A realist evaluation of the continuum of HIV services for men who have sex with men.

BACKGROUND: Men who have Sex with Men (MSM) represent the risk group that are disproportionately most affected by the human immunodeficiency virus (HIV) and continue to drop-off from the steps of the continuum of HIV services that have been adopted to overcome poor engagement and retention in care. This realist evaluation aimed at: (1) describing the evaluation carried out in Haiti aiming to ascertain why, how and under which circumstances MSM are linked and retained along the continuum, (2) assessing the outcomes of this approach and (3) exploring the motivators and facilitators for the HIV continuum of services through mechanisms and pathways. METHODS: Guided by a realist approach, first, an initial program theory (IPT) was developed based on literature and frameworks review, participant observations and discussions with stakeholders. Then, the IPT was tested using a mixed method explanatory study: a quantitative phase to build the continuum from a cross-sectional analysis, and a qualitative phase to explore the motivators and facilitators related to proper linkages along the continuum. Finally, the IPT was refined by eliciting the mechanisms and pathways for outcomes improvement. RESULTS: The results showed that the current service delivery model is suboptimal in identifying, engaging, linking and retaining MSM, resulting in loss to follow-up at every step of the continuum and failure to fully realize the health and prevention benefits of antiretroviral. However, the mechanisms through which linkages across the continuum can be improved are: self-acceptance, sense of community support and sense of comprehensive and tailored HIV services. These mechanisms are based on 10 different pathways: self-esteem, awareness and pride, perception of HIV risk, pcceptance and HIV status, addressing community stigma, strengthening of MSM organizations and community networks, societal acceptation and tolerance, stigma reduction training for healthcare providers, engagement of peers as educators and navigators and, adapted services delivery through drug dispensing points and mobile technology and financial assistance. CONCLUSIONS: The study findings show that engagement, adherence and retention to the continuum of HIV service for MSM are affected by a multi-layer of factors, thus highlighting the importance of taking a comprehensive approach to improve the program.

Risk factors for vaginal fistula symptoms in Sub-Saharan Africa: a pooled analysis of national household survey data.

BACKGROUND: Vaginal fistula (VF) is one of the most severe maternal morbidities with the immediate consequence of chronic urinary and/or fecal incontinence. The epidemiological evidence regarding risk factors for VF is dominated by facility-based studies. Our aim is to estimate the effect size of selected risk factors for VF using population-based survey data. METHODS: We pooled all available Demographic and Health Surveys and Multiple Indicators Cluster Surveys carried out in sub-Saharan Africa that collected information on VF symptoms. Bayesian matched logistic regression models that accounted for the imperfect sensitivity and specificity of self-reports of VF symptoms were used for effect size estimation. RESULTS: Up to 27 surveys were pooled, including responses from 332,889 women. Being able to read decreased the odds of VF by 13% (95% Credible Intervals (CrI): 1% to 23%), while higher odds of VF symptoms were observed for women of short stature (<150 cm) (Odds Ratio (OR) = 1.31; 95% CrI: 1.02-1.68), those that had experienced intimate partner sexual violence (OR = 2.13; 95% CrI: 1.60-2.86), those that reported sexual debut before the age of 14 (OR = 1.41; 95% CrI: 1.16-1.71), and those that reported a first birth before the age of 14 (OR = 1.39; 95% CrI: 1.04-1.82). The effect of post-primary education, female genital mutilation, and having problems obtaining permission to seek health care were not statistically significant. CONCLUSIONS: Increasing literacy, delaying age at first sex/birth, and preventing sexual violence could contribute to the elimination of obstetric fistula. Concomitant improvements in access to quality sexual and reproductive healthcare are, however, required to end fistula in sub-Saharan Africa.

Obstetric Fistula "Disease" and Ensuing Care: Patients' Views in West-Africa.

We explored obstetric fistula patients' real-life experience of care in modern Health System. Our aim was to analyze how these women's views impacted their care uptake and coping. We conducted 67 in-depth interviews with 35 fistula patients or former patients in 5 fistula repair centers within referral hospitals in Mali and Niger. Perceptions of obstetric fistula influenced the care experience and vice versa. Obstetric fistula was viewed as a severe chronic disease due to length of care process, limitation of surgery and persisting physical and moral suffering. We highlight the opportunity to build on patients' views on obstetric fistula trauma and care in order to implement an effective holistic care process.

Medico-social pathways of obstetric fistula patients in Mali and Niger: an 18-month cohort follow-up.

OBJECTIVES: To gain understanding of care pathways and induced mobility patterns of obstetric fistula patients in French-speaking West African fistula repair centres. METHODS: We followed prospectively during 18 months a cohort of obstetric fistula patients in Mali and Niger (2008-2009). 120 patients were recruited at different stages of their care process in 5 reference fistula repair centres. Follow-up was carried out in repair centres and communities. Quantitative data were collected through close-ended questionnaires at three time points. Medico-social pathways were explored through a longitudinal analysis focusing on six indicators: fistula duration, care process duration, patients' mobility, marital status, number of surgeries and continence status. RESULTS: Patients' pathways were characterised by their length: fistula duration (median 4 years), care process duration (median 2.7 years), aggregated time spent in repair centres during study (median 7 months). Patients developed four mobility patterns (homebound, itinerant, institutionalised and urbanised). Adverse marital status change continued over time. Sample stratification according to number of previous surgeries revealed differences in care process duration and outcome: 23/31 new cases (≤1 surgery) gained continence with a mean of 1.5 surgeries in a median of 0.6 year while only 17/78 old cases (≥2 surgeries) became continent with a mean of 4 surgeries in a median time of 4.9 years. CONCLUSION: The quest for continence does not end with admission to a fistula repair centre. Analysing fistula care experience across time within the varying settings highlights the twofold population and mixed medico-social outcomes that should prompt new development in obstetric fistula care management and research.

A realist systematic review of stigma reduction interventions for HIV prevention and care continuum outcomes among men who have sex with men.

While stigma associated with human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) is well recognized, there remains relatively limited intervention data on effective stigma reduction strategies. This systematic review was conducted to highlight the mechanisms through which sexual and HIV stigma is reduced in relation to HIV prevention and care engagement. Search of PubMed and Scopus resulted in 11 tested interventions to include in our preliminary model constructed from programme frameworks and recommendations. We refined the preliminary programme theory to identify whether, why, or how mitigation strategies produce observed outcomes. Our review showed that the interventions produced stigma reduction through three groups of mechanisms: (1) Self-acceptance, leadership, and motivational activation for behaviour change from intrapersonal strategies, such as education and mobile health strategies, which intervene on internalized and anticipated stigma; (2) socialization, knowledge sharing, and social empowerment from interpersonal strategies, such as peer support and training for care providers; and (3) community introspection, self-reflection, and humanistic activation from structural strategies such as community leaders' sensitization, which intervene on both anticipated and enacted stigma. Interventions mechanisms act complementarily and can be activated in different contexts in which MSM exposed to and infected with HIV are living.

Prevalence of symptoms of vaginal fistula in 19 sub-Saharan Africa countries: a meta-analysis of national household survey data.

BACKGROUND: Vaginal fistula is a serious medical disorder characterised by an abnormal opening between the vagina and the bladder or rectum, which results in continuous leakage of urine or stool. The burden of this disorder in sub-Saharan Africa is uncertain. We estimated the lifetime and point prevalence of symptoms of vaginal fistula in this region using national household surveys based on self-report of symptoms. METHODS: We considered all Demographic and Health Surveys (DHS) and Multiple Indicators Cluster Surveys (MICS) from sub-Saharan Africa and included data for women of reproductive age (15-49 years). We estimated lifetime prevalence and point prevalence of vaginal fistula with use of Bayesian hierarchical meta-analysis. FINDINGS: We included 19 surveys in our analysis, including 262,100 respondents. Lifetime prevalence was 3.0 cases (95% credible interval 1.3-5.5) per 1000 women of reproductive age. After imputation of missing data, point prevalence was 1.0 case (0.3-2.4) per 1000 women of reproductive age. Ethiopia had the largest number of women who presently have symptoms of vaginal fistula. INTERPRETATION: This study is the first to estimate the burden of vaginal fistula in 19 sub-Saharan Africa countries using nationally representative survey data. Point prevalence was slightly lower than previously estimated but these earlier estimates are within the prevalence's credible intervals. Although vaginal fistula is relatively rare, it is still too common in sub-Saharan Africa. FUNDING: None.