Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey

BACKGROUND

Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments.

METHODS

This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs.

FINDINGS

Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings.

INTERPRETATION

Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV.

FUNDING

National Institutes of Health.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Characterizing Cross-Culturally Relevant Metrics of Stigma Among Men Who Have Sex With Men Across 8 Sub-Saharan African Countries and the United States

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02-0.05; comparative fit index/Tucker-Lewis index = 0.97-1.00/0.94-1.00; standardized root mean square residual = 0.04-0.08), consisting of "stigma from family and friends," "anticipated health-care stigma," and "general social stigma," with internal consistency estimates across countries of α = 0.36-0.80, α = 0.72-0.93, and α = 0.51-0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions.

The role of sex work laws and stigmas in increasing HIV risks among sex workers

Globally HIV incidence is slowing, however HIV epidemics among sex workers are stable or increasing in many settings. While laws governing sex work are considered structural determinants of HIV, individual-level data assessing this relationship are limited. In this study, individual-level data are used to assess the relationships of sex work laws and stigmas in increasing HIV risk among female sex workers, and examine the mechanisms by which stigma affects HIV across diverse legal contexts in countries across sub-Saharan Africa. Interviewer-administered socio-behavioral questionnaires and biological testing were conducted with 7259 female sex workers between 2011-2018 across 10 sub-Saharan African countries. These data suggest that increasingly punitive and non-protective laws are associated with prevalent HIV infection and that stigmas and sex work laws may synergistically increase HIV risks. Taken together, these data highlight the fundamental role of evidence-based and human-rights affirming policies towards sex work as part of an effective HIV response.

Characterizing social cohesion and gender identity as risk determinants of HIV among cisgender men who have sex with men and transgender women in Côte d'Ivoire

PURPOSE

HIV prevalence has been previously estimated among cisgender men who have sex with men (MSM) in Côte d'Ivoire; however, limited data exist relating to the role of social cohesion and gender identity within this population. This study aims to examine these factors as risk determinants of HIV among MSM in Côte d'Ivoire.

METHODS

We conducted a cross-sectional study using respondent-driven sampling for recruitment with a structured sociobehavioral instrument and testing for HIV. After respondent-driven sampling adjustment, chi-squared tests and bivariate logistic regression and multivariate logistic regression analyses were performed to characterize social and identity-based risk determinants of biologically confirmed prevalent HIV infection.

RESULTS

HIV prevalence was 11.2% (n = 146/1301). Transgender woman identity was associated with higher odds of HIV compared with cisgender MSM (aOR = 3.4, 95% CI [2.0-5.8], P < .001). Having a combined social cohesion score of medium (aOR = 0.4, 95% CI [0.2-0.8], P < .01) or high (aOR = 0.2, 95% CI [0.1-0.3], P < .001) was associated with lower odds of HIV compared with a low score.

CONCLUSION

These data suggest that social cohesion is a determinant of prevalent HIV infection in Côte d'Ivoire among gay men, other cisgender MSM, and transgender women. The differences in HIV burden and social cohesion between transgender women and cisgender MSM highlight the need to better target the diversity of people traditionally included in the MSM umbrella to ensure comprehensive HIV prevention and treatment interventions.

Sexual behavior stigma and depression among transgender women and cisgender men who have sex with men in Côte d'Ivoire

PURPOSE

Transgender women (TGW) and cisgender men who have sex with men (cisMSM) across sub-Saharan Africa experience health inequalities relative to other adults. Recent research has also revealed health inequalities between these often-conflated groups. Among TGW and cisMSM in Côte d'Ivoire, we sought to determine whether transgender female identity was associated with probable depression, and whether sexual behavior stigma mediated this association.

METHODS

In 2015-2016, a cross-sectional respondent-driven sampling survey of adult TGW and cisMSM was conducted across five cities. We conducted a three-way decomposition of mediation and interaction of gender identity and sexual behavior stigma. Depression was measured by the nine-item Patient Health Questionnaire (PHQ-9).

RESULTS

Of 1301 participants, 339 (26.1%) were TGW. The prevalence of probable depression was 22.7% among TGW and 12.2% among cisMSM (P < .001). After confounder adjustment, the relative risk of depression attributable to transgender female gender identity was 1.68 (95% CI = 1.36, 2.00) with 69.9% (95% CI = 42.6, 97.1) of this effect mediated by sexual behavior stigma. The effect of stigma on depression did not differ significantly by gender.

CONCLUSIONS

These data suggest that stigma mitigation interventions specifically addressing the stigma affecting transgender women may also address mental health inequalities between transgender women and cisMSM in Côte d'Ivoire.

Bayesian Estimation of MSM Population Size in Côte d'Ivoire

Côte d'Ivoire has among the most generalized HIV epidemics in West Africa with an estimated half million people living with HIV. Across West Africa, key populations, including gay men and other men who have sex with men (MSM), are often disproportionately burdened with HIV due to specific acquisition and transmission risks. Quantifying population sizes of MSM at the subnational level is critical to ensuring evidence-based decisions regarding the scale and content of HIV prevention interventions. While survey-based direct estimates of MSM numbers are available in a few urban centers across Côte d'Ivoire, no data on MSM population size exists in other areas without any community group infrastructure to facilitate sufficient access to communities of MSM. The data are used in a Bayesian regression setup to produce estimates of the numbers of MSM in areas of Côte d'Ivoire prioritized in the HIV response. Our hierarchical model imputes missing covariates using geo-spatial information and allows for proper uncertainty quantification leading to confidence bounds for predicted MSM population size estimates. This process provided population size estimates where there are no empirical data, to guide the prioritization of further collection of empirical data on MSM and inform evidence-based scaling of HIV prevention and treatment programs for MSM across Côte d'Ivoire.

Effect of isoniazid preventive therapy on risk of death in west African, HIV-infected adults with high CD4 cell counts: long-term follow-up of the Temprano ANRS 12136 trial

BACKGROUND

Temprano ANRS 12136 was a factorial 2 × 2 trial that assessed the benefits of early antiretroviral therapy (ART; ie, in patients who had not reached the CD4 cell count threshold used to recommend starting ART, as per the WHO guidelines that were the standard during the study period) and 6-month isoniazid preventive therapy (IPT) in HIV-infected adults in Côte d'Ivoire. Early ART and IPT were shown to independently reduce the risk of severe morbidity at 30 months. Here, we present the efficacy of IPT in reducing mortality from the long-term follow-up of Temprano.

METHODS

For Temprano, participants were randomly assigned to four groups (deferred ART, deferred ART plus IPT, early ART, or early ART plus IPT). Participants who completed the trial follow-up were invited to participate in a post-trial phase. The primary post-trial phase endpoint was death, as analysed by the intention-to-treat principle. We used Cox proportional models to compare all-cause mortality between the IPT and no IPT strategies from inclusion in Temprano to the end of the follow-up period.

FINDINGS

Between March 18, 2008, and Jan 5, 2015, 2056 patients (mean baseline CD4 count 477 cells per μL) were followed up for 9404 patient-years (Temprano 4757; post-trial phase 4647). The median follow-up time was 4·9 years (IQR 3·3-5·8). 86 deaths were recorded (Temprano 47 deaths; post-trial phase 39 deaths), of which 34 were in patients randomly assigned IPT (6-year probability 4·1%, 95% CI 2·9-5·7) and 52 were in those randomly assigned no IPT (6·9%, 5·1-9·2). The hazard ratio of death in patients who had IPT compared with those who did not have IPT was 0·63 (95% CI, 0·41 to 0·97) after adjusting for the ART strategy (early vs deferred), and 0·61 (0·39-0·94) after adjustment for the ART strategy, baseline CD4 cell count, and other key characteristics. There was no evidence for statistical interaction between IPT and ART (p_interaction=0·77) or between IPT and time (p_interaction=0·94) on mortality.

INTERPRETATION

In Côte d'Ivoire, where the incidence of tuberculosis was last reported as 159 per 100 000 people, 6 months of IPT has a durable protective effect in reducing mortality in HIV-infected people, even in people with high CD4 cell counts and who have started ART.

FUNDING

National Research Agency on AIDS and Viral Hepatitis (ANRS).

Early Diagnosis of HIV Infection in Infants - One Caribbean and Six Sub-Saharan African Countries, 2011-2015

Pediatric human immunodeficiency virus (HIV) infection remains an important public health issue in resource-limited settings. In 2015, 1.4 million children aged <15 years were estimated to be living with HIV (including 170,000 infants born in 2015), with the vast majority living in sub-Saharan Africa (1). In 2014, 150,000 children died from HIV-related causes worldwide (2). Access to timely HIV diagnosis and treatment for HIV-infected infants reduces HIV-associated mortality, which is approximately 50% by age 2 years without treatment (3). Since 2011, the annual number of HIV-infected children has declined by 50%. Despite this gain, in 2014, only 42% of HIV-exposed infants received a diagnostic test for HIV (2), and in 2015, only 51% of children living with HIV received antiretroviral therapy (1). Access to services for early infant diagnosis of HIV (which includes access to testing for HIV-exposed infants and clinical diagnosis of HIV-infected infants) is critical for reducing HIV-associated mortality in children aged <15 years. Using data collected from seven countries supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), progress in the provision of HIV testing services for early infant diagnosis was assessed. During 2011-2015, the total number of HIV diagnostic tests performed among HIV-exposed infants within 6 weeks after birth (tests for early infant diagnosis of HIV), as recommended by the World Health Organization (WHO) increased in all seven countries (Cote d'Ivoire, the Democratic Republic of the Congo, Haiti, Malawi, South Africa, Uganda, and Zambia); however, in 2015, the rate of testing for early infant diagnosis among HIV-exposed infants was <50% in five countries. HIV positivity among those tested declined in all seven countries, with three countries (Cote d'Ivoire, the Democratic Republic of the Congo, and Uganda) reporting >50% decline. The most common challenges for access to testing for early infant diagnosis included difficulties in specimen transport, long turnaround time between specimen collection and receipt of results, and limitations in supply chain management. Further reductions in HIV mortality in children can be achieved through continued expansion and improvement of services for early infant diagnosis in PEPFAR-supported countries, including initiatives targeted to reach HIV-exposed infants, ensure access to programs for early infant diagnosis of HIV, and facilitate prompt linkage to treatment for children diagnosed with HIV infection.

[Gingival displacement techniques in daily practice. Survey among dental surgeons in Abidjan, Ivory Coast]

INTRODUCTION

Access to cervical margins allows the practitioner to record the entire cervical margin in order to provide a true copy to the technician. This requires a gingival displacement obtainable by different techniques. This study aimed to assess the implementation of gingival displacement methods prior to impression taking in fixed prosthodontics.

MATERIALS AND METHODS

This is a descriptive and cross-sectional survey of sample of 71 dentists practising in Abidjan, Ivory Coast; which ran from October 2nd, 2010 to November 14th, 2010. A survey form was administered to dentists. The questionnaire was organised around the following headings: identification of dentists and practice of gingival displacement methods. The data processing done using software Epi Info 6 and Excel XP on Window XP, allowed calculation of frequencies, means and proportions and the establishment of connection between variables with the chi2 test. The significance level was set at p < 0.05.

RESULTS

The results of the survey indicate that non-surgical methods of gingival displacement, including retraction cords and temporary crowns are those they use most frequently (76.4%) because the vast majority of practitioners (87.22%) believe the most traumatic to the periodontium are surgical methods.

CONCLUSION

Our study showed that the gingival displacement methods are frequently carried out in daily practice, regardless of the topography of the abutment teeth and their number, but with a preference for non-surgical methods, particularly those using retraction cords and temporary crowns. The use of injectable gingival displacement paste is not harmful to the periodontal tissues, easy to use and have a very efficient haemostatic action. It should also be known and practiced.

A Trial of Early Antiretrovirals and Isoniazid Preventive Therapy in Africa

BACKGROUND

In sub-Saharan Africa, the burden of human immunodeficiency virus (HIV)-associated tuberculosis is high. We conducted a trial with a 2-by-2 factorial design to assess the benefits of early antiretroviral therapy (ART), 6-month isoniazid preventive therapy (IPT), or both among HIV-infected adults with high CD4+ cell counts in Ivory Coast.

METHODS

We included participants who had HIV type 1 infection and a CD4+ count of less than 800 cells per cubic millimeter and who met no criteria for starting ART according to World Health Organization (WHO) guidelines. Participants were randomly assigned to one of four treatment groups: deferred ART (ART initiation according to WHO criteria), deferred ART plus IPT, early ART (immediate ART initiation), or early ART plus IPT. The primary end point was a composite of diseases included in the case definition of the acquired immunodeficiency syndrome (AIDS), non-AIDS-defining cancer, non-AIDS-defining invasive bacterial disease, or death from any cause at 30 months. We used Cox proportional models to compare outcomes between the deferred-ART and early-ART strategies and between the IPT and no-IPT strategies.

RESULTS

A total of 2056 patients (41% with a baseline CD4+ count of ≥500 cells per cubic millimeter) were followed for 4757 patient-years. A total of 204 primary end-point events were observed (3.8 events per 100 person-years; 95% confidence interval [CI], 3.3 to 4.4), including 68 in patients with a baseline CD4+ count of at least 500 cells per cubic millimeter (3.2 events per 100 person-years; 95% CI, 2.4 to 4.0). Tuberculosis and invasive bacterial diseases accounted for 42% and 27% of primary end-point events, respectively. The risk of death or severe HIV-related illness was lower with early ART than with deferred ART (adjusted hazard ratio, 0.56; 95% CI, 0.41 to 0.76; adjusted hazard ratio among patients with a baseline CD4+ count of ≥500 cells per cubic millimeter, 0.56; 95% CI, 0.33 to 0.94) and lower with IPT than with no IPT (adjusted hazard ratio, 0.65; 95% CI, 0.48 to 0.88; adjusted hazard ratio among patients with a baseline CD4+ count of ≥500 cells per cubic millimeter, 0.61; 95% CI, 0.36 to 1.01). The 30-month probability of grade 3 or 4 adverse events did not differ significantly among the strategies.

CONCLUSIONS

In this African country, immediate ART and 6 months of IPT independently led to lower rates of severe illness than did deferred ART and no IPT, both overall and among patients with CD4+ counts of at least 500 cells per cubic millimeter. (Funded by the French National Agency for Research on AIDS and Viral Hepatitis; TEMPRANO ANRS 12136 ClinicalTrials.gov number, NCT00495651.).

[Spontaneous splenic rupture in the first trimester of pregnancy: report of a case and review of the literature]

The authors return a case of spontaneous rupture of the spleen occured at the first quater of pregnancy. It is a rare accident during pregnancy that often entails the maternal death. Its exact reasons are difficult to determine. Among the reasons of the hemoperitoines at the firt quarter it is necessary to know how to think about the rupture of the spleen. Its diagnosis is unsuspected. The hold in charge surgical fast in our case permitted the pursuit of pregnancy.