The impact of economic sanctions on health and health systems in low-income and middle-income countries: a systematic review and narrative synthesis.

INTRODUCTION: Economic sanctions restrict customary commercial and financial ties between states to induce change in political constitution or conduct of the targeted country. Although the stated goals of sanctions often include humanitarian objectives, prospective procedures for health risk assessment are not regularly incorporated in their implementation. Moreover, past experience suggests that the burden of economic isolation may fall on the civilian population. We present key findings from a WHO-sponsored evidence review on the impact of economic sanctions on health and health systems in low-income and middle-income countries, aiming at comprehensive coverage and explicit consideration of issues of causality and mechanisms. METHODS: Broad searches of PubMed and Google Scholar (1970-2021) were designed to retrieve published and grey English-language literature expected to cut across disciplines, terminology and research methods. Studies providing an impact estimate were rated by a structured assessment based on ROBINS-I risk of bias domains, synthesised via vote counting and contextualised into the broader literature through a thematic synthesis. RESULTS: Included studies (185) were mostly peer-reviewed, mostly single-country, largely coming from medicine and public health, and chiefly concerned with three important target countries-Iraq, Haiti and Iran. Among studies providing impact estimates (31), most raised multiple risk-of-bias concerns. Excluding those with data integrity issues, a significant proportion (21/27) reported consistently adverse effects of sanctions across examined outcomes, with no apparent association to assessed quality, focus on early episodes or publication period. The thematic synthesis highlights the complexity of sanctions, their multidimensionality and the possible mechanisms of impact. CONCLUSION: Future research should draw on qualitative knowledge to collect domain-relevant data, combining it with better estimation techniques and study design. However, only the adoption of a risk assessment framework based on prospective data collection and monitoring can certify claims that civilians are adequately protected.

Insights for speed management among Iranian drivers: a social marketing formative research study.

BACKGROUND: Road traffic crashes are among the leading causes of death and disability in the world, particularly in low and middle-income countries. This study aimed at to conduct a social marketing formative research to inform the development of a campaign to manage driving speed on the intercity roads of Iran. METHODS: To carry out the social marketing formative research, a qualitative and quantitative study were conducted. Also, a literature review of the speed management strategies was carried out and an analysis of traffic accident data and speeding violations was performed in selected provinces during 2019 and 2020. RESULTS: Based on the findings of the qualitative study, perceived sense of lack of speed control, poor monitoring system, and law enforcement are the main reasons drivers exceed the speed limit. They mostly suggest using punitive levers and more stringent law enforcement practices for speed management. Literature reviews also confirm that to successfully develop an effective speed management plan a set of measures should be implemented together, including road safety engineering, raising awareness, social marketing strategies, and finally strict law enforcement. The overriding findings of the formative research revealed that to persuade Iranian drivers to respect the speed limit, the messages of the campaign should focus on strict law enforcement in the selected corridors. CONCLUSIONS: In the minds of the Iranian audience, strict law enforcement is of paramount importance for a speed management strategy to work; hence it should be taken into consideration when tailoring the campaign messages. From the findings of the present study, it can be concluded that to manage speed on intercity routes in Iran, a social marketing campaign is needed to encourage compliance with speed limits.

Prevention and control of non-communicable diseases in iran: the case for Investment.

BACKGROUND: Non-communicable diseases are imposing a considerable burden on Iran. This study aims to assess the Return on Investment (ROI) for implementation of Non-communicable diseases (NCDs) prevention program in Iran. METHODS: Four disease groups including cardiovascular diseases, diabetes, cancer, and respiratory diseases were included in our ROI analysis. The study followed four steps: 1) Estimating the total economic burden of NCDs using the Cost-of-Illness approach. 2) Estimating the total costs of implementing clinical and preventive interventions using an ingredient based costing at delivering level and a program costing method at central level.3) Calculating health impacts and economic benefits of interventions using the impact measures of avoided incidence, avoided mortality, healthy life years (HLYs) gained, and avoided direct treatment costs. 4) Calculating the ROI for each intervention in 5- and 15- year time horizons. RESULTS: The total economic burden of NCDs to the Iranian economy was IRR 838.49 trillion per year (2018), which was equivalent to 5% of the country's annual Gross Domestic Product (GDP). The package of NCD will lead to 549 000 deaths averted and 2 370 000 healthy life years gained over 15 years, and, financially, Iranian economy will gain IRR 542.22 trillion over 15 years. The highest ROI was observed for the package of physical activity interventions, followed by the interventions addressing salt, tobacco package and clinical interventions. Conclusions NCDs in Iran are causing a surge in health care costs and are contributing to reduced productivity. Those actions to prevent NCDs in Iran, as well as yielding to a notable health impact, are giving a good economic return to the society. This study underscores an essential need for establishment of a national multi-sectorial NCD coordination mechanism to bring together and strengthen existing cross-agency initiatives on NCDs.

Addressing the health-related SDGs in the Eastern Mediterranean Region: Regional Health Alliance strengthens collaboration towards better health.

The United Nations launched the Sustainable Development Agenda 2030 and its 17 Sustainable Development Goals (SDGs) in 2015, as a more detailed and ambitious follow-up to the Millennium Developments Goals (MDGs). Health and wellbeing of all, at all ages, is addressed by the third SDG (SDG3) and health-related targets of other SDGs. However, progress to date on the health-related SDGs in the Eastern Mediterranean Region (EMR) is not on track. Although there was progress in over half of the 50 health-related SDG targets and indicators between 2015 and 2019, there is still a long way to go. Progress is required, among others, in reducing maternal, child and neonatal mortality; increasing vaccination coverage; reducing the number of cases of malaria and HIV; and in tackling the increase in mortality rates due to noncommunicable diseases. Much progress is needed in many health-related SDGs considered as important social, economic and environmental determinants of health.

The Effect of the COVID-19 Pandemic on Non-Communicable Disease Prevention and Management Services in the Primary Health Care System of Iran.

Background: The COVID-19 pandemic has caused significant disruptions in the provision of non-communicable disease (NCDs) prevention and control services in many countries, and there is a concern that it would lead to long-term complications of the diseases. The aim of this study is to assess the changes in the provisions of selected NCD services before and after the COVID-19 epidemic in Iran's primary healthcare system. Methods: In this descriptive-analytical retrospective study, the number of eight NCD services provided during the first 10 months of the COVID-19 pandemic from Feb 2020 to Dec 2020 were compared with the same period in the previous year using the data from the Iranian integrated electronic health record system (SIB) and also the association between the number of deaths due to COVID-19 and a sample of NCD services were assessed using cross-correlation analysis. The statistical analysis was performed in Stata Software v.14. Results: The NCD services have decreased by an average of 18.89% compared to the same period in the previous year; this decline was much more severe at the beginning of the epidemic period (up to 75% in some services) and was greater in physician-provided services than in non-physician services. Also, examining the course of the selected services during this period, a gradual compensation was evident after the initial reduction. Conclusion: The general trend of the selected services of prevention and control of NCDs in the PHC system of Iran within 10 months after the onset of COVID-19 showed a sharp decline and subsequent gradual compensation. Although the process of compensation in some services may be considered somewhat reassuring, in the case of some essential services, more effort and attention to the implementation of programs or compensatory policies seem necessary.

Primary Health Care Model for Non-Communicable Diseases Management during COVID-19 Pandemic in the Islamic Republic of Iran.

Background: Given the importance of appropriate response to prevent and manage Non-Communicable Diseases (NCDs), this study aimed to analyze the state of NCDs services at the level of the PHC system during the COVID-19 pandemic and to determine the main strategies. Methods: In this qualitative study, first, the circulars and guides in Iran's PHC system from the beginning of the pandemic to the end of September 2020 were retrieved manually and by searching the internal websites of the Ministry of Health. All documents about decision-making or governance and coordination mechanisms for the provision of NCDs services were enrolled and analyzed. In the second phase, the status of service delivery for major NCDs was presented in a model, and finally, SWOT analysis was used to analyze the situation and determine the main strategies. Results: 25 out of 199 circulars and guides were eligible and analyzed. In the crisis phase, most risk assessment, screening, and diagnosis services for NCDs have been suspended, and follow-up and care of patients with major NCDs were done by telephone. In the reopening phase, the general strategies and strategies to increase capacity and provide delayed care were adopted, and the PHC model of the provision of essential services for the major NCDs was developed in low-risk, intermediate and high-risk pandemic conditions. Finally, 16 main strategies were determined with the approach of integrating and focusing on essential services, considering vulnerable groups and the use of E-health technologies. Conclusion: The results indicate on interruption of NCDs services in the crisis phase while adopting strategies for responding to the pandemic. Revision of the COVID-19 guides with a particular focus on NCDs is recommended.

Routine COVID-19 testing may not be necessary for most cancer patients.

Cancer patients are at risk for severe complications or death from COVID-19 infection. Therefore, the need for routine COVID-19 testing in this population was evaluated. Between 1st August and 30th October 2020, 150 cancer patients were included. Symptoms of COVID-19 infection were evaluated. All eligible individuals went through RT-PCR and serological tests for COVID-19. At the same time, 920 non-cancer patients were recruited from a random sample of individuals who were subject to routine molecular and anti-body screening tests. Of 150 cancer patients, 7 (4.7%) were RT-PCR positive. Comorbidity made a significant difference in the RT-PCR positivity of cancer patients, 71.4% positive versus 25.8% negative (P-value = 0.02). The average age for negative and positive groups was 53.3 and 58.2 respectively (P-value = 0.01). No significant difference was observed between cancer and non-cancer patients regarding COVID-19 antibody tests. However, cancer patients were 3 times less likely to have a positive RT-PCR test result OR = 0.33 (CI: 0.15-0.73). The probability of cancer patients having a positive routine test was significantly lower than non-cancer patients, and the concept that all cancer patients should be routinely tested for COVID-19 may be incorrect. Nevertheless, there may be a subgroup of patients with comorbidities or older age who may benefit from routine COVID-19 testing. Importantly, these results could not be subjected to multivariate analysis.

Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies.

BACKGROUND: Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels. METHODOLOGY: We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure-two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment. FINDINGS: Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%-39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%-58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%-27%] reduction in management costs, and allocating resources optimally. SIGNIFICANCE: With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.

Investment for health and well-being: a review of the social return on investment from public health policies to support implementing the Sustainable Development Goals by building on Health 2020

Governments across the WHO European Region need to take urgent action to address the growing public health, inequality, economic and environmental challenges in order to achieve sustainable development (meeting current needs without compromising the ability of future generations to meet their own needs) and to ensure health and well-being for present and future generations. Based on a scoping review, this report concludes that current investment policies and practices (doing business as usual) are unsustainable, with high costs to individuals, families, communities, societies, the economy and the planet. Investment in public health policies that are based on values and evidence provides effective and efficient, inclusive and innovative solutions that can drive social, economic and environmental sustainability. Investing for health and well-being is a driver and an enabler of sustainable development, and vice versa, and it empowers people to achieve the highest attainable standard of health for all. This publication was tabled as a background document during the Sixty-seventh session of the Regional Committee for Europe, Budapest, 11–14 September 2017.

Инвестиции в интересах здоровья и благополучия: анализ общественной эффективности инвенций в стратегии общественного здравоохранения для поддержки выполнения Целей в области устойчивого развития на основе политики Здоровье-2020

Правительствам стран Европейского региона ВОЗ необходимо принять срочные меры для преодоления растущих проблем в области общественного здравоохранения, неравенств, а также экономических и экологических вызовов для того, чтобы добиться устойчивого развития (т.е. удовлетворить нынешние потребности без ущерба для способности будущих поколений удовлетворять свои собственные потребности) и гарантировать здоровье и благополучие нынешнему и будущим поколениям. На основе оценки масштабов осуществляемой деятельности авторы доклада делают вывод о том, что нынешняя инвестиционная политика и практика (“работа в привычном режиме”) является неустойчивой и влечет за собой высокие издержки для отдельных граждан, их семей, сообществ, обществ, национальной экономики и всей планеты. Инвестиции в реализацию мер общественного здравоохранения, которые опираются на ценностные ориентиры и фактические данные, обеспечивают эффективные и рациональные, инклюзивные и инновационные решения, которые могут служить стимулом для обеспечения социальной, экономической и экологической устойчивости. Инвестиции в интересах здоровья и благополучия стимулируют и делают возможным устойчивое развитие (и наоборот), что позволяет обеспечить наивысший достижимый уровень здоровья для всех людей. Эта публикация была представлена для обсуждения в качестве справочного документа на Шестьдесят седьмой сессии Европейского регионального комитета, Будапешт, 11–14 сентября 2017 г.

Key policies for addressing the social determinants of health and health inequities

Evidence indicates that actions within four main themes (early child development, fair employment and decent work, social protection, and the living environment) are likely to have the greatest impact on the social determinants of health and health inequities. A systematic search and analysis of recommendations and policy guidelines from intergovernmental organizations and international bodies identified practical policy options for action on social determinants within these four themes. Policy options focused on early childhood education and care; child poverty; investment strategies for an inclusive economy; active labour market programmes; working conditions; social cash transfers; affordable housing; and planning and regulatory mechanisms to improve air quality and mitigate climate change. Applying combinations of these policy options alongside effective governance for health equity should enable WHO European Region Member States to reduce health inequities and synergize efforts to achieve the United Nations Sustainable Development Goals. This publication was tabled as a background document during the Sixty-seventh session of the Regional Committee for Europe, Budapest, 11–14 September 2017.

Social return on investment: accounting for value in the context of implementing Health 2020 and the 2030 Agenda for Sustainable Development (Investment for Health and Development Discussion Paper)

Social return on investment (SROI) is a concept to account for social value when evaluating investments. It goes beyond traditional economic evaluation tools, by considering value produced for multiple stakeholders in all three dimensions of development: economic, social and environmental. This discussion paper reviews the main features of SROI (stakeholder engagement, the theory of change and accounting for social value) and finds that they are coherent with the key features of the Health 2020 policy framework and the 2030 Agenda for Sustainable Development. It concludes that SROI represents an interesting opportunity to evaluate cross-sectoral investments which aim to promote health and development, in the WHO European Region and beyond. This publication was tabled as a background document during the Sixty-seventh session of the Regional Committee for Europe, Budapest, 11–14 September 2017.

Ключевые меры политики для воздействия на социальные детерминанты здоровья и сокращения неравенства в отношении здоровья

Согласно имеющимся фактическим данным, вмешательства в четырех сферах – раннее развитие в детском возрасте, реализация права на труд и достойные условия труда, социальная защита и условия жизни – в состоянии оказывать максимальное воздействие на социальные детерминанты здоровья и неравенства в здоровье. В ходе систематического поиска и анализа рекомендаций и руководств в отношении политики, опубликованных межправительственными организациями и международными структурами, авторы сформулировали несколько реалистичных вариантов политики, на которых могут основываться конкретные меры по воздействию на социальные детерминанты в пределах вышеуказанных четырех тем. Варианты политики в первую очередь затрагивают такие вопросы, как образование и уход в раннем детском возрасте, детская бедность, стратегии инвестиций в условиях инклюзивной экономики, активные программы для рынка труда, условия труда, социальные выплаты наличными средствами, доступное жилье и механизмы планирования и регулирования для улучшения качества воздуха и смягчения последствий изменения климата. Авторы полагают, что применение различных комбинаций таких вариантов политики, наряду с эффективным руководством в поддержку справедливости в здоровье, позволит государствам-членам в Европейском регионе ВОЗ сократить неравенства в здоровье и синхронизировать усилия по достижению Целей в области устойчивого развития ООН. Эта публикация была представлена для обсуждения в качестве справочного документа на Шестьдесят седьмой сессии Европейского регионального комитета, Будапешт, 11–14 сентября 2017 г.

Key policies for addressing the social determinants of health and health inequities

Evidence indicates that actions within four main themes (early child development, fair employment and decent work, social protection, and the living environment) are likely to have the greatest impact on the social determinants of health and health inequities. A systematic search and analysis of recommendations and policy guidelines from intergovernmental organizations and international bodies identified practical policy options for action on social determinants within these four themes. Policy options focused on early childhood education and care; child poverty; investment strategies for an inclusive economy; active labour market programmes; working conditions; social cash transfers; affordable housing; and planning and regulatory mechanisms to improve air quality and mitigate climate change. Applying combinations of these policy options alongside effective governance for health equity should enable WHO European Region Member States to reduce health inequities and synergize efforts to achieve the United Nations Sustainable Development Goals.

Investment for health and well-being: a review of the social return on investment from public health policies to support implementing the Sustainable Development Goals by building on Health 2020

Governments across the WHO European Region need to take urgent action to address the growing public health, inequality, economic and environmental challenges in order to achieve sustainable development (meeting current needs without compromising the ability of future generations to meet their own needs) and to ensure health and well-being for present and future generations. Based on a scoping review, this report concludes that current investment policies and practices (doing business as usual) are unsustainable, with high costs to individuals, families, communities, societies, the economy and the planet. Investment in public health policies that are based on values and evidence provides effective and efficient, inclusive and innovative solutions that can drive social, economic and environmental sustainability. Investing for health and well-being is a driver and an enabler of sustainable development, and vice versa, and it empowers people to achieve the highest attainable standard of health for all.

The effectiveness of community based distribution of injectable contraceptives using community health extension workers in Gombe State, Northern Nigeria.

This study reports on findings of a pilot of community-based distribution (CBD) of injectable contraceptives in two local government areas (LGAs) of Gombe State, Nigeria. From August 2009 to January 2010, the project enrolled, trained and equipped community health extension workers (CHEWs) to distribute condoms, oral and injectable contraceptives in communities. The project mobilized communities and stakeholders to promote Family Planning (FP) services in the selected communities. Using anonymised unlinked routine service data, the mean couple years of protection (CYP) achieved through CBD was compared to that achieved in FP clinics. The CBD mean CYP for injectables- depo medroxy-progesterone acetate (DMPA) and norethisterone enantate was higher (27.72 & 18.16 respectively) than the facility CYP (7.21 & 5.08 respectively) (p < 0.05) with no injection related complications. The CBD's mean CYP for all methods was also found to be four times higher (11.65) than that generated in health facilities (2.86) (p < 0.05). This suggests that the CBD of injectable contraceptives is feasible and effective, even in a setting like northern Nigeria that has sensitivities about FP.

Closing the Prevention of Mother-to-Child Transmission Gap in Nigeria: an Evaluation of Service Improvement Intervention in Nigeria

Objectives: The objective was to assess improvement; or lack thereof; in the uptake of prevention of mother-to-child transmission (MTCT) services at selected sites supported sites by the Global HIV/AIDS Initiative Nigeria (GHAIN).Design: The study used aggregated monthly service statistics to evaluate service improvement efforts that were conducted before and after these were undertaken between July 2007-June 2008. Settings and subjects: The service improvement efforts took place in 60 public healthcare facilities. Outcome measures: The study measured changes in the number of pregnant women who attended antenatal clinics for the first time; the number of pregnant women tested for human immunodeficiency virus (HIV); the number of HIV-positive women receiving antiretroviral (ARV) prophylaxis; and the service ratio; an indicator of the relative uptake of ARV prophylaxis. An estimate of MTCT events that were averted through ARV prophylaxis taken by the pregnant women was also calculated. Results: One hundred and twenty thousand; five hundred and thirty-seven women attended an antenatal clinic (ANC) for the first time. There was an average of 167.4 monthly attendances per facility. ANC attendance increased per facility by 11.1 women monthly post-intervention (p-value 0.01). The uptake of HIV testing was 87; with a monthly average increase of 17.8 women tested per facility (p-value 0.01). ARV prophylaxis uptake rose from 3.3-5.4 women per facility per month (p-value 0.01). The service ratio per facility improved from 5.3 women receiving ARVs to 6.5 for every 10 women who tested positive for HIV (p-value 0.01). Applying risk reduction estimates of different ARV regimens; it was estimated that between 88-169 MTCT events were averted pre-intervention; and 143-276 events; post-intervention. Conclusion: Service improvement intervention improved the utilisation of PMTCT services. It should be a key intervention that is used to close the PMTCT gap in Nigeria

Adverse drug reactions to antiretroviral therapy (ARVs): incidence, type and risk factors in Nigeria.

BACKGROUND: Data on adverse drug reactions (ADRs) related to antiretroviral (ARV) use in public health practice are few indicating the need for ART safety surveillance in clinical care. OBJECTIVES: To evaluate the incidence, type and risk factors associated with adverse drug reactions (ADRs) among patients on antiretroviral drugs (ARV). METHODS: Patients initiated on ARVs between May 2006 and May 2009 were evaluated in a retrospective cohort analysis in three health facilities in Nigeria. Regimens prescribed include nucleoside backbone of zidovudine (AZT)/lamivudine (3TC), stavudine (d4T)/3TC, or tenofovir (TDF)/3TC in combination with either nevirapine (NVP) or efavirenz (EFV). Generalized Estimating Equation (GEE) model was used to identify risk factors associated with occurrence of ADR. RESULTS: 2650 patients were followed-up for 2456 person-years and reported 114 ADRs (incidence rate = 4.6/100 person-years).There were more females 1706(64%) and 73(64%) of the ADRs were reported by women. Overall, 61(54%) of ADRs were reported by patients on AZT with 54(47%) of these occurring in patients on AZT/NVP. The commonest ADRs reported were pain 25(30%) and skinrash 10(18%). Most ADRs were grade 1(39%) with only 1% being life threatening (grade 4). Adjusted GEE analysis showed that ADR was less likely to occur in patients on longer duration of ART compared to the first six months on treatment; 6-12 months AOR 0.38(95% CI:0.16-0.91) and 12-24 months AOR 0.34(95% CI:0.16-0.73) respectively. Compared to patients on TDF, ADR was less likely to occur in patients on d4T and AZT AOR 0.18(95% CI 0.05-0.64) and AOR 0.24(95% CI:0.7-0.9) respectively. Age, gender and CD4 count were not significantly associated with ADRs. CONCLUSION: ADRs are more likely to occur within the first six months on treatment. Close monitoring within this period is required to prevent occurrence of severe ADR and improve ART adherence. Further research on the tolerability of tenofovir in this environment is recommended.

HIV prevalence and risk behaviours among men having sex with men in Nigeria.

OBJECTIVE: To evaluate HIV and syphilis prevalence among men who have sex with men (MSM) in Nigeria, and assess their HIV-related risk behaviours and exposure to HIV prevention interventions. METHODS: Cross-sectional study using respondent-driven sampling conducted in Lagos, Kano and Cross River states, Nigeria, between July and September 2007. RESULTS: A total of 879 MSM participated, 293 from each state. Eight participants (1.1%, CI 0.1% to 2.2%) in Cross River, 27 (9.3%, CI 5.7% to 15.4%) in Kano and 74 (17.4%, CI 12.3% to 23.2%) in Lagos tested positive for HIV. No syphilis was detected. The median age was 22 years. MSM reported an average of 4.2 male anal sex partners in the past 6 months. Between 24.4% (Lagos) and 36.0% (Kano) of MSM reported selling sex to other men. Up to 49.7% of MSM reported sex with a girlfriend and ≤ 6.5% purchased sex from female sex workers. Consistent condom use in commercial sex with other men over the past 6 months ranged from 28.0% (Cross River) to 34.3% (Kano), in contrast to between 23.9% (Kano) and 45.8% (Lagos) for non-commercial sex. Associations with HIV positivity included age in the three states, having been the receptive partner in anal sex in the past 6 months in Lagos and in Lagos and Kano feeling at risk of HIV. CONCLUSION: Large differentials in HIV prevalence between states together with high mobility, inconsistent condom use and behavioural links with female sex partners, have the potential for further HIV transmission within MSM networks, and between MSM and the general population.