RESUMO
Female sex workers (FSW) are affected by individual, network, and structural risks, making them vulnerable to poor health and well-being. HIV prevention strategies and local community-based programs can rely on estimates of the number of FSW to plan and implement differentiated HIV prevention and treatment services. However, there are limited systematic assessments of the number of FSW in countries across sub-Saharan Africa to facilitate the identification of prevention and treatment gaps. Here we provide estimated population sizes of FSW and the corresponding uncertainties for almost all sub-national areas in sub-Saharan Africa. We first performed a literature review of FSW size estimates and then developed a Bayesian hierarchical model to synthesize these size estimates, resolving competing size estimates in the same area and producing estimates in areas without any data. We estimated that there are 2.5 million (95% uncertainty interval 1.9 to 3.1) FSW aged 15 to 49 in sub-Saharan Africa. This represents a proportion as percent of all women of childbearing age of 1.1% (95% uncertainty interval 0.8 to 1.3%). The analyses further revealed substantial differences between the proportions of FSW among adult females at the sub-national level and studied the relationship between these heterogeneities and many predictors. Ultimately, achieving the vision of no new HIV infections by 2030 necessitates dramatic improvements in our delivery of evidence-based services for sex workers across sub-Saharan Africa.
Assuntos
Síndrome da Imunodeficiência Adquirida , Infecções por HIV , Profissionais do Sexo , Adulto , Humanos , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Teorema de Bayes , África Subsaariana/epidemiologiaRESUMO
BACKGROUND: A substantial proportion of persons on antiretroviral therapy (ART) considered lost to follow-up have actually transferred their human immunodeficiency virus (HIV) care to other facilities. However, the relationship between facility switching and virologic outcomes, including viral rebound, is poorly understood. METHODS: We used data from 40 communities (2015-2020) in the Rakai Community Cohort Study to estimate incidence of facility switching and viral rebound. Persons aged 15-49 years with serologically confirmed HIV who self-reported ART use and contributed ≥1 follow-up visit were included. Facility switching and virologic outcomes were assessed between 2 consecutive study visits (ie, index and follow-up visits, interval of approximately 18 months). Those who reported different HIV treatment facilities between index and follow-up study visits were classified as having switched facilities. Virologic outcomes included viral rebound among individuals initially suppressed (<200â copies/mL). Multivariable Poisson regression was used to estimate associations between facility switching and viral rebound. RESULTS: Overall, 2257 persons who self-reported ART use (median age, 35 years; 65% female, 92% initially suppressed) contributed 3335 visit-pairs and 5959 person-years to the analysis. Facility switching was common (4.8 per 100 person-years; 95% confidence interval [CI], 4.2-5.5) and most pronounced in persons aged <30 years and fishing community residents. Among persons suppressed at their index visit (n = 2076), incidence of viral rebound was more than twice as high in persons who switched facilities (adjusted incidence rate ratio = 2.27; 95% CI, 1.16-4.45). CONCLUSIONS: Facility switching was common and associated with viral rebound among persons initially suppressed. Investments in more agile, person-centered models for mobile clients are needed to address system inefficiencies and bottlenecks that can disrupt HIV care continuity.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Carga Viral , Humanos , Adulto , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Infecções por HIV/virologia , Uganda/epidemiologia , Feminino , Masculino , Pessoa de Meia-Idade , Adolescente , Adulto Jovem , Incidência , Fármacos Anti-HIV/uso terapêutico , Instalações de Saúde/estatística & dados numéricos , Estudos de CoortesRESUMO
PURPOSE OF REVIEW: Big Data Science can be used to pragmatically guide the allocation of resources within the context of national HIV programs and inform priorities for intervention. In this review, we discuss the importance of grounding Big Data Science in the principles of equity and social justice to optimize the efficiency and effectiveness of the global HIV response. RECENT FINDINGS: Social, ethical, and legal considerations of Big Data Science have been identified in the context of HIV research. However, efforts to mitigate these challenges have been limited. Consequences include disciplinary silos within the field of HIV, a lack of meaningful engagement and ownership with and by communities, and potential misinterpretation or misappropriation of analyses that could further exacerbate health inequities. Big Data Science can support the HIV response by helping to identify gaps in previously undiscovered or understudied pathways to HIV acquisition and onward transmission, including the consequences for health outcomes and associated comorbidities. However, in the absence of a guiding framework for equity, alongside meaningful collaboration with communities through balanced partnerships, a reliance on big data could continue to reinforce inequities within and across marginalized populations.
Assuntos
Big Data , Ciência de Dados , Infecções por HIV , Humanos , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Desigualdades de Saúde , Justiça SocialRESUMO
HIV-related stigma remains a significant barrier to implementing effective HIV treatment and prevention strategies in Nigeria. Despite the high uptake of peer support groups among people living with HIV (PLHIV) in Nigeria, the potential role of such peer support on the burden of internalized stigma remains understudied. To address this gap, we conducted a secondary analysis of the PLHIV Stigma Index 2.0, a socio-behavioral survey implemented by PLHIV led-organizations to assess the relationship between group membership and internalized stigma. Internalized stigma was measured using the Internalized AIDS-related Stigma Scale. Multinomial logistic regression was used to measure the association between self-reported engagement in peer support groups and internalized stigma adjusting for age, education, duration since HIV diagnosis, employment, disclosure status, and sex-work engagement. Of the 1,244 respondents in this study, 75.1% were engaged in HIV peer support groups. Over half (55.5%) and about one-fourth (27.3%) demonstrated low/moderate and high levels of internalized stigma, respectively. PLHIV engaged in HIV peer support groups were less likely to report both low/moderate (versus no) (adjusted odds ratio (aOR): 0.47 [95% CI: 0.27 to 0.81]; p = 0.006) and high (versus no) (aOR: 0.30 [95% CI: 0.17 to 0.53]; p < 0.001) levels of internalized stigma compared to those not engaged. In this study, the burden of internalized stigma is high among PLHIV in Nigeria. However, engagement in peer support groups appears to mitigate these stigmas. Stigma mitigation strategies to increase peer support may represent a critical tool in decreasing sustained HIV treatment gaps among PLHIV in Nigeria.
Assuntos
Infecções por HIV , Humanos , Infecções por HIV/tratamento farmacológico , Nigéria/epidemiologia , Estigma Social , Grupos de Autoajuda , Inquéritos e QuestionáriosRESUMO
The sexual and reproductive health needs of female sex workers (FSW) are often understudied and underserved in the context of HIV-related research in countries across Sub-Saharan Africa and West Africa. We assessed the lived experiences of FSW across Côte d'Ivoire to characterize unmet reproductive health needs and opportunities to address them. From February-August, 2020, ENDA Santé, Côte d'Ivoire conducted 75 in-depth interviews and 15 focus group discussions with FSW and community informants in five cities in Côte d'Ivoire. Themes that emerged included the inconsistent use of contraception services, a history of unintended pregnancies, and experiences of stigma at public healthcare facilities. Opportunities to increase the impact of both SRH and HIV services included strengthening existing HIV and family planning service integration for FSW. Taken together, the results highlight the importance of addressing the unmet reproductive health needs of FSW to both optimize the HIV response and increase the delivery of human-rights affirming sexual and reproductive health services for sex workers.
In Côte d'Ivoire, female sex workers (FSW) continue to have an unmet need for sexual and reproductive health (SRH) and HIV prevention services. The disproportionate burden of HIV/STIs is driven by several shared factors including behavioral, social, and structural determinants of HIV, STIs, and pregnancy; as well as biological efficiency of transmission of HIV in the context of STIs. This qualitative study examined the unmet SRH needs of FSW in 5 cities in Côte d'Ivoire to better understand how to offer integrated and high quality SRH and HIV programs and services. Working together with ENDA Santé Côte d'Ivoire, an organization that works closely with FSW, 75 in-depth interviews were held among FSW and community informants, and 15 focus group discussions with FSW. After analyzing the transcripts, several key themes emerged including use of contraceptive methods and unintended pregnancy, the experience of pregnancy and childbirth, HIV care access and quality, FSW-differentiated healthcare services and providers, and opportunities for service integration. The findings from this study underline gaps in the health system for FSW and the benefits of including SRH programming into routine HIV services to strengthen existing efforts.
Assuntos
Infecções por HIV , Profissionais do Sexo , Gravidez , Feminino , Humanos , Côte d'Ivoire , Saúde Reprodutiva , Direitos HumanosRESUMO
OBJECTIVE: To better understand rectal STI screening practices for Black gay, bisexual and other men who have sex with men (BGBMSM). FINDINGS: Although 15% of BGBMSM lab tested positive for a rectal STI, the majority of these (94%) were asymptomatic. Though all participants reported their status as HIV negative/unknown, 31 of 331 (9.4%) tested positive on HIV rapid tests. Neither condomless anal intercourse nor the number of male sex partners was associated with rectal STI or HIV diagnosis, although rectal STI diagnosis was positively related to testing HIV positive. CONCLUSIONS: Findings suggest that substantial numbers of BGBMSM have asymptomatic STIs but are not tested-an outcome that is likely a strong driver of onward HIV acquisition. Therefore, we must address the asymptomatic STI epidemic among GBMSM in order to reduce HIV transmission, as well as temper STI transmission, among this key population.
Assuntos
Bissexualidade/estatística & dados numéricos , População Negra/estatística & dados numéricos , Homossexualidade Masculina/estatística & dados numéricos , Programas de Rastreamento/normas , Reto/microbiologia , Reto/virologia , Minorias Sexuais e de Gênero/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/diagnóstico , Adulto , Bissexualidade/etnologia , Portador Sadio/microbiologia , Portador Sadio/virologia , Gonorreia/epidemiologia , Infecções por HIV/epidemiologia , Homossexualidade Masculina/etnologia , Humanos , Masculino , Programas de Rastreamento/métodos , Diagnóstico Ausente , Comportamento Sexual , Parceiros Sexuais , Infecções Sexualmente Transmissíveis/epidemiologia , Sífilis/epidemiologia , Adulto JovemRESUMO
Despite demonstrated efficacy for HIV prevention, substantial challenges remain for the successful rollout of oral pre-exposure prophylaxis (PrEP), especially among adolescent girls and young women (AGYW). We characterized trajectories of PrEP adherence among 200 AGYW in South Africa and analyzed data from 22 qualitative interviews and 3 focus group discussions for explanatory purposes. Two adherence trajectory groups were identified: 52% with high early adherence that declined after month three and 48% with low adherence throughout. Adherence in the "consistently low" group was related to social support and logistical concerns, while the decrease in the "high declining" group corresponded to a change in the frequency of study visits from monthly to quarterly. PrEP support should be differentiated for those who need more frequent visits and adherence support initially versus later in PrEP use. Visits every month, when needed, should be considered for AGYW who need sustained support later into use.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Adolescente , Fármacos Anti-HIV/uso terapêutico , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Humanos , Sexo Seguro , África do SulRESUMO
Fertility intentions are thought to be dynamic among women of reproductive age, yet few studies have assessed fertility intentions over time among women with HIV. We examine temporal patterns of fertility intentions in women with HIV to assess the extent to which fertility intentions - and the corresponding need for safer conception and judicious antiretroviral therapy (ART) regimen selection - vary over time. 850 non-pregnant HIV-positive women aged 18-35 on or being initiated onto ART in Johannesburg, South Africa were enrolled into a prospective cohort study (2009-2010). Fertility intentions were assessed at enrollment and at 30-day intervals via an interviewer-administered questionnaire. We used group-based trajectory modelling to identify longitudinal patterns of fertility intentions over 12 months. We identified four patterns of fertility intentions, which we labelled "consistently low" (representing â¼60% of the population), "low and increasing" (â¼23%), "high and increasing" (â¼12%), and "high and decreasing" (â¼5%). Our findings suggest that a single family-planning assessment at one time point is insufficient to fully identify and meet the reproductive needs of women with HIV. As HIV testing and treatment evolve in South Africa, routine screening for fertility intentions can offer important opportunities to optimize HIV treatment, prevention, and maternal and child health.
Assuntos
Terapia Antirretroviral de Alta Atividade , Aconselhamento , Fertilidade , Infecções por HIV/tratamento farmacológico , Infecções por HIV/psicologia , Intenção , Adolescente , Adulto , Feminino , Infecções por HIV/epidemiologia , Humanos , Masculino , Gravidez , Estudos Prospectivos , Serviços de Saúde Reprodutiva , África do Sul/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Black men who have sex with men (BMSM) are disproportionately affected by sexually transmitted infections (STI), including chlamydia and gonorrhea. Transactional sex is an hypothesized risk factor for STI acquisition in BMSM. METHODS: We estimated the association of transactional sex with incident chlamydia/gonococcal infection among BMSM using longitudinal data from a randomized trial in Atlanta (2012-2015). BMSM were eligible for inclusion if they tested human immunodeficiency virus (HIV)-antibody-negative and reported both ≥2 male sex partners and any condomless anal sex in the last year. We defined chlamydia/gonorrhea incidence as the first occurrence of either rectal or urogenital chlamydia or gonococcal infections after a negative result at enrollment. We used Poisson regression to estimate the incidence rate (IR) for chlamydia/gonorrhea over 12 months. Incidence rate ratios (IRR) compared estimates by reported experience of transactional sex. Subgroup analyses assessed potential heterogeneity by age and sexual identity. RESULTS: This analysis included 416 BMSM, of whom 191 (46%) were gay-identified, 146 (42%) reported a history of transactional sex, and 57 (14%) had prevalent chlamydia/gonococcal infection at baseline. Over a median of 1 year of follow-up, an additional 55 men tested laboratory-positive for chlamydia/gonorrhea (IR, 17.3 per 100 person-years). Transactional sex was not associated with chlamydia/gonorrhea incidence overall. However, among gay-identified BMSM, transactional sex was associated with incident chlamydia/gonorrhea (IRR, 2.9; 95% confidence interval, 1.2-6.8). CONCLUSIONS: Economic and social vulnerabilities may motivate engagement in high-risk sexual behaviors through commodified sex, potentially increasing the burden of STIs among BMSM. In this investigation, the relationship between transactional sex and chlamydia/gonorrhea was not homogenous across BMSM with diverse sexual identities in Atlanta, suggesting that within select sexual networks, transactional sex may drive STI risks. Delivering accessible and targeted STI screening for marginalized BMSM should be prioritized for STI and HIV prevention.
Assuntos
Negro ou Afro-Americano/psicologia , Infecções por Chlamydia/etnologia , Gonorreia/etnologia , Homossexualidade Masculina/etnologia , Trabalho Sexual/estatística & dados numéricos , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Chlamydia/isolamento & purificação , Infecções por Chlamydia/epidemiologia , Georgia/epidemiologia , Gonorreia/epidemiologia , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Incidência , Estudos Longitudinais , Masculino , Neisseria gonorrhoeae/isolamento & purificação , Trabalho Sexual/etnologia , Comportamento Sexual , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/etnologia , Inquéritos e QuestionáriosRESUMO
The HIV epidemic in the United States has disproportionately burdened Black men who have sex with men (MSM), particularly in the South. While pre-exposure prophylaxis (PrEP) has high demonstrated efficacy, uptake is low among Black MSM. We utilized a sample of 345 HIV-negative or unknown HIV status Black MSM from Atlanta, Georgia. Bivariate and multivariable logistic regression models examined the effects of sexual orientation and disclosure on PrEP awareness and use. Despite the majority of the sample reporting PrEP awareness (91%), few Black MSM in our sample had ever used PrEP (10%). Bisexual Black MSM were less likely to have been aware of PrEP compared to their same-gender loving/gay counterparts. Black MSM who had disclosed their sexual orientation to some or all of the members of their networks were more aware of PrEP compared to their counterparts who reported lower levels of disclosure, but were not more likely to actually use PrEP. Alarmingly, the gap in PrEP awareness and use has not decreased over the past 5 years. These findings suggest that disclosure may be a relevant characteristic to consider for PrEP awareness, but there may be more to consider in closing the awareness-uptake gap among Black MSM.
Assuntos
População Negra , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/etnologia , Profilaxia Pré-Exposição , Comportamento Sexual , Revelação da Verdade , Adolescente , Adulto , Negro ou Afro-Americano , Idoso , Conscientização , Bissexualidade , Feminino , Georgia , Conhecimentos, Atitudes e Prática em Saúde , Homossexualidade Masculina/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Estados Unidos , Adulto JovemRESUMO
Poor HIV care retention impedes optimal treatment outcomes in persons living with HIV. Women trying to become pregnant may be motivated by periconception horizontal and vertical transmission concerns and thus more likely to attend HIV care visits than women not trying to conceive. We estimated the effect of fertility intentions on HIV care attendance over 12 months among non-pregnant, HIV-positive women aged 18-35 years who were on or initiating antiretroviral therapy in Johannesburg, South Africa. The percentage of women attending an HIV care visit decreased from 93.4% in the first quarter to 82.8% in the fourth quarter. Fertility intentions were not strongly associated with care attendance in this cohort of reproductive-aged women; however, attendance declined over time irrespective of childbearing plans. These findings suggest a need for reinforced efforts to support care engagement and risk reduction, including safer conception practices for women wishing to conceive.
Assuntos
Fertilidade , Infecções por HIV/psicologia , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Intenção , Participação do Paciente , Comportamento de Redução do Risco , Adolescente , Adulto , Terapia Antirretroviral de Alta Atividade , Estudos de Coortes , Feminino , Fertilização , Infecções por HIV/tratamento farmacológico , Infecções por HIV/prevenção & controle , Infecções por HIV/transmissão , Humanos , Masculino , Gravidez , Reprodução , África do Sul , Adulto JovemRESUMO
We sought to examine how self-perception of risk for HIV and HIV status information avoidance are related to HIV testing uptake and engagement in routine health care among Black men who have sex with men (BMSM)-the group at highest risk for HIV in the USA. To do so, we used generalized linear modeling and serial mediation modeling to assess data from 342 HIV-negative BMSM collected from 2017 to 2019 in Atlanta, GA, USA. Participants reported considerable concern for testing HIV-positive; 40% reported believing they would test positive for HIV; 27% reported being "extremely concerned about getting HIV"; and 17% reported worrying about HIV "all the time". Mediation analyses demonstrated that greater concern for HIV was associated with longer intervals since the last HIV test and the last health-care appointment. BMSM perceived themselves to be at considerable risk for HIV, but critically, this outlook did not yield improved health-care behaviors. Findings highlight the need to reconceptualize our public health approach to reaching BMSM. Emphasizing risk behavior and targeting efforts toward BMSM may have unintended consequences and need to be reevaluated. Despite continued efforts to improve HIV-related outcomes, we are failing to meet the needs of BMSM.
Assuntos
Negro ou Afro-Americano , Homossexualidade Masculina , Medição de Risco , Adulto , Infecções por HIV/transmissão , Teste de HIV , Acessibilidade aos Serviços de Saúde , Humanos , Entrevistas como Assunto , Masculino , Pesquisa Qualitativa , Assunção de Riscos , Adulto JovemRESUMO
BACKGROUND: Understanding sexual networks involving acute human immunodeficiency virus (HIV)-1 infections (AHI) may lead to prevention opportunities to mitigate high rates of onward transmission. We evaluated HIV-1 phylogenetic and behavioral characteristics among persons with AHI and their referred partners. METHODS: Between 2012 and 2014, 46 persons with AHI in Malawi participated in a combined behavioral and biomedical intervention. Participants referred sexual partners by passive referral. Demographics and sexual behaviors were collected through interviews and HIV-1 genetic relationships were assessed with phylogenetics. RESULTS: Among 45 AHI participants with HIV-1 sequences, none was phylogenetically-linked with another AHI index. There were 19 (42%) AHI participants who referred a single partner that returned for testing. Most partners (n = 17) were HIV-infected, with 15 (88%) presenting with an established infection. There were 14 index-partner pairs that had sequences available; 13 (93%) pairs were phylogenetically-linked dyads. The AHI index was female in 7/13 (54%) dyads. Age-disparate relationships among dyads were common (≥5-year age difference in 67% of dyads), including 3/6 dyads involving a male index and a younger woman. Index participants with a referred partner were more likely to report no casual partners and to be living with their current partner than participants not in dyads. CONCLUSIONS: Passive-partner referral successfully identified partners with genetically-similar HIV infections-the likely source of infection-but only 40% of index cases referred partners who presented for HIV-1 testing. Future work evaluating assisted partner notification may help reach susceptible partners or more people with untreated HIV-1 infections connected to acute transmission. CLINICAL TRIALS REGISTRATION: NCT01450189.
Assuntos
Demografia/estatística & dados numéricos , Infecções por HIV/transmissão , HIV-1/genética , Filogenia , Comportamento Sexual/estatística & dados numéricos , Doença Aguda/epidemiologia , Adulto , Busca de Comunicante , Feminino , Infecções por HIV/epidemiologia , HIV-1/classificação , Humanos , Malaui/epidemiologia , Masculino , Parceiros Sexuais , Adulto JovemRESUMO
BACKGROUND: Identification of acute HIV infection (AHI) allows for important opportunities for HIV prevention through behavior change and biomedical intervention. Here, we evaluate changes in sexual risk behaviors among persons with AHI enrolled in a combined behavioral and biomedical intervention designed to reduce onward transmission of HIV. METHODS: Participants were randomized to standard HIV counseling, a multisession behavioral intervention, or a multisession behavioral intervention plus antiretrovirals. Sexual behaviors were assessed periodically over 1 year. RESULTS: Four weeks after diagnosis, the predicted probability of reporting multiple sexual partners decreased from 24% to 9%, and the probability of reporting unprotected sex decreased from 71% to 27%. These declines in sexual risk behaviors were sustained over follow-up irrespective of study arm. CONCLUSIONS: Diagnosis of AHI alone may be sufficient to achieve immediate and sustained behavior change during this highly infectious period.
Assuntos
Aconselhamento , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Assunção de Riscos , Comportamento Sexual/psicologia , Comportamento Sexual/estatística & dados numéricos , Doença Aguda , Adulto , Terapia Comportamental , Feminino , Humanos , Malaui/epidemiologia , Masculino , Programas de Rastreamento , Comportamento de Redução do Risco , Sexo Seguro/estatística & dados numéricos , Parceiros Sexuais/psicologia , Sexo sem Proteção/psicologia , Sexo sem Proteção/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Estimating the size of key populations, including female sex workers (FSW) and men who have sex with men (MSM), can inform planning and resource allocation for HIV programs at local and national levels. In geographic areas where direct population size estimates (PSEs) for key populations have not been collected, small area estimation (SAE) can help fill in gaps using supplemental data sources known as auxiliary data. However, routinely collected program data have not historically been used as auxiliary data to generate subnational estimates for key populations, including in Namibia. OBJECTIVE: To systematically generate regional size estimates for FSW and MSM in Namibia, we used a consensus-informed estimation approach with local stakeholders that included the integration of routinely collected HIV program data provided by key populations' HIV service providers. METHODS: We used quarterly program data reported by key population implementing partners, including counts of the number of individuals accessing HIV services over time, to weight existing PSEs collected through bio-behavioral surveys using a Bayesian triangulation approach. SAEs were generated through simple imputation, stratified imputation, and multivariable Poisson regression models. We selected final estimates using an iterative qualitative ranking process with local key population implementing partners. RESULTS: Extrapolated national estimates for FSW ranged from 4777 to 13,148 across Namibia, comprising 1.5% to 3.6% of female individuals aged between 15 and 49 years. For MSM, estimates ranged from 4611 to 10,171, comprising 0.7% to 1.5% of male individuals aged between 15 and 49 years. After the inclusion of program data as priors, the estimated proportion of FSW derived from simple imputation increased from 1.9% to 2.8%, and the proportion of MSM decreased from 1.5% to 0.75%. When stratified imputation was implemented using HIV prevalence to inform strata, the inclusion of program data increased the proportion of FSW from 2.6% to 4.0% in regions with high prevalence and decreased the proportion from 1.4% to 1.2% in regions with low prevalence. When population density was used to inform strata, the inclusion of program data also increased the proportion of FSW in high-density regions (from 1.1% to 3.4%) and decreased the proportion of MSM in all regions. CONCLUSIONS: Using SAE approaches, we combined epidemiologic and program data to generate subnational size estimates for key populations in Namibia. Overall, estimates were highly sensitive to the inclusion of program data. Program data represent a supplemental source of information that can be used to align PSEs with real-world HIV programs, particularly in regions where population-based data collection methods are challenging to implement. Future work is needed to determine how best to include and validate program data in target settings and in key population size estimation studies, ultimately bridging research with practice to support a more comprehensive HIV response.
Assuntos
Infecções por HIV , Profissionais do Sexo , Minorias Sexuais e de Gênero , Humanos , Feminino , Masculino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Homossexualidade Masculina , Teorema de Bayes , Namíbia/epidemiologia , Infecções por HIV/epidemiologiaRESUMO
BACKGROUND: Given intersecting social and structural factors, female sex workers (FSW) exhibit elevated risk of HIV and substance use. However, there is limited study of how distinct substance use typologies influence HIV treatment outcomes among FSW. SETTING: A cross-sectional survey with objective viral load assessments of 1391 FSW enrolled into a treatment optimization-focused trial in Durban, South Africa (2018-2020). METHODS: We used latent class analysis to uncover discrete patterns in past-month self-reported use of the following substances: heavy alcohol use, cannabis, cocaine, crack, ecstasy, methamphetamine, heroin, and Whoonga . We used Wald tests to identify multilevel predictors of latent class membership and multivariable mixture modeling to quantify associations of substance use classes with HIV viremia (≥50 RNA copies/mL). RESULTS: Substance use (87%) and HIV viremia (62%) were highly prevalent. Latent class analysis uncovered 3 polysubstance use profiles: Heavy Alcohol Use Only (â¼54%); Cannabis, Heavy Alcohol, & Crack Use (â¼28%); and Whoonga & Crack Use (â¼18%). Whoonga & Crack Use was associated with social and structural adversities, including homelessness, outdoor/public sex work, HIV stigma, and violence. Relative to Heavy Alcohol Use Only , HIV viremia was significantly higher in the Whoonga & Crack Use class (adjusted odds ratio 1.97, 95% confidence interval: 1.13 to 3.43), but not in the Cannabis, Heavy Alcohol, & Crack Use class (adjusted odds ratio 1.17, 95% confidence interval: 0.74 to 1.86). CONCLUSION: HIV viremia differed significantly across identified polysubstance use profiles among South African FSW. Integrating drug treatment and harm reduction services into HIV treatment programs is key to improving virologic outcomes in marginalized communities.
Assuntos
Cannabis , Infecções por HIV , Profissionais do Sexo , Transtornos Relacionados ao Uso de Substâncias , Humanos , Feminino , África do Sul/epidemiologia , Infecções por HIV/tratamento farmacológico , Estudos Transversais , Análise de Classes Latentes , Viremia/epidemiologia , Viremia/complicações , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/complicaçõesRESUMO
Introduction: Adolescent girls and young women (AGYW) continue to experience a high incidence of HIV in southern and eastern Africa, even in the context of large-scale HIV prevention interventions. In Tanzania, AGYW account for the largest proportion of new infections and have a higher risk of HIV acquisition than males of comparable age. Methods: We used routinely collected data from the PEPFAR/USAID-funded Sauti Project, a large combination HIV prevention program, to examine the relationship between transactional sex and sex with older partners among AGYW in Tanzania (2015-2020). Out-of-school AGYW 15-24 years completed a vulnerability index and were tested for HIV. We estimated weighted prevalence ratios (PR) and 95% confidence intervals (CI) for the associations of transactional sex (sex exchanged for money/services/gifts outside of sex work) and sex with older partners (≥5-years older, ≥10-years older) with prevalent HIV. Age cutoffs of 5 and 10 years were used to align partner age differences with age-disparate and intergenerational sex, respectively. We assessed potential synergism between exposures, and subgroup analyses explored associations among girls 15-19. Results: Sixty seven thousand three hundred fifty seven AGYW completed the vulnerability index and 14,873 had captured HIV testing records. Median age was 20 years (IQR 18-22). Transactional sex and age-disparate sex were common (35% and 28%, respectively); 13% of AGYW reported both behaviors. HIV prevalence was associated with both transactional sex (PR: 1.28; 95% CI 1.00-1.63) and age-disparate sex (PR:1.26, 95% CI 0.99-1.60). In common referent analysis, transactional sex remained strongly associated with HIV, even in the absence of age-disparate sex (PR 1.41; 95% CI 1.02-1.94). Discussion: Evidence of statistical synergism was not present, suggesting both transactional sex and age-disparate sex operate through similar pathways to increase HIV risk. Increased specificity within HIV prevention programs is needed to better meet the sexual and reproductive health needs of AGYW at high risk of HIV in Tanzania, including investment in tailored youth-friendly strategies for AGYW who have been marginalized from the current HIV response.
RESUMO
INTRODUCTION: Population-level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale-up. METHODS: In 2015-2020, we measured VLS (<200 RNA copies/ml) among participants in the Rakai Community Cohort Study, a longitudinal population-based HIV surveillance cohort in southern Uganda. Persons with unsuppressed viral loads were characterized as having low-level (200-999 copies/ml) or high-level (≥1000 copies/ml) viraemia. Individual virologic outcomes were assessed over two consecutive RCCS survey visits (i.e. visit-pairs; â¼18-month visit intervals) and classified as durable VLS (<200 copies/ml at both visits), new/renewed VLS (<200 copies/ml at follow-up only), viral rebound (<200 copies/ml at initial visit only) or persistent viraemia (≥200 copies/ml at both visits). Population prevalence of each outcome was assessed over calendar time. Community-level prevalence and individual-level predictors of persistent high-level viraemia were also assessed using multivariable Poisson regression with generalized estimating equations. RESULTS: Overall, 3080 participants contributed 4604 visit-pairs over three survey rounds. Most visit-pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow-up, 91.3% of which was high-level viraemia. One-fifth (20.8%) of visit-pairs exhibiting persistent high-level viraemia self-reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high-level viraemia varied substantially across communities and was significantly elevated among young persons aged 15-29 years (vs. 40- to 49-year-olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21-3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87-3.07), persons reporting inconsistent condom use with non-marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10-1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03-1.16). The prevalence of persistent high-level viraemia was highest among males <30 years (32.0%). CONCLUSIONS: Following universal ART provision, most persons living with HIV in south-central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high-level viraemia for ≥12 months and reported higher-risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control.
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Fármacos Anti-HIV , Infecções por HIV , HIV-1 , Masculino , Feminino , Humanos , Estudos de Coortes , Uganda/epidemiologia , Carga Viral , Viremia/diagnóstico , Viremia/tratamento farmacológico , Viremia/epidemiologia , Infecções por HIV/diagnóstico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , HIV-1/genética , Fármacos Anti-HIV/uso terapêuticoRESUMO
Understanding prior knowledge and experience with pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) is critical to its implementation. In fall 2011, NYC MSM were recruited via banner advertisements on six popular dating websites and asked questions about their knowledge and use of PrEP (n = 329). Overall, 123 (38%) respondents reported knowledge of PrEP, of whom two (1.5%) reported PrEP use in the past 6 months. Knowledge of PrEP was associated with high educational attainment, gay identity and recent HIV testing, suggesting an uneven dissemination of information about PrEP and missed opportunities for education. To avoid disparities in use during scale-up, MSM should be provided with additional information about PrEP.
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Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/prevenção & controle , Homossexualidade Masculina/psicologia , Sorodiagnóstico da AIDS/estatística & dados numéricos , Adolescente , Adulto , Coleta de Dados , Escolaridade , Conhecimentos, Atitudes e Prática em Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Masculino , Cidade de Nova Iorque/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: Female sex workers (FSW) and adolescent girls and young women (AGYW) face a disproportionately high risk of HIV in South Africa. Oral preexposure prophylaxis (PrEP) can avert new infections, but its effectiveness is linked to consistent use. Early discontinuation of PrEP in this population is high, but less is known about longitudinal patterns of PrEP use, including patterns of re-initiation and cycling. DESIGN: Longitudinal descriptive analysis of routine program data. METHODS: Between 2016 and 2021, 40 681 FSW and AGYW initiated PrEP at TB HIV Care, the largest PrEP provider to this population in South Africa and were included. Using survival analyses and group-based trajectory modeling, we described patterns of initiation, discontinuation, re-initiation, and cycling. RESULTS: Total initiations increased over the life of the program for both FSW and AGYW. About 40% of FSW [0.41, 95% confidence interval (CI) [0.40-0.42]] and AGYW (0.38, 95% CI [0.37-0.38]) remained on PrEP at one month. FSW were more likely to restart PrEP, however <10% restarted PrEP within a year of initiation. Three latent trajectory groups of PrEP use were identified for FSW (low use, early cycling, and ongoing cycling) and two for AGYW (low use and ongoing cycling). Persistence was negatively associated with initiation among AGYW, but there was no clear relationship among FSW. Those initiating later in the program and older women had a reduced risk of discontinuation. CONCLUSIONS: Persistence on PrEP was low, but cycling on and off PrEP was common, with early missed visits and inconsistent, but ongoing use. A push to increase PrEP initiations needs to factor in readiness and persistence support, to achieve public health impact.