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

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

Differences in HIV, STI and Other Risk Factors Among Younger and Older Male Sex Workers Who Have Sex With Men in Nairobi, Kenya.

Introduction: Previous surveys of male sex workers (MSW) in sub-Saharan Africa have not fully documented the HIV and sexually transmitted infections (STIs) rates and vulnerabilities by age category. Methods: The bio-behavioral survey of MSW in Nairobi, Kenya, utilized respondent-driven sampling to recruit MSW. Structured interviews captured MSW's behavioral aspects, and biological tests for HIV and other STIs. Results: Analysis of the two age categories, 18-24 years (younger MSW) and 25 years and above (older MSW), shows that of all participants, a significantly higher proportion of younger MSW (59.6% crude, 69.6% RDS-adjusted) were recruited compared to older MSW (40.4% crude, 30.4% RDS-adjusted, P < 0.001). Young male sex workers were more likely to report multiple sexual partnerships in the last 12 months and had multiple receptive anal intercourses (RAI) acts in the last 30 days than older MSW: 0-2 RAI acts (20.6 vs. 8.6%, P = 0.0300), 3-5 RAI acts (26.3 vs. 11.5, P < 0.001), and >5 RAI acts (26.3 vs. 11.5%, P < 0.01). Furthermore, younger MSW were significantly more likely to have 3-5 insertive anal intercourse (IAI) with a regular male sex partner in the last 30 days than older MSW (24.3 vs. 8.0%, P < 0.01). Younger MSW were also more likely to report other STIs [28.5% (95% CI: 19.1-40.4%)] than older MSW [19.0% (95% CI: 7.7-29.2%)]. However, older MSWs were more likely to be infected with HIV than younger MSW (32.3 vs. 9.9 %, P < 0.01). Conclusions: Owing to the high risk sexual behaviors, HIV and STIs risks among younger and older MSW, intensified and targeted efforts are needed on risk reduction campaigns and expanded access to services.

Venue-Based HIV Testing at Sex Work Hotspots to Reach Adolescent Girls and Young Women Living With HIV: A Cross-sectional Study in Mombasa, Kenya.

BACKGROUND: We estimated the potential number of newly diagnosed HIV infections among adolescent girls and young women (AGYW) using a venue-based approach to HIV testing at sex work hotspots. METHODS: We used hotspot enumeration and cross-sectional biobehavioral survey data from the 2015 Transition Study of AGYW aged 14-24 years who frequented hotspots in Mombasa, Kenya. We described the HIV cascade among young females who sell sex (YFSS) (N = 408) versus those young females who do not sell sex (YFNS) (N = 891) and triangulated the potential (100% test acceptance and accuracy) and feasible (accounting for test acceptance and sensitivity) number of AGYW that could be newly diagnosed through hotspot-based HIV rapid testing in Mombasa. We identified the profile of AGYW with an HIV in the past year using generalized linear mixed regression models. RESULTS: N = 37/365 (10.1%) YFSS and N = 30/828 (3.6%) YFNS were living with HIV, of whom 27.0% (N = 10/37) and 30.0% (N = 9/30) were diagnosed and aware (P = 0.79). Rapid test acceptance was 89.3%, and sensitivity was 80.4%. There were an estimated 15,635 (range: 12,172-19,097) AGYW at hotspots. The potential and feasible number of new diagnosis was 627 (310-1081), and 450 (223-776), respectively. Thus, hotspot-based testing could feasibly reduce the undiagnosed fraction from 71.6% to 20.2%. The profile of AGYW who recently tested was similar among YFSS and YFNS. YFSS were 2-fold more likely to report a recent HIV test after adjusting for other determinants [odds ratio (95% confidence interval): 2.2 (1.5 to 3.1)]. CONCLUSION: Reaching AGYW through hotspot-based HIV testing could fill gaps left by traditional, clinic-based HIV testing services.

Low program access despite high burden of sexual, structural, and reproductive health vulnerabilities among young women who sell sex in Mombasa, Kenya.

BACKGROUND: Across Sub-Saharan Africa, young women who sell sex (YSW) face institutional barriers in accessing sexual health and HIV prevention programs designed for female sex workers. In 2018, Kenya developed a national framework to guide service provision for YSW aged 14-24 years. To help inform the implementation of the framework, we estimated the burden of vulnerabilities related to the Sustainable Development Goals (SDGs related to health and gender equality) and program contact among YSW. METHODS: We used data from Transitions, a 2015 bio-behavioural cross-sectional survey of 408 YSW aged 14-24 years in Mombasa, Kenya. We estimated the prevalence of sexual (inconsistent condom use), structural (financial, violence), and reproductive health vulnerabilities; and characterized engagement with local HIV programs tailored to sex workers. We then compared the prevalence of vulnerabilities by age group (14-18 years, N = 117; 19-24 years, N = 291) and by program contact (ever contacted by local program for sex workers). RESULTS: 47.3% reported inconsistent condom use with any partner in the previous week (no difference by age-group, p = 1.00). Structural vulnerabilities were common and did not vary by age: 83.6% did not have a regular source of income; 29.9 and 29.2% had experienced physical and sexual violence, respectively. 26.5% reported at least one pregnancy before age 18, and 18.5% used a non-reliable form of contraception with little variability by age. 25.7% were aware of at least one program, and only 13.7% of YSW had ever been contacted by a program (8.5% of those aged 14-18 years; and 15.8% of those aged 19-24 years, p = 0.06). Sexual, structural, and reproductive health vulnerabilities did not vary by program contact. CONCLUSIONS: SDG-related vulnerabilities begin early in the lives of YSW who are not currently reached by programs designed for female sex workers.

HIV prevention programme cascades: insights from HIV programme monitoring for female sex workers in Kenya.

INTRODUCTION: HIV prevention cascades have emerged as a programme management and monitoring tool that outlines the sequential steps of an HIV prevention programme. We describe the application of an HIV combination prevention programme cascade framework to monitor and improve HIV prevention interventions for female sex workers (FSWs) in Kenya. METHODS: Two data sources were analysed: (1) annual programme outcome surveys conducted using a polling booth survey methodology in 2017 among 4393 FSWs, and (2) routine programme monitoring data collected by (a) 92 implementing partners between July 2017 and June 2018, and (b) Learning Site in Mombasa (2014 to 2015) and Nairobi (2013). We present national, sub-national and implementing partner level cascades. RESULTS: At the national level, the population size estimates for FSW were 133,675 while the programme coverage targets were 174,073. Programme targets as denominator, during the period 2017 to 2018, 156,220 (90%) FSWs received peer education and contact, 148,713 (85%) received condoms and 83,053 (48%) received condoms as per their estimated need. At the outcome level, 92% of FSWs used condoms at the last sex with their client but 73% reported consistent condom use. Although 96% of FSWs had ever tested for HIV, 85% had tested in the last three months. Seventy-nine per cent of the HIV-positive FSWs were enrolled in HIV care, 73% were currently enrolled on antiretroviral therapy (ART) and 52% had attended an ART clinic in the last month. In the last six months, 48% of the FSWs had experienced police violence but 24% received violence support. National and sub-national level cascades showed proportions of FSWs lost at each step of programme implementation and variability in programme achievement. Hotspot and sub-population level cascades, presented as examples, demonstrate development and use of these cascades at the implementation level. CONCLUSIONS: HIV prevention programme cascades, drawing on multiple data sources to provide an understanding of gaps in programme outputs and outcomes, can provide powerful information for monitoring and improving HIV prevention programmes for FSWs at all levels of implementation and decision-making. Complexity of prevention programmes and the paucity of consistent data can pose a challenge to development of these cascades.

Vulnerabilities at First Sex and Their Association With Lifetime Gender-Based Violence and HIV Prevalence Among Adolescent Girls and Young Women Engaged in Sex Work, Transactional Sex, and Casual Sex in Kenya.

BACKGROUND: Adolescent girls and young women (AGYW) experience high rates of HIV early in their sexual life course. We estimated the prevalence of HIV-associated vulnerabilities at first sex, and their association with lifetime gender-based violence (GBV) and HIV. METHODS: We conducted a cross-sectional biobehavioral survey among AGYW (14-24 years) in Mombasa, Kenya in 2015. We compared the prevalence of first sex vulnerabilities across AGYW who self-identified as engaging in sex work (N = 408), transactional sex (N = 177), or casual sex (N = 714) and used logistic regression to identify age-adjusted associations between first sex vulnerabilities and outcomes (GBV after first sex; HIV). RESULTS: The median age at first sex was 16 years (interquartile range 14-18). A total of 43.6% received gifts or money at first sex; 41.2% and 11.2% experienced a coerced and forced first sex, respectively. First sex vulnerabilities were generally more common among AGYW in sex work. GBV (prevalence 23.8%) and HIV (prevalence 5.6%) were associated with first sex before age 15 [GBV adjusted odds ratio (AOR) 1.4, 95% confidence interval (CI): 1.0 to 1.9; HIV AOR 1.9, 95% CI: 1.1 to 1.3]; before or within 1 year of menarche (GBV AOR 1.3, 95% CI: 1.0 to 1.7; HIV AOR 2.1, 95% CI: 1.3 to 3.6); and receipt of money (GBV AOR 1.9, 95% CI: 1.4 to 2.5; HIV AOR 2.0, 95% CI: 1.2 to 3.4). CONCLUSIONS: HIV-associated vulnerabilities begin at first sex and potentially mediate an AGYW's trajectory of risk. HIV prevention programs should include structural interventions that reach AGYW early, and screening for a history of first sex vulnerabilities could help identify AGYW at risk of ongoing GBV and HIV.

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.

Ecologies of security: On the everyday security tactics of female sex workers in Nairobi, Kenya.

This paper highlights important environmental dimensions of HIV vulnerability by describing how the sex trade operates in Nairobi, Kenya. Although sex workers there encounter various forms of violence and harassment, as do sex workers globally, we highlight how they do not merely fall victim to a set of environmental risks but also act upon their social environment, thereby remaking it, as they strive to protect their health and financial interests. In so doing, we illustrate the mutual constitution of 'agency' and 'structure' in social network formations that take shape in everyday lived spaces. Our findings point to the need to expand the focus of interventions to consider local ecologies of security in order to place the local knowledges, tactics, and capacities that communities might already possess on centre stage in interventions. Planning, implementing, and monitoring interventions with a consideration of these ecologies would tie interventions not only to the risk reduction goals of global public health policy, but also to the very real and grounded financial priorities of what it means to try to safely earn a living through sex work.