Describing the effect of COVID-19 on sexual and healthcare-seeking behaviours of men who have sex with men in three counties in Kenya: a cross-sectional study.

BACKGROUND: While the COVID-19 pandemic disrupted HIV preventative services in sub-Saharan Africa, little is known about the specific impacts the pandemic has had on men who have sex with men (MSM) in Kenya. METHODS: Data were from an HIV self-testing intervention implemented in Kisumu, Mombasa and Kiambu counties in Kenya. Baseline data collection took place from May to July 2019, and endline in August-October 2020, coinciding with the lifting of some COVID-19 mitigation measures. Using endline data, this study characterised the impact the pandemic had on participants' risk behaviours, experience of violence and behaviours related to HIV. Logistic regression was used to understand factors related to changes in risk behaviours and experiences of violence; adjusted AORs (AORs) and 95% CIs are reported. RESULTS: Median age was 24 years (IQR: 21-27). Most respondents (93.9%) reported no change or a decrease in the number of sexual partners (median number of male sexual partners: 2, IQR: 2-4). Some participants reported an increase in alcohol (10%) and drug (16%) consumption, while 40% and 28% reported decreases in alcohol and drug consumption, respectively. Approximately 3% and 10% reported an increase in violence from intimate partners and police/authorities, respectively. Compared with those with primary education, those with post-secondary education were 60% less likely to report an increase in the number of male sexual partners per week (AOR: 0.4, 95% CI: 0.2 to 0.9), while those who were HIV positive were at twofold the odds of reporting an increase or sustained levels of violence from intimate partners (AOR: 2.0, 95% CI: 1.1 to 4.0). CONCLUSION: The results of this study demonstrate heterogeneity in participants' access to preventative HIV and clinical care services in Kenya after the onset of the COVID-19 epidemic. These results indicate the importance of responding to specific needs of MSM and adapting programmes during times of crisis.

Equity trends for the UHC service coverage sub-index for reproductive, maternal, newborn and child health in Pakistan: evidence from demographic health surveys.

BACKGROUND: Pakistan, the world's sixth most populous country and the second largest in South Asia, is facing challenges related to reproductive, maternal, newborn and child health (RMNCH) that are exacerbated by various inequities. RMNCH coverage indicators such as antenatal care (ANC) and deliveries at health facilities have been improving over time, and the maternal mortality ratio (MMR) is gradually declining but not at the desired rates. Analysing and documenting inequities with reference to key characteristics are useful to unmask the disparities and to amicably implement targeted equity-oriented interventions. METHODS: Pakistan Demographic Health Survey (PDHS) based UHC service coverage tracer indicators were derived for the RMNCH domain at the national and subnational levels for the two rounds of the PDHS in 2012 and 2017. These derivations were subgrouped into wealth quintiles, place of residence, education and mothers' age. Dumbbell charts were created to show the trends and quintile-specific coverage. The UHC service coverage sub-index for RMNCH was constructed to measure the absolute and relative parity indices, such as high to low absolute difference and high to low ratios, to quantify health inequities. The population attributable risk was computed to determine the overall population health improvement that is possible if all regions have the same level of health services as the reference point (national level) across the equity domains. RESULTS: The results indicate an overall improvement in coverage across all indicators over time, but with a higher concentration of data points towards higher coverage among the wealthiest groups, although the poorest quintile continues to have low coverage in all regions. The UHC service coverage sub-index on RMNCH shows that Pakistan has improved from 45 to 63 overall, while Punjab improved from 50 to 59 and Sindh from 43 to 55. The highest improvement is evident in Khyber Pakhtunkhwa (KP) province, which has increased from 31 in 2012 to 51 in 2017. All regions made slow progress in narrowing the gap between the poorest and wealthiest groups, with particularly noteworthy improvements in KP and Sindh, as indicated by the parity ratio. The RMNCH service coverage sub-index gap was the greatest among women aged 15-19 years, those who belonged to the poorest wealth quintile, had no education, and resided in rural areas. CONCLUSIONS: Analysing existing data sources from an equity lens supports evidence-based policies, programs and practices with a focus on disadvantaged subgroups.

Prevalence and factors associated with HIV epidemic among female sex workers in Pakistan: results of the fifth round of integrated biological and behavioural surveillance.

OBJECTIVES: We examined data collected as part of the fifth round of integrated biological and behavioural surveillance to determine the prevalence and factors associated with HIV infection among female sex workers (FSWs) in Pakistan. METHODS: FSWs were defined as 'all females, age 13 years and above, who receive money or goods in exchange for sexual services, regardless of the site of operation'. Data were collected between October 2016 and January 2017 in 18 cities using multistage sampling techniques to randomly select FSWs from spots facilitated by peers. Behavioural data were collected by interviewers using structured questionnaires, which was followed by obtaining finger prick blood samples tested for HIV using two rapid tests. Multivariate logistic regression analysis was done to assess independent associations of potential correlates using HIV status as dependent variable. RESULTS: We invited 5728 FSWs to participate, of which 68 refused to participate (refusal rate=1.2%). Of the 5660 FSWs who participated, 121 were HIV seropositive (weighted HIV prevalence 2.3%; 95% CI 1.9% to 2.7%) mostly concentrated within cities in Sindh. Multivariate analysis showed being uneducated/illiterate (adjusted OR (aOR) 2.1; 95% CI 1.4 to 3.4), directly dealing with clients without a pimp (aOR 1.8; 95% CI 1.1 to 2.8), non-use of condom with clients (aOR 1.8; 95% CI 1.1 to 2.8), having sexual contact with people who inject drugs (PWID) (aOR 2.2; 95% CI 1.3 to 3.7) and non-participation in HIV programmes (aOR 1.7; 95% CI 1.0 to 3.1) as factors independently associated with HIV seropositivity. CONCLUSIONS: We found a weighted national HIV prevalence of 2.3% and identified factors independently associated with HIV in FSWs. The country needs to scale up HIV prevention programmes to improve coverage, prioritising FSWs who are illiterate, work independently and have PWID as sex partners. Emphasis should be laid on strategies to improve condom use with both regular and non-regular partners.

Programmatic mapping and size estimation of female sex workers, transgender sex workers and men who have sex with men in Istanbul and Ankara, Turkey.

OBJECTIVES: Despite a growing HIV threat, there is no definition and characterisation of key populations (KPs), who could be the major drivers of the epidemic in Turkey. We used programmatic mapping to identify locations where KPs congregate, estimate their numbers and understand their operational dynamics to develop appropriate HIV programme implementation strategies. METHODS: Female and transgender sex workers (FSWs and TGSWs), and men who have sex with men (MSM) were studied in Istanbul and Ankara. Within each district, hot spots were identified by interviewing key informants and a crude spot list in each district was developed. The spot validation process was led by KP members who facilitated spot access and interviews of KPs associated with that spot. Final estimates were derived by aggregating the estimated number of KPs at all spots, which was adjusted for the proportion of KPs who visit multiple spots, and for the proportion of KPs who do not visit spots. RESULTS: FSWs were the largest KP identified in Istanbul with an estimate of 30 447 (5.8/1000 women), followed by 15 780 TGSWs (2.9/1000 men) and 11 656 MSM (2.1/1000). The corresponding numbers in Ankara were 9945 FSWs (5.2/1000 women), 1770 TGSWs (1/1000 men) and 5018 MSM (2.5/1000 men). Each KP had unique typologies based on the way they find and interact with sex partners. MSM were mostly hidden and a higher proportion operated through internet and phone-based applications. Night time was the peak time with Friday, Saturday and Sunday being the peak days of activity in both Istanbul and Ankara. CONCLUSIONS: This study has highlighted the presence of a substantial number of FSWs, TGSW and MSM in Istanbul and Ankara. The information obtained from this study can be used to set priorities for resource allocation and provide HIV prevention services where coverage could be the highest.

Evaluation of community-based HIV self-testing delivery strategies on reducing undiagnosed HIV infection, and improving linkage to prevention and treatment services, among men who have sex with men in Kenya: a programme science study protocol.

BACKGROUND: HIV prevalence among men having sex with men (MSM) in Kenya is 18.2%. Despite scale-up of HIV testing services, many MSM remain unaware of their HIV status and thus do not benefit from accessing HIV treatment or prevention services. HIV self-testing (HIVST) may help address this gap. However, evidence is limited on how, when, and in what contexts the delivery of HIVST to MSM could increase awareness of HIV status and lead to early linkage to HIV treatment and prevention. METHODS: The study will be embedded within existing MSM-focused community-based HIV prevention and treatment programmes in 3 counties in Kenya (Kisumu, Mombasa, Kiambu). The study is designed to assess three HIV testing outcomes among MSM, namely a) coverage b) frequency of testing and c) early uptake of testing. The study will adopt a mixed methods programme science approach to the implementation and evaluation of HIVST strategies via: (i) a baseline and endline bio-behavioural survey with 1400 MSM; (ii) a socio-sexual network study with 351 MSM; (iii) a longitudinal qualitative cohort study with 72 MSM; (iv) routine programme monitoring in three sites; (v) a programme-specific costing exercise; and (vi) mathematical modelling. This protocol evaluates the impact of community-based implementation of HIV self-testing delivery strategies among MSM in Kenya on reducing the undiagnosed MSM population, and time for linkage to prevention, treatment and care following HIV self-testing. Baseline data collection started in April 2019 and the endline data collection will start in July 2020. DISCUSSION: This study is one of the first programme science studies in Sub-Saharan Africa exploring the effectiveness of integrating HIVST interventions within already existing HIV prevention and treatment programmes for MSM in Kenya at scale. Findings from this study will inform national best approaches to scale up HIVST among MSM in Kenya.

Key Programme Science lessons from an HIV prevention 'Learning Site' for sex workers in Mombasa, Kenya.

OBJECTIVES: In 2013, Kenya's National AIDS and STI Control Programme established a Learning Site (LS) in Mombasa County to support and strengthen capacity for HIV prevention programming within organisations working with sex workers. A defining feature of LS was the use of a Programme Science approach throughout its development and implementation. We provide an overview of the key components of LS, present findings from 23 months of programme monitoring data, and highlight key Programme Science lessons from its implementation and monitoring. METHODS: Routine monitoring data collected from September 2013 through July 2015 are presented. Individual-level service utilisation data were collected monthly and indicators of interest were analysed over time to illustrate trends in enrolment, programme coverage and service utilisation among sex workers in Mombasa County. RESULTS: Over the monitoring period, outreach programme enrolment occurred rapidly; condom distribution targets were met consistently; rates of STI screening remained high and diagnoses declined; and reporting of and response to violent incidents increased. At the same time, enrolment in LS clinics was relatively low among female sex workers, and HIV testing at LS was low among both female and male sex workers. CONCLUSION: Lessons learnt from operationalising the Programme Science framework through the Mombasa LS can inform the development and implementation of similar LS in different geographical and epidemiological contexts. Importantly, meaningful involvement of sex workers in the design, implementation and monitoring processes ensures that overall programme performance is optimised in the context of local, 'on-the-ground' realities. Additionally, learnings from LS highlight the importance of introducing enhanced monitoring and evaluations systems into complex programmes to better understand and explain programme dynamics over time.

The contributions and future direction of Program Science in HIV/STI prevention.

BACKGROUND: Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health. DISCUSSION: To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States. CONCLUSION: In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science.

Programmatic mapping to determine the size and dynamics of sex work and injecting drug use in Mauritius.

HIV in Mauritius is in a concentrated phase. Most HIV infection is among key populations (KPs) including female sex workers (FSW), people who inject drugs (PWID), men who have sex with men (MSM), and transgender sex workers (TGSW). The objective of this research was to use geographical mapping to determine the precise locations, typologies and population estimates of each KP in Mauritius. From May to July 2014 a programmatic mapping approach determined national estimates and information on the specific locations, "hotspots", frequented by KPs in Mauritius. Data were collected through multiple levels of activity. Key informants provided information about hotspots where KPs congregated and were actively engaged in risky behaviours. Validation of hotspots was done by engaging KPs. A total of 17 248 KP members were estimated spread over 1 964 hotspots in Mauritius. The largest KP was PWID with an estimate of 7 598 (range: 4 091-6 223), followed by 6 223 (range: 5 090-7 456) FSWs, spread over 694 and 731 hotspots respectively. A total of 2 020 (range: 1 595-2 446) MSM and 294 geographic MSM hotspots, and 1 407 TGSWs (range: 1 165-1 649) distributed over 245 hotspots. This research provided Mauritius with validated KPs size estimations and provided the first national data on KP hotspots and operational dynamics. The use of these data will strengthen HIV prevention, intervention, and programme planning in the country through focusing efforts to systematically target high-risk areas.

HIV prevalence and related risk behaviors in men who have sex with men, Yemen 2011.

Men who have sex with men (MSM) are at growing risk of HIV infection in many parts of the world; however, the epidemic has not been well explored among this population in most Arab countries. To estimate the prevalence of HIV and related risk behaviors among MSM in Yemen, we recruited 261 adult MSM from the port cities of Aden and Al-Hudaydah through venue- and facility-based sampling. Behavioral data were collected with a face-to-face questionnaire, and HIV status was determined by serological testing. HIV prevalence was 5.9 % (95 % CI 4.8-7.3). One-fourth (25.8 %, 95 % CI 20.7-31.5) had tested for HIV in the last year and received results; 27.8 % (95 % CI 22.5-33.7) had comprehensive knowledge about HIV; 20.0 % (95 % CI 15.8-25.0) reported condom use at last anal sex; and 31.4 % (95 % CI 25.9-37.3) reported that they or their sexual partner had a sexually transmitted disease symptom. Injecting drugs in the last year was reported by 0.8 % (95 % CI 0.1-9.2). Multiple risk behaviors, low HIV knowledge, few preventive behaviors, and HIV prevalence greater than 5 % denote a concentrated and potentially expanding HIV epidemic among MSM in Yemen. No time should be lost in intervening to prevent further expansion of the epidemic to levels already seen among MSM outside the Middle East.

Advancing Programme Science approaches to understand gaps in HIV prevention programme coverage for key populations in 12 Nigerian states: findings from the 2020 Integrated Biological and Behavioural Surveillance Survey.

INTRODUCTION: Effective HIV prevention programme coverage is necessary to achieve Nigeria's goal of ending the epidemic by 2030. Recent evidence highlights gaps in service coverage and utilization across the country. The Effective Programme Coverage framework is a Programme Science tool to optimize a programme's population-level impact by examining gaps in programme coverage using data generated through programme-embedded research and learning. We apply the framework using Integrated Biological and Behavioural Surveillance Survey (IBBSS) data from Nigeria to examine coverage of four prevention interventions-condoms, HIV testing, and needle and syringe programmes (NSP)-among four key population groups-female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID) and transgender people. METHODS: Data from Nigeria's 2020 IBBSS, implemented in 12 states, were analysed to examine HIV prevention programme coverage among key populations. For each key population group and prevention intervention of interest, weighted IBBSS data were used to retrospectively generate coverage cascades that identify and quantify coverage gaps. Required coverage targets were informed by targets articulated in Nigeria's National HIV/AIDS Strategic Framework or, in their absence, by guidelines from policy normative bodies. Availability-, outreach- and utilization coverage proxy indicators were defined using variables from IBBSS data collection tools. Sankey diagrams are presented to visualize pathways followed by participants between coverage cascade steps. RESULTS: Required coverage targets were missed for HIV testing and NSP among all key population groups. Condom availability coverage surpassed required coverage targets among FSW and MSM, while utilization coverage only among FSW exceeded the 90% required coverage target. Outreach coverage was low for all key population groups, falling below all required coverage targets. CONCLUSIONS: Our findings identify critical gaps in HIV prevention programme coverage for key populations in Nigeria and demonstrate non-linear movement across coverage cascades, signalling the need for innovative solutions to optimize coverage of prevention services. Programme-embedded research is required to better understand how key population groups in Nigeria access and use different HIV prevention services so that programmes, policies and resource allocation decisions can be optimized to achieve effective programme coverage and population-level impact.

Geographical targeting of active case finding for tuberculosis in Pakistan using hotspots identified by artificial intelligence software (SPOT-TB): study protocol for a pragmatic stepped wedge cluster randomised control trial.

INTRODUCTION: Pakistan has significantly strengthened its capacity for active case finding (ACF) for tuberculosis (TB) that is being implemented at scale in the country. However, yields of ACF have been lower than expected, raising concerns on its effectiveness in the programmatic setting. Distribution of TB in communities is likely to be spatially heterogeneous and targeting of ACF in areas with higher TB prevalence may help improve yields. The primary aim of SPOT-TB is to investigate whether a policy change to use a geographically targeted approach towards ACF supported by an artificial intelligence (AI) software, MATCH-AI, can improve yields in Pakistan. METHODS AND ANALYSIS: SPOT-TB will use a pragmatic, stepped wedge cluster randomised design. A total of 30 mobile X-ray units and their field teams will be randomised to receive the intervention. Site selection for ACF in the intervention areas will be guided primarily through the use of MATCH-AI software that models subdistrict TB prevalence and identifies potential disease hotspots. Control areas will use existing approaches towards site selection that are based on staff knowledge, experience and analysis of historical data. The primary outcome measure is the difference in bacteriologically confirmed incident TB detected in the intervention relative to control areas. All remaining ACF-related procedures and algorithms will remain unaffected by this trial. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Health Services Academy, Islamabad, Pakistan (7-82/IERC-HSA/2022-52) and from the Common Management Unit for TB, HIV and Malaria, Ministry of Health Services, Regulation and Coordination, Islamabad, Pakistan (26-IRB-CMU-2023). Findings from this study will be disseminated through publications in peer-reviewed journals and stakeholder meetings in Pakistan with the implementing partners and public-sector officials. Findings will also be presented at local and international medical and public health conferences. TRIAL REGISTRATION NUMBER: NCT06017843.

A sub-national HIV epidemic appraisal in Kenya: a new approach for identifying priority geographies, populations and programmes for optimizing coverage for HIV prevention.

INTRODUCTION: The HIV Prevention 2025 Roadmap, developed by UNAIDS, recommends the adoption of a precision prevention approach focused on priority populations and geographies. With reduction in new HIV acquisitions in many countries, designing a differentiated HIV prevention response, using a Programme Science approach, based on the understanding of the epidemic and transmission dynamics at a sub-national level, is critical. METHODS: To support strategic planning, an epidemic appraisal at the sub-national level across 47 counties, with the 2019 population ranging from 0.14 million in Lamu to 4.40 million in Nairobi City, was conducted in Kenya using several existing data sources. Using 2021 Spectrum/EPP/Naomi model estimates of national and sub-national HIV incidence and prevalence, counties with high HIV incidence and prevalence were identified for geographic prioritization. The size of local key population (KP) networks and HIV prevalence in key and general populations were used to define epidemic typology and prioritize populations for HIV prevention programmes. Analysis of routine programme monitoring data for 2021 was used to assess coverage gaps in HIV prevention programmes, including prevention of vertical transmission, anti-retroviral therapy, KP programmes, adolescent girls and young women programme, and voluntary male medical circumcision programme. RESULTS: Ten counties with more than 1000 incident acquisitions in 2021 accounted for 57% of new acquisitions. Twenty-four counties were grouped into the concentrated epidemic type-due to their low prevalence in the general population, high prevalence in KPs and relatively higher density of female sex workers and men who have sex with men populations. Four counties reflected a generalized epidemic, where HIV prevalence was more than 10% and 30%, respectively, among the general and key populations. The remaining 19 counties were classified as having mixed epidemics. Gaps in programmes were identified and counties where these gaps need to be addressed were also prioritized. CONCLUSIONS: The HIV burden in Kenya is unevenly distributed and hence the mix of prevention strategies may vary according to the epidemic typology of the county. Prioritization of programmes based not only on disease burden and epidemic typology, but also on the prevailing gaps in coverage for reducing inequities is a key aspect of this appraisal.

Assessing Outcomes in HIV Prevention and Treatment Programs With Female Sex Workers and Men Who Have Sex With Men: Expanded Polling Booth Survey Protocol.

BACKGROUND: Assessing HIV outcomes in key population prevention programs is a crucial component of the program cycle, as it facilitates improved planning and monitoring of anticipated results. The Joint United Nations Programme on HIV and AIDS recommends using simple, rapid methods to routinely measure granular and differentiated program outcomes for key populations. Following a program science approach, Partners for Health and Development in Africa, in partnership with the Nairobi County Government and the University of Manitoba, aims to conduct an outcome assessment using a novel, expanded polling booth survey (ePBS) method with female sex workers and men who have sex with men in Nairobi County, Kenya. OBJECTIVE: This study aims to (1) estimate the incidence and prevalence of HIV; (2) assess biomedical, behavioral, and structural outcomes; and (3) understand barriers contributing to gaps in access and use of available prevention and treatment services among female sex workers and men who have sex with men in Nairobi. METHODS: The novel ePBS approach employs complementary data collection methods, expanding upon the traditional polling booth survey (PBS) method by incorporating additional quantitative, qualitative, and biological data collection components and an improved sampling methodology. Quantitative methods will include (1) PBS, a group interview method in which individuals provide responses through a ballot box in an unlinked and anonymous way, and (2) a behavioral and biological survey (BBS), including a face-to-face individual interview and collection of linked biological samples. Qualitative methods will include focus group discussions. The ePBS study uses a 2-stage, population- and location-based random sampling approach involving the random selection of locations from which random participants are selected at a predetermined time on a randomly selected day. PBS data will be analyzed at the group level, and BBS data will be analyzed at an individual level. Qualitative data will be analyzed thematically. RESULTS: Data were collected from April to May 2023. The study has enrolled 759 female sex workers (response rate: 759/769, 98.6%) and 398 men who have sex with men (response rate: 398/420, 94.7%). Data cleaning and analyses are ongoing, with a focus on assessing gaps in program coverage and inequities in program outcomes. CONCLUSIONS: The study will generate valuable HIV outcome data to inform program improvement and policy development for Nairobi County's key population HIV prevention program. This study served as a pilot for the novel ePBS method, which combines PBS, BBS, and focus group discussions to enhance its programmatic utility. The ePBS method holds the potential to fill an acknowledged gap for a rapid, low-cost, and simple method to routinely measure HIV outcomes within programs and inform incremental program improvements through embedded learning processes.

Applying the Effective Programme Coverage framework to assess gaps in HIV prevention programmes for female sex workers and men who have sex with men in Nairobi, Kenya: findings from an expanded Polling Booth Survey.

INTRODUCTION: Measuring the coverage of HIV prevention services for key populations (KPs) has consistently been a challenge for national HIV programmes. The current frameworks and measurement methods lack emphasis on effective coverage, occur infrequently, lack timeliness and limit the participation of KPs. The Effective Programme Coverage framework, which utilizes a programme science approach, provides an opportunity to assess gaps in various coverage domains and explore the underlying reasons for these gaps, in order to develop targeted solutions. We have demonstrated the application of this framework in partnership with the KP community in Nairobi, Kenya, using an expanded Polling Booth Survey (ePBS) method. METHODS: Data were collected between April and May 2023 among female sex workers (FSWs) and men who have sex with men (MSM) using (a) PBS, (b) bio-behavioural survey and (c) focus group discussions. Data collection and analysis involved both KP community and non-community researchers. Descriptive analysis was performed, and proportions were used to assess the programme coverage gaps. The data were weighted to account for the sampling design and unequal selection probabilities. Thematic analysis was conducted on the qualitative data. RESULTS: The condom programme for FSW and MSM had low availability (60.2% and 50.9%), contact (68.8% and 65.9%) and utilization (52.1% and 43.9%) coverages. The pre-exposure prophylaxis (PrEP) programme had very low utilization coverage for FSW and MSM (4.4% and 2.8%), while antiretroviral therapy utilization coverage was higher (86.6% and 87.7%). Reasons for coverage gaps included a low peer educator-to-peer ratio, longer distance to the clinics, shortage of free condoms supplied by the government, experienced and anticipated side effects related to PrEP, and stigma and discrimination experienced in the facilities. CONCLUSIONS: The Effective Programme Coverage framework allows programmes to assess coverage gaps and develop solutions and a research agenda targeted at specific domains of coverage with large gaps. The ePBS method works well in collecting data to understand coverage gaps rapidly and allows for the engagement of the KP community.

Second-generation surveillance for HIV/AIDS in Pakistan: results from the 4th round of Integrated Behavior and Biological Survey 2011-2012.

OBJECTIVES: In an effort to fully analyse and understand the HIV situation and its epidemiology in Pakistan, a bilateral collaboration between the National AIDS Control Program and the Canadian International Development Agency resulted in the establishment of an effective second-generation surveillance (SGS) system for HIV/AIDS between 2004 and 2012 in accordance with the published guidelines. This paper presents findings from the 4th round of SGS. METHODS: A mapping exercise was initially conducted for size estimations of the key vulnerable populations: people who inject drugs (PWIDs), male sex workers (MSWs), hijra sex workers (HSWs), and female sex workers (FSWs), followed by an Integrated Behavioral and Biological Surveillance in 20 selected cities across Pakistan. RESULTS: The estimated sizes of the four key populations mapped in the 20 cities were 89 178 FSWs, 46 351 PWIDs, 23 317 HSWs and 19 119 MSWs. The HIV sero-prevalence among PWIDs was the highest among all key populations surveyed at 37.8% (CI 37.3 to 38.3) nationally, followed by a prevalence of 7.2% (CI 6.8 to 7.5) among HSWs, 3.1% (CI 2.8 to 3.4) among MSWs and 0.8% (CI 0.4 to 1.0) for FSWs. Various key risk behaviours, that is, sharing of syringes by PWIDs and inconsistent use of condoms by sex workers, were documented. CONCLUSIONS: Pakistan's HIV epidemic that once was characterised primarily by transmission among PWIDs is now increasingly characterised by significant sexual transmission, and all types of sex workers (male, hijra and female) exhibit epidemiological proportions of infection. There is a need to develop concrete strategic plans for each vulnerable subpopulation, initially focusing prevention resources on those with a higher risk or vulnerability.

Sexual behaviour, structural vulnerabilities and HIV prevalence among female sex workers in Pakistan.

BACKGROUND: We sought to describe differences in individual and structural vulnerabilities faced by female sex workers (FSWs) in Pakistan between 2006 and 2011, and to characterise risk factors for inconsistent condom use and HIV prevalence in this population. METHODS: To describe differences in vulnerabilities, we analysed behavioural data from serial cross-sectional surveys conducted across nine cities in 2006 and 2011. Using data from 12 cities in 2011, we used logistic regression to characterise risk factors for (a) inconsistent condom use in the past month (N=6987), and (b) HIV (N=4301). RESULTS: Compared to FSWs in 2006, FSWs in 2011 were significantly more likely to solicit clients via cell phones, and to report a larger client volume and anal sex with clients, but also consistent condom use with clients (30.0% vs 23.6% in 2006). In 2011, independent risk factors for inconsistent condom use with clients included: recent sexual violence, recent sex with a person who injects drugs, and absence of programme exposure. HIV prevalence was 0.63% (95% CI 0.43% to 0.92%) in 2011, and was associated with a recent history of injection drug use and absence of programme exposure. CONCLUSIONS: While condom use with clients was higher in 2011, protective behaviours remained low and vulnerabilities related to sex work may have risen. HIV is emerging in this population and an adaptive HIV prevention programme that addresses different vulnerabilities and the intersection of sexual networks with injection drug use is needed.

The organisation, operational dynamics and structure of female sex work in Pakistan.

BACKGROUND: Pakistan is known to have large populations of female sex workers (FSWs) with considerable geographic heterogeneity in their characteristics. In this paper, we describe the social organisation and structural patterns of female sex work in different geographic regions of Pakistan. METHODS: We report geographic and network mapping data collected among FSWs in 15 cities across Pakistan in 2011 as part of the Canada-Pakistan HIV/AIDS Surveillance Project. RESULTS: A total number of 89 178 FSWs were estimated in the target cities for an average of 7.2 FSWs per 1000 adult males. 55% of the estimated number of FSWs concentrated in Karachi and Lahore. Based on the operations of female sex work, two major typologies of FSWs were identified: establishment-based and non-establishment-based. FSWs were further subtyped into those operating through brothels, homes, kothikhanas, streets and by cell phone. Cities varied considerably in terms of predominance of different FSW typologies. CONCLUSIONS: There is considerable heterogeneity among FSWs in Pakistan, geographically and in terms of operational typology. Understanding the social organisation of sex work and the influence of social-cultural and legal factors in Pakistan is essential for the design of HIV prevention programmes and other services for FSWs.

Translating knowledge from Pakistan's second generation surveillance system to other global contexts.

BACKGROUND: From 2004 to 2011, a collaborative project was undertaken to enhance the capacity of the Government of Pakistan to implement an effective second-generation surveillance system for HIV/AIDS, known as the HIV/AIDS Surveillance Project (HASP). In four separate rounds, behavioural questionnaires were administered among injection drug users, and female, male and hijra (transgender) sex workers. Dried blood spots were collected for HIV testing. METHODS: Through interviews with project staff in Pakistan and Canada, we have undertaken a critical review of the role of HASP in generating, using and translating knowledge, with an emphasis on capacity building within both the donor and recipient countries. We also documented ongoing and future opportunities for the translation of knowledge produced through HASP. RESULTS: Knowledge translation activities have included educational workshops and consultations held in places as diverse as Colombia and Cairo, and the implementation of HASP methodologies in Asia, the Middle East and sub-Saharan Africa. HASP methodologies have been incorporated in multiple WHO reports. Importantly, the donor country, Canada, has benefited in significant ways from this partnership. Operational and logistical lessons from HASP have, in turn, improved how surveillance is performed in Canada. Through this project, significant capacity was built among the staff of HASP, non-governmental organisations which were engaged as implementation partners, data coordination units which were established in each province, and in the laboratory. As is to be expected, different organisations have different agendas and priorities, requiring negotiation, at times, to ensure the success of collaborative activities. Overall, there has been considerable interest in and opportunities made for learning about the methodologies and approaches employed by HASP. CONCLUSIONS: Generally, the recognition of the strengths of the approaches and methodologies used by HASP has ensured an appetite for opportunities of mutual learning.

Geographical and temporal variation of injection drug users in Pakistan.

OBJECTIVES: We describe the characteristics of injecting drug users (IDU) in Pakistan in 2006 and 2011, and assess the heterogeneity of IDU characteristics across different cities and years as well as factors associated with HIV infection. METHODS: Cross-sectional, integrated behavioural-biological surveys of IDU were conducted in 10 cities across Pakistan in 2006 and 2011. Univariate and multivariable analyses were used to describe the differences in HIV prevalence and risk behaviours between cities and over time. RESULTS: Large increases in HIV prevalence among injection drug users in Pakistan were observed, with overall HIV prevalence increasing from 16.2% in 2006 to 31.0% in 2011; an increase in HIV prevalence was also seen in all geographic areas except one. There was an increase in risk behaviours between 2006 and 2011, anecdotally related to a reduction in the availability of services for IDU. In 2011, larger proportions of IDU reported injecting several times a day and using professional injectors, and fewer reported always using clean syringes. An increase in the proportion living on the street was also observed and this was associated with HIV infection. Cities differ in terms of HIV prevalence, risk profiles, and healthcare seeking behaviours. CONCLUSIONS: There is a high prevalence of HIV among injection drug users in Pakistan and considerable potential for further transmission through risk behaviours. HIV prevention programs may be improved through geographic targeting of services within a city and for involving groups that interact with IDU (such as pharmacy staff and professional injectors) in harm reduction initiatives.

Heterogeneity of characteristics, structure, and dynamics of male and hijra sex workers in selected cities of Pakistan.

BACKGROUND: We sought to describe the characteristics and operational dynamics of male sex workers (MSW) and hijra sex workers (HSWs) in 11 cities across Pakistan in 2011. METHODS: We report descriptive statistics of self-reported sexual behaviour data from cross-sectional mapping and biological and behavioural surveys conducted among 1431 MSWs and 1415 HSWs in four cities across Pakistan in 2011. RESULTS: While Karachi had the largest numbers of MSWs and HSWs, Quetta had the largest relative population sizes, with 3.6 MSWs per 1000 male adults and 3.3 HSWs per 1000 male adults. There was considerable variability in the proportion of HSWs who operate through deras, ranging from 2.2% in Peshawar to 62.7% in Karachi. The number of HSWs per guru varies by city, from 1.5 in Quetta to 16.5 HSWs per guru in Karachi. Among HSWs, the use of mobile phones for solicitation ranged from 37.6% in Quetta to 83% in Peshawar and among MSWs the use of mobile phones ranged from 27% in Karachi to 52% in Quetta. In Quetta, a large proportion of HSWs (41%) find clients through gurus. Client volume tended to be higher among HSWs and among both MSWs and HSWs in Quetta and Peshawar. Condom use with clients was most consistent in Quetta, with 31% of MSWs and 41% of HSWs reporting always using condoms with clients. Peshawar had the greatest proportion reporting never using condoms. CONCLUSIONS: There is considerable geographic heterogeneity in the characteristics and operational dynamics of MSWs and HSWs across Pakistan.