Community Insights in Phylogenetic HIV Research: The CIPHR Project Protocol.

Inferring HIV transmission networks from HIV sequences is gaining popularity in the field of HIV molecular epidemiology. However, HIV sequences are often analyzed at distance from those affected by HIV epidemics, namely without the involvement of communities most affected by HIV. These remote analyses often mean that knowledge is generated in absence of lived experiences and socio-economic realities that could inform the ethical application of network-derived information in 'real world' programmes. Procedures to engage communities are noticeably absent from the HIV molecular epidemiology literature. Here we present our team's protocol for engaging community activists living in Nairobi, Kenya in a knowledge exchange process - The CIPHR Project (Community Insights in Phylogenetic HIV Research). Drawing upon a community-based participatory approach, our team will (1) explore the possibilities and limitations of HIV molecular epidemiology for key population programmes, (2) pilot a community-based HIV molecular study, and (3) co-develop policy guidelines on conducting ethically safe HIV molecular epidemiology. Critical dialogue with activist communities will offer insight into the potential uses and abuses of using such information to sharpen HIV prevention programmes. The outcome of this process holds importance to the development of policy frameworks that will guide the next generation of the global response.

Informal settlements, Covid-19 and sex workers in Kenya.

This paper highlights the challenges faced by female sex workers living and working in the urban informal settlements in Nairobi, Kenya, during the Covid-19 outbreak and the aftermath of the pandemic. Using data collected through phone interviews during the immediate crisis, we document the experiences of urban poor sex workers, illustrating the acute problems they faced, including precarious housing with the reality of eviction and demolition. The paper highlights the ramifications of the Covid-19 crisis for the sex industry and predominantly women working within this informal, illegal economy. Through our empirical data we illustrate how the nature of selling sex has changed for sex workers in this context, increasing risks of violence including police abuses. We argue that examining the Covid-19 crisis through the lens of one the most marginalised populations graphically highlights how the pandemic has and will continue to deepen pre-existing structural urban inequalities and worsen public health outcomes among the urban poor. Sex worker communities are often located at the intersections of structural inequalities of gender, class, race and nation and the socio-spatial fragmentations of how they live make them some of the most vulnerable in society. We close with comments in relation to sexual citizenship, exclusionary state practices and the feminisation of urban poverty.

The precarity of mobile loan debt and repayment among female sex workers in Nairobi, Kenya: Implications for sexual health.

Financial technology tools have been utilised to create readily available mobile loan platforms for urban-based, daily-wage earners in Kenya. From a financial lending perspective, this development signals greater inclusion and equality in formal bank financing systems. In this paper, however, we examine mobile loans and their repayment from the perspective of women who sell sex in Nairobi, drawing upon the qualitative findings of two community-based studies conducted in close collaboration with sex worker-led organisations serving the sexual health needs of their peers. Our findings suggest that mobile loans may undermine the financial security strategies and economic independence of sex workers, leaving these women in more precarious economic circumstances, which have been shown in other instances to have effects on sexual risk taking and vulnerability to HIV infection.

Adequate funding of comprehensive community-based programs for key populations needed now more than ever to reach and sustain HIV targets.

INTRODUCTION: Globally, over half of the estimated new HIV infections now occur among key populations, including men who have sex with men, sex workers, people who inject drugs, transgender individuals, and people in prisons and other closed settings, and their sexual partners. Reaching epidemic control will, for many countries, increasingly require intensified programming and targeted resource allocation to meet the needs of key populations and their sexual partners. However, insufficient funding, both in terms of overall amounts and the way the funding is spent, contributes to the systematic marginalization of key populations from needed HIV services. DISCUSSION: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently highlighted the urgent need to take action to end inequalities, including those faced by key populations, which have only been exacerbated by the COVID-19 pandemic. To address these inequalities and improve health outcomes, key population programs must expand the use of a trusted access platform, scale up differentiated service delivery models tailored to the needs of key populations, rollout structural interventions and ensure service integration. These critical program elements are often considered "extras," not necessities, and consequently costing studies of key population programs systematically underestimate the total and unitary costs of services for key populations. Findings from a recent costing study from the LINKAGES project suggest that adequate funding for these four program elements can yield benefits in program performance. Despite this and other evidence, the lack of data on the true costs of these elements and the costs of failing to provide them prevents sufficient investment in these critical elements. CONCLUSIONS: As nations strive to reach the 2030 UNAIDS goals, donors, governments and implementers should reconsider the true, but often hidden costs in future healthcare dollars and in lives if they fail to invest in the community-based and community-driven key population programs that address structural inequities. Supporting these efforts contributes to closing the remaining gaps in the 95-95-95 goals. The financial and opportunity cost of perpetuating inequities and missing those who must be reached in the last mile of HIV epidemic control must be considered.

Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in Nairobi, Kenya.

This paper uses empirical data collected from 117 female sex workers living in informal settlements in Nairobi and 15 healthcare providers to highlight specific effects of COVID-19 and related restrictions on healthcare access for the sex workers. We highlight the existing gender and health inequalities that have now been reinforced by the initial outbreak of the COVID-19 pandemic. Specifically, we focus on the most concerning healthcare needs for the sex workers including HIV prevention, care and treatment and sexual and reproductive healthcare. Our study findings reveal that the various restrictions imposed by the government to help curb the spread of COVID-19 to a large extent made it difficult for the sex workers to access their healthcare needs. The paper discusses the challenges of healthcare service delivery reflecting on some innovative and pioneering responses from health care providers to address the emergency situation.

The effects of COVID-19 on the health and socio-economic security of sex workers in Nairobi, Kenya: Emerging intersections with HIV.

The COVID-19 pandemic, and its attendant responses, has led to massive health, social, and economic challenges on a global scale. While, so far, having a relatively low burden of COVID-19 infection, it is the response in lower- and middle- income countries that has had particularly dire consequences for impoverished populations such as sex workers, many of whom rely on regular income in the informal economic sector to survive. This commentary captures the challenges in Kenya posed by daily curfews and lost economic income, coupled with further changes to sex work that increase potential exposure to infection, stigmatisation, violence, and various health concerns. It also highlights the ways in which communities and programmes have demonstrated resourcefulness in responding to this unprecedented disruption in order to emerge healthy when COVID-19, and the measures to contain it, subside.

Implementation of Isoniazid Preventive Therapy Among HIV-Infected Children at Health Facilities in Nairobi County, Kenya: A Cross-Sectional Study.

BACKGROUND: HIV is the strongest risk factor for developing tuberculosis (TB) among people with latent or new Mycobacterium tuberculosis infection. Isoniazid preventive therapy (IPT) reduces the risk of active TB among people living with HIV by up to 62%. Despite evidence that IPT is safe and efficacious, its provision remains low globally. The current study aimed at documenting IPT uptake, adherence, and completion rates, as well as the correlates of IPT uptake among HIV-infected children in Kenya. The study also assessed the knowledge, attitude, and practices of health-care workers (HCWs) with regard to IPT. METHODS: A health facility-based cross-sectional study was conducted. Data were collected from caregivers of HIV-infected children as well as HCWs using an interviewer-administered questionnaire. Logistic regression was used to determine the factors associated with IPT uptake. RESULTS: The study enrolled 111 child-caregiver dyads. Most of the caregivers were female (n=75, 77.3%) and HIV-positive (n=82, 85.4%). The majority of children were male (n=65, 58.6%) and on ART (n=106, 95.5%). Overall, 59 children were on IPT (uptake of 53.2%, 95% confidence interval [CI], 43.9% to 62.4%). Out of the 25 children who had been on IPT for more than 6 months, 22 (88.0%) successfully completed the 6-month course of treatment. Further, 27 of the 34 children (78.4%) who were on IPT at the time of the study demonstrated satisfactory adherence to the therapy (no doses missed). The caregivers' attributes that were associated with IPT uptake included having a secondary school education (adjusted odds ratio [aOR] 0.13; 95% CI, 0.03 to 0.67) and having been on IPT (aOR 27.50; 95% CI, 5.39 to 140.28). The characteristics of children that were significantly associated with IPT uptake were higher median baseline CD4 count (P=.007) and higher median current CD4 count (P=.024). CONCLUSION: The study demonstrated suboptimal IPT uptake but favourable adherence and treatment completion rates. There was almost universal awareness of IPT within the study sample. Furthermore, the majority of the HCWs had a favourable attitude towards IPT. However, the attendant IPT practices were inadequate, with majority of HCWs reporting that they had never initiated IPT, prescribed IPT within the last 12 months, or renewed an isoniazid prescription.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies.

BACKGROUND: Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur. METHODS AND FINDINGS: We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing. CONCLUSIONS: Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

Ecologies of security: On the everyday security tactics of female sex workers in Nairobi, Kenya.

This paper highlights important environmental dimensions of HIV vulnerability by describing how the sex trade operates in Nairobi, Kenya. Although sex workers there encounter various forms of violence and harassment, as do sex workers globally, we highlight how they do not merely fall victim to a set of environmental risks but also act upon their social environment, thereby remaking it, as they strive to protect their health and financial interests. In so doing, we illustrate the mutual constitution of 'agency' and 'structure' in social network formations that take shape in everyday lived spaces. Our findings point to the need to expand the focus of interventions to consider local ecologies of security in order to place the local knowledges, tactics, and capacities that communities might already possess on centre stage in interventions. Planning, implementing, and monitoring interventions with a consideration of these ecologies would tie interventions not only to the risk reduction goals of global public health policy, but also to the very real and grounded financial priorities of what it means to try to safely earn a living through sex work.

A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up.

A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach for addressing HIV in sex workers, with its focus on addressing the broad context within which the heightened risk for infection takes places in these individuals. However, large-scale implementation of community empowerment-based approaches has been scarce. We undertook a comprehensive review of community empowerment approaches for addressing HIV in sex workers. Within this effort, we did a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers in low-income and middle-income countries. We found that community empowerment-based approaches to addressing HIV among sex workers were significantly associated with reductions in HIV and other sexually transmitted infections, and with increases in consistent condom use with all clients. Despite the promise of a community-empowerment approach, we identified formidable structural barriers to implementation and scale-up at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; and intersecting social stigmas, discrimination, and violence. The evidence base for community empowerment in sex workers needs to be strengthened and diversified, including its role in aiding access to, and uptake of, combination interventions for HIV prevention. Furthermore, social and political change are needed regarding the recognition of sex work as work, both globally and locally, to encourage increased support for community empowerment responses to HIV.

Global epidemiology of HIV among female sex workers: influence of structural determinants.

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per µL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.