Reducing Partner Violence Against Women who Exchange Sex and use Drugs through a Combination Microfinance and HIV Risk Reduction Intervention: A Cluster Randomized Trial.

Women who exchange sex and use drugs (WESUD) are at high risk for HIV infection and partner violence. The few tested interventions at the intersection of HIV and IPV show mixed results. This analysis examined the impact of a combination HIV risk reduction (HIVRR) and microfinance (MF) intervention on reported paying and intimate partner violence against WESUD in Kazakhstan. This cluster randomized controlled trial enrolled 354 women from 2015 to 2018 and randomized them to either a combination of HIVRR and MF intervention or HIVRR alone. Outcomes were assessed at four time points over 15 months. Logistic regression within a Bayesian approach assessed change in odds ratio (OR) of recent physical, psychological, or sexual violence perpetrated by current or past intimate partners; and paying partners/clients by study arm over time. Compared to the control arm, the combination intervention decreased the odds of participants experiencing physical violence from past intimate partners by 14% (OR = 0.861, p = 0.049). Women in the intervention group reported significantly lower rates of sexual violence from paying partners (HIVRR + MF - HIVRR: 25.9%; OR = 0.741, p = 0.019) at 12-month follow-up. No significant differences in rates from current intimate partners were found. A combination HIVRR and microfinance intervention may reduce gender-based violence from paying and intimate partners among WESUD above and beyond HIVRR interventions alone. Future research should examine how microfinance reduces partner violence and how to implement combination interventions in diverse settings.

RESUMEN: Las mujeres que intercambian sexo y consumen drogas (WESUD) tienen un alto riesgo de infección por VIH y violencia por parte de sus parejas. Las pocas intervenciones que se han probado en la intersección del VIH y la violencia de pareja muestran resultados mixtos. Este ensayo controlado aleatorio por grupos inscribió a 354 mujeres de 2015 a 2018 y las asignó al azar a una intervención combinada de HIVRR y MF o HIVRR sola. Los resultados se evaluaron en 4 puntos temporales durante 15 meses. La regresión logística dentro de un enfoque bayesiano evaluó el cambio en la violencia reciente perpetrada por las parejas que pagan y/o las parejas y ex-parejas (p.ej. esposos, novios) por brazo de estudio, a través del tiempo. En comparación con el grupo de control, la intervención combinada disminuyó las probabilidades de que los participantes sufrieran violencia física por parte de sus parejas íntimas anteriores en un 14% (OR = 0,861, p = 0,049). Las mujeres en el grupo de intervención informaron tasas significativamente más bajas de violencia sexual por parte de parejas que pagan (HIVRR + MF - HIVRR: 25,9%; OR = 0,741, p = 0,019) a los 12 meses de seguimiento. No se encontraron diferencias significativas en las tasas de parejas íntimas actuales. La combinación de HIVRR y microfinanzas puede ofrecer mayores reducciones en la violencia de las parejas que pagan y las ex-parejas en esta población.

Reproductive justice in the time of COVID-19: a systematic review of the indirect impacts of COVID-19 on sexual and reproductive health.

OBJECTIVE: Despite gendered dimensions of COVID-19 becoming increasingly apparent, the impact of COVID-19 and other respiratory epidemics on women and girls' sexual and reproductive health (SRH) have yet to be synthesized. This review uses a reproductive justice framework to systematically review empirical evidence of the indirect impacts of respiratory epidemics on SRH. METHODS: We searched MEDLINE and CINAHL for original, peer-reviewed articles related to respiratory epidemics and women and girls' SRH through May 31, 2021. Studies focusing on various SRH outcomes were included, however those exclusively examining pregnancy, perinatal-related outcomes, and gender-based violence were excluded due to previously published systematic reviews on these topics. The review consisted of title and abstract screening, full-text screening, and data abstraction. RESULTS: Twenty-four studies met all eligibility criteria. These studies emphasized that COVID-19 resulted in service disruptions that effected access to abortion, contraceptives, HIV/STI testing, and changes in sexual behaviors, menstruation, and pregnancy intentions. CONCLUSIONS: These findings highlight the need to enact policies that ensure equitable, timely access to quality SRH services for women and girls, despite quarantine and distancing policies. Research gaps include understanding how COVID-19 disruptions in SRH service provision, access and/or utilization have impacted underserved populations and those with intersectional identities, who faced SRH inequities notwithstanding an epidemic. More robust research is also needed to understand the indirect impact of COVID-19 and epidemic control measures on a wider range of SRH outcomes (e.g., menstrual disorders, fertility services, gynecologic oncology) in the long-term.

The impact of respiratory epidemics, like COVID-19 on women and girls' sexual and reproductive health (SRH) is not yet known. This review applies a reproductive justice framework, to systematically review the impact of respiratory epidemics on SRH, in order to examine the impact of COVID-19 on equitable, sustained access to quality SRH services for all populations. This framework highlights the right to reproductive autonomy, including the right to have an abortion, conceive, bear and raise children; and is inclusive of the intersectionality of race, class and gender. This review includes original, peer-reviewed research related to COVID-19 and women and girls' SRH through May 31, 2021, and consisted of title and abstract screening, full-text screening, and data abstraction. Overall, twenty-four studies met eligibility criteria. Results emphasize that the COVID-19 pandemic resulted in service disruptions that effected access to abortion, contraceptives, HIV/STI testing, and changes in changes in sexual behaviors, menstruation, and pregnancy intentions. These findings highlight the urgent need to enact policies that ensure equitable, timely access to quality SRH services for women and girls, despite pandemic response policies. This review also highlights opportunities to better understand how COVID-19 related disruptions in SRH service provision, access and/or utilization have impacted underserved populations and those with intersectional identities, who faced SRH inequities prior to the COVID-19 pandemic. More research is needed to understand the indirect impact of COVID-19 and epidemic control measures on a wider range of SRH outcomes (e.g., menstrual disorders, fertility services, gynecologic oncology) in the long-term.

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan.

BACKGROUND: Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic. METHODS: Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively. RESULTS: Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28-2.71; aIRRsexual: 2.28, 1.56-3.35]; [client violence: aIRRphysical: 2.20, 1.44-3.42; aIRRsexual: 2.54, 1.72-3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41-4.03; aIRRsexual: 2.16, 1.35-3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence. CONCLUSION: HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction.

Intertwined epidemics: progress, gaps, and opportunities to address intimate partner violence and HIV among key populations of women.

The intersection of intimate partner violence and HIV is a public health problem, particularly among key populations of women, including female sex workers, women who use drugs, and transgender women, and adolescent girls and young women (aged 15-24 years). Intimate partner violence results in greater risk of HIV acquisition and creates barriers to HIV prevention, testing, treatment, and care for key populations of women. Socioecological models can be used to explain the unique multilevel mechanisms linking intimate partner violence and HIV. Few interventions, modelling studies, and economic evaluations that concurrently address both intimate partner violence and HIV exist, with no interventions tailored for transgender populations. Most combination interventions target individual-level risk factors, and rarely consider community or structural factors, or evaluate cost-efficacy. Addressing intimate partner violence is crucial to ending the HIV epidemic; this Review highlights the gaps and opportunities for future research to address the intertwined epidemics of intimate partner violence and HIV among key populations of women.

Human-Centered Design for Public Health Innovation: Codesigning a Multicomponent Intervention to Support Youth Across the HIV Care Continuum in Mozambique.

Adolescents and young people represent a growing proportion of people living with HIV (AYAHIV), and there is an urgent need to design, implement, and test interventions that retain AYAHIV in care. Using a human-centered design (HCD) approach, we codesigned CombinADO, an intervention to promote HIV viral suppression and improve antiretroviral therapy (ART) adherence and retention in care among AYAHIV in Nampula, Mozambique. The HCD process involves formative design research with AYAHIV, health care providers, parents/caretakers, and experts in adolescent HIV; synthesis of findings to generate action-oriented insights; ideation and prototyping of intervention components; and a pilot study to assess feasibility, acceptability, and uptake of intervention components.CombinADO promotes ART adherence and retention in care by fostering peer connectedness and belonging, providing accessible medical knowledge, demystifying and destigmatizing HIV, and cultivating a sense of hope among AYAHIV. Successful prototypes included a media campaign to reduce HIV stigma and increase medical literacy; a toolkit to help providers communicate and address the unique needs of AYAHIV clients; peer-support groups to improve medical literacy, empower youth, and provide positive role models for people living with HIV; support groups for parents/caregivers; and discreet pill containers to promote adherence outside the home. In the next phase, the effectiveness of CombinaADO on retention in care, ART adherence, and viral suppression will be evaluated using a cluster-randomized control trial.We demonstrate the utility of using HCD to cocreate a multicomponent intervention to retain AYAHIV in care. We also discuss how the HCD methodology enriches participatory methods and community engagement. This is then illustrated by the youth-driven intervention development of CombinADO by fostering youth empowerment, addressing power imbalances between youth and adult stakeholders, and ensuring that language and content remain adolescent friendly.

Social and structural determinants of health associated with police violence victimization: A latent class analysis of female sex workers who use drugs in Kazakhstan.

INTRODUCTION: Punitive legal environments remain a challenge to HIV prevention efforts in Central Asia, and female sex workers who use drugs are vulnerable to police violence. Little is known about the heterogeneity of police violence against female sex workers who use drugs and factors associated with HIV risk in Central Asia, despite the growing HIV epidemic. METHODS: We recruited a community-based sample of 255 female sex workers who use drugs in Almaty, Kazakhstan between February 2015 and May 2017. We used latent class analysis to differentiate women into distinct classes of police violence victimization, and multinomial logistic regression to identify individual-level health outcomes, HIV risk behaviors, and social and structural factors within the risk environment associated with class membership. RESULTS: A three-class model emerged: Low Victimization (51%), Discrimination and Extortion (15%), and Poly-Victimization (34%). Relative to Low Victimization, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR: 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (2.73 (1.15, 6.50)), injection drug use (IDU) (2.00 (1.12, 3.58)), greater number of unsafe IDU behaviors (1.21 (1.08, 1.35)), homelessness (1.92 (1.06, 3.48)), greater drug use (1.22 (1.07, 1.39)) and sex work stigma (1.23 (1.06, 1.43)), greater number of sex work clients (2.40 (1.33, 4.31)), working for a boss/pimp (2.74 (1.16, 6.50)), client violence (2.99 (1.65, 5.42)), economic incentives for condomless sex (2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (3.47 (1.42, 8.50)), recent arrest (2.99 (1.36, 6.55)) and detention (2.93 (1.62, 5.30)), and negative police perceptions (8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics. CONCLUSION: Police violence against female sex workers who use drugs is pervasive in Kazakhstan. Patterns of police violence vary, with greater HIV susceptibility associated with a higher probability of experiencing multiple forms of police violence. Police sensitization workshops that integrate policing and harm reduction, and drug policy reforms that decriminalize drug use may help mitigate the HIV epidemic in Kazakhstan.

Using community engagement to implement evidence-based practices for opioid use disorder: A data-driven paradigm & systems science approach.

Community-driven responses are essential to ensure the adoption, reach and sustainability of evidence-based practices (EBPs) to prevent new cases of opioid use disorder (OUD) and reduce fatal and non-fatal overdoses. Most organizational approaches for selecting and implementing EBPs remain top-down and individually oriented without community engagement (CE). Moreover, few CE approaches have leveraged systems science to integrate community resources, values and priorities. This paper provides a novel CE paradigm that utilizes a data-driven and systems science approach; describes the composition, functions, and roles of researchers in CE; discusses unique ethical considerations that are particularly salient to CE research; and provides a description of how systems science and data-driven approaches to CE may be employed to select a range of EBPs that collectively address community needs. Finally, we conclude with scientific recommendations for the use of CE in research. Greater investment in CE research is needed to ensure contextual, equitable, and sustainable access to EBPs, such as medications for OUD (MOUD) in communities heavily impacted by the opioid epidemic. A data-driven approach to CE research guided by systems science has the potential to ensure adequate saturation and sustainability of EBPs that could significantly reduce opioid overdose and health inequities across the US.

Association of Violence Against Female Sex Workers Who Use Drugs With Nonfatal Drug Overdose in Kazakhstan.

Importance: Female sex workers (FSWs) who use drugs face increased risk of intimate partner violence (IPV) and nonpartner violence (NPV). The association between violence and drug overdose is unknown. Objective: To examine the association between IPV, NPV, and nonfatal drug overdose among FSWs who use drugs in Kazakhstan. Design, Setting, and Participants: This cross-sectional study included 400 adult FSWs in Kazakhstan who reported illicit drug use in the past year, exchanged sex for money or drugs, and reported having unprotected sex in the past 90 days. Baseline data were collected from February 2015 to May 2017 from Project Nova, an HIV prevention study among FSWs who use drugs in Kazakhstan. Data analysis was conducted from April 2019 to March 2020. Exposures: Lifetime and recent (past 90 day) experiences of physical, sexual, and psychological IPV and NPV using the Revised Conflict Tactics Scale. Subtypes of violence were identified using exploratory factor analysis. Main Outcomes and Measures: Lifetime and recent incidence of nonfatal overdose; sociodemographic characteristics as well as lifetime and recent sex work and drug use behaviors were also collected. Results: The 400 participants had a mean (SD) age of 34.1 (8.4) years. Most experienced food insecurity (358 [89.5%]) and homelessness (232 [58.0%]) in the past 90 days; one-third (130 [32.5%]) reported a history of incarceration. Most (359 [89.7%]) experienced some form of violence; 150 (37.5%) reported a lifetime nonfatal overdose, of whom 27 (18.0%) reported nonfatal overdose in the past 90 days. Lifetime severe physical violence (adjusted odds ratio [aOR], 1.27; 95% CI, 1.02-1.59; P = .03), engagement in sex work for more than 10 years (aOR, 2.54; 95% CI, 1.50-4.28; P < .001), and a history of incarceration (aOR, 4.34; 95% CI, 2.58-7.32; P < .001) were associated with greater odds of nonfatal overdose. Engaging in sex work for more than 10 years (aOR, 3.97; 95% CI, 1.36-11.61; P = .01) and a history of incarceration (aOR, 3.63; 95% CI, 1.39-9.48; P = .008) were associated with greater odds of recent nonfatal overdose. Conclusions and Relevance: In this study, violence against FSWs who use drugs in Kazakhstan was associated with increased odds of nonfatal overdose. Harm reduction programs for women should consider including services to address gender-based violence and the needs of women after incarceration.

Determinants of alcohol use among people living with HIV initiating isoniazid preventive therapy in Ethiopia.

BACKGROUND: Hepatotoxicity, an adverse effect of isoniazid preventative therapy (IPT), is exacerbated by alcohol consumption. Although the WHO recommends IPT for people living with HIV (PLHIV), it is contraindicated in regular alcohol users. The objective of this study was to identify the prevalence and determinants of alcohol use among PLHIV initiating IPT in Ethiopia. METHODS: Baseline data (July 2013-May 2015) from 316 participants in the Enhance Initiation and Retention in IPT Care for HIV (ENRICH) study were used to assess the prevalence of alcohol use. Multinomial logistic regression was used to identify determinants of non-hazardous and hazardous alcohol use, compared to no alcohol use. RESULTS: Overall, 41.8% of participants reported alcohol use, of which 45.5% reported hazardous use. Compared to non-alcohol users, hazardous users were younger (adjusted odds ratio [AOR]: 1.06; 95% confidence interval [95% CI]: 1.02, 1.11), more likely to be male (AOR: 6.40; 95% CI: 3.17, 12.93), Orthodox (AOR: 3.96; 95% CI: 1.74, 9.00), have larger support networks (AOR: 3.82; 95% CI: 1.61, 9.06), and report greater amount (AOR: 14.80; 95% CI: 5.76, 38.02) and frequency (AOR: 5.91; 95% CI: 2.75, 12.67) of khat use. CONCLUSIONS: Alcohol use was prevalent in this population, and current WHO guidelines would exclude a substantial proportion of the population from receiving IPT. PLHIV in this region would benefit from routine screening for alcohol and khat use, and from substance use education and counseling while receiving IPT until it can be determined whether alcohol users can safely receive IPT.

Evaluation of a hepatitis C education intervention with clients enrolled in methadone maintenance and needle/syringe programs in Malaysia.

BACKGROUND: Approximately 40%-90% of people who inject drugs (PWID) in Malaysia have hepatitis C (HCV). PWID continue to be disproportionately affected by HCV due to their lack of knowledge, perceived risk and interest in HCV treatment. Education interventions may be an effective strategy for increasing HCV knowledge in PWID, and harm reduction services are uniquely positioned to implement and deploy such interventions. METHODS: We recruited 176 clients from methadone maintenance treatment (MMT: N=110) and needle/syringe programs (NSP: N=66) between November 2015 and August 2016. After baseline knowledge assessments, clients participated in a standardized, 45-min HCV education program and completed post-intervention knowledge assessments to measure change in knowledge and treatment interest. RESULTS: Participants were mostly male (96.3%), Malay (94.9%), and in their early 40s (mean=42.6years). Following the intervention, overall knowledge scores and treatment interest in MMT clients increased by 68% and 16%, respectively (p<0.001). In contrast, NSP clients showed no significant improvement in overall knowledge or treatment interest, and perceived greater treatment barriers. Multivariate linear regression to assess correlates of HCV knowledge post-intervention revealed that optimal dosage of MMT and having had an HIV test in the past year significantly increased HCV knowledge. Having received a hepatitis B vaccine, however, was not associated with increased HCV knowledge after participating in an education session. CONCLUSION: Generally, HCV knowledge and screening is low among clients engaged in MMT and NSP services in Malaysia. Integrating a brief, but comprehensive HCV education session within harm reduction services may be a low-cost and effective strategy in improving overall HCV knowledge and risk behaviors in resource-limited settings. In order to be an effective public health approach, however, education interventions must be paired with strategies that improve social, economic and political outcomes for PWID. Doing so may reduce HCV disparities by increasing screening and treatment interest.

Factors associated with interest in receiving prison-based methadone maintenance therapy in Malaysia.

INTRODUCTION: Methadone maintenance therapy (MMT) is crucial for HIV prevention and treatment in people who inject opioids. In Malaysia, a large proportion of the prison population is affected by both HIV and opioid use disorders. This study assessed individual preferences and factors associated with interest in receiving MMT among male prisoners meeting criteria for opioid dependence in Malaysia. METHODS: A convenience sample of 96 HIV-positive and 104 HIV-negative incarcerated men who met pre-incarceration criteria for opioid dependence was interviewed using a structured questionnaire to examine participant characteristics and attitudes toward MMT. Factors associated with interest in prison-based MMT initiation were identified using logistic regression analysis. RESULTS: Among all participants, 85 (42.5%) were interested in receiving MMT within prison. Independent correlates of interest in prison-based MMT were being previously married (AOR=4.15, 95% CI: 1.15, 15.02), previously incarcerated (AOR=5.68, 95% CI: 1.54, 21.02), depression (AOR=3.66, 95% CI: 1.68, 7.98), daily heroin use in the 30days prior to incarceration (AOR=5.53, 95% CI: 1.65, 18.58), and more favorable attitudes toward MMT (AOR=19.82, 95% CI: 6.07, 64.74). CONCLUSIONS: Overall, interest in receiving prison-based MMT was low, and was associated with adverse social, mental health, and drug use consequences. Incarceration provides a unique opportunity to initiate MMT for those who need it, however, optimal scale-up efforts must be systemic and address modifiable factors like improving attitudes toward and motivation for MMT. Informed or shared decision-making tools may be useful in improving expectations and acceptability of MMT.