Africa: a systematic review, meta-analysis, and meta-regression

BACKGROUND

The epidemiology of Chlamydia trachomatis in the Middle East and north Africa is poorly understood. We aimed to provide a comprehensive epidemiological assessment of C trachomatis infection in the Middle East and north Africa.

METHODS

We did a systematic review of C trachomatis infection as well as a meta-analysis and meta-regression of C trachomatis prevalence. We searched PubMed and Embase, as well as regional and national databases up to March 13, 2019, using broad search terms with no language or year restrictions. Any document or report including biological measures for C trachomatis prevalence or incidence was eligible for inclusion. We extracted all measures of current (genital or rectal), recent, and ever infection with C trachomatis. We estimated pooled average prevalence in different populations using random-effects meta-analysis. Factors associated with prevalence and sources of between-study heterogeneity were determined using meta-regression.

FINDINGS

We identified a total of 1531 citations, of which 255 reports contributed to 552 C trachomatis prevalence measures from 20 countries. No incidence measures were identified. Pooled prevalence of current genital infection was 3·0% (95% CI 2·3-3·8) in general populations, 2·8% (1·0-5·2) in intermediate-risk populations, 13·2% (7·2-20·7) in female sex workers, 11·3% (9·0-13·7) in infertility clinic attendees, 12·4% (7·9-17·7) in women with miscarriage, 12·4% (9·4-15·7) in symptomatic women, and 17·4% (12·5-22·8) in symptomatic men. Pooled prevalence of current rectal infection was 7·7% (4·2-12·0) in men who have sex with men. Substantial between-study heterogeneity was found. Multivariable meta-regression explained 29·0% of variation. Population type was most strongly associated with prevalence. Additional associations were found with assay type, sample size, country, and sex, but not with sampling methodology or response rate (about 90% of studies used convenience sampling and >75% had unclear response rate). There was no evidence for temporal variation in prevalence between 1982 and 2018.

INTERPRETATION

C trachomatis prevalence in the Middle East and north Africa is similar to other regions, but higher than expected given its sexually conservative norms. High prevalence in infertility clinic attendees and in women with miscarriage suggests a potential role for C trachomatis in poor reproductive health outcomes in this region.

FUNDING

National Priorities Research Program from the Qatar National Research Fund (a member of Qatar Foundation).

Field evaluation of a blood based test for active tuberculosis in endemic settings

Over 9 million new active tuberculosis (TB) cases emerge each year from an enormous pool of 2 billion individuals latently infected with Mycobacterium tuberculosis (M. tb.) worldwide. About 3 million new TB cases per year are unaccounted for, and 1.5 million die. TB, however, is generally curable if diagnosed correctly and in a timely manner. The current diagnostic methods for TB, including state-of-the-art molecular tests, have failed in delivering the capacity needed in endemic countries to curtail this ongoing pandemic. Efficient, cost effective and scalable diagnostic approaches are critically needed. We report a multiplex TB serology panel using microbead suspension array containing a combination of 11 M.tb. antigens that demonstrated overall sensitivity of 91% in serum/plasma samples from TB patients confirmed by culture. Group wise sensitivities for sputum smear positive and negative patients were 95%, and 88%, respectively. Specificity of the test was 96% in untreated COPD patients and 91% in general healthy population. The sensitivity of this test is superior to that of the frontline sputum smear test with a comparable specificity (30–70%, and 93–99%, respectively). The multiplex serology test can be performed with scalability from 1 to 360 patients per day, and is amenable to automation for higher (1000s per day) throughput, thus enabling a scalable clinical work flow model for TB endemic countries. Taken together, the above results suggest that well defined antibody profiles in blood, analyzed by an appropriate technology platform, offer a valuable approach to TB diagnostics in endemic countries.

Point of care HIV testing with oral fluid among returnee migrants in a rural area of Bangladesh

Objectives

To determine HIV prevalence and assess the acceptability of HIV testing using oral fluid as a point of care (PoC) test method among returnee migrants in a rural area of Bangladesh.

Design

A cross-sectional study.

Methods

Matlab is a rural area southeast of Dhaka where icddr,b hosts a health and demographic surveillance system covering 225 826 people of whom 934 are returnee migrants. The sample size of 304 was proportionately distributed among randomly selected households. HIV antibodies in oral fluid were tested using OraQuick Rapid HIV 1/2 antibody test. To understand reasons of acceptability a short questionnaire was applied and 32 in-depth interviews were conducted.

Results

Of 304 returnee migrants approached, 97.4% accepted the test. The prevalence of HIV was 0.3% without a confirmatory blood test. Reasons for acceptance included easy accessibility of the test at the door-step which saved resources (i.e., time and money), comfortable test-procedure without any pain and fear, and receiving quick results with confidentiality. Some described knowing HIV status as a way to ‘get certified’ (of sexual fidelity) and to confront a prevailing silent stigma against migrants. Acceptability was moreover found to be grounded in icddr,b's institutional reputation and its close relationship with the local community.

Conclusions

The PoC oral fluid test for HIV has shown for the first time that assessment of HIV prevalence in rural-based returnee migrants is possible. Findings also suggest that PoC oral fluid test has the potential of increasing accessibility to HIV testing as it was found to be highly acceptable.

Exploring urban male non-marital sexual behaviours in Pakistan

BACKGROUND

In Pakistan, sexual practices outside marriage are proscribed by law. We aimed to assess the range and magnitude of non-marital sexual behaviours of urban men, focusing on men having sex with men.

METHODS

In this cross sectional survey undertaken in six cities of Pakistan, we interviewed 2400 men aged 16-45 years selected through a multistage systematic sampling design. Sexual behaviours were assessed through a structured questionnaire. Multivariable analysis was used to identify association between various individual level characteristics and probability of engaging in sexual activities involving men.

RESULTS

Nearly one-third (29 percent) reported having had non-marital sex in their lifetime. Of these men 16 percent reported premarital sex, while 11 percent reported engaging in both pre- and extramarital sex. Only two percent reported exclusive extramarital sex. In total 211 respondents, 9 percent reported ever having had sexual relations with men. While 62 respondents, 2.6 percent reported exclusive sex with males. Factors that were significantly associated with MSM behaviours were being less than 27 years (adjusted OR 5.4, 95% CI 3.8-7.7, p < 0.000), less than 10 years of schooling (adjusted OR 2.1, 95% CI 1.4-3.2, p < 0.000), being unemployed (adjusted OR 2.7, 95% CI 1.6-4.3, p < 0.000), being exposed to pornographic materials (adjusted OR 4.8, 95% CI 3.0-7.7, p < 0.000) and being a migrant (adjusted OR 2.1, 95% CI 1.3-3.4, p < 0.002). Factors significantly associated with exclusive homosexual behaviour were having sexual debut at a younger age i.e. 16-22 years (adjusted OR 12.5, 95% CI: 3.8-40.7, p < 0.000), being unemployed (adjusted OR 8.8, 95% CI: 3.0-26.0, p = 0.000), having had exposure to pornographic materials (adjusted OR 3.3, 95% CI: 1.5-7.2, p = 0.002).

CONCLUSIONS

To prevent the spread of STI's in Pakistan, preventive interventions should focus on reaching out to young uneducated men offering them with appropriate counselling and skills to adopt "safe sex practices" through workplace orientation sessions; while for youth in schools, life skills education be included in the curriculum. Through public-private partnership stigmatised groups should be reached through established community networks and provided with information on accessing voluntary counseling and treatment centres.

HIV and STI prevalence and determinants among male migrant workers in India

BACKGROUND

Our objective was to estimate for the first time the prevalence and determinants of human immunodeficiency virus type 1 (HIV-1) and sexually transmitted infections (STIs) among male migrants in India.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a multi-stage stratified probability sample survey of migrant (defined as not born in Surat city) men aged 18 to 49 years working in the diamond and textile industries in Surat city. Behavioural and biological data were collected. Biological data included laboratory diagnosed herpes simplex virus type 2 (HSV-2), syphilis, chlamydia, gonorrhoea, Trichomonas vaginalis (together defined as 'any STI') and HIV-1. Likely recently acquired STIs included chlamydia, gonorrhoea, T. vaginalis and syphilis with rapid plasma reagin ≥1:8. The response rate was 77% (845/1099). Among 841 participants, HIV-1 prevalence was 1.0%, 'any STI' prevalence was 9.5% and 38.9% of these STIs were likely to have been recently acquired. Being a diamond worker, Surat resident for 10+ years and recent antibiotic use were each associated with higher odds of 'any STI' (aORs 1.83 (95% CI 1.09-3.09), 1.98 (95% CI 1.22-3.22) and 2.57 (95% CI 1 .17-5.64), respectively) after adjusting for the other two factors and age. The main study limitation was social desirability bias for self-reported sexual behaviour; STIs were diagnosed in some self-reported virgins.

CONCLUSIONS/SIGNIFICANCE

HIV and STI prevalence were lower than expected, but prevention interventions remain necessary in Surat since almost 40% of STIs among participants were probably recently acquired and sentinel surveillance HIV prevalence remains high. The participants had a similar HIV prevalence to Surat antenatal clinic attendees, a proxy for the general population. This suggests migrants are not always at higher risk of HIV compared to the general population in their migration destination. Our findings highlight the need to contextualise research findings from a specific setting with other local information to guide HIV/STI prevention interventions.

Screening for HIV among tuberculosis patients: a cross-sectional study in Sindh, Pakistan

OBJECTIVE

To describe feasibility and results of systematic screening of tuberculosis (TB) patients for HIV.

DESIGN

Cross-sectional study.

SETTING

Six selected sentinel sites (public DOTS clinics) in the province of Sindh, Pakistan.

PARTICIPANTS

All TB patients aged 16-60 years registered for treatment from April 2008 to March 2012.

MEASUREMENT

Demographic information of registered TB patients, screening for HIV through rapid testing and confirmation by referral lab of Sindh AIDS Control Program, according to national guidelines.

RESULTS

Of a total of 18 461 registered TB patients, 12 882 fulfilled the inclusion criteria and were given education and counselling. Of those counselled 12 552 (97.4%) were screened for HIV using a rapid test. Men made up 48% of the sample and 76.5% of patients had pulmonary TB. Of the total patients tested, 42 (0.34%) were HIV-positive after confirmatory testing at the Sindh AIDS Control Program Laboratory. Prevalence of HIV among male patients was 0.67% whereas prevalence among female patients was 0.03% (p value <0.001). Prevalence of HIV among pulmonary TB patients was 0.29% and among extrapulmonary TB patients was 0.48% (p value=0.09).

CONCLUSION

In public DOTS clinics in Pakistan it is feasible to test TB patients for HIV. Prevalence of HIV is three times higher among TB patients as compared with the general population in Pakistan. Although the results are not representative of Pakistan or Sindh province they cover a large catchment area and closely match WHO estimate for the country. Routinely screening all TB patients for HIV infection, especially targeting men and ensuring antiretroviral therapy, can significantly improve TB/HIV collaborative activities in Pakistan and identify many cases of HIV, improve health outcomes and save lives.

Condom use during commercial sex among clients of Hijra sex workers in Karachi, Pakistan (cross-sectional study)

Objective To describe the prevalence and predictors of condom use and sexual risk in the male clients of Hijra sex workers (HSWs) in Karachi, Pakistan. Design Cross-sectional study. Setting Karachi, Pakistan. Participants Clients of HSWs were recruited with assistance from HSWs and a non-governmental organisation (NGO) focused on men who have sex with men (MSM) during October-November 2010. Measurements The interviewer administered the questionnaire to each participant to solicit information on demographics, HIV/AIDS knowledge/attitudes and sexual risk behaviours/practices, including condom use in the last sexual act with the HSW. Results Of the 203 participants, 42.4% reported that they used condoms during their last sexual act with HSW, 40% were married, 18% had ever used drugs or alcohol, and 52% reported also engaging with female sex workers in the last month. Casual HSW clients were more likely to use condoms than regular clients (adjusted OR (AOR), 2.50; 95% CI 1.34 to 4.65), as were persons with a higher education level (AOR 5.8; 95% CI 1.6 to 20.3). Drug/alcohol users and non-users were equally likely to use condoms (AOR 1.11; 95% CI 0.51 to 2.24). Conclusion Clients of HSWs in Pakistan are at risk of acquiring HIV/STI infections. Concerted efforts are needed to increase condom use in this key bridge population to curtail the spread of HIV in the general population.

Sexual risk behaviour of rural-to-urban migrant taxi drivers in Dhaka, Bangladesh: a cross-sectional behavioural survey

OBJECTIVES

Human immunodeficiency virus (HIV) research in Bangladesh has mainly focused on key vulnerable groups (e.g. sex workers, drug users). In order to develop appropriate HIV prevention strategies in an evolving epidemic, there is a need for evidence on sexual practices in other population groups. This research aims to describe the prevalence of risky behaviours and factors affecting sexual behaviour/practices among rural-to-urban migrant taxi drivers in Dhaka.

STUDY DESIGN

Cross-sectional study.

METHODS

This paper reports on the cross-sectional survey component of a mixed methods research study amongst migrant workers in Bangladesh. The sample (n = 437) comprised rural-to-urban migrant taxi drivers in Dhaka (aged 18-35 years). The survey data were analysed statistically using Statistical Package for the Social Sciences.

RESULTS

Very high levels of pre- and extramarital sexual behaviour were found (84% and 51%, respectively) amongst the sample (n = 437). The reported sexual activity included high levels of risky/unsafe sex in the past year: 64% of the sample reported sex with multiple commercial sex partners (mean = 13.21), and 21.7% reported sex with other males/transgenders (mean = 2.53). Protection against risk was low: 78.2% reported that their last commercial sexual encounter was unprotected, and only 5.6% used condoms consistently. Multivariate analysis revealed that the odds of risky sexual behaviour were higher in migrant men who were not married (odds ratio 35.3, P < 0.001) and married men who were living apart from their spouses (odds ratio 41.7, P < 0.001). Additionally, reported risk behaviours were significantly associated with frequency of home visits, duration of separation from spouse and alcohol consumption. Thus, male migration without family or spouse appears to be a key driver of risky sexual practices.

CONCLUSIONS

This study provides important new information for understanding the dynamics of sexual behaviour in Bangladesh, and suggests that migrant men should be a key population for HIV prevention efforts. Nonetheless, the fact that most men were having unprotected sex with sex workers reinforces the importance of continuing to target interventions towards commercial sex contexts.

Epidemiology of HIV infection in the Middle East and North Africa

OBJECTIVE

The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region.

METHODS

A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents.

RESULTS

Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited.

CONCLUSION

Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

Evaluation of bias in HIV seroprevalence estimates from national household surveys

OBJECTIVES

To evaluate HIV seroprevalence estimates from demographic and health surveys (DHS) and AIDS indicator surveys (AIS) for potential bias because of non-response and exclusion of non-household population groups.

METHODS

Data are from 14 DHS/AIS surveys with HIV testing, conducted during 2003-6. Blood samples were collected and analysed for HIV using standard laboratory and quality control procedures. HIV prevalence among non-tested adults was predicted based on multivariate statistical models of HIV for those who were interviewed and tested, using a common set of predictor variables. Estimates of the size of non-household populations in national censuses were used to assess potential bias because of their exclusion in the household surveys under different assumptions about proportion of adults and HIV prevalence in non-household populations.

RESULTS

Non-tested men had significantly higher predicted HIV prevalence than those tested in eight of the 14 countries, while non-tested women had significantly higher predicted prevalence than those tested in seven of the 14 countries. Effects of non-response were somewhat stronger in lower-prevalence countries. The overall effect of non-response on observed national HIV estimates was small and insignificant in all countries. Estimated effects of exclusion of non-household population groups were generally small, even in concentrated epidemics in India and Cambodia under the scenario that 75% of the non-household population was adults having 20 times greater HIV prevalence than adults in household surveys.

CONCLUSIONS

Non-response and the exclusion of non-household population groups tend to have small, insignificant effects on national HIV seroprevalence estimates obtained from household surveys.

HIV related risks among Croatian migrant workers 2004-2006

Two waves of a cross-sectional research study focusing on HIV-related risks in a population of migrant workers were carried out in 2004 and 2006. The research focused on changes in HIV knowledge, beliefs about condom use and risk-taking behaviours. The study included 552 migrant workers in 2004 and 671 in 2006. Using a self-administered questionnaire, data was collected in occupational health offices in nine cities during the process of medical examination required for licensing. Three major changes were observed in the 2004-2006 period. HIV knowledge improved and an increase in condom use at last sexual intercourse with casual partner and at last anal sex was reported. The changes in condom use were observed only among participants who were married or in a relationship. No significant change was recorded in the rates of HIV testing. In 2006, marital status, occupation, beliefs about condom use and personal HIV concerns were found significant predictors of HIV-related behavioural change. Overall, the findings suggest a small reduction in HIV-related sexual risks among migrant workers in Croatia.