Intersectional analysis of the experiences of women who fail to conceive in low and middle income neighbourhoods of Delhi, India: Findings from a qualitative study.

BACKGROUND: Experiences of delayed conception and infertility have been reported among women. However, the concept of intersectionality is rarely utilised in studies of infertility, and it is particularly uncommon in research from low- and middle- income countries. RESEARCH QUESTION: What are the lived experiences of women with delayed conception in low to -middle income neighbourhoods of Delhi, India? METHODS: This was a qualitative study (n = 35) that recruited women who had failed to conceive after 18 months of regular unprotected sexual intercourse. Data were collected between February and July 2021. Data were collected through focus group discussions in low income to middle income neighbourhoods of Delhi, India. Analysis identified themes related to intersecting axes of inequality. RESULTS: The results showed that gender intersected with economics, masculinity, patriarchal norms and class to influence the experiences of women. The intersection of gender, economics and patriarchal norms compromised women's agency to be active generators of family income, and this dynamic was exacerbated by patrilocal residence. In addition, masculinity contributed to stigmatisation and blaming of women, due to the inaccurate perception that men did not contribute to a couple's infertility. The intersection of gender and social class in medical settings created barriers to women's access to medical information. CONCLUSION: Findings from this study provide representative examples of the variety of axes of inequality that shape women's experiences in the study setting. Although these findings may not be generalisable to all women who are experiencing delayed conception, they highlight a need for improved awareness and education on infertility, as well as a need to ensure the availability and accessibility of fertility care for couples in need.

Financial costs of assisted reproductive technology for patients in low- and middle-income countries: a systematic review.

STUDY QUESTION: What are the direct costs of assisted reproductive technology (ART), and how affordable is it for patients in low- and middle-income countries (LMICS)? SUMMARY ANSWER: Direct medical costs paid by patients for infertility treatment are significantly higher than annual average income and GDP per capita, pointing to unaffordability and the risk of catastrophic expenditure for those in need. WHAT IS KNOWN ALREADY: Infertility treatment is largely inaccessible to many people in LMICs. Our analysis shows that no study in LMICs has previously compared ART medical costs across countries in international dollar terms (US$PPP) or correlated the medical costs with economic indicators, financing mechanisms, and policy regulations. Previous systematic reviews on costs have been limited to high-income countries while those in LMICs have only focussed on descriptive analyses of these costs. STUDY DESIGN SIZE DURATION: Guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA), we searched PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit, PsycINFO, Latin American & Caribbean Health Sciences Literature, and grey literature for studies published in all languages from LMICs between 2001 and 2020. PARTICIPANTS/MATERIALS SETTING METHODS: The primary outcome of interest was direct medical costs paid by patients for one ART cycle. To gauge ART affordability, direct medical costs were correlated with the GDP per capita or average income of respective countries. ART regulations and public financing mechanisms were analyzed to provide information on the healthcare contexts in the countries. The quality of included studies was assessed using the Integrated Quality Criteria for Review of Multiple Study designs. MAIN RESULTS AND THE ROLE OF CHANCE: Of the 4062 studies identified, 26 studies from 17 countries met the inclusion criteria. There were wide disparities across countries in the direct medical costs paid by patients for ART ranging from USD2109 to USD18 592. Relative ART costs and GDP per capita showed a negative correlation, with the costs in Africa and South-East Asia being on average up to 200% of the GDP per capita. Lower relative costs in the Americas and the Eastern Mediterranean regions were associated with the presence of ART regulations and government financing mechanisms. LIMITATIONS REASONS FOR CAUTION: Several included studies were not primarily designed to examine the cost of ART and thus lacked comprehensive details of the costs. However, a sensitivity analysis showed that exclusion of studies with below the minimum quality score did not change the conclusions on the outcome of interest. WIDER IMPLICATIONS OF THE FINDINGS: Governments in LMICs should devise appropriate ART regulatory policies and implement effective mechanisms for public financing of fertility care to improve equity in access. The findings of this review should inform advocacy for ART regulatory frameworks in LMICs and the integration of infertility treatment as an essential service under universal health coverage. STUDY FUNDING/COMPETING INTERESTS: This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO). The authors declare no competing interests. TRIAL REGISTRATION NUMBER: This review is registered with PROSPERO, CRD42020199312.

Indicators of infertility and fertility care: a systematic scoping review.

STUDY QUESTION: What is the scope of literature regarding infertility and fertility care indicators in terms of types and dimensions of these indicators? SUMMARY ANSWER: Most available infertility and fertility care indicators are outcomes indicators of effectiveness and efficiency dimensions. WHAT IS KNOWN ALREADY: The use of appropriate, relevant and valid indicators of infertility and fertility care is critical for monitoring access, equity and utilization. STUDY DESIGN SIZE DURATION: A systematic scoping review was conducted. We searched MEDLINE, Pubmed, JSTOR, CINAHL, Web of Science and Scopus electronic databases from inception to May 2022 without imposing language or date restrictions. We searched gray literature and online libraries of relevant organizations. We hand-searched the list of relevant references. PARTICIPANTS/MATERIALS SETTING METHODS: This scoping systematic review followed the framework of Arksey and O'Malley and the Joanna Briggs Institute guidelines. Records identified by the search were independently screened and data were extracted. We performed conceptual synthesis by grouping the reported indicators by typology and dimensions. Structured tabulation and graphical synthesis were used along with narrative commentary. MAIN RESULTS AND THE ROLE OF CHANCE: We included 46 reports from 88 countries. The reporting of infertility and fertility care indicators was voluntary in 63 countries (72%) and compulsory in 25 countries (28%). Reporting for cycles or deliveries was based on individual cycles in 56 countries (64%) and on cumulative cycles in 32 countries (36%). Most indicators were utilized as outcome indicators with fewer being process indicators or structural indicators. For the dimension of indicators, most indicators were utilized as effectiveness and efficiency indicators with fewer utilized as indicators of safety, patient-centeredness, equity and timeliness. LIMITATIONS REASONS FOR CAUTION: Most indicators fall into the domain of assisted reproductive technology and are reported by fertility clinics. Indicators of safety, patient-centeredness, equity and timeliness as well as non-clinical indicators are almost invisible. WIDER IMPLICATIONS OF THE FINDINGS: A wide range of indicators of infertility and fertility care exist in literature. Most indicators were effectiveness and efficiency indicators, while indicators of safety, patient-centeredness, equity and timeliness remain almost invisible. The scope of the current indicators indicates a predominant focus on clinical metrics, with substantial invisibility of non-clinical indicators and indicators outside the ART domain. These gaps need to be considered in further work of identifying a core set of indicators. STUDY FUNDING/COMPETING INTERESTS: This work received funding from the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored program executed by the World Health Organization (WHO). The authors had no competing interests. TRIAL REGISTRATION NUMBER: Open Science Framework vsu42.

Characteristics, experiences and actions taken by women to address delayed conception: A mixed-methods cross-sectional study protocol.

BACKGROUND: The impact of infertility on mental, emotional, physical and sexual health is grave, particularly in a pronatalist society. Literature is replete with evidence of wide ranging psychosocial consequences of infertility in women, indicating the need for identifying the gaps and designing appropriate context specific interventions to improve access and utilization of services. Data that are accessible, primarily from infertility clinics and women visiting hospitals for infertility treatment; information from community settings is rare. This is a protocol paper for a study to understand women's experiences and actions taken by them to cope with delayed conception. METHODS: Mixed-methods cross-sectional design is used to obtain deep insights into the experiences of delayed conception, coping mechanisms, medical assistance and other help sought. Information is also being obtained on socio-demographic profile, fertility intentions, fertility quality of life, general medical history, obstetric, gynecological and sexual history, substance use and mental health status. A sample of 1530 women will be administered 4 modules of a quantitative survey. Focus group discussions, about four or till saturation point, will be conducted using purposive sampling. The study is recruiting from a population of women who previously participated in the 'Women and Infants Integrated Interventions for Growth Study (WINGS) and failed to conceive during 18 months follow up period. Data collected through questionnaire will be assembled, cleaned, analyzed and reported. The findings will be disseminated through reports with the ethics review committee, government entities, academic and research publications. DISCUSSION: This study will provide insights on the experiences and coping strategies of women with delayed conception in the study community. Results will assist in designing appropriate interventions to meet the holistic health and psychosocial needs of women with delayed conception and promote sexual and reproductive health within the broader framework of Sustainable Development Goals and Universal health coverage. TRIAL REGISTRATION: Trial registration number: CTRI/2020/03/023955.

Prevalence of reproductive tract infections including sexually transmitted infections among married women in urban and peri-urban mid to low socioeconomic neighbourhoods of Delhi, North India: an observational study protocol.

INTRODUCTION: The Global Health Sector Strategy on sexually transmitted infections (STIs), endorsed by the World Health Assembly in 2016 aims to end STIs as public health threat by 2030. WHO conducts global estimates of prevalence to monitor progress towards achieving the same. However, limited laboratory confirmed data exist of STIs and reproductive tract infections (RTIs) apart from few prevalence surveys among key populations and clinic-based reports, including in India. Syndromic approach is the cornerstone of RTI/STI management and to maximise the diagnostic accuracy, there is a need to determine the main aetiologies of vaginal discharge. This study aims to estimate the prevalence of common STIs and RTIs and their aetiological organisms in symptomatic and asymptomatic women living in the urban and peri-urban, mid to low socioeconomic neighbourhoods of Delhi, North India. METHODS AND ANALYSIS: A cross-sectional study will be conducted among 440 married women who participated in the 'Women and Infants Integrated Interventions for Growth Study (WINGS)'. Information on sociodemographic profile, sexual and reproductive health will be collected, followed by examination and collection of vaginal swabs for nucleic acid amplification tests to diagnose Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis and microscopy to identify bacterial vaginosis and Candida albicans. Treatment will be as per the syndromic approach recommendations in the Indian National Guidelines. Data will be analysed to estimate prevalence, presence of symptoms and signs associated with laboratory confirmed RTIs/STIs using STATA V.16.0 (StataCorp). ETHICS AND DISSEMINATION: This study protocol has been approved by the ethics review committees of the WHO and Society for Applied Studies (SAS/ERC/RHR-RTI/STI/2020). Approval has been obtained by the WINGS investigators from SAS ethics research committee to share the contact details of the participants with the investigators. The findings will be published in peer-reviewed journals and disseminated through scientific conferences. TRIAL REGISTRATION NUMBER: CTRI/2020/03/023954.

Postpartum contraceptive practices among urban and peri-urban women in North India: a mixed-methods cohort study protocol.

BACKGROUND: Postpartum family planning (PPFP) helps women space childbirths, increase exclusive breastfeeding and prevent unintended pregnancies, leading to reduction in maternal, infant and child morbidities and mortality. Unmet need of family planning is highest among women in the postpartum period due to lack of knowledge, cultural and religious barriers, access barriers and low antenatal care service utilization. However, in spite of low prevalence of postpartum family planning practices, birth-to-birth interval is reportedly high in Delhi, India. This study explores the postpartum contraception practices and the relationship between use of postpartum contraception and subsequent child linear growth. METHODS: This is a mixed method cohort study on PPFP and is nested within an ongoing "Women and Infants Integrated Interventions for Growth Study" (WINGS). Married women aged 18-30 years who have delivered a live baby are recruited for quantitative interviews at 6 weeks, 6, 12, and 24 months postpartum. In-depth interviews are conducted with a randomly selected sub-sample of women at each of the four time points, 35 husbands and 20 local service providers to understand their perspectives on PPFP practices. DISCUSSION: The findings from the study will provide useful insights into couples' contraception preferences and choice of contraception, modern and traditional, initiation time and the effect of birth spacing and contraception use on subsequent linear growth of the child. This knowledge will be of significant public health relevance and will help in designing appropriate interventions for appropriate postpartum contraception use and delivery strategies. The study aims to work address the Sexual and Reproductive Health and Rights goal of promoting reproductive health, voluntary and safe sexual and reproductive choices for women. TRIAL REGISTRATION: Trial registration number: CTRI/2020/03/023954 .

Estimating the government public economic benefits attributed to investing in assisted reproductive technology: a South African case study.

Limited resources and high treatment costs are arguments often used in many public health systems in low- and middle-income countries to justify providing limited treatments for people with infertility. In this analysis, we apply a government public economic perspective to evaluate public subsidy for in-vitro fertilization (IVF) in South Africa. A fiscal model was developed that considered lifetime direct and indirect taxes paid and government transfers received by a child conceived by IVF. The model was constructed from public data sources and was adjusted for mortality, age-specific educational costs, participation in the informal economy, proportions of persons receiving social grants, and health costs. Based on current proportions of individuals receiving social grants and average payments, including education and health costs, we estimate each citizen will receive ZAR513,165 (USD35,587) in transfers over their lifetime. Based on inflated age-specific earnings, we estimate lifetime direct and indirect taxes paid per citizen of ZAR452,869 (USD31,405) and ZAR494,521 (USD34,294), respectively, which also includes adjustments for the proportions of persons participating in the informal economy. The lifetime net tax after deducting transfers was estimated to be ZAR434,225 (USD31,112) per person. Based on the average IVF investment cost needed to achieve one live birth, the fiscal return on investment (ROI) for the South African Government is 5.64. Varying the discount rate from 4% to 7%, the ROI ranged from 9.54 to 1.53, respectively. Positive economic benefits can emanate from public financing of IVF. The fiscal analytic framework described here can be a useful approach for health services to evaluate future public economic benefits.

Economic costs of infertility care for patients in low-income and middle-income countries: a systematic review protocol.

INTRODUCTION: Infertility, a condition of the reproductive system, affects millions of individuals and couples worldwide. Despite infertility treatment's existence, it is largely unavailable and inaccessible in low/middle-income countries (LMICs) due to the prohibitive costs compounded by an absence of financing. Previous systematic reviews have shown that there is scanty information in LMICs on out-of-pocket (OOP) payments for infertility treatment. This protocol outlines the methodological approach and analytical process to appraise the extent of economic burden due to payments for infertility care services in LMICs. METHOD AND ANALYSIS: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach, we will primarily search for articles indexed in PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature, EconLit and PsycINFO databases. Grey literature from relevant organisations' virtual libraries shall also be searched. Backward and forward searches on the articles selected will also be done. Quantitative studies on infertility treatment costs from LMICs across the world regions within the last 20 years will be considered. The primary outcome of interest shall include OOP payments, catastrophic health expenditure and direct costs for infertility services. Conversely, informal payments and indirect costs related to infertility treatments shall be considered as secondary outcomes. Integrated quality Criteria for Review Of Multiple Study designs will be used to assess the quality of the studies included in the review. Meta-analysis shall be considered if sufficient studies identified are homogenous in characteristics. Also, the review shall analyse the average cost of infertility treatment against the respective countries' economic indicators like gross domestic product per capita if data permit. ETHICS AND DISSEMINATION: Research and ethics approval will not be required given this will be a review of published articles on the subject. The findings shall be disseminated through publication in a peer-reviewed journal and presentation to the WHO and its partners. PROSPERO REGISTRATION NUMBER: CRD42020199312.

Determinants of Women's Drug Use During Pregnancy: Perspectives from a Qualitative Study.

INTRODUCTION: Drug use during pregnancy can have negative effects on maternal and child health. However, there is a dearth of data regarding drug use among pregnant women in Kenya, where illicit drug use is on the rise. In this paper, we report factors influencing women's decisions to use drugs during pregnancy. METHODS: In 2015, we conducted in-depth interviews and focus group discussions with 45 women who inject drugs and five key stakeholders involved in provision of services to people who use drugs in coastal Kenya. Inductive thematic analysis was conducted to draw out themes related to key determinants of drug use during pregnancy. RESULTS: Four key themes emerged outlining determinants of drug use during pregnancy: (i) the use of drugs to cope with the stress of unexpected pregnancy, (ii) the continued drug use during pregnancy to manage withdrawal, (iii) the dual effect of pregnancy on drug use either as a facilitator or as a moderator of drug use, and (iv) the role of male intimate partner in influencing women's drug use during pregnancy. CONCLUSION: Our paper reports women's drug use during pregnancy and the factors influencing this phenomenon. To safeguard the health and well-being of pregnant women and their unborn children, there is a need for education and awareness raising, implementing couple-based harm reduction approaches to leverage on positive male influences, improving availability of drug treatment, and provision of family planning interventions for women who use drugs.

Syphilis infection among people who use and inject drugs in Cambodia: a cross-sectional study using the respondent-driven sampling method.

This cross-sectional study explored the prevalence and correlates of syphilis infection among people who use and inject drugs (PWUD/PWID) in Cambodia. Data were collected in 2017 from 1,677 PWUD/PWID living in the capital city of Phnom Penh and 11 other major provinces using the respondent-driven sampling method. The SD Bioline HIV/Syphilis Duo test was used to determine human immunodeficiency virus (HIV) and current or past syphilis infection. A multivariable logistic regression analysis was conducted to identify risk factors associated with current or past syphilis infection. The prevalence of current or past syphilis infection was 3.8% (95% confidence interval = 2.4-4.6). After adjustment, current or past syphilis infection remained positively associated with being female, living on the streets, having an average monthly income of US$100-299, having transactional sex in the past three months, and having been to a rehabilitation centre in the past 12 months. Current or past syphilis infection was negatively associated with having attained at least high school level of formal education. The findings indicate vulnerability to syphilis infection among PWUD/PWID in Cambodia, particularly among subpopulations who are more marginalized. Syphilis prevention and control programmes should be systematically integrated into HIV and sexually transmitted infection policy and services in the country.

Outcomes of HIV treatment from the private sector in low-income and middle-income countries: a systematic review protocol.

INTRODUCTION: Private sector provision of HIV treatment is increasing in low-income and middle-income countries (LMIC). However, there is limited documentation of its outcomes. This protocol reports a proposed systematic review that will synthesise clinical outcomes of private sector HIV treatment in LMIC. METHODS AND ANALYSIS: This review will be conducted in accordance with the preferred reporting items for systematic review and meta-analyses protocols. Primary outcomes will include: (1) proportion of eligible patients initiating antiretroviral therapy (ART); (2) proportion of those on ART with <1000 copies/mL; (3) rate of all-cause mortality among ART recipients. Secondary outcomes will include: (1) proportion receiving Pneumocystis jiroveci pneumonia prophylaxis; (2) proportion with >90% ART adherence (based on any measure reported); (3) proportion screened for non-communicable diseases (specifically cervical cancer, diabetes, hypertension and mental ill health); (iv) proportion screened for tuberculosis. A search of five electronic bibliographical databases (Embase, Medline, PsychINFO, Web of Science and CINAHL) and reference lists of included articles will be conducted to identify relevant articles reporting HIV clinical outcomes. Searches will be limited to LMIC. No age, publication date, study-design or language limits will be applied. Authors of relevant studies will be contacted for clarification. Two reviewers will independently screen citations and abstracts, identify full text articles for inclusion, extract data and appraise the quality and bias of included studies. Outcome data will be pooled to generate aggregative proportions of primary and secondary outcomes. Descriptive statistics and a narrative synthesis will be presented. Heterogeneity and sensitivity assessments will be conducted to aid interpretation of results. ETHICS AND DISSEMINATION: The results of this review will be disseminated through a peer-reviewed scientific manuscript and at international scientific conferences. Results will inform quality improvement strategies, replication of identified good practices, potential policy changes, and future research. PROSPERO REGISTRATION NUMBER: CRD42016040053.

Prevalence and correlates of amphetamine-type stimulant use among transgender women in Cambodia.

BACKGROUND: The use of amphetamine-type stimulants (ATS) is associated with increases in HIV infections and other negative health outcomes. Globally, transgender women are among the most vulnerable to HIV. In this paper, we report the prevalence and correlates of ATS use among transgender women in Cambodia. METHODS: In 2016, 1375 transgender women were recruited for the National Integrated Biological and Behavioural Survey using respondent-driven sampling method. Participants were recruited from the capital city of Phnom Penh and 12 other provinces. A structured questionnaire was used to collect information on demographic characteristics, sexual behaviours, ATS and other substance use, depressive symptoms, gender-based violence, adverse childhood experiences, stigmatization, and social support. Weighted multivariable logistic regression analyses were conducted to identify risk factors associated with ATS use in the past three months. RESULTS: Overall, the most commonly reported illicit drug used by the survey participants was ATS (10.4%). ATS use was more likely to occur among participants who: (1) were urban dwellers, (2) were 25 to 34 years old, 3) had low levels of education, (4) engaged in transactional sex, (5) inconsistently used condoms with commercial partners, (6) reported binge drinking, (7) had depressive symptoms, (8) had a feeling that co-workers/classmates were not supportive regarding their transgender identity, and (9) had experienced emotional abuse during childhood. CONCLUSION: ATS were the most commonly reported illicit drugs among transgender women in this study. To mitigate potential negative outcomes, developing and implementing additional harm reduction strategies tailored to ATS use among transgender women is needed. Integration of HIV and mental health interventions into harm reduction programs is required.

Prevalence and risk factors of HIV infection among people who inject drugs in Cambodia: findings from a national survey.

BACKGROUND: Globally, people who inject drugs (PWID) continue to be among the most vulnerable populations to acquire infection of human immunodeficiency virus (HIV). The most recent national survey found that nearly a quarter of PWID in Cambodia were infected with HIV in 2012. The aim of this study is to estimate the current prevalence of and factors associated with HIV infection among PWID in Cambodia. METHODS: This national integrated biological and behavioral survey was conducted from June to December 2017. Participants were recruited from the capital city and 11 major provinces using the respondent driven sampling method. Face-to-face interviews were conducted using a structured questionnaire, and blood samples were collected for HIV, syphilis, and hepatitis C virus (HCV) testing. Multiple logistic regression analysis was conducted to identify risk factors for HIV infection. All analyses were estimated with sampling weights that corrected for non-response and sample design. RESULTS: A total of 310 PWID participated in the study, and the mean age was 31.8 years (SD = 7.8). The prevalence of HIV was 15.2%. More than half (57.4%) of the HIV-positive participants were co-infected with HCV, and 44.7% were not aware of their HIV status prior to this study. After adjustment for other covariates, HIV infection remained positively associated with being female (AOR = 1.88, 95% CI = 1.03-4.04), being in the older age group of ≥35 (AOR = 2.99, 95% CI 1.33-9.22), being widowed, divorced or separated (AOR = 2.57, 95% CI = 1.04-6.67), living on the streets (AOR = 2.86, 95% CI 1.24-4.37), and HCV infection (AOR = 3.89, 95% CI 1.86-1.15). The HIV infection remained negatively associated with having higher level of formal education of ≥10 years (AOR = 0.44, 95% CI 0.13-0.83) and higher average income of ≥US$200 per month (AOR = 0.20, 95% CI = 0.05-0.74). CONCLUSIONS: The prevalence of HIV among PWID in Cambodia remains high, but is reducing compared with the 24.8% reported in the 2012 national survey. Findings from this study provide critical information for tailoring interventions based on identified vulnerabilities and risk factors for HIV. Our findings underline the importance of socio-structural factors in HIV epidemiology among PWID in Cambodia, which require mitigation.

Prevalence and correlates of HIV infection among people who use drugs in Cambodia: a cross-sectional survey using respondent driven sampling method.

BACKGROUND: Most of studies on the relationship between drug use and HIV have focused largely on people who inject drugs. Non-injecting drug use is much more common than injecting drug use, and although it can also predispose people to HIV infection, it is not widely explored. We therefore conducted this study to explore the prevalence of HIV and identify risk factors for HIV infection among people who use non-injecting drugs (PWUD) in Cambodia. METHODS: This cross-sectional study was conducted in 2017. The Respondent Driven Sampling method was used to recruit the study participants who were interviewed face-to-face using a structured questionnaire. Blood samples were collected for HIV and syphilis testing. A multivariable logistic regression analysis was conducted to identify risk factors associated with HIV infection. RESULTS: In total, 1367 PWUD were included in this study, whose mean age was 28.0 (SD = 7.7) years. The majority (95.1%) of the participants used methamphetamine. The prevalence of HIV was 5.7, and 35.2% of the identified HIV-positive PWUD were not aware of their status prior to the survey. After adjustment for other covariates, HIV infection remained significantly associated with being in the age group of ≥35 (AOR = 2.34, 95% CI = 1.04-6.11), having lower level of formal education of ≤ 6 years (AOR = 2.26, 95% CI = 1.04-5.15), living on the streets (AOR = 2.82, 95% CI = 1.10-7.23), perception that their HIV risk was higher as compared to that of the general population (AOR = 3.18, 95% CI = 1.27-8.62), having used injecting drugs in lifetime (AOR = 3.8, 95% CI = 1.36-4.56), and having cuts or sores around the genital area in the past 12 months (AOR = 3.42, 95% CI = 1.09-6.33). CONCLUSIONS: The prevalence of HIV among PWUD in this study was more than 10 times higher than the prevalence in the general adult population. The findings reveal a higher vulnerability to HIV infection among specific sub-populations of PWUD, such as those who are homeless, who may benefit from tailored interventions that respond to their specific needs. To enhance HIV case finding, stratification of PWUD to facilitate HIV risk profiling based on socio-economic profiles and drug injection history is recommended.

Developing integrated community-based HIV prevention, harm reduction, and sexual and reproductive health services for women who inject drugs.

BACKGROUND: Despite being a priority population for HIV prevention and harm reduction programs, the sexual and reproductive health (SRH) needs of women who inject drugs are being overlooked. Furthermore, models for providing integrated SRH, HIV, and harm reduction services for women who inject drugs are rare. This article reports the development of community-based outreach services that integrated family planning and other SRH interventions with HIV and harm reduction services for this population in coastal Kenya. METHODS: Using mixed-methods implementation research, a qualitative baseline needs assessment was conducted with women who inject drugs and harm reduction stakeholders using a combination of in-depth interviews and focus group discussions. The qualitative data from participants was subjected to thematic analysis using Nvivo. Based on the baseline needs assessment, integration of SRH into existing HIV and harm reduction services was implemented. After two years of implementation, an evaluation of the program was conducted using a combination of qualitative interviews and review of quantitative service delivery records and other program documents. The process, impacts, and challenges of integrating SRH into a community-based HIV prevention and harm reduction program were identified. RESULTS: This article highlights: 1) low baseline utilization of family planning services among women who inject drugs, 2) improved utilization and high acceptability of outreach-based provision of SRH services including contraception among this population, 3) importance of training, capacity strengthening, technical support and financial resourcing of community-based organizations to integrate SRH into HIV prevention and harm reduction services, and 4) the value of beneficiary involvement, advocacy, and collaboration with other partners in the planning, designing and implementing of SRH interventions for women who inject drugs. CONCLUSIONS: Women who inject drugs in this study had low utilization of family planning and other SRH services, which can be improved through the integration of contraceptive and other SRH interventions into existing outreach-based HIV prevention and harm reduction programs. This integration is acceptable to women who inject drugs, and is programmatically feasible. For successful integration, a rights-based beneficiary involvement, coupled with sustainable technical and financial capacity strengthening at the community level is essential.

Prevalence of and risk factors for hepatitis C virus antibody among people who inject drugs in Cambodia: a national biological and behavioral survey.

BACKGROUND: Hepatitis C virus (HCV) is a significant global health concern. Despite evidence of the relationship between injecting drug use and HCV, studies on HCV among people who inject drugs in developing countries remain scarce. To address this need, we conducted this study to explore the prevalence of and factors associated with HCV antibody positivity among people who inject drugs in Cambodia. METHODS: Data used for this study were collected as part of the National Integrated Biological and Behavioral Survey among people who use and inject drugs conducted in 2017. We used the respondent-driven sampling method to recruit participants in 12 provinces for face-to-face interviews and HIV and HCV antibody testing. Weighted multivariable logistic regression analysis was conducted to identify risk factors associated with HCV antibody positivity. RESULTS: This study included 286 people who inject drugs with a mean age of 31.6 (SD = 7.5) years. The prevalence of HCV antibody among participants in this study was 30.4%, of whom 31.0% were co-infected with HIV. After adjustment for other covariates, the odds of HCV antibody positivity was significantly higher among participants who were in the older age group of 25 to 34 (AOR = 1.85, 95% CI = 1.06-7.92) and ≥ 35 (AOR = 2.67, 95% CI = 1.24-5.71), were in Vietnamese ethnic group (AOR = 5.44, 95% CI = 2.25-13.14), were living on the streets (AOR = 3.01, 95% CI = 1.29-704), had been sent to a drug rehabilitation center in the past 12 months (AOR = 2.67, 95% CI = 1.21-5.90), had received methadone maintenance therapy in the past 12 months (AOR = 3.02, 95% CI = 1.32-6.92), and were tested positive for HIV (AOR = 3.80, 95% CI = 1.58-9.12) compared to their respective reference group. CONCLUSION: The prevalence of HCV antibody among people who inject drugs in Cambodia is high, particularly in older and more vulnerable subgroups. Tailor-made interventions are required to increase access to culturally sensitive harm reduction interventions to prevent primary HCV infection and reinfection. In addition, there is an opportunity to expand screening, diagnosis, and treatment with new directly acting antiviral agents.

HIV risk behaviours among women who inject drugs in coastal Kenya: findings from secondary analysis of qualitative data.

BACKGROUND: Injecting drug users are at high risk of HIV infection globally. Research related to female drug users is rare in Kenya, yet it is required to inform the development of gender-sensitive HIV prevention and harm reduction services in East Africa, where injecting drug use is on the rise. METHODS: This study aimed to document the nature of HIV risks encountered by women who inject drugs in the Mombasa and Kilifi, Kenya. Secondary data analysis was conducted on an existing dataset from a 2015 primary qualitative study involving 24 interviews and 3 focus group discussions with 45 women who inject drugs. These were complemented with five interviews with key stakeholders involved in the provision of services to women who inject drugs. Guided by the social ecology theory, a thematic analysis was conducted to identify the nature of HIV risks and their underlying determinants. RESULTS: HIV risk behaviours fell into two broad categories: unsafe injecting and unprotected sex. These risks occurred in the form of sharing of needles, unprotected oral, anal, and vaginal sex, sexual assaults, injecting drug use during sex, sex work, and other types of transactional sex. The primary determinants underlying these risks were a low-risk perception, inequitable gender power, economic pressures, and poor availability of needles and condoms. These social-ecological determinants did not exist in isolation, but intersected with each other to create powerful influences which exposed women to HIV. Social-ecological determinants exerted constant influence and created a persistent 'HIV risk environment' that was involuntarily experienced by women. CONCLUSION: Individual, interpersonal, and societal-structural factors intersect to produce HIV risk behaviours. As a minimum, these risks will require a combination of multifaceted micro-level interventions including self-efficacy training, risk assessment skills, couple counselling, and universal access to the recommended harm reduction package. In addition, the current focus on micro-level interventions in Kenya needs to shift to incorporate macro-level interventions, including livelihood, employability, and gender norms-transforming interventions, to mitigate economic and gender-related drivers of HIV risks. In the Kenyan context, injecting drug use during sex work is emerging as an increasingly important HIV risk behaviour needing to be addressed.

Role of boyfriends and intimate sexual partners in the initiation and maintenance of injecting drug use among women in coastal Kenya.

INTRODUCTION: Gender dynamics and interpersonal relations within intimate partnerships are known to determine health behaviors, including substance use, within couples. In addition, influence from intimate partners may occur in the context of wider social ecological determinants of health behavior. The aim of this study was to document the role of intimate partners in influencing injecting drug use among women in Kenya, where injecting drug use is on the rise. METHODS: We performed secondary data analysis of an existing dataset from a 2015 qualitative study involving 45 women who inject drugs and 5 key stakeholders in coastal Kenya. Primary data had been collected via a combination of in-depth interviews and focus group discussions exploring sexual, reproductive, drug use, and other social contexts of women who inject drugs. The process by which intimate partners influenced women's initiation of drug use, transition to injecting practices, and maintenance of injecting drug use were identified using thematic analysis. RESULTS: Boyfriends and intimate either facilitated or restrained women's drug-injecting. On the one hand, young women's entry into drug use was prompted by relationship problems, or a need to acquiesce with their drug-using boyfriends. Once women started injecting, intimate partners facilitated ongoing drug-injecting by financing the acquisition of drugs, peddling drugs to their women, or sharing their drugs with their women. The social capital that peddlers held insulated women from police arrests, and encouraged women to seek and sustain intimate relations with well-connected peddlers. Men's influences over women were driven by an underlying patriarchal drug acquisition and economic power. On the other hand, boyfriends and intimate partners who were non-injectors or non-drug users sought to moderate women's injecting drug use by encouraging them to inject less, to smoke or snort instead of injecting, or to enroll into rehabilitation. These moderating influences were most prominent when couples were pregnant. Despite men being a source of practical and emotional support, women were frequently unable limit or alter their injecting drug use, due to its addictive nature. Men's disagreement with women's ongoing injecting strained relationships, and occasionally led to separation. CONCLUSIONS: Some boyfriends facilitated women's injecting drug use, while others moderated it, supporting assertions that intimate relationships can both be a site of injecting risks or protection. At the micro-level, these findings highlight an opportunity for couple-based interventions, leveraging on non-drug injecting males as a resource to support women adopt safer injecting practices. At a macro level, incorporating livelihood interventions into harm reduction programs is required in order to mitigate economic-based influence of male intimate partners on women's injecting drug use. At both levels, gender transformative approaches are essential. To gain a comprehensive understanding of women's injecting drug use, future studies drug use should explore women's contexts beyond micro influences and consider their wider macro-structural determinants.