Prevalence and factors associated to disclosure of same-sex practices to family members and health care workers among men who have sex with men in Togo.

Disclosure of same-sex practices is associated with improved access to health services and better health outcomes. Our aim was to estimate the prevalence of same-sex practice disclosure to family members and health care workers (HCW) in two cities in Togo. 683 MSM ≥18 years of age were surveyed using respondent driven sampling (RDS) for a cross-sectional survey using a structured questionnaire in Lomé (354 (51.8%)) and Kara (n = 329 (48.2%)). Median age was lower in Lomé than in Kara. A significantly higher proportion of MSM in Lomé (RDSa: 37.0%; 95% CI: 29.7, 44.3) than in Kara (RDSa: 8.0%; 95% CI: 4.7, 11.3) told a HCW that they have sex with men. Disclosure to a family member was associated with female gender, living with HIV, difficulties accessing health services, and blackmail. Disclosure to a HCW was associated with living with HIV, and physical abuse. MSM had decreased odds of disclosure to a HCW if they were living in Kara, reported female gender or intersex, or if had difficulties accessing health services. These data highlight the positive health outcomes associated with disclosure contextualized by the complex environments in which disclosure of same-sex practices takes place.

Development and reliability of metrics to characterize types and sources of stigma among men who have sex with men and female sex workers in Togo and Burkina Faso.

BACKGROUND: Stigma is a multifaceted concept that potentiates Human Immunodeficiency Virus and sexually transmitted infection acquisition and transmission risks among key populations, including men who have sex with men (MSM) and female sex workers (FSW). Despite extensive stigma literature, limited research has characterized the types and sources of stigma reported by key populations in Sub-Saharan Africa. METHODS: This study leveraged data collected from 1356 MSM and 1383 FSW in Togo and Burkina Faso, recruited via respondent-driven sampling. Participants completed a survey instrument including stigma items developed through systematic reviews and synthesis of existing metrics. Using exploratory factor analysis with promax oblique rotation, 16 items were retained in a stigma metric for MSM and 20 in an FSW stigma metric. To assess the measures' convergent validity, their correlations with expected variables were examined through bivariate logistic regression models. RESULTS: One factor, experienced stigma, included actions that were carried out by multiple types of perpetrators and included being arrested, verbally harassed, blackmailed, physically abused, tortured, or forced to have sex. Other factors were differentiated by source of stigma including healthcare workers, family and friends, or police. Specifically, stigma from healthcare workers loaded on two factors: experienced healthcare stigma included being denied care, not treated well, or gossiped about by healthcare workers and anticipated healthcare stigma included fear of or avoiding seeking healthcare. Stigma from family and friends included feeling excluded from family gatherings, gossiped about by family, or rejected by friends. Stigma from police included being refused police protection and items related to police confiscation of condoms. The Cronbach's alpha ranged from 0.71-0.82. Median stigma scores, created for each participant by summing the number of affirmative responses to each stigma item, among MSM were highest in Ouagadougou and among FSW were highest in both Ouagadougou and Bobo-Dioulasso. Validation analyses demonstrated higher stigma was generally significantly associated with suicidal ideation, disclosure of involvement in sex work or same-sex practices, and involvement in organizations for MSM or FSW. CONCLUSIONS: Taken together, these data suggest promising reliability and validity of metrics for measuring stigma affecting MSM and FSW in multiple urban centers across West Africa.

Using a social ecological framework to characterize the correlates of HIV among men who have sex with men in Lomé, Togo.

In the mixed and concentrated HIV epidemics of West Africa, the relative disproportionate burden of HIV among men who have sex with men (MSM) compared to other reproductive-age men is higher than that observed in Southern and Eastern Africa. Our aim is to describe the correlates of HIV infection among MSM living in Lomé, Togo, using the Modified Social Ecological Model (MSEM). A total of 354 MSM ≥18 years of age were recruited using respondent driven sampling (RDS) for a cross-sectional survey in Lomé, Togo. Participants completed a structured questionnaire and were tested for HIV and syphilis. Statistical analyses included RDS-weighted proportions, bootstrapped confidence intervals (CI), and logistic regression models. Mean age of participants was 22 years; 71.5% were between 18 and 24 years. RDS-weighted HIV prevalence was 9.2% (95% CI=5.4-13.2). In RDS-adjusted (RDSa) bivariate analysis, HIV infection was associated with disclosure of sexual orientation to a family member, discriminatory remarks made by family members, forced sex, ever being blackmailed because of being MSM, community and social stigma and discrimination, and health service stigma and discrimination. In the multivariable model, HIV infection was associated with being 25 years or older (RDSa adjusted OR (aOR)=4.3, 95% CI=1.5-12.2), and having sex with a man before age 18 (RDSa aOR=0.3, 95% CI=0.1-0.9). HIV prevalence was more than seven times higher than that estimated among adults aged 15-49 living in Togo. Using the MSEM, network, community, and policy-level factors were associated with HIV infection among MSM in Lomé, Togo. Through the use of this flexible risk framework, a structured assessment of the multiple levels of HIV risk was characterized, highlighting the need for evidence-based and human-rights affirming combination HIV prevention and treatment programs that address these various risk levels for MSM in Lomé.

Consistent Condom Use Among Men Who Have Sex With Men in Lomé and Kara, Togo.

High transmission probability of HIV during condomless anal sex puts men who have sex with men (MSM), transgender, and nonbinary individuals at increased risk of infection. This analysis aims to examine the socioeconomic, biological, and behavioral factors that are associated with consistent condom use (CCU) during insertive/receptive anal sex among MSM in the last month in the cities of Lomé and Kara, Togo. A total of 683 MSM ≥18 years of age were surveyed using respondent-driven sampling (RDS) for a cross-sectional survey in Lomé (n = 354; 51.8%) and Kara (n = 329; 48.2%). Participants completed a structured questionnaire and were tested for HIV and syphilis. Statistical analyses included RDS-weighted proportions, bootstrapped confidence intervals (CIs), and logistic regression models. When compared with Lomé, MSM in Kara had lower odds of CCU [adjusted odds ratio (aOR) = 0.29, 95% CI = 0.19-0.44]. Other factors associated with lower CCU were having an income of 2,000 Communaute Financiere Africaine (CFA)-12,000 CFA (aOR = 0.53, 95% CI = 0.36-0.77) or above 12,000 CFA (aOR = 0.34, 95% CI = 0.20-0.57), transgender women (aOR = 0.47, 95% CI = 0.25-0.92), and intersex gender (aOR = 0.42, 95% CI = 0.24-0.73), and ever being forced to have sex (aOR = 0.42, 95% CI = 0.21-0.82). Factors associated with CCU were identified in this study including older age (aOR = 1.49, 95% CI = 1.04-2.14) and having easy access to condoms (aOR = 2.70, 95% CI = 1.23-5.94) and very easy access to condoms (aOR = 2.73, 95% CI = 1.20-6.16). Reported condom use in this study was low, and several factors associated with CCU were identified including older age and access to condoms. This study highlights multiple barriers to preventive services experienced by MSM in Togo and therefore leveraging strategies to address these barriers may improve prevention of HIV and syphilis.

Characterising the relationship between migration and stigma affecting healthcare engagement among female sex workers in Lomé, Togo.

Migration in West Africa is common and complicates the sustained delivery of comprehensive HIV care programmes for those with specific vulnerabilities to HIV, including female sex workers (FSW). This study evaluated whether migration potentiates the burden of stigma affecting FSW in Lomé, Togo. Respondent driven sampling identified 354 FSW who completed HIV testing and a questionnaire. Multivariable logistic regression was used to identify factors associated with stigma among FSW. Among study participants, 76.3% (270/354) were migrants, with 30.2% (107/354) reporting stigma. Migrant FSW were less likely to report stigma (aOR 0.40; 95% CI:0.22-0.73). FSW who had an abortion (aOR 3.40; 95% CI:1.79-6.30) and were tested for a sexually transmitted infection (STI) or HIV (aOR 2.03; 95% CI:1.16-3.55) were more likely to report stigma. Among FSW, 59.8% (211/353) disclosed selling sex to a health worker. Disclosure was more common among FSW who had been tested for an STI or HIV (36.7%; 77/210), or both (55.7%; 117/210), and resulted in an attenuated but significant association between STI or HIV testing and stigma, indicating that disclosure partially mediated the relationship. These results highlight the need to mitigate healthcare-related stigma affecting FSW, while also considering decentralised HIV testing approaches, including HIV self-testing.

Reproductive health needs of female sex workers and opportunities for enhanced prevention of mother-to-child transmission efforts in sub-Saharan Africa.

INTRODUCTION: HIV infection and pregnancy are both common among female sex workers (FSW), indicating the need for prevention of mother-to-child transmission (PMTCT) among FSW. METHODS: FSW were enrolled into studies in Swaziland, Burkina Faso and Togo using respondent-driven sampling. Women completed interview-administered socio-behavioural surveys and HIV counselling and testing. This secondary analysis describes contraceptive use and attempted pregnancy among reproductive-aged FSW (16-49 years). Robust Poisson regression with generalised estimating equations to account for clustering within recruitment networks was used to separately estimate associations between current unmet contraceptive need and attempted pregnancy among FSW. RESULTS: Overall 1666 FSW were enrolled, 1372 (82.4%) of whom had ever been pregnant. In Togo and Burkina Faso, 83 FSW reported a prior HIV diagnosis and having a child, of which 12.1% (10/83) reported a child known to be HIV-positive. Twenty-five per cent of FSW had an unmet need for contraception; 9% of FSW employed dual contraception, including highly effective non-barrier methods and consistent condom use. Consistent condom use varied substantially by partner type and was higher with clients than non-paying partners. Nineteen per cent (n=313/1666) of FSW were trying to conceive. HIV-positive, undiagnosed FSW were more likely to be trying to conceive as compared to HIV-negative FSW; among 98 HIV-positive women trying to conceive, 25.5% were on antiretroviral therapy. CONCLUSIONS: FSW have varying reproductive goals and contraceptive usage. Efforts to improve coverage of comprehensive family planning - including efforts to increase HIV testing and engagement in treatment among FSW trying to conceive - are necessary for PMTCT.

Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Côte d'Ivoire, Togo and Burkina Faso.

INTRODUCTION: Transgender women are at high risk for the acquisition and transmission of HIV. However, there are limited empiric data characterizing HIV-related risks among transgender women in sub-Saharan Africa. The objective of these analyses is to determine what factors, including sexual behaviour stigma, condom use and engagement in sex work, contribute to risk for HIV infection among transgender women across three West African nations. METHODS: Data were collected via respondent-driven sampling from men who have sex with men (MSM) and transgender women during three- to five-month intervals from December 2012 to October 2015 across a total of six study sites in Togo, Burkina Faso and Côte d'Ivoire. During the study visit, participants completed a questionnaire and were tested for HIV. Chi-square tests were used to compare the prevalence of variables of interest between transgender women and MSM. A multilevel generalized structural equation model (GSEM) was used to account for clustering of observations within study sites in the multivariable analysis, as well as to estimate mediated associations between sexual behaviour stigma and HIV infection among transgender women. RESULTS: In total, 2456 participants meeting eligibility criteria were recruited, of which 453 individuals identified as being female/transgender. Transgender women were more likely than MSM to report selling sex to a male partner within the past 12 months (p<0.01), to be living with HIV (p<0.01) and to report greater levels of sexual behaviour stigma as compared with MSM (p<0.05). In the GSEM, sexual behaviour stigma from broader social groups was positively associated with condomless anal sex (adjusted odds ratio (AOR)=1.33, 95% confidence interval (CI)=1.09, 1.62) and with selling sex (AOR=1.23, 95% CI=1.02, 1.50). Stigma from family/friends was also associated with selling sex (AOR=1.42, 95% CI=1.13, 1.79), although no significant associations were identified with prevalent HIV infection. CONCLUSIONS: These data suggest that transgender women have distinct behaviours from those of MSM and that stigma perpetuated against transgender women is impacting HIV-related behaviours. Furthermore, given these differences, interventions developed for MSM will likely be less effective among transgender women. This situation necessitates dedicated responses for this population, which has been underserved in the context of both HIV surveillance and existing responses.

Suicidal ideation among MSM in three West African countries: Associations with stigma and social capital.

BACKGROUND: Suicidal ideation is understudied among men who have sex with men (MSM) across Sub-Saharan Africa. AIMS: This study aimed to explore social capital and sexual behavior stigma associated with suicidal ideation among MSM in the West African nations of The Gambia, Burkina Faso and Togo. METHODS: Participants were recruited using respondent-driven sampling and snowball sampling across multiple cities (n = 1555) from July 2011 to August 2013. During a single study visit, participants completed a survey. Logistic regression models were used to assess bivariate and multivariable associations with suicidal ideation. RESULTS: The prevalence of lifetime suicidal ideation was 13% overall and ranged 6%-17% across study sites. After adjusting for potential confounders, MSM who reported stigma as a result of having sex with men were more likely to report suicidal ideation. Physical and sexual violence was strongly associated with suicidal ideation, including being physically harmed (adjusted odds ratio (aOR) = 2.94, 95% confidence interval (CI) = 1.91, 4.52), tortured (aOR = 3.86, 95% CI = 2.17, 6.86) and raped (aOR = 3.07, 95% CI = 2.05, 4.60). In contrast, increasing social participation with the broader community was associated with decreased report of suicidal ideation (aOR = 0.91, 95% CI = 0.85, 0.99). CONCLUSION: Sexual behavior stigma should be addressed to improve mental health among MSM in Western Sub-Saharan Africa.

Using Population-Size Estimation and Cross-sectional Survey Methods to Evaluate HIV Service Coverage Among Key Populations in Burkina Faso and Togo.

OBJECTIVES: The objective of our study was to measure progress toward the UNAIDS 90-90-90 HIV care targets among key populations in urban areas of 2 countries in West Africa: Burkina Faso and Togo. METHODS: We recruited female sex workers (FSWs) and men who have sex with men (MSM) through respondent-driven sampling. From January to July 2013, 2738 participants were enrolled, tested for HIV, and completed interviewer-administered surveys. We used population-size estimation methods to calculate the number of people who were engaged in the HIV continuum of care. RESULTS: HIV prevalence ranged from 0.6% (2 of 329) of MSM in Kara, Togo, to 32.9% (115 of 350) of FSWs in Bobo Dioulasso, Burkina Faso. Of those confirmed to be HIV infected, a range of 0.0% (0 of 2) of MSM in Kara to 55.7% (64 of 115) of FSWs in Bobo Dioulasso were using ART. Based on population estimates, the percentage gap between HIV-infected people who should be using ART (per the 90-90-90 targets) and those who reported using ART ranged from 31.5% among FSWs in Bobo Dioulasso to 100.0% among MSM in Kara. CONCLUSIONS: HIV service coverage among MSM and FSWs in Burkina Faso and Togo was low in 2013. Interventions for improving engagement of these at-risk populations in the HIV continuum of care should include frequent, routine HIV testing and linkage to evidence-based HIV treatment services. Population-size estimates can be used to inform governments, policy makers, and funding agencies about where elements of HIV service coverage are most needed.