Frequent chlamydia and gonorrhoea but very infrequent syphilis among men who have sex with men using HIV pre-exposure prophylaxis in West Africa.

OBJECTIVES: Although oral pre-exposure prophylaxis (PrEP) for HIV is being rolled out in West Africa, data on sexually transmitted infections (STIs) in PrEP users are scarce. We assessed the prevalence, incidence and determinants of bacterial STIs in men who have sex with men (MSM) taking PrEP in Burkina Faso, Côte d'Ivoire, Mali and Togo. METHODS: A prospective cohort study among MSM initiating PrEP as part of a comprehensive HIV prevention package was conducted between 2017 and 2021 in community-based clinics in the four study countries. Molecular screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) was performed at months 0, 6 and 12. Serological testing for syphilis was performed every 3 months over the first year of follow-up. Determinants of CT and/or NG incidence were identified using Poisson generalised linear mixed models. RESULTS: A total of 598 participants with a median age of 24.7 years were included. Prevalence of CT and/or NG was 24.4% (95% CI 21.0 to 28.1), 22.4% (95% CI 18.4 to 26.8) and 29.0% (95% CI 24.2 to 34.1) at months 0, 6 and 12, respectively. The prevalence of syphilis ranged from 0.2% (95% CI 0.0 to 0.9) at month 0 to 0.8% (95% CI 0.2 to 2.4) at month 12. Ninety incident CT and/or NG infections occurred during a total follow-up time of 280.6 person-years (incidence rate 32.1 per 100 person-years, 95% CI 25.8 to 39.4). Three incident syphilis infections were detected during a total follow-up time of 459.7 person-years (incidence rate 0.7 per 100 person-years, 95% CI 0.1 to 1.9). CT and/or NG incidence was associated with condomless insertive anal sex (adjusted incidence rate ratio 1.96, 95% CI 1.04 to 3.71, p=0.038). CONCLUSIONS: CT and NG were frequent but syphilis was very infrequent in MSM using HIV PrEP in West Africa. HIV programme managers should integrate STI services into PrEP programmes.

Men Who Have Sex with Both Men and Women in West Africa: Factors Associated with a High Behavioral Risk of Acquiring HIV from Male Partners and Transmission to Women (CohMSM ANRS 12324-Expertise France).

HIV is highly prevalent in men who have sex with men (MSM) in West Africa. Many MSM in the region also have sex with women (MSMW). Accordingly, they are a potential bridge subpopulation for HIV transmission to women. We aimed to evaluate the proportions and characteristics of West African MSMW at high behavioral risk of acquiring HIV from male partners and transmitting it to female partners (HBRMF). The cohort ANRS-12324 CohMSM Study included 630 HIV-negative MSM in Burkina Faso, Cote d'Ivoire, Mali, and Togo. Among MSMW (i.e., with ≥ 1 female partner) in the cohort, HBRMF was identified using trajectory models based on seven at-risk sexual practices with male and female partners, including inconsistent condom use, multiple partnerships, and receptive same-sex anal intercourse. To assess the relevance of using trajectory models, we compared the proportions of participants who seroconverted during the cohort follow-up among those at HBRMF and those not at HBRMF. Factors associated with HBRMF were identified using a generalized estimation equation logistic regression model accounting for longitudinal data. Approximately half (47%) of the 304 MSMW (22% of all CohMSM study participants) were at HBRMF. This group accounted for 75% of the 28 HIV seroconversions observed during follow-up (p = 0.001). HBRMF was positively associated with being aged < 25 years (aOR 95% CI 1.67 [1.23-2.27]), being sexually attracted only to men (1.97 [1.38-2.78]), feelings of loneliness (1.92 [1.38-2.65]), and homonegative violence score (1.22 [1.05-1.41]). HBRMF was negatively associated with having had both stable and casual female partners in the previous 6 months (0.34 [0.20-0.60] vs. only a stable female partner). HBRMF tended to be negatively associated with having ≥ 4 sexual intercourses with female partners in the previous four weeks (0.54 [0.27-1.06] vs. no intercourse). Establishing official relationships with women might be a strategy for young and/or stigmatized MSMW to comply with social pressure to display a heterosexual lifestyle. However, this seems to increase the risk of HIV transmission to female partners. In the present study, almost half of MSMW were at HBRMF. This result stresses the need to adapt HIV research and prevention to MSMW and their female partners.

The Perceived Added Value of Bimonthly Injectable Pre-Exposure Prophylaxis According to West African Men Who Have Sex with Men: A Focus Group Study.

Bimonthly long-acting injectable pre-exposure prophylaxis (LAI-PrEP) can become an important additional tool for HIV prevention among West African men who have sex with men (MSM). The objective was to explore the perceived added value of LAI-PrEP as an HIV prevention tool among MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo. We conducted eight focus group discussions among 62 HIV-negative MSM between April and May 2021. Participants were recruited via local community-based clinics. Data collection and analysis were guided by grounded theory and community-based participatory approaches. Participants were generally knowledgeable about HIV, and explained particular barriers for HIV prevention in their communities (e.g., denial of HIV). The added value of LAI-PrEP relative to condoms was similar to oral pre-exposure prophylaxis (PrEP) in terms of perceived advantages (e.g., improved sexual satisfaction) or disadvantages (e.g., no protection against other sexually transmitted infections). Compared with oral PrEP, LAI-PrEP was perceived to provide better protection against HIV and to be more convenient (e.g., no need to be mindful of intake and less risk for stigma). Concerns included fear of needles, doubts about efficacy, potential side effects, and difficulties for ensuring timely injections (e.g., when traveling abroad). The results demonstrate that injectable PrEP can be of particular interest to subgroups of West African MSM, although existing HIV prevention tools such as condoms and oral PrEP will remain valuable alongside of, or instead of, LAI-PrEP. Increasing awareness about HIV and tackling discrimination based on sexual orientation continue to be crucial factors to be addressed for HIV prevention.

Longitudinal study of pregnancy intention and its association with pregnancy occurrence among female sex workers in Benin and Mali.

BACKGROUND: The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent as are HIV and sexually transmitted infections, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects on wanted pregnancies. METHODS: We recruited 330 FSWs in Benin and 322 in Mali and followed them for 12 months. We evaluated their pregnancy intention at recruitment and 6-month follow-up, using a multidimensional prospective measure that we developed. We assessed pregnancy occurrence with a pregnancy test and a retrospective questionnaire at 6 and 12 months. A Cox proportional hazard model was used to estimate the association between intention and pregnancy. We carried out an analysis to take losses to follow-up into account using the inverse of probability of censoring weights and a cluster analysis to corroborate that the multidimensional measure of pregnancy intention fitted the data. RESULTS: 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Mean age was 30.9 years. The pregnancy intention distribution was similar between the two periods: 15.2% in the first period and 16.3% in the second had a positive intention. One out of four were ambivalent and almost 60% (57.7% and 56.3%) had a negative intention. For 38.2% of the FSWs, the intention changed between the two periods. The global incidence rate (to first event) was 19.1 pregnancies per 100 person-years. There was a borderline significant trend (p = 0.0529) of decreased pregnancy incidence with decreasing intention. Compared to positive intention, the adjusted hazard ratio (aHR) for ambivalent and negative intentions were 0.71 [95% confidence interval (95% CI) 0.32-1.60] and 0.46 (95% CI 0.21-1.01), respectively. CONCLUSION: The level of pregnancy intention influences its occurrence among FSWs and nearly one out of six wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care. Given other health risks associated with sex work this care may decrease potential risks of adverse maternal, fetal and neonatal outcomes.

The intention of becoming pregnant has an evident impact on the prenatal and postnatal period. For female sex workers (FSWs) in West Africa, among whom pregnancies are frequent, a better understanding of their pregnancy intention and its influence on pregnancy occurrence could help prevent unwanted pregnancies and adverse effects of wanted pregnancies. We recruited 330 FSWs in Benin and 322 in Mali and we followed them for 12 months. We evaluated their pregnancy intention at recruitment and at 6-month follow-up. We assessed pregnancy occurrence with a pregnancy urine test and with a retrospective questionnaire asking on pregnancy occurrence at 6 and 12 months. With these data we estimated the association between intention and pregnancy. 407 FSWs were included in the first 6-month analysis and 284 at 12 months. Sixteen percent of the FSWs had a positive intention of having a pregnancy in the next 6 months in both the first 6-month and 12 months. One out of four were ambivalent and almost 60% had a negative intention. For 38.2% of the FSWs the intention changed between the two periods. Women with an ambivalent intention compared to those with positive intention, had 30% less pregnancies whereas for negative intention, women had 54% less pregnancies during the study follow-up. As for any woman, the level of pregnancy intention influences its occurrence. Moreover, nearly one out of six FSWs wants a baby despite working in the sex trade. Programmatically, early identification of these women could facilitate provision of quality antenatal and postnatal care.

Mycoplasma genitalium and Antimicrobial Resistance Among a Cohort of West African Men Who Have Sex With Men Using Preexposure Prophylaxis (CohMSM-PrEP ANRS 12369-Expertise France Study).

Background: Antimicrobial resistance to macrolides and fluoroquinolones in Mycoplasma genitalium (MG) among men who have sex with men (MSM) is worryingly high in high-resource countries. Data in Africa are lacking. We aimed to assess the burden of MG including the presence of resistance-associated mutations (RAMs) in MG among MSM using human immunodeficiency virus preexposure prophylaxis in Burkina Faso, Côte d'Ivoire, Mali, and Togo. Methods: MSM were included in a prospective cohort study (2017-2021). Molecular detection of MG in urine, anorectal, and pharyngeal samples was performed at baseline and after 6 and 12 months. Detection of RAMs to macrolides and fluoroquinolones was performed by sequencing the 23S ribosomal RNA, parC, and gyrA genes. A sample was found to be possibly resistant to fluoroquinolones if alterations were found in ParC position 83/87. Results: Of 598 participants, 173 (28.9%) were positive at least once for MG and global point-prevalence was 19.4%. Interestingly, 238 of 250 (95.2%) infections were asymptomatic and 72 of 138 MG infections with follow-up data (52.2%) cleared during the study. Only 1 macrolide RAM was found (0.6%). Prevalence of fluoroquinolones RAMs was 11.3% overall, ranging from 2.4% in Burkina Faso to 17.5% in Mali. Conclusions: Although MG was highly prevalent in these MSM, macrolide resistance was almost nonexistent. Nevertheless, >10% of the samples were possibly resistant to fluoroquinolones. Heterogeneity in the prevalence of fluoroquinolone RAMs between countries may be explained by different antimicrobial consumption in humans and animals.

Loss to Follow-Up from HIV Pre-Exposure Prophylaxis Care in Men Who Have Sex with Men in West Africa.

Loss to follow-up (LTFU) from HIV pre-exposure prophylaxis (PrEP) care compromises the goal of HIV elimination. We investigated the proportion of LTFU and associated risk factors among men who have sex with men (MSM) enrolled in a PrEP demonstration project in Burkina Faso, Côte d'Ivoire, Mali, and Togo. CohMSM-PrEP, a prospective cohort study, was conducted between November 2017 and June 2021 in community-based clinics. MSM aged 18 years or older at substantial risk of HIV infection received a comprehensive prevention package, including PrEP and peer education. LTFU was defined as not returning to the clinic for six months. Associated risk factors were investigated using a time-varying Cox's model. Of 647 participants followed up for a median time of 15 months, 372 were LTFU (57.5%). LTFU was associated with younger age (adjusted hazard ratio [95% Confidence Interval]; 1.50 [1.17-1.94]), unemployment (1.33 [1.03-1.71]), depression (1.63 [1.12-2.38]), and perceiving no HIV risk with stable male partners (1.61 [1.23-2.10]). Contacting peer educators outside of scheduled visits was protective (0.74 [0.56-0.97]). Our findings show that LTFU from PrEP care in West African MSM is a major challenge to achieving HIV elimination, but that the involvement of peer educators in PrEP delivery helps to limit LTFU by providing users with adequate support.

Rapid antiretroviral therapy initiation and its effect on treatment response in MSM in West Africa.

OBJECTIVE: To assess the time from HIV diagnosis to ART initiation and the effect of rapid ART initiation (i.e. within 7 days of HIV diagnosis) on attrition and virologic and immunologic responses among MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo. DESIGN: Prospective cohort study between 2015 and 2019. METHODS: MSM aged 18 years or older newly diagnosed with HIV infection were eligible to participate. ART was proposed to participants upon HIV diagnosis, irrespective of clinical stage and CD4+ cell count, and was initiated as soon as possible, with no specific time frame. Determinants of rapid ART initiation and its effect on treatment outcomes were assessed using multivariate analyses. RESULTS: Of 350 MSM, 335 (95.7%) initiated ART after a median time of 5 days. Of the latter, 216 (64.5%) had rapid ART initiation. The 335 participants were followed up for a median time of 24.1 months. One hundred and eleven (33.1%) were not retained in care. Rapid ART initiation was less likely in participants with a CD4+ cell count at least 200 cells/µl [adjusted odds ratio (aOR) 0.37, 95% confidence interval (CI) 0.15-0.88]. It improved viral load suppression (aOR 6.96, 95% CI 1.98-24.46) but had no effect on attrition (aOR 0.87, 95% CI 0.57-1.33) or CD4+ cell count increase (adjusted coefficient 28.23, 95% CI -17.00 to 73.45). CONCLUSION: These results in MSM in West Africa support the WHO recommendation for rapid ART initiation. Clinics need to develop context-specific strategies for rapid ART initiation and for retaining MSM in HIV care.ClinicalTrials.gov, number NCT02626286.

Adherence to quarterly HIV prevention services and its impact on HIV incidence in men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France).

BACKGROUND: Access to tailored HIV prevention services remains limited for West African MSM. We assessed adherence to quarterly HIV prevention services and its impact on HIV incidence in MSM followed up in four cities in Burkina Faso, Côte d'Ivoire, Mali, and Togo. METHODS: We performed a prospective cohort study between 2015 and 2018. HIV-negative MSM aged over 18 benefited from quarterly medical visits which included a clinical examination, HIV testing, screening and treatment for other sexually transmitted infections, peer-led counselling and support, and the provision of condoms and lubricants. Determinants of adherence to quarterly follow-up visits and incident HIV infections were identified using generalized estimating equation models and Cox proportional hazard models, respectively. RESULTS: 618 MSM were followed up for a median time of 20.0 months (interquartile range 15.2-26.3). Overall adherence to quarterly follow-up visits was 76.5% (95% confidence interval [CI] 75.1-77.8), ranging from 66.8% in Abidjan to 87.3% in Lomé (p < 0.001). 78 incident HIV infections occurred during a total follow-up time of 780.8 person-years, giving an overall incidence of 10.0 per 100 person-years (95% CI 8.0-12.5). Adherence to quarterly follow-up visits was not associated with the risk of incident HIV infection (adjusted hazard ratio 0.80, 95% CI 0.44-1.44, p = 0.545). CONCLUSIONS: Strengthening HIV prevention services among MSM in West Africa, including the use of PrEP, will be critical for controlling the epidemic, not only in this key population but also in the general population. Quarterly follow-up of MSM, which is essential for PrEP delivery, appears feasible. TRIAL REGISTRATION: ClinicalTrials.gov, number NCT02626286 (December 10, 2015).

Assessment of mental health outcomes and associated factors among workers in community-based HIV care centers in the early stage of the COVID-19 outbreak in Mali.

BACKGROUND AND OBJECTIVES: In Mali, the non-governmental association (NGO) ARCAD Santé PLUS launched the CovidPrev program in response to the COVID-19 outbreak to ensure continuity of HIV care-related activities. This study aimed to identify individual and structural factors associated with mental health disorders (MHD) in the NGO's healthcare workers (HCW) in the early stage of the outbreak. METHODS: Data were collected between April 6 and 11, 2020 for 135 HCW in ARCAD Santé PLUS's 18 community-based HIV care centers. Outcomes corresponded to the PHQ-9, GAD-7 and ISI instruments for depression, anxiety and insomnia, respectively. A general mixture model with a negative binomial distribution was implemented. RESULTS: Most HCW were men (60.7%) and median age was 40 years IQR[33-46]. Symptoms of depression, anxiety and insomnia were declared by 71.9, 73.3, and 77% participants, respectively. Women were at greater risk of MHD. A lack of personal protection equipment and human resources, especially nurses, was associated with a high risk of MHD. CONCLUSIONS: Health policy must place non-front line HCW, including those in NGOs, at the core of the healthcare system response to the COVID-19 outbreak, as they ensure continuity of care for many diseases including HIV. The efficacy of public health strategies depends on the capacity of HCW to fully with and competently perform their duties.

Combined Sexual Behavioral Profiles in HIV-Seronegative Men Who have Sex with Men in West Africa (CohMSM ANRS 12324-Expertise France).

Understanding the dynamics of HIV infection in men who have sex with men (MSM) can help improve efficiency in existing prevention strategies. We aimed to identify and describe the sexual behaviors of MSM most at risk of HIV infection in West Africa. HIV-negative MSM were provided a quarterly preventive follow-up package in the community-based cohort CohMSM. They completed face-to-face sociobehavioral questionnaires every 6 months. This sub-study on 520 participants used a baseline, 6-, 12- and 18-month data cluster analysis to categorize two profiles (high risk [HRE] and moderate risk [MRE] of exposure to HIV) based on three risky sexual practices over the previous 6 months. HRE-MSM (61%) were more engaged in receptive practices, had a higher proportion of inconsistent condom use during anal sex, and reported more sexual partners than MRE-MSM (39%). The proportion of HIV seroconversions observed during the first 18 months of follow-up using sexual behavioral profiles (92% are HRE-MSM) was higher than using the three risky sexual practices separately. Factors associated with the HRE-MSM profile were being younger (18-21 years), reporting stigma, and having had no female partner while being attracted only to men. Our findings suggest that in order to identify MSM most at risk of HIV infection, several risky sexual practices need to be evaluated in a combined approach. Prevention programs should pay particular attention to younger MSM, and implement activities addressing questions of MSM identity and stigma in order to reduce the dynamic of HIV infection in Western African MSM.

Sex work among female workers in the traditional mining sector in Mali - results from the ANRS-12339 Sanu Gundo cross-sectional study in 2015.

Female sex workers (FSW) in mining sites are considered to be at very high risk of HIV infection. We aimed to characterize FSW at the Kôkôyô artisanal gold mining site in Mali, and identify factors associated with sex work using data from ANRS-12339 Sanu Gundo, a cross-sectional survey conducted in 2015 at the mine by ARCAD-SIDA, a Malian non-governmental organisation. People attending HIV-prevention activities were invited to participate in the quantitative and qualitative parts of the survey. A probit logistic regression was used for data analysis. Of 101 women who participated in the survey, 26.7% reported sex work as their main activity. Multivariate analysis showed that the probability of sex work as a main activity decreased by 1% per 1-year age increase (p = 0.020). Sex work was significantly more likely to be reported by single, divorced and widowed women (25.4% probability; p = 0.007). FSW were significantly more likely to be non-Malian (36.3% probability; p = 0.003), more likely to have a secondary activity (77% probability; p = 0.002), to work fewer than 56h/week (40.2% probability; p = 0.001) and to be in good health (12.1% probability; p = 0.016). In addition, being aware of the existence of sexually transmitted infection, using psychoactive substances, and having unprotected receptive anal sex during the previous six months were significantly associated with sex work (50.2%; p = 0.006; 45.6%, p = 0.003; and 7.4%, p = 0.016 probability, respectively). Qualitative findings confirm that poverty and boyfriends' refusal to use condoms remain key barriers to systematic condom use among FSW.

Empowering Malian women living with HIV regarding serostatus disclosure management: Short-term effects of a community-based intervention.

OBJECTIVE: The objective of this study was to assess the short-term effects of Gundo-So-a program aimed at empowering Malian women living with HIV (WLHIV) regarding serostatus disclosure management. METHODS: A pre-experimental study with two measures (one week before and four weeks after Gundo-So) was carried out. A 35-item questionnaire was administered to a convenience sample of 210 WLHIV. Six outcomes were considered: ability to decide whether or not to disclose HIV status, self-efficacy to keep HIV status a secret, self-efficacy to disclose HIV status, feeling crushed by the weight of secrecy, perceived physical health, and perceived psychological health. For each outcome, temporal changes associated with the intervention were assessed using linear regressions with random intercepts. RESULTS: Statistically significant change was observed for all six outcomes between the pre- and post-intervention measures. Furthermore, several variables were associated with the baseline levels of the outcomes and the intervention effect. CONCLUSION: The results suggest that Gundo-So empowers Malian WLHIV with regard to serostatus disclosure management, thus improving their perceived physical and psychological health. PRACTICAL IMPLICATIONS: These results highlight the need for programs to empower WLHIV regarding serostatus disclosure, so that WLHIV can make free and informed decisions regarding serostatus disclosure.