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Majeed T, Hopkin G, Wang K, Nepal S, Votruba N, Gronholm P, Gurung D, Semrau M, Bagade T, Farina N, Musyimi C, Pingani L, Breuer E, Lund C, Thornicroft G, Evans-Lacko S. Anti-stigma interventions in low-income and middle-income countries: a systematic review. EClinicalMedicine 2024; 72:102612. [PMID: 38707913 PMCID: PMC11066569 DOI: 10.1016/j.eclinm.2024.102612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/31/2024] [Accepted: 04/09/2024] [Indexed: 05/07/2024] Open
Abstract
Background Stigma exacerbates power imbalances and societal disparities, significantly impacting diverse identities and health conditions, particularly for low and middle-income countries (LMICs). Though crucial for dismantling harmful stereotypes, and enhancing healthcare utilisation, existing research on anti-stigma interventions is limited with its condition-focused approach. We aimed to thoroughly evaluate peer-reviewed and non-peer-reviewed literature for a comprehensive review of anti-stigma interventions for diverse identities and all health conditions in LMICs. Methods This review systematically explored peer-reviewed and non-peer-reviewed literature, in ten electronic databases up to January 30, 2024, covering all anti-stigma interventions across various stigmatised identities and health conditions in LMICs. Quality assessment for this systematic review was conducted as per Cochrane Collaboration's suggested inclusions. The review was registered with PROSPERO (Registration: 2017 CRD42017064283). Findings Systematic synthesis of the 192 included studies highlights regional imbalances, while providing valuable insights on robustness and reliability of anti-stigma research. Most studies used quasi-experimental design, and most centred on HIV/AIDS or mental health related stigma, with very little work on other issues. Certain high-population LMICs had no/little representation. Interpretation The interventions targeted diverse segments of populations and consequently yielded a multitude of stigma-related outcomes. However, despite the heterogeneity of studies, most reported positive outcomes underscoring the effectiveness of existing interventions to reduce stigma. Funding This study is supported by the UK Medical Research Council Indigo Partnership (MR/R023697/1) award.
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Affiliation(s)
- Tazeen Majeed
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Australia
| | - Gareth Hopkin
- National Institute for Health and Care Excellence, United Kingdom
| | - Katie Wang
- Department of Social and Behavioral Sciences, Yale School of Public Health, United Kingdom
| | | | - Nicole Votruba
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Petra Gronholm
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, United Kingdom
- Centre for Implementation Science and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Dristy Gurung
- Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Transcultural Psychosocial Organization, Kathmandu, Nepal
| | - Maya Semrau
- Centre of Excellence for Global Health Research, Brighton & Sussex Medical School, Brighton, UK
| | - Tanmay Bagade
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Australia
| | - Nick Farina
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Luca Pingani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Dipartimento ad Attività Integrata di Salute Mentale e Dipendenze Patologiche, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Erica Breuer
- School of Medicine and Public Health, College of Health, Medicine and Wellbeing, University of Newcastle, Australia
- Alan J Fisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Crick Lund
- Centre for Implementation Science and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Alan J Fisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Graham Thornicroft
- Centre for Implementation Science and Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sara Evans-Lacko
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, United Kingdom
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2
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Alessi EJ, Lee YG, Chikalogwe VP, Tarusarira W, Raymond H, Lynn M, Kahn S. Pilot study of an arts- and theatre-based HIV prevention intervention for men who have sex with men and transgender women migrants in South Africa: acceptability, feasibility and preliminary efficacy. HEALTH EDUCATION RESEARCH 2023; 38:392-411. [PMID: 37229526 DOI: 10.1093/her/cyad021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/27/2023]
Abstract
Innovative approaches addressing the elevated human immunodeficiency virus (HIV) risk among men who have sex with men (MSM) or transgender women (TGW) migrants in South Africa are urgently needed. We sought to present the acceptability, feasibility and preliminary efficacy of 'Externalize and Mobilize!', a multi-session arts- and theatre-based HIV prevention group intervention for MSM and TGW migrants in South Africa. Fourteen participants-MSM (n = 7; 50%), genderqueer/nonbinary persons (n = 4; 29%) and TGW (n = 3; 21%)-in Cape Town were recruited and enrolled in the intervention and administered pre- and post-intervention assessments of HIV knowledge, HIV risk-reduction self-efficacy, stigma and resilience. The intervention, delivered over 4 days, was completed by all 14 participants. Scores on HIV knowledge and HIV risk-reduction self-efficacy were statistically significantly higher at post-intervention compared with pre-intervention. Additionally, participants responded affirmatively (i.e. 'Agree' or 'Strongly agree') on all items assessing intervention acceptability. Findings demonstrate the high acceptability, feasibility and preliminary efficacy of an arts- and theatre-based intervention for increasing HIV knowledge and HIV risk-reduction self-efficacy among MSM and TGW migrants in South Africa. This study provides further support for the use of creative and innovative interventions to address entrenched HIV disparities in South Africa.
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Affiliation(s)
- E J Alessi
- Rutgers University School of Social Work, New Brunswick, NJ 08901, USA
| | - Y G Lee
- Rutgers University School of Social Work, New Brunswick, NJ 08901, USA
| | | | - W Tarusarira
- PASSOP, Cape Town, Western Cape 8001, South Africa
| | - H Raymond
- Rutgers University School of Public Health, Piscataway, NJ 08854, USA
| | - M Lynn
- Rutgers University School of Social Work, New Brunswick, NJ 08901, USA
| | - S Kahn
- McGill University School of Social Work, Montreal, Quebec H3A 1B9, Canada
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3
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Chama J, Adebiyi R, Volpi C, Ononaku U, Maigida J, Aka A, Katu C, Shutt A, Charurat M, Adebajo S, Nowak RG. Brief Report: Prevalence and Predictors of Concern About Anal Cancer Among Sexual and Gender Minorites Living With HIV in Abuja, Nigeria. J Acquir Immune Defic Syndr 2023; 93:313-318. [PMID: 37018922 PMCID: PMC10330150 DOI: 10.1097/qai.0000000000003206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Anal cancer rates are rising among sexual and gender minorities (SGM) who live with HIV and engage in anal sex. Given that secondary cancer prevention programs for nonanal cancers are underutilized in sub-Saharan Africa, our objective was to assess concerns for anal cancer and hesitancy with cancer prevention among at-risk Nigerian SGM. METHODS Within 4 weeks, SGM living with HIV were surveyed on levels of worry and hesitancy in engaging with a future anal cancer screening and treatment study. Worry was measured on a 5-point Likert scale (0%, 25%, 50%, 75%, 100%) and categorized as low ≤25%, moderate 50%, and high ≥75%. Ordinal logistic regression identified factors associated with worry by estimating unadjusted and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). RESULTS Of 800 enrolled SGM, median age was 32 (interquartile range: 25-38) years, 99.2% were on antiretroviral therapy, of which 78.5% reported ≥95% pill adherence. The prevalence of moderate and high worry was 46.9% and 39.5%, respectively. Increasing worry was associated with reporting as a bottom for sexual position (aOR: 3.12; 95% CI: 2.04 to 4.80), top or bottom for sexual position (aOR: 2.94; 95% CI: 1.92 to 4.52), or knowing anyone with anal cancer (aOR: 2.99; 95% CI: 1.36 to 6.57). Participants aged ≥35 years were less worried (aOR: 0.72; 95% CI: 0.59 to 0.95). Ninety-nine percent of participants provided contact information for a future cancer prevention study. DISCUSSION SGM who heard about and engaged in at-risk practices for anal cancer were willing to access secondary prevention. Addressing biopsychosocial factors such as age could foster future engagement.
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Affiliation(s)
- John Chama
- Center for International Health Education Biosecurity, University of Maryland Baltimore, Abuja, Nigeria
| | - Ruxton Adebiyi
- Center for International Health Education Biosecurity, University of Maryland Baltimore, Abuja, Nigeria
| | - Connor Volpi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Uche Ononaku
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | - John Maigida
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Abayomi Aka
- International Centre for Advocacy on Right to Health, Abuja Nigeria
| | | | - Ashley Shutt
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Man Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sylvia Adebajo
- Center for International Health Education Biosecurity, University of Maryland Baltimore, Abuja, Nigeria
| | - Rebecca G. Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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4
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Earnshaw VA, Cox J, Wong PL, Saifi R, Walters S, Azwa I, Omar SFS, Collier ZK, Hassan AA, Lim SH, Wickersham J, Haddad MS, Kamarulzaman A. "I want the doctors to know that I am as bright as a candle": : Experiences with and Hopes for Doctor Interactions Among Malaysian Key Populations and People Living with HIV. AIDS Behav 2022; 27:2103-2112. [PMID: 36472685 PMCID: PMC9734400 DOI: 10.1007/s10461-022-03942-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/12/2022]
Abstract
Stigma in healthcare settings is a pernicious barrier to HIV prevention and treatment in contexts with strong HIV-related structural stigma. Previous work has documented substantial stigma towards key populations and people living with HIV (PLWH) among Malaysian doctors. The perspectives of Malaysian key populations and PLWH, however, remain understudied. In 2021, 34 Malaysian participants representing key populations and PLWH engaged in a photovoice study designed to qualitatively explore their experiences with and hopes for doctor interactions. Many participants reported stigma from their doctors, perceiving that doctors view them as not normal, sinful, misguided, and incapable. Several emphasized that they wear figurative masks to conceal aspects of themselves from doctors. Yet, many also remain hopeful for constructive relationships with doctors. They want their doctors to know that they are bright, capable, kind, and valuable. Interventions are needed to address stigma among doctors working in contexts with strong structural stigma.
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Affiliation(s)
- Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, 111 Alison Hall West, Newark, DE, 19716, USA.
| | - Jon Cox
- Department of Art and Design, University of Delaware, Newark, DE, USA
| | - Pui Li Wong
- Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Rumana Saifi
- Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Centre of Excellence for Research in AIDS, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Suzan Walters
- School of Global Public Health, New York University, New York, NY, USA
| | - Iskandar Azwa
- Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | | | - Asfarina Amir Hassan
- Centre of Excellence for Research in AIDS, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Sin How Lim
- Department of Social and Preventive Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | | | - Marwan S Haddad
- Center for Key Populations, Community Health Center, Inc, New Britain, CT, USA
| | - Adeeba Kamarulzaman
- Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- Centre of Excellence for Research in AIDS, Universiti Malaya, Kuala Lumpur, Malaysia
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Adamson T, Lett E, Glick J, Garrison-Desany HM, Restar A. Experiences of violence and discrimination among LGBTQ+ individuals during the COVID-19 pandemic: a global cross-sectional analysis. BMJ Glob Health 2022; 7:bmjgh-2022-009400. [PMID: 36130772 PMCID: PMC9494011 DOI: 10.1136/bmjgh-2022-009400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives To characterise the extent to which the levels of violence and discrimination against lesbian, gay, bisexual, transgender and queer (LGBTQ+) people have changed amid COVID-19. Design Cross-sectional, secondary analysis. Setting 79 countries. Participants All adults (aged ≥18 years) who used the Hornet social networking application and provided consent to participate. Main outcome measure The main outcome was whether individuals have experienced less, or the same or more levels of discrimination and violence from specific groups (eg, police and/or military, government representatives, healthcare providers). Results 7758 LGBTQ+ individuals provided responses regarding levels of discrimination and violence. A majority identified as gay (78.95%) and cisgender (94.8%). Identifying as gay or queer was associated with increased odds of experiencing the same or more discrimination from government representatives (OR=1.89, 95% CI 1.04 to 3.45, p=0.045) and healthcare providers (OR=2.51, 95% CI 0.86 to 7.36, p=0.002) due to COVID-19. Being a member of an ethnic minority was associated with increased odds of discrimination and violence from police and/or military (OR=1.32, 95% CI 1.13 to 1.54, p=0.0) and government representatives (OR=1.47, 95% CI 1.29 to 1.69, p=0.0) since COVID-19. Having a disability was significantly associated with increased odds of violence and discrimination from police and/or military (OR=1.38, 95% CI 1.15 to 1.71, p=0.0) and healthcare providers (OR=1.35, 95% CI 1.07 to 1.71, p=0.009). Conclusions Our results suggest that despite the upending nature of the COVID-19 pandemic, around the world, government representatives, policymakers and healthcare providers continue to perpetuate systemic discrimination and fail to prevent violence against members of the LGBTQ+ community.
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Affiliation(s)
- Tyler Adamson
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elle Lett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Applied Transgender Studies, Chicago, Illinois, USA
| | - Jennifer Glick
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Henri M Garrison-Desany
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Arjee Restar
- Center for Applied Transgender Studies, Chicago, Illinois, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
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6
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LeeVan E, Hu F, Mitchell AB, Kokogho A, Adebajo S, Garges EC, Qian H, Ake JA, Robb ML, Charurat ME, Baral SD, Nowak RG, Crowell TA. Associations of gender identity with sexual behaviours, social stigma and sexually transmitted infections among adults who have sex with men in Abuja and Lagos, Nigeria. J Int AIDS Soc 2022; 25:e25956. [PMID: 35794838 PMCID: PMC9259961 DOI: 10.1002/jia2.25956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Sexual and gender minority populations are disproportionately affected by the global syndemic of HIV and other sexually transmitted infections (STIs). We hypothesized that transgender women (TGW) and non‐binary individuals in Nigeria have more STIs than cis‐gender men who have sex with men (cis‐MSM), and that experiences of stigma and sexual practices differ between these three groups. Methods From 2013 to 2020, TRUST/RV368 enrolled adults assigned male sex at birth who reported anal sex with men in Abuja and Lagos, Nigeria. Participants were tested for STIs and completed questionnaires about sexual behaviours and social stigma every 3 months. Participants were categorized as cis‐MSM, TGW or non‐binary/other based on self‐reported gender identity. Gender group comparisons were made of HIV, gonorrhoea and chlamydia prevalence and incidence; stigma indicators; and condom use during anal sex. Results Among 2795 participants, there were 2260 (80.8%) cis‐MSM, 284 (10.2%) TGW and 251 (9.0%) non‐binary/other individuals with median age of 23 years (interquartile range 20–27). HIV prevalence among cis‐MSM, TGW and non‐binary/other participants was 40.8%, 51.5% and 47.6%, respectively (p = 0.002). HIV incidence was 8.7 cases per 100 person‐years (PY) (95% confidence interval [CI] 6.9–10.8), 13.1 cases/100 PY (95% CI 6.5–23.4) and 17.6 cases/100 PY (95% CI 9.8–29.0, p = 0.025), respectively. Anorectal gonorrhoea incidence was lower in cis‐MSM than TGW (22.2 [95% CI 19.6–25.0] vs. 35.9 [95% CI 27.3–46.3]). TGW were more likely than cis‐MSM to report being affected by stigma, including assault (47.2% vs. 32.3%), fear of walking around (32.4% vs. 19.2%) and healthcare avoidance (25.0% vs. 19.1%; all p < 0.05). TGW were more likely to report always using condoms than non‐binary/other individuals (35.3% vs. 26.2%, p = 0.041) during receptive anal sex. Conclusions Sexual and gender minorities in Nigeria have heterogeneous sexual behaviours and experiences of social stigma that may influence the vulnerability to HIV and other STIs. There is a need for tailored interventions that acknowledge and are informed by gender. Further research is needed, particularly among understudied non‐binary individuals, to better understand disparities and inform tailored interventions to improve outcomes among these communities.
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Affiliation(s)
- Elyse LeeVan
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Fengming Hu
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | | | | | - Sylvia Adebajo
- Center for International Health and Biosecurity (Ciheb)AbujaNigeria
| | - Eric C. Garges
- Department of Preventive Medicine and BiostaticsUniformed Services UniversityBethesdaMarylandUSA
| | - Haoyu Qian
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | - Julie A. Ake
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
| | - Merlin L. Robb
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | | | - Stefan D. Baral
- Johns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Rebecca G. Nowak
- Institute of Human VirologyUniversity of MarylandBaltimoreMarylandUSA
| | - Trevor A. Crowell
- U.S. Military HIV Research ProgramWalter Reed Army Institute of ResearchSilver SpringMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
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Adamson T, Hanley M, Baral S, Beyrer C, Wallach S, Howell S. Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study. BMJ Open 2022; 12:e041896. [PMID: 35414537 PMCID: PMC9006192 DOI: 10.1136/bmjopen-2020-041896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight. METHODS In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare. RESULTS 5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money. CONCLUSION Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.
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Affiliation(s)
- Tyler Adamson
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | | | - Stefan Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Chris Beyrer
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Sara Wallach
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins University School of Public Health, Baltimore, Maryland, USA
| | - Sean Howell
- LGBT Foundation, San Francisco, California, USA
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8
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Geng EH, Nash D, Phanuphak N, Green K, Solomon S, Grimsrud A, Sohn AH, Mayer KH, Bärnighausen T, Bekker LG. The question of the question: impactful implementation science to address the HIV epidemic. J Int AIDS Soc 2022; 25:e25898. [PMID: 35384312 PMCID: PMC8982316 DOI: 10.1002/jia2.25898] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 02/18/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Questions about the implementation of evidence-based intervention to treat and prevent HIV have risen to the top of the field's scientific priorities. Despite the availability of highly efficacious treatment and prevention interventions, impact has fallen short of targets because these interventions are used with insufficient reach, consistency, sustainability and equity in diverse real-world settings. At present, substantial excitement for implementation science - defined as research methods and strategies to improve use of evidence-based interventions - has focused on developing and disseminating methods to conduct rigorous research. Yet, impactful answers depend on a sometimes less visible, but even more important, step: asking good questions about implementation. DISCUSSION In this commentary, we offer several considerations for researchers formulating implementation research questions based on several distinctive features of the field. First, as findings are used not only by other researchers but by implementers, scientific questions must incorporate a range of stakeholder and community perspectives to be most relevant. Second, real-world settings are contextually diverse, and the most relevant scientific questions must position answers to make sense within these contexts (whether geographical, organizational and sociological), rather than apart from them. Third, implementation is complex and dynamic; consequently, research questions must make use of emerging standards in describing implementation strategies and their effects whenever possible. Finally, the field of implementation science continues to evolve, so framing problems with a diverse disciplinary lens will enable researchers to pose insightful and impactful questions. CONCLUSIONS We are now at a juncture marked by both rich evidence-based interventions and a persistent global pandemic. To achieve continued scientific progress against the HIV epidemic, asking the right questions might be part of the answer itself.
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Affiliation(s)
- Elvin H Geng
- Center for Dissemination and Implementation, Institute of Public Health, Division of Infectious Diseases, Department of Medicine, School of Medicine at Washington University in St. Louis, St. Louis, Missouri, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, USA.,Department of Epidemiology and Biostatistics, Graduate School of Public Health, City University of New York, New York, USA
| | | | | | - Sunil Solomon
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Kenneth H Mayer
- The Fenway Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg, Germany
| | - Linda-Gail Bekker
- Institute of Infectious Disease and Molecular Medicine, Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
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9
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Stierman EK, Kalbarczyk A, Oo HNL, Koller TS, Peters DH. Assessing Barriers to Effective Coverage of Health Services for Adolescents in Low- and Middle-Income Countries: A Scoping Review. J Adolesc Health 2021; 69:541-548. [PMID: 33712382 PMCID: PMC8442758 DOI: 10.1016/j.jadohealth.2020.12.135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/15/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Understanding barriers to health services, as experienced by adolescents, is important to expand effective and equitable coverage; however, there is limited discussion on methods for conducting barrier assessments and translating findings into action. METHODS We conducted a scoping review of literature published between 2005 and 2019 on barriers to health services for adolescents in low- and middle-income countries. The review was guided by a framework that conceptualized barriers across multiple dimensions of access (availability, geographic accessibility, affordability, and acceptability), utilization, and effective coverage. RESULTS We identified 339 studies that assessed barriers related to at least one dimension of the operational framework. Acceptability (93%) and availability (88%) of health services were the most frequently studied access dimensions; affordability (45%) and geographic access (32%) were studied less frequently. Less than half (40%) of the studies evaluated utilization, and none of the 339 studies assessed effective coverage. Attention to equity stratifiers (e.g., income, disability) was limited. Topics studied reflected only a subset of the major causes of adolescent death and disability. CONCLUSIONS Holistic, equity-oriented approaches are needed to better understand barriers across multiple dimensions that together determine whether health services are accessible, used, and effectively meet the needs of different adolescent groups.
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Affiliation(s)
- Elizabeth K. Stierman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland,Address correspondence to: Elizabeth K. Stierman, M.P.H., Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205.
| | - Anna Kalbarczyk
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Htet Nay Lin Oo
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Theadora Swift Koller
- Gender, Equity and Human Rights Team, World Health Organization, Geneva, Switzerland
| | - David H. Peters
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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10
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Jin H, Restar A, Beyrer C. Overview of the epidemiological conditions of HIV among key populations in Africa. J Int AIDS Soc 2021; 24 Suppl 3:e25716. [PMID: 34190412 PMCID: PMC8242974 DOI: 10.1002/jia2.25716] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Despite extraordinary progress in HIV treatment coverage and expanding access to HIV prevention services and that multiple African countries are on track in their efforts to reach 90-90-90 goals, the epidemic continues to persist, with prevalence and incidence rates too high in some parts of the continent to achieve epidemic control. While data sources are improving, and research studies on key populations in specific contexts have improved, work on understanding the HIV burdens and barriers to services for these populations remains sparse, uneven and absent altogether in multiple settings. More data have become available in the last several years, and data published in 2010 or more recently are reviewed here for each key population. This scoping review assesses the current epidemiology of HIV among key populations in Africa and the social and political environments that contribute to the epidemic, both of which suggest that without significant policy reform, these epidemics will likely continue. RESULTS AND DISCUSSION Across Africa, the HIV epidemic is most severe among key populations including women and men who sell or trade sex, men who have sex with men, people who inject drugs, transgender women who have sex with men and prisoners and detainees. These groups account for the majority of new infections in West and Central Africa, and an estimated 25% of new infections in East and Southern Africa, despite representing relatively small proportions of those populations. The HIV literature in Africa emphasizes that despite significant health needs, key populations experience barriers to accessing services within the healthcare and legal justice systems. Current shortcomings of surveillance systems in enumerating key populations impact the way funding mechanisms and resources are allocated and distributed. Adapting more equitable and epidemiologically sound frameworks will be necessary for current and future HIV programming investments. CONCLUSIONS Through this review, the available literature on HIV epidemiology among key populations in Africa brings to light a number of surveillance, programmatic and research gaps. For many communities, interventions targeting the health and security conditions continue to be minimal. Compelling evidence suggests that sweeping policy and programmatic changes are needed to effectively tackle the persistent HIV epidemic in Africa.
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Affiliation(s)
- Harry Jin
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public Health
| | - Arjee Restar
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public Health
| | - Chris Beyrer
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public Health
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11
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Kokogho A, Amusu S, Baral SD, Charurat ME, Adebajo S, Makanjuola O, Tonwe V, Storme C, Michael NL, Robb ML, Ake JA, Nowak RG, Crowell TA. Disclosure of Same-Sex Sexual Practices to Family and Healthcare Providers by Men Who Have Sex with Men and Transgender Women in Nigeria. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:1665-1676. [PMID: 32193812 PMCID: PMC8017753 DOI: 10.1007/s10508-020-01644-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 06/10/2023]
Abstract
Disclosure of same-sex sexual practices by men who have sex with men (MSM) and transgender women (TGW) may facilitate appropriate healthcare engagement, including risk assessment for HIV and other sexually transmitted infections (STIs), and negotiation of condom use with partners. However, disclosure may also generate stigma. In these cross-sectional analyses, MSM and TGW were categorized based on self-report of disclosure to family members and healthcare providers (HCP) at enrollment into the TRUST/RV368 study of comprehensive HIV and STI care programs in Abuja and Lagos, Nigeria. Multivariable Poisson regression models with robust error variance were used to estimate relative risk of disclosure with 95% confidence intervals. Pearson's chi-squared test was used to compare condom use and stigma indicators by disclosure status. Of 2557 participants who answered baseline questions about disclosure, 384 (15.0%) had ever disclosed to a family member and 733 (28.7%) to HCP, including 192 (7.5%) who disclosed to both. Higher education, prevalent HIV infections, and residence in Lagos were each associated with increased likelihood of disclosure to family and HCP. Older participants were more likely to disclose to HCP but not family. Participants who made a disclosure to family or HCP were more likely to report condom use during anal sex as well as perceived and experienced stigma that included healthcare avoidance, blackmail, assault, and sexual violence as compared to participants who had not disclosed. Improved disclosure practices within safe spaces may enhance engagement of MSM and TGW in healthcare and HIV prevention services.
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Affiliation(s)
- Afoke Kokogho
- U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- HJF Medical Research International, Abuja, Nigeria
| | - Senate Amusu
- U.S. Army Medical Research Directorate-Africa, Nairobi, Kenya
- HJF Medical Research International, Abuja, Nigeria
| | - Stefan D Baral
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | - Veronica Tonwe
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Casey Storme
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Nelson L Michael
- Center for Infectious Disease Research, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Merlin L Robb
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Julie A Ake
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Rebecca G Nowak
- Institute of Human Virology, University of Maryland, Baltimore, MD, USA
| | - Trevor A Crowell
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, 20817, USA.
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.
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Gu LY, Zhang N, Mayer KH, McMahon JM, Nam S, Conserve DF, Moskow M, Brasch J, Adu-Sarkodie Y, Agyarko-Poku T, Boakye F, Nelson LE. Autonomy-Supportive Healthcare Climate and HIV-Related Stigma Predict Linkage to HIV Care in Men Who Have Sex With Men in Ghana, West Africa. J Int Assoc Provid AIDS Care 2021; 20:2325958220978113. [PMID: 33733909 PMCID: PMC7983411 DOI: 10.1177/2325958220978113] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM (N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate (OR = 1.63, p < .01), vicarious HIV stigma (OR = 2.73, p < .01), and age (OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC (OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.
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Affiliation(s)
- Lily Y. Gu
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Nanhua Zhang
- Division of Biostatistics and Bioinformatics, Department of Environmental Health, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | | | | | - Soohyun Nam
- School of Nursing, Yale University, New Haven, CT, USA
| | - Donaldson F. Conserve
- Milken Institute School of Public Health, George Washington University, Washington DC, USA
| | - Marian Moskow
- School of Nursing, University of Rochester, Rochester, NY, USA
| | - Judith Brasch
- School of Nursing, University of Rochester, Rochester, NY, USA
| | - Yaw Adu-Sarkodie
- School of Medical Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | - Thomas Agyarko-Poku
- School of Medical Sciences, Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | | | - LaRon E. Nelson
- School of Nursing, Yale University, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
- Yale Institute of Global Health, Yale University, New Haven, CT, USA
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
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13
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Sekoni AO, Jolly K, Gale NK. Hidden healthcare populations: using intersectionality to theorise the experiences of LGBT+ people in Nigeria, Africa. Glob Public Health 2020; 17:134-149. [PMID: 33287671 DOI: 10.1080/17441692.2020.1849351] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Minority population groups are often excluded or marginalised within health systems and in health research and policy. This article argues that theories of intersectionality can help us to understand these issues and develops the concept of 'hidden healthcare populations' - using the case of people who identify as Lesbian, Gay, Bisexual, Transgender Plus (LGBT+) in Nigeria, in sub-Saharan Africa. The findings present original qualitative data from a seldom heard population group about instances of abuse, rejection and marginalisation by healthcare providers working in public and private healthcare facilities, and the attempts of LGBT+ people to resist and survive in that context. We extend theoretical understandings of intersectionality in global public health and explore how the concept relates to the social determinants of health. The article has significant implications for policy and healthcare education and responds to a call from the World Health Organisation to generate context-specific data to guide interventions targeted at minority population groups. Additionally, our discussion has wider significance because it highlights the Western-centric nature of much theory in health policy - and offers analysis and reinterpretation that incorporates queer, postcolonial, African perspectives.
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Affiliation(s)
| | - Kate Jolly
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Nicola Kay Gale
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, UK
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14
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HIV status disclosure by Nigerian men who have sex with men and transgender women living with HIV: a cross-sectional analysis at enrollment into an observational cohort. BMC Public Health 2020; 20:1282. [PMID: 32842997 PMCID: PMC7448976 DOI: 10.1186/s12889-020-09315-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background Men who have sex with men (MSM) and transgender women (TGW) are disproportionately impacted by HIV and may face barriers to HIV status disclosure with negative ramifications for HIV prevention and care. We evaluated HIV status disclosure to sexual partners, HIV treatment outcomes, and stigma patterns of MSM and TGW in Abuja and Lagos, Nigeria. Methods Previously-diagnosed MSM and TGW living with HIV who enrolled in the TRUST/RV368 cohort from March 2013 to August 2018 were asked, “Have you told your (male/female) sexual partners (MSP/FSP) that you are living with HIV?” In separate analyses, robust Poisson regression models were used to estimate risk ratios (RRs) and 95% confidence intervals (95% CIs) for characteristics associated with HIV status disclosure to MSP and FSP. Self-reported stigma indicators were compared between groups. Results Of 493 participants living with HIV, 153 (31.0%) had disclosed their HIV status to some or all MSP since being diagnosed. Among 222 with FSP, 34 (15.3%) had disclosed to some or all FSP. Factors independently associated with disclosure to MSP included living in Lagos (RR 1.58 [95% CI 1.14–2.20]) and having viral load < 50 copies/mL (RR 1.67 [95% CI 1.24–2.25]). Disclosure to FSP was more common among participants who were working in entertainment industries (RR 6.25 [95% CI 1.06–36.84]) or as drivers/laborers (RR 6.66 [95% CI 1.10–40.36], as compared to unemployed) and also among those married/cohabiting (RR 3.95 [95% CI 1.97–7.91], as compared to single) and prescribed ART (RR 2.27 [95% CI 1.07–4.83]). No differences in self-reported stigma indicators were observed by disclosure status to MSP but disclosure to FSP was associated with a lower likelihood of ever having been assaulted (26.5% versus 45.2%, p = 0.042). Conclusions HIV status disclosure to sexual partners was uncommon among Nigerian MSM and TGW living with HIV but was associated with improved HIV care outcomes. Disclosure was not associated with substantially increased experiences of stigma. Strategies to encourage HIV status disclosure may improve HIV management outcomes in these highly-marginalized populations with a high burden of HIV infection.
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15
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Kerani RP, Satcher Johnson A, Buskin SE, Rao D, Golden MR, Hu X, Hall HI. The Epidemiology of HIV Among People Born Outside the United States, 2010-2017. Public Health Rep 2020; 135:611-620. [PMID: 32805191 DOI: 10.1177/0033354920942623] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Although some studies have reported a higher incidence of HIV infection among non-US-born people than among US-born people, national data on this topic are scarce. We compared the epidemiology of HIV infection between US-born and non-US-born residents of the United States and examined the characteristics of non-US-born people with diagnosed HIV infection by region of birth (ROB). METHODS We used a cross-sectional study design to produce national, population-based data describing HIV infection among US-born and non-US-born people. We analyzed National HIV Surveillance System data for people with HIV infection diagnosed during 2010-2017 and reported to the Centers for Disease Control and Prevention (CDC). We compared data on demographic characteristics, transmission risk category, and stage 3 infection (AIDS) classification within 3 months of HIV diagnosis, by nativity and ROB. RESULTS During 2010-2017, 328 317 children and adult US residents were diagnosed with HIV infection and were reported to CDC: 214 973 (65.5%) were US-born, 50 301 (15.3%) were non-US-born, and 63 043 (19.2%) were missing data on country of birth. After adjusting for missing country of birth, 266 147 (81.1%) people were US-born and 62 170 (18.9%) were non-US-born. This group accounted for 15 928 of 65 645 (24.2%) HIV diagnoses among girls and women and 46 242 of 262 672 (17.6%) HIV diagnoses among boys and men. A larger percentage of non-US-born people than US-born people had stage 3 infection (AIDS) at HIV diagnosis (31.2% vs 23.9%). Among non-US-born people with HIV diagnoses, 19 876 (39.5%) resided in the South. CONCLUSIONS Characterizing non-US-born people with HIV infection is essential for developing effective HIV interventions, particularly in areas with large immigrant populations.
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Affiliation(s)
- Roxanne P Kerani
- 7284 Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle, WA, USA.,7285 HIV/STD Program, Public Health-Seattle and King County, Seattle, WA, USA.,7284 Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Anna Satcher Johnson
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Susan E Buskin
- 7285 HIV/STD Program, Public Health-Seattle and King County, Seattle, WA, USA.,7284 Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Deepa Rao
- 7284 Department of Global Health, University of Washington, Seattle, WA, USA
| | - Matthew R Golden
- 7284 Division of Allergy and Infectious Disease, Department of Medicine, University of Washington, Seattle, WA, USA.,7285 HIV/STD Program, Public Health-Seattle and King County, Seattle, WA, USA.,7284 Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Xiaohong Hu
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - H Irene Hall
- Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
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16
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Mmbaga EJ, Leyna GH, Leshabari MT, Moen K. Early Anal Sex Experience Among Men Who Have Sex with Men in Dar Es Salaam Tanzania: Implications for HIV Prevention and Care. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:2045-2055. [PMID: 31872388 DOI: 10.1007/s10508-019-01529-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 07/15/2019] [Accepted: 07/25/2019] [Indexed: 06/10/2023]
Abstract
Early age at first sex experience has been attributed to medical and psychological consequences, including practice of risk behaviors and HIV infection later in life. Studies have examined early heterosexual experience, but little is known about early anal sexual experience among men who have sex with men (MSM) in Africa. We conducted a time to event analysis to examine the extent and role of early anal sexual experience and HIV risk and infection in the largest MSM survey in Africa. A total of 753 MSM with a mean age of 26.5 years and that at first anal sexual experience of 18.3 years participated. Of those who participated, 29.0% (219/753) had their first anal sexual experience at age below 15. MSM reporting early anal sexual experience were young, had men as first sexual partner (adjusted hazard ratio-AHR, 4.75; 95%CI: 3.51-6.43), assumed receptive position during last anal sex (AHR, 3.25; 95%CI: 2.42-4.35), had anal sex as first penetrative sexual experience (AHR, 5.05, 95%CI; 3.68-6.97), had unprotected first anal sex (AHR, 1.55, 95%CI: 1.03-2.33), not preferring women for sex (AHR, 2.78; 95%CI: 2.11-3.67), had non-consensual first sex (AHR, 1.53, 95%CI: 1.10-9.41), and HIV positive (AHR, 1.75; 95%CI: 1.21-2.50). A third of MSM engaged in anal sex at an early age and were more likely to report sexual abuse, practice HIV risk behaviors, and been HIV seropositive. Roll-out of the existing Comprehensive Guideline for HIV Treatment and Care for key population in Tanzania should be implemented alongside measures addressing sexual abuse among young people.
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Affiliation(s)
- Elia John Mmbaga
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway.
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, 9 United Nation Road, P.O.Box 65015, Dar es Salaam, Tanzania.
| | - Germana Henry Leyna
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, 9 United Nation Road, P.O.Box 65015, Dar es Salaam, Tanzania
| | | | - Kåre Moen
- Department of Community Medicine and Global Health, Institute of Health and Society, University of Oslo, Oslo, Norway
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17
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Mbeda C, Ogendo A, Lando R, Schnabel D, Gust DA, Guo X, Akelo V, Dominguez K, Panchia R, Mbilizi Y, Chen Y, Chege W. Healthcare-related stigma among men who have sex with men and transgender women in sub-Saharan Africa participating in HIV Prevention Trials Network (HPTN) 075 study. AIDS Care 2020; 32:1052-1060. [PMID: 32500722 DOI: 10.1080/09540121.2020.1776824] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
ABSTRACT The inability to access health services when needed is a critical barrier to HIV prevention, treatment and care among men who have sex with men (MSM) and transgender women (TGW). Using data collected in HPTN 075, we explored factors associated with any experienced healthcare-related stigma. HPTN 075 was a cohort study to assess the feasibility of recruiting and retaining MSM and TGW in clinical trials in sub-Saharan Africa. Of 401 MSM and TGW enrolled at four sites (Kisumu, Kenya; Blantyre, Malawi; Cape Town, Soweto, South Africa) 397 contributed to the analysis (79.9% cis-gender and 20.1% TGW). Of these, (45.3%; 180/397) reported one or more of healthcare-related stigma experiences. Most frequently reported experiences included fear to seek healthcare services (36.3%) and avoiding seeking such services because of the discovery of MSM status (29.2%). Few men and TGW (2.5%) reported having been denied health services because of having sex with men. In multivariable analysis, more participants in Soweto [adjusted odds ratio (AOR) = 2.60] and fewer participants in Blantyre (AOR = 0.27) reported any healthcare-related stigma experiences, in comparison to participants in Kisumu. MSM and TGW that did not have a supportive gay community to rely on were more likely to report any healthcare-related stigma experiences (AOR = 1.46), whereas MSM and TGW who reported high social support and who never had engaged in transactional sex were less likely to report such experiences (AOR = 0.76 and AOR = 0.43, respectively). Our results suggest that encouraging support groups for MSM and TGW as well as training and sensitizing healthcare staff, and the general community, on MSM and TGW health issues and cultural competence may reduce stigma, improve access to healthcare, which could ultimately reduce HIV transmission.
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Affiliation(s)
| | | | | | - David Schnabel
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Deborah A Gust
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Xu Guo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Victor Akelo
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Ravindre Panchia
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Yamikani Mbilizi
- Malawi College of Medicine - Johns Hopkins University Research Project, Blantyre, Malawi
| | - Ying Chen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Wairimu Chege
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
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- Columbia University and New York State Psychiatric Institute, New York, NY, USA
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18
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Affiliation(s)
- Chris Beyrer
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Medicine, Baltimore, MD 21205, USA.
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19
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Smith MK, Wei C, Liu C, Pan SW, Ong JJ, Tucker JD. Gender Identity and Sexual Orientation in Chinese Men Who Have Sex with Men: A Latent Class Analysis. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:721-731. [PMID: 31571020 PMCID: PMC7035172 DOI: 10.1007/s10508-019-01481-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 05/24/2019] [Accepted: 06/01/2019] [Indexed: 06/10/2023]
Abstract
Men who have sex with men (MSM) are a diverse population yet are often treated as a monolithic risk group. In China, MSM have long been characterized as a "bridge population" of closeted men who are married to (or will marry) women due to sociocultural expectations. Latent class models can inform a more nuanced yet empirical characterization of this population. In total, 1424 eligible respondents recruited online provided self-reported behavioral data. Nine items related to constructs including sexual behaviors, sexual orientation, and gender identity informed the latent class model. Logistic regression was used to measure associations between latent class membership and HIV-related sexual and health-seeking behaviors. Model fit indicated a population structure made up of four classes that we characterized as "Gender nonconforming" (4.3%), "Closeted-unmarried" (29.9%), "Closeted-married" (24.6%), and "Out" (41.2%). Members of the "gender nonconforming" class were more likely to report HIV-related risk behaviors, and "Closeted-unmarried" class members were less likely to report health-seeking behaviors, both relative to "Out" members. The largest latent class was made up of members of the "Out" class, an enlightening revision of a population traditionally viewed as largely closeted men. Two types of "closeted" classes emerged, distinguished by divergent tendencies regarding marriage and health seeking. Findings suggest that current understandings of Chinese MSM are simplistic (regarding closeted behaviors) and too narrow (in its definition of MSM as cisgender men). A more nuanced understanding of MSM subgroups and their heterogeneous risk behaviors will be critical for provision of more meaningful prevention services.
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Affiliation(s)
- M Kumi Smith
- Division of Epidemiology and Community Health, University of Minnesota Twin Cities, 1300 South 2nd St., Suite 300, Minneapolis, MN, 55454, USA.
- University of North Carolina Project-China, Guangzhou, China.
| | - Chongyi Wei
- University of North Carolina Project-China, Guangzhou, China
- Center for Health, Identity, Behavior and Prevention Studies, Rutgers University, New Brunswick, NJ, USA
| | - Chuncheng Liu
- University of North Carolina Project-China, Guangzhou, China
- Department of Sociology, University of California San Diego, San Diego, CA, USA
| | - Stephen W Pan
- University of North Carolina Project-China, Guangzhou, China
- Xi'an Jiatong-Liverpool University, Suzhou, China
| | - Jason J Ong
- University of North Carolina Project-China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, England, UK
| | - Joseph D Tucker
- University of North Carolina Project-China, Guangzhou, China
- Department of Medicine, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
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20
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Dick S, O’Connor Y, Heavin C. Approaches to Mobile Health Evaluation: A Comparative Study. INFORMATION SYSTEMS MANAGEMENT 2019. [DOI: 10.1080/10580530.2020.1696550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Samantha Dick
- Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland
| | - Yvonne O’Connor
- Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland
| | - Ciara Heavin
- Business Information Systems, Cork University Business School, University College Cork, Cork, Ireland
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21
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Krieger N. Measures of Racism, Sexism, Heterosexism, and Gender Binarism for Health Equity Research: From Structural Injustice to Embodied Harm-An Ecosocial Analysis. Annu Rev Public Health 2019; 41:37-62. [PMID: 31765272 DOI: 10.1146/annurev-publhealth-040119-094017] [Citation(s) in RCA: 180] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Racism. Sexism. Heterosexism. Gender binarism. Together, they comprise intimately harmful, distinct, and entangled societal systems of self-serving domination and privilege that structure the embodiment of health inequities. Guided by the ecosocial theory of disease distribution, I synthesize key features of the specified "isms" and provide a measurement schema, informed by research from both the Global North and the Global South. Metrics discussed include (a) structural, including explicit rules and laws, nonexplicit rules and laws, and area-based or institutional nonrule measures; and (b) individual-level (exposures and internalized) measures, including explicit self-report, implicit, and experimental. Recommendations include (a) expanding the use of structural measures to extend beyond the current primary emphasis on psychosocial individual-level measures; (b) analyzing exposure in relation to both life course and historical generation; (c) developing measures of anti-isms; and (d) developing terrestrially grounded measures that can reveal links between the structural drivers of unjust isms and their toll on environmental degradation, climate change, and health inequities.
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Affiliation(s)
- Nancy Krieger
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA;
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22
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German D, Grabowski MK, Beyrer C. Enhanced use of phylogenetic data to inform public health approaches to HIV among men who have sex with men. Sex Health 2019; 14:89-96. [PMID: 27584826 DOI: 10.1071/sh16056] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 07/29/2016] [Indexed: 12/14/2022]
Abstract
The multidimensional nature and continued evolution of HIV epidemics among men who have sex with men (MSM) requires innovative intervention approaches. Strategies are needed that recognise the individual, social and structural factors driving HIV transmission; that can pinpoint networks with heightened transmission risk; and that can help target intervention in real time. HIV phylogenetics is a rapidly evolving field with strong promise for informing innovative responses to the HIV epidemic among MSM. Currently, HIV phylogenetic insights are providing new understandings of characteristics of HIV epidemics involving MSM, social networks influencing transmission, characteristics of HIV transmission clusters involving MSM, targets for antiretroviral and other prevention strategies and dynamics of emergent epidemics. Maximising the potential of HIV phylogenetics for HIV responses among MSM will require attention to key methodological challenges and ethical considerations, as well as resolving key implementation and scientific questions. Enhanced and integrated use of HIV surveillance, sociobehavioural and phylogenetic data resources are becoming increasingly critical for informing public health approaches to HIV among MSM.
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Affiliation(s)
- Danielle German
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624N. Broadway, Baltimore, MD 21205, USA
| | - Mary Kate Grabowski
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624N. Broadway, Baltimore, MD 21205, USA
| | - Chris Beyrer
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 624N. Broadway, Baltimore, MD 21205, USA
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Kemp CG, Jarrett BA, Kwon CS, Song L, Jetté N, Sapag JC, Bass J, Murray L, Rao D, Baral S. Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review. BMC Med 2019; 17:6. [PMID: 30764820 PMCID: PMC6376798 DOI: 10.1186/s12916-018-1237-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions. METHODS PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR). RESULTS A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven. CONCLUSION Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.
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Affiliation(s)
| | - Brooke A. Jarrett
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD USA
| | - Churl-Su Kwon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY USA
| | - Lanxin Song
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD USA
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY USA
| | - Jaime C. Sapag
- Departments of Public Health and Family Medicine, School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Office of Transformative Global Health, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON Canada
| | - Judith Bass
- Department of Mental Health, Johns Hopkins University, Baltimore, MD USA
| | - Laura Murray
- Department of Mental Health, Johns Hopkins University, Baltimore, MD USA
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD USA
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McKenzie KC, Bauer J, Reynolds PP. Asylum Seekers in a Time of Record Forced Global Displacement: the Role of Physicians. J Gen Intern Med 2019; 34:137-143. [PMID: 29907914 PMCID: PMC6318190 DOI: 10.1007/s11606-018-4524-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 01/23/2018] [Accepted: 05/11/2018] [Indexed: 10/28/2022]
Abstract
In 2016, over 65 million individuals were displaced from their homes due to human rights abuses, and 262,000 people applied for asylum in the USA. Individuals who have experienced persecution are present in many primary and specialty clinics. A medical forensic evaluation can increase the likelihood of a successful asylum case. This paper reviews the legal framework for asylum and the contribution forensic evaluations can make to this vulnerable population. Physicians without asylum expertise can help these patients by recognizing their legal right to residential protection and referring them to lawyers and physicians with expert skills. Performing forensic examinations of asylum seekers offers physicians the opportunity to collaborate with attorneys, immigration officials, and human rights experts. Clinicians who do this work find it personally and professionally rewarding, especially when they impart their expert knowledge and skills to future clinicians by involving trainees in these evaluations. Physicians who encounter refugees or asylum seekers in their roles as providers or as preceptors should have familiarity with the field of asylum medicine to enhance the comprehensive care they deliver.
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Affiliation(s)
- Katherine C McKenzie
- Yale Center for Asylum Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Jon Bauer
- Asylum and Human Rights Clinic, University of Connecticut School of Law, Hartford, CT, USA
| | - P Preston Reynolds
- Division of General Medicine, Hospitalist Medicine, Geriatrics and Palliative Care, University of Virginia School of Medicine, Charlottesville, VA, USA
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25
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Allen SH, Leslie LA. Considering the Role of Nativity in the Health and Psychological Wellbeing of Black LGBT Adults. JOURNAL OF HOMOSEXUALITY 2018; 66:1769-1796. [PMID: 30222074 DOI: 10.1080/00918369.2018.1511134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Recent scholars have underscored how the experiences of LGBT people of color cannot be fully understood by considering only the independent contributions of race and sexual orientation. Framed by an intersectional lens, the current study seeks to address this gap in understanding by considering the role of nativity on the health and wellbeing of Black sexual minority adults; we also examined the moderating effects of family support and racial community climate on this relationship. Using national data from the Social Justice Sexuality Project (N = 2,166), we discovered that foreign-born Black LGBT adults had similar levels of psychological wellbeing and physical health as their native counterparts; family support and racial community climate did not moderate this relationship. Our findings did, however, substantiate the importance of family and community support for all Black LGBT adults, regardless of immigration status. Implications of this finding, in addition to directions for future intersectional work on racial minority LGBT people, are discussed.
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Affiliation(s)
- Samuel H Allen
- Department of Family Science, University of Maryland , College Park , Maryland , USA
| | - Leigh A Leslie
- Department of Family Science, University of Maryland , College Park , Maryland , USA
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26
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Williamson RT, Fiscian V, Olson RU, Poku FN, Whittal J. A Reporting System to Protect the Human Rights of People Living with HIV and Key Populations. Health Hum Rights 2017; 19:211-222. [PMID: 29302177 PMCID: PMC5739371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
People living with HIV and key populations face human rights violations that affect their access to health services, relationships in their communities, housing options, and employment. To address these violations, government and civil society organizations in Ghana developed a discrimination reporting system managed by the Commission on Human Rights and Administrative Justice that links people living with HIV and key populations to legal services. This article presents findings on how Ghanaian stakeholders built this reporting system and discusses preliminary data on its impact. To organize our analysis, we used a conceptual framework that outlines the legal frameworks that protect human rights, the institutions that promote access to justice, and the mechanisms that link people living with HIV and key populations to legal services. Using in-depth interviews, we show that targeted technical assistance increased stakeholders' knowledge of issues that affect people living with HIV and key populations, strengthened these stakeholders' commitment to address discrimination, streamlined case management systems, and improved relationships between civil society and the government. Through case review, we find that most discrimination happens when accessing government services, inside communities and families, and in the workplace. Finally, we describe implications for other human rights commissions that are considering using a reporting system to protect human rights, including using legal frameworks, developing case management systems, and working with civil society.
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Affiliation(s)
- R. Taylor Williamson
- Health systems manager in the International Development Group at RTI International, Washington, DC, USA
| | | | - Ryan Ubuntu Olson
- Senior associate for health, HIV and gender and sexual diversity at the Palladium Group, Washington, DC, USA
| | - Fred Nana Poku
- Acting policy manager at the Ghana AIDS Commission, Accra, Ghana
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27
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Mannell J, Hawkes S. Decriminalisation of gender-based violence is a global health problem. BMJ Glob Health 2017; 2:e000438. [PMID: 29082023 PMCID: PMC5656114 DOI: 10.1136/bmjgh-2017-000438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Sarah Hawkes
- Institute for Global Health, University College London, London, UK
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28
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Kahn S, Alessi E, Woolner L, Kim H, Olivieri C. Promoting the wellbeing of lesbian, gay, bisexual and transgender forced migrants in Canada: providers' perspectives. CULTURE, HEALTH & SEXUALITY 2017; 19:1165-1179. [PMID: 28322629 DOI: 10.1080/13691058.2017.1298843] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Researchers are beginning to document the experiences of lesbian, gay, bisexual and transgender (LGBT) forced migrants in settlement. However, studies exploring the perceptions of service providers working with this vulnerable population are limited. These may shed light on the challenges of meeting the needs of LGBT forced migrants, especially mental health issues and problems. This qualitative study elicited the views of 22 Canadian service providers, including advocates, lawyers and mental health practitioners, who serve LGBT forced migrants. Grounded theory analysis revealed the following four themes: facilitating safety, buffering rejection; tracking avoidance patterns; interpreting mental health; and negotiating identity paradigms. Participants' accounts suggest that LGBT forced migrants may be best served by providers who understand the exigencies of establishing trust and safety for their clients; recognise their clients' nuanced social support needs; facilitate the refugee claims process; grasp the complexity of their clients' mental health challenges; and interrogate their own cultural biases regarding sexual orientations and gender identities.
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Affiliation(s)
- Sarilee Kahn
- a School of Social Work , McGill University , Montreal , Canada
| | - Edward Alessi
- b School of Social Work , Rutgers University New Brunswick , New Jersey , USA
| | - Leah Woolner
- a School of Social Work , McGill University , Montreal , Canada
| | - Hanna Kim
- a School of Social Work , McGill University , Montreal , Canada
| | - Christina Olivieri
- c AGIR: Action LGBTQ avec les Immigrantes et Réfugiés, Montreal , Canada
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29
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Alessi EJ, Kahn S, Van Der Horn R. A Qualitative Exploration of the Premigration Victimization Experiences of Sexual and Gender Minority Refugees and Asylees in the United States and Canada. JOURNAL OF SEX RESEARCH 2017; 54:936-948. [PMID: 27715333 DOI: 10.1080/00224499.2016.1229738] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Progress in analyzing and interpreting the concepts of sexual orientation and gender identity in the context of refugee law has contributed to a rise in individuals seeking asylum in such countries as the United States and Canada. However, few studies have examined the victimization experiences of sexual- and gender-identity forced migrants prior to their arrival in North America. This qualitative study used thematic analysis to explore the premigration adult victimization experiences of 26 lesbian, gay, and transgender individuals who obtained refugee, asylee, or withholding-of-removal status in the United States or Canada based on persecution for their sexual orientation and/or gender identity. Participants originated from countries in Asia, Africa, the Caribbean, Eastern Europe, Latin America, and the Middle East. Analysis revealed the following themes: living on the edge, adopting concealment strategies, routine victimization, and protectors as perpetrators. Participants described living in a constant state of hypervigilance, and they adopted numerous strategies to protect themselves from victimization. Despite the use of such strategies, participants experienced victimization by community members and state actors, leaving them no choice but to flee to ensure their safety and well-being. Findings are discussed using the ecological framework outlined by the World Health Organization (WHO). The discussion concludes with implications for international policy and clinical practice.
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Affiliation(s)
- Edward J Alessi
- a School of Social Work, Rutgers , The State University of New Jersey
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30
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Li DH, Rawat S, Rhoton J, Patankar P, Ekstrand ML, Simon Rosser BR, Wilkerson JM. Harassment and Violence Among Men Who Have Sex with Men (MSM) and Hijras After Reinstatement of India's "Sodomy Law". SEXUALITY RESEARCH & SOCIAL POLICY : JOURNAL OF NSRC : SR & SP 2017; 14:324-330. [PMID: 29552236 PMCID: PMC5851470 DOI: 10.1007/s13178-016-0270-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
On December 11, 2013, the Indian Supreme Court recriminalized non-peno-vaginal sex under Sec. 377 of the Indian Penal Code (IPC), overturning a 2009 ruling that deemed IPC Sec. 377 unconstitutional. Similar "sodomy laws" in other countries have been associated with increased violence, harassment, and other discrimination against men who have sex with men (MSM) and transgender women. However, few studies have looked at the effects of such a law in an Indian context. This study examined experiences of victimization among MSM and hijra/transgender women (MSM-H) in the State of Maharashtra using a mixed-method approach. Data came from a quantitative survey and qualitative focus groups and interviews from an HIV prevention study as well as qualitative media and case reports from a local MSM-H-serving community-based organization. MSM-H in Maharashtra reported experiencing a high frequency of harassment, violence, and extortion, particularly from male sex partners met online and police. IPC Sec. 377 was implicated across qualitative sources as creating a culture of protection for harassment against MSM-H by being used directly as a tool for harassment, hindering victims of harassment from seeking legal recourse, and adversely impacting HIV and healthcare services. The reinstated IPC Sec. 377 may directly and indirectly facilitate negative health outcomes among MSM-H. Health agencies and advocates should continue to monitor the impact of IPC Sec. 377, incorporate rights-based approaches to protect MSM-H identities while addressing their health and well-being, and explore avenues to initiate discussions with the government to work toward repealing the law.
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Affiliation(s)
- Dennis H Li
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
- Institute for Sexual and Gender Minority Health and Wellbeing, Northwestern University, 625 N. Michigan Ave., Suite 2700, Chicago, IL 60611, USA
| | | | - Jayson Rhoton
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | | | - Maria L Ekstrand
- Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA, USA
| | - B R Simon Rosser
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - J Michael Wilkerson
- Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
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31
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Orangias J, Simms J, French S. The Cultural Functions and Social Potential of Queer Monuments: A Preliminary Inventory and Analysis. JOURNAL OF HOMOSEXUALITY 2017; 65:705-726. [PMID: 28777713 DOI: 10.1080/00918369.2017.1364106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Public monuments function as cultural agents, reifying dominant public narratives or fostering change. Either way, their representation of people and events intervene in public discourse and contribute to cultural, economic, political, and social environments. Queer monuments, defined here as heritage sites that honor gender and sexual minorities, represent communities that have often been excised in dominant public narratives. This article provides a preliminary global inventory of queer monuments and describes three of their major functions: (1) to provide visibility and reduce stigma; (2) to educate the public on the abuse and attempted extermination of gender and sexual minorities; and (3) to stimulate public debate and discourse about gender and sexual minority rights. This still rare type of monument is growing more common and prompting more active and equitable representations in public space. Queer monuments have the potential of lessening stigma and improving the lives of sexual and gender minorities.
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Affiliation(s)
- Joseph Orangias
- Independent Researcher, Brooklyn, New York and Geneva, Switzerland
| | - Jeannie Simms
- School of the Museum of Fine Arts, Tufts University, Boston, Massachusetts, USA
| | - Sloane French
- Department of English, Colorado State University, Fort Collins, Colorado, USA
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32
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Correlates of Sexual Risk among Recent Gay and Bisexual Immigrants from Western and Eastern Africa to the USA. J Urban Health 2017; 94:330-338. [PMID: 28258531 PMCID: PMC5481211 DOI: 10.1007/s11524-017-0135-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We examined correlates of sexual risk among gay and bisexual men, who recently migrated from western and eastern African countries to the USA and lived in New York City and who are HIV negative or of unknown status. These men migrate from countries where same-sex sexuality is socially rejected and mostly illegal contributing to the motivation to migrate. Their background might predispose these men to engagement in sexual risk practices, while they are not specifically addressed in HIV prevention programming. Participants (N = 62) reported in face-to-face interviews on pre- and postmigration experiences, psychosocial determinants of sexual risk, and current sexual practices. Operationalization of sexual risk was based on the number of men with whom they had condomless receptive and/or insertive anal sex. Over a third of the men reported always having used condoms in the past year; among the other men, sexual risk varied. Multivariate analyses showed that sexual risk was lower among men with a stronger motivation to avoid HIV infection and higher among men who currently engaged in transactional sex. Further analyses indicated that housing instability was independently associated with reduced motivation to avoid HIV infection and with engagement in transactional sex in the USA. In recent western and eastern African gay and bisexual immigrants to the USA, structural factors, including housing instability, are strongly associated with sexual risk.
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McKenzie KC, Thomas A. Assisting asylum seekers in a time of global forced displacement: Five clinical cases. J Forensic Leg Med 2017; 49:37-41. [PMID: 28501717 DOI: 10.1016/j.jflm.2017.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/14/2017] [Accepted: 04/23/2017] [Indexed: 10/19/2022]
Abstract
According to the United Nations High Commissioner on Refugees, over 65 million people were displaced from their homes due to conflict and persecution in 2015. Many physicians express an interest in human rights and a desire to assist this group of refugees and asylum seekers. Physicians are able to use their unique skills by performing medical forensic evaluations of individuals seeking asylum. Some asylum seekers have psychological or physical scars or functional abnormalities relating to injuries or ill-treatment they experience due to persecution. Documenting these findings can significantly improve the likelihood that they will be granted asylum. This manuscript outlines the historical and legal background of asylum. Each of the individuals presented in this paper experienced persecution in different forms. One person was tortured due to his political opinion and one was assaulted because he was gay. One woman sought asylum due to domestic violence, another woman because she had been subjected to female genital mutilation/cutting (FGM/C) and the last suffered severe psychological trauma related to a forced marriage. Five typical clinical cases of medical forensic evaluations are outlined, each with different forms of persecution and physical or psychological findings. Physicians have an interest in using their expertise to help this underserved population. They report that working with asylum seekers is rewarding, intellectually stimulating and a novel way to use their training and skills.
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Affiliation(s)
| | - Arielle Thomas
- Yale Center for Asylum Medicine, Yale School of Medicine, United States; UNC Chapel Hill School of Medicine, MS4, Yale School of Public Health, MPH, 919-946-5654, United States.
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Raifman J, Moscoe E, Austin SB, McConnell M. Difference-in-Differences Analysis of the Association Between State Same-Sex Marriage Policies and Adolescent Suicide Attempts. JAMA Pediatr 2017; 171:350-356. [PMID: 28241285 PMCID: PMC5848493 DOI: 10.1001/jamapediatrics.2016.4529] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Suicide is the second leading cause of death among adolescents between the ages of 15 and 24 years. Adolescents who are sexual minorities experience elevated rates of suicide attempts. OBJECTIVE To evaluate the association between state same-sex marriage policies and adolescent suicide attempts. DESIGN, SETTING, AND PARTICIPANTS This study used state-level Youth Risk Behavior Surveillance System (YRBSS) data from January 1, 1999, to December 31, 2015, which are weighted to be representative of each state that has participation in the survey greater than 60%. A difference-in-differences analysis compared changes in suicide attempts among all public high school students before and after implementation of state policies in 32 states permitting same-sex marriage with year-to-year changes in suicide attempts among high school students in 15 states without policies permitting same-sex marriage. Linear regression was used to control for state, age, sex, race/ethnicity, and year, with Taylor series linearized standard errors clustered by state and classroom. In a secondary analysis among students who are sexual minorities, we included an interaction between sexual minority identity and living in a state that had implemented same-sex marriage policies. INTERVENTIONS Implementation of state policies permitting same-sex marriage during the full period of YRBSS data collection. MAIN OUTCOMES AND MEASURES Self-report of 1 or more suicide attempts within the past 12 months. RESULTS Among the 762 678 students (mean [SD] age, 16.0 [1.2] years; 366 063 males and 396 615 females) who participated in the YRBSS between 1999 and 2015, a weighted 8.6% of all high school students and 28.5% of students who identified as sexual minorities reported suicide attempts before implementation of same-sex marriage policies. Same-sex marriage policies were associated with a 0.6-percentage point (95% CI, -1.2 to -0.01 percentage points) reduction in suicide attempts, representing a 7% relative reduction in the proportion of high school students attempting suicide owing to same-sex marriage implementation. The association was concentrated among students who were sexual minorities. CONCLUSIONS AND RELEVANCE State same-sex marriage policies were associated with a reduction in the proportion of high school students reporting suicide attempts, providing empirical evidence for an association between same-sex marriage policies and mental health outcomes.
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Affiliation(s)
- Julia Raifman
- Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ellen Moscoe
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - S. Bryn Austin
- Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts4Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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35
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Rudrum S, Oliffe JL, Benoit C. Discourses of masculinity, femininity and sexuality in Uganda's Stand Proud, Get Circumcised campaign. CULTURE, HEALTH & SEXUALITY 2017; 19:225-239. [PMID: 27684495 DOI: 10.1080/13691058.2016.1214748] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This paper analyses discourses of masculinity, femininity and sexuality in Stand Proud, Get Circumcised, a public health campaign promoting circumcision as an HIV-prevention strategy in Uganda. The campaign includes posters highlighting the positive reactions of women to circumcised men, and is intended to support the national rollout of voluntary medical male circumcision. We offer a critical discourse analysis of representations of masculinity, femininity and sexuality in relation to HIV prevention. The campaign materials have a playful feel and, in contrast to ABC (Abstain, Be faithful, Use condoms) campaigns, acknowledge the potential for pre-marital and extra-marital sex. However, these posters exploit male anxieties about appearance and performance, drawing on hegemonic masculinity to promote circumcision as an idealised body aesthetic. Positioning women as the campaign's face reasserts a message that women are the custodians of family health and simultaneously perpetuates a norm of estrangement between men and their health. The wives' slogan, 'we have less chance of getting HIV', is misleading, because circumcision only directly prevents female-to-male HIV transmission. Reaffirming hegemonic notions of appearance- and performance-based heterosexual masculinity reproduces existing unsafe norms about masculinity, femininity and sexuality. In selling male circumcision, the posters fail to promote an overall HIV-prevention message.
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Affiliation(s)
- Sarah Rudrum
- a Institute for Gender, Race, Sexuality and Social Justice , University of British Columbia , Vancouver , British Columbia , Canada
| | - John L Oliffe
- b School of Nursing , University of British Columbia , Vancouver , British Columbia , Canada
| | - Cecilia Benoit
- c Department of Sociology , University of Victoria , Victoria , British Columbia , Canada
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36
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Nagata JM. Challenges, health implications, and advocacy opportunities for lesbian, gay, bisexual, and transgender global health providers. Glob Health Promot 2017; 25:70-73. [PMID: 28059616 DOI: 10.1177/1757975916677504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this commentary, I reflect on challenges with conducting global health research internationally as a lesbian, gay, bisexual, and transgender (LGBT) person, grapple with decisions related to coming out in regions with anti-LGBT laws, and outline the risks and benefits of different advocacy options related to the promotion of LGBT health globally. Despite significant advances in LGBT rights in many countries, homosexuality remains illegal in many others. Using a critical medical anthropology framework, I argue that anti-LGBT laws constitute structural violence and have many detrimental consequences including discrimination and violence; poorer mental and physical health outcomes; and risky sexual behaviors. As a global health provider, there are many options for the promotion of LGBT health worldwide.
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Affiliation(s)
- Jason M Nagata
- Department of Pediatrics, Stanford University, Palo Alto, CA, USA
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37
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Wu E, Terlikbayeva A, Hunt T, Primbetova S, Gun Lee Y, Berry M. Preliminary Population Size Estimation of Men Who Have Sex with Men in Kazakhstan: Implications for HIV Testing and Surveillance. LGBT Health 2016; 4:164-167. [PMID: 28005454 DOI: 10.1089/lgbt.2015.0152] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The purpose of this study is to estimate the population size of men who have sex with men (MSM) in Kazakhstan and their HIV testing history. METHODS We conducted structured interviews with MSM in four geographically disparate cities-N = 400 (n = 100/city)-to implement four population estimation methods and ascertain HIV testing history. RESULTS Approximately 3.2% of men-corresponding to ∼154,000 individuals-in Kazakhstan aged 18-59 are MSM. The 49.9% of the sample who reported taking an HIV test far exceeds the <1% reported as MSM in surveillance data. CONCLUSION HIV testing surveillance in Kazakhstan has underestimated the number of MSM. This underscores the need to redress social and structural barriers to HIV testing and disclosure of sexual behavior experienced by MSM in Kazakhstan. Recommendations include promoting cultural sensitivity among testing staff through quality assurance and regular training, and increasing protection and public awareness through antidiscrimination policy development.
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Affiliation(s)
- Elwin Wu
- 1 Social Intervention Group, Columbia University School of Social Work , New York, New York
| | | | - Timothy Hunt
- 1 Social Intervention Group, Columbia University School of Social Work , New York, New York
| | | | - Yong Gun Lee
- 1 Social Intervention Group, Columbia University School of Social Work , New York, New York
| | - Mark Berry
- 3 Centers for Disease Control and Prevention , Atlanta, Georgia
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Schwartz SR, Nowak RG, Orazulike I, Keshinro B, Ake J, Kennedy S, Njoku O, Blattner WA, Charurat ME, Baral SD. The immediate eff ect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort. Lancet HIV 2016; 2:e299-306. [PMID: 26125047 DOI: 10.1016/s2352-3018(15)00078-8] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In January, 2014, the Same-Sex Marriage Prohibition Act was signed into law in Nigeria, further criminalising same-sex sexual relationships. We aimed to assess the immediate effect of this prohibition act on stigma, discrimination, and engagement in HIV prevention and treatment services in men who have sex with men (MSM) in Nigeria. METHODS The TRUST cohort study uses respondent-driven sampling to assess the feasibility and effectiveness of engagement of MSM in HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community. TRUST is a prospective implementation research cohort of MSM (≥16 years) in Abuja, Nigeria. We compared HIV clinical outcomes and stigma, including fear and avoidance of health care, across baseline and quarterly visits before and after implementation of the the Same-Sex Marriage Prohibition Act. Outcomes assessed were measures of stigma and discrimination, loss to follow-up, antiretroviral therapy status, and viral load. We compared outcomes before and after the legislation with χ2 statistics, and estimated incident stigma-related events and loss to follow-up with Poisson regression. FINDINGS Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures, contributing to 756 before legislation (prelaw) and 420 after legislation (postlaw) visits. Reported history of fear of seeking health care was significantly higher in postlaw visits than in prelaw visits (n=161 [38%] vs n=187 [25%]; p<0・0001), as was avoidance of health care (n=118 [28%] vs n=151 [20%]; p=0・001). In incidence analyses, of 192 MSM with follow-up data and no history of an event at baseline, reported fear of seeking health care was higher in the postlaw than the prelaw period (n=144; incidence rate ratio 2・57, 95% CI 1・29–5・10; p=0・007); loss to follow-up and incident healthcare avoidance were similar across periods. Of the 161 (89%) of 181 HIV-infected MSM with HIV viral loads available, those who had disclosed sexual behaviour with a health-care provider were more often virally suppressed at baseline than those with no previous disclosure (18 [29%] of 62 vs 13 [13%] of 99 men; p=0・013). INTERPRETATION These analyses represent individual-level, quantitative, real-time prospective data for the health-related effects resulting from the enactment of legislation further criminalising same-sex practices. The negative effects of HIV treatment and care in MSM reinforce the unintended consequences of such legislation on global goals of HIV eradication. Strategies to reach MSM less likely to engage in HIV testing and care in highly stigmatised environments are needed to reduce time to HIV diagnosis and treatment. FUNDING National Institutes of Health.
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Beyrer C, Baral SD, Collins C, Richardson ET, Sullivan PS, Sanchez J, Trapence G, Katabira E, Kazatchkine M, Ryan O, Wirtz AL, Mayer KH. The global response to HIV in men who have sex with men. Lancet 2016; 388:198-206. [PMID: 27411880 DOI: 10.1016/s0140-6736(16)30781-4] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Gay, bisexual, and other men who have sex with men (MSM) continue to have disproportionately high burdens of HIV infection in countries of low, middle, and high income in 2016. 4 years after publication of a Lancet Series on MSM and HIV, progress on reducing HIV incidence, expanding sustained access to treatment, and realising human rights gains for MSM remains markedly uneven and fraught with challenges. Incidence densities in MSM are unacceptably high in countries as diverse as China, Kenya, Thailand, the UK, and the USA, with substantial disparities observed in specific communities of MSM including young and minority populations. Although some settings have achieved sufficient coverage of treatment, pre-exposure prophylaxis (PrEP), and human rights protections for sexual and gender minorities to change the trajectory of the HIV epidemic in MSM, these are exceptions. The roll-out of PrEP has been notably slow and coverage nowhere near what will be required for full use of this new preventive approach. Despite progress on issues such as marriage equality and decriminalisation of same-sex behaviour in some countries, there has been a marked increase in anti-gay legislation in many countries, including Nigeria, Russia, and The Gambia. The global epidemic of HIV in MSM is ongoing, and global efforts to address it remain insufficient. This must change if we are ever to truly achieve an AIDS-free generation.
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Affiliation(s)
- Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Stefan D Baral
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Eugene T Richardson
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Jorge Sanchez
- Asociacion Civil Impacta Salud y Educacion, Lima, Peru
| | | | | | - Michel Kazatchkine
- United Nations Special Envoy for AIDS in Eastern Europe and Central Asia, Geneva, Switzerland
| | - Owen Ryan
- The International AIDS Society, Geneva, Switzerland
| | - Andrea L Wirtz
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth H Mayer
- Fenway Health and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Muller A, Hughes TL. Making the invisible visible: a systematic review of sexual minority women's health in Southern Africa. BMC Public Health 2016; 16:307. [PMID: 27066890 PMCID: PMC4827176 DOI: 10.1186/s12889-016-2980-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 03/22/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Over the past two decades research on sexual and gender minority (lesbian, gay, bisexual and transgender; LGBT) health has highlighted substantial health disparities based on sexual orientation and gender identity in many parts of the world. We systematically reviewed the literature on sexual minority women's (SMW) health in Southern Africa, with the objective of identifying existing evidence and pointing out knowledge gaps around the health of this vulnerable group in this region. METHODS A systematic review of publications in English, French, Portuguese or German, indexed in PubMed or MEDLINE between the years 2000 and 2015, following PRISMA guidelines. Additional studies were identified by searching bibliographies of identified studies. Search terms included (Lesbian OR bisexual OR "women who have sex with women"), (HIV OR depression OR "substance use" OR "substance abuse" OR "mental health" OR suicide OR anxiety OR cancer), and geographical specification. All empirical studies that used quantitative or qualitative methods, which contributed to evidence for SMW's health in one, a few or all of the countries, were included. Theoretical and review articles were excluded. Data were extracted independently by 2 researchers using predefined data fields, which included a risk of bias/quality assessment. RESULTS Of 315 hits, 9 articles were selected for review and a further 6 were identified through bibliography searches. Most studies were conducted with small sample sizes in South Africa and focused on sexual health. SMW included in the studies were racially and socio-economically heterogeneous. Studies focused predominately on young populations, and highlighted substance use and violence as key health issues for SMW in Southern Africa. CONCLUSIONS Although there are large gaps in the literature, the review highlighted substantial sexual-orientation-related health disparities among women in Southern Africa. The findings have important implications for public health policy and research, highlighting the lack of population-level evidence on the one hand, and the impact of criminalizing laws around homosexuality on the other hand.
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Affiliation(s)
- Alexandra Muller
- />Gender Health and Justice Research Unit, University of Cape Town, Health Sciences Faculty, Falmouth Building, Room 1.01.5, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Tonda L. Hughes
- />Global Health University of Illinois at Chicago College of Nursing (M/C 802) Room 1160 Chicago, ᅟ, IL 60612-7350 USA
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Larsson M, Ross MW, Tumwine G, Agardh A. Determinants of unmet needs for healthcare and sexual health counselling among Ugandan university students with same-sex sexuality experience. Glob Health Action 2016; 9:30790. [PMID: 27032809 PMCID: PMC4816809 DOI: 10.3402/gha.v9.30790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Research from sub-Saharan Africa has shown that persons with same-sex sexuality experience are at elevated risk for ill health due to sexual risk taking, stigma, and discrimination. However, studies of healthcare seeking among young people in this region with same-sex sexuality experience are limited. OBJECTIVE To identify determinants of unmet healthcare and sexual health counselling needs, respectively, among Ugandan university students with experience of same-sex sexuality. DESIGN In 2010, 1,954 Ugandan university students completed a questionnaire assessing socio-demographic factors, mental health, alcohol usage, sexual behaviours, and healthcare seeking. The study population consisted of those 570 who reported ever being in love with, sexually attracted to, sexually fantasised about, or sexually engaged with someone of the same sex. RESULTS Findings showed that 56% and 30% reported unmet healthcare and sexual health counselling needs, respectively. Unmet healthcare needs were associated with poor mental health and exposure to sexual coercion (OR 3.9, 95% confidence intervals [CI]: 2.7-5.7; OR 2.0, 95% CI: 1.3-3.0, respectively). Unmet sexual health counselling needs were significantly associated with poor mental health (OR 3.2, 95% CI: 2.1-4.8), exposure to sexual coercion (OR 2.6, 95% CI: 1.7-3.9), frequent heavy episodic drinking (OR 3.3, 95% CI: 1.9-5.8), and number of sexual partners (OR 1.9, 95% CI: 1.04-3.3). The associations between poor mental health, sexual coercion, and unmet healthcare needs (AOR 4.2, 95% CI: 2.1-8.5; AOR 2.8, 95% CI: 1.3-5.8) and unmet needs for sexual health counselling (AOR 3.3, 95% CI: 1.6-7.1; AOR 2.7, 95% CI: 1.4-5.4) persisted after adjustment for socio-demographic factors, number of sexual partners, and frequent heavy episodic drinking. CONCLUSIONS These findings indicate that exposure to sexual coercion and poor mental health may influence healthcare seeking behaviours of same-sex sexuality experienced students. Targeted interventions that integrate mental health and trauma response are critical to meet the health needs of this population.
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Affiliation(s)
- Markus Larsson
- Division for Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden;
| | - Michael W Ross
- Program in Human Sexuality, Department of Family Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gilbert Tumwine
- Department of Obstetrics and Gynaecology, St Francis Hospital Nsambya, Kampala, Uganda
| | - Anette Agardh
- Division for Social Medicine and Global Health, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Moore CB, Ciaraldi E. Quality of Care and Service Expansion for HIV Care and Treatment. Curr HIV/AIDS Rep 2016; 12:223-30. [PMID: 25855339 DOI: 10.1007/s11904-015-0263-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The last two decades have seen exceptional development of antiretroviral treatment programs throughout the world. Over 14 million persons are accessing antiretroviral treatment (ART) treatment as of early 2015, and life expectancy has risen markedly in the most-affected populations. However, large patient numbers threaten to overwhelm already over-burdened health care systems and retention in care remains suboptimal. Developing innovative strategies to alleviate these burdens and retain patients in care remains a challenge. Furthermore, despite this expansion, large populations of HIV-infected persons remain undiagnosed and are unwilling or unable to access care and treatment programs. Marginalized and high-risk populations are particularly in danger of remaining outside of care and are also disproportionately affected by HIV. To reverse the trend and "fast track" our way out of the epidemic, ambitious treatment targets are required, and a concerted effort has to be made to engage these populations into care, initiate ART, and attain viral suppression.
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Alessi EJ, Kahn S, Chatterji S. 'The darkest times of my life': Recollections of child abuse among forced migrants persecuted because of their sexual orientation and gender identity. CHILD ABUSE & NEGLECT 2016; 51:93-105. [PMID: 26615778 DOI: 10.1016/j.chiabu.2015.10.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/29/2015] [Accepted: 10/30/2015] [Indexed: 06/05/2023]
Abstract
Numerous studies demonstrate that lesbian, gay, bisexual, and transgender (LGBT) children and youth are likely to experience abuse by peers, parents, and other adults and that these experiences correlate with a host of mental health problems. However, there is little understanding of the experiences of LGBT children and youth living in countries where social and legal protections for sexual and gender minorities are limited or nonexistent. This qualitative study used thematic analysis to explore the child and adolescent abuse experiences and their impact on the pre-migration mental health of LGBT forced migrants. We analyzed 26 interviews with individuals who obtained refugee or asylee status in the United States or Canada on the basis of sexual orientation or gender identity. Participants originated from countries in Asia, Africa, the Caribbean, Eastern Europe, Latin America, and the Middle East. Analysis revealed the following themes: abuse by parents and caregivers, abuse by peers and school personnel, having nowhere to turn, and dealing with psychological distress. Findings indicate that participants experienced severe verbal, physical, and sexual abuse throughout childhood and adolescence and that this abuse occurred at home, in school, and in the community. Furthermore, there were no resources or sources of protection available to them. Participants linked their abuse to subjective experiences of depression, anxiety, and traumatic stress, as well as suicidal ideation and suicide attempts. We conclude with implications for refugee adjudication practices, mental health care, and international policy.
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Affiliation(s)
- Edward J Alessi
- School of Social Work, Rutgers, The State University of New Jersey, 360 Martin Luther King Jr. Blvd, Hill Hall, Room 401, Newark, NJ 07102, USA
| | - Sarilee Kahn
- School of Social Work, McGill University, 3506 University Street, Room 426, Montreal, QC, Canada H3A 2A7
| | - Sangeeta Chatterji
- School of Social Work, Rutgers, The State University of New Jersey, 536 George Street, New Brunswick, NJ 08901, USA
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Stigma Toward Men Who Have Sex with Men Among Future Healthcare Providers in Malaysia: Would More Interpersonal Contact Reduce Prejudice? AIDS Behav 2016; 20:98-106. [PMID: 26324078 DOI: 10.1007/s10461-015-1168-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Men who have sex with men (MSM) living in countries with strong stigma toward MSM are vulnerable to HIV and experience significant barriers to HIV care. Research is needed to inform interventions to reduce stigma toward MSM in these countries, particularly among healthcare providers. A cross-sectional survey of 1158 medical and dental students was conducted at seven Malaysian universities in 2012. Multivariate analyses of variance suggest that students who had interpersonal contact with MSM were less prejudiced toward and had lower intentions to discriminate against MSM. Path analyses with bootstrapping suggest stereotypes and fear mediate associations between contact with prejudice and discrimination. Intervention strategies to reduce MSM stigma among healthcare providers in Malaysia and other countries with strong stigma toward MSM may include facilitating opportunities for direct, in-person or indirect, media-based prosocial contact between medical and dental students with MSM.
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Poteat TC, Logie CH, Adams D, Mothopeng T, Lebona J, Letsie P, Baral S. Stigma, sexual health, and human rights among women who have sex with women in Lesotho. REPRODUCTIVE HEALTH MATTERS 2015; 23:107-16. [PMID: 26719002 DOI: 10.1016/j.rhm.2015.11.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022] Open
Abstract
In recent years, gender and sexual minorities have become increasingly visible across sub-Saharan Africa, marking both the progression and violation of their human rights. Using data from a study with sexual minorities in Lesotho, this analysis leveraged the social ecological model to examine relationships between stigma, human rights, and sexual health among women who have sex with women in Lesotho. A community-based participatory approach was used for the mixed-method, cross-sectional study. A total of 250 women who have sex with women completed a structured questionnaire, of which 21 participated in a total of three focus group discussions. Stigma was common within and outside the health sector. Stigma and human rights abuses were associated with increased risk for HIV and STIs. Interventions to address stigma at the structural, community, and interpersonal levels are essential to ensuring sexual health and rights for women who have sex with women in Lesotho.
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Affiliation(s)
- Tonia C Poteat
- Assistant Professor, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Carmen H Logie
- Assistant Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada
| | - Darrin Adams
- Research Fellow, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | - Judith Lebona
- Provincial Officer Northwest, National Religious Association for Social Development, Cape Town, South Africa
| | - Puleng Letsie
- Mobilisation and Networking Advisor, UNAIDS, Maseru, Lesotho
| | - Stefan Baral
- Director of Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Assessment of policy and access to HIV prevention, care, and treatment services for men who have sex with men and for sex workers in Burkina Faso and Togo. J Acquir Immune Defic Syndr 2015; 68 Suppl 2:S189-97. [PMID: 25723984 DOI: 10.1097/qai.0000000000000450] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Burkina Faso and Togo, key populations of men who have sex with men (MSM) and sex workers (SW) have a disproportionately higher HIV prevalence. This study analyzed the 2 countries' policies impacting MSM and SW; to what extent the policies and programs have been implemented; and the role of the enabling environment, country leadership, and donor support. METHODS The Health Policy Project's Policy Assessment and Advocacy Decision Model methodology was used to analyze policy and program documents related to key populations, conduct key informant interviews, and hold stakeholder meetings to validate the findings. RESULTS Several policy barriers restrict MSM/SW from accessing services. Laws criminalizing MSM/SW, particularly anti-solicitation laws, result in harassment and arrests of even nonsoliciting MSM/SW. Policy gaps exist, including few MSM/SW-supportive policies and HIV prevention measures, e.g., lubricant not included in the essential medicines list. The needs of key populations are generally not met due to policy gaps around MSM/SW participation in decision-making and funding allocation for MSM/SW-specific programming. Misaligned policies, eg, contradictory informed consent laws and protocols, and uneven policy implementation, such as stockouts of sexually transmitted infection kits, HIV testing materials, and antiretrovirals, undermine evidence-based policies. Even in the presence of a supportive donor and political community, public stigma and discrimination (S&D) create a hostile enabling environment. CONCLUSIONS Policies are needed to address S&D, particularly health care provider and law enforcement training, and to authorize, fund, guide, and monitor services for key populations. MSM/SW participation and development of operational guidelines can improve policy implementation and service uptake.
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Charurat ME, Emmanuel B, Akolo C, Keshinro B, Nowak RG, Kennedy S, Orazulike I, Ake J, Njoku O, Baral S, Blattner W. Uptake of treatment as prevention for HIV and continuum of care among HIV-positive men who have sex with men in Nigeria. J Acquir Immune Defic Syndr 2015; 68 Suppl 2:S114-23. [PMID: 25723975 PMCID: PMC4853821 DOI: 10.1097/qai.0000000000000439] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Experimental evidence has shown that treatment of HIV infection with antiretroviral therapy (ART) prevents heterosexual transmission of HIV to an uninfected partner. However, the "real-world" application of this strategy to key populations such as men who have sex with men (MSM) has been limited. We report findings on acceptability of a treatment as prevention (TasP) strategy among HIV-infected MSM at a Trusted Community Center providing comprehensive HIV prevention and treatment services to MSM in Abuja, Nigeria. METHODS Using respondent-driven sampling (RDS), MSM who were 16 years and older and have engaged in either receptive or insertive anal intercourse within the previous 12 months were recruited into a prospective combination HIV prevention and treatment study (TRUST). Two weeks after enrollment, HIV testing and counseling was conducted. At each 3-month follow-up visits, HIV-infected individuals underwent clinical and laboratory evaluation, including CD4 count, plasma HIV viral load, immediate 3 weekly sessions of ART preparation, and then ART initiation per TasP strategy irrespective of CD4 count. Reasons for not engaging in pre-TasP preparation and TasP were documented. Characteristics associated with TasP engagement and loss to follow-up (LTFU) were determined using logistic and Cox regression, respectively. RESULTS Of 186 HIV-positive MSM enrolled, 58 (31.2%) were on ART at the time of recruitment, whereas 128 (68.8%) were ART-naive and provided opportunity for engaging TasP. Of these, 70 (54.7%) engaged in TasP. Compared with MSM who did not engage in TasP, those who engaged had significantly lower mean CD4 count (P = 0.001), were more likely to be Christian (P = 0.01), and had disclosed being MSM to family (P = 0.02) or health care providers (P = 0.02). In multivariate models, disclosure of being MSM to health care providers remained significantly associated with uptake of TasP. Among individuals engaged in TasP, 10% were LTFU in care at 18 months since enrollment. Being engaged in TasP (relative hazards = 0.08, P < 0.001) and on ART (relative hazards = 0.17, P < 0.001) were associated with decreased risk of LTFU. CONCLUSIONS Although there was high acceptance of HIV testing and low LTFU among individuals who were already on ART or engaged in TasP, a higher than expected proportion did not engage in TasP, suggesting the need for customized treatment preparation and an increase in enabling environments to support HIV treatment access with this key population.
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Affiliation(s)
- Man E Charurat
- *Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD; †Institute of Human Virology-Nigeria, Abuja, Nigeria; ‡US Military HIV Research Program, Silver Spring, MD; §International Centre for Advocacy on Rights to Health, Abuja, Nigeria; and ‖Johns Hopkins University, Center for Human Rights, Baltimore, MD
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Beyrer C. Tailoring biomedical interventions for key populations. Lancet HIV 2015; 2:e8-e9. [PMID: 26424235 DOI: 10.1016/s2352-3018(14)00037-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 12/08/2014] [Indexed: 06/05/2023]
Affiliation(s)
- Chris Beyrer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St E 7152, Baltimore, MD 21205, USA.
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