Quantifying the impact of cascade inequalities: a modelling study on the prevention impacts of antiretroviral therapy scale-up in Eswatini.

Background: Inequalities in the antiretroviral therapy (ART) cascade across subpopulations remain an ongoing challenge in the global HIV response. Eswatini achieved the UNAIDS 95-95-95 targets by 2020, with differentiated programs to minimize inequalities across subpopulations, including for female sex workers (FSW) and their clients. We sought to estimate additional HIV infections expected in Eswatini if cascade scale-up had not been equal, and under which epidemic conditions these inequalities could have the largest influence. Methods: Drawing on population-level and FSW-specific surveys in Eswatini, we developed a compartmental model of heterosexual HIV transmission which included eight subpopulations and four sexual partnership types. We calibrated the model to stratified HIV prevalence, incidence, and ART cascade data. Taking observed cascade scale-up in Eswatini as the base-case-reaching 95-95-95 in the overall population by 2020-we defined four counterfactual scenarios in which the population overall reached 80-80-90 by 2020, but where FSW, clients, both, or neither were disproportionately left behind, reaching only 60-40-80. We quantified relative additional cumulative HIV infections by 2030 in counterfactual vs base-case scenarios. We further estimated linear effects of viral suppression gap among FSW and clients on additional infections by 2030, plus effect modification by FSW/client population sizes, rates of turnover, and HIV prevalence ratios. Results: Compared with the base-case scenario, leaving behind neither FSW nor their clients led to the fewest additional infections by 2030: median (95% credible interval) 14.9 (10.4, 18.4)% vs 26.3 (19.7, 33.0)% if both were left behind-a 73 (40, 149)% increase. The effect of lower cascade on additional infections was larger for clients vs FSW, and both effects increased with population size and relative HIV incidence. Conclusions: Inequalities in the ART cascade across subpopulations can undermine the anticipated prevention impacts of cascade scale-up. As Eswatini has shown, addressing inequalities in the ART cascade, particularly those that intersect with high transmission risk, could maximize incidence reductions from cascade scale-up.

"They are human beings, they are Swazi": intersecting stigmas and the positive health, dignity and prevention needs of HIV-positive men who have sex with men in Swaziland.

INTRODUCTION: Despite the knowledge that men who have sex with men (MSM) are more likely to be infected with HIV across settings, there has been little investigation of the experiences of MSM who are living with HIV in sub-Saharan Africa. Using the framework of positive health, dignity and prevention, we explored the experiences and HIV prevention, care and treatment needs of MSM who are living with HIV in Swaziland. METHODS: We conducted 40 in-depth interviews with 20 HIV-positive MSM, 16 interviews with key informants and three focus groups with MSM community members. Qualitative analysis was iterative and included debriefing sessions with a study staff, a stakeholders' workshop and coding for key themes using Atlas.ti. RESULTS: The predominant theme was the significant and multiple forms of stigma and discrimination faced by MSM living with HIV in this setting due to both their sexual identity and HIV status. Dual stigma led to selective disclosure or lack of disclosure of both identities, and consequently a lack of social support for care-seeking and medication adherence. Perceived and experienced stigma from healthcare settings, particularly around sexual identity, also led to delayed care-seeking, travel to more distant clinics and missed opportunities for appropriate services. Participants described experiences of violence and lack of police protection as well as mental health challenges. Key informants, however, reflected on their duty to provide non-discriminatory services to all Swazis regardless of personal beliefs. CONCLUSIONS: Intersectionality provides a framework for understanding the experiences of dual stigma and discrimination faced by MSM living with HIV in Swaziland and highlights how programmes and policies should consider the specific needs of this population when designing HIV prevention, care and treatment services. In Swaziland, the health sector should consider providing specialized training for healthcare providers, distributing condoms and lubricants and engaging MSM as peer outreach workers or expert clients. Interventions to reduce stigma, discrimination and violence against MSM and people living with HIV are also needed for both healthcare workers and the general population. Finally, research on experiences and needs of MSM living with HIV globally can help inform comprehensive HIV services for this population.

Association between condom use and use of other contraceptive methods among female sex workers in Swaziland: a relationship-level analysis of condom and contraceptive use.

OBJECTIVES: Nonbarrier modern contraceptive users often are less likely to use condoms, particularly with more intimate sex partners. We examine whether female sex workers (FSWs) in Swaziland who use nonbarrier contraception use condoms less consistently and whether this inverse association varies by relationship type. METHODS: In 2011, we conducted a survey among 325 Swazi FSWs using respondent-driven sampling. Each woman reported on condom use during sexual activity in the past month with up to 3 partner types (new clients, regular clients, noncommercial partners). We used a generalized estimating equation model to conduct a relationship-level multivariate logistic regression analysis of correlates of consistent condom use in the past month. We tested whether relationship type modified the effect of nonbarrier modern contraception on condom use. RESULTS: Each participant reported up to 3 observations, for a total of 892 measures of condom use in the past month. Compared with sexual activity with new clients, sex with regular clients and noncommercial partners was less likely to be protected by consistent condom use (adjusted odds ratio, 0.30 [95% confidence interval, 0.19-0.47] for regular clients; adjusted odds ratio, 0.15 [95% confidence interval, 0.09-0.24] for noncommercial partners). There was no significant association between condom use and nonbarrier modern contraceptive use. CONCLUSIONS: These data highlight the need to provide condoms and condom-compatible lubricants and targeted education programs for FSWs and their male sex partners to encourage the consistent use of these commodities with all sex partners, irrespective of the use of other contraceptive methods.