Providing comprehensive health services for young key populations: needs, barriers and gaps

Low HIV Testing and PrEP Uptake of Adolescent and Young Men who have Sex with Men in Vietnam

Little is known about HIV testing, pre-exposure prophylaxis (PrEP) awareness and uptake among adolescent and young men who have sex with men (AYMSM) in Vietnam. We conducted an online survey among AYMSM in Vietnam to determine the prevalence of HIV testing, PrEP awareness, uptake and their correlates. From December 2022-March 2023, 120 HIV-negative AYMSM from 15 to 19 years old in Hanoi and Ho Chi Minh city, Vietnam were recruited through peer referral to complete an online survey, which included questions on demographics, sexual behaviors, HIV risk perception and knowledge, HIV and sexually transmitted infections (STI) testing, PrEP awareness and uptake. Separate multivariable models were used to determine the correlates of HIV testing, PrEP awareness and uptake. Only 58% of participants had ever been tested for HIV. The majority of participants had heard of PrEP before (82%), but only 36% had ever used PrEP. HIV knowledge (aPR (adjusted prevalence ratio) = 1.59; 95%CI:1.06-2.39), a history of STI testing (aPR = 1.32; 95%CI:1.06-1.64), having had anal sex with another man (aPR = 4.49; 95%CI:1.40-14.38) and lower HIV risk perception (aPR = 0.62; 95%CI:0.47-0.83) were associated with HIV testing. HIV knowledge (aPR = 1.38; 95%CI:1.06-1.78) and a history of STI testing (aPR = 1.16; 95%CI:1.03-1.32) were also associated with PrEP awareness. Higher HIV risk perception was negatively associated with PrEP use (aPR = 0.59; 95%CI:0.35-0.99). Our findings underscored the urgent need for further research to explore the causes of the gaps in HIV testing and PrEP use as well as to design innovative interventions tailored to the needs of AYMSM to support HIV testing and PrEP use.

Attitudes toward scale-up of an Intensive Combination Approach to Rollback the Epidemic in Nigerian adolescents (iCARE) intervention for youth in Nigeria: results of a mixed methods early-implementation study

BACKGROUND

Youth living with HIV (YLH) are disproportionately impacted by HIV with poor outcomes along the entire HIV care continuum. In a 2020-2022 pilot study, iCARE Nigeria, successfully tested a combination intervention incorporating mobile health technology and peer navigation to: 1) improve testing and linkage to HIV care for young men, especially young men who have sex with men (YMSM) and 2) improve medication adherence and treatment outcomes for YLH. The intervention was scaled up to 5 sites in 3 Nigerian cities. Implementation research was used to understand site perspectives on feasibility, readiness and potential facilitators and barriers soon after scale-up commencement.

METHODS

An explanatory mixed-methods implementation study was conducted, including quantitative surveys on adoption and reach among peer navigators (PNs) and other study staff (55 testing, 172 treatment), and interviews and focus group discussions with PNs and other study staff in both intervention groups (n = 31). Data were analyzed using descriptive statistics (quantitative) and directed content analysis using the Consolidated Framework for Implementation Research and RE-AIM (qualitative).

RESULTS

Early into scale-up, PNs and other study staff in the testing and treatment interventions reported high readiness, adoption, feasibility, and appropriateness. Facilitating factors and strategies across both interventions, included supportive institutional culture, ongoing supportive supervision, provision of a manual and training, relevant PN working experiences, communication methods designed to ensure anonymity of targeted youth (testing) or confidentiality (treatment), and access to cellular data and internet. Facilitators specific to each intervention were also identified including PN knowledge of the MSM community, using multiple social media platforms for outreach (testing) and problem-solving by PN and staff to respond to client needs (treatment). Barriers in both interventions included client financial and transportation challenges, and societal stigma. Intervention-specific barriers included legal limitations for MSM and few YMSM friendly clinics (testing), limited client financial resources and cell-phone access (treatment).

CONCLUSIONS

Implementers of the initial scale-up of both components of the iCARE Nigeria intervention reported high readiness and adoption, supported by implementation strategies and facilitating factors including intervention design. These results are important for informing future work to scale-out iCARE and similar interventions to new settings.

TRIAL REGISTRATION

ClinicalTrials.gov number, NCT04950153, retrospectively registered July 6, 2021, https:// clinicaltrials.gov/.

"They are not HIV treatments drugs; they are preventive drugs (PrEP)". Experiences of PrEP uptake among vulnerable adolescent girls and young women in Tanzania

INTRODUCTION

HIV poses a significant global health concern, affecting adolescents among other populations. This is attributed to various vulnerabilities including biological factors, gender inequalities and limited access to comprehensive sexual and reproductive health services in sub-Saharan Africa. In Tanzania, adolescent girls, and young women (AGYW) face double the risk of HIV infection compared to their male counterparts. The introduction of pre-exposure prophylaxis (PrEP) in early 2018 brought hope for changing the HIV cascade in the country. However, numerous challenges still hinder PrEP uptake. Therefore, this study explored experiences of PrEP uptake among vulnerable AGYW in Tanzania.

METHODS

This study employed a phenomenological qualitative approach; 52 semi-structured interviews were carried out between May to November 2022 in the selected healthcare facilities in Tanzania. The study adopted inductive-deductive thematic analysis guided by the Social Ecological Model (SEM) to elicit the views of AGYW aged 15-24. Nvivo software was utilised to organise data.

RESULTS

This study has uplifted barriers and facilitators on PrEP uptake among AGYW in Tanzania. The barriers are categorized at individual, interpersonal, and institutional levels. The individual level barriers included pre-requisites for initiating PrEP, disbelief in the effectiveness of PrEP, interference of refill hours with working hours, financial constraints, and adherence to the pills. The interpersonal level barriers included misconceptions about PrEP pills, and labelling of PrEP users. The institutional level barriers included inadequate privacy, PrEP drug stockout, being turned away by health care facilities (HCF), long waiting times, and distance to the HCF. Facilitators included factors at individual level (experienced benefit of PrEP, adequate PrEP knowledge, having multiple partners, perceived risk due to the nature of the work, PrEP ensuring privacy), interpersonal level (support from social networks), and institutional level (Free availability of PrEP, receiving refill reminders).

CONCLUSIONS

To overcome barriers to PrEP uptake among AGYW, it is crucial to develop multi-level interventions that consider personal, social, and structural factors hindering PrEP uptake. Implementing strategies like prioritizing off-site PrEP delivery and expanding community outreach for PrEP awareness can help dispel misconceptions and enhance uptake.

A Pandemic Adaptation and Its Aftermath: Using AI and In-Person Facilitation for Community Health Education in Liberia and the United States

Health promotion commonly focuses on supporting youth wellness, as health behaviors acquired in childhood and adolescence tend to have a significant impact on an individual's future. Adolescent health education is associated with positive health and educational outcomes, yet young people experience barriers to fully engaging in learning about health issues that are often unique to their social location. Barriers for successful engagement in health education for African diaspora youth in North American and European contexts may include school initiatives built around engagement models that do not center Black youth; for Black youth in majority-Black societies, barriers may include access to resources or exclusionary practices based on other social characteristics. Global health promotion has used a variety of multimodal educational tools from radio to more recently online engagement, especially in African contexts, to reach young people. This essay shares experiences using AI and in-person facilitation to engage in community health education with youth in Liberia and the United States. In our practice, we found that there are far more underlying systemic and structural similarities to the inequities experienced between African and Black American youth and that utilizing AI tools alongside of in-person discussion may contribute to better outcomes for youth health education.

Effective preexposure prophylaxis in young women and girls, a key population for HIV prevention

PURPOSE OF REVIEW

Although there is substantial momentum to scale up preexposure prophylaxis (PrEP) for HIV prevention in adolescent girls and young women (AGYW) at risk of HIV acquisition, this key population has demonstrated difficulty in sustained PrEP use. Despite being a user-controlled and discreet prevention option, effective oral PrEP use requires a series of complex daily decisions in the life of the PrEP user. In this review, we describe how the number of decisions AGYW have to execute for effective and continued PrEP use may potentially be reduced by providing simplified, integrated, differentiated sexual and reproductive health services that include PrEP, and introducing a choice of PrEP products, including less frequently dosed, longer acting and/or multipurpose prevention technology (MPT) products.

RECENT FINDINGS

PrEP uptake and effective use are enhanced when AGYW experience PrEP service delivery channels as convenient, integrated with their other sexual and reproductive health needs and matching their experiences (including limited autonomy) and lifestyle. Longer acting or less frequently dosed PrEP products or MPTs may reduce the cognitive burden associated with prevention decision-making and is, therefore, likely more suitable for the majority of AGYW who struggle with daily pill adherence.

SUMMARY

In the scaling up of HIV prevention for AGYW, implementers are encouraged to consider both PrEP products and PrEP delivery outlet preferences. Understanding and responding to AGYW's different needs will allow for preferred PrEP delivery outlets and choice in PrEP products, leading to a greater likelihood of effective PrEP use in this key population.

The impact of COVID-19 restrictions on HIV prevention and treatment services for key populations in South Africa: an interrupted time series analysis

BACKGROUND

Key populations (KP), including men who have sex with men (MSM), female sex workers (FSW), and transgender women (TGW), experience a disproportionate burden of HIV, even in generalized epidemics like South Africa. Given this disproportionate burden and unique barriers to accessing health services, sustained provision of care is particularly relevant. It is unclear how the COVID-19 pandemic and its associated restrictions may have impacted this delivery. In this study, we aimed to describe patterns of engagement in HIV prevention and treatment services among KP in South Africa and assess the impact of different COVID-19 restriction levels on service delivery.

METHODS

We leveraged programmatic data collected by the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported KP partners in South Africa. We divided data into three discrete time periods based on national COVID-19 restriction periods: (i) Pre-restriction period, (ii) High-level restriction period, and (iii) After-high level restriction period. Primary outcomes included monthly total HIV tests, new HIV cases identified, new initiations of pre-exposure prophylaxis (PrEP), and new enrollments in antiretroviral therapy (ART). We conducted interrupted time series segmented regression analyses to estimate the impact of COVID-19 restrictions on HIV prevention and treatment service utilization.

RESULTS

Between January 2018 and June 2022, there were a total of 231,086 HIV tests, 27,051 HIV positive cases, 27,656 pre-exposure prophylaxis (PrEP) initiations, and 15,949 antiretroviral therapy initiations among MSM, FSW and TGW in PEPFAR-supported KP programs in South Africa. We recorded 90,457 total HIV tests during the 'pre-restriction' period, with 13,593 confirmed new HIV diagnoses; 26,134 total HIV tests with 2,771 new diagnoses during the 'high-level restriction' period; and 114,495 HIV tests with 10,687 new diagnoses during the after high-level restriction period. Our Poisson regression model estimates indicate an immediate and significant decrease in service engagement at the onset of COVID-19 restrictions, including declines in HIV testing, treatment, and PrEP use, which persisted. As programs adjusted to the new restrictions, there was a gradual rebound in service engagement, particularly among MSM and FSW. Towards the end of the high-level restriction period, with some aspects of daily life returning to normal but others still restricted, there was more variability. Some indicators continued to improve, while others stagnated or decreased.

CONCLUSION

Service provision rebounded from the initial shock created by pandemic-related restrictions, and HIV services were largely maintained for KP in South Africa. These results suggest that HIV service delivery among programs designed for KP was able to be flexible and resilient to the evolving restrictions. The results of this study can inform plans for future pandemics and large-scale disruptions to the delivery of HIV services.

Exploring the uptake of sexual and reproductive health services for lesbians and bisexual women in Bulawayo, Zimbabwe. A quantitative enquiry

Background

Sexual and reproductive healthcare is essential for all individuals, including LGBTQ+ individuals. However, lesbians and bisexual women often lack tailored services, leading to underutilization. This study aimed to assess the availability and uptake of sexual and reproductive health services for lesbian and bisexual Bulawayo women.

Methods

A cross-sectional study surveyed 67 lesbian and bisexual women recruited through the Voice of the Voiceless Organization. The participants completed a structured questionnaire on available services, factors influencing their uptake, and access challenges. Cross-tabulation was used to examine the associations between variables. Data were analyzed using Microsoft Excel and STATA Version 15 S.E.

Results

Most respondents were bisexual women aged 35 years. Cross-tabulations revealed significant associations between delayed or avoided services and the absence of specific services for lesbians and bisexual women as well as the presence of gender identity nondiscrimination policies.

Conclusion

Sexual and reproductive health programs play a vital role in meeting lesbian and bisexual women's needs. Improving service uptake requires strengthening the linkages between clinics and sexual health education programs, providing lesbian and bisexual women-friendly clinical services, and ensuring access to comprehensive information.

Transactional sex and age-disparate sexual partnerships among adolescent girls and young women in Tanzania

Introduction

Adolescent girls and young women (AGYW) continue to experience a high incidence of HIV in southern and eastern Africa, even in the context of large-scale HIV prevention interventions. In Tanzania, AGYW account for the largest proportion of new infections and have a higher risk of HIV acquisition than males of comparable age.

Methods

We used routinely collected data from the PEPFAR/USAID-funded Sauti Project, a large combination HIV prevention program, to examine the relationship between transactional sex and sex with older partners among AGYW in Tanzania (2015-2020). Out-of-school AGYW 15-24 years completed a vulnerability index and were tested for HIV. We estimated weighted prevalence ratios (PR) and 95% confidence intervals (CI) for the associations of transactional sex (sex exchanged for money/services/gifts outside of sex work) and sex with older partners (≥5-years older, ≥10-years older) with prevalent HIV. Age cutoffs of 5 and 10 years were used to align partner age differences with age-disparate and intergenerational sex, respectively. We assessed potential synergism between exposures, and subgroup analyses explored associations among girls 15-19.

Results

Sixty seven thousand three hundred fifty seven AGYW completed the vulnerability index and 14,873 had captured HIV testing records. Median age was 20 years (IQR 18-22). Transactional sex and age-disparate sex were common (35% and 28%, respectively); 13% of AGYW reported both behaviors. HIV prevalence was associated with both transactional sex (PR: 1.28; 95% CI 1.00-1.63) and age-disparate sex (PR:1.26, 95% CI 0.99-1.60). In common referent analysis, transactional sex remained strongly associated with HIV, even in the absence of age-disparate sex (PR 1.41; 95% CI 1.02-1.94).

Discussion

Evidence of statistical synergism was not present, suggesting both transactional sex and age-disparate sex operate through similar pathways to increase HIV risk. Increased specificity within HIV prevention programs is needed to better meet the sexual and reproductive health needs of AGYW at high risk of HIV in Tanzania, including investment in tailored youth-friendly strategies for AGYW who have been marginalized from the current HIV response.

A Systematic Review of Interventions for Young Men Who Have Sex With Men and Young Transgender Women Living with HIV

Young men who have sex with men (YMSM) and young transgender women (YTGW) have unique challenges to HIV care. We conducted a systematic review to summarize behavioral and structural interventions exclusively targeting YMSM and YTGW living with HIV. We screened 6546 records published through August 19th, 2022 from six databases. For eligibility, studies needed to involve structural or behavioral interventions exclusively targeting YMSM and/or YTGW living with HIV or presenting disaggregated data in this group. Quality assessment was performed using the ICROMS checklist. Twenty studies from 18 interventions were included in the review. There was considerable heterogeneity in intervention characteristics, including population, location, content and format of the interventions and targeted outcomes. Half of the interventions were described as pilot studies, and all but one study was conducted in the United States. The most common outcomes included the HIV care continuum, followed by HIV knowledge and self-efficacy, HIV-risk behaviors and mental health. The evidence base remained sparse, and the results on effectiveness were inconsistent, with some interventions reporting improved outcomes among participants after receiving treatment and others not reporting any meaningful changes. Although there has been some progress in the development of interventions targeting this group, we highlighted several directions for future research. Interventions expanding to low-resource settings, addressing structural barriers, and targeting different aspects of health among participants are warranted. Rigorous studies with larger sample sizes that follow participants over longer periods are necessary to increase the strength of the evidence.

Fast-track interventions for HIV and AIDS epidemic control among key populations: A rapid review

BACKGROUND

Targeted interventions for key populations remain critical for realisation of epidemic control for human immunodeficiency virus (HIV) infection because of the causal relationship between HIV infection in the general population and among key population groups.

AIM

To consolidate evidence on the fast-track interventions towards achieving HIV epidemic control among key populations.

METHODS

A rapid scoping review was conducted using the methodological framework by Arksey and O' Malley. The Population, Intervention, Context and Outcome (PICO) framework was used to identify relevant studies using key words with Boolean operators in electronic data bases, namely CINHAL, Web of Science, Psych Info and Sabinet. Studies were extracted using a modified data extraction tool, and results were presented narratively.

RESULTS

A total of 19 articles were included in this review. Most articles were primary studies (n = 17), while another involved the review of existing literature and policies (n = 2) and routinely collected data (n = 1). Most studies were conducted in the United States of America (n = 6), while another were conducted in China, Kenya, Botswana, South Africa and Mozambique. All studies revealed findings on tested interventions to achieve HIV epidemic control among key populations.

CONCLUSION

Effective interventions for HIV epidemic control were stand-alone behavioural preventive interventions, stand-alone biomedical preventive strategies and combination prevention approaches. Furthermore, the findings suggest that effective activities to achieve HIV epidemic control among key populations should be centred around prevention.Contribution: The findings of this study have policy and practice implications for high HIV burden settings such as South Africa in terms of interventions to facilitate realisation of the Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets, thereby contributing to HIV epidemic control.

Assessing high-risk sexual practices associated with human immunodeficiency virus infection among young female sex workers in Lubumbashi, Democratic Republic of the Congo: a cross-sectional study

INTRODUCTION

Young female sex workers (YFSWs) face a higher risk of HIV infection compared to older workers, but there is a lack of comprehensive data on their sexual practices and HIV infection risks, which may present unique challenges and vulnerabilities. The study aimed to identify high-risk sexual practices associated with HIV infection among YFSWs in Lubumbashi.

METHODS

We conducted an analytical cross-sectional study and used a comprehensive sample of all YFSWs who presented to the HIV/Sexually Transmitted Infections Screening and Treatment Center in Lubumbashi between April 2016 and December 2017. We collected data on socio-demographic characteristics and behavioral risk factors of female sex workers were collected using a structured questionnaire. Using STATA version 16, multivariate logistic regression was fitted and the results were presented as adjusted odds ratios (aORs) with their 95% confidence intervals (95% CIs).

RESULTS

A total of 572 YFSWs were included in the study, 19 of whom were HIV-positive (3.3%; 95% CI: 2.1-5.1%). Participants who were forced to have sex (aOR = 12.2; 95% CI: 3.2-46.4; p < 0.0001), those who did not use condoms systematically (aOR = 4.1; 95% CI: 1.3-13.0; p = 0.018), and those who had anal sex (aOR = 23.8; 95% CI: 6.9-82.4; p < 0.0001) were more likely to be HIV-positive.

CONCLUSION

The study reveals a concerning trend of higher hospital HIV prevalence among YFSWs compared to the general Congolese population. It also highlights a significant link between high-risk sexual practices and HIV infection, highlighting the need for urgent interventions.

Exploring challenges to the uptake of sexual and reproductive health services among lesbian and bisexual women in Bulawayo, Zimbabwe: a qualitative enquiry

Background

Reproductive healthcare is essential for all people, including lesbian and bisexual women. However, lesbians and bisexual women are among society's most marginalised and excluded members.

Objective

This study aimed to explore the challenges faced by lesbian and bisexual women in accessing Sexual and Reproductive Health (SRH) Services in Bulawayo, Zimbabwe.

Design

An exploratory, descriptive qualitative study was conducted on two populations that included eight participants identified through the Voice of the Voiceless organisation in Bulawayo and 10 key informants and probed the challenges faced by lesbians and bisexual women when accessing SRH services.

Methods

Data were gathered through 10 key informant interviews and 1 focus group discussion (FGD; with 8 participants). The interviews and FGDs were recorded, transcribed verbatim, coded and thematically analysed.

Results

The themes that emerged included the uptake of SRH services among lesbians and bisexual women, the challenges faced by lesbians and bisexual women when accessing SRH services, and strategies to aid the uptake of SRH services by lesbians and bisexual women. The findings showed that the uptake of SRH services was generally low and was influenced by factors such as clinical settings. The challenges mentioned included stigma and the unavailability of specific lesbian and bisexual women's services. By contrast, the most frequent strategies included affirmative training for healthcare providers and improved clinical settings to become friendly and inclusive.

Conclusion

There is an imperative for targeted SRH services that address the distinct needs of lesbians and bisexual women, in line with the 95-95-95 strategy and Sustainable Development Goals target 3.7. The observed low uptake of these services can be attributed to several systemic barriers, including inadequate training of health providers, negative attitudes and lack of inclusive policies. Enhancing the sensitivity of health facilities, strengthening links to sexual health education and implementing supportive legal frameworks are essential steps to improve SRH outcomes in this population. These findings elucidate critical gaps within the current healthcare system and present significant opportunities for policymakers to formulate evidence-based strategies to ensure equitable access to SRH services, thereby advancing public health objectives.

"I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia

ABSTRACT

Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.

Young women who sell sex in Bangui, Central African Republic: a neglected group highly vulnerable to HIV

BACKGROUND

The objectives of this study were to determine the association between the vulnerability factors linked to human immunodeficiency virus (HIV) and other sexually transmitted infection among the young women who sell sex (YWSS) group (15-24 years) and adult sex workers, engaged in consensual sex for money (AFSW).

METHODS

A cross-sectional study was conducted among AFSW involved in commercial sex transactions. Prevalence ratios (PR) analysis was carried out using log-binomial regression model.

RESULTS

The prevalence of HIV-1 was 29.4% among YWSS compared to 19.6% among female sex worker (PR = 1.43 [1.07-1.91]). Consistent condoms use last 3 months were very low at 22.3% and 41.2%, respectively (PR = 0.52 [0.37-0.74]), the low education level among YWSS versus AFSW (PR = 0.55 [0.40-0.76]); YWSS having been a victim of sexual violence in the last 12 months (PR = 2.00 [1.52-2.63]), were also more likely to be HIV positive.

CONCLUSIONS

The YWSS had a high prevalence of HIV, experienced other socioeconomic vulnerabilities and remain a key population for comprehensive HIV programs. To reach all YWSS, programs need to consider many outreach programs and address the shared determinants of HIV risk.

The impact of community-based integrated HIV and sexual and reproductive health services for youth on population-level HIV viral load and sexually transmitted infections in Zimbabwe: protocol for the CHIEDZA cluster-randomised trial

BACKGROUND

Youth have poorer HIV-related outcomes when compared to other age-groups. We describe the protocol for a cluster randomised trial (CRT) to evaluate the effectiveness of community-based, integrated HIV and sexual and reproductive health services for youth on HIV outcomes.

PROTOCOL

The CHIEDZA trial is being conducted in three provinces in Zimbabwe, each with eight geographically demarcated areas (clusters) (total 24 clusters) randomised 1:1 to standard of care (existing health services) or to the intervention. The intervention comprises community-based delivery of HIV services including testing, antiretroviral therapy, treatment monitoring and adherence support as well as family planning, syndromic management of sexually transmitted infections (STIs), menstrual health management, condoms and HIV prevention and general health counselling. Youth aged 16-24 years living within intervention clusters are eligible to access CHIEDZA services. A CRT of STI screening (chlamydia, gonorrhoea and trichomoniasis) is nested in two provinces (16 of 24 clusters). The intervention is delivered over a 30-month period by a multidisciplinary team trained and configured to provide high-quality, youth friendly services.Outcomes will be ascertained through a population-based survey of 18-24-year-olds. The primary outcome is HIV viral load <1000 copies/ml in those living with HIV and proportion who test positive for STIs (for the nested trial). A detailed process and cost evaluation of the trial will be conducted.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Medical Research Council of Zimbabwe, the Biomedical Research and Training Institute Institutional Review Board and the London School of Hygiene & Tropical Medicine Research Ethics Committee. Results will be submitted to open-access peer-reviewed journals, presented at academic meetings and shared with participating communities and with national and international policy-making bodies.

TRIAL REGISTRATION

https://clinicaltrials.gov/: NCT03719521.

The impact of community-based integrated HIV and sexual and reproductive health services for youth on population-level HIV viral load and sexually transmitted infections in Zimbabwe: protocol for the CHIEDZA cluster-randomised trial

Background

Youth have poorer HIV-related outcomes when compared to other age-groups. We describe the protocol for a cluster randomised trial (CRT) to evaluate the effectiveness of community-based, integrated HIV and sexual and reproductive health services for youth on HIV outcomes.

Protocol

The CHIEDZA trial is being conducted in three provinces in Zimbabwe, each with eight geographically demarcated areas (clusters) (total 24 clusters) randomised 1:1 to standard of care (existing health services) or to the intervention. The intervention comprises community-based delivery of HIV services including testing, antiretroviral therapy, treatment monitoring and adherence support as well as family planning, syndromic management of sexually transmitted infections (STIs), menstrual health management, condoms and HIV prevention and general health counselling. Youth aged 16-24 years living within intervention clusters are eligible to access CHIEDZA services. A CRT of STI screening (chlamydia, gonorrhoea and trichomoniasis) is nested in two provinces (16 of 24 clusters). The intervention is delivered over a 30-month period by a multidisciplinary team trained and configured to provide high-quality, youth friendly services.Outcomes will be ascertained through a population-based survey of 18-24-year-olds. The primary outcome is HIV viral load <1000 copies/ml in those living with HIV and proportion who test positive for STIs (for the nested trial). A detailed process and cost evaluation of the trial will be conducted.

Ethics and Dissemination

The trial protocol was approved by the Medical Research Council of Zimbabwe, the Biomedical Research and Training Institute Institutional Review Board and the London School of Hygiene & Tropical Medicine Research Ethics Committee. Results will be submitted to open-access peer-reviewed journals, presented at academic meetings and shared with participating communities and with national and international policy-making bodies.

Trial Registration

https://clinicaltrials.gov/: NCT03719521.

Neglected gaps in improving the health, wellbeing, and care for sexual and gender minority young people living in low- and lower-middle- income countries: a scoping review

BACKGROUND

There is a lack of reliable data on the size, characteristics, and experiences of sexual and gender minority (SGM) young people (ages 10-24) in low- and lower-middle- income countries (LMICs). This review examines the research conducted in the last thirteen years with and about SGM young people living in low-income settings and seeks to answer the question: What is known about the mental and physical health needs, safety, and wellbeing of SGM young people living in LMICs?

METHODS

We conducted a scoping review informed by the methodological frameworks put forth by Arksey and O'Malley and the Joanna Briggs Institute. We systematically searched two general social science databases and one topic-specific database for peer-reviewed papers, of any research design, that included SGM young people or explored attitudes toward SGM young people in LMICs. We included papers that reported on factors influencing the health and wellbeing of SGM populations, including physical and mental health, healthcare-seeking behaviors, substance use, experiences of discrimination and/or stigma, experiences of violence and abuse (emotional, physical, and/or sexual), economically motivated paid sex practices, housing or economic security, and attitudes of others toward SGM populations.

RESULTS

Of the 5,409 unique records identified, 79 papers drawing from data collected from 74 unique studies met the inclusion criteria. Only 50 of the 79 papers included SGM young people as participants, with just 13 focusing exclusively on SGM young people ages 10-24. The included papers were classified into three thematic groupings: attitudes toward SGM populations (n = 26), risks to health (n = 40), and experiences of stigma and discrimination (n = 13).

CONCLUSION

The findings indicate that the health and wellbeing of SGM young people in LMICs has been historically under-researched. While SGM young people have received more attention from researchers in recent years, the body of literature as a whole is disjointed and sparse, and often studies are about SGM young people, rather than with and for them. Our review highlights the need for more and better research, more accurate and disaggregated demographic data, and leadership and participation of SGM-led community-based organizations in the co-design of studies that focus on SGM young people.

Sexual and Gender Minorities Inclusion and Uptake of Sexual and Reproductive Health Services: A Scoping Review of Literature

Despite the efforts to ensure that sexual and reproductive health services are integrated into global, regional, and national initiatives, a significant number of countries are overwhelmed by frames of exclusion and violations of fundamental human rights, particularly for sexual and gender minority groups such as lesbians, gays, bisexuals, and transgender people. This study sought to review the literature on access and barriers faced by sexual and gender minorities. A scoping literature review was conducted on literature that focused on sexual and gender minorities and sexual and reproductive health services and published in the English language. Studies were independently screened and coded, categorizing themes such as policies, uptake of services, barriers to sexual and reproductive health access, and strategies to aid the uptake of services. The search yielded 1,148 literature sources, of which 39 met the inclusion criteria and were reviewed. The average sexual and reproductive health service uptake was generally low overall and was influenced by factors such as clinical settings, punitive laws, and availability of services specific to sexual and gender minorities. Noted strategies to aid sexual and reproductive health uptake include education, friendly health care facilities, availability of specific services, and legislative reform. The sexual and reproductive health program is an important component of short-term and long-term sexual and reproductive health needs. Health intervention initiatives targeted at improving or increasing sexual and reproductive health uptake must be supported by suitable legal and regulatory framework contexts and based on context-specific evidence.

Facilitators and barriers to engaging with the DREAMS initiative among young women who sell sex aged 18-24 in Zimbabwe: a qualitative study

BACKGROUND

Adolescent girls and young women (AGYW) are at high risk of contracting HIV and exchanging sex for financial or material support heightens their risk. In Zimbabwe, the DREAMS initiative integrated education and employment opportunities within HIV health promotion and clinical services for vulnerable young women, including those who sell sex. While most participants accessed health services, fewer than 10% participated in any social programmes.

METHODS

We conducted semi-structured qualitative interviews with 43 young women aged 18-24 to understand their experiences of engaging with the DREAMS programme. We purposively sampled participants for diversity in level of education, type and location of selling sex. We analysed the data by applying the Theoretical Domains Framework to explore facilitators and barriers to engaging with DREAMS.

RESULTS

Eligible women were motivated by hopes of escaping poverty, and their longer-term engagement was sustained through exposure to new social networks, including friendships with less vulnerable peers. Barriers included opportunity costs and expenses such as transport or equipment required for job placements. Participants also described pervasive stigma and discrimination related to their involvement in selling sex. Interviews highlighted the young women's struggles in a context of entrenched social and material deprivation and structural discrimination that hindered their ability to take up most of the social services offered.

CONCLUSIONS

This study demonstrates that while poverty was a key driver of participation in an integrated package of support, it also constrained the ability of highly vulnerable young women to benefit fully from the DREAMS initiative. Multi-layered HIV prevention approaches such as DREAMS that seek to alter complex and longstanding social and economic deprivation address many of the challenges faced by YWSS but will only succeed if the underlying drivers of HIV risk among YWSS are also addressed.

Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa

Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.

Inconsistent condom use with casual partners among men who have sex with men in Brazil: a cross-sectional study

OBJECTIVE

This study aimed to evaluate factors associated with inconsistent condom use with casual partners in a population of men who have sex with men (MSM) in Brazil.

METHODS

In 2016, 4,176 MSM >18 years were enrolled in 12 capitals of Brazil using a Respondent Driven Sampling (RDS) method. For the construction of the outcome, we evaluated questions about condom use in all anal intercourse (receptive and insertive) in the previous six months and the last sexual intercourse. Estimates were calculated using a weighted complex sample design. We performed a logistic regression analysis to determine the associations between sociodemographic and behavioral factors and inconsistent condom use in sexual relationships with casual male partners.

RESULTS

More than half of our sample (50.8%) had not used condoms consistently with casual partners in the previous six months. Inconsistent condom use was significantly associated with: low education (weighted odds ratio - wOR: 1.55; 95% confidence interval - CI 0.99-2.40), lack of counseling on sexually transmitted infections STI (wOR: 1.51; 95%CI 1.05-2.17), non-use of condoms at sexual debut (wOR: 3.05; 95%CI 2.12-4.40) and moderate and high perceived risk for HIV (wOR: 1.51; 95%CI 1.07-2.14). Higher age was negatively associated with inconsistent condom use (wOR=0.97, 95%CI 0.89-0.99).

CONCLUSION

Despite being an individual behavior, condom use is related to factors beyond the individual scope. HIV/Aids prevention policies should focus on younger MSM, providing qualified information about condom use, preferably before the beginning of their sexual life.

'I was in need of somewhere to release my hurt:' Addressing the mental health of vulnerable adolescent mothers in Harare, Zimbabwe, through self-help groups

Background

Adolescents experiencing multiple vulnerabilities, including poverty, curtailed education, transactional sex and early childbearing, are at risk of poor mental health. In Zimbabwe, girls who are pregnant or new mothers and involved in selling sex struggle to cope with the combined pressures of parenthood, financial insecurity, and social stigma. A pilot intervention brought such girls together into self-help groups to increase peer support, resources and skills.

Objective

This study aimed to explore whether and how participation in a self-help group intervention affected vulnerable young mothers’ experiences and perceptions of mental health stressors.

Methods

Self-help groups received 12 participatory sessions over 6 months. Eighteen semi-structured interviews and three focus group discussions were held with participants and drop-outs. Before and after the intervention, participants completed the locally validated 14-item Shona Symptom Questionnaire tool to indicate the probable prevalence of common mental health disorders.

Results

Adolescent girls described mutually reinforcing stressors in their lives and reported low self-esteem and anxiety. Key themes emerging from qualitative data centred around girls’ struggles with adverse life events, the burden of new motherhood, social isolation related to sex work and self-help groups as a source of hope. Participants joined groups to obtain support and felt their mental well-being improved due to new social networks, feelings of solidarity with peers, and increased confidence for positive action, that is, seeking health services for themselves and their babies. Prior to enrolment 16% showed signs of possible common mental disorders falling to 2% at follow-up.

Conclusions

Participants believed involvement in interactive self-help groups improved their mental health by strengthening peer support and engendering hope for the future. Although reduced mental distress cannot be attributed to the programme, the pilot intervention offers a low-cost approach that could be rigorously tested and adapted to a wide range of community settings.

HIV, sexual violence, and termination of pregnancy among adolescent and adult female sex workers in Malawi: A respondent-driven sampling study

Female Sex Workers (FSWs) are a hard-to-reach and understudied population, especially those who begin selling sex at a young age. In one of the most economically disadvantaged regions in Malawi, a large population of women is engaged in sex work surrounding predominantly male work sites and transport routes. A cross-sectional study in February and April 2019 in Nsanje district used respondent driven sampling (RDS) to recruit women ≥13 years who had sexual intercourse (with someone other than their main partner) in exchange for money or goods in the last 30 days. A standardized questionnaire was filled in; HIV, syphilis, gonorrhea, and chlamydia tests were performed. CD4 count and viral load (VL) testing occurred for persons living with HIV (PLHIV). Among 363 study participants, one-quarter were adolescents 13-19 years (25.9%; n = 85). HIV prevalence was 52.6% [47.3-57.6] and increased with age: from 14.7% (13-19 years) to 87.9% (≥35 years). HIV status awareness was 95.2% [91.3-97.4], ART coverage was 98.8% [95.3-99.7], and VL suppression 83.2% [77.1-88.0], though adolescent FSWs were less likely to be virally suppressed than adults (62.8% vs. 84.4%). Overall syphilis prevalence was 29.7% [25.3-43.5], gonorrhea 9.5% [6.9-12.9], and chlamydia 12.5% [9.3-16.6]. 72.4% had at least one unwanted pregnancy, 17.9% had at least one abortion (40.1% of which were unsafe). Half of participants reported experiencing sexual violence (SV) (47.6% [42.5-52.7]) and more than one-tenth (14.2%) of all respondents experienced SV perpetrated by a police officer. Our findings show high levels of PLHIV-FSWs engaged in all stages of the HIV cascade of care. The prevalence of HIV, other STIs, unwanted pregnancy, unsafe abortion, and sexual violence remains extremely high. Peer-led approaches contributed to levels of ART coverage and HIV status awareness similar to those found in the general district population, despite the challenges and risks faced by FSWs.

Analysis of four syringe dispensing machine point-of-access data 2017-2020 in Melbourne, Australia: machine utilisation and client demographics

BACKGROUND

Australian needle and syringe distribution occurs via a mix of modalities, including syringe dispensing machines (SDMs). SDMs are electronic vending machines providing (often) 24-h access to needles/syringes and may attract greater numbers of people who are younger, female, and/or have limited connection to health care services compared to individuals accessing fixed-site needle and syringe programs (NSPs). However, validating the demographic characteristics of SDM clients has proven difficult in previous research.

METHODS

In this paper, we analyse SDM order and client demographic data from four SDMs located in South-East Melbourne, Australia, and compare this against the managing fixed-site NSP between May 2017 and December 2020. SDM data were collected via a novel 0-9 numeric keypad input tool. Via the tool, SDM clients were requested to input their categorised age, gender and postcode. Given the novelty of the tool, we evaluate the feasibility of the data collection method. We analysed data according to: (1) total SDM orders made, (2) estimated 'unique SDM presentations' and (3) describing the demographics of unique SDM clients. Importantly, we noted substantial invalid demographic data, and consequently, severely restricted data for analysis.

RESULTS

There were 180,989 SDM orders made across the four SDMs to an estimated 90,488 unique SDM presentations. There was little variation in unique presentations across days of the week, but 69% occurred out of NSP operating hours. Across the study period, the SDMs distributed 66% of the number of syringes distributed by the fixed-site NSP. Due to invalid demographic data, our restriction method provided only 10,914 (6% of all data) unique presentations for analysis. There were some demographic differences between SDM and NSP client, but these should be treated with caution.

CONCLUSIONS

The data collection tool provides a novel means of comparing SDM and fixed-site presentations, demonstrating the substantial expansion of service via the SDMs. However, the validity of the demographic data was highly questionable and requires significant data coding, meaning it is not feasible for community NSPs. While we recommend the inclusion of automatically collected SDM order data, the use of a 0-9 numeric keypad to collect demographic data-while an innovation-requires alteration to support NSP data.

"I am not shy anymore": A qualitative study of the role of an interactive mHealth intervention on sexual health knowledge, attitudes, and behaviors of South African adolescents with perinatal HIV

BACKGROUND

South Africa has one of the highest burdens of adolescents with perinatally-acquired HIV (APHIV) in the world. APHIV in South Africa have limited access to sexual and reproductive health (SRH) education and services specific to their HIV status. When lacking comprehensive SRH education, APHIV are prone to sexual risk behaviors that can lead to unintended pregnancy, sexually transmitted infections, and HIV transmission. The use of mHealth interventions has been shown to deliver information, foster social support, and improve decision-making skills. In this study, we evaluate how an mHealth intervention influences sexual health knowledge and behaviors in APHIV.

METHODS

We purposively enrolled adolescents from the intervention arm of a randomized clinical trial assessing a multi-module, moderated WhatsApp-based intervention-Interactive Transition Support for Adolescents Living with HIV (InTSHA)-within a government supported clinic in KwaMashu, an urban township of KwaZulu-Natal, South Africa. We conducted in-depth interviews based on World Health Organization guidelines for asking adolescents about SRH. We thematically analyzed data through an iterative, team-based coding approach combining deductive and inductive elements to contextualize SRH attitudes, knowledge, and behaviors before and after receiving the InTSHA intervention.

RESULTS

Of the 21 participants, 13 (61.9%) were female and the mean age was 16.6 years. Most participants reported first learning about SRH as young teenagers in school through non-targeted and negative ways, seeking clarification through peers and the internet rather than clinicians or caregivers. Participants reported that InTSHA provided a holistic perspective on relationships, gender, and sexuality specific to growing up with HIV in South Africa. They praised the ability to give and receive information from peers in a moderated setting through the mHealth intervention, building their confidence, decision-making skills, and communication with partners and caregivers throughout their everyday lives. Despite reporting some technological challenges, adolescents agreed that InTSHA was convenient, confidential, and user-friendly.

CONCLUSIONS

South African APHIV receive incomplete and conflicting sexual education from peers, caregivers, teachers, and technology that can be supplemented by mHealth curricula targeted for the unique needs of APHIV. Future, scaled-up mHealth interventions can lower SRH stigma by expanding access to sexual education and peer support, supplementing adolescents' existing SRH education.

HIV prevention programme with young women who sell sex in Mombasa, Kenya: learnings for scale-up

INTRODUCTION

In 2018, the National AIDS and sexually transmitted infection (STI) Control Programme developed a national guidelines to facilitate the inclusion of young women who sell sex (YWSS) in the HIV prevention response in Kenya. Following that, a 1-year pilot intervention, where a package of structural, behavioural and biomedical services was provided to 1376 cisgender YWSS to address their HIV-related risk and vulnerability, was implemented.

METHODS

Through a mixed-methods, pre/post study design, we assessed the effectiveness of the pilot, and elucidated implementation lessons learnt. The three data sources used included: (1) monthly routine programme monitoring data collected between October 2019 and September 2020 to assess the reach and coverage; (2) two polling booth surveys, conducted before and after implementation, to determine the effectiveness; and (3) focus group discussions and key informant interviews conducted before and after intervention to assess the feasibility of the intervention. Descriptive analysis was performed to produce proportions and comparative statistics.

RESULTS

During the intervention, 1376 YWSS were registered in the programme, 28% were below 19 years of age and 88% of the registered YWSS were active in the last month of intervention. In the survey, respondents reported increases in HIV-related knowledge (61.7% vs. 90%, p <0.001), ever usage of pre-exposure prophylaxis (8.5% vs. 32.2%, p < 0.001); current usage of pre-exposure prophylaxis (5.3% vs. 21.1%, p<0.002); ever testing for HIV (87.2% vs. 95.6%, p <0.04) and any clinic visit (35.1 vs. 61.1, p <0.001). However, increase in harassment by family (11.7% vs. 23.3%, p<0.04) and discrimination at educational institutions (5.3% vs. 14.4%, p<0.04) was also reported. In qualitative assessment, respondents reported early signs of success, and identified missed opportunities and made recommendations for scale-up.

CONCLUSIONS

Our intervention successfully rolled out HIV prevention services for YWSS in Mombasa, Kenya, and demonstrated that programming for YWSS is feasible and can effectively be done through YWSS peer-led combination prevention approaches. However, while reported uptake of treatment and prevention services increased, there was also an increase in reported harassment and discrimination requiring further attention. Lessons learnt from the pilot intervention can inform replication and scale-up of such interventions in Kenya.

A retrospective cross sectional study assessing factors associated with retention and non-viral suppression among HIV positive FSWs receiving antiretroviral therapy from primary health care facilities in Kampala, Uganda

BACKGROUND

Patient retention in care and sustained viral load suppression are a cornerstone to improved health and quality of life, among people living with HIV. However, challenges of retention on ART remain among female sex workers (FSWs). We report lost to follow up (LTFU), viral load suppression, and the associated factors among FSWs that access HIV treatment at primary health care facilities in Kampala.

METHODS

We retrospectively abstracted and analysed patient management data of HIV positive FSWs who enrolled in care between January 2018 to December 2020. LTFU was defined as failure of a FSW to return for treatment at least 90 days from the date of their last clinic appointment. We defined viral suppression as having a last viral load of ≤ 1000 copies/ml preceding data abstraction. Data were analysed using Stata 15.1 software.

RESULTS

A total of 275 FSWs were included in our study sample. We found low retention of 85.1% (n = 234) at six months, corresponding to LTFU of 14.9 (n = 41) within the same period. Retention decreased with duration of being in care up to 73.5% (n = 202) at 24 months, and this translates to LTFU of 26.5% (n = 73). Viral load testing coverage was 62% (n = 132) and of these, 90.9% (n = 120) were virally suppressed. Factors associated with LTFU in univariable logistic regression; and viral load suppression in multivariable logistic regression models were; having a telephone contact (OR: 0.3, 95% CI: 0.1-0.9 p = 0.031), having enrolled in HIV care aged ≥ 35 years (OR: 0.5, 95% CI: 0.2-1.0 p = 0.048), (OR:0.03, 95%CI: 0.00-0.5, p = 0.016); and having good ART adherence (OR: 0.2, 95% CI: 0.1-0.5 p = 0.001), (OR:24.0, 95% CI: 3.7-153.4 p = 0.001) respectively. Having good ART adherence remained statistically significant (OR: 0.2, 95% CI: 0.08-0.53 p = 0.001) in multivariable logistic regression for LTFU.

CONCLUSION

This study found low retention among HIV diagnosed FSWs in care. Viral load suppression was acceptable and comparable to that of the general population, however viral load coverage was low. Strategies that increase retention in care and access to viral load testing such as individual client centred care models are vital to improve retention and viral load coverage among FSWs.

Brief Report: Adolescent Girls Who Sell Sex in Zimbabwe: HIV Risk, Behaviours, and Service Engagement

BACKGROUND

To reduce HIV incidence among adolescent girls who sell sex (AGSS) in Zimbabwe, we need to better understand how vulnerabilities intersect with HIV infection and how those living with HIV engage in care.

METHODS

In 2017, we conducted social mapping in 4 locations in Zimbabwe and recruited girls aged 16-19 years who sell sex, using respondent-driven sampling or census sampling methods. Participants completed a questionnaire and provided finger prick blood samples for HIV antibody testing.

RESULTS

Of 605 AGSS recruited, 74.4% considered themselves sex workers, 24.4% reported experiencing violence in the past year, 91.7% were not in school, and 83.8% had less than a complete secondary education. Prevalence of HIV increased steeply from 2.1% among those aged 16 years to 26.9% among those aged 19 years; overall, 20.2% of AGSS were HIV-positive. In the multivariate analysis, age, education, marital status, and violence from a client were associated with HIV. Among the 605 AGSS, 86.3% had ever tested for HIV, with 64.1% having tested in the past 6 months. Among AGSS living with HIV, half (50.8%) were aware of their status, among whom 83.9% reported taking antiretroviral therapy.

CONCLUSION

The steep rise in HIV prevalence among those aged between 16 and 19 years suggests the window to engage with AGSS before HIV acquisition is short. To accelerate reductions in incidence among AGSS, intensified combination prevention strategies that address structural factors and tailor services to the needs of AGSS are required, particularly ensuring girls enroll and remain in school.

Engagement in HIV services over time among young women who sell sex in Zimbabwe

INTRODUCTION

Young female sex workers (FSW) are disproportionately vulnerable to HIV. Zimbabwe data show higher HIV incidence and lower engagement in services compared to older FSW. Utilizing data from a combination HIV prevention and treatment intervention, we describe engagement in the HIV services over time among FSW 18-24 years, compared to those ≥25 years of age.

MATERIALS AND METHODS

Data were collected via respondent-driven sampling (RDS) surveys in 14 communities in 2013 and 2016, with >2500 FSW per survey. They included blood samples for HIV and viral load testing. As the intervention had no significant impact on HIV care cascade outcomes, data were aggregated across study arms. Analyses used RDS-II estimation.

RESULTS

Mean age in 2013 and 2016 was 31 and 33 years, with 27% and 17% aged 18-24 years. Overall HIV prevalence was 59% at each timepoint, and 35% and 36% among younger FSW. From 2013 to 2016 there was an increase in young HIV-positive FSW knowing their status (38% vs 60%, OR = 2.51, p<0.01). Outcomes for all FSW improved significantly over time at all steps of the cascade, and the relative change over time was similar among older versus younger FSW for most cascade variables.

DISCUSSION

Young FSW had improvements in care cascade outcomes, and proportionate improvements similar to older FSW, yet they remain less engaged in services overall. This implies that the dedicated FSW services in Zimbabwe are having a comparably positive impact across age groups, however more is likely required to address young FSW's unique vulnerabilities and needs.

"My Friends Would Believe My Word": Appropriateness and Acceptability of Respondent-Driven Sampling in Recruiting Young Tertiary Student Men Who Have Sex with Men for HIV/STI Research in Nairobi, Kenya

(1) Background: We conducted formative research to assess the appropriateness and acceptability of respondent-driven sampling (RDS) in recruiting tertiary student men who have sex with men (TSMSM) into a prospective human immunodeficiency virus/sexually transmitted infection (HIV/STI) biobehavioral survey in Nairobi, Kenya. (2) Methods: Between September and October 2020, semi-structured qualitative interviews were held with service providers from organizations that serve MSM (n = 3), and TSMSM (n = 13). Interviews were conducted in English, audio-recorded and transcribed, then thematically analyzed using NVivo version 11. (3) Results: Service providers reflected that RDS was appropriate due to the large though concealed networks of TSMSM. TSMSM perceived RDS to be acceptable based on their large social network sizes and the trust that existed amongst themselves. TSMSM were concerned about participating due to the risk of being outed as MSM and hence emphasized that researchers needed to assure them of their confidentiality and include MSM as part of the study team to encourage participation. (4) Conclusions: RDS was perceived as both an appropriate and acceptable sampling method. Use of RDS should be considered as a strategy for recruiting young, marginalized populations for HIV/STI research.

"One-time interventions, it doesn't lead to much" - healthcare provider views to improving sexual and reproductive health services for young migrants in Sweden

Background

Sexual and reproductive health and rights (SRHR) is an important aspect for young people. In Sweden, young migrants often encounter barriers to accessing and using sexual and reproductive health (SRH) services, despite that these services are free of charge for young people (ages 15–25). Healthcare providers’ views and best practices are of great importance for improving the utilisation of existing SRH services, particularly for young people. This study aims to understand healthcare providers’ experiences and perspectives on barriers to SRHR among young migrants and their suggestions for strategies to improve the provision of SRH services to this group.

Methods

Midwives, counsellors and nurses with at least five years of professional experience within SRHR were reached through a purposeful sample at primary care clinics, specialised clinics and youth-friendly clinics, which provide SRH services to migrant youths in Stockholm. Twelve interviews were conducted from May 2018 to February 2020. Qualitative content analysis was performed.

Results

The analysis identified one theme: Improving the fragmentation in the SRH services, and four sub-themes: 1. Being unaware of SRHR; 2. Creating trust and responsive interactions; 3. Communicating in the same language; and 4. Collaborating to build bridges. The barriers included distrust in the healthcare system, socio-cultural norms surrounding SRHR, incomplete translations, and a need for long-lasting collaboration with SRH services and other range of services for migrants. The strategies for improvement as suggested by participants included involving existing cultural groups and organisations to enable trust, consistent and dependable interpreters, a streamline of SRH services with other healthcare staff and health facilities, and collaborations with homes designated for young migrants and language schools for a direct linkage to service providers.

Conclusions

Findings indicate that there are fragmentations in SRH services, and these include lack of knowledge about SRHR among migrant youth, language and communication barriers, and a lack of structure needed to build dependable services that go beyond one-time interventions. While initiatives and strategies from healthcare providers for improvement of SRH services exist, the implementation of some strategies may also require involving the regional and national decision-makers and multi-stakeholders like communities, civil society and young migrants themselves.

Perspectives of Adolescents, Parents, Service Providers, and Teachers on Mobile Phone Use for Sexual Reproductive Health Education

Mobile health (mHealth) programs offer opportunities to improve the sexual and reproductive health (SRH) of adolescents by providing information. This paper reports the findings of a study carried out in Homabay County, Kenya, to assess stakeholders’ perspectives on access to and use of mobile phones by adolescents for SRH education. We aimed to establish whether mobile phones could facilitate access to SRH information by adolescents and the barriers to be addressed. This was a qualitative exploratory study involving adolescents, parents, teachers, health care workers, and community health volunteers. Data were collected through focus group discussions (FGDs) and key informant interviews (KIIs), and were analyzed through thematic and content analysis. Respondents lauded mHealth as an effective and efficient approach to adolescent SRH education with a potential to promote the learning of useful SRH information to influence their behavior formation. Respondents pointed out bottlenecks such as the limited ownership of and inequitable access to phones among adolescents, logistical barriers such as lack of electricity, internet connectivity, and the impact of phones on school performance, which must be addressed. The usefulness of mHealth in adolescent SRH education can be enhanced through inclusive program formulation and co-creation, implemented through safe spaces where adolescents would access information in groups, and supported by trained counselors.

Two years after lockdown: reviewing the effects of COVID-19 on health services and support for adolescents living with HIV in South Africa

INTRODUCTION

South Africa's progress towards the 95-95-95 goals has been significantly slower among adolescents living with HIV (ALHIV), among whom antiretroviral therapy (ART) adherence, retention in care and viral suppression remain a concern. After 2 years of living with COVID-19, it is important to examine the direct and indirect effects of the pandemic on healthcare resources, access to HIV services and availability of support structures, to assess their impact on HIV care for ALHIV.

DISCUSSION

The COVID-19 response in South Africa has shifted healthcare resources towards combatting COVID-19, affecting the quality and availability of HIV services-especially for vulnerable populations, such as ALHIV. The healthcare system's response to COVID-19 has threatened to diminish fragile gains in engaging ALHIV with HIV services, especially as this group relies on overburdened public health facilities for their HIV care. Reallocation of limited health resources utilized by ALHIV disrupted healthcare workers' capacity to form and maintain therapeutic relationships with ALHIV and monitor ALHIV for ART-related side effects, treatment difficulties and mental health conditions, affecting their ability to retain ALHIV in HIV care. Prevailing declines in HIV surveillance meant missed opportunities to identify and manage opportunistic infections and HIV disease progression in adolescents. "Lockdown" restrictions have limited access to healthcare facilities and healthcare workers for ALHIV by reducing clinic appointments and limiting individual movement. ALHIV have had restricted access to social, psychological and educational support structures, including national feeding schemes. This limited access, coupled with reduced opportunities for routine maternal and sexual and reproductive health services, may place adolescent girls at greater risk of transactional sex, child marriages, unintended pregnancy and mother-to-child HIV transmission.

CONCLUSIONS

Adolescent HIV care in South Africa is often overlooked; however, ART adherence among ALHIV in South Africa is particularly susceptible to the consequences of a world transformed by COVID-19. The current structures in place to support HIV testing, ART initiation and adherence have been reshaped by disruptions to health structures, new barriers to access health services and the limited available education and psychosocial support systems. Reflecting on these limitations can drive considerations for minimizing these barriers and retaining ALHIV in HIV care.

Acceptability and uptake of HIV self-testing in emergency care settings: A systematic review and meta-analysis

BACKGROUND

Emergency departments (ED) interface with large numbers of patients that are often missed by conventional HIV testing approaches. ED-based HIV self-testing (HIVST) is an innovative engagement approach which has potential for testing gains among populations that have failed to be reached. This systematic review and meta-analysis evaluated acceptability and uptake of HIVST, as compared to standard provider-delivered testing approaches, among patients seeking care in ED settings.

METHODS

Six electronic databases were systematically searched (Dates: January 1990-May 2021). Reports with data on HIVST acceptability and/or testing uptake in ED settings were included. Two reviewers identified eligible records (κ= 0.84); quality was assessed using formalized criteria. Acceptability and testing uptake metrics were summarized, and pooled estimates were calculated using random-effects models with assessments of heterogeneity.

RESULTS

Of 5773 records identified, seven met inclusion criteria. The cumulative sample was 1942 subjects, drawn from three randomized control trials (RCTs) and four cross-sectional studies. Four reports assessed HIVST acceptability. Pooled acceptability of self-testing was 92.6% (95% confidence interval [CI]: 88.0%-97.1%). Data from two RCTs demonstrated that HIVST significantly increased testing uptake as compared to standard programs (risk ratio [RR] = 4.41, 95% CI: 1.95-10.10, I2  = 25.8%). Overall, the quality of evidence was low (42.9%) or very low (42.9%), with one report of moderate quality (14.2%).

CONCLUSIONS

Available data indicate that HIVST may be acceptable and may increase testing among patients seeking emergency care, suggesting that expanding ED-based HIVST programs could enhance HIV diagnosis. However, given the limitations of the reports, additional research is needed to better inform the evidence base.

Young key populations left behind: The necessity for a targeted response in Mozambique

INTRODUCTION

The first exposure to high-risk sexual and drug use behaviors often occurs during the period of youth (15-24 years old). These behaviors increase the risk of HIV infection, especially among young key populations (KP)-men how have sex with men (MSM), female sex workers (FSW), and people who inject drugs (PWID). We describe the characteristics of young KP participants in the first Biobehavioral Surveillance (BBS) surveys conducted in Mozambique and examine their risk behaviors compared to adult KP.

METHODS

Respondent-driven sampling (RDS) methodology was used to recruit KP in three major urban areas in Mozambique. RDS-weighted pooled estimates were calculated to estimate the proportion of young KP residing in each survey city. Unweighted pooled estimates of risk behaviors were calculated for each key population group and chi-square analysis assessed differences in proportions between youth (aged less than 24 years old) and older adult KP for each population group.

RESULTS

The majority of MSM and FSW participants were young 80.7% (95% CI: 71.5-89.9%) and 71.9% (95% CI: 71.9-79.5%), respectively, although not among PWID (18.2%, 95% CI: 13.2-23.2%). Young KP were single or never married, had a secondary education level or higher, and low employment rates. They reported lower perception of HIV risk (MSM: 72.3% vs 56.7%, p<0.001, FSW: 45.3% vs 24.4%, p<0.001), lower HIV testing uptake (MSM: 67.5% vs 72.3%, p<0.001; FSW: 63.2% vs 80.6%; p<0.001, PWID: 53.3% vs 31.2%; p = 0.001), greater underage sexual debut (MSM: 9.6% vs 4.8%, p<0.001; FSW: 35.2% vs 22.9%, p<0.001), and greater underage initiation of injection drug use (PWID: 31.9% vs 7.0%, p<0.001). Young KP also had lower HIV prevalence compared to older KP: MSM: 3.3% vs 27.0%, p<0.001; FSW: 17.2% vs 53.7%, p<0.001; and PWID: 6.0% vs 55.0%, p<0.001. There was no significant difference in condom use across the populations.

CONCLUSION

There is an immediate need for a targeted HIV response for young KP in Mozambique so that they are not left behind. Youth must be engaged in the design and implementation of interventions to ensure that low risk behaviors are sustained as they get older to prevent HIV infection.

"He is the Same as Me": Key Populations' Acceptability and Experience of a Community-Based Peer Navigator Intervention to Support Engagement in HIV Care in Tijuana, Mexico

Engagement in the HIV care continuum among people living with HIV is essential to prevent ongoing transmission. Although there is evidence for the need for comprehensive approaches (e.g., peer navigation) to improve the HIV care continuum, there is limited knowledge of how the peer navigation model might work to improve the HIV care continuum in low resource settings among Latinx key populations (e.g., persons who inject drugs, female sex workers, men who have sex with men, and transgender women). Therefore, this article aims to qualitatively assess members of key populations' acceptability of Conexiones Saludables (Healthy Connections), a community-based peer navigation intervention implemented in Tijuana, Mexico. This analysis draws upon the postintervention survey data from 34 participants and data from qualitative interviews with 10 participants. Participants found the intervention to be acceptable and discussed the ways in which peer navigators were influential in educating participants about HIV, antiretroviral therapy (ART), linking participants to existing HIV care and ancillary services in Tijuana, and in providing emotional and instrumental support to facilitate engagement in HIV treatment and ART adherence. The intervention emphasized the use of peer navigators who had a deep understanding of the sociostructural barriers (e.g., substance use, homelessness) that HIV-positive key populations face in Tijuana. Findings from this study may inform programs with highly vulnerable populations in similar settings.

Project BESPOKE (Integrated Bio-Behavioral Assessment of HIV and STI Among Young Tertiary Student Men Who Have Sex With Men in Nairobi, Kenya): A Respondent-Driven Sampling Survey Protocol

Introduction: Globally, men who have sex with men (MSM) are a key population for the human immunodeficiency virus (HIV) epidemic. Among MSM, young men who have sex with men (YMSM) are disproportionately affected by HIV and other sexually transmitted infections (STI). However, there is a dearth of research and interventions targeting HIV/STI prevention among YMSM. In Kenya, there is paucity of knowledge on the burden of HIV/STI and related factors among YMSM, including tertiary student men who have sex with men (TSMSM). The barriers TSMSM experience in accessing and utilizing health services in their learning institutions have seldom been explored. In the context of healthcare providers (HCP) working in tertiary institutions, little is known about their knowledge, attitudes, and practices toward providing services to TSMSM. Methods: The aims of the study are to: estimate prevalence and correlates of HIV/STI among TSMSM; estimate population size of TSMSM; explore experiences of TSMSM with access and utilization of health services; and assess HCP knowledge of, attitudes toward, and practices in provision of services to TSMSM. A mixed-methods approach will be used in three phases: Phase I-formative qualitative research will be conducted to understand TSMSM social networks, select "seeds", and explore strategies for implementing a respondent-driven sampling (RDS) survey. Interviews will be conducted with at least three staff who work in community based/non-governmental organizations (CBO/NGO) that serve MSM and at least 10 TSMSM. Phase II-an integrated bio-behavioral assessment (IBBA) will be conducted, where 200 TSMSM recruited by RDS will be offered HIV/STI testing, complete a behavioral survey, and provide information for population size estimation (PSE). Phase III-in-depth interviews will be held with 20 TSMSM selected from 200 TSMSM in phase II, to explore their experiences with access and utilization of healthcare services. Focus group discussions (FGD) will be conducted with HCP working in tertiary institutions to assess their knowledge of, attitudes toward, and practices in providing services to TSMSM. Data collection started in September 2020 and is expected to end by September 2021. Discussion: Findings from this study will be useful in informing HIV/STI prevention programming for TSMSM, by policy makers such the Kenyan ministries of health and education, tertiary education institutions, service providers, advocacy groups, and other interested stakeholders.

A realist evaluation of the continuum of HIV services for men who have sex with men

Background

Men who have Sex with Men (MSM) represent the risk group that are disproportionately most affected by the human immunodeficiency virus (HIV) and continue to drop-off from the steps of the continuum of HIV services that have been adopted to overcome poor engagement and retention in care. This realist evaluation aimed at: (1) describing the evaluation carried out in Haiti aiming to ascertain why, how and under which circumstances MSM are linked and retained along the continuum, (2) assessing the outcomes of this approach and (3) exploring the motivators and facilitators for the HIV continuum of services through mechanisms and pathways.

Methods

Guided by a realist approach, first, an initial program theory (IPT) was developed based on literature and frameworks review, participant observations and discussions with stakeholders. Then, the IPT was tested using a mixed method explanatory study: a quantitative phase to build the continuum from a cross-sectional analysis, and a qualitative phase to explore the motivators and facilitators related to proper linkages along the continuum. Finally, the IPT was refined by eliciting the mechanisms and pathways for outcomes improvement.

Results

The results showed that the current service delivery model is suboptimal in identifying, engaging, linking and retaining MSM, resulting in loss to follow-up at every step of the continuum and failure to fully realize the health and prevention benefits of antiretroviral. However, the mechanisms through which linkages across the continuum can be improved are: self-acceptance, sense of community support and sense of comprehensive and tailored HIV services. These mechanisms are based on 10 different pathways: self-esteem, awareness and pride, perception of HIV risk, pcceptance and HIV status, addressing community stigma, strengthening of MSM organizations and community networks, societal acceptation and tolerance, stigma reduction training for healthcare providers, engagement of peers as educators and navigators and, adapted services delivery through drug dispensing points and mobile technology and financial assistance.

Conclusions

The study findings show that engagement, adherence and retention to the continuum of HIV service for MSM are affected by a multi-layer of factors, thus highlighting the importance of taking a comprehensive approach to improve the program.

A community-based mobile clinic model delivering PrEP for HIV prevention to adolescent girls and young women in Cape Town, South Africa

BACKGROUND

Daily doses of pre-exposure prophylaxis (PrEP) can reduce the risk of acquiring HIV by more than 95 %. In sub-Saharan Africa, adolescent girls and young women (AGYW) are at disproportionately high risk of acquiring HIV, accounting for 25 % of new infections. There are limited data available on implementation approaches to effectively reach and deliver PrEP to AGYW in high HIV burden communities.

METHODS

We explored the feasibility and acceptability of providing PrEP to AGYW (aged 16-25 years) via a community-based mobile health clinic (CMHC) known as the Tutu Teen Truck (TTT) in Cape Town, South Africa. The TTT integrated PrEP delivery into its provision of comprehensive sexual and reproductive health services (SRHS). We analyzed data from community meetings and in-depth interviews with 30 AGYW PrEP users to understand the benefits and challenges of PrEP delivery in this context.

RESULTS

A total of 585 young women started PrEP at the TTT between July 2017 - October 2019. During in-depth interviews a subset of 30 AGYW described the CMHC intervention for PrEP delivery as acceptable and accessible. The TTT provided services at times and in neighborhood locations where AGYW organically congregate, thus facilitating service access and generating peer demand for PrEP uptake. The community-based nature of the CMHC, in addition to its adolescent friendly health providers, fostered a trusting provider-community-client relationship and strengthened AGYW HIV prevention self-efficacy. The integration of PrEP and SRHS service delivery was highly valued by AGYW. While the TTT's integration in the community facilitated acceptability of the PrEP delivery model, challenges faced by the broader community (community riots, violence and severe weather conditions) also at times interrupted PrEP delivery.

CONCLUSIONS

PrEP delivery from a CMHC is feasible and acceptable to young women in South Africa. However, to effectively scale-up PrEP it will be necessary to develop diverse PrEP delivery locations and modalities to meet AGYW HIV prevention needs.

Criminalization of Sexual and Gender Minorities and Its Consequences for the HIV Epidemic in Zambia: A Critical Review and Recommendations

ABSTRACT

To elaborate the negative impacts of sexual and gender minority (SGM)-related legislation for the HIV epidemic in Zambia, we reviewed Zambian legislation that restricts the rights of SGM people and synthesized its consequences. We retrieved legal documents through the National Assembly of Zambia and the Zambia Legal Information Institute and conducted a critical review based on four academic databases following thematic synthesis methodology. Eighteen literature records and six Zambian laws were included in the review. Existing laws criminalize same-sex sexual behavior and restrict same-sex marriage and the adoption of children. Anti-SGM legislation has limited legal protections for SGM people and increased vulnerability of criminal prosecution and HIV exposure, persistent stigma/discrimination, insufficient public health resources, and lessened access to HIV-related services. We recommend enacting legal protections for SGM people, decriminalizing anti-SGM laws, rectifying misinformation to destigmatize SGM people, targeting health care for SGM people, and including SGM people in the national HIV strategy.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

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

Introduction

The Curitiba (Brazil)-based Project, A Hora é Agora (AHA), evaluated a comprehensive HIV control strategy among men who have sex with men (MSM) aimed at expanding access to HIV rapid testing and linking HIV-positive MSM to health services and treatment. AHA’s approach included rapid HIV Testing Services (HTC) in one mobile testing unit (MTU); a local, gay-led, non-governmental organization (NGO); an existing government-run health facility (COA); and Internet-based HIV self-testing. The objectives of the paper were to compare a) number of MSM tested in each strategy, its positivity and linkage; b) social, demographic and behavioral characteristics of MSM accessing the different HTC and linkage services; and c) the costs of the individual strategies to diagnose and link MSM to services.

Methods

We used data for 2,681 MSM tested at COA, MTU and NGO from March 2015 to March 2017. This is a cross sectional comparison of the demographics and behavioral factors (age group, race/ethnicity, education, sexually transmitted diseases, knowledge of AHA services and previous HIV test). Absolute frequencies, percentage distributions and confidence intervals for the percentages were used, as well as unilateral statistical tests.

Results and discussion

AHA performed 2,681 HIV tests among MSM across three in-person strategies: MTU, NGO, and COA; and distributed 4,752 HIV oral fluid tests through the self-testing platform. MTU, NGO and COA reported 365 (13.6%) HIV positive diagnoses among MSM, including 28 users with previous HIV diagnosis or on antiretroviral treatment for HIV. Of these, 89% of MSM were eligible for linkage-to-care services. Linkage support was accepted by 86% of positive MSM, of which 66.7% were linked to services in less than 90 days. The MTU resulted in the lowest cost per MSM tested ($137 per test), followed by self-testing ($247).

Conclusions

AHA offered MSM access to HTC through innovative strategies operating in alternative sites and schedules. It presented the Curitiba HIV/AIDS community the opportunity to monitor HIV-positive MSM from diagnosis to treatment uptake. Self-testing emerged as a feasible strategy to increase MSM access to HIV-testing through virtual tools and anonymous test kit delivery and pick-up. Cost per test findings in both the MTU and self-testing support expansion to other regions with similar epidemiological contexts.

Effect of community-based interventions targeting female sex workers along the HIV care cascade in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Female sex workers are extremely vulnerable and highly susceptible to being infected with human immunodeficiency virus. As a result, community-based targeted interventions have been recommended as one of the models of care to improve access to HIV services and continued engagement in care. We conducted a systematic review to (1) assess the effect of FSW-targeted community interventions on the improvement of HIV services access along the treatment cascade and (2) describe community-based interventions that positively affect continuation in HIV care across the HIV treatment cascade for FSWs in sub-Saharan Africa.

METHODS

We defined the 5 steps that make up the HIV care cascade and categorized them as outcomes, namely, HIV testing and diagnosis, linkage to care, receipt of ART, and achievement of viral suppression. We conducted a systematic search of randomized controlled trials, cohort, and cross-sectional studies done in sub-Saharan African countries and published from 2004 to 2020. The period was selected based on the time span within which ART was scaled up through widespread roll-out of comprehensive HIV programs in sub-Saharan Africa. We reviewed studies with data on the implementation of community interventions for any of the HIV care cascade stage. The data were analyzed using random effects meta-analysis where possible, and for the rest of the studies, data were synthesized using summary statistics.

RESULTS

The significant impact of the community interventions was observed on HIV testing, HIV diagnosis, and ART use. However, for HIV testing and ART use, the improvement was not sustained for the entire period of implementation. There were minimal interventions that had impact on HIV diagnosis, with only one community service delivery model showing significance. Generally, the interventions that had reasonable impact are those that implemented targeted and comprehensive package of HIV services provided at one location, and with unique strategies specific to each cascade stage.

CONCLUSIONS

The evidence brought forward from this review shows that the effect of community-based interventions varies across the different stages of HIV care cascade. A broad package of interventions including a combination of behavioral, biomedical, and structural, designed with specific strategies, unique to each cascade stage appears to be more effective, although information on long-term treatment outcomes and the extent to which FSWs remain engaged in care is sparse. There is need to conduct a further research to deepen the assessment of the effectiveness of community-based interventions on HIV care cascade for FSWs. This will enhance identification of evidence-based optimal interventions that will guide effective allocation of scarce resources for strategies that would have a significant impact on HIV service delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020157623.

Addressing gaps in adolescent tuberculosis programming and policy in Nigeria from a public health perspective

OBJECTIVES

Tuberculosis (TB) is a leading infectious cause of death globally. Of the estimated 10 million people who developed active TB in 2019, 1.8 million (18%) were adolescents and young adults aged 15-24 years. Adolescents have poorer rates of TB screening, treatment initiation and completion compared to adults. Unfortunately, there is relatively less programme, research and policy focus on TB for adolescents aged 10-19 years. This article reviews the scope of health services and the relevant policy landscape for TB case notification and care/treatment, TB/HIV management, and latent TB infection for adolescents in Nigeria. Additionally, it discusses considerations for TB vaccines in this population.

CONTENT

All Nigeria Federal Ministry of Health policy documents relevant to adolescent health services and TB, and published between 2000 and 2020 underwent narrative review. Findings were reported according to the service areas outlined in the Objectives.

SUMMARY AND OUTLOOK

Nine policy documents were identified and reviewed. While multiple policies acknowledge the needs of adolescents in public health and specifically in TB programming, these needs are often not addressed in policy, nor in program integration and implementation. The lack of age-specific epidemiologic and clinical outcomes data for adolescents contributes to these policy gaps. Poor outcomes are driven by factors such as HIV co-infection, lack of youth-friendly health services, and stigma and discrimination. Policy guidelines and innovations should include adaptations tailored to adolescent needs. However, these adaptations cannot be developed without robust epidemiological data on adolescents at risk of, and living with TB. Gaps in TB care integration into primary reproductive, maternal-child health and nutrition services should be addressed across multiple policies, and mechanisms for supervision, and monitoring and evaluation of integration be developed to guide comprehensive implementation. Youth-friendly TB services are recommended to improve access to quality care delivered in a patient-centered approach.

High HIV Prevalence and Low HIV-Service Engagement Among Young Women Who Sell Sex: A Pooled Analysis Across 9 Sub-Saharan African Countries

BACKGROUND

Epidemiological data are needed to characterize the age-specific HIV burden and engagement in HIV services among young, marginalized women in sub-Saharan Africa.

SETTING

Women aged ≥18 years who reported selling sex were recruited across 9 countries in Southern, Central, and West Africa through respondent driven sampling (N = 6592).

METHODS

Individual-level data were pooled and age-specific HIV prevalence and antiretroviral therapy (ART) coverage were estimated for each region using generalized linear mixed models. HIV-service engagement outcomes (prior HIV testing, HIV status awareness, and ART use) were compared among women living with HIV across age strata (18-19, 20-24, and ≥25 years) using generalized estimating equations.

RESULTS

By age 18%-19%, 45.4% [95% confidence interval (CI): 37.9 to 53.0], 5.8% (95% CI: 4.3 to 7.8), and 4.0% (95% CI: 2.9 to 5.4) of young women who sell sex were living with HIV in Southern, Central, and West Africa respectively. Prevalence sharply increased during early adulthood in all regions, but ART coverage was suboptimal across age groups. Compared with adult women ≥25, young women aged 18-19 were less likely to have previously tested for HIV [prevalence ratio (PR) 0.76; 95% CI: 0.72 to 0.80], less likely to already be aware of their HIV status (PR 0.48; 95% CI: 0.35 to 0.64), and less likely to be taking ART (PR 0.67; 95% CI: 0.59 to 0.75).

CONCLUSIONS

HIV prevalence was already high by age 18-19 in this pooled analysis, demonstrating the need for prevention efforts that reach women who sell sex early in their adolescence. ART coverage remained low, with women in the youngest age group the least engaged in HIV-related services. Addressing barriers to HIV service delivery among young women who sell sex is central to a comprehensive HIV response.

Venue-Based HIV Testing at Sex Work Hotspots to Reach Adolescent Girls and Young Women Living With HIV: A Cross-sectional Study in Mombasa, Kenya

BACKGROUND

We estimated the potential number of newly diagnosed HIV infections among adolescent girls and young women (AGYW) using a venue-based approach to HIV testing at sex work hotspots.

METHODS

We used hotspot enumeration and cross-sectional biobehavioral survey data from the 2015 Transition Study of AGYW aged 14-24 years who frequented hotspots in Mombasa, Kenya. We described the HIV cascade among young females who sell sex (YFSS) (N = 408) versus those young females who do not sell sex (YFNS) (N = 891) and triangulated the potential (100% test acceptance and accuracy) and feasible (accounting for test acceptance and sensitivity) number of AGYW that could be newly diagnosed through hotspot-based HIV rapid testing in Mombasa. We identified the profile of AGYW with an HIV in the past year using generalized linear mixed regression models.

RESULTS

N = 37/365 (10.1%) YFSS and N = 30/828 (3.6%) YFNS were living with HIV, of whom 27.0% (N = 10/37) and 30.0% (N = 9/30) were diagnosed and aware (P = 0.79). Rapid test acceptance was 89.3%, and sensitivity was 80.4%. There were an estimated 15,635 (range: 12,172-19,097) AGYW at hotspots. The potential and feasible number of new diagnosis was 627 (310-1081), and 450 (223-776), respectively. Thus, hotspot-based testing could feasibly reduce the undiagnosed fraction from 71.6% to 20.2%. The profile of AGYW who recently tested was similar among YFSS and YFNS. YFSS were 2-fold more likely to report a recent HIV test after adjusting for other determinants [odds ratio (95% confidence interval): 2.2 (1.5 to 3.1)].

CONCLUSION

Reaching AGYW through hotspot-based HIV testing could fill gaps left by traditional, clinic-based HIV testing services.

Perceived barriers to the uptake of health services among first-year university students in Johannesburg, South Africa

BACKGROUND

Young people face many barriers to accessing appropriate health care services including screening for HIV and tuberculosis (TB). The study aimed to identify perceived barriers to the uptake of health services among young adults entering the tertiary education system in South Africa.

METHODS

We conducted a cross-sectional study among first-year students aged 18-25 years, registered at one of three universities in Johannesburg, South Africa, in 2017. Participants completed a self-administered paper-based questionnaire. We describe perceived barriers to accessing health services, stratified by gender and recent engagement in TB or HIV services, together with sources of information about HIV and TB.

RESULTS

Seven hundred and ninety-two (792) students were included in the study of which 54.8% were female. Perceived barriers to accessing services included long waiting time (n = 342,43.2%), attitude of health workers (n = 263,33.2%), lack of sufficient information/poor health literacy (n = 148,18.7%), and inability to leave/stay away from studies (n = 137,17.3%). Among participants who tested for HIV in the past 6 months (n = 400, 50.5%), waiting time and attitude of health care workers were perceived as barriers to accessing services. Compared to males, females were more likely to view attitudes of health workers (40.3% vs. 25.0%; p = 0.001) and inability to leave/stay away from studies (20.5% vs.13.4%; p = 0.025) as potential barriers. While just over half of the students (50.5%; 400/792) in this study had accessed health services in the past 6 months, very few (15.0%) opted to use campus health services, and even less (5%) reported receiving information about HIV and TB from the university itself.

CONCLUSION

Despite perceived barriers to accessing HIV and TB services off campus, fewer than one in five students starting out at university opted to use campus health services. Campus health services could address many of the barriers unique to university students.

Using mobile phones to improve young people sexual and reproductive health in low and middle-income countries: a systematic review to identify barriers, facilitators, and range of mHealth solutions

BACKGROUND

Globally, reproductive health programs have used mHealth to provide sexual and reproductive health (SRH) education and services to young people, through diverse communication channels. However, few attempts have been made to systematically review the mHealth programs targeted to improve young people SRH in low-and-middle-income countries (LMICs). This review aims to identify a range of different mHealth solutions that can be used for improving young people SRH in LMICs and highlight facilitators and barriers for adopting mHealth interventions designed to target SRH of young people.

METHODS

Databases including PubMed, CINAHL Plus, Science Direct, Cochrane Central, and grey literature were searched between January 01, 2005 and March 31, 2020 to identify various types of mHealth interventions that are used to improve SRH services for young people in LMICs. Of 2948 titles screened after duplication, 374 potentially relevant abstracts were obtained. Out of 374 abstracts, 75 abstracts were shortlisted. Full text of 75 studies were reviewed using a pre-defined data extraction sheet. A total of 15 full-text studies were included in the final analysis.

RESULTS

The final 15 studies were categorized into three main mHealth applications including client education and behavior change communication, data collection and reporting, and financial transactions and incentives. The most reported use of mHealth was for client education and behavior change communication [n = 14, 93%] followed by financial transactions and incentives, and data collection and reporting Little evidence exists on other types of mHealth applications described in Labrique et al. framework. Included studies evaluated the impact of mHealth interventions on access to SRH services (n = 9) and SRH outcomes (n = 6). mHealth interventions in included studies addressed barriers of provider prejudice, stigmatization, discrimination, fear of refusal, lack of privacy, and confidentiality. The studies also identified barriers to uptake of mHealth interventions for SRH including decreased technological literacy, inferior network coverage, and lower linguistic competency.

CONCLUSION

The review provides detailed information about the implementation of mobile phones at different levels of the healthcare system for improving young people SRH outcomes. This systematic review recommends that barriers to uptake mHealth interventions be adequately addressed to increase the potential use of mobile phones for improving access to SRH awareness and services.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018087585 (Feb 5, 2018).

Age Matters: Determinants of sexual and reproductive health vulnerabilities amongst young women who sell sex (16-24 years) in Zimbabwe

INTRODUCTION

Female sex workers bear a disproportionate burden of HIV and other poor sexual and reproductive health (SRH) outcomes which has led to the tailoring of SRH interventions to mitigate risk. Understanding of the SRH vulnerabilities of young women who sell sex (YWSS) (16-24 years) in Southern Africa is under-represented in research which may result in a mismatch in current SRH interventions and service design.

OBJECTIVE

This paper is based on a sub-analysis of a qualitative study investigating the SRH of young women who sell sex (16-24 years) in Zimbabwe. We explored the differences in dynamics of SRH vulnerability amongst YWSS within the 16-24 year age band.

METHODS

In-depth interviews (IDIs) were conducted amongst key informants (n = 4), health care providers (n = 5), and peer educators (n = 16). Amongst YWSS, we conducted IDIs (n = 42) and focus group discussions (n = 30). Transcripts were inductively coded for emergent themes and categories.

RESULTS

Age and life stage determinants led to key differences in SRH vulnerabilities between younger (16-19 years) and older YWSS (20-24 years). These determinants emerged in the following ways: 1) distancing of younger participants from a "sex worker" identity leading to difficulties in identification and limiting intervention reach, 2) inexperience in dealing with clients and immature cognitive development leading to greater exposure to risk, and 3) the subordinate social position and exploitation of young participants within sex worker hierarchies or networks and lack of protective networks.

CONCLUSIONS

We highlight the presence of a diverse group of vulnerable young women who may be missed by sex worker programme responses. In future intervention planning, there is need to consider the age-related needs and vulnerabilities within a spectrum of young women involved in a wide range of transactional relationships to ensure that services reach those most vulnerable to poor SRH outcomes.

Integrating sexual and reproductive health into health system strengthening in humanitarian settings: a planning workshop toolkit to transition from minimum to comprehensive services in the Democratic Republic of Congo, Bangladesh, and Yemen

Background

Planning to transition from the Minimum Initial Service Package for Sexual and Reproductive Health (SRH) toward comprehensive SRH services has been a challenge in humanitarian settings. To bridge this gap, a workshop toolkit for SRH coordinators was designed to support effective planning. This article aims to describe the toolkit design, piloting, and final product.

Methods

Anchored in the Health System Building Blocks Framework of the World Health Organization, the design entailed two complementary and participatory strategies. First, a collaborative design phase with iterative feedback loops involved global partners with extensive operational experience in the initial toolkit conception. The second phase engaged stakeholders from three major humanitarian crises to participate in pilot workshops to contextualize, evaluate, validate, and improve the toolkit using qualitative interviews and end-of-workshop evaluations. The aim of this two-phase design process was to finalize a planning toolkit that can be utilized in and adapted to diverse humanitarian contexts, and efficiently and effectively meet its objectives. Pilots occurred in the Democratic Republic of Congo for the Kasai region crisis, Bangladesh for the Rohingya humanitarian response in Cox’s Bazar, and Yemen for selected Governorates.

Results

Results suggest that the toolkit enabled facilitators to foster a systematic, participatory, interactive, and inclusive planning process among participants over a two-day workshop. The approach was reportedly effective and time-efficient in producing a joint work plan. The main planning priorities cutting across settings included improving comprehensive SRH services in general, healthcare workforce strengthening, such as midwifery capacity development, increasing community mobilization and engagement, focusing on adolescent SRH, and enhancing maternal and newborn health services in terms of quality, coverage, and referral pathways. Recommendations for improvement included a dedicated and adequately anticipated pre-workshop preparation to gather relevant data, encouraging participants to undertake preliminary study to equalize knowledge to partake fully in the workshop, and enlisting participants from marginalized and underserved populations.

Conclusion

Collaborative design and piloting efforts resulted in a workshop toolkit that could support a systematic and efficient identification of priority activities and services related to comprehensive SRH. Such priorities could help meet the SRH needs of communities emerging from acute humanitarian situations while strengthening the overall health system.