Knowledge of the abortion law and key legal issues of sexual and reproductive health and rights among recently arrived migrants in Sweden: a cross-sectional survey.

BACKGROUND: Sexual and reproductive health and rights (SRHR), including access and information on the laws and policies related to abortion, varies considerably between countries. Migrants may have limited knowledge of SRHR and related resources in their new country. This study investigates migrants' knowledge of the right to safe and legal abortion and other associated factors including the recent law on sexual consent, the legal age for sexual consent and age to marry in Sweden. METHODS: We conducted a cross-sectional study from 2018 to 2019 among recent migrants attending high schools or Swedish language schools. Descriptive statistics were computed on the knowledge of the Swedish abortion law and other legal aspects. Univariable and multivariable logistic regression analyses were conducted to assess if migrants' socio-demographic characteristics were associated with knowledge (i.e. correct/incorrect) of the Swedish abortion law and other key SRHR-related legal issues. RESULTS: Of the total 6,263 participants, 3,557 (57%) responded about whether it is legal to have an induced abortion in Sweden, and of these, 2,632 (74%) answered incorrectly. While more than half (61%) of the respondents knew the sexual consent law, nearly half (48%) did not know that sexual consent is also required for married couples. About 90% correctly responded that it is illegal to have sex with a minor (under the age of 15) and were aware of the legal age (18 years) to marry in Sweden. Incorrect knowledge of the Swedish abortion law was associated with being religious (adjusted odds ratio (AOR), 2.12; 95% confidence interval (CI), 1.42-3.15), not having previous sexual health education (AOR, 1.68; 95% CI, 1.38-2.05), coming from a country with predominantly restrictive abortion laws (AOR, 1.46; 95% CI, 1.16-1.84), low level of education (AOR, 1.29; 95% CI, 1.04-1.61) and having a temporary residence permit (AOR, 1.27; 95% CI, 1.02-1.57). CONCLUSION: We found a substantial lack of knowledge among migrants of reproductive age in Sweden regarding important laws and policies of SRHR, particularly the right to abortion. SRHR-related programmes and comprehensive sexual health education for recently arrived migrants could include components to increase knowledge of legal and safe abortions and other laws concerning SRHR.

Prevalence and risk factors for transactional sex among Swedish-born and foreign-born MSM in Sweden.

BACKGROUND: Little is known about transactional sex (TS) (selling and buying sex) among men who have sex with men (MSM) in Sweden, especially among foreign-born MSM. This study aims to assess the prevalence and risk factors of TS (ever and in the previous five years) among MSM living in Sweden and to determine if there is a difference between Swedish-born MSM and foreign-born MSM. METHODS: Swedish data from a multicountry online banner survey (EMIS-2017) was used (n = 4443). Multivariable regression analysis was applied to analyse the data. RESULTS: The prevalence of ever-selling sex among all MSM participants was 13.2% and 5.9% in the previous five years. Selling sex ever and in the previous five years was higher among foreign-born MSM (16% and 8.4%, respectively) than Swedish-born MSM (12.7% and 5.4%, respectively). Among all participants, younger age (aOR:3.19, 95% CI:1.57-6.45) and really struggling to live on current income (aOR:3.37, 95% CI:2.29-4.96) increased the odds of selling sex. Being foreign-born MSM (aOR:1.33, 95% CI:1.02-1.73) and having had sex with a woman in the previous 12 months increased the odds of selling sex (aOR:1.44, 95% CI:1.00-2.07). The prevalence of ever buying sex among MSM participants in Sweden was 10.8% and 6.7% in the previous five years, with the same trend among foreign-born MSM (11.6% and 6.9%, respectively) and Swedish-born MSM (10.7% and 6.6%, respectively). Higher education and not having a current partner increased the odds of buying sex. Younger age was protective for buying sex (aOR:0.05, 95% CI:0.02-0.14). Among the foreign-born MSM, the length of stay in Sweden decreased the odds of buying sex (aOR: 0.98, 95% CI: 0.96-0.99). CONCLUSIONS: The comparatively high prevalence of TS among MSM participants in Sweden, where buying sex is illegal, with a higher prevalence among foreign-born MSM participants, calls for sexual and reproductive health and rights interventions in this population. Increased attention, including HIV prevention programming and education, should be aimed at younger MSM, MSM struggling with their current income, and foreign-born MSM, as they are more likely to report selling sex.

"One-time interventions, it doesn't lead to much" - healthcare provider views to improving sexual and reproductive health services for young migrants in Sweden.

BACKGROUND: Sexual and reproductive health and rights (SRHR) is an important aspect for young people. In Sweden, young migrants often encounter barriers to accessing and using sexual and reproductive health (SRH) services, despite that these services are free of charge for young people (ages 15-25). Healthcare providers' views and best practices are of great importance for improving the utilisation of existing SRH services, particularly for young people. This study aims to understand healthcare providers' experiences and perspectives on barriers to SRHR among young migrants and their suggestions for strategies to improve the provision of SRH services to this group. METHODS: Midwives, counsellors and nurses with at least five years of professional experience within SRHR were reached through a purposeful sample at primary care clinics, specialised clinics and youth-friendly clinics, which provide SRH services to migrant youths in Stockholm. Twelve interviews were conducted from May 2018 to February 2020. Qualitative content analysis was performed. RESULTS: The analysis identified one theme: Improving the fragmentation in the SRH services, and four sub-themes: 1. Being unaware of SRHR; 2. Creating trust and responsive interactions; 3. Communicating in the same language; and 4. Collaborating to build bridges. The barriers included distrust in the healthcare system, socio-cultural norms surrounding SRHR, incomplete translations, and a need for long-lasting collaboration with SRH services and other range of services for migrants. The strategies for improvement as suggested by participants included involving existing cultural groups and organisations to enable trust, consistent and dependable interpreters, a streamline of SRH services with other healthcare staff and health facilities, and collaborations with homes designated for young migrants and language schools for a direct linkage to service providers. CONCLUSIONS: Findings indicate that there are fragmentations in SRH services, and these include lack of knowledge about SRHR among migrant youth, language and communication barriers, and a lack of structure needed to build dependable services that go beyond one-time interventions. While initiatives and strategies from healthcare providers for improvement of SRH services exist, the implementation of some strategies may also require involving the regional and national decision-makers and multi-stakeholders like communities, civil society and young migrants themselves.

Qualitative Assessment of Barriers and Facilitators of PrEP Use Before and After Rollout of a PrEP Program for Priority Populations in South-central Uganda.

Uganda piloted HIV pre-exposure prophylaxis (PrEP) for priority populations (sex workers, fishermen, truck drivers, discordant couples) in 2017. To assess facilitators and barriers to PrEP uptake and adherence, we explored perceptions of PrEP before and experiences after rollout among community members and providers in south-central Uganda. We conducted 75 in-depth interviews and 12 focus group discussions. We analyzed transcripts using a team-based thematic framework approach. Partners, family, peers, and experienced PrEP users provided adherence support. Occupational factors hindered adherence for sex workers and fishermen, particularly related to mobility. Pre-rollout concerns about unskilled/untrained volunteers distributing PrEP and price-gouging were mitigated. After rollout, awareness of high community HIV risk and trust in PrEP effectiveness facilitated uptake. PrEP stigma and unexpected migration persisted as barriers. Community-initiated, tailored communication with successful PrEP users may optimize future engagement by addressing fears and rumors, while flexible delivery and refill models may facilitate PrEP continuation and adherence.

RESUMEN: En 2017, Uganda introdujo profilaxis pre-exposición (PrEP), dirigida a las populaciones con alto riesgo de contraer al VIH (trabajadoras sexuales, pescadores, camioneros, parejas sero-discordantes). Para investigar facilitadores y barreras para la adopción y la adherencia a la PrEP, exploramos percepciones de PrEP antes y después de su introducción en Uganda. Realizamos 75 entrevistas y 12 grupos focales con miembros de la comunidad y trabajadores de salud. Analizamos las transcripciones temáticamente usando un marco de referencia. Parejas, familias, compañeros, y clientes usando PrEP apoyaron a los demás mantener adherencia. Movilidad fue una barrera para la adherencia a la PrEP para trabajadoras sexuales y pescadores. Preocupaciones sobre el entrenamiento de los distribuidores de PrEP y la especulación de precios no fueron realizadas. Percepciones del riesgo del VIH y confianza en la eficacia de PrEP facilitaron su adopción. Estigma y migración inesperada persistieron como barreras para la adopción de PrEP. Comunicaciones manejadas por clientes usando PrEP pueden motivar interés en PrEP y abordar rumores. Sistemas flexibles del entrego y la recarga de medicinas pueden permitir continuación de, y adherencia a, la PrEP.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men.

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

RESUMEN: Existe una necesidad urgente para medir los impactos de COVID-19 entre hombres gay y otros hombres que tienen sexo con hombres (HSH). Hemos conducido una encuesta multifuncional con una prueba mundial de hombres gay y otros HSH (n = 2732) desde el 16 de Abril hasta el 4 de Mayo del 2020, a través de una aplicación de red social. Nosotros caracterizamos los impactos económicos, de salud mental, prevención del VIH y tratamiento del VIH e impactos a COVID-19 y la respuesta de COVID-19, y examinamos si subgrupos de nuestra población de estudio fueron impactados desproporcionadamente por COVID-19. Muchos hombres no tan solo reportaron consecuencias económicas y de salud mental, sino también interrupciones de prevención y de pruebas de VIH, y cuidado del VIH y servicios de tratamiento. Encontramos consecuencias más significantes entre personas viviendo con VIH, grupos raciales/etnicos, migrantes, sexo servidores, y groupos socioeconomicamente disfavorecidos. Los resultados subrayan la necesidad crucial de mitigar los impactos multifacéticos de COVID-19 entre los hombres homosexuales y otros HSH, especialmente para aquellos con vulnerabilidades entrelazadas.

A qualitative assessment in acceptability and barriers to use pre-exposure prophylaxis (PrEP) among men who have sex with men: implications for service delivery in Vietnam.

BACKGROUND: HIV Pre-exposure prophylaxis (PrEP) is being considered for implementation among MSM nationwide in Vietnam. However, there may be concerns about potential obstacles for PrEP adherence among Vietnamese MSM. This study aims to assess the acceptability to use PrEP, potential barriers and facilitators, and the preferences for PrEP service accessibility and delivery among Vietnamese MSM. METHODS: Four focus group discussions (FGDs) were conducted with 30 HIV-negative MSM in January 2018 in Hanoi, Vietnam. FGDs explored MSM's awareness regarding PrEP, perceived benefits and barriers of PrEP use, and willingness to use PrEP. FGDs were audio-recorded and transcribed verbatim. Content analysis was used. RESULTS: The mean age of participants was 23.9 years old. Most participants realized the advantages of PrEP given its efficacy in HIV risk reduction and expressed high motivation and interest to use PrEP in the future. PrEP was considered as a supplement alongside condoms. Common concerns about PrEP included side-effects, forgetting to take the pill daily, stigmatization due to using PrEP, negative attitudes toward PrEP from other MSM and accessibility of PrEP. Participants would prefer an injectable PrEP regime if available as it was seen as easier to adhere to. Concerns were also raised that PrEP usage could be interpreted as an indication of engaging in sexual risk behavior for HIV, potentially causing suspicion in love relationships or by family and friends. Participants preferred to receive PrEP in civil business organizations and MSM-friendly clinics, and recommended that pharmacy stores would not be suitable for PrEP implementation due to lack of trust and fear of fake drugs. CONCLUSION: This study indicated a high level of willingness to use PrEP among MSM in Vietnam in combination with condom. Strategies to raise awareness of PrEP, reduce stigma towards PrEP, and improve the accessibility among MSM in Vietnam is needed. Existing MSM-friendly clinics were recommended to implement PrEP programs in Vietnam.

Precarious employment and general, mental and physical health in Stockholm, Sweden: a cross-sectional study.

Objectives: To investigate the association between precarious employment and health in a sample of non-standard employees in Stockholm County, Sweden, by addressing three specific research questions: is the degree of precarious employment (low, moderate, high) associated with self-rated. . . (a) general health, (b) mental health, (c) musculoskeletal pain? Methods: Web-based respondent-driven sampling was used to recruit a sample of 415 employees in Stockholm, Sweden, during 2016-2017. Questionnaire data were collected on employment conditions (the Swedish version of the employment precariousness scale (EPRES-Se)), general health, mental health and musculoskeletal pain. EPRES-Se scores were categorised as low, moderate or high. Generalised linear models with Poisson distribution, log link functions and robust variances were applied for calculating crude and adjusted prevalence ratios (PR; aPR) with 95% confidence intervals (CIs) for all outcomes. Results: The prevalence ratios of poor self-rated general and mental health increased with increased degree of precariousness, as indicated by estimates of moderate precarious employment (a2PRModerate 1.44 (CI 0.98-2.11); a2PRModerate 1.13 (CI 0.82-1.62)), and high precarious employment (a2PRHigh 1.78 (CI 1.21-2.62); a2PRHigh 1.69 (CI 1.25-2.28)), albeit only significantly so for high precarious employment. Conclusions: This is the first study in Sweden reporting on the association between precarious employment, as measured with a multidimensional scale, and multiple health outcomes. The results add to the evidence of an association between precarious employment and self-rated poor general and mental health. Larger, representative studies with longitudinal designs using the EPRES-Se are called for in order to strengthen these results and the already existing evidence of the harm of precarious employment.

An exploratory assessment of the preference for eHealth interventions to prevent HIV and sexually transmitted infections among men who have sex with men in Hanoi, Vietnam.

BACKGROUND: Electronic health (eHealth) interventions are promising in HIV and sexually transmitted infections (STIs) prevention among men who have sex with men (MSM), given a high rate of the Internet use in this population. This study determined the preferences for eHealth interventions to prevent HIV and STIs among MSM in Hanoi, Vietnam to guide the development of future eHealth interventions. METHODS: Five focus group discussions (FGD) were conducted with 35 MSM recruited by purposive sampling in January 2018 in Hanoi, Vietnam. The FGDs addressed attitudes towards the feasibility and uptake of HIV/STI interventions via online modalities such as smartphone applications (apps, social network sites, or emails); preferences and concerns regarding an online HIV/STI intervention. FGDs were audio-recorded and transcribed verbatim. Content analysis was used to determine themes. RESULTS: MSM reported that they commonly searched for information regarding HIV/STI and sexual health on Facebook and a variety of mobile apps. They perceived a lack of reliable online sources, a high need, and interest for an online intervention. Most of them preferred short and concise messages without perceived sensitive words such as "HIV" or "STI". Diversity of online modalities were preferred with information from credible sources about HIV/STI symptoms, testing and treatment, safe sex practices and testing locations with a focus on safe MSM-friendly clinics. Concerns about the need to trust the organization behind the online information and interventions, and the importance of confidentiality when participating in online interventions were raised. CONCLUSION: High acceptance and perceived need for an online HIV/STI intervention were reported. The importance of establishing trust within the MSM community as a reliable source of information was emphasized, as well as the importance of confidentiality.

A qualitative study of facilitators and barriers to participate in a needle exchange program for women who inject drugs.

BACKGROUND: Women who inject drugs (WWID) show higher levels of injecting risk behaviour compared to men, putting them at risk of contracting HIV and hepatitis C (HCV). Compared to men, WWID are also less present in harm reduction programs such as needle exchange programs (NEP). The aim of this study is to investigate reasons for, and barriers to, participation in NEP among WWID in Sweden, and to identify measures that could be taken to strengthen the program and increase participation among WWID. METHOD: In-depth interviews (IDIs) were conducted with 20 WWID who had participated in the Stockholm NEP for at least six months and was over 18 years old. IDIs were audio recorded and transcribed et verbatim. Qualitative content analysis was used to identify themes. RESULTS: The need for sterile injection equipment was identified as the main driver to join and remain in the NEP program. Continuous participation in the NEP was further driven by easy access to a multitude of health-related services. The most valued service was the sexual and reproductive health services (SRHR), allowing participants to access contraceptives, cervical cancer screening and sexually transmitted infections testing (STI-testing). NEP staffs' respectful treatment of participants further contributed to program participation. However, participants also expressed a number of concerns around NEP participation, which created barriers to joining. These included losing custody or visitation rights to children, male partner jealousy and violence, unwillingness to spend time in the waiting area and fear of receiving positive HIV/HCV test results. Practical barriers included limited opening hours and travel distance to the NEP. To strengthen the program, most participants requested additional SRHR services. Most participants also proposed some form of "women only" access to the NEP, to strengthen the feeling of the NEP as a safe space. CONCLUSION: This study identified factors that may increase uptake of NEP among WWID. Additional SRHR services and "women only" access are recommended to be implemented and evaluated as part of NEP. These findings may inform and improve the current scale-up of NEPs in Sweden to ensure equal access to services.

Uptake of peer-led venue-based HIV testing sites in Sweden aimed at men who have sex with men (MSM) and trans persons: a cross-sectional survey.

OBJECTIVES: HIV testing among high-risk groups is a key intervention to diagnose persons living unknowingly with HIV to enable linkage to care and effective antiretroviral treatment. This study aimed to evaluate the uptake of Testpoint, the first large-scale HIV testing programme in Sweden where peer, non-healthcare personnel offered venue-based testing. Testing was performed by staff from the Swedish Foundation for Lesbian, Gay, Bisexual and Transgender Rights (RFSL Sweden) and testing was performed at the RFSL offices, gay clubs and gay cruising areas, as well as at various gay festivals. The test was a rapid test using capillary blood from a finger prick. METHODS: A cross-sectional survey of all persons aged >18 years who came for HIV testing at one of Testpoint's locations in Sweden between 1 February and 31 December 2016. RESULTS: 595 respondents (96% response rate) were included. Five persons were diagnosed with HIV and referred for treatment and care. A fifth of participants had never tested for HIV before. More than half of the participants were foreign born and the median age was 31 years. About one-fifth of participants stated they would not have tested through the healthcare system if Testpoint was not available. CONCLUSIONS: Testpoint reached their target population of young, foreign-born men who have sex with men (MSM) as well as first time testers and persons who stated that they would not have tested within the healthcare system. Such peer HIV testing outside the healthcare setting is a possible way of increasing uptake of testing in high-risk groups.

A Systematic Review of eHealth Interventions Addressing HIV/STI Prevention Among Men Who Have Sex With Men.

A systematic review was conducted to summarize and appraise the eHealth interventions addressing HIV/STI prevention among men who have sex with men (MSM), and characterize features of successful eHealth interventions. Fifty-five articles (17 pilots and 38 full efficacy trials) were included with the predominance of web-based interventions in the United States-based settings. Intervention modalities include web-based, short message service (SMS)/text messges/email reminder, online video-based, computer-assisted, multimedia-based, social network, live chat and chat room, virtual simulation intervention, and smartphone applications. Forty-nine eHealth interventions achieved a short-term behaviour change among participants. Four studies were conducted with 12-month follow-ups; and only one of them could maintain the behaviour change over this longer time period which could be due to the lack of booster interventions. Our study suggests that eHealth interventions can achieve short term behaviour change among MSM, however limited interventions could maintain behaviour change over 12 months. Further eHealth intervention strategies to promote HIV prevention among MSM should be conducted and rigorously evaluated.

An assessment of stigma and human right violations among men who have sex with men in Abuja, Nigeria.

BACKGROUND: There have been several barriers in effectively engaging men who have sex with men for STI/HIV prevention and treatment programming in Nigeria including social stigma, policies, and laws criminalizing same-sex practices. The objective of this study was to describe the human rights context for MSM in Abuja and characterize factors associated with having had a genital ulcer disease in the previous 12 months, a health outcome associated with increased risk of HIV acquisition and transmission. METHODS: A convenience sample of 297 men reporting ever having had anal intercourse with another man participated in the study in 2008. A structured survey instrument including sexual risk behaviour for STI/HIV, disclosure of sexual orientation, perceived and enacted human rights violations were performed. Descriptive and inferential data analyses were conducted using Stata11 software. RESULTS: 36% reported having been discriminated due to sexual orientation and 17% reported being afraid to walk the streets of their community. Enacted rights violations included 41% having been blackmailed, 36% been beaten, 13% been denied housing, and 11% been jailed due to sexual orientation. Having been blackmailed due to sexual orientation (aOR 3.40, 95%CI: 1.35-8.56) was significantly associated with reporting having had a genital ulcer in the last 12 months. Having been beaten due to sexual orientation (aOR 2.36, 95%CI:0.96-5.82) was moderately significantly associated with reporting having had a genital ulcer in the last 12 months. CONCLUSIONS: High levels of experienced stigma, discrimination and human rights violations among MSM in Abuja was reported, constituting structural risks that are linked to sexual risk behaviour for STI/HIV. Given data on the high prevalence and incidence of HIV among MSM in Abuja, these findings reinforce the need for structural interventions to mediate access to STI/HIV prevention and treatment services.

A systematic review of adherence to oral pre-exposure prophylaxis for HIV - how can we improve uptake and adherence?

INTRODUCTION: Oral pre-exposure prophylaxis (PrEP) is an effective strategy to reduce the risk of HIV transmission in high risk individuals. However, the effectiveness of oral pre-exposure prophylaxis is highly dependent on user adherence, which some previous trials have struggled to optimise particularly in low and middle income settings. This systematic review aims to ascertain the reasons for non-adherence to pre-exposure prophylaxis to guide future implementation. METHODS: We performed structured literature searches of online databases and conference archives between August 8, 2016 and September 16, 2017. In total, 18 prospective randomized control trials and implementation studies investigating oral pre-exposure prophylaxis were reviewed. A structured form was used for data extraction and findings summarized regarding efficacy, effectiveness, adherence and possible reasons for non-adherence. RESULTS: Adherence varied between differing populations both geographically and socioeconomically. Common reasons for non-adherence reported over multiple studies were; social factors such as stigma, low risk perception, low decision making power, an unacceptable dosing regimen, side effects, and the logistics of daily life. Oral pre-exposure prophylaxis with included antiviral regimens was not associated with a high risk of antiviral resistance development in the reviewed studies. CONCLUSION: Our findings indicate that oral pre-exposure prophylaxis should be delivered within a holistic intervention, acknowledging the other needs of the targeted demographic in order to maximise acceptability. Socioeconomic factors and poor governmental policy remain major barriers to widespread implementation of pre-exposure prophylaxis.

HIV testing and prevention among foreign-born Men Who have Sex with Men: an online survey from Sweden.

BACKGROUND: There is an increasing trend toward international migration worldwide. With it comes a challenge for public health and public funded health care systems to meet the migrating population's health needs. Men who have sex with men are a key population for HIV, contributing an estimated 42% of new HIV cases in Europe in 2013. HIV monitoring data suggest that foreign-born MSM are not only exposed to a high risk of HIV before migration but also while living in Sweden. The aim of this study is to examine HIV testing prevalence and uptake of HIV prevention interventions among foreign-born MSM living in Sweden. METHODS: A web survey available in English and Swedish was conducted from October 1 to October 30, 2013 via a Scandinavian Web community for Lesbian, Gay, Bisexual, Transgender and Intergender people. The web survey included modules on sociodemographics, condom use, sexual risk behaviour and HIV/STI testing experience. 244 eligible MSM participants born abroad and living in Sweden participated in the study. Descriptive and inferential analysis was performed. RESULTS: Half of the foreign-born MSM participants in this study had been tested for HIV during the last 12 months. Participants who had lived in Sweden less than or equal to 5 years were more likely to have been tested for HIV during the last 12 months. Having talked about HIV/STI with a prevention worker during the past year was associated with having been tested for HIV. Requested services among the majority of participants were HIV rapid test, anonymous HIV testing, HIV/STI testing outside of the health care setting and MSM-friendly clinics. CONCLUSION: Efforts are needed to promote HIV testing among foreign-born MSM. Peer outreach, individual and group counselling may be preferred interventions to do so. In addition, it is critically important to increase HIV testing among foreign-born MSM who have lived in Sweden for more than five years. Further research should explore if scale up of implementation of requested services may increase frequency of HIV testing and detection of new cases linked to treatment among foreign-born MSM living in Sweden.

HIV and sexually transmitted infection-related risks among female sex workers in Mongolia: second-generation surveillance survey, 2011-2012.

BACKGROUND: Surveillance studies among female sex workers (FSWs) in Mongolia have found no HIV but high rates of syphilis, ranging from 10.7% in 2002 to 20.8% in 2007. OBJECTIVES: To determine the current prevalence of HIV and syphilis among FSWs, and to identify syphilis risk factors. METHODS: 761 FSWs were recruited by time-location sampling between 2 January and 29 March 2012 in Ulaanbaatar city, Darkhan-Uul, Orkhon, Khuvsgul and Dornod provinces in Mongolia. Participants were administered an anonymous structured survey. Blood samples were tested for HIV and syphilis. Bivariate and multivariate logistic regression analyses were performed to identify factors associated with syphilis. RESULTS: The mean age of participants was 31 (median 30, interquartile range 24-38). HIV knowledge was modest: 41.3% correctly answered all questions. Consistent condom use with clients was reported by 49.1% of participants and exposure to HIV prevention programmes by 50.1%. Although no cases of HIV were found, syphilis prevalence was -27.8% (95% CI 24.3% to 31.7%). In multivariate analyses, variables associated with syphilis were younger age (age >30 years, OR=0.96, 95% CI 0.92 to 0.99) and occurrence of genital ulcer (OR=2.24, 95% CI 1.17 to 4.28). CONCLUSIONS: A syphilis epidemic continues to grow among FSWs in Mongolia. These women are at high risk of HIV transmission if introduced into their sexual networks. With the increase in migration of mining workers in Mongolia, introduction of HIV may be imminent. Efforts to intensify treatment and prevention programmes among FSWs are needed.

Evolving understanding of the epidemiology of HIV and prevention needs among men who have sex with men in Ulaanbaatar, Mongolia.

This study describes HIV and syphilis bio-behavioral survey conducted among 200 men who have sex with men (MSM) recruited via respondent-driven sampling (RDS) between January 4 and February 1, 2012 in Ulaanbaatar, Mongolia. Participants were administered a structured questionnaire and data were analyzed with RDS-network program in STATA. Of 196 participants who agreed to be tested for HIV and syphilis, 21 (10.7 %; weighted 7.5; 95 % CI: 4.9, 11.4) and 8 (4.1 %; weighted 3.4; 95 % CI: 1.7, 6.7) were positive for HIV and syphilis, respectively. Exposure to HIV prevention programs in the last 12 months was reported by 51.8 % (weighted 33.6; 95 % CI: 27.6, 40.1) of participants. This study found high HIV prevalence and limited uptake of HIV prevention services among MSM in Mongolia. Given the concentrated HIV epidemic among MSM in Mongolia, HIV prevention, treatment and care services should focus on MSM as the population group most affected by HIV.

A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi.

BACKGROUND: In the context of a generalized epidemic and criminalization of homosexuality, men who have sex with men (MSM) in Malawi have a disproportionate burden of HIV compared to other adults. Past research has documented low uptake of HIV prevention and health services among MSM, self-reported fear of seeking health services, and concerns of disclosure of sexual orientation and discrimination in health settings. Qualitative research was conducted among MSM and health service providers in Blantyre, Malawi to understand underlying factors related to disclosure and health seeking behaviors and inform the development of a community-based comprehensive HIV prevention intervention. METHODS: Using peer recruitment, eight MSM participants representing a range of ages, orientations, and social and behavioral characteristics were enrolled for in-depth interviews. Five service providers were recruited from the district hospital, local health and STI clinics, and a HIV prevention service organization. We use the Health Belief Model as a framework to interpret the influential factors on 1) health seeking and uptake among MSM, and 2) influences on provision of services by healthcare providers for MSM. RESULTS: Results highlight disclosure fears among MSM and, among providers, a lack of awareness and self-efficacy to provide care in the face of limited information and political support. Service providers reported concerns of adverse repercussions related to the provision of services to men in same sex sexual relationships. Some MSM demonstrated awareness of HIV risk but believed that within the wider MSM community, there was a general lack of HIV information for MSM, low awareness of appropriate prevention, and low perception of risks related to HIV infection. CONCLUSIONS: Qualitative research highlights the need for appropriate information on both HIV risks and acceptable, effective HIV prevention options for MSM. Information and educational opportunities should be available to the wider MSM community and the health sector. Health sector interventions may serve to increase cultural and clinical competency to address health problems experienced by MSM. To ensure availability and use of services in light of the criminalization and stigmatization of same sex practices, there is need to increase the safety of uptake and provision of these services for MSM.

Prevalence and associated factors for poor mental health among young migrants in Sweden: a cross-sectional study.

BACKGROUND: Young migrants face multiple challenges that can affect their mental, sexual and reproductive health. OBJECTIVE: To assess the prevalence of self-reported poor mental health and its associated demographic, post-migration and sexual risk behaviour factors among young migrants (aged 15-25) in Sweden. METHODS: Data were drawn from a cross-sectional survey conducted with migrants aged 15-65 years old in Sweden between December 2018 and November 2019 (n = 6449). Among these, 990 participants aged 15-25 were eligible for the study. Mental health was measured using the Refugee Health Screener-13. Missing data indicator analysis and multivariable logistic regression models were conducted to estimate the association between mental health, sexual risk behaviour, demographic and migration-related variables. RESULTS: Of the 990 participants, 59% reported poor mental health. Participants reporting poor mental health were more likely to be female (AOR:1.63, 95% CI:1.18-2.25), to have lived in Sweden more than three years (AOR:2.16, 95% CI:1.17-3.97), to engage in any sexual risk behaviour (AOR:1.99, 95% CI:1.25-3.17), and to live alone (AOR:1.95, 95% CI:1.25-3.03) or with friends they already knew (AOR:1.60, 95% CI:1.37-4.91). People arriving from the Americas (AOR:0.54, 95% CI:0.33-0.88), Asia (AOR:0.44, 95% CI:0.22-0.86), Europe (AOR:0.30, 95% CI:0.14-0.61) and Africa (AOR 0.37, 95% CI: 0.23-0.60) had lower odds of poor mental health than those arriving from Syria. CONCLUSION: The prevalence of poor mental health among young migrants in Sweden was high, with specific subgroups (women, asylum seekers, people arriving from Syria, and those residing longer in Sweden) being particularly vulnerable. Our results indicate the interconnectedness between poor mental health and sexual risk behaviour in this population. Thus, policies targeting young migrants should ensure that healthcare services screen for both poor sexual and mental health at the same time.

Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries.

We conducted a systematic review and meta-analysis of community empowerment interventions for HIV prevention among sex workers in low- and middle-income countries from 1990-2010. Two coders abstracted data using standardized forms. Of 6,664 citations screened, ten studies met inclusion criteria. For HIV infection, two observational studies showed a significantly protective combined effect [odds ratio (OR): 0.84, 95% confidence interval (CI): 0.709-0.988]. For STI infection, one longitudinal study showed reduced gonorrhoea/chlamydia (OR: 0.51, 95% CI: 0.26-0.99). Observational studies showed reduced gonorrhoea (OR: 0.65, 95% CI: 0.47-0.90), but non-significant effects on chlamydia and syphilis. For condom use, one randomized controlled trial showed improvements with clients (beta: 0.3447, p = 0.002). One longitudinal study showed improvements with regular clients (OR: 1.9, 95% CI: 1.1-3.3), but no change with new clients. Observational studies showed improvements with new clients (OR: 3.04, 95% CI: 1.29-7.17), regular clients (OR: 2.20, 95% CI: 1.41-3.42), and all clients (OR: 5.87, 95% CI: 2.88-11.94), but not regular non-paying partners. Overall, community empowerment-based HIV prevention was associated with significant improvements across HIV outcomes and settings.

Patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities in Bugisu, Eastern Uganda.

Objectives: To describe patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities across Bugisu, Eastern Uganda. Methods: We surveyed 37 public and private-not-for-profit healthcare facilities and conducted a retrospective review of antimicrobial prescribing patterns among febrile under-five outpatients (with a focus on antibiotics) in 2019-20, based on outpatient registers. Multilevel logistic regression analysis was used to identify determinants of antibiotic prescribing at patient- and healthcare facility-levels. Results: Antibiotics were prescribed for 62.2% of 3471 febrile under-five outpatients. There were a total of 2478 antibiotic prescriptions of 22 antibiotic types: amoxicillin (52.2%), co-trimoxazole (14.7%), metronidazole (6.9%), gentamicin (5.7%), ceftriaxone (5.3%), ampicillin/cloxacillin (3.6%), penicillin (3.1%), and others (8.6%). Acute upper respiratory tract infection (AURTI) was the commonest single indication for antibiotic prescribing, with 76.3% of children having AURTI as their only documented diagnosis receiving antibiotic prescriptions. Only 9.2% of children aged 2-59 months with non-severe pneumonia received antibiotic prescriptions in line with national guidelines. Higher health centre levels, and private-not-for-profit ownership (adjusted OR, 4.30; 95% CI, 1.91-9.72) were significant contextual determinants of antibiotic prescribing. Conclusions: We demonstrated a high antibiotic prescribing prevalence among febrile under-five outpatients in Bugisu, Eastern Uganda, including prescriptions for co-trimoxazole and ampicillin/cloxacillin (which are not indicated in the management of the common causes of under-five febrile illness in Uganda). Study findings may be linked to limited diagnostic capacity and inadequate antibiotic availability, which require prioritization in interventions aimed at improving rational antibiotic prescribing among febrile under-five outpatients.