Comprehensive approach to HIV/AIDS testing and linkage to treatment among men who have sex with men in Curitiba, Brazil

Mapping projects for expanding rapid HIV testing in key populations, Brazil, 2004-2021

The HIV/AIDS epidemic remains a persistent and real issue, especially in key populations such as men who have sex with men (MSM), travestis and transgender persons. Projects for expanding rapid HIV testing are strategic initiatives aimed at the earliest possible identification of individuals' serological status and thus early treatment, screening of sex partners, and upscaling of preventive actions to interrupt the transmission chain. This study thus maps, describes, and systematizes the projects for expanding rapid HIV testing implemented from 2004 to 2021 in Brazil, highlighting the on-going contribution of civil society organizations and discussing the interoperability and cooperation resulting from public governance processes. We selected 67 documents for analysis, including 30 scientific publications retrieved from electronic databases and 37 documents produced by government institutions and nongovernmental organizations (NGOs). Find Out (Fique Sabendo), I Want to Get Tested (Quero Fazer), The Time is Now (A Hora É Agora), Live Better Knowing (Viva Melhor Sabendo), and Live Better Knowing Young (Viva Melhor Sabendo Jovem) were the projects mapped. Results show that the projects have used strategies adapted to the key population, such as mobile testing units, peer education, and innovative community engagement approaches. Such actions were enabled by effective cooperation and interoperability between participating stakeholders, especially NGOs.

Counseling Supporting HIV Self-Testing and Linkage to Care Among Men Who Have Sex With Men: Systematic Review and Meta-Analysis

BACKGROUND

Counseling supporting HIV self-testing (HIVST) is helpful in facilitating linkage to care and promoting behavior changes among men who have sex with men (MSM). Different levels of counseling support for MSM HIVST users may lead to variance in the linkage to care.

OBJECTIVE

This study aims to synthesize evidence on counseling supporting MSM HIVST users and to conduct a meta-analysis to quantify the proportion of MSM HIVST users who were linked to care.

METHODS

A systematic search was conducted using predefined eligibility criteria and relevant keywords to retrieve studies from the MEDLINE, Global Health, Web of Science, Embase, APA PsycINFO, and Scopus databases. This search encompassed papers and preprints published between July 3, 2012, and June 30, 2022. Studies were eligible if they reported counseling supporting HIVST or quantitative outcomes for linkage to care among MSM and were published in English. The screening process and data extraction followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The quality of the included studies was assessed by the National Institutes of Health quality assessment tool. Data were extracted using random effects models to combine the proportion of HIVST users who were linked to care. Subgroup analyses and metaregression were conducted to assess whether linkage to care varied according to study characteristics. All analyses were performed with R (version 4.2.1; R Foundation for Statistical Computing) using the metafor package.

RESULTS

A total of 55 studies published between 2014 and 2021, including 43 observational studies and 12 randomized controlled trials, were identified. Among these studies, 50 (91%) provided active counseling support and 5 (9%) provided passive counseling support. In studies providing active counseling support, most MSM HIVST users were linked to various forms of care, including reporting test results (97.2%, 95% CI 74.3%-99.8%), laboratory confirmation (92.6%, 95% CI 86.1%-96.2%), antiretroviral therapy initiation (90.8%, 95% CI 86.7%-93.7%), and referral to physicians (96.3%, 95% CI 85%-99.2%). In studies providing passive counseling support, fewer MSM HIVST users were linked to laboratory confirmation (78.7%, 95% CI 17.8%-98.4%), antiretroviral therapy initiation (79.1%, 95% CI 48.8%-93.7%), and referral to physicians (79.1%, 95% CI 0%-100%). Multivariate metaregression indicated that a higher number of essential counseling components, a smaller sample size (<300), and the use of mobile health technology to deliver counseling support were associated with better linkage to care. The quality of the studies varied from fair to good with a low to high risk of bias.

CONCLUSIONS

Proactively providing counseling support for all users, involving a higher number of essential components in the counseling support, and using mobile health technology could increase the linkage to care among MSM HIVST users.

TRIAL REGISTRATION

PROSPERO CRD42022346247; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=346247.

Barriers and facilitators for HIV rapid testing among transgender women and gay and other men who have sex with men in Brazil: A scoping review

Transgender women (TGW) and men who have sex with other men (MSM) often encounter disparities in accessing HIV testing, leading to delayed diagnoses and worse prognoses. We analysed barriers and facilitators for accessing HIV rapid testing by TGW and MSM in Brazil, 2004-2023. Citations were included whether the study population consisted of individuals aged ≥18y old, and studies addressed HIV testing and have been conducted in Brazil. The study protocol was based on Joanna Briggs' recommendations for scoping reviews. We included 11 studies on TGW and 17 on MSM. The belief that one is not at risk of contracting HIV infection, fear expressed in different ways (e.g. lack of confidentiality) and younger age were the main barriers. Feeling at risk for HIV infection, curiosity, and favourable characteristics of the setting where the testing takes place were cited as the main facilitators. Barriers and facilitators specifically for HIV self-testing included, respectively, concerns about conducting the test alone vs. autonomy/flexibility. Brazil is unlikely to achieve the UN' 95-95-95 goal without minimising testing disparities. Combating prejudice against TGW and MSM in testing settings, along with educational campaigns and transparent protocols to ensure confidentiality, can help increase HIV testing among these populations.

How much does HIV self-testing cost in low and middle income countries? A systematic review of evidence from economic studies

Objectives

HIV self-testing (HIVST) has been proposed as an innovative strategy to diagnose human immunodeficiency virus (HIV). While HIVST offers the potential to broaden accessibility of early HIV diagnosis and treatment initiation, this testing strategy incurs additional cost and requires confirmatory testing and treatment. We have conducted the first systematic review to summarize the current economic literature for HIVST in low- and middle-income countries (LMICs).

Design

A search strategy was developed including key terms for HIV, self-testing and cost-effectiveness and was conducted in Medline and Embase databases. Studies were included that reported costs per outcome and included both cost-effectiveness and cost-utility outcome measures. The search strategy identified publications up until August 15, 2023 were included. Abstract and full text screening was conducted and a standardized data abstraction form was used for included studies. Costs are reported in USD, 2020.

Results

Our search strategy identified 536 total titles from the search strategy, which were screened down to 25 relevant studies that provided both cost and outcome data on HIVST. There was significant heterogeneity in the HIVST intervention, study population, costs and outcomes reported among included studies. Cost per person tested ranged from $1.09-155. Cost per case diagnosed ranged from $20-1,277. Cost-utility estimates ranged from cost-saving to $1846 per DALY averted. Higher cost-effectiveness estimates were associated with more expensive testing algorithms with increased support for linkage to care and post-test counseling.

Conclusion

All studies considered HIVST cost-effective although major drivers were identified included underlying HIV prevalence, testing cost and linkage to care. HIVST is likely to be cost-effective in a LMIC context, however policy makers should be aware of the drivers of cost-effectiveness when implementing HIVST programs as these underlying factors can impact the overall cost-effectiveness of HIVST.

Sexual behavior and self-declaration of sexual orientation among people 18-64 years in Brazil: results from the Knowledge, Attitudes, and Practices survey, 2013 and the National Health Survey, 2019

BACKGROUND

Population surveys involving the monitoring of high-risk sexual behavior have been recognized as important public health tools to control the HIV epidemic and other sexually transmitted infections (STIs).

METHODS

Using data from the Knowledge, Attitudes, and Practices survey (PCAP-2013) and from the National Health Survey (PNS-2019), indicators of sexual behavior were compared according to sociodemographic characteristics among individuals aged 18-64 years, including size (%) estimates of men who have sex with men (MSM) and women who have sex with women (WSW). Specifically, the PNS-2019 prevalence estimates of homosexual, bisexual, heterosexual males and females were compared with those from the PCAP-2013. To compare PCAP and PNS proportional distributions, the Pearson's chi-square test, adjusted by the Rao-Scott's correction, was applied.

RESULTS

Size (%) estimates of MSM and WSW obtained by direct questions from the PCAP-2013, showed higher homosexuality prevalence estimates than those resulting from the PNS-2019 self-declared sexual orientation. Significant differences were found between the MSM proportions according to the PCAP-2013 (3.7%; 95% CI 3.1-4.4%) and to the PNS-2019 (2.2%; 95% CI 1.9-2.5), and between the WSW proportions (4.6%; 95% CI 4.0-5.4%) and (2.1%; 95% CI 1.8-2.4), respectively. Results from both surveys showed MSM and WSW prevalence estimates increase with educational level, decrease with age, and is larger among people who do not live with partner, live in urban areas and in state capitals. Regarding condom use at last sexual intercourse, no differences between the PCAP-2013 and the PNS-2019 estimates were found at the national level, but significant improvements were found for MSM, people aged 18-24 and 25-34 years, and individuals not living with a partner.

CONCLUSIONS

The underestimation of MSM and WSW prevalence by self-declared sexual orientation suggests that sexual minorities face many difficulties related to disclosing their sexuality and reinforces the importance of developing public health interventions for changing population attitudes and promoting sexual orientation disclosure. Moreover, the low use of condoms in both surveys (PCAP-2013 and PNS-2019) carried out 6 years apart highlights the need of public policies to expand prevention strategies for HIV infection and other STIs.