Livelihood activities, human mobility, and risk of malaria infection in elimination settings: a case-control study.

BACKGROUND: Livelihood activities and human movements participate in the epidemiology of vector-borne diseases and influence malaria risk in elimination settings. In Saudi Arabia, where malaria transmission intensity varies geographically, it is vital to understand the components driving transmission within specific areas. In addition, shared social, behavioural, and occupational characteristics within communities may provoke the risk of malaria infection. This study aims to understand the relationship between human mobility, livelihood activities, and the risk of malaria infection in the border region of Jazan to facilitate further strategic malaria interventions. In addition, the study will complement and reinforce the existing efforts to eliminate malaria on the Saudi and Yemen border by providing a deeper understanding of human movement and livelihood activities. METHODS: An unmatched case-control study was conducted. A total of 261 participants were recruited for the study, including 81 cases of confirmed malaria through rapid diagnostic tests (RDTs) and microscopy and 180 controls in the Baish Governorate in Jazan Provinces, Saudi Arabia. Individuals who received malaria tests were interviewed regarding their livelihood activities and recent movement (travel history). A questionnaire was administered, and the data was captured electronically. STATA software version 16 was used to analyse the data. Bivariate and multivariate analyses were conducted to determine if engaging in agricultural activities such as farming and animal husbandry, recent travel history outside of the home village within the last 30 days and participating in spiritual gatherings were related to malaria infection status. RESULTS: A logistical regression model was used to investigate components associated with malaria infection. After adjusting several confounding factors, individuals who reported travelling away from their home village in the last 30 days OR 11.5 (95% CI 4.43-29.9), and those who attended a seasonal night spiritual gathering OR 3.04 (95% CI 1.10-8.42), involved in animal husbandry OR 2.52 (95% CI 1.10-5.82), and identified as male OR 4.57 (95% CI 1.43-14.7), were more likely to test positive for malaria infection. CONCLUSION: Human movement and livelihood activities, especially at nighttime, should be considered malaria risk factors in malaria elimination settings, mainly when the targeted area is limited to a confined borderland area.

Self-perceived health of older adults in Latin America and the Caribbean: a scoping review.

Objective: To systematically map the existing evidence on self-perceived health among adults aged 60 and older in Latin America and the Caribbean, describe the use of the single-item measure of self-perceived health with this population, and identify gaps in the existing literature. Methods: Following PRISMA Extension for Scoping Reviews guidelines, eight databases were searched for publications that were published between 2009 and 2019 and reported self-perceived health of adults over 60 years old in Latin America and the Caribbean. Data on study characteristics, sample characteristics, and the use and analysis of the self-perceived health measure were charted. Results: The database and secondary searches identified 516 articles. After removing duplicates and assessing titles and abstracts for inclusion, 263 full-text articles were assessed for eligibility using the inclusion criteria and an additional 89 articles were excluded. Ultimately, 174 articles were included in the scoping review. Studies included participants from 17 countries in the region, led in frequency by Brazil with 120 articles. The self-perceived health question most often included a five-category response scale (130), and response options were predominantly divided into two (86) or three (48) categories for analysis. Conclusions: Information on the health and social needs of people aged 60 and older across Latin America and the Caribbean, particularly their perceptions of health, is limited. We highlight the need to expand research throughout the region, include particularly vulnerable populations, utilize data from longitudinal and qualitative studies, and call for transparency in how questions and responses are worded and analyzed. This review serves to inform future studies, programs, and policies directed at this population.

"Todo se trata de a quién conoces": Social Networks and Drug Use Among Female Sex Workers Living with HIV in the Dominican Republic.

The purpose of this study was to characterize the social networks of female sex workers (FSWs) living with HIV in the Dominican Republic (DR) and to examine the association between daily drug use and network risk profile. The study employed a micro-longitudinal observational design using a 7-day mobile health (mHealth) daily diary to collect daily substance use behaviors and social network data was collected at study enrollment. A series of crude and adjusted modified log-Poisson repeated measures regression models with generalized estimating equations (GEE), clustering by individual with a compound symmetry working correlation structure were fit to estimate the relative risks and 95% confidence intervals. Controlling for individual level factors, findings revealed that FSWs with more network members who were drug users (≥ 3) and more network members who were sexual partners and also drugs users (≥ 2) were 8.89 (95% CI 2.62, 30.22) and 6.08 (95% CI 1.20, 30.92) times more likely to engage in daily drug use compared to women with small drug and sex and drug networks. Study findings demonstrate the role high risk networks have on risk behaviors. Results may be used to inform interventions that focus on modifying negative social ties, creating and/or improving existing positive support relationships, and integrating drug use harm reduction promotion within HIV treatment programs.

RESUMEN: El objetivo de este estudio era de caracterizar las redes sociales de las trabajadoras sexuales viviendo con VIH en la República Dominicana y examinar la asociación entre el uso diario de drogas y las características de la red de riesgo. El estudio utilizó un diseño observacional micro-longitudinal utilizando un diario móvil de 7 días para capturar los comportamientos diarios del uso de sustancias, y los datos de las redes sociales fue recolectado durante la inscripción al estudio. Una serie de modelos crudos y ajustados de regresión de log-Poisson con medidas repetidas y Ecuaciones de Estimación Generalizadas (EEG), agrupando por individuo con una estructura de correlación de simetría compuesta para estimar el riesgo relativo y los intervalos de confianza al 95%. Los hallazgos mostraron que las trabajadoras sexuales con mayor número de miembros de sus redes sociales que usaran drogas (>3) y parejas sexuales que usaran drogas (>2) fueron 8.89 (95% IC: 2.62, 30.33) y 6.08 (95% CI: 1.02, 30.92) veces más probables de participar en el consumo diario de drogas en comparación con las mujeres con pequeñas redes de consumo de drogas y sexo, controlando por factores a nivel individual. Los resultados del estudio demuestran el papel que las redes de alto riesgo tienen en los comportamientos de riesgo. Los resultados pueden ser utilizados para informar intervenciones que se enfoquen en el cambio de las relaciones negativas, creando o mejorando las relaciones de apoyo, e integrando la promoción de la reducción del uso de drogas dentro de los programas de tratamiento del VIH.

Participatory geographic mapping and activity space diaries: innovative data collection methods for understanding environmental risk exposures among female sex workers in a low-to middle-income country.

BACKGROUND: A common approach for measuring place-based exposure is to use geographically-defined administrative boundaries and to link neighborhood characteristics at this level. This approach, however, may not be feasible in low-to middle-income countries where neighborhood-level data are limited or unavailable, and administrative boundaries are often unstandardized and not proportional to population size. Furthermore, such traditional approaches may not be appropriate for marginalized populations whose environments can be more difficult to study. In this paper, we describe two innovative and feasible methods to generate geospatial data to characterize and assess the role of risk environments on drug use among female sex workers living with HIV in the Dominican Republic. METHODS: Participatory geographic mapping and daily activity space travel diaries were employed. RESULTS: The methods presented in this study were feasible to implement, acceptable by study participants, and yielded rich geospatial data to analyze the impact of contextual factors on risk behaviors of female sex workers in a low-to middle-income country. CONCLUSION: Participatory geographic mapping and activity space diaries are two alternative methods for collecting geospatial data among hard-to-reach populations in resource constrained settings. Moreover, the methods are interactive and educational, allowing study participants to take an active role in the data collection process and potentially allowing for a deeper understanding of place-based effects on health and behavior.

HIV Stigma, Mental Health, and Alcohol Use Disorders among People Living with HIV/AIDS in New Orleans.

Evidence suggests that HIV-related stigma is a contributing factor to mental health and substance use problems among people living with HIV (PLWH). Limited research, however, has examined the differential effects that multiple stigma constructs, specifically, anticipated, enacted, and internalized stigma may have on mental health and alcohol use disorders among PLWH. Furthermore, no studies have examined this relationship within the larger context of urban life stressors. The purpose of this study was to examine associations of an overall HIV-related stigma measure and four HIV stigma subscales on depression, anxiety, and hazardous drinking among a sample of 380 PLWH in New Orleans. Log-Poisson models with generalized estimating equations were used to estimate relative risks (RR) and 95% confidence intervals (CI). A test of interaction was used to determine presence of effect modification by urban life stressors. Overall, higher levels of HIV-stigma were associated with depressive symptoms (RR 1.67, 95% CI 1.25, 2.23), anxiety symptoms (RR 1.91, 95% CI 1.17, 3.12), and hazardous drinking (RR 1.45, 95% CI 1.02, 2.05). Internalized HIV-stigma (measured using the negative self-image subscale) was associated with all three outcomes and had the highest magnitude point estimates across the four stigma subscales. Urban life stressors, measured by the Urban Life Stressors Scale (ULSS), modified the association between HIV-related stigma and mental health and alcohol use disorders (P < 0.2), highlighting the importance for examining the larger urban environmental context. Findings from this study may inform interventions to reduce HIV-related stigma operating at the individual and structural level.

"Wherever doctors cannot reach, the sunshine can": overcoming potential barriers to malaria elimination interventions in Haiti.

BACKGROUND: Haiti and the Dominican Republic, the only two Caribbean countries with endemic malaria transmission, are committed to eliminating malaria. With a Plasmodium falciparum prevalence under 1% and a highly focal transmission, the efforts towards elimination in Haiti will include several community-based interventions that must be tailored to the local sociocultural context to increase their uptake. However, little is known about local community perceptions regarding malaria and the planned elimination interventions. The aim of this study is to develop a robust understanding of how to tailor, implement and promote malaria elimination strategies in Haiti. METHODS: A cross-sectional qualitative study was conducted December 2015-August 2016 in Grande-Anse and the North Department in Haiti. Data collection included key informant interviews (n = 51), in-depth interviews (n = 15) and focus group discussions (n = 14) with health workers, traditional healers, teachers, priests or pastors, informal community leaders, public officials, and community members. Following a grounded theory approach, transcripts were coded and analysed using content analysis. Coded text was sorted by the types of interventions under consideration by the malaria elimination programme. RESULTS: The level of knowledge about malaria was low. Many participants noted community beliefs about malaria being caused by magical phenomena in addition to vector-borne transmission. Participants described malaria as a problem rooted in the environment, with vector control the most noted method of prevention. Though participants noted malaria a severe disease, it ranked lower than other health problems perceived as more acute. Access barriers to healthcare were described including a lack of bed nets. Some distrust about pills, tests, and foreigners in general was expressed, and in few cases linked to previous experience with malaria campaigns under dictatorial regimes. CONCLUSIONS: There are several potential barriers and opportunities to implement community-based malaria elimination interventions in rural Haiti. Elimination efforts should include the collaboration of voodoo priests and other traditional healers, be coupled with solutions to wider community concerns or other health interventions, and learn from previous or similar programmes, such as the campaign to eliminate lymphatic filariasis. It is essential to engage with communities and gain their trust to successfully implement targeted aggressive elimination activities.

For data's sake: dilemmas in the measurement of gender minorities.

Gender-minority health disparity research is limited by binary gender measurement practices. This study seeks to broaden current discourse on gender identity measurement in the USA, including measurement adoption challenges and mitigation strategies, thereby allowing for better data collection to understand and address health disparities for people of all genders. Three data sources were used to triangulate findings: expert interviews with gender and sexuality research leaders; key-informant interviews with gender minorities in New Orleans, LA; and document analysis of relevant surveys, guides and commentaries. Ten key dilemmas were identified: 1) moving beyond binary gender construction; 2) conflation of gender, sex and sexual orientation; 3) emerging nature of gender-related language; 4) concerns about item sensitivity; 5) research fatigue among gender minorities; 6) design and analytical limitations; 7) categorical and procedural consistency; 8) pre-populated vs. open-field survey items; 9) potential misclassification; and 10) competing data collection needs. Researchers must continue working toward consensus concerning better practices is gender measurement and be explicit about their methodological choices. The existence of these dilemmas must not impede research on important health issues affecting gender minorities.

What Messages are Adolescent Voluntary Medical Male Circumcision (VMMC) Clients Getting and How? Findings From an Observational Study in Tanzania.

Uncircumcised adolescent males in sub-Saharan Africa are an important group to reach with voluntary medical male circumcision (VMMC) services due to high HIV burden occurring among this age group. Appropriateness of the content and delivery of sexual health and HIV prevention messages to adolescent VMMC clients has not been extensively described. A study was conducted in Tanzania to examine quality, delivery and content of messages provided to adolescent (aged 15-19) and adult (aged 20+) VMMC clients (n = 320). Results show that counseling of mixed age groups during group education lacked selected key messages, compared to more age-homogeneous groups. Additionally, adolescents received more comprehensive information in individual counseling compared to group education. We recommend that health care providers are provided with skills and job aides to assist them to segment VMMC clients by age; provide age-appropriate messages; and increase use of individual counseling as a means to communicate with adolescent clients.

Evidence of the negative effect of sexual minority stigma on HIV testing among MSM and transgender women in San Salvador, El Salvador.

A cross sectional survey was administered to 670 men who have sex with men (MSM) and transgender women (TW) in San Salvador through respondent driven sampling to identify determinants of ever testing for HIV using a minority stress framework. A positive association was found between ever testing and older age [adjusted odds ratio (aOR) 2.10], past experience of sexual assault (aOR 2.92), perceiving that most social acquaintances had tested (aOR 1.81), and knowing a PLHIV (aOR 1.94). A negative association was found between homelessness and ever testing (aOR 0.43). Among the MSM sub-sample (n = 506), similar results were found for older age (aOR 2.63), and past experience of sexual assault (aOR 2.56). Internalized homonegativity was negatively associated with ever testing for HIV among MSM (aOR 0.46), and HIV testing stigma and experienced provider discrimination further strengthened this relationship. It is important to mitigate sexual minority stigma in order to increase HIV testing among MSM. Future research should explore this construct among TW.

Binge Drinking among Men Who Have Sex with Men and Transgender Women in San Salvador: Correlates and Sexual Health Implications.

High rates of heavy alcohol use among men who have sex with men (MSM) and transgender women (TW) have been linked to increased vulnerability for HIV and poor mental health. While theories explaining elevated drinking levels among sexual minorities have been forwarded, few investigations have assessed the potential pathways using empirical data, particularly with an explicit focus on self-stigma and among MSM and TW in low- and middle-income countries. This study examined the relationship between stigma-related stress (specifically, self-stigma and concealment of one's sexual orientation) and binge drinking in a sample of MSM and TW (n = 670) in San Salvador, El Salvador, recruited using respondent-driven sampling. Levels of alcohol consumption among participants were high: only 39 % of the sample did not drink alcohol or did not binge drink, while 34 % engaged in binge drinking at least weekly. Among MSM, high self-stigma was associated with binge drinking at least weekly (adjusted relative risk ratio (aRRR) = 2.1, p < 0.05). No such relationship was found with less than weekly binge drinking. Among both MSM and TW, having a female partner was associated with binge drinking less than weekly (aRRR = 3.3, p < 0.05) and binge drinking at least weekly (aRRR = 3.4, p < 0.05), while disclosure of sexual orientation to multiple types of people was associated with binge drinking less than weekly (aRRR = 2.9 for disclosure to one-two types of people, p < 0.01; aRRR = 4.0 for disclosure to three-nine types of people, p < 0.01). No such relationship was found with at least weekly binge drinking. Binge drinking at least weekly was marginally associated with a number of sexual health outcomes, including high number of lifetime partners (adjusted odds ratio (aOR) = 1.7, p < 0.10), inconsistent condom use with a non-regular partner (aOR = 0.5, p < 0.10), and decreased intention to test for HIV in the next 12 months (aOR = 0.6, p < 0.10). With the exception of inconsistent condom use with a non-regular partner (aOR = 0.4, p < 0.05), binge drinking less than weekly was not associated with increased sexual risk behavior and was actually associated with increased intention to test for HIV in the next 12 months (aOR = 2.8, p < 0.01). These findings support multiple pathways linking stigma-related stress to alcohol use. Specifically, those with high self-stigma and identity concealment may be using alcohol as a maladaptive coping and emotion regulation strategy, while those who have disclosed their sexual orientation to multiple types of people may be more engaged with the sexual minority community, likely in bars and other venues where permissive norms for alcohol use prevail. That this frequency of binge drinking does not appear to be associated with increased sexual risk behavior (and may even be associated with increased intention to test for HIV in the next 12 months) lends further support to the suggestion that these individuals with healthy concepts of the self (as indicated by high levels of disclosure and low levels of risky sexual behavior) may engage in binge drinking because of the influence of the social environment. Further research is needed to establish the pathways linking stigma-related stress to heavy alcohol use so that points of intervention can be identified.

Evidence of increased STI/HIV-related risk behavior among male perpetrators of intimate partner violence in Guatemala: results from a national survey.

Intimate partner violence (IPV) is a significant public health problem with a demonstrated link to increased sexually transmitted infection (STI)/HIV-related risk and vulnerability. While IPV is an important issue in Central America, the link to STI/HIV risk has not been explored in this region. In this study, the relationship between emotional and physical/sexual IPV and the STI/HIV-related risk behaviors of sex worker patronage and infidelity is assessed among male IPV perpetrators using data from a national survey conducted in 2009 in Guatemala (n = 4773 married/partnered men). Bivariate associations between background characteristics and emotional and physical IPV perpetration were explored. Logistic regression models were run to test associations between IPV for each sexual risk behavior. Perpetration of emotional and physical/sexual IPV was more common among married/partnered men who were older than 24, had more education, lived in urban areas, or were in common law versus married unions. Reports of past-year emotional IPV perpetration increased as wealth quintile increased. After adjusting for demographics and other characteristics, physical/sexual IPV perpetration was associated with past-year infidelity (AOR 1.9, 95% CI: 1.1-3.6). Lifetime emotional IPV (AOR 1.4, 95% CI: 1.1-1.7) and physical/sexual IPV 1.6 (95% CI 1.2-2.0) were positively associated with a history of sex worker patronage. Endorsement of traditional gender role norms showed a marginally positive association with past-year infidelity in the adjusted model (AOR 1.3, 95% CI 1.0-1.8). The study findings from Guatemala reinforce the growing evidence globally that male IPV perpetrators are more likely to engage in risky sexual behavior, including sex worker patronage and main partner infidelity. The concurrency of violence and increased STI/HIV risk may compound the health risks for female victims of IPV who also face injury and psychological trauma. Integration of prevention and screening of IPV and STI/HIV prevention services should be adopted in Guatemala and other similar contexts.

Community end user perceptions of hessian fabric transfluthrin vapour emanators for protecting against mosquitoes under conditions of routine use in Port-au-Prince, Haiti.

BACKGROUND: A treated fabric device for emanating the volatile pyrethroid transfluthrin was recently developed in Tanzania that protected against night-biting Anopheles and Culex mosquitoes for several months. Here perceptions of community end users provided with such transfluthrin emanators, primarily intended to protect them against day-active Aedes vectors of human arboviruses that often attack people outdoors, were assessed in Port-au-Prince, Haiti. METHODS: Following the distribution of transfluthrin emanators to participating households in poor-to-middle class urban neighbourhoods, questionnaire surveys and in-depth interviews of end-user households were supplemented with conventional and Photovoice-based focus group discussions. Observations were assessed synthetically to evaluate user perceptions of protection and acceptability, and to solicit advice for improving and promoting them in the future. RESULTS: Many participants viewed emanators positively and several outlined various advantages over current alternatives, although some expressed concerns about smell, health hazards, bulkiness, unattractiveness and future cost. Most participants expressed moderate to high satisfaction with protection against mosquitoes, especially indoors. Protection against other arthropod pests was also commonly reported, although satisfaction levels were highly variable. Diverse use practices were reported, some of which probably targeted nocturnal Culex resting indoors, rather than Aedes attacking them outdoors during daylight hours. Perceived durability of protection varied: While many participants noted some slow loss over months, others noted rapid decline within days. A few participants specifically attributed efficacy loss to outdoor use and exposure to wind or moisture. Many expressed stringent expectations of satisfactory protection levels, with even a single mosquito bite considered unsatisfactory. Some participants considered emanators superior to fans, bedsheets, sprays and coils, but it is concerning that several preferred them to bed nets and consequently stopped using the latter. CONCLUSIONS: The perspectives shared by Haitian end-users are consistent with those from similar studies in Brazil and recent epidemiological evidence from Peru that other transfluthrin emanator products can protect against arbovirus infection. While these encouraging sociological observations contrast starkly with evidence of essentially negligible effects upon Aedes landing rates from parallel entomological assessments across Haiti, Tanzania, Brazil and Peru, no other reason to doubt the generally encouraging views expressed herein by Haitian end users could be identified.

High levels of unprotected anal intercourse and never testing for HIV among men who have sex with men in Nigeria: evidence from a cross-sectional survey for the need for innovative approaches to HIV prevention.

OBJECTIVES: To describe sexual risk behaviour, correlates of unprotected anal intercourse (UAI) and never testing for HIV and its implications for HIV prevention interventions among men who have sex with men (MSM) in Nigeria and other similar contexts. METHODS: A cross-sectional survey was administered to 712 MSM in Abuja, Ibadan and Lagos, recruited through respondent-driven sampling (RDS). Levels of sexual risk behaviour and never having tested for HIV prior to the survey were calculated using weighted data for each city and unweighted data for the pooled sample. Correlates of UAI and never testing for HIV were determined using multiple logistic regression. RESULTS: The risk for HIV and STI among MSM in Nigeria is high, with 43.4% reporting UAI at last sex, 45.1% never having been tested for HIV and 53.9% reporting exchange of sex for resources in the past 6 months. Correlates of UAI in multivariate analysis included living in Ibadan, marriage or cohabitation with a woman, identification as bisexual, not having tested for HIV and being HIV-positive. Correlates of not having tested for HIV in multivariate analysis included living in Ibadan, young age, less education, unemployment and report of UAI. CONCLUSIONS: HIV testing is low and associated with UAI. Findings merit targeted and innovative approaches for HIV prevention for MSM, especially access to HIV self-testing. Attention to social and structural determinants of health-seeking and sexual risk behaviour is also needed, including the criminalisation of homosexuality and social marginalisation of MSM.

A Qualitative Assessment of Social Norms Related to Seeking Help for Intimate Partner Violence in Honduras.

Intimate partner violence (IPV) is a major public health issue in Honduras and other low- and middle-income countries, with few victims seeking help. While structural factors, such as lack of services and economic barriers, are often cited as reasons for not seeking help, social and cultural factors may also play a role. This study aims to describe the normative social environment that may hinder women's help-seeking behaviors for IPV. Thematic analysis was conducted on data from four focus group discussions with 30 women at a busy health center in urban Tegucigalpa, Honduras. Data were coded inductively and themes were identified deductively using the theory of normative social behavior and its components (descriptive and injunctive social norms, expected outcomes, and groups of reference). Four themes emerged: social norms and expected outcomes that discourage IPV help-seeking; factors that determine the direction of a social norm, either discouraging or encouraging help-seeking; groups of reference for IPV victims; and society sets women up for failure. Social norms, expected outcomes, and groups of reference hinder women's help-seeking behavior after IPV. These findings have significant implications for designing effective interventions and policies to support women and their families affected by IPV.

Disclosure of HIV status to sex partners among HIV-infected men and women in Cape Town, South Africa.

This study examines factors influencing HIV sero-status disclosure to sex partners among a sample of 630 HIV-infected men and women with recent sexual contact attending anti-retroviral therapy (ART) clinics in Cape Town, South Africa, with a focus on sex partner type, HIV-related stigma, and ART as potential correlates. About 20% of the sample had not disclosed their HIV status to their most recent sex partners. HIV disclosure to sex partner was more likely among participants who had a steady sex partner [Adjusted odds ratio (AOR) = 2.7; 95% CI: 1.6-4.6], had a partner with known-HIV status [AOR = 7.8; 95% CI: 3.2-18.7]; perceived less stigma [AOR = 1.9; 95% CI: 1.2-2.9]; and were on ART [AOR = 1.6; 95% CI: 1.1-2.3]. Stratified analyses by the type of sex partner further reveals that stigma and ART were significantly associated with HIV disclosure within steady relationships but were not significant correlates of HIV disclosure with casual sex partners. The findings support a positive prevention strategy that emphasizes increased access to ART, and behavioral interventions to reduce casual sex partnerships for persons who are HIV-positive. Mitigating the influence of HIV stigma on HIV status disclosure particularly within steady sex partnerships is also important and may be accomplished through individual and couple counseling.

HIV and incarceration in the Caribbean: the experiences of Puerto Rico and Jamaica.

Worldwide, HIV has disproportionally affected incarcerated populations since early in the epidemic. Current trends in the Caribbean demonstrate that correctional facilities house most at-risk individuals. The experience of incarceration and the HIV epidemic in the Caribbean are as diverse as the region. In this paper we present descriptive information from Puerto Rico and Jamaica as two unique examples of current efforts to address HIV among prisoners. While different, these countries provide a comparison of correctional health care in a sexually driven epidemic versus one where injecting drug use plays a major role, bridging cultural differences, and contrasting approaches in the provision of HIV services relevant for other Caribbean countries. While the evidence of effective interventions within correctional facilities in the Caribbean is limited, the knowledge gained through the services implemented and research completed in different countries can facilitate the process of developing and testing new interventions. The experience of these islands and coordinating lessons learned and innovations from throughout the region can assist in developing a resourceful way forward.

Homophobia, stigma and HIV in Jamaican prisons.

Success in addressing HIV and AIDS among men who have sex with men, a key population in the global epidemic, is impeded by homophobia. Homophobia as a barrier to HIV prevention and AIDS treatment is a particularly acute problem in the prison setting. In this qualitative study, we explore HIV and AIDS, stigma and homosexuality in the largest all male prison in Jamaica by conducting iterative in-depth interviews with 25 inmates. Participant narratives unveil a purposeful manipulation of beliefs related to homosexuality that impedes an effective response to HIV and AIDS both in prison and wider society. Findings indicate that homophobia is both a social construction and a tangible tool used to leverage power and a sense of solidarity in a larger political and economic landscape. This use of homophobia may not be unique to Jamaica and is an important issue to address in other low- and middle-income post-colonialist societies.

Intersecting Stigmas among HIV-Positive People Who Inject Drugs in Vietnam.

HIV-related stigma remains a barrier to ART adherence among people living with HIV (PLWH) globally. People who inject drugs (PWID) may face additional stigma related to their behavior or identity; yet, there is little understanding of how these stigmas may co-exist and interact among these key populations. This study aims to explore the existence of multiple dimensions of HIV-related stigma, and how they may intersect with stigma related to drug injection. The study took place in Vietnam, where the HIV epidemic is concentrated among 3 key population groups; of those, PWID account for 41% of PLWH. The vast majority (95%) of PWID in Vietnam are male. Data came from in-depth interviews with 30 male PWID recruited from outpatient clinics, where they had been receiving ART medications. Deductive, thematic analysis was employed to organize stigma around the 3 dimensions: enacted, anticipated, and internalized stigma. Findings showed that HIV- and drug use-related stigma remained high among participants. All 3 stigma dimensions were prevalent and perceived to come from different sources: family, community, and health workers. Stigmas related to HIV and drug injection intersected among these individuals, and such intersection varied widely across types of stigma. The study revealed nuanced perceptions of stigma among this marginalized population. It is important for future studies to further investigate the influence of each dimension of stigma, and their interactive effects on HIV and behavioral outcomes among PWID.

Daily activity spaces and drug use among female sex workers living with HIV in the Dominican Republic.

The purpose of this study was to explore the daily activity spaces of female sex workers living with HIV in the Dominican Republic and assess the relationship between activity path and location-based risk exposure measures and daily drug use. The study employed a micro-longitudinal observational study design using an innovative 7-day travel diary to capture daily activity routes and a 7-day mobile health (mHealth) daily diary to collect daily substance use behaviors among 51 female sex workers. To estimate between-subject variability, a series of crude and adjusted modified log-Poisson repeated measures regression models with generalized estimating equations, clustering by individual with a compound symmetry working correlation structure were fit to estimate the relative risks and 95% confidence intervals. Controlling for individual level factors, findings showed that female sex workers exposed to a higher number of risk outlets (e.g., liquor stores, bars, hotels, nightclubs, brothels, etc.) within 200 and 100-meters of sex work locations were at an increased risk of daily drug use (RRadj: 1.03, 95%CI: 1.01, 1.05, RRadj: 1.05, 95%CI: 1.01, 1.09). No association was detected between activity path exposure and daily drug use. These findings illustrate the importance of moving beyond static residential neighborhood boundaries for measuring risk exposures and highlight the significant role that daily work environments have on drug harms among a highly stigmatized and vulnerable population.

HIV coping self-efficacy: a key to understanding stigma and HIV test acceptance among incarcerated men in Jamaica.

Although prisons have been noted as important venues for HIV testing, few studies have explored the factors within this context that may influence HIV test acceptance. Moreover, there is a dearth of research related to HIV and incarcerated populations in middle and low-income countries, where both the burden of HIV and the number of people incarcerated is higher compared to high-income countries. This study explores the relationship between HIV coping self-efficacy, HIV-related stigma, and HIV test acceptance in the largest prisons in Jamaica. A random sample of inmates (n=298) recruited from an HIV testing demonstration project were asked to complete a cross-sectional quantitative survey. Participants who reported high HIV coping self-efficacy (adjusted odds ratio (AOR) 1.86: 95% confidence interval CI 1.24-2.78, p-value=0.003), some perceived risk of HIV (AOR 2.51: 95% (CI) 1.57-4.01, p-value=0.000), and low HIV testing stigma (AOR 1.71: 95% CI 1.05-2.79, p-value=0.032) were more likely to test for HIV. Correlates of HIV coping self-efficacy included external and internal HIV stigma (AOR 1.28: 95% CI 1.25-1.32, p-value=0.000 and AOR 1.76: 95% CI 1.34-2.30, p-value=0.000, respectively), social support (AOR 2.09: 95% CI 1.19-3.68, p-value=0.010), and HIV knowledge (AOR 2.33: 95% CI 1.04-5.22, p-value=0.040). Policy and programs should focus on the interrelationships of these constructs to increase participation in HIV testing in prison.