The prevalence and impact of childhood sexual abuse on HIV-risk behaviors among men who have sex with men (MSM) in India

Cumulative violence exposures among men who have sex with men living with HIV in India: Psychosocial correlates of HIV care continuum outcomes

Lifetime exposures to violence among men who have sex with men (MSM) are associated with multiple psychosocial health risks and can affect engagement and outcomes of HIV treatment. This study a) explored relationships between levels of exposures to violence and HIV care continuum outcomes among MSM living with HIV in India, and b) identified psychosocial correlates of HIV care continuum outcomes among MSM living with HIV and those with lifetime cumulative exposures to violence (CVE). CVE referred to exposures to violence in both childhood and adulthood. This cross-sectional analysis used survey data collected between August 2016 and May 2017 from 1763 men who have sex with men living with HIV across 10 cities in India, using respondent-driven sampling. We found that higher levels of violence exposure were significantly associated with lower awareness of HIV positive status, and lower likelihood of initiating antiretroviral therapy. Compared with MSM living with HIV that had no CVE, those with CVE were more likely to report perpetration of interpersonal violence, alcohol misuse, depressive symptoms, and HIV transmission risk behaviors and to have two to four co-occurring psychosocial problems. In multivariable analysis with the subset of MSM with CVE, psychosocial correlates significantly associated with at least one HIV care continuum outcome were HIV transmission risk behaviors, perpetration of interpersonal violence, depression, and alcohol misuse. The findings highlight the need for integrating care for lifetime violence exposures and associated behavioral problems in HIV care settings for men who have sex with men living with HIV in India.

Earlier Sexual Debut and Anti-Gay Victimization Among Men Who Have Sex With Men (MSM) in Kazakhstan

Limited research has examined predictors of anti-gay victimization among men who have sex with men (MSM), despite anti-gay violence continuing to be a global problem. We conducted a secondary analysis of data from structured interviews with 600 MSM adults to examine anti-gay victimization and earlier sexual debut among MSM in Kazakhstan. Multiple linear regression was used to test for associations between earlier sexual debut-categorized as age of sexual onset between 13 and 15 years of age and prior to 13 years old, with ages 16 and older as the reference group-and recent and lifetime anti-gay victimization. Adjusted logistic regression models were used to assess earlier sexual debut and specific types of victimization. The majority of MSM reported lifetime (89%) or recent (68%) experiences of anti-gay victimization. Earlier sexual debut prior to 13 years of age was significantly associated with greater number of types of lifetime and recent reports of anti-gay victimization. Among specific types of anti-gay victimization, earlier sexual debut was associated with higher odds of experiencing verbal, physical, and sexual violence. Anti-gay violence in Kazakhstan is a significant and prevalent public health issue. Future research and clinical interventions addressing anti-gay victimization among MSM populations should consider the lifetime and current implications of consensual and non-consensual childhood and adolescent sexual experiences.

Measuring the prevalence of autistic traits in a cohort of adults living with HIV or taking HIV pre-exposure prophylaxis and mapping safer-sex barriers and facilitators: a study protocol

INTRODUCTION

Autistic individuals identify with a wider range of sexual orientations than non-autistic individuals, including higher rates of bisexual orientation in autistic men. Gay, bisexual and other men who have sex with men are at greater risk for HIV. Prevalence data of autistic traits in people living with HIV or using Pre-Exposure Prophylaxis (PrEP) for HIV are lacking so far. Such data, combined with insights in barriers and facilitators for safer sex in autistic people living with HIV or using PrEP, are a first step to improve health support for autistic people in HIV clinics. This support is crucial since autistic individuals have worse physical and mental health outcomes. The objective of this research is to determine the prevalence of autistic traits within the group of people living with HIV or using PrEP in Belgium and to describe specific facilitators and barriers for sexual safer behaviour in people living with HIV and PrEP users with autistic traits.

METHODS AND ANALYSIS

The research is a cross-sectional, observational and multicentre study with recruitment of individual participants. The research consists of two phases. In phase 1, adults coming for HIV/AIDS care or HIV PrEP in participating Belgian HIV Reference Centres will be invited to fill in the validated Autism Spectrum Quotient questionnaire. In phase 2, participants with a score above the predefined cut-off for autistic traits (>26), who agreed to be informed about this score, will be invited to complete an additional survey, inquiring facilitators and barriers for sexual safer behaviour.

ETHICS AND DISSEMINATION OF RESULTS

Institutional Review Board Institute of Tropical Medicine Antwerp, 25 July 2022, REF 1601/22 and University Hospital of Antwerp, 12 September 2022, Project ID 3679: BUN B3002022000111. Study results will be published in peer-reviewed journals and presented to Belgian HIV Reference Centres and at conferences.

Coping strategies among older adults living with HIV/AIDS with history of childhood sexual abuse

Background: Childhood sexual abuse (CSA) may be a risk factor for poor mental health in adulthood. Survivors may experience emotions detrimental to their social and mental wellbeing. Some of these emotions may include anger, fear, rage, helplessness, guilt, shame, which may impact their coping strategies. The aim of this study was to determine the association between CSA and coping among older adults living with HIV (OALH). Method: Data were obtained from 91 OALH via convenience sampling. The participants were recruited from an immunology clinic and were at least 50 years or older and living with HIV. CSA was operationalized using questions from the Adverse Childhood Experiences Questionnaire. Coping was assessed using the Brief COPE Inventory. Crude and adjusted linear regression models, controlling for age, sex, race, gender, and income were used to determine the association between CSA and each coping subscale. The analyses were conducted in SAS version 9.4. Results: Crude analyses showed statistically significant associations between CSA and specific coping strategies: humor (β = 1.244; p = 0.0018), religion (β = 1.122; p = 0.0291), Self-blame (β = 1.103; p = 0.0154), planning β = 1.197; p = 0.0196), venting (β = 1.218; p = 0.0063), substance use (β = 0.828; p = 0.0335) and instrumental support (β = 0.949; p = 0.0416) After adjusting for sociodemographic characteristics, there was a statistically significant association between CSA and humor (β = 1.321; p = 0.0048) and self-blame (β = 1.046; p = 0.0382). Conclusion: OALH with a history of CSA were more likely to use humor and self-blame as coping strategies. Trauma-informed interventions should be geared towards decreasing self-blame for OALH who are CSA survivors.

Global trends in depression among patients living with HIV: A bibliometric analysis

Background

Human immunodeficiency virus (HIV) related depression has seriously affected the quality of life and treatment outcomes of patients living with HIV (PLWH), which has become a hot topic in recent years. This study aims to discover the main keywords, predict frontier topics, and give meaningful suggestions for researchers by bibliometric analysis.

Methods

Publications between 1999 and 2022 on depression in HIV/AIDS were searched in the Web of Science core collection. Microsoft Excel 2010 and VOSviewer were utilized to key contributors (e.g., authors, journals, institutions, and countries). VOSviewer and CiteSpace were used to analyze the knowledge evolution, collaborative maps, hot topics, and keywords trends in this field.

Results

In total, 8,190 publications were included in the final analysis. From 1999 to 2021, the number of published articles roughly presents a steadily increasing trend. The United States, South Africa, and the United Kingdom were three key contributing countries/regions to this field. University Calif San Francisco (United States), University Calif Los Angeles (United States), and Johns Hopkins University (United States) were three key contributing institutions. Safren, Steven A. was the most productive and highest cited author. AIDS Care was the top prolific journal. Antiretroviral therapy and adherence, men has sex with men, mental health, substance abuse, stigma, and Sub-Saharan Africa were the central topics regarding the depression-related research in HIV/AIDS.

Conclusion

This bibliometric analysis reported the publication trend, major contributing countries/regions, institutions, authors, journals and mapped the knowledge network of depression-related research on HIV/AIDS. In this field, topics such as “adherence,” “mental health,” “substance abuse,” “stigma,” “men who have sex with men” and “South Africa” have attracted considerable attention.

Prevalence, Characteristics, and Factors Associated With Sexual Violence in Adulthood Among Brazilian MSM

Most studies of sexual violence are with women, and although men who have sex with men (MSM) is the group of the men that has been most investigated for sexual violence, there are still several questions to be answered about sexual violence and sexual revictimization among MSM. This study aimed to estimate the prevalence of sexual violence in different stages of life and identify factors associated with sexual violence in adulthood among Brazilian MSM. We conducted an analysis with data from the study conducted in 2016 with 4,176 MSM from 12 Brazilian cities recruited through respondent-driven sampling (RDS), who answered a survey to a set of questions, among which some specific about sexual violence. Most participants were under 25 years old (56.5%), with more than 12 years of schooling (71.2%), mixed race (40.8%), single (86.2%), and belonging to some religion (50.9%). The lifetime prevalence of sexual violence was 20.3%. In our analyses, having experienced sexual violence in childhood and adolescence increased the odds of experiencing sexual violence in adulthood (prevalence ratio ratios [PRR] 4.93 (95% CI [1.99, 12.21]), as did experiencing physical violence (PRR 1.99; 95% CI [1.07, 3.71]) and receiving money for sex (PRR 2.26; 95% CI [1.17, 4.36]). In addition to violence in childhood and adolescence being risk factors for sexual violence in adulthood, we also observed that half of the sample experienced sexual violence repeatedly, characterizing sexual revictimization. It is important that health services are prepared to receive boys and men victims in order to reduce the chances of revictimization and other outcomes.

Intervention program needs for older adults living with HIV who are childhood sexual abuse survivors

OBJECTIVES

Childhood sexual abuse (CSA) prevalence estimates range from 8-11% among older adults and may range from 16 to 22% among older adults living with HIV (OALH). CSA experiences can still impact the quality of life of older adults. To the best of our knowledge, however, there are no CSA-focused interventions tailored for OALH. Using a qualitative approach, this study characterized the desired components of a trauma-focused intervention for OALH who are CSA survivors.

METHODS

Twenty-four (24) adults aged 50 years of age or older who were living with HIV and had experienced CSA were recruited from a large HIV immunology center in South Carolina. Participants completed in-depth, qualitative, semi-structured interviews. We iteratively examined verbatim transcripts using thematic analysis.

RESULTS

Three main themes emerged: program format and modality, program content, and program coordinator. Most participants expressed a desire for a trauma-focused intervention program in which the CSA experience was addressed and they could talk to someone either individually, as a group, and/or both.

CONCLUSION

A trauma-focused intervention addressing CSA may be helpful for OALH who are CSA survivors. Future research should focus on designing and implementing age-appropriate interventions addressing the CSA experience, increasing resilience, and developing adaptive coping skills.

Current of Child Sexual Abuse in Asia: A Systematic Review of Prevalence, Impact, Age of First Exposure, Perpetrators, and Place of Offence

BACKGROUND: Child sexual abuse (CSA) is a serious global problem and challenge for all people because it increases the risk of various issues. AIM: This study investigated the CSA in Asian countries focusing on prevalence rates, impact, victim’s age of first exposure, type of CSA, perpetrator, and places of CSA offence. METHODS: We searched PubMed, Medline, ProQuest, ScienceDirect, CINAHL, Academic Search Complete, ClinicalKey, PsycINFO, Google Scholar, and manual search for studies published between January 2011 and November 2020. Only articles related to CSA in Asia were included in this review. RESULTS: The results showed that prevalence of CSA ranged from 2.2% - 94% for girls and 1.7% - 49.5% for boys. The prevalence rates for non-contact abuse were 12.6% - 56.5% for girls and 0.7% - 68.7% for boys; contact abuse was 5.3% - 67.2% for girls and 2.2% - 53.3% for boys; penetrating abuse was 0.5% - 88.24% for girls and 1.7% - 57.1% for boys. The findings reported most victims’ age of first exposure was preteen. The rate of the violation occurring in the victim’s house was 6.1% - 41.9%; most CSA perpetrators are known by victims. This study reported adverse impacts on CSA victims such as psychological, health, and physical disorders, and changes in behavior. In addition, other findings were found, including recovery, perceptions, values, causes, and expectations of victims of CSA. CONCLUSIONS: The incidence of CSA in Asia is still high and the age of the first victims is early adolescence. The majority of victims are women who already know the perpetrator, and taboo cultural factors are thought to play a role in increasing CSA in Asia. The results indicate the need to develop CSA prevention efforts that involve culture.

Syndemic Conditions, Sexual Risk Behavior, and HIV Infection Among Men Who Have Sex with Men in Taiwan

Men who have sex with men (MSM) continue to constitute the majority of HIV incidence in Taiwan. This study examined the associations between five co-occurring psychosocial health conditions (PHCs)-childhood physical abuse (CPA), childhood sexual abuse (CSA), intimate partner violence (IPV), internalized homophobia (IH), and methamphetamine use (MU), and two outcomes (HIV infection and condomless anal sex) among a community sample of 1,000 Taiwanese MSM (mean age 28.5 years). Compared to MSM who had never experienced any PHC, MSM with one or more PHCs had greater than twofold higher odds of being HIV-positive, and those with three or more PHCs had twofold higher odds of having condomless anal sex. Interactive effects on HIV infection were identified from CPA + CSA + MU and CPA + IPV + MU. An interactive effect on condomless anal sex was detected between IH and MU. In order to control the escalating HIV epidemic among MSM in Taiwan, interventions are needed to address syndemic psychosocial health conditions.

Sexual Violence in Childhood and Post-Childhood: The Experiences of Young Men Who Have Sex With Men in Beirut

Sexual violence has been found to have psychosocial and sexual ramifications for men who have sex with men (MSM) but has not been studied in the Middle East. We assessed the prevalence and correlates of experiences of child and post-child sexual violence among young MSM residing in Beirut, Lebanon. In total, 226 MSM, aged 18 to 29, were recruited with long-chain peer referrals and administered a survey that included questions on history of being pressured to have sex, as well as specific forms of sexual harassment and abuse, in addition to measures of psychosocial functioning and sexual behavior. Logistic regression analysis was used to examine correlates of child sex abuse and experiences of sexual violence post-childhood; 17.3% experienced sexual abuse as a child (below age 13), while 63.3% experienced any form of sexual violence post-childhood-furthermore, 48.7% had experienced being forced or pressured to have sex during their lifetime, including 32.3% prior to age 18. Participants who experienced child sex abuse were more likely to experience abusive relationships in adulthood, as well as at least one type of sexual harassment/abuse post-childhood. Experience of any sexual violence post-childhood was correlated with greater recent sexuality-related discrimination and more recent male sex partners. These findings reveal a high prevalence of sexual violence among MSM in Beirut, both in childhood and post-childhood. More research within the Middle East is needed to better understand the drivers of sexual violence in this population, and how to best provide prevention and coping services.

Association between childhood sexual abuse and patterns of HIV risky sexual behaviors among men who have sex with men in China: A latent class analysis

BACKGROUND

Increasing prevalence of risky sexual behaviors among men who have sex with men (MSM) exacerbate the transmission of HIV. Previous studies had demonstrated that childhood sexual abuse (CSA) was associated with one or more sexual behaviors, but few studies have been conducted among MSM in China.

OBJECTIVE

This present study aimed to estimate latent classes of risky sexual behaviors and test for CSA differences in latent class memberships among Chinese MSM.

PARTICIPANTS AND SETTING

The eligible participants were MSM aged 16 years or older who reported ever having oral or anal sex with men in the past 6 months.

METHODS

Data were obtained from an anonymous questionnaire between September 2017 to January 2018 in three cities in China, and contained questions about sexual-related behaviors and CSA experience. Latent class analysis (LCA) was used to classify the patterns of sexual behaviors and binomial regression was used to examine the relationships among these variables.

RESULTS

Among 628 MSM, 22.6% reported experiencing CSA. A two-classes pattern of sexual behaviors was identified, with 46.7% in the low-risk class and 53.3% in the high-risk class. MSM who experienced CSA were more likely to be high-risk group compared to those without CSA experiences [odds ratio (OR) = 1.981; 95% confidence interval (CI) =1.329-2.954)].

CONCLUSIONS

CSA was prevalent among Chinese MSM. And MSM with CSA experiences are more prone to be assigned to the high-risk group. Future HIV interventions need to focus on MSM who experienced CSA.

When Did I Become a Victim? Exploring Narratives of Male Childhood Sexual Abuse

This report presents narrative data of adult men self-identifying as victims of sexual abuse occurring in childhood or adolescence (CSA). Preliminary data were derived from written public stories posted by men to the Internet (n = 90). Many of these accounts indicate same-sex sexual abuse (male victim, male perpetrator). The primary research question: "how have adult male victims of childhood sexual abuse constructed written narratives of victimization?" The men in this study who posted public narratives about their sexual abuse demonstrated evidence in of two (turmoil and taking control) of six life course themes uncovered by Draucker and Martsolf (2010). Two temporally related additional subthemes emerged within the category "taking control": during the abusive event/relationship and after abuse in adulthood. Understanding how male victims organize and make sense of the trajectory of their victim and/or survivor identity may contribute to a more integrated healing for victims. This could also shape programs for outreach and support. The result of the study would aid in the development of diagnostic tools and frameworks for interviewing abuse victims who are not publicly presenting or formally reporting their stories.

Sexual violence experiences and pornography media exposure with sexual risk behavior among PLWHA MSM in Bandung, Indonesia

Background

HIV number continues to increase, especially among the minority of Men who have Sex with Men (MSM) due to the high risks of their sexual behavior. This study aims to identify the correlation between sexual violence experiences and pornography media exposure to sexual risk behavior among people with HIV/AIDS (PLWHA) MSM.

Design and Method

The study employed a cross-sectional design with the consecutive sampling technique and involved 258 PLWHA MSM under the guidance of an NGO in Bandung, Jawa Barat, Indonesia. The data were collected by employing an online questionnaire.

Result

The results show that there is a significant correlation between sexual violence experiences and sexual risk behavior (p-value = 0.000, α = 0.05; OR = 6.496), pornography media exposure and sexual risk behavior (p-value = 0.000, α = 0.05; OR = 4.271). The multivariate analysis of multiple logistics regression results reveals that the sexual violence experience is the factor that mostly influences the sexual risk behavior among PLWHA MSM (p-value = 0.000, α = 0.05; OR = 3.784).

Conclusions

The sexual violence experiences and pornography media exposure have a significant positive relationship to sexual risk behavior. Therefore, nurses need to improve a comprehensive assessment, counseling, and personal education to reduce sexual risk behavior that can transmit HIV and other sexually transmitted diseases and create innovations through positive activities to reduce pornography consumption.

Childhood Sexual Abuse and Adult Sexual Risk Behavior: A Review and Critique

Childhood sexual abuse (CSA) is a global problem with serious repercussions for survivors in various domains of adult interpersonal functioning, including sexual risk behavior. This review aimed to summarize findings from the recent literature on the connections between CSA and later adult sexual risk behaviors (e.g., unprotected intercourse, sexually transmitted infection [STSI] diagnosis). The sexual risk behaviors consistently associated with CSA were having sex under the influence of alcohol/substances and reports of concurrent sexual partners/infidelity. Notably, studies investigating the links between CSA and history of STI diagnosis and CSA and reports of unprotected sex (with the exception of samples comprised men who have sex with men) produced inconsistent findings. The methodological limitations of existing studies are considered and suggestions for future research are offered.

Strengthening resilience to reduce HIV risk in Indian MSM: a multicity, randomised, clinical efficacy trial

BACKGROUND

Men who have sex with men (MSM) in India are extremely marginalised and stigmatised, and therefore experience immense psychosocial stress. As current HIV prevention interventions in India do not address mental health or resilience to these stressors, we aimed to evaluate a resilience-based psychosocial intervention in the context of HIV and sexually transmitted infection (STI) prevention.

METHODS

We did a multicity, randomised, clinical efficacy trial in Chennai (governmental tuberculosis research institute) and Mumbai (non-governmental organisation for MSM), India. Inclusion criteria were MSM, aged 18 years or older, who were at risk of HIV acquisition or transmission, defined as having any of the following in the 4 months before screening: anal sex with four or more male partners (protected or unprotected), diagnosis of an STI, history of transactional sex activity, or condomless anal sex with a man who was of unknown HIV status or serodiscordant. Participants were required to speak English, Tamil (in Chennai), or Hindi (in Mumbai) fluently. Eligible individuals were randomly assigned (1:1) to either a resilience-based psychosocial HIV prevention intervention, consisting of group (four sessions) and individual (six sessions) counselling alongside HIV and STI voluntary counselling and testing, or a standard-of-care control comprising voluntary counselling and testing alone. The primary outcomes were number of condomless anal sex acts with male partners during the past month (at baseline and 4 months, 8 months, and 12 months after randomisation), and incident bacterial STIs (at 12 months after randomisation). Resilience-related mediators included self-esteem, self-acceptance, and depression. Recruitment is now closed. This trial is registered with ClinicalTrials.gov, NCT02556294.

FINDINGS

Between Sept 4, 2015, and June 28, 2018, we enrolled 608 participants; 305 (50%) were assigned to the psychosocial intervention condition and 303 (50%) were assigned to the control condition. 510 (84%) of 608 men completed an assessment at 4 months after randomisation, 483 (79%) at 8 months, and 515 (85%) at 12 months. 512 (99%) of 515 men had STI data from the 12-month assessment. The intervention condition had a 56% larger reduction in condomless anal sex acts (95% CI 35-71; p<0·0001) from baseline to 4-month follow-up, 72% larger reduction (56-82; p<0·0001) from baseline to 8-month follow-up, and 72% larger reduction (53-83; p<0·0001) from baseline to 12-month follow-up, compared with the standard-of-care control condition (condition by time interaction; χ2=40·29, 3 df; p<0·0001). Improvements in self-esteem and depressive symptoms both mediated 9% of the intervention effect on condomless anal sex acts. Bacterial STI incidence did not differ between study conditions at 12-month follow-up.

INTERPRETATION

A resilience-based psychosocial intervention for MSM at risk of HIV acquisition or transmission in India was efficacious in reducing condomless anal sex acts, with evidence for mediation effects in two key target resilience variables. HIV prevention programmes for MSM in India should address mental health resilience to augment reductions in the risk of sexually transmitted HIV.

FUNDING

National Institute of Mental Health.

Breaking the silence: Development of a qualitative measure for inquiry of child sexual abuse (CSA) awareness and perceived barriers to CSA disclosure

The present study aimed to develop a qualitative measure for assessment of child sexual abuse (CSA) awareness and perceived barriers to CSA disclosure based on adolescents' perspectives and expert consensus. Focus group discussions (FGD) were conducted with the adolescents (n = 10) and the Delphi method was used to gain expert consensus (n = 5). The FGDs were audio recorded and Delphi method was conducted via email. Salient domains and themes were identified through manual thematic analysis of the qualitative data obtained from both the methods. Data validity and authentication was obtained through data and researcher triangulation. The qualitative measure for assessment of CSA awareness and perceived barriers to CSA disclosure consisting of 13 qualitative questions was developed based on these domains and expert opinion. The test-version was administered to a pilot sample of 20 adolescents meeting the inclusion criteria for this study. Based on their feedback on ease of understanding and clarity, questions were modified and rearranged. Participation rate was found to be high amongst adolescents as they readily agreed to engage in the study. Findings further indicated that the ambit of CSA awareness includes knowledge of multiple aspects like forms of sexual abuse, characteristics associated with people at risk for perpetration and at risk for victimisation, prevalent beliefs about CSA, prevention strategies and CSA legislation in India. Perceived barriers to CSA disclosure were identified in the context of self, others and the society. Implications for research, and the need for preventive frameworks for CSA in Indian context are discussed.

Transgenders are the most vulnerable amongst individuals engaging in receptive anal intercourse: A cross-sectional study from North India

Background:

In India, sexuality not confirming to hetero-conjugal and peno-vaginal norm is abhorred and discriminated against. Individuals engaging in Receptive Anal Intercourse (RAI) are marginalized. Reappraisal of their sexual health conditions is likely to promote inclusive health care.

Methods:

Eighty-five consenting adults with RAI history were recruited from a tertiary care hospital in Delhi. Clinico-demographic data was noted and anal cytology samples were reported by Bethesda 2014 terminology.

Results:

There were 29 transgenders (TGs), 51 males (31 bisexual) and five females. Fifty-four subjects were Human Immunodeficiency Virus (HIV) infected (22 TGs, 31 males (17 bisexual) and one female) and 52 were receiving anti-retroviral treatment (ART). Thirty-one subjects had anal warts (6 TGs, 20 males, five females). Anal cytology revealed squamous intra-epithelial lesions (SIL) in 20 (5 TGs, 13 males, two females). TGs had significantly risker sexual practices than homosexual males, bisexual males and females, with consistently earlier age of first RAI exposure and frequent childhood (≤16 years) RAI experience compared to homosexual males, bisexual males and females, even after stratification by HIV status, warts and SIL.

Conclusions:

TGs had the highest sexual health risk profile including higher frequency of HIV infection compared to other subjects with RAI history. Bisexuality was common; their risk profile was variably lower than homosexual males. Mindfulness of above is likely to help overcome barriers to health care access and promote compassionate approach at all levels including primary care physicians.

Willingness to Use HIV Self-Testing and Associated Factors Among Transgender Women in Malaysia

Background: While global research on the implementation of HIV self-testing (HIVST) has increased exponentially, few studies have assessed information on HIVST uptake factors (i.e., willingness, preferences) in transgender women (TW) and none in the Malaysian context. We therefore sought to assess willingness to use HIVST among this understudied key population. Methods: A cross-sectional survey was conducted among 361 HIV-negative Malaysian TW in 2017. Participants were recruited using flyers, announcements through social media, and direct referral from staff members of the community-based organizations serving the TW communities. Multivariable logistic regression was used to identify correlates of willingness to use HIVST. Results: Nearly half of the participants (47.6%) reported that they would be willing to use HIVST. Multivariable analysis showed that willingness to use HIVST was positively associated with having experienced sexual assault in childhood (adjusted odds ratio [aOR]=3.239, p<0.001), having ever used mobile phone or apps to find sex work clients (aOR=1.677, p=0.040), and having engaged in condomless sex in the past 6 months (aOR=1.886, p=0.018). In contrast, living in Kuala Lumpur (aOR=0.559, p=0.032), having higher number of sex work clients per day (aOR=0.927, p=0.004), and current depressive symptoms (aOR=0.576, p=0.026) were negatively associated with willingness to use HIVST. Conclusions: Findings in this study suggest that TW in our sample were moderately willing to use HIVST. Especially important here is the increased interest in HIVST among TW who are at higher risk for HIV infection. Overall, our findings underscore the need for additional research on how to most effectively implement HIVST for key populations, including TW, such that uptake and retention in regular HIV screening is sustained.

Association of co-occurring psychosocial health conditions and HIV infection among MSM in Malaysia: Implication of a syndemic effect

In Malaysia, the HIV epidemic is concentrated in a highly stigmatized population, men who have sex with men (MSM). The relationship of multiple psychosocial health conditions and HIV risks have not been investigated. This study aims to assess the association of multiple psychosocial factors with risky sexual behaviour and HIV infection among MSM. Data on demographic characteristics, psychosocial health conditions, condomless anal intercourse (CAI), HIV testing and HIV status were collected via an anonymous online survey. Multivariable logistic regression model was used to determine whether psychosocial health conditions among MSM have a syndemic association with HIV status. Between July 2017 and February 2018, 622 MSM completed the online survey. Overall, 54.3% of participants reported engaging in CAI in the past three months and 46.0% were found to have two or more psychosocial health conditions. Increasing numbers of psychosocial health conditions (1, 2, 3, 4 or more) were significantly associated with HIV infection compared to those without psychosocial health condition (odds ratio [OR] 3.39, 95% confidence interval [CI]: 1.41–8.14; OR 3.51, 95% CI: 1.43–8.61; OR 4.22, 95% CI: 1.68–10.96, and OR 7.58, 95% CI: 2.44–23.55, respectively). Comprehensive HIV prevention programs addressing mental health and substance use are needed for MSM in Malaysia.

Beyond biomedical and comorbidity approaches: Exploring associations between affinity group membership, health and health seeking behaviour among MSM/MSW in Nairobi, Kenya

We explored general health and psychosocial characteristics among male sex workers and other men who have sex with men in Nairobi, Kenya. A total of 595 MSM/MSW were recruited into the study. We assessed group differences among those who self-reported HIV positive (SR-HIVP) and those who self-reported HIV negative (SR-HIVN) and by affinity group membership. Quality of life among SR-HIVP participants was significantly worse compared to SR-HIVN participants. Independent of HIV status and affinity group membership, participants reported high levels of hazardous alcohol use, harmful substance use, recent trauma and childhood abuse. The overall sample exhibited higher prevalence of moderate to severe depressive symptoms compared to the general population. Quality of life among participants who did not report affinity group membership (AGN) was significantly worse compared to participants who reported affinity group membership (AGP). AGN participants also reported significantly lower levels of social support. Membership in affinity groups was found to influence health seeking behaviour. Our findings suggest that we need to expand the mainstay biomedical and comorbidity focused research currently associated with MSM/MSW. Moreover, there are benefits to being part of MSM/MSW organisations and these organisations can potentially play a vital role in the health and well-being of MSM/MSW.

Childhood abuse as a risk factor for injection drug use: A systematic review of observational studies

ISSUES

Childhood abuse is a public health challenge with lifelong impacts, including future drug use. However, previous research has been mixed regarding impacts on injection drug use. This systematic review examines the impact of childhood abuse (sexual, physical and emotional) on adult injection drug use.

APPROACH

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science and grey literature to identify relevant studies from database inception to 26 September 2018. Studies were eligible if: (i) they were empirical original research published in English; (ii) considered childhood abuse as potential risk factors for lifetime history of injection drug use; and (iii) included adult participants. Risk of bias was assessed using the modified Newcastle-Ottawa Scale.

KEY FINDINGS

Of the 1994 articles screened, 17 studies met the inclusion criteria. Most studies were conducted in the USA and utilised cross-sectional research designs. All of the 17 studies measured sexual abuse, six studies measured physical abuse and three studies measured emotional abuse; most (N = 11) of which reported a statistically significant and positive association between at least one sub-scale of childhood abuse and injection drug use.

IMPLICATIONS

Our findings highlight the need for devising interventions to reduce the harms associated with childhood abuse.

CONCLUSIONS

The evidence base suggests a significant positive association between experiences of childhood physical abuse and elevated risks of injection drug initiation with mixed results for sexual and emotional abuse.

The Relationship between Childhood Maltreatment and Risky Sexual Behaviors: A Meta-Analysis

Childhood maltreatment is associated with risky sexual behaviors (RSBs). Previous systematic reviews and meta-analysis focused only on the relationship between childhood sexual abuse and RSBs, thus the association between childhood maltreatment and RSBs has yet to be systematically and quantitatively reviewed. We aimed to provide a systematic meta-analysis exploring the effect of childhood maltreatment and its subtypes on subsequent RSBs in adolescence and adulthood. PubMed, Google Scholar, EMBASE, Medline were searched for qualified articles up to April 2019. We calculated the pooled risk estimates using either the random-effect model or fixed-effect model. The potential heterogeneity moderators were identified by subgroup and sensitivity analysis. Overall, childhood maltreatment was significantly associated with an early sexual debut (odds ratio (OR) = 2.22; 95% confidence interval (CI): 1.64–3.00), multiple sexual partners (OR = 2.22; 95% CI: 1.78–2.76), transactional sex (OR = 3.05; 95% CI: 1.92–4.86) and unprotected sex (OR = 1.59; 95% CI: 1.22-2.09). Additionally, different types of childhood maltreatment were also significantly associated with higher risk of RSBs. Relevant heterogeneity moderators have been identified by subgroup analysis. Sensitivity analysis yielded consistent results. Childhood maltreatment is significantly associated with risky sexual behaviors. The current meta-analysis indicates it is vital to protect children from any types of maltreatment and provide health education and support for maltreated individuals.

The syndemic of violence victimisation, drug use, frequent alcohol use, and HIV transmission risk behaviour among men who have sex with men: Cross-sectional, population-based study in India

The theory of syndemics has been used to explain elevated HIV risk facing men who have sex with men (MSM). However, few studies have employed suitable analytical methods to test this theory. Using data from a probability-based sample of MSM in India, we tested three proposed models linking the co-occurring epidemics of violence victimisation, drug use, and frequent alcohol use to HIV risk: 1) the syndemic model of synergistically interacting epidemics; 2) the "chains of risk" model; and 3) the model of mutually causal epidemics. The primary outcome was inconsistent condom use with male or hijra (transgender women) partners in the past month. For the syndemic model, we included product terms between the exposures and assessed for interaction on the additive (linear probability regression) and multiplicative (logistic regression) scales. Path analysis was used to test the models of serially causal epidemics and mutually causal epidemics. Among 22,297 HIV-negative MSM, violence victimisation (24.7%), frequent alcohol use (27.5%), and drug use (10.9%) frequently co-occurred. We found evidence for a three-way interaction between violence victimisation, drug use and frequent alcohol use on both the multiplicative (semi-elasticity = 0.28; 95% CI 0.10, 0.47) and additive (b = 0.14; 95% CI 0.01, .27) scales. We also estimated statistically significant two-way interactions between violence victimisation and frequent alcohol use on the multiplicative (semi-elasticity = .10; 95% CI 0.008, 0.20) and additive (b = 0.05, 95% CI 0.002, 0.107) scales, and between drug use and frequent alcohol use on the multiplicative (semi-elasticity = 0.13, 95% CI 0.02, 0.24) and additive (b = 0.06, 95% CI 0.007, 0.129) scales. Thus, we found strong evidence for the syndemic model. The models of serially causal and mutually causal epidemics were partially supported. These findings highlight the need to sharpen how syndemic models are specified so that their empirical predictions can be adequately tested and distinguished from other theories of disease distribution.

Child sexual abuse in India: A systematic review

Objective

Child Sexual Abuse (CSA) is a pressing human right issue and public health concern. We conducted a systematic review of quantitative and qualitative studies published in the past decade on CSA in India to examine the distribution of the prevalence estimates for both genders, to improve understanding of the determinants and consequences of CSA and identify gaps in the current state of research.

Methods

For this systematic review, we searched electronic literature databases (PubMed, POPLINE, and PsycINFO) for articles published in English on Child Sexual Abuse in India between January 1, 2006 and January 1, 2016 using 55 search terms. Data were extracted from published articles only.

Findings

Fifty-one studies met inclusion criteria for the review. The review indicates that prevalence rates of CSA is high among both boys and girls in India. Due to heterogeneity of study designs and lack of standardised assessments, reported prevalence estimates varied greatly among both genders in different studies. There is a need to conduct representative studies using a validated instrument to obtain valid epidemiological estimates. Commercial sex workers, men who have sex with men, and women with psychiatric disorders were at higher risks for sexual abuse during childhood. In addition, the synthesis of qualitative data across studies included in the review suggests that exposure and perpetration of CSA is a multifaceted phenomenon grounded in the interplay between individual, family, community, and societal factors. The review indicates poor physical, behavioural, social, and mental health outcomes of CSA in India. We conclude with a research agenda calling for quantitative and qualitative studies to explore the determinants and perpetration of child sexual abuse in India from an ecological lens. This research agenda may be necessary to inform the development of a culturally tailored primary prevention and treatment strategy for CSA victims in India.

Relationship Between Childhood Sexual Abuse and HIV-Related Risks Among Men Who Have Sex with Men: Findings from Mainland China

Men who have sex with men (MSM) carry the burden of HIV infection in China. Outside of China, a history of childhood sexual abuse (CSA) has been associated with HIV-related risks (behavioral, sexual, and mental health outcomes) among MSM. We therefore evaluated the relationship between CSA and these HIV-related risks among MSM in China. Cross-sectional data were collected via a survey from gay websites and social networking applications from MSM in 30 provinces in mainland China during a 3-month period in 2014 and 2015. Overall, 999 screened MSM who responded to questions on CSA were included. Multinomial logistic regression models-adjusted for sociodemographic confounders-showed that men who reported experiencing regular CSA and contact CSA, respectively, were more likely to use substances (adjusted odds ratio [AOR], 1.91; 95% confidence interval [CI] 1.39-2.62 and AOR, 1.70; 95% CI 1.25-2.31), had a history of sexually transmitted infections (AOR, 1.81; 95% CI 1.29-2.55 and AOR, 1.65; 95% CI 1.18-2.96), had more male sexual partners (AOR, 1.06; 95% CI 1.04-1.09 and AOR, 1.05; 95% CI 1.03-1.08), engaged in more condomless sex with men (AOR, 1.89; 95% CI 1.39-2.56 and AOR, 1.72; 95% CI 1.29-2.30), and experienced more psychological distress (AOR, 1.05; 95% CI 1.02-1.08 and AOR, 1.05; 95% CI 1.03-1.08). Both frequent and contact forms of CSA were positively associated with HIV-related risks among MSM, suggesting that general CSA prevention strategies and interventions are needed to support this population.

Ethical and definitional considerations in research on child sexual violence in India

BACKGROUND

While critically important, child sexual violence (CSV) research poses numerous ethical and safety challenges. Recently, the studies dedicated to understanding and addressing CSV in India have been on the rise, but no published ethical guidelines to direct such research currently exist. To help inform ethical and safety recommendations for the design, conduct, and reporting of future CSV research in India and similar settings, we systematically reviewed the ethics and safety practices reported in recent Indian CSV literature.

METHODS

A multi-tiered approach was used to understand current ethical practices and gaps: 1) systematic review of Indian CSV studies published over the past decade, 2) examination of existing guidelines on related topics to develop an ethical framework, 3) development of an ethics checklist based on the recommendations from the surveyed guidelines, and 4) application of the checklist to each of the reviewed studies.

RESULT

Our search yielded 51 eligible studies. From each, data from 6 major thematic areas was extracted: informed consent, confidentiality, selection, training, and protection of study team members, validity of CSV measurement methods, measures to minimize participant harm, and participant compensation. Several gaps were noted: only two-thirds reported approval by ethics committees, obtaining informed consent, and assured participants of confidentiality. Only 25% (13/51) reported assessing ongoing CSV risk and providing necessary support services, none noted whether ongoing CSV was reported to authorities (required by Indian law), and none reported safeguards to protect staff from the effects of conducting CSV research. Further, 43% (22/51) limited surveillance of CSV to one form of abuse and/or used a "loaded term," increasing the potential for underreporting.

CONCLUSIONS

Through enhancing understanding of current ethical practices and gaps in CSV research in India, this systematic review informs reporting protocols and future guidelines for CSV research in India and other similar settings.

Is there synergy in syndemics? Psychosocial conditions and sexual risk among men who have sex with men in India

Syndemic theory describes the clustering and synergistic interaction of disease driven by contextual and social factors, which worsen health outcomes for a population, and has been applied to men who have sex with men (MSM) and their risk for HIV and other sexually transmitted infections. Recent reviews, however, have critiqued prevailing approaches in syndemic studies that assess only additive associations without evaluation of synergy. Following these suggestions, we compared the traditional additive approach with a test for synergistic association of 5 syndemic conditions (alcohol dependence, illicit drug use, depression, intimate partner violence (IPV), and childhood sexual abuse (CSA)) with unprotected anal intercourse (UAI) and active syphilis infection among 11,771 MSM recruited through respondent driven sampling from 12 cities in India. UAI was assessed via self-report and active syphilis infection was diagnosed by RPR and THPA tests. An additive association was explored using a condition count (range 0-5), and synergy was tested using relative excess risk due to interactions (RERIs) calculated from all 2-way and common 3-way interactions between conditions in adjusted regression models. There was a significant dose response associated with the syndemic count and UAI, and a similar pattern for syphilis, though not statistically significant. RERIs showed synergy for only one pair of conditions for UAI and syphilis, respectively: IPV + depression and alcohol dependence + illicit drug use. In this study, we found an additive association between syndemic conditions and UAI with evidence of synergistic interaction between a pair of psychosocial conditions, and no significant additive association, but a synergistic interaction between another pair of psychosocial conditions for syphilis. Our results lend further support to a critical reassessment of syndemic analyses. Closer attention to the cumulative development, underlying causal pathways, and possible synergistic interaction of co-occurring epidemics through combined qualitative and quantitative methodologies may yield more effective interventions for vulnerable, marginalized populations.