A Scoping Review of Oral Pre-exposure Prophylaxis for Cisgender and Transgender Adolescent Girls and Young Women: What Works and Where Do We Go from Here?

Adolescent girls and young women (AGYW) are disproportionately affected by HIV, and oral pre-exposure prophylaxis (PrEP) can reduce HIV acquisition. The purpose of this scoping review was to synthesize results from interventions along the PrEP continuum for AGYW to inform research and programs. We searched electronic databases for studies published between January 2012-July 2021 and conducted secondary reference searching. Studies were included if they assessed interventions to increase PrEP interest, uptake, or continuation among AGYW. Results were synthesized narratively. Of 2168 citations identified, 50 studies were eligible for inclusion, and 20 contained AGYW-specific data. Among cisgender and transgender AGYW, studies overall demonstrated a positive impact on PrEP interest and uptake but generally attained suboptimal continuation rates. Results demonstrate feasibility of deploying PrEP across diverse settings-particularly when interventions are layered, tailored to AGYW, and include differentiated delivery-but also highlight knowledge gaps and the need for more holistic metrics of success.

RESUMEN: Las adolescentes y las mujeres jóvenes se ven afectadas de forma desproporcionada por el VIH, y la Profilaxis Pre-Exposición oral (PrEP) puede reducir la adquisición del VIH. El propósito de esta revisión de alcance fue sintetizar los resultados de las intervenciones a lo largo del continuo de la PrEP para las adolescentes y las mujeres jóvenes con el fin de informar la investigación y los programas. Se realizaron búsquedas en bases de datos electrónicas de estudios publicados entre enero 2012 a julio 2021 y se llevó a cabo una búsqueda secundaria de referencias. Los estudios se incluyeron si evaluaban intervenciones para aumentar el interés, la iniciación, o la continuación de la PrEP entre las adolescentes y las mujeres jóvenes. Los resultados se sintetizaron narrativamente. De las 2168 citas identificadas, 50 estudios fueron elegibles para inclusión y 20 contenían datos específicos de las adolescentes y las mujeres jóvenes. Entre las adolescentes y las mujeres jóvenes cisgénero y transgénero, los estudios demostraron un impacto positivo en el interés y la iniciación de la PrEP, pero en general alcanzaron tasas de continuación subóptimas. Los resultados demuestran la viabilidad del despliegue de la PrEP en diversos entornos­en particular cuando las intervenciones son estratificadas, se adaptan a las adolescentes y las mujeres jóvenes, e incluyen una prestación diferenciada­pero también destacan las lagunas de conocimiento y la necesidad de una métrica más holística del éxito.

Assessing an inclusive model to increase access to comprehensive gender-based violence response services and improve HIV outcomes in Puerto Plata, Dominican Republic.

Experiences of gender-based violence (GBV) are associated with increased vulnerability to HIV and difficulty accessing HIV services; at the same time, people living with HIV are at an increased risk of GBV. Key populations most affected by HIV - gay and other men who have sex with men, female sex workers and transgender women - also experience a disproportionate burden of GBV. In Puerto Plata, Dominican Republic, a local civil society organisation has led efforts to improve and integrate GBV and HIV services while making them welcoming to key population members and people living with HIV. According to interviews with service providers and service users and an analysis of service statistics, the intervention improved service quality and coordination, increased disclosures of violence and increased GBV response service uptake among the general population, key population members and people living with HIV. Findings also suggest that the intervention increased the uptake of HIV services, including HIV testing and post-exposure prophylaxis, and improved mental health among those receiving GBV response services. This case study of integrated GBV and HIV services describes a new model for simultaneously, synergistically and inclusively addressing two major epidemics negatively affecting health and well-being in affected communities today.

The health impacts of violence perpetrated by police, military and other public security forces on gay, bisexual and other men who have sex with men in El Salvador.

Gay, bisexual and other men who have sex with men face both high levels of violence and a disproportionate burden of poor health outcomes. We explored violence perpetrated against Salvadoran gay, bisexual and other men who have sex with men by public security forces; perceived motivations of violence; and impacts on health. We conducted structured qualitative interviews with 20 participants and used systematic coding and narrative analysis to identify emergent themes. Nearly all participants described the physical, emotional, sexual and/or economic violence by public security forces. Most attributed being targeted to their gender expression and/or perceived sexual orientation. The most common impact was emotional distress, including humiliation, fear and depression; lasting physical injuries were also widely reported. Study participants felt unable to report these incidents for fear of retribution or inaction. Men reported feelings of helplessness and distrust, avoidance of authorities and altering when, where or how often they appeared in public spaces. Programmes and interventions should focus on providing mental health services for LGBTI (lesbian, gay, bisexual, transgender and intersex) victims of violence, educating public security forces on the legal rights of Salvadorans and expanding current LGBTI-inclusive policies to all public security forces.

The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development.

Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.

"We're Going to Leave You for Last, Because of How You Are": Transgender Women's Experiences of Gender-Based Violence in Healthcare, Education, and Police Encounters in Latin America and the Caribbean.

Transgender (trans) women experience gender-based violence (GBV) throughout their lives, which impedes their access to services and contributes to poor health outcomes and quality of life. To inform policies and health programs, trans women worked with the United States Agency for International Development (USAID)- and President's Emergency Plan for AIDS Relief (PEPFAR)-supported LINKAGES project, the United Nations Development Programme, The University of the West Indies, and local organizations to document experiences of GBV and transphobia in healthcare, education, and police encounters. Trans women conducted 74 structured interviews with other trans women in El Salvador, Trinidad and Tobago, Barbados, and Haiti in 2016. We conducted qualitative applied thematic analysis to understand the nature and consequences of GBV and transphobia and descriptive quantitative analysis to identify the proportion who experienced GBV in each context. A high proportion experienced GBV in education (85.1%), healthcare (82.9%), from police (80.0%), and other state institutions (66.1%). Emotional abuse was the most common in all contexts and included gossiping, insults, and refusal to use their chosen name. Participants also experienced economic, physical, and sexual violence, and other human rights violations based on their gender identity and expression. At school, participants were physically threatened and assaulted, harassed in bathrooms, and denied education. In healthcare, participants were given lower priority and received substandard care. Healthcare workers and police blamed participants for their health and legal problems, and denied them services. From police, participants also experienced physical and sexual assault, theft, extortion for sex or money, and arbitrary arrest and detention. Participants had difficulty obtaining identification documents that matched their gender identity, sometimes being forced to alter their appearance or being denied an identification card. Service providers not only failed to meet the specific needs of trans women but also discriminated against them when they sought services, exacerbating their economic, health, and social vulnerability. Although international and regional resolutions call for the legal protection of transgender people, states do not meet these obligations. To respect, promote, and fulfill trans women's human rights, governments should enact and enforce antidiscrimination and gender-affirming laws and policies. Governments should also sensitize providers to deliver gender-affirming services.

Experiences of gender-based violence among female sex workers, men who have sex with men, and transgender women in Latin America and the Caribbean: a qualitative study to inform HIV programming.

BACKGROUND: Female sex workers, MSM, and transgender women-collectively referred to as key populations (KPs)-are disproportionately affected by gender-based violence (GBV) and HIV, yet little is known about the violence they face, its gender-based origins, and responses to GBV. The purpose of this study was to understand the nature and consequences of GBV experienced, to inform HIV policies and programming and to help protect KPs' human rights. METHODS: Using a participatory approach, FSWs, MSM, and transgender women in Barbados, El Salvador, Trinidad and Tobago, and Haiti conducted 278 structured interviews with peers to understand their experiences of and responses to GBV. Responses to open-ended questions were coded in NVivo and analyzed using an applied thematic analysis. RESULTS: Nearly all participants experienced some form of GBV. Emotional and economic GBV were the most commonly reported but approximately three-quarters of participants reported sexual and physical GBV and other human rights violations. The most common settings for GBV were at home, locations where sex work took place such as brothels, bars and on the street; public spaces such as parks, streets and public transport, health care centers, police stations and-for transgender women and MSM-religious settings and schools. The most common perpetrators of violence included: family, friends, peers and neighbors, strangers, intimate partners, sex work clients and other sex workers, health care workers, police, religious leaders and teachers. Consequences included emotional, physical, and sexual trauma; lack of access to legal, health, and other social services; and loss of income, employment, housing, and educational opportunities. Though many participants disclosed experiences of GBV to friends, colleagues and family, they rarely sought services following violence. Furthermore, less than a quarter of participants believed that GBV put them at risk of HIV. CONCLUSIONS: Our study found that across the four study countries, FSWs, MSM, and transgender women experienced GBV from state and non-state actors throughout their lives, and much of this violence was directly connected to rigid and harmful gender norms. Through coordinated interventions that address both HIV and GBV, this region has the opportunity to reduce the national burden of HIV while also promoting key populations' human rights.

Can a national government implement a violence prevention and response strategy for key populations in a criminalized setting? A case study from Kenya.

INTRODUCTION: Key population (KP) members frequently experience violence that violates their human rights, increases their risk of HIV, and acts as a barrier to access and uptake of HIV services. To be effective, HIV programmes for members of KPs need to prevent and respond to violence against them. We describe a violence prevention and response strategy led by the national KP programme in Kenya and examine trends in reports of and responses to violence (provision of support to an individual who reports violence within 24 hours of receiving the report). METHODS: Quarterly programme monitoring data on the number of reports of violence and the number of responses to violence from 81 implementing partners between October 2013 and September 2017 were aggregated annually and analysed using simple trend analysis. Reports of violence relative to KP members reached, expressed as a percentage, and the percentage of reports of violence that received a response were also examined. RESULTS AND DISCUSSION: Between 2013 and 2017, annual reports of violence increased from 4171 to 13,496 cases among female sex workers (FSWs), 910 to 1122 cases among men who have sex with men (MSM) and 121 to 873 cases among people who inject drugs (PWID). Reports of violence relative to KP members reached increased among FSWs (6.2% to 9.7%; p < 0.001) and PWID (2.1% to 6.0%; p < 0.001) and decreased among MSM (10.0% to 4.2%; p < 0.001). During the same period, timely responses to reports of violence increased from 53% to 84% (p < 0.001) among FSWs, 44% to 80% (p < 0.001) among MSM and 37% to 97% (p < 0.001) among PWID. CONCLUSIONS: Over the past four years in Kenya, there has been an increase in violence reporting among FSWs and PWID and an increase in violence response among all KPs. This case study demonstrates that violence against KP members can be effectively addressed under the leadership of the national government, even in an environment where KP members' behaviours are criminalized. Creating an enabling environment to promote wellbeing and safety for KP members is a critical enabler for HIV prevention programmes to achieve 95-95-95 goals.

How can we better serve adolescent key populations? Strategies to encourage and inform future data collection, analysis, and use.

Young key populations (ages 10-24) (YKPs) are uniquely vulnerable to HIV infection. Yet they are often underserved, due in part to a limited understanding of their needs. Many successful approaches to understanding YKPs exist but are not widely used. To identify the most useful approaches and encourage their uptake, we reviewed strategic information on YKPs and experiences collecting, analysing, and utilising it from countries in Africa, Asia, and Central and Eastern Europe. As a result, we recommend one central guiding principle - any effort to understand and serve YKPs should include a specific focus on adolescent key populations (AKPs) (ages 10-19) - and three strategies to inform data collection, analysis, and use: tailor recruitment practices to ensure young people's representation, select indicators and research methods based on their ability to inform responsive programming for and give a voice to YKPs, and thoroughly disaggregate data. We demonstrate the utility of each strategy in YKP research and programmes, and in doing so note the particular importance for AKPs. We hope that this paper encourages additional research on YKPs and helps bridge the gap between research and effective programmes to serve the youngest and most vulnerable members of key populations.

Putting the t in tools: a roadmap for implementation of new global and regional transgender guidance.

Transgender (trans) activists and global health partners have collaborated to develop new tools and guidance for assessing and addressing HIV and other health needs within trans populations. Trans women experience a heavy burden of HIV and other sexually transmitted infections (STIs), high incidence of violence and difficulties accessing gender-affirming services. At the same time, little has been published on trans men's health, HIV issues, needs and experiences. Young trans people are especially marginalized and vulnerable, with few programmes and services specifically tailored to their needs. Trans-specific data and guidance are needed to adapt the global response to HIV to meet the needs of the trans population. While the needs of this group have only recently received attention, global, regional and other technical guidance documents are being developed to address these gaps. Regional blueprints for comprehensive care for trans people in Latin America, the Caribbean, and Asia and the Pacific are now available. These tools - supported by the Pan American Health Organization, World Health Organization, US President's Emergency Plan for AIDS Relief and the United Nations Development Programme, in collaboration with regional trans groups - provide a contextual map, indicating opportunities for interventions in health, HIV, violence, stigma and discrimination, social protection and human rights. Global guidance includes the World Health Organization's Policy Brief: Transgender People and HIV, and the interagency publication, Implementing Comprehensive HIV and STI Programmes with Transgender People. Community empowerment and capacity building are the focus of the new tools for global and regional transgender guidance. The goal is to strengthen and ensure community-led responses to the HIV challenge in trans populations. This article describes the new tools and guidance and considers the steps needed to use them to appropriately support and engage transgender populations within national AIDS, STI, and sexual and reproductive health responses and programmes. The time to use these tools and guidance for advocacy, strategic planning, capacity building, programme design and training is now.