Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review

Implementation of gender-based violence screening guidelines in public HIV treatment programs: A mixed methods evaluation in Uganda

BACKGROUND

HIV and gender-based violence (GBV) intersect to threaten population health. The Uganda Ministry of Health recommends routine GBV screening alongside HIV care but evidence detailing its implementation in HIV care settings is limited. We evaluated screening practices in public HIV clinics to generate evidence supporting GBV screening optimization.

METHODS

To evaluate GBV screening implementation in antiretroviral therapy (ART) clinics, we extracted client data from GBV registers at 12 public ART clinics in Uganda (January 2019-December 2021). We concurrently evaluated perceptions of GBV screening/referral practices by conducting in-depth qualitative interviews with providers (N = 30) and referral partners (N = 10). We contextualized quantitative findings with interview data which were analyzed using a thematic analysis approach.

RESULTS

During the evaluation period, >90% of providers in participating health facilities implemented GBV screening. Among 107,767 clients served in public ART clinics, providers identified 9,290 (8.6%) clients who experienced past-year physical, sexual and/or emotional GBV of whom 86% received counseling and 19% were referred to support services-most commonly to legal services. Key factors influencing GBV screening implementation included awareness of screening guidelines; client volume; and client's level of engagement in HIV care. Providers and referral partners identified important benefits to clients (e.g., pursuit of justice and removal from violent environments) when referrals were successful. Key factors influencing referrals included financial constraints that limited referral partners' ability to provide services at no cost to clients and socio-cultural norms that inhibited client willingness to pursue support services.

CONCLUSIONS

GBV screening implementation in ART clinics supports identification and referral of clients exposed to violence. The effectiveness of GBV screening may be limited by socio-cultural factors that inhibit client capacity to pursue referrals and fragmented and resource-constrained referral networks. Providers and referral partners identified allocating funds to support referrals and collaborative networking meetings as important opportunities for strengthening GBV referrals.

Reducing stigma and promoting HIV wellness/mental health of sexual and gender minorities: RCT results from a group-based programme in Nigeria

INTRODUCTION

High levels of HIV stigma as well as stigma directed towards sexual and/or gender minorities (SGMs) are well documented in the African setting. These intersecting stigmas impede psychosocial wellbeing and HIV prevention and care. Yet, there are few if any evidence-based interventions that focus on reducing internalized stigma and promoting mental health and HIV wellness for SGMs in Africa. We developed and evaluated a group-based intervention drawing on cognitive behavioural therapy (CBT) strategies for men who have sex with men (MSM) and transgender women (TGW) at risk for or living with HIV in Lagos, Nigeria.

METHODS

The intervention comprised four weekly in-person group sessions facilitated by community health workers. We conducted a delayed intervention group randomized controlled trial (April-September 2022), with pre-post surveys plus 3-month follow-up (immediate group only), as well as qualitative research with participants and programme staff. Outcomes included internalized stigma related to SGM and HIV status, depression, resiliency/coping and pre-exposure prophylaxis (PrEP)/HIV treatment use.

RESULTS

Mean age of the 240 participants was 26 years (range 18-42). Seventy-seven percent self-identified as MSM and 23% TGW; 27% were people with HIV. Most (88%) participants attended all four sessions, and 98% expressed high intervention satisfaction. There was significant pre-post improvement in each psychosocial outcome, in both the immediate and delayed arms. There were further positive changes for the immediate intervention group by 3-month follow-up (e.g. in intersectional internalized stigma, depression). While baseline levels of ever-PrEP use were the same, 75% of immediate-group participants reported currently using PrEP at 3 months post-intervention versus 53% of delayed-group participants right after the intervention (p<0.01). Participants post-intervention described (in qualitative interviews) less self-blame, and enhanced social support and resilience when facing stigma, as well as motivation to use PrEP, and indicated that positive pre-intervention changes in psychosocial factors found in the delayed group mainly reflected perceived support from the study interviewers.

CONCLUSIONS

This study demonstrated the feasibility and acceptability of a group-based CBT model for MSM and TGW in Nigeria. There were also some indications of positive shifts related to stigma, mental health and PrEP, despite issues with maintaining the randomized design in this challenging environment.

Mental Health and Treatment Engagement among Low-Income Women of Color Living with HIV

Low-income women of color are disproportionately more likely to contract HIV, struggle with treatment adherence, and have compromised health as a result of HIV infections in comparison to White and more affluent women. The current study is a secondary analysis aimed at examining the association between stress, symptoms of depression, trauma exposure, healthcare engagement, and adherence self-efficacy, among low-income women of color with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). Structural equation modeling is used to identify latent mental health symptoms that may influence one another, as well as outcomes involving treatment engagement. Participants contributing to this dataset (n = 134) were low income, women of color (primarily African American) living with HIV or AIDS, receiving care at a major medical center in the northeastern United States. Findings indicate significant indirect associations between perceived stress and the outcome of medical appointment attendance. Significant mediators of this indirect relationship include depressive symptoms, parenting stress, and adherence self-efficacy. Implications for health and behavioral health practice and policy interventions are drawn. Areas in need of future research are identified.

The importance of insufficient national data on sexual and reproductive health and rights in international databases

Looking at SRHR as an isolated set of elements, as is the current practice, does not do justice to the needs and rights of people and communities and may be one of the reasons why challenges remain in the attainment of SRHR for all. SRHR Infographic snapshots were developed for all 194 WHO Member States and included 120 indicators covering a broad range of policy, health systems and service delivery interventions. The snapshots were created using data less than 10 years old publicly available in data repositories maintained by international and global agencies. Data availability was not consistent across countries with low and lower-middle income countries having higher data availability (71%) compared to high income countries (40%). SRHR data that is easily accessible and consistently reported can improve accountability and opportunities for learning to improve people-centred approaches to accelerate the attainment of SRHR for all.

Adverse childhood experiences, HIV and sexual risk behaviors - Five sub-Saharan countries, 2018-2020

BACKGROUND

Adverse childhood experiences (ACEs) have been shown to have negative, lasting effects on health including increasing the likelihood of engaging in sexual risk behaviors.

OBJECTIVE

This study aimed to identify associations between exposures to ACEs and sexual risk behaviors and HIV service utilization among young people.

PARTICIPANTS AND SETTING

A sample of 8023 sexually active young people (19-24 year olds) from five sub-Saharan African countries participated Violence Against Children and Youth Surveys (VACS).

METHODS

Descriptive analysis of demographic variables, individual ACEs, cumulative ACEs, sexual risk behaviors, HIV testing, antiretroviral treatment (ART) and Antenatal Care (ANC) attendance were completed. Bivariate and multivariable logistic regression analyses were conducted to assess the associations between both individual and cumulative ACEs, sexual HIV risk behaviors, and service utilization while controlling for important covariates such as demographic, having ever been pregnant, had an STI, and used contraception.

RESULTS

Exposure to three or more ACEs was higher among males (26.1 %) compared to females (21.3 %); p = 0.003. The most prominent sexual risk behavior for females was having sexual partners who were at least 5 years older (45.7 % compared to males 3.7 %; p < 0.0001) whereas in males it was no or infrequent condom use (45.3 % compared to females 30.1 %; p < 0.0001). Males and females exposed to childhood sexual violence had seven and four times the odds of engaging in transactional sex (aOR = 7.34, 95 % CI: [3.5-15.0]) and (aOR =3.75, 95 % CI: [2.3-6.2], respectively. Females exposed to three or more ACEs were four times more likely to engage in transactional sex (aOR = 4.85, 95 %, CI: [1.6-14.4]) compared to those who did not experience any ACEs. Males exposed to three or more ACEs were two times more likely to engage in early sexual debut (aOR = 2.2, 95 % CI: [1.3-3.4]),]) compared to those who did not experience any ACEs. Females who had witnessed IPV or violence in the community had significantly higher odds of getting tested for HIV (aOR = 2.16, 95 % CI: [1.63-2.87]) and (aOR = 1.36, 95 % CI: [1.03-1.81]), respectively.

CONCLUSIONS

This study demonstrated that experiencing ACEs during childhood is associated with higher HIV risk behaviors in sub-Saharan Africa (SSA) with unique differences between males and females.

Global burden of diseases attributable to intimate partner violence: findings from the Global Burden of Disease Study 2019

PURPOSE

Our study aims to evaluate the global burden of disease attributable to IPV from 1990 to 2019 at global, regional, national, and socio-demographic index (SDI) levels. Our research question is: What is the global burden of disease attributable to intimate partner violence (IPV) from 1990 to 2019, and how does it vary at global, regional, national, and socio-demographic index (SDI) levels?

METHODS

Data parameters for the number of deaths, disability-adjusted life years (DALYs), and age-standardized rate were obtained from the Global Burden of Disease Study 2019. We calculated the percentage change and population attributable fraction with 95% uncertainty intervals.

RESULTS

IPV directly accounted for 0.14% [95% UI 0.09%, 0.21%] and 0.32% [95% UI 0.17%, 0.49%] of global all-cause deaths and DALYs in 2019, respectively. The age-standardized deaths and DALYs rates of IPV increased by 12.83% and 4.00% respectively from 1990 to 2019. Women aged 35-39 and 30-34 had the highest deaths and DALYs rate respectively. The highest age-standardized rates of IPV-related deaths and DALYs were observed in Southern Sub-Saharan. Both of deaths and DALYs were high in low-socio-demographic Index (SDI) quintile in 2019.

CONCLUSIONS

A higher level of deaths and DALYs attributable to IPV were reported in younger women, in the early 2000s, in Southern Sub-Saharan regions and in low SDI regions. Our study provides policymakers with up-to-date and comprehensive information.

Correlation between gender-based violence and poor treatment outcomes among transgender women living with HIV in Brazil

BACKGROUND

Transgender women are disproportionately affected by both HIV and gender-based violence (GBV), defined as physical, sexual, or emotional violence perpetrated against an individual based on their gender identity/expression. While a growing body of evidence demonstrates that GBV leads to poor HIV care and treatment outcomes among cisgender women, less research has examined this association among transgender women. We assessed the impact of lifetime experiences of GBV on subsequent retention in HIV care and laboratory confirmed viral suppression among a sample of transgender women living with HIV (TWH) in Brazil.

METHODS

A pilot trial of a peer navigation intervention to improve HIV care and treatment among TWH was conducted in São Paulo, Brazil between 2018 and 2019. TWH were recruited and randomized into the intervention or control arm and participated in a baseline and 9-month follow-up survey and ongoing extraction of clinical visit, prescribing, and laboratory data. Generalized linear model regressions with a Poisson distribution estimated the relative risk (RR) for the association of lifetime physical and sexual violence reported at baseline with treatment outcomes (retention in HIV care and viral suppression) at follow-up, adjusting for baseline sociodemographic characteristics.

RESULTS

A total of 113 TWH participated in the study. At baseline, median age was 30 years, and the prevalence of lifetime physical and sexual violence was 62% and 45%, respectively. At follow-up, 58% (n = 66/113) were retained in care and 35% (n = 40/113) had evidence of viral suppression. In adjusted models, lifetime physical violence was non-significantly associated with a 10% reduction in retention in care (aRR: 0.90, 95% CI: 0.67, 1.22) and a 31% reduction in viral suppression (aRR: 0.69; 95% CI: 0.43, 1.11). Lifetime sexual violence was non-significantly associated with a 28% reduction in retention in HIV care (aRR: 0.72, 95% CI: 0.52, 1.00) and significantly associated with a 56% reduction in viral suppression (aRR: 0.44; 95% CI: 0.24, 0.79).

CONCLUSION

Our findings are among the first to demonstrate that lifetime experiences with physical and sexual violence are associated with poor HIV outcomes over time among transgender women. Interventions seeking to improve HIV treatment outcomes should assess and address experiences of GBV among this population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03525340.

Antiretroviral Therapy Concealment Behaviors and their Association with Antiretroviral Therapy Adherence among People with HIV: Findings from the Florida Cohort Study

Little is known about HIV medication concealment behaviors and the effect of medication concealment on antiretroviral therapy (ART) adherence among people with HIV (PWH). This study aims to (1) to describe medication concealment behaviors and factors associated with these behaviors, and (2) assess the association between medication concealment and suboptimal ART adherence. The Florida Cohort Study enrolled adult PWH from community-based clinics around the state from October 2020 to September 2022 (n = 416, 62% aged 50+, 56% male, 44% non-Hispanic Black, 18% Hispanic). Participants responded to questions about sociodemographics, stigma, ART adherence (≥ 85%), symptoms of depression, social networks and disclosure to their networks, and actions to conceal ART to avoid inadvertent disclosure of their HIV status. Analyses were conducted using multivariable logistic regressions models. The most common concealment behavior was hiding ART while having guests over (32%), followed by removing ART labels (26%), and putting ART into a different bottle (16%). Overall, 43% reported ≥ 1 behavior. In multivariable models, depressive symptoms, incomplete disclosure of HIV to close social networks, and not having a close social network were associated with ART concealment. After adjusting for risk factors for suboptimal ART adherence, endorsing hiding medication while having guests was associated with suboptimal ART adherence (aOR 2.87, 95% CI 1.15-7.55). Taking any action and other individual behaviors were not associated. ART concealment behaviors were common but did not consistently negatively influence adherence when accounting for other factors. PWH may want to receive ART medications in ways that ensure privacy and reduce the risk of inadvertent disclosure.

Social Support and the Association Between Certain Forms of Violence and Harassment and Suicidal Ideation Among Transgender Women - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020

Violence and harassment toward transgender women are associated with suicidal thoughts and behaviors, and social support might moderate such association. This analysis explored the association between certain forms of violence and harassment and suicidal ideation and moderation by social support. Better understanding of these associations could guide mental health services and structural interventions appropriate to lived experiences of transgender women. This cross-sectional analysis used data from CDC's National HIV Behavioral Surveillance Among Transgender Women. During 2019-2020, transgender women were recruited via respondent-driven sampling from seven urban areas in the United States for an HIV biobehavioral survey. The association between experiencing certain forms of violence and harassment (i.e., gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation was measured using adjusted prevalence ratios and 95% CIs generated from log-linked Poisson regression models controlling for respondent-driven sampling design and confounders. To examine moderation, the extents of social support from family, friends, and significant others were assessed for interaction with certain forms of violence and harassment; if p interaction was <0.05, stratified adjusted prevalence ratios were presented. Among 1,608 transgender women, 59.7% experienced certain forms of violence and harassment and 17.7% reported suicidal ideation during the past 12 months; 75.2% reported high social support from significant others, 69.4% from friends, and 46.8% from family. Experiencing certain forms of violence and harassment and having low-moderate social support from any source was associated with higher prevalence of suicidal ideation. Social support from family moderated the association between experiencing certain forms of violence and harassment and suicidal ideation (p interaction = 0.01); however, even in the presence of high family social support, experiencing certain forms of violence and harassment was associated with higher prevalence of suicidal ideation. Social support did not completely moderate the positive association between experiencing violence and harassment and suicidal ideation. Further understanding of the social support dynamics of transgender women might improve the quality and use of social support. Policymakers and health care workers should work closely with transgender women communities to reduce the prevalence of violence, harassment, and suicide by implementing integrated, holistic, and transinclusive approaches.

Access to healthcare among transgender women living with and without HIV in the United States: associations with gender minority stress and resilience factors

BACKGROUND

Transgender women (TW) experience significant inequities in healthcare access and health disparities compared to cisgender populations. Access to non-transition related healthcare is understudied among TW. We aimed to assess the association between access to care and gender minority stress and resilience factors among TW living with and without HIV in eastern and southern United States.

METHODS

This study was a cross-sectional analysis of baseline data drawn from a cohort of 1613 adult TW from the LITE Study. The cohort permitted participation through two modes: a site-based, technology-enhanced mode and an exclusively online (remote) mode. Exploratory and confirmatory factor analyses determined measurement models for gender minority stress, resilience, and healthcare access. Structural equation modeling was used to assess the relationships between these constructs. Models were evaluated within the overall sample and separately by mode and HIV status.

RESULTS

Higher levels of gender minority stress, as measured by anticipated discrimination and non-affirmation were associated with decreased access to healthcare. Among TW living with HIV, higher levels of anticipated discrimination, non-affirmation, and social support were associated with decreased healthcare access. Among TW living without HIV in the site-based mode, resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. Among TW living without HIV in the online mode, anticipated discrimination was associated with barriers to healthcare access; resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access.

CONCLUSIONS

Gender minority stress was associated with increased barriers to healthcare access among TW in the US, regardless of HIV status. Resilience factors did not mediate this effect. Interventions aiming to increase healthcare access among TW can be aided by efforts to mitigate drivers of gender minority stress and improve patient experiences in healthcare facilities.

Reducing Partner Violence Against Women who Exchange Sex and use Drugs through a Combination Microfinance and HIV Risk Reduction Intervention: A Cluster Randomized Trial

Women who exchange sex and use drugs (WESUD) are at high risk for HIV infection and partner violence. The few tested interventions at the intersection of HIV and IPV show mixed results. This analysis examined the impact of a combination HIV risk reduction (HIVRR) and microfinance (MF) intervention on reported paying and intimate partner violence against WESUD in Kazakhstan. This cluster randomized controlled trial enrolled 354 women from 2015 to 2018 and randomized them to either a combination of HIVRR and MF intervention or HIVRR alone. Outcomes were assessed at four time points over 15 months. Logistic regression within a Bayesian approach assessed change in odds ratio (OR) of recent physical, psychological, or sexual violence perpetrated by current or past intimate partners; and paying partners/clients by study arm over time. Compared to the control arm, the combination intervention decreased the odds of participants experiencing physical violence from past intimate partners by 14% (OR = 0.861, p = 0.049). Women in the intervention group reported significantly lower rates of sexual violence from paying partners (HIVRR + MF - HIVRR: 25.9%; OR = 0.741, p = 0.019) at 12-month follow-up. No significant differences in rates from current intimate partners were found. A combination HIVRR and microfinance intervention may reduce gender-based violence from paying and intimate partners among WESUD above and beyond HIVRR interventions alone. Future research should examine how microfinance reduces partner violence and how to implement combination interventions in diverse settings.

Health care workers' perceptions and bias toward men as HIV clients in Malawi and Mozambique: A qualitative study

Men are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs' buy-in for male-specific interventions. Focus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique and were originally conducted to evaluate barriers to universal treatment (not HCW bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients and any explicit bias against men, using inductive and deductive coding in Atlas.ti v.8, and analyzed using constant comparison methods. 20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong explicit bias against men as clients. Most HCWs believed men could easily navigate HIV services due to their elevated position within society, regardless of facility-level barriers faced. Men were described in pejorative terms as ill-informed and difficult clients who were absent from health systems. Men were largely seen as "bad clients" due to assumptions about men's 'selfish' and 'prideful' nature, resulting in little HCW sympathy for men's poor use of care. Our study highlights a strong explicit bias against men as HIV clients, even when gender and bias were not the focus of data collection. As a result, HCWs may have little motivation to implement male-specific interventions or improve provider-patient interactions with men. Framing men as problematic places undue responsibility on individual men while minimizing institutional barriers that uniquely affect them. Bias in local, national, and global discourses about men must be immediately addressed.

Assessing sex differences in viral load suppression and reported deaths using routinely collected program data from PEPFAR-supported countries in sub-Saharan Africa

BACKGROUND

In sub-Saharan Africa, more women than men access HIV testing and treatment and may have better viral load suppression (VLS). We utilized routinely reported aggregated HIV program data from 21 sub-Saharan African countries to examine sex differences in VLS and death rates within antiretroviral therapy (ART) programs supported by the United States President's Emergency Plan for AIDS Relief (PEPFAR).

METHODS

We included VLS and reported death data for persons aged 15 + years on ART from October-December 2020 disaggregated by sex and age for each subnational unit (SNU). We used linear mixed-model regression to estimate VLS proportion and negative binomial mixed-model regression to estimate the rates of death and death plus interruptions in treatment (IIT). All models were weighted for SNU-level ART population size and adjusted for sex, age, HIV/tuberculosis coinfection, country, and SNU; models for reported deaths and deaths plus IIT were also adjusted for SNU-level VLS.

RESULTS

Mean VLS proportion was higher among women than men (93.0% vs. 92.0%, p-value < 0.0001) and 50 + than 15-49 age group (93.7% vs. 91.2%, p-value < 0.0001). The mean rate of reported deaths was higher among men than women (2.37 vs. 1.51 per 1000 persons, p-value < 0.0001) and 50 + than 15-49 age group (2.39 vs. 1.50 per 1000, p-value < 0.0001); the mean rate of reported deaths plus IIT was higher among men (30.1 in men vs. 26.0 in women per 1000, p-value < 0.0001) and higher among 15-49 than 50 + age group (34.7 vs. 22.6 per 1000, p-value < 0.0001).

CONCLUSIONS

The mean rate of reported deaths was higher among men in most models despite adjusting for VLS. Further exploration into differences in care-seeking behaviors; coverage of screening, prophylaxis, and/or treatment of opportunistic infections; and more extensive testing options for men to include CD4 is recommended.

Systematic screening of gender violence and domestic violence among HIV-positive patients: the VIHOLETA study

We conducted a multicentre observational study in people living with HIV (PLHIV) on antiretroviral therapy in Alicante (Spain) from 2019 to 2020 aiming to analyse the prevalence of abuse and assess treatment adherence according to this variable. We used the Abuse Assessment Screen tool, the simplified medication adherence questionnaire and the medication possession ratio to assess outcomes.. Of the 161 included PLHIV, 53 (32.9%) had suffered abuse (27 emotional abuse, 6 physical abuse, 3 sexual abuse, 13 emotional and physical abuse, 4 unknown type). Seven (4.3%) had suffered abuse in the last year (5 emotional, 2 physical). Abuse had lasted a median of 48 months (interquartile range 12-81). HIV status was considered as a cause of violence by 9.4% of victims. In the multivariable analysis, only abuse was independently associated with non-adherence [adjusted odds ratio (aOR) 3.92; 95% confidence interval (CI) 1.80-8.84; p = 0.0007]. Abuse (aOR 6.14; 95% CI 1.63-27.70; p = 0.001) and previous incarceration (aOR 15.08 95% CI 2.71-104.71; p = 0.003) were associated with detectable viral load. In conclusion, the prevalence of abuse is high in PLHIV, hampering adherence and virological success. Abuse screening tools should be incorporated into routine HIV care.

Comparing typologies of violence exposure and associations with syndemic health outcomes among cisgender and transgender female sex workers living with HIV in the Dominican Republic

Violence against women research largely excludes transgender women's experiences and violence from perpetrators other than intimate partners. This study compares patterns of violence exposure among cisgender and transgender female sex workers (FSWs) and the associations with syndemic health outcomes. We used cross-sectional surveys from samples of cisgender and transgender FSWs living with HIV in the Dominican Republic (N = 211 and 100, respectively). We used latent class analysis to identify patterns of emotional, physical, and sexual violence and harassment by partners, clients, and police. We assessed sociodemographic and occupational predictors in relation to class membership, and class membership in relation to health (HIV continuum of care outcomes, mental health, substance use), using logistic regression. Two classes were identified in cisgender sample: Low Reported Violence Exposure (Class 1) and Sex Work-related Police Harassment (Class 2). Class 2 participants had greater odds of scoring abnormal or borderline abnormal anxiety on the Hospital Anxiety and Depression Scale (HADS-A) (adjusted OR = 3.97, p<0.01), moderate-to-severe depression per the Patient Health Questionnaire-9 (PHQ-9) (aOR = 5.74, p<0.01), and any illicit drug use in the past six months (aOR = 3.06, p<0.05), compared to Class 1. The transgender sample produced three classes: Low Reported Violence Exposure (Class 1); Sex Work-related Police Harassment (Class 2); and Sex Work-related Violence and Harassment (Class 3). Class 3 participants had greater odds of having anxiety (aOR = 6.65, p<0.01) and depression (aOR = 4.45, p<0.05), while Class 2 participants had greater odds of perfect ART adherence during the previous four days (aOR = 2.78, p<0.05), compared to Class 1. The more diverse and extreme violence patterns uncovered for the transgender sample show this group's heightened risk, while similar patterns across groups regarding police abuse highlight a need for police-focused violence prevention interventions. Each sample's highest violence class was associated with poor mental health, underscoring the need for mental health interventions for all FSWs.

The Success of Serious Games and Gamified Systems in HIV Prevention and Care: Scoping Review

BACKGROUND

AIDS, which is caused by HIV, has long been one of the most significant global public health issues. Since the beginning of the HIV epidemic, various types of nonelectronic communication tools have been commonly used in HIV/AIDS prevention and care, but studies that apply the potential of electronic games are still limited.

OBJECTIVE

We aimed to identify, compare, and describe serious games and gamified systems currently used in HIV/AIDS prevention and care that were studied over a specific period of time.

METHODS

A scoping review was conducted into serious games and gamified systems used in HIV prevention and care in various well-known digital libraries from January 2010 to July 2021.

RESULTS

After identifying research papers and completing the article selection process, 49 of the 496 publications met the inclusion criteria and were examined. A total of 32 articles described 22 different serious games, while 17 articles described 13 gamified systems for HIV prevention and care.

CONCLUSIONS

Most of the studies described in the publications were conducted in the United States, while only a few studies were performed in sub-Saharan African countries, which have the highest global HIV/AIDS infection rates. Regarding the development platform, the vast majority of HIV/AIDS gaming systems were typically deployed on mobile devices. This study demonstrates the effectiveness of using serious games and gamified systems. Both can improve the efficacy of HIV/AIDS prevention strategies, particularly those that encourage behavior change.

Exploring gender differences in HIV-related stigma and social support in a low-resource setting: A qualitative study in the Dominican Republic

HIV-related stigma can affect health by compromising coping and social support. Gender differences in stigma experiences and social support are underexplored, particularly in the Caribbean. We conducted semi-structured interviews (N = 32) with patients at two HIV clinics in the Dominican Republic. Transcripts were coded using qualitative content analysis (deductive and inductive approaches) to identify themes regarding stigma experiences and social support, which were then compared across men and women participants to identify gender differences. While both men and women described experienced stigma, including verbal abuse, men's experience of stigma were subtler and women described outright rejection and instances of physical violence, including intimate partner violence. Both men and women described job discrimination, but women described severe disempowerment as well as permanent loss of income and/or employment whereas men described temporary changes in employment and /or decrease in income. Men and women described modifying behavior due to anticipated stigma, but only women discussed isolating themselves and discomfort taking HIV medication in front of others. Regarding internalized stigma, both men and women described shame, guilt, and depression over their HIV status, though these experiences were more common among women. Women's experiences prevented health care seeking and included suicidality, while men sometimes blamed women for their HIV status and expressed a desire to "move on" and "look ahead." Both men and women described receiving financial support from family and friends, community support from neighbors, governmental support, and support from other people living with HIV. Women most frequently discussed receiving support from family and friends and using religiosity to cope, whereas men referenced general family support and government benefits and were less forthcoming about personal relationships and social networks, oftentimes not disclosing HIV status to others. The social context of HIV-related stigma affects women and men differently with physical and mental health impacts and may require distinct mitigation approaches.

Development of a relationship counselling website to identify and mitigate risk of intimate partner violence in the context of women's PrEP use

Discreet, accessible interventions are urgently needed to mitigate the risk of intimate-partner violence (IPV) and other relationship barriers that women encounter to using HIV prevention methods such as pre-exposure prophylaxis (PrEP). We adapted a counsellor-administered intervention, CHARISMA, into a mobile-optimized website to enhance accessibility and reduce human resources required for HIV prevention and relationship counseling. Using human-centered design and participatory methods, CHARISMA was adapted through workshops with former CHARISMA in-person intervention participants (n = 14; ages 18-45) and web development 'sprints' combined with cognitive interviews (n = 24). 'CHARISMA mobile' was then beta-tested with 81 women naïve to the in-person intervention. In beta-testing, participants used a 'think aloud' process to provide feedback on ease of use and rated design, functionality, comprehension, confidentiality, safety, and usefulness on a scale of 1 to 5 via a survey. Data were conducted in four rounds, interspersed with rapid assessment according to go/no-go criteria, and website adaptations. The updated website was pilot tested for 'real-world' feasibility and acceptability among 159 women using their own smartphones at a location of their choice. Feedback was measured via surveys and website analytics. Workshops and cognitive interviews generated insights on technology use, contextual adaptations, and confidentiality, which were integrated into the beta version. The beta version met all 'go' criteria and was further adapted for pilot testing. In pilot testing, users found the website was useful (mean rating 4.54 out of 5), safe (4.5 out of 5), and had few concerns about confidentiality (1.75, representing low concern). On average, users rated the website more than 4 stars out of 5. Beta and pilot-testing suggested the smartphone-optimized website was well-accepted, relevant, engaging, feasible to administer, discreet and safe. Results contributed to a refined website, suitable for adaptations to other contexts and further evaluation where outcomes related to PrEP use and relationships should be assessed.

A global bibliometric analysis of intimate partner violence in the field of HIV/AIDS: implications for interventions and research development

This study aimed to explore the research landscape of intimate partner violence (IPV)-harm-induced behavior in an intimate relationship and HIV/AIDS to determine lessons learnt and gaps that may be filled by future research. Publications related to IPV, and HIV/AIDS published from 1997 to 2019 were collected from Web of Science (WoS). STATA and VOSviewer software tools were used for bibliometric analysis. Content analysis, common topics, and the map of co-occurrence terms were structured by Latent Dirichlet allocation and VOSviewer software tool. 941 studies were included. Factors associated with domestic violence and interventions to reduce IPV were the two most common themes. Meanwhile, mental health illness among pregnant women affected by HIV and IPV, and HIV-risk among youth suffering from IPV have not received adequate attention. We suggest that more research focusing on adolescents and pregnant women affected by HIV and IPV. In addition, the development of collaborative networks between developed and developing countries should also be addressed.

Understanding the effect of gender-based violence on uptake and utilisation of HIV prevention, treatment, and care services among transgender women: a qualitative study in the greater Kampala metropolitan area, Uganda

BACKGROUND

Transwomen (also known as transgender women) are disproportionately affected by all forms of gender-based violence (GBV). The high prevalence of physical, sexual and emotional violence not only predisposes transwomen to HIV infection but also limits the uptake/access to HIV prevention, care, and treatment services. Despite the high prevalence of HIV infection and GBV among transwomen, there is limited evidence on how GBV affects the uptake and utilisation of HIV prevention, care, and treatment services. Therefore, this qualitative study explored how GBV affects uptake and utilisation of HIV prevention, treatment, and care services among transwomen in the Greater Kampala Metropolitan Area (GKMA), Uganda.

METHODS

This participatory qualitative study was conducted among transwomen in the GKMA. A total of 20 in-depth interviews, 6 focus group discussions, and 10 key informant interviews were conducted to explore how GBV affects the uptake and utilisation of HIV prevention, treatment, and care services among transwomen. Data were analysed using a thematic content analysis framework. Data were transcribed verbatim, and NVivo version 12 was used for coding.

RESULTS

At the individual level, emotional violence suffered by transwomen led to fear of disclosing their HIV status and other health conditions to intimate partners and healthcare providers respectively; inability to negotiate condom use; and non-adherence to antiretroviral therapy (ART). Sexual violence compromised the ability of transwomen to negotiate condom use with intimate partners, clients, and employers. Physical and emotional violence at the community level led to fear among transwomen traveling to healthcare facilities. Emotional violence suffered by transwomen in healthcare settings led to the limited use of pre-exposure prophylaxis and HIV testing services, denial of healthcare services, and delays in receiving appropriate care. The fear of emotional violence also made it difficult for transwomen to approach healthcare providers. Fear of physical violence such as being beaten while in healthcare settings made transwomen shun healthcare facilities.

CONCLUSION

The effects of GBV on the uptake and utilisation of HIV prevention, care, and treatment services were observed in individual, community, and healthcare settings. Across all levels, physical, emotional, and sexual violence suffered by transwomen led to the shunning of healthcare facilities, denial of healthcare services, delays in receiving appropriate care, and the low utilisation of post-exposure prophylaxis, and HIV testing services. Given its effects on HIV transmission, there is a need to develop and implement strategies/ interventions targeting a reduction in GBV. Interventions should include strategies to sensitize communities to accept transwomen. Healthcare settings should provide an enabling environment for transwomen to approach any healthcare provider of their choice without fear of experiencing GBV.

Pharmacokinetics of dose-adjusted levonorgestrel emergency contraception combined with efavirenz-based antiretroviral therapy or rifampicin-containing tuberculosis regimens

OBJECTIVES

To determine if double-dose levonorgestrel emergency contraception (EC) in combination with efavirenz or rifampicin, 2 drugs known to decrease levonorgestrel exposure, resulted in similar pharmacokinetics compared to standard-dose levonorgestrel EC without drug-drug interactions.

STUDY DESIGN

We conducted a phase 2, open-label, multicenter, partially randomized, 4 parallel group trial in pre-menopausal females ≥16 years old without an indication for EC and not on hormonal contraception. Participants on dolutegravir-based antiretroviral therapy (ART) received levonorgestrel 1.5 mg (control group); those on rifampicin-containing tuberculosis therapy received levonorgestrel 3 mg; those on efavirenz-based ART were randomized 1:2 to levonorgestrel 1.5 mg or 3 mg. Plasma was collected through 48 hours post-dose to assess levonorgestrel pharmacokinetics. Area under the concentration-time curve (AUC) over 8 hours was the primary outcome. Levonorgestrel pharmacokinetic parameters were compared between groups using geometric mean ratios (GMR) with 90% confidence intervals.

RESULTS

The median (Q1, Q3) age for all participants (n = 118) was 34 (27, 41) years and BMI was 23.2 (20, 26.3) kg/m2. Participants receiving levonorgestrel 1.5mg plus efavirenz (n = 17) had 50% lower AUC0-8h compared to the control group (n = 32) [0.50 (0.40, 0.62)]. Participants receiving levonorgestrel 3 mg had a similar AUC0-8h when receiving either efavirenz (n = 35) [0.99 (0.81, 1.20)] or rifampicin (n = 34) [1.16 (0.99, 1.36)] compared to control. Levonorgestrel 3 mg resulted in similar or higher maximum concentration with either efavirenz [1.17 (0.96, 1.41)] or rifampicin [1.27 (1.09, 1.49)] compared to the control group.

CONCLUSIONS

Doubling the dose of levonorgestrel EC successfully increased levonorgestrel exposure over the first 8 hours in participants receiving either efavirenz-based ART or rifampicin-containing tuberculosis therapy.

IMPLICATIONS

Adjusting levonorgestrel emergency contraception from 1.5 mg to 3 mg improves levonorgestrel pharmacokinetic exposure in participants receiving either efavirenz-based antiretroviral regimens or rifampicin-containing tuberculosis therapy. These data support guideline recommendations to double the dose of levonorgestrel emergency contraception in persons on medications that decrease levonorgestrel exposure by inducing levonorgestrel metabolism.

Relationships Between Stress-Responsive Biomarkers, ART Adherence, and Viral Suppression Among Adolescent Girls and Young Women Living With HIV in South Africa: An HPTN 068 Analysis

BACKGROUND

Adolescent girls and young women (AGYW) living with HIV who have higher stress levels may be at risk of stress-related biological alterations, which could influence HIV progression and adherence to antiretroviral therapy (ART).

SETTING

We aimed to estimate associations among stress-responsive biomarkers, ART adherence, and viral suppression in AGYW living with HIV in South Africa. We also hypothesized that psychosocial stressors [eg, depression, food insecurity, low socioeconomic status (SES), and HSV-2] would be associated with higher biomarker levels.

METHODS

We used 2018/2019 data from the HIV Prevention Trials Network 068 cohort to assess associations between stress-responsive biomarkers and viral suppression (<1000 copies/mL) and ART adherence measured using dried blood spot cards. Stress-responsive biomarkers included C-reactive protein, herpes simplex virus type 1, and cytomegalovirus infection and reactivation. Associations were estimated using unadjusted log-binomial or ordinal logistic regression models.

RESULTS

In 166 AGYW living with HIV, there was no association between stress-responsive biomarkers and viral suppression or ART adherence. However, increased C-reactive protein levels were associated with higher HSV-2 infection [odds ratio (OR) 1.98; 95% confidence interval (CI) 1.11, 3.52], being a government grant recipient (OR 3.21; 95% CI: 1.30, 7.92), lower food insecurity (OR 0.34; 95% CI: 0.13, 0.90), and increased body mass index (OR 1.07; 95% CI: 1.01, 1.14).

CONCLUSIONS

High prevalence of psychosocial stressors and persistent herpesviruses in AGYW living with HIV has the potential to lead to poorer health outcomes. More research is needed to untangle relationships between economic stability, chronic disease, and chronic stress.

Integrating Gender-Based Violence Screening and Support into the Research Clinic Setting: Experiences from an HIV Prevention Open-Label Extension Trial in Sub-Saharan Africa

HIV and gender-based violence (GBV) are syndemic in sub-Saharan Africa and provision of support for participants who disclose GBV constitutes part of comprehensive care. Consequently, a process was undertaken to develop, implement, and evaluate standard operating procedures (SOPs) in MTN-025/HOPE, a study of the dapivirine vaginal ring for HIV prevention. The SOP was developed using needs assessment surveys in addition to World Health Organization (WHO) guidelines and other literature. Sites tailored and implemented the SOP through HOPE implementation. At study end, staff reported increased training 32/35 (91.43%); improved confidence (18/26; 69.23%); and improved vicarious trauma prevention onsite (17/28; 60.71%). Leadership reported increased staff competence in GBV response. Obstacles included limited referral organizations and time for follow-up, continued training needs, and cultural norms. Development and implementation of an SOP is a feasible strategy to build a GBV response to improve health systems and support sustained effective use of HIV prevention products.

Intimate Partner Violence and Engagement in the HIV Care Continuum among Women in Sub-Saharan Africa: A Prospective Cohort Study

Research suggests that women's experience of intimate partner violence (IPV) is associated with poor engagement in HIV care and treatment. However, most studies have been cross-sectional and conducted in North America. We examined the association between physical IPV and HIV care outcomes in a prospective cohort study of women living with HIV (WLHIV) in Malawi, South Africa, Uganda, and Zimbabwe. At enrollment, 15% of the 351 participants self-reported physical IPV. IPV experience was not associated with time to first engagement in HIV care or the proportion virally suppressed after 6 months on ART. Women reporting physical IPV were less likely to initiate ART within 6 months of becoming eligible (adjusted RR 0.74, 95% CI 0.53-1.03). IPV screening is critical to identify survivors and link them to appropriate services. However, addressing IPV may not increase engagement in HIV care or viral load suppression among WLHIV in sub-Saharan Africa.

Impacts of intimate partner violence and sexual abuse on antiretroviral adherence among adolescents living with HIV in South Africa

OBJECTIVE

We are failing to reach 95-95-95 for adolescents living with HIV (ALHIV). Sexual abuse and intimate partner violence (IPV) may impact antiretroviral therapy (ART) adherence, with high rates of 17.4 and 29.7%, respectively, across the southern sub-Saharan African region. However, evidence on their associations with adolescent ART adherence remains limited, with only three cross-sectional studies globally.

DESIGN

A prospective cohort of ALHIV (sample N = 980, 55% female individuals, baseline mean age 13.6 years) were recruited from 53 health facilities in South Africa's Eastern Cape Province and responded to a structured questionnaire at 18-month and 36-month follow-up (2015-2016, 2017-2018).

METHODS

A repeated-measures random effects model assessed multivariable associations of self-reported sexual abuse and IPV with past-week ART adherence, controlling for individual, socioeconomic, and HIV-related factors. Past-week adherence was defined based on currently taking ART and not having missed any doses in the past 7 days (including weekends). We further fitted a moderation model by sex.

RESULTS

Fifty-one percent of adolescents reported consistent ART adherence at both time points. Exposure to IPV was associated with lower odds of self-reported ART adherence (aOR 0.39, 95% CI 0.21-0.72, P = 0.003), as was sexual abuse (aOR 0.54, 95% CI 0.29-0.99, P = 0.048). The marginal predicted probability of ART adherence for adolescents with no exposure to either IPV or sexual abuse was 72% (95% CI 70-74%) compared with 38% (95% CI 20-56%) for adolescents with exposure to both IPV and sexual abuse. Moderation results showed similar associations between sexual violence and ART adherence by sex.

CONCLUSION

Sexual violence prevention and postviolence care may be essential components of supporting adolescent ART adherence. Integration of HIV and violence prevention services will require accessible services and simple referral systems.

The effects of intimate partner violence on women's risk of HIV acquisition and engagement in the HIV treatment and care cascade: a pooled analysis of nationally representative surveys in sub-Saharan Africa

BACKGROUND

Achieving the 95-95-95 targets for HIV diagnosis, treatment, and viral load suppression to end the HIV epidemic hinges on eliminating structural inequalities, including intimate partner violence (IPV). Sub-Saharan Africa has among the highest prevalence of IPV and HIV worldwide. We aimed to examine the effects of IPV on recent HIV infection and women's engagement in the HIV care cascade in sub-Saharan Africa.

METHODS

We did a retrospective pooled analysis of data from nationally representative, cross-sectional surveys with information on physical or sexual IPV (or both) and HIV testing, from Jan 1, 2000, to Dec 31, 2020. Relevant surveys were identified from data catalogues and previous large-scale reviews, and included the Demographic and Health Survey, the AIDS Indicator Survey, the Population-based HIV Impact Assessment, and the South Africa National HIV Prevalence, Incidence, Behavior and Communication Survey. Individual-level data on all female respondents who were ever-partnered (currently or formerly married or cohabiting) and aged 15 years or older were included. We used Poisson regression to estimate crude and adjusted prevalence ratios (PRs) for the association between past-year experience of physical or sexual IPV (or both), as the primary exposure, and recent HIV infection (measured with recency assays), as the primary outcome. We also assessed associations of past-year IPV with self-reported HIV testing (also in the past year), and antiretroviral therapy (ART) uptake and viral load suppression at the time of surveying. Models were adjusted for participant age, age at sexual debut (HIV recency analysis), urban or rural residency, partnership status, education, and survey-level fixed effects.

FINDINGS

57 surveys with data on self-reported HIV testing and past-year physical or sexual IPV were available from 30 countries, encompassing 280 259 ever-partnered women aged 15-64 years. 59 456 (21·2%) women had experienced physical or sexual IPV in the past year. Six surveys had information on recent HIV infection and seven had data on ART uptake and viral load suppression. The crude PR for recent HIV infection among women who had experienced past-year physical or sexual IPV, versus those who had not, was 3·51 (95% CI 1·64-7·51; n=19 179). The adjusted PR was 3·22 (1·51-6·85). Past-year physical or sexual IPV had minimal effect on self-reported HIV testing in the past year in crude analysis (PR 0·97 [0·96-0·98]; n=274 506) and adjusted analysis (adjusted PR 0·99 [0·98-1·01]). Results were inconclusive for the association of ART uptake with past-year IPV among women living with HIV (crude PR 0·90 [0·85-0·96], adjusted PR 0·96 [0·90-1·02]; n=5629). Women living with HIV who had experienced physical or sexual IPV in the past year were less likely to achieve viral load suppression than those who had not experienced past-year IPV (crude PR 0·85 [0·79-0·91], adjusted PR 0·91 [0·84-0·98], n=5627).

INTERPRETATION

Past-year physical or sexual IPV was associated with recent HIV acquisition and less frequent viral load suppression. Preventing IPV is inherently imperative but eliminating IPV could contribute to ending the HIV epidemic.

FUNDING

Canadian Institutes of Health Research, the Canada Research Chairs Program, and Fonds de recherche du Québec-Santé.

TRANSLATIONS

For the French, Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Adolescent Girls’ Experiences Regarding Teenage Pregnancy in the Rural Villages of Limpopo Province, South Africa

Every year, 7.3 million girls become pregnant before they turn 18. Teenage pregnancy increases when girls are denied the right to make decisions about their sexual health and well-being, which is a gender equality issue. Among the challenges of gender equality are those expectations that communities have about girls and early motherhood, sexual violence, and rape. Another challenge is the early marriages of children to older men coupled with the unique risks faced by these girls during pregnancy, for example, the interruption of their education, health risks, such as HIV, premature birth, and increased maternal mortality, denying the girls the right to live a healthy life. This study sought to explore the experiences of adolescent girls regarding teenage pregnancy in the rural villages of the Mopani District, Limpopo. A descriptive, explorative, and qualitative design was followed to collect data from 20 pregnant teenagers in a 13–19 years-old age group. A nonprobability purposive sampling method was used to select the participants from the three villages of the Mopani District. The data were collected using an in-depth individual interview. Tesch’s eight steps of data analysis were also applied. The study findings reveal several factors that explain the high rates of teenage pregnancy in rural Limpopo. Among these are the socioeconomic and cultural factors that predispose teens to pregnancy. The consequences of teenage pregnancy were expressed in terms of regret and ill health.

Differential Effects of Patient Navigation across Latent Profiles of Barriers to Care among People Living with HIV and Comorbid Conditions

Engaging people living with HIV who report substance use (PLWH-SU) in care is essential to HIV medical management and prevention of new HIV infections. Factors associated with poor engagement in HIV care include a combination of syndemic psychosocial factors, mental and physical comorbidities, and structural barriers to healthcare utilization. Patient navigation (PN) is designed to reduce barriers to care, but its effectiveness among PLWH-SU remains unclear. We analyzed data from NIDA Clinical Trials Network's CTN-0049, a three-arm randomized controlled trial testing the effect of a 6-month PN with and without contingency management (CM), on engagement in HIV care and viral suppression among PLWH-SU (n = 801). Latent profile analysis was used to identify subgroups of individuals' experiences to 23 barriers to care. The effects of PN on engagement in care and viral suppression were compared across latent profiles. Three latent profiles of barriers to care were identified. The results revealed that PN interventions are likely to be most effective for PLWH-SU with fewer, less severe healthcare barriers. Special attention should be given to individuals with a history of abuse, intimate partner violence, and discrimination, as they may be less likely to benefit from PN alone and require additional interventions.

Help-seeking and challenges faced by transwomen following exposure to gender-based violence; a qualitative study in the Greater Kampala Metropolitan Area, Uganda

BACKGROUND

The high prevalence of gender-based violence (GBV) among transwomen is a human rights and public health challenge. Nonetheless, there is limited evidence of sources of GBV support services and the challenges faced by transwomen while help-seeking, especially in transphobic settings like Uganda. This study explored the sources of GBV support services and the challenges faced by transwomen in the Greater Kampala Metropolitan Area during help-seeking.

METHODS

A qualitative study design involving 60 transwomen and 10 key informants was conducted. Respondents were recruited using snowball sampling. An in-depth interview (IDI), and a focus group discussion guide were used to collect data from 20 IDI respondents and six focus group discussants. Each focus group discussion averaged six participants. A key informant interview guide was used for key informant interviews. Data were transcribed verbatim and analysed following a thematic framework, informed by the socio-ecological model. Data were organised into themes and subthemes using NVivo 12.0.

RESULTS

The sources of support following exposure to GBV included key population-friendly healthcare facilities and civil society organisations (CSOs), and friends and family. Friends and family provided emotional support while key population-friendly healthcare facilities offered medical services including HIV post-exposure prophylaxis. Key population CSOs provided shelter, nutritional support, and legal advice to GBV victims. Lack of recognition of transgender identity; long distances to healthcare facilities; discrimination by healthcare providers and CSO staff, inappropriate questioning of the trans-gender identity by police officers and healthcare providers, and the lack of trans-competent healthcare providers and legal personnel hindered help-seeking following exposure to GBV.

CONCLUSION

The immediate sources of GBV support services included key population-friendly healthcare facilities and CSOs, police, and friends and family. However, a significant number of transwomen did not report incidences of GBV. Transwomen were discriminated against at some key population healthcare facilities and CSOs, and police, which hindered help-seeking following exposure to GBV. This study highlights the need to tackle internalized stigma and discrimination against transwomen at the existing sources of GBV support. There is also a need to train law enforcers and legal personnel on the right to access healthcare among transwomen in Uganda.

Men's conceptualization of gender-based violence directed to women in Alexandra Township, Johannesburg, South Africa

BACKGROUND

Gender-based violence (GBV) is a crucial global public health challenge disenfranchising women and girls from enjoying their fundamental human rights, thereby threatening their well-being. While the concept of GBV does not imply that violence is always unidirectional, literature shows that women and girls are the most common victims of this type of violence. One in three women, globally, have suffered physical or sexual violence by an intimate partner or non-partner. Evidence has shown that a number of women who experience GBV varies widely, with 37% being in Eastern Mediterranean, 37.7% in South-East Asia, 29.8% in America, 36.6% in Africa, 44% in sub-Saharan Africa (SSA) and 53% in South Africa.

METHODS

Using a semi-structured face-to-face interview with fifteen conveniently sampled adult males, who met the selection criteria, this study explored men's conceptualisation of GBV in Alexandra Township, using qualitative research methods.

RESULTS

Socio-economic factors and evolving cultural dynamics were perceived to be among the key factors aggravating gender-based violence. Participants viewed poverty and substance abuse as the main causes of violence towards women, a phenomenon tied to the growing frustration emanating from men's inability to provide for their families. Cultural factors related to the patriarchal system and diminishing value of respect between men and women were identified as root causes of GBV. The participants also blamed the government for what they considered to be "too many rights" for women, resulting in men exerting their authority through abuse. Participants also expressed concerns over feminisation of GBV, asserting that men fall prey to GBV too. Partner infidelity and insecurities also contributed to GBV.

CONCLUSION

The study results provided important insights on how men conceptualize GBV in Alexandra Township, South Africa. These results revealed that socio-economic conditions, alongside some gender stereotypes are pervasive and shape how men view GBV in Alexandra Township. This evidence is necessary for developing interventions aimed at curbing GBV and may also be suggestive of the need to redesign programmes targeting men, so that certain stereotypes can be uprooted.

Mechanisms linking gender-based violence to worse HIV treatment and care outcomes among women in the United States

OBJECTIVE

To test whether substance use mediates the associations between gender-based violence (GBV) and suboptimal adherence to antiretroviral therapy (ART), and GBV and poor engagement in care, among women living with HIV (WLHIV) in the United States (US).

DESIGN

We analyzed longitudinal data collected among 1717 WLHIV in the Women's Interagency HIV Study (WIHS).

METHODS

From 2013 to 2017, WLHIV completed semi-annual assessments on GBV, substance use, and HIV treatment and care. Adjusted multilevel logistic regression models were built to estimate the impact of GBV on; suboptimal (<95%) adherence and at least one missed HIV care appointment without rescheduling in the past 6 months. Mediation analyses were performed to test whether heavy drinking and illicit drug use mediated the associations between GBV and the two HIV outcomes.

RESULTS

The mean age was 47 (standard deviation = 9), 5% reported experiencing GBV, 17% reported suboptimal adherence and 15% reported at least one missed appointment in the past 6 months. Women who experienced GBV had a significantly higher odds of suboptimal adherence [adjusted odds ratio (aOR) = 1.99; 95% confidence interval (CI) = 1.40-2.83] and missed appointments (aOR = 1.92, 95% CI = 1.32-2.33). Heavy drinking and illicit drug use mediated 36 and 73% of the association between GBV and suboptimal adherence and 29 and 65% of the association between GBV and missed appointments, respectively.

CONCLUSIONS

Substance use is an underlying mechanism through which GBV affects outcomes along the HIV care continuum among WLHIV in the US. To optimize HIV treatment and care among women, interventions should address the combined epidemics of substance use, violence, and HIV.

Intersectional stigmas are associated with lower viral suppression rates and antiretroviral therapy adherence among women living with HIV

OBJECTIVES

To explore the associations between intersectional poverty, HIV, sex, and racial stigma, adherence to antiretroviral therapy (ART), and viral suppression among women with HIV (WHIV).

DESIGN

We examined intersectional stigmas, self-report ART adherence, and viral suppression using cross-sectional data.

METHODS

Participants were WHIV ( N  = 459) in the Women's Adherence and Visit Engagement, a Women's Interagency HIV Study substudy. We used Multidimensional Latent Class Item Response Theory and Bayesian models to analyze intersectional stigmas and viral load adjusting for sociodemographic and clinical covariates.

RESULTS

We identified five intersectional stigma-based latent classes. The likelihood of viral suppression was approximately 90% lower among WHIV who experienced higher levels of poverty, sex, and racial stigma or higher levels of all intersectional stigmas compared with WHIV who reported lower experiences of intersectional stigmas. ART adherence accounted for but did not fully mediate some of the associations between latent intersectional stigma classes and viral load.

CONCLUSION

The negative impact of intersectional stigmas on viral suppression is likely mediated, but not fully explained, by reduced ART adherence. We discuss the research and clinical implications of our findings.

Multisectoral, Combination HIV Prevention for Adolescent Girls and Young Women: A Qualitative Study of the DREAMS Implementation Trajectory in Zambia

OBJECTIVE

To identify solutions to the implementation challenges with the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women) Partnership in Zambia, this study examines the rollout and evolution of the DREAMS Partnership's implementation.

METHODS

In September-October 2018, implementing partner (IP) staff (n=15) and adolescent girls and young women (AGYW) participating in DREAMS programming (n=32) completed in-depth interviews exploring early rollout and scale-up of DREAMS, experiences with program participation, and shifting service delivery approaches in response to emerging implementation challenges. Inductive and deductive thematic analysis of 47 interviews uncovered salient service delivery facilitators and barriers in the first 2 years of DREAMS implementation, which were subsequently mapped onto the following domains: reach, effectiveness, adoption, implementation, and maintenance.

RESULTS

Key implementation successes identified by IP staff included using standardized recruitment and risk assessment tools across IP organizations, using a mentor model for delivering program content to AGYW, and offering centralized service delivery at venues accessible to AGYW. Implementation challenges identified early in the DREAMS Partnership's lifecycle were rectified through adaptive service delivery strategies. Monthly in-person coordination meetings were established to resolve IP staff jurisdictional disputes over recruitment and target setting. To address high participant attrition, IP staff adopted a cohort approach to sequentially recruit AGYW who enrolled together and provided social support to one another to sustain involvement in DREAMS programming. Prominent barriers to implementation fidelity included challenges recruiting the highest-risk AGYW (e.g., those out of school), limited resources to incentivize participation by young women, and inadequate planning to facilitate absorption of individual DREAMS interventions by the public sector upon project conclusion.

CONCLUSIONS

Delivering multisectoral HIV prevention programs like DREAMS with fidelity requires a robust implementation infrastructure (e.g., adaptable workplans and harmonized record management systems), early coordination between IP organizations, and sustained financial commitments from donors.

Perceived Barriers to HIV Care and Viral Suppression Comparing Newly Diagnosed Women Living with HIV in Rural Uganda with and without a History of Intimate Partner Violence

Intimate partner violence (IPV) is associated with poor HIV care linkage and retention, medication adherence, and viral suppression. However, limited knowledge exists regarding potential mechanisms linking IPV to these outcomes. We aimed to (a) identify the top barriers to accessing HIV care experienced by women living with HIV (WLHIV) who report a history of IPV and have suppressed viral load (VL) versus unsuppressed VL and (b) understand how these barriers influence VL, comparing WLHIV with a history of IPV to WLHIV without a history of IPV. Study data come from newly diagnosed WLHIV in rural Uganda participating in the standard-of-care control arm of a randomized trial (n = 152). Descriptive results ranking mean scores from highest to lowest showed that, among women with a history of IPV, irrespective of viral suppression status, paying for transportation to come to clinic, having to wait at the clinic for long periods of time, and finding a clinic within reasonable travel distance were the top three barriers to accessing HIV care. WLHIV with a history of IPV were significantly more likely to have unsuppressed VL versus suppressed VL if they reported higher levels of difficulty finding a clinic within reasonable travel distance (RRR = 1.7, 95% CI [1.1-2.7]), getting permission to take time off from work (RRR = 1.5, 95% CI [1.0-2.9]), and finding time to come to the clinic for an appointment (RRR = 1.6, 95% CI [1.0-2.6]). The same relationships were not present among WLHIV without a history of IPV, suggesting these barriers and their effect on VL may be uniquely related to IPV. Interventions should address IPV and HIV care continuum outcomes in tandem, targeting barriers to accessing HIV care likely associated with IPV. Additional research is necessary to better understand how IPV relates to HIV care barriers and VL.

Associations between sexual identity, living with disability, bully victimisation, and HIV status and intimate partner violence among residents in Nigeria

Background

The aim of the study was to determine the associations between sexual identity, disability and HIV status and bullying victimisation, and a history of physical, emotional and sexual violence in Nigeria.

Methods

This was a secondary analysis of a primary dataset generated through an online survey conducted between February 7 and 19, 2021. The 3197 participants for the primary study were recruited through snowballing. The dependent variables were physical, emotional and sexual violence. The independent variables were sexual identity (heterosexual and sexual minority), HIV status (negative, positive and unknown), bullying victimisation (yes/no) and living with disability (yes/no). A multivariate logistic regression model was developed for each form of IPV. Each model was adjusted for age, sex assigned at birth, marital status and education level.

Results

Respondents living with HIV had higher odds for physical (AOR: 2.01; 95% CI: 1.46–2.76; p < 0.001), sexual (AOR: 2.17; 95%CI: 1.55–3.05; p < 0.001), and emotional (AOR: 1.59; 95%CI: 1.24–2.06; p < 0.001) violence. Also, those with history of bullying victimisation had higher odds for physical (AOR: 3.79; 95%CI: 2.86 – 5.68; p < 0.001), sexual (AOR: 3.05; 95%CI: 2.27 – 4.10; p < 0.001) and emotional (AOR: 2.66; 95%CI: 2.10 – 3.37; p < 0.001) violence. In addition, females had higher odds of physical (AOR: 1.52; 95%CI: 1.13–2.043; p < 0.001) and sexual (AOR: 1.83; 95%CI: 1.34 – 2.50; p < 0.001) violence; and respondents cohabiting (AOR: 1.95; 95%CI: 1.12 – 3.28; p = 0.012) had higher odds for emotional violence. Respondents who were married have significantly lower odds of experiencing physical (AOR: 0.66; 95%CI: 0.45 – 9.60; p = 0.029), sexual (AOR: 0.40; 95%CI: 0.26 – 0.62; p < 0.001) and emotional (AOR: 0.68; 95%CI: 0.50 – 0.93; p = 0.015) violence when compared to singles. Younger respondents also had lower odds of experiencing sexual violence (AOR: 0.97; 95%CI: 0.95–0.99; p = 0.016).

Conclusion

HIV positive status and bullying victimisation seem to increase the risk for all forms of IPV while the experience of IPV did not differ by sexual identity and disability status. The associations between age, sex, marital status and IPV may suggest moderating roles of the factors taking cognisance of the cultural context of these relationships. Future relational analysis is necessary to further understand the pathways for the associations found between the variables in this study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14186-6.

A qualitative study of how stigma influences HIV services for transgender men and women in Nigeria

INTRODUCTION

Transgender men and women in Nigeria experience many barriers in accessing HIV prevention and treatment services, particularly given the environment of transphobia (including harassment, violence and discrimination) and punitive laws in the country. HIV epidemic control in Nigeria requires improving access to and quality of HIV services for key populations at high risk, including transgender men and women. We assessed how stigma influences HIV services for transgender people in Lagos, Nigeria.

METHODS

In-depth interviews (IDIs) and focus group discussions were conducted with transgender men (n = 13) and transgender women (n = 25); IDIs were conducted with community service organization (CSO) staff (n = 8) and healthcare providers from CSO clinics and public health facilities (n = 10) working with the transgender population in March 2021 in Lagos. Content analysis was used to identify how stigma influences transgender people's experiences with HIV services.

RESULTS AND DISCUSSION

Three main findings emerged. First, gender identity disclosure is challenging due to anticipated stigma experienced by transgender persons and fear of legal repercussions. Fear of being turned in to authorities was a major barrier to disclose to providers in facilities not affiliated with a transgender-inclusive clinic. Providers also reported difficulty in eliciting information about the client's gender identity. Second, respondents reported lack of sensitivity among providers about gender identity and conflation of transgender men with lesbian women and transgender women with being gay or men who have sex with men, the latter being more of a common occurrence. Transgender participants also reported feeling disrespected when providers were not sensitive to their pronoun of preference. Third, HIV services that are not transgender-inclusive and gender-affirming can reinforce stigma. Both transgender men and women spoke about experiencing stigma and being refused HIV services, especially in mainstream public health facilities, as opposed to transgender-inclusive CSO clinics.

CONCLUSIONS

This study highlights how stigma impedes access to appropriate HIV services for transgender men and women, which can have a negative impact along the HIV care continuum. There is a need for transgender-inclusive HIV services and competency trainings for healthcare providers so that transgender clients can receive appropriate and gender-affirming HIV services.

Relationship Dynamics are Associated with Self-Reported Adherence but not an Objective Adherence Measure in Malawi

Couple relationships can be leveraged to improve adherence to antiretroviral therapy (ART), but few studies have identified relationship factors to target in interventions in sub-Saharan Africa. We conducted a cross-sectional study with 211 couples in southern Malawi with at least one partner on ART to test for associations between ART adherence and relationship dynamics (intimacy, trust, relationship satisfaction, unity, commitment, and partner support). We measured ART adherence through subjective measures (patient and partner reports) and an objective measure (ART drug levels in hair) and hypothesized that more positive relationship dynamics (e.g., higher intimacy) would be associated with better adherence. Multi-level logistic and linear regression models were used to evaluate study hypotheses, controlling for the clustering of individuals within couples. High levels of adherence were found by all three measures. Unity, satisfaction, and partner support were associated with higher patient and partner reports of adherence, and additional relationship dynamics (intimacy, trust) were associated with higher partner reported adherence. No associations were found between relationship dynamics and drug levels in hair, although drug levels were high overall. Future studies should perform longitudinal assessments of relationship dynamics and objective metrics of adherence, and examine these associations in populations with lower adherence levels such as young women or individuals starting ART.

Bidirectional Violence Is Associated with Poor Engagement in HIV Care and Treatment in Malawian Couples

Growing evidence suggests that intimate partner violence (IPV) is a barrier to engagement in HIV care. Bidirectional IPV-being both a perpetrator and victim-may be the most common pattern of IPV, yet no research has examined its effect on engagement in care, which could identify couples in most need of interventions. Married couples (N = 211) with at least one partner on antiretroviral therapy were recruited from HIV clinic waiting rooms in Zomba, Malawi. Partners completed separate surveys on physical, sexual, and emotional IPV, medication adherence, and appointment attendance. We created categorical variables indicating no violence, perpetrator-only, victim-only, and bidirectional violence. Generalized estimating equation regression models tested for associations between IPV and engagement in care. The bidirectional pattern represented 25.4%, 35.5%, and 34.0% of all physical, sexual, and emotional IPV. Physical IPV victimization-only (adjusted odds ratio [AOR]: 0.28, 95% confidence interval [CI]: 0.08, 0.92) was associated with lower adherence, but the association was stronger for bidirectional physical IPV (AOR: 0.10, 95% CI: 0.02, 0.51). Bidirectional sexual IPV was also associated with lower adherence (AOR: 0.14, 95% CI: 0.02, 0.80). Bidirectional physical IPV (AOR: 4.04, 94% CI: 1.35, 12.14) and emotional IPV (AOR: 3.78, 95% CI: 1.78, 8.05) were associated with missing 1+ appointment. Interventions to address the health effects of bidirectional IPV, which may be greater than victim-only or perpetrator-only IPV, should intervene with both partners to break cycles of violence. Couple-based interventions may be a viable option by intervening on both partners' trauma and aggression simultaneously.

Predictors of testing history and new HIV diagnosis among adult outpatients seeking care for symptoms of acute HIV infection in coastal Kenya: a cross-sectional analysis of intervention participants in a stepped-wedge HIV testing trial

Background

HIV testing is the first step to stop transmission. We aimed to evaluate HIV testing history and new diagnoses among adult outpatients in Kenya aged 18–39 years seeking care for symptoms of acute HIV infection (AHI).

Methods

The Tambua Mapema Plus study, a stepped-wedge trial, enrolled patients presenting to care at six primary care facilities with symptoms of AHI for a targeted HIV-1 nucleic acid (NA) testing intervention compared with standard provider-initiated testing using rapid antibody tests. Intervention participants underwent a questionnaire and NA testing, followed by rapid tests if NA-positive. Multinomial logistic regression was used to analyse factors associated with never testing or testing > 1 year ago (“late retesting”) relative to testing ≤ 1 year ago (“on-time testers”). Logistic regression was used to analyse factors associated with new diagnosis. All analyses were stratified by sex.

Results

Of 1,500 intervention participants, 613 (40.9%) were men. Overall, 250 (40.8%) men vs. 364 (41.0%) women were late retesters, and 103 (16.8%) men vs. 50 (5.6%) women had never tested prior to enrolment. Younger age, single status, lower education level, no formal employment, childlessness, sexual activity in the past 6 weeks, and > 1 sexual partner were associated with testing history among both men and women. Intimate partner violence > 1 month ago, a regular sexual partner, and concurrency were associated with testing history among women only. New diagnoses were made in 37 (2.5%) participants (17 men and 20 women), of whom 8 (21.6%) had never tested and 16 (43.2%) were late retesters. Newly-diagnosed men were more likely to have symptoms for > 14 days, lower education level and no religious affiliation and less likely to be young, single, and childless than HIV-negative men; newly-diagnosed women were more likely to report fever than HIV-negative women. Among men, never testing was associated with fivefold increased odds (95% confidence interval 1.4–20.9) of new diagnosis relative to on-time testers in adjusted analyses.

Conclusion

Most new HIV diagnoses were among participants who had never tested or tested > 1 year ago. Strengthening provider-initiated testing targeting never testers and late retesters could decrease time to diagnosis among symptomatic adults in coastal Kenya.

Trial registration

ClinicalTrials.gov Identifier: NCT03508908 registered on 26/04/2018.

Mental Health Mediates the Association Between Gender-Based Violence and HIV Treatment Engagement in US Women

BACKGROUND

Gender-based violence (GBV) is associated with poorer engagement in HIV care and treatment. However, there is a dearth of research on the psychological (eg, mental health) and structural (eg, food insecurity) factors that mediate and moderate this association. GBV could lead to poor mental health, which in turn affects adherence, whereas food insecurity could worsen the effect of GBV on engagement in care. This study uses data from the Women's Interagency HIV Study to address these gaps.

METHODS

Women completed 6 assessments from 2013 to 2016 on GBV, mental health, food insecurity, adherence to antiretroviral therapy, and missed HIV care appointments in the past 6 months. Multilevel logistic regression models estimated associations between GBV and engagement in care and whether associations were mediated by depression, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) and moderated by food insecurity.

RESULTS

GBV was associated with higher odds of suboptimal adherence (adjusted odds ratio: 1.88; 95% confidence interval: 1.24 to 2.87) and missed appointments (adjusted odds ratio: 1.76; 95% confidence interval: 1.16 to 2.67). The association between GBV and adherence was mediated by depressive symptoms, GAD, and PTSD, accounting for 29.7%, 15.0%, and 16.5%, respectively, of the total association. The association between GBV and missed appointments was mediated by depression and GAD, but not PTSD, with corresponding figures of 25.2% and 19.7%. Associations did not differ by food insecurity.

CONCLUSIONS

GBV is associated with suboptimal engagement in care, which may be explained by mental health. Interventions should address women's mental health needs, regardless of food insecurity, when improving engagement in HIV care.

Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa

Background

Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa.

Methods

We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach.

Results

We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men’s fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men’s expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family’s health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner’s results. Facility-level barriers such as long wait times continued to prevent some men from accessing care.

Conclusions

Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men’s and women’s engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.

Understanding factors influencing utilization of HIV prevention and treatment services among patients and providers in a heterogeneous setting: A qualitative study from South Africa

Despite advances made in HIV prevention and treatment interventions in South Africa, barriers to their utilization continue to exist. Understanding perspectives from patients and providers of healthcare can shed light on the necessary strategies to enhance uptake of HIV services. A cross-sectional qualitative study was conducted in July 2020 in Ekurhuleni District. Based on HIV prevalence estimates from a national survey, male condom use coverage and antiretroviral treatment (ART) initiation rates from routinely collected clinical data for 2012, we selected facilities from geographical areas with varying HIV prevalence and uptake of HIV services. In-depth interviews were conducted with adult (≥18 years) patients and healthcare workers in selected primary healthcare facilities. Thematic analysis was performed following a framework built around the social cognitive theory to describe behavioural, personal, and social/environmental factors influencing utilization of HIV services. Behavioural factors facilitating uptake of HIV services included awareness of the protective value of condoms, and the benefits of ART in suppressing viral load and preventing mother-to-child HIV transmission which was evident across geographical areas. Barriers in high prevalence areas included suboptimal condom use, fears of a positive HIV result, and anticipated HIV-related stigma while seeking healthcare services. Across the geographical areas, personal factors included ability to correctly use available services enhanced by knowledge acquired during counselling sessions and community-based health promotion activities. Further, social support from family reinforced engagement in care. Compared to low uptake areas, clinics in high uptake areas used care-facilitators, outreach teams and decanting programs to address the environmental barriers including staff shortages and long queues. Barriers at multiple levels prevent optimal utilization of HIV services, calling for strategies that target and address the different levels and tailored to needs of specific settings. Overall, improved delivery of HIV prevention or treatment interventions can be achieved through strengthening training of healthcare providers in facilities and communities and addressing negative sequelae from utilising services in low uptake areas.

Gender violence perpetrated against trans women

ABSTRACT Objectives: to identify scientific evidence on gender violence perpetrated against trans women. Methods: integrative review, carried out in June 2020, without time frame, in the Scopus, MEDLINE, Embase, CINAHL, WoS, PsycInfo and LILACS databases. The controlled descriptors of DeCS, MeSH and their entry terms were used: “Transgender People”, “Transgender”, “Gender Identity”, “Transsexuality”, “Gender Violence”, “Aggression”, “Sexual Offenses”, “Rape”, “Violence”, “Domestic Violence”. The presentation and synthesis of the results were presented in the PRISMA-2009 flowchart. Results: the final sample, consisting of 16 articles, identified different types of violence (sexual, physical, verbal, psychological and financial), perpetrated by family members, strangers, police officers, intimate partners, health professionals, acquaintances, or friends. Conclusions: trans women suffer violence and social exclusion that result from stigma and discrimination due to gender identity and result in unrestricted damage to physical health.

Uptake, Retention, and Adherence to Pre-exposure Prophylaxis (PrEP) in TRIUMPH: A Peer-Led PrEP Demonstration Project for Transgender Communities in Oakland and Sacramento, California

BACKGROUND

TRIUMPH (Trans Research-Informed communities United in Mobilization for the Prevention of HIV) was a community-led, transgender-specific pre-exposure prophylaxis (PrEP) demonstration project at 2 community-based clinical sites in California. TRIUMPH used peer health education, community mobilization, and clinical integration of PrEP with hormone therapy to promote PrEP knowledge and acceptability. The goal of this study was to evaluate PrEP uptake, retention, and adherence among TRIUMPH participants and examine site-based differences.

METHODS

Eligible participants were adult transgender and gender diverse people interested in PrEP. Participants were seen at baseline and at 1, 3, 6, 9, and 12 months for PrEP provision, clinical visits, and HIV testing. PrEP uptake was defined as dispensation of PrEP, PrEP retention was defined as proportion of expected visits completed among those who initiated PrEP, and PrEP adherence was assessed by measuring tenofovir diphosphate concentrations in dried blood spots. Logistic regression models quantified the association of variables with PrEP outcomes.

RESULTS

TRIUMPH enrolled 185 participants; the median age was 28 years (interquartile range: 23-35), 7% was Black, and 58% was Latinx. PrEP uptake was as follows: 78% in Oakland and 98% in Sacramento; 91% among trans women, 96% among trans men, and 70% among nonbinary participants. Almost half (47%) rarely/never believed about HIV, and 42% reported condomless sex act in the past 3 months. Participants who reported higher numbers of sex partners were more likely to be retained and adherent; other predictors of adherence included not having a primary partner and not experiencing violence in the past 3 months.

CONCLUSIONS

This community-led, trans-specific PrEP demonstration project documents high levels of PrEP initiation in a young transgender and gender diverse cohort at risk of HIV acquisition.

Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study

Background

Intensive adherence counseling (IAC) is an intervention recommended by the World Health Organization to improve anti-retroviral therapy (ART) adherence among people living with HIV on ART with unsuppressed viral load; and in 2016, the intervention was implemented in Uganda. This study evaluated the effect and experiences of providing IAC in an urban HIV care center in Kampala, Uganda.

Methods

This was a sequential explanatory mixed-method study that compared viral load suppression during IAC implementation (intervention) to the period before IAC at Kisenyi Health centre IV. Data were abstracted from patient files and viral load register. The effect of IAC on viral load suppression and associated factors were analyzed using modified Poisson regression with robust standard errors. Using in-depth interviews and an inductive analysis approach in Atlas-ti 8. We also explored experiences of providing IAC among healthcare workers.

Results

A total of 500 records were sampled: 249 (49.8%) in the intervention period and 251 (51.2%) in the pre-intervention period. The mean age was lower during the intervention period 33.1 (± 12.0) than 36.5 (± 13.4) in the pre- intervention period, p = 0.002. More clients were currently on Protease-based regimen in the pre-intervention period 179 (71.3%) than 135 (54.2%) in the intervention period, p ≤ 0.001. In the intervention period, all eligible clients received IAC [249/249 (100.0%)]. Overall, 325 (65.0%) received IAC and of these, 143 (44.1%) achieved viral load suppression compared to 46 (26.3%) who received regular counseling. Receiving IAC significantly increased viral load suppression by 22% (aPR 1.22, 95% CI 1.01–1.47). Clients on Protease-based regimen were less likely to suppress than those on Efavirenz or Nevirapine-based regimens (aPR 0.11, 95% CI 0.08–0.15). All the interviewed healthcare workers lauded IAC for improving ART adherence. However, patient and health care system related factors hindered adherence during IAC.

Conclusions

The full potential of IAC in achieving viral load suppression in this setting has not been reached due to a combination of the patient and health care system related factors. Provision of adequate IAC necessities and use of patient centered approach should be emphasized to obtain the maximum benefit of the intervention.

HIV Prevention Program Eligibility Among Adolescent Girls and Young Women - Namibia, 2019

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) relies on comprehensive and reliable population data to implement interventions to reduce HIV transmission in high-incidence areas among populations disproportionately affected by the HIV epidemic. Adolescent girls and young women in sub-Saharan Africa account for a disproportionate number of new HIV infections compared with their male peers (1). The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program includes multisectoral, layered interventions aimed at reducing factors that contribute to vulnerability to HIV infection among adolescent girls and young women in PEPFAR-supported sub-Saharan African countries (1). Namibia, a southern African country with a population of approximately 2.55 million among whom approximately 8% live with HIV infection, had their DREAMS program first implemented in 2017* (2,3). Data from the 2019 Namibia Violence Against Children and Youth Survey (VACS), the most recent and comprehensive nationally representative data source available to study the epidemiology of violence and other HIV risk factors, were used to estimate the percentage of adolescent girls and young women aged 13-24 years who would be eligible for DREAMS program services. The prevalence of individual DREAMS eligibility criteria, which comprise known age-specific risk factors associated with HIV acquisition, were estimated by age group. Among all adolescent girls and young women in Namibia, 62% were eligible for DREAMS based on meeting at least one criterion. Common eligibility criteria included adverse childhood experiences, specifically exposure to physical, emotional, and sexual violence and being an orphan;^† and high-risk behaviors, such as early alcohol use,^§ recent heavy alcohol use,^¶ and infrequent condom use.** Using VACS data to estimate the prevalence of HIV risk factors and identify adolescent girls and young women at elevated risk for HIV acquisition in countries like Namibia with high HIV-incidence can inform programs and policies aimed at improving the well-being of these adolescent girls and young women and help control the HIV epidemics in these countries.

Modeling the epidemiological impact of the UNAIDS 2025 targets to end AIDS as a public health threat by 2030

BACKGROUND

UNAIDS has established new program targets for 2025 to achieve the goal of eliminating AIDS as a public health threat by 2030. This study reports on efforts to use mathematical models to estimate the impact of achieving those targets.

METHODS AND FINDINGS

We simulated the impact of achieving the targets at country level using the Goals model, a mathematical simulation model of HIV epidemic dynamics that includes the impact of prevention and treatment interventions. For 77 high-burden countries, we fit the model to surveillance and survey data for 1970 to 2020 and then projected the impact of achieving the targets for the period 2019 to 2030. Results from these 77 countries were extrapolated to produce estimates for 96 others. Goals model results were checked by comparing against projections done with the Optima HIV model and the AIDS Epidemic Model (AEM) for selected countries. We included estimates of the impact of societal enablers (access to justice and law reform, stigma and discrimination elimination, and gender equality) and the impact of Coronavirus Disease 2019 (COVID-19). Results show that achieving the 2025 targets would reduce new annual infections by 83% (71% to 86% across regions) and AIDS-related deaths by 78% (67% to 81% across regions) by 2025 compared to 2010. Lack of progress on societal enablers could endanger these achievements and result in as many as 2.6 million (44%) cumulative additional new HIV infections and 440,000 (54%) more AIDS-related deaths between 2020 and 2030 compared to full achievement of all targets. COVID-19-related disruptions could increase new HIV infections and AIDS-related deaths by 10% in the next 2 years, but targets could still be achieved by 2025. Study limitations include the reliance on self-reports for most data on behaviors, the use of intervention effect sizes from published studies that may overstate intervention impacts outside of controlled study settings, and the use of proxy countries to estimate the impact in countries with fewer than 4,000 annual HIV infections.

CONCLUSIONS

The new targets for 2025 build on the progress made since 2010 and represent ambitious short-term goals. Achieving these targets would bring us close to the goals of reducing new HIV infections and AIDS-related deaths by 90% between 2010 and 2030. By 2025, global new infections and AIDS deaths would drop to 4.4 and 3.9 per 100,000 population, and the number of people living with HIV (PLHIV) would be declining. There would be 32 million people on treatment, and they would need continuing support for their lifetime. Incidence for the total global population would be below 0.15% everywhere. The number of PLHIV would start declining by 2023.