From conceptualising to modelling structural determinants and interventions in HIV transmission dynamics models: a scoping review and methodological framework for evidence-based analyses.

BACKGROUND: Including structural determinants (e.g. criminalisation, stigma, inequitable gender norms) in dynamic HIV transmission models is important to help quantify their population-level impacts and guide implementation of effective interventions that reduce the burden of HIV and inequalities thereof. However, evidence-based modelling of structural determinants is challenging partly due to a limited understanding of their causal pathways and few empirical estimates of their effects on HIV acquisition and transmission. METHODS: We conducted a scoping review of dynamic HIV transmission modelling studies that evaluated the impacts of structural determinants, published up to August 28, 2023, using Ovid Embase and Medline online databases. We appraised studies on how models represented exposure to structural determinants and causal pathways. Building on this, we developed a new methodological framework and recommendations to support the incorporation of structural determinants in transmission dynamics models and their analyses. We discuss the data and analyses that could strengthen the evidence used to inform these models. RESULTS: We identified 17 HIV modelling studies that represented structural determinants and/or interventions, including incarceration of people who inject drugs (number of studies [n] = 5), violence against women (n = 3), HIV stigma (n = 1), and housing instability (n = 1), among others (n = 7). Most studies (n = 10) modelled exposures dynamically. Almost half (8/17 studies) represented multiple exposure histories (e.g. current, recent, non-recent exposure). Structural determinants were often assumed to influence HIV indirectly by influencing mediators such as contact patterns, condom use, and antiretroviral therapy use. However, causal pathways' assumptions were sometimes simple, with few mediators explicitly represented in the model, and largely based on cross-sectional associations. Although most studies calibrated models using HIV epidemiological data, less than half (7/17) also fitted or cross-validated to data on the prevalence, frequency, or effects of exposure to structural determinants. CONCLUSIONS: Mathematical models can play a crucial role in elucidating the population-level impacts of structural determinants and interventions on HIV. We recommend the next generation of models reflect exposure to structural determinants dynamically and mechanistically, and reproduce the key causal pathways, based on longitudinal evidence of links between structural determinants, mediators, and HIV. This would improve the validity and usefulness of predictions of the impacts of structural determinants and interventions.

Piloting the Inclusion of the Key Populations Unique Identifier Code in the South African Routine Health Information Management System: Protocol for a Multiphased Study.

BACKGROUND: The global community has set an ambitious goal to end HIV/AIDS as a public health threat by 2030. Significant progress has been achieved in pursuing these objectives; however, concerns remain regarding the lack of disaggregated routine data for key populations (KPs) for a targeted HIV response. KPs include female sex workers, transgender populations, gay men and other men who have sex with men, people who are incarcerated, and people who use drugs. From an epidemiological perspective, KPs play a fundamental role in shaping the dynamics of HIV transmission due to specific behaviors. In South Africa, routine health information management systems (RHIMS) do not include a unique identifier code (UIC) for KPs. The purpose of this protocol is to develop the framework for improved HIV monitoring and programming through piloting the inclusion of KPs UIC in the South African RHIMS. OBJECTIVE: This paper aims to describe the protocol for a multiphased study to pilot the inclusion of KPs UIC in RHIMS. METHODS: We will conduct a multiphased study to pilot the framework for the inclusion of KPs UIC in the RHIMS. The study has attained the University of Johannesburg Research Ethics Committee approval (REC-2518-2023). This study has four objectives, including a systematic review, according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines (objective 1). Second, policy document review and in-depth stakeholder interviews using semistructured questionnaires (objective 2). Third, exploratory data analysis of deidentified HIV data sets (objective 3), and finally, piloting the framework to assess the feasibility of incorporating KPs UIC in RHIMS using findings from objectives 1, 2, and 3 (objective 4). Qualitative and quantitative data will be analyzed using ATLAS.ti (version 6; ATLAS.ti Scientific Software Development GmbH) and Python (version 3.8; Python Software Foundation) programming language, respectively. RESULTS: The results will encompass a systematic review of literature, qualitative interviews, and document reviews, along with exploratory analysis of deidentified routine program data and findings from the pilot study. The systematic review has been registered in PROSPERO (International Prospective Register of Systematic Reviews; CRD42023440656). Data collection is planned to commence in September 2024 and expected results for all objectives will be published by December 2025. CONCLUSIONS: The study will produce a framework to be recommended for the inclusion of the KP UIC national rollout. The study results will contribute to the knowledge base around the inclusion of KPs UIC in RHIMS data. TRIAL REGISTRATION: PROSPERO CRD42023440656; https://tinyurl.com/msnppany. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55092.

Comparative acceptability of saliva-based self-testing versus blood-based self-testing for HIV screening among key populations in Kisangani.

INTRODUCTION: HIV self-testing represents a convenient and confidential option for HIV testing-the present study aimed to assess the acceptability of blood versus saliva self-tests among key populations in Kisangani. METHODS: This study was an analytical cross-sectional study. Our sample size was 363 subjects. After obtaining their consent, we administered a questionnaire to participants. We asked participants to choose between blood and saliva self-testing. We defined the acceptability of the self-test (saliva or blood) as the intention to use the self-test using a 5-point Likert scale. Descriptive statistics were described by estimating proportions for categorical variables and means with standard deviations for symmetrically distributed quantitative variables. The variable of interest was the acceptability of self-testing, which was dichotomized (Very Likely/Unlikely). The corresponding endpoint was the proportion of participants accepting the self-test in HIV screening. A bivariate analysis was performed to determine factors related to the acceptability of the self-test, using Pearson's Chi-square (χ2) and ANOVA followed by 2-to-2 multiple comparisons (Bonferroni) for comparison of means and proportions. A progressive stepwise logistic regression model at the 5% threshold included variables with a bi-variate association. RESULTS: The acceptability of the blood self-test was 71.6% compared to 28.4% for the saliva self-test. Factors associated with acceptability of the self-test were higher level of education aOR CI95%: 1.5(0.4-5.5) p = 0.006; non-use of condoms with casual partners aOR CI95%: 2.8(1.4-5) p = 0.003; knowledge of the type of self-test aOR CI95%:2.4(1.02-5.65) p = 0.043 and the obstacle to acceptability of the self-test was non-availability of the self-test aOR CI 95%: 18.9(6.5-54.9) p < 0.0001. CONCLUSION: Our study showed that key populations in Kisangani preferred blood self-testing over saliva self-testing. Blood self-tests must be made available to key population groups, as this would improve access to testing for these populations, thus boosting the first UNAIDS target 95.

PrEP in the key population community: a qualitative study of perspectives on pre-exposure prophylaxis by men who have sex with men and female sex workers in Kigali, Rwanda.

Background: Men who have sex with men (MSM) and female sex workers (FSW) are increasingly and disproportionately impacted by HIV in sub-Saharan Africa, yet current PrEP care models in this region are not optimized for these communities. Limited data exist describing experiences and preferences of MSM and FSW with respect to accessing and using PrEP. Methods: We conducted qualitative, semi-structured interviews with MSM and FSW recruited from three health centers and seven community organizations in Kigali, Rwanda. Data were analyzed using a mixed deductive and inductive approach to describe key themes related to initiating and adhering to PrEP. Results: Participants included 18 MSM and 14 FSW; 12 were using PrEP at the time of interview, 9 had previously used PrEP, and 11 had never used it. Participants highlighted the central role of their social networks as key sources of information about and support for PrEP use, and described a strong motivation to use PrEP as a way to protect both themselves and their communities from HIV. While stigma and discrimination were pervasive, these were experienced differently by MSM and FSW. Participants suggested community access points that allowed more discreet and less frequent contact with health care workers as important and desired strategies to improve engagement. Conclusions: These findings suggest that leveraging community resources for disseminating information about HIV prevention and delivering PrEP could contribute to successful implementation of PrEP for MSM and FSW in Rwanda and other settings in SSA.

Changes in the HIV Epidemic in Lower Silesia, Poland, Between 2010 and 2020: The Characteristics of the Key Populations.

The HIV (Human Immunodeficiency Virus) epidemic remains a significant public health issue, requiring ongoing access to preventive methods. This study aimed to analyze the evolution of the HIV epidemic in Lower Silesia from 2010 to 2020, focusing on the key populations. A retrospective analysis of the medical records from newly diagnosed HIV patients at a major HIV clinic in Wroclaw was conducted, examining demographic data, infection routes, and laboratory results. An 84% increase in newly diagnosed HIV cases was observed over the decade, with the most common route of infection being sex between men (70% among those with a known infection route). These patients were generally in better clinical condition compared to their heterosexual counterparts, as indicated by a higher median CD4+ T cell count (465/µL vs. 250/µL). The changes in clinical status and infection routes were statistically significant. The HIV epidemic in Lower Silesia has shifted, with a notable rise in new infections among men who have sex with men. Heterosexual patients were often diagnosed at more advanced stages. Prevention strategies should adapt to these changing trends, with education and testing accessibility remaining priorities nationwide.

Public health response to Mpox: Safeguarding vulnerable Key Populations and People Living with HIV in Zanzibar.

Mpox, caused by the Monkeypox virus (MPXV), has emerged as a significant global public health concern, particularly affecting vulnerable populations. The recent outbreak in the Democratic Republic of the Congo (DRC) is the largest recorded, driven by the highly virulent clade 1 strain. Transmission has shifted from animal contact to primarily sexual contact among Key Populations (KPs) such as Sex Workers (SW) and Men who have Sex with Men (MSM). In Zanzibar, where HIV prevalence is significantly higher among Key Populations, People Living with Human Immunodeficiency Virus (PLHIV) are at increased risk of Mpox infection due to socioeconomic challenges and immunosuppression. Despite no reported cases in Zanzibar, the spread of Mpox in non-endemic areas highlights the need for proactive measures. Leveraging Zanzibar's strengthened public health infrastructure, key strategies include tailored awareness campaigns, improved vaccine access through existing COVID-19 vaccination models, healthcare infrastructure enhancement, and mental health support. These targeted actions aim to protect Zanzibar's most vulnerable populations and bolster preparedness against Mpox, emphasizing the importance of resource-appropriate interventions to mitigate potential outbreaks.

The impact of COVID-19 restrictions on HIV prevention and treatment services for key populations in South Africa: an interrupted time series analysis.

BACKGROUND: Key populations (KP), including men who have sex with men (MSM), female sex workers (FSW), and transgender women (TGW), experience a disproportionate burden of HIV, even in generalized epidemics like South Africa. Given this disproportionate burden and unique barriers to accessing health services, sustained provision of care is particularly relevant. It is unclear how the COVID-19 pandemic and its associated restrictions may have impacted this delivery. In this study, we aimed to describe patterns of engagement in HIV prevention and treatment services among KP in South Africa and assess the impact of different COVID-19 restriction levels on service delivery. METHODS: We leveraged programmatic data collected by the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported KP partners in South Africa. We divided data into three discrete time periods based on national COVID-19 restriction periods: (i) Pre-restriction period, (ii) High-level restriction period, and (iii) After-high level restriction period. Primary outcomes included monthly total HIV tests, new HIV cases identified, new initiations of pre-exposure prophylaxis (PrEP), and new enrollments in antiretroviral therapy (ART). We conducted interrupted time series segmented regression analyses to estimate the impact of COVID-19 restrictions on HIV prevention and treatment service utilization. RESULTS: Between January 2018 and June 2022, there were a total of 231,086 HIV tests, 27,051 HIV positive cases, 27,656 pre-exposure prophylaxis (PrEP) initiations, and 15,949 antiretroviral therapy initiations among MSM, FSW and TGW in PEPFAR-supported KP programs in South Africa. We recorded 90,457 total HIV tests during the 'pre-restriction' period, with 13,593 confirmed new HIV diagnoses; 26,134 total HIV tests with 2,771 new diagnoses during the 'high-level restriction' period; and 114,495 HIV tests with 10,687 new diagnoses during the after high-level restriction period. Our Poisson regression model estimates indicate an immediate and significant decrease in service engagement at the onset of COVID-19 restrictions, including declines in HIV testing, treatment, and PrEP use, which persisted. As programs adjusted to the new restrictions, there was a gradual rebound in service engagement, particularly among MSM and FSW. Towards the end of the high-level restriction period, with some aspects of daily life returning to normal but others still restricted, there was more variability. Some indicators continued to improve, while others stagnated or decreased. CONCLUSION: Service provision rebounded from the initial shock created by pandemic-related restrictions, and HIV services were largely maintained for KP in South Africa. These results suggest that HIV service delivery among programs designed for KP was able to be flexible and resilient to the evolving restrictions. The results of this study can inform plans for future pandemics and large-scale disruptions to the delivery of HIV services.

Social network-based approaches to HIV testing: a systematic review and meta-analysis.

INTRODUCTION: Social network-based testing approaches (SNAs) encourage individuals ("test promoters") to motivate sexual partners and/or those in their social networks to test for HIV. We conducted a systematic review to examine the effectiveness, acceptability and cost-effectiveness of SNA. METHODS: We searched five databases from January 2010 to May 2023, and included studies that compared SNA with non-SNA. We used random-effects meta-analysis to combine effect estimates. Certainty was assessed using the GRADE approach. RESULTS: We identified 47 studies. SNA may increase uptake of HIV testing compared to non-SNA (RR 2.04, 95% CI: 1.06-3.95, Low certainty). The proportion of first-time testers was probably higher among partners or social contacts of test promoters using SNA compared to non-SNA (RR 1.49, 95% CI: 1.22-1.81, Moderate certainty). The proportion of people who tested positive for HIV may be higher among partners or social contacts of test promoters using SNA compared to non-SNA (RR 1.84, 95% CI: 1.01-3.35, Low certainty). There were no reports of any adverse events or harms associated with SNA. Based on six cost-effectiveness studies, SNA was generally cheaper per person tested and per person diagnosed compared to non-SNA. Based on 23 qualitative studies, SNA is likely to be acceptable to a variety of populations. DISCUSSION: Our review collated evidence for SNA to HIV testing covering the key populations and the general population who may benefit from HIV testing. We summarized evidence for the effectiveness, acceptability and cost-effectiveness of different models of SNA. While we did not identify an ideal model of SNA that could be immediately scaled up, for each setting and population targeted, we recommend various implementation considerations as our meta-analysis showed the effectiveness might differ due to factors which include the testing modality (i.e. use of HIV self-testing), type of test promoters, long or short duration of recruitment and use of financial incentives. CONCLUSIONS: Social network-based approaches may enhance HIV testing uptake, increase the proportion of first-time testers and those testing positive for HIV. Heterogeneity among studies highlights the need for context-specific adaptations, but the overall positive impact of SNA on HIV testing outcomes could support its integration into existing HIV testing services.

Willingness to Use Long-acting Injectable Pre-exposure Prophylaxis Among Key Populations at a Large Hiv Prevention Clinic in Kampala, Uganda: a Cross-sectional Study.

Background: Long-acting injectable (LAI)-PrEP provides better protection against HIV compared to oral PrEP, which requires taking a daily pill. Our study aimed to assess knowledge about oral and LAI-PrEP and identify factors associated with willingness to use LAI-PrEP among key populations (KP) in Uganda. Methods: We conducted a cross-sectional study at the Most at Risk Populations Initiative (MARPI) clinic between November and December 2021. Participants were recruited through convenience sampling and interviewed using a structured questionnaire by trained interviewers. Participants were categorised into three groups based on their oral PrEP use: those who had not yet initiated PrEP, those who had discontinued oral PrEP, and those currently on oral PrEP. Modified Poisson regression analysis was performed to determine factors associated with the participant's willingness to use LAI-PrEP. Data was analysed using STATA 14 software. Results: Of the 234 participants, 135 (56.7%) were female, 82.5% knew about LAI-PrEP, and 67.5% were willing to use it. The mean age was 28.7 years (standard deviation [SD] 5.8). Willingness to use LAI-PrEP was less likely among divorced, widowed, or separated individuals than those in relationships (adjusted prevalence ratio [aPR] 0.65, 95% CI: 0.43-0.98). Relative to current oral PrEP users, willingness to use LAI-PrEP was similar among those who discontinued oral PrEP (aPR 1.39, 95% CI: 0.92-2.11) and those who had not yet initiated PrEP but were at risk for HIV (aPR 1.26, 95% CI: 0.83-1.89). Conclusions: In this cross-sectional analysis of diverse members of key populations in Uganda, previous or non-use of oral PrEP was not associated with willingness to use LAI-PrEP relative to current users. Future studies should investigate effective methods for promoting the uptake of long-acting PrEP formulations among populations at high risk of HIV acquisition.

Using a Knowledge and Awareness Survey to Engage and Inform a Community-Based Tuberculosis Intervention among Nomads in Adamawa State, Nigeria.

BACKGROUND: Nomadic populations are frequently isolated and vulnerable to diseases including tuberculosis (TB) and human immunodeficiency virus (HIV) due to limited access to health-related information and services, poverty, and social exclusion. We designed and implemented community-driven and -based outreach for TB and HIV based on the results of a TB knowledge, attitude, and practices (KAP) survey in Adamawa, Nigeria. METHODS: We conducted a cross-sectional study on KAP among nomads using an adapted WHO survey. A TB and HIV community-level active case-finding intervention among nomadic populations was planned and delivered based on the KAP survey results. RESULTS: Among 81 respondents, 26 (32.1%) knew what caused TB. More than 60% reported no health facilities in their community. Radio and healthcare workers were primary sources of information on health. Using community input, we developed and broadcasted radio jingles to sensitize people to TB services. Outreach initiatives led to the verbal screening of 61,891 individuals and 306 were diagnosed with TB. Additionally, 4489 people underwent HIV testing, and 69 were HIV-positive, all of whom were linked to treatment. CONCLUSIONS: The results of KAP surveys can inform the design of evidence-based TB and HIV community-driven and -based case-finding interventions in rural Nigeria among nomadic populations.

Understanding Practical, Robust Implementation and Sustainability of Home-based Comprehensive Sexual Health Care: A Realist Review.

This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counseling). Peer-reviewed quantitative and qualitative literature from PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO published between February 2012 and February 2023 was examined. The PRISM framework was used to systematically assess the reach of key populations, effectiveness of the intervention, and effects on the adoption, implementation, and maintenance within routine sexual health care. Of 730 uniquely identified records, 93 were selected for extraction. Of these studies, 60% reported actual interventions and 40% described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/93) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness of most studies was (expected) increased HIV testing. Adoption of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity of the intervention. Most studies suggested maintenance of home-based CSH complementary to clinic-based care. Context and mechanisms were identified which may enhance implementation and maintenance of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of STI and HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of STI and HIV testing among key populations.

Programme science in action: lessons from an observational study of HIV prevention programming for key populations in Lusaka, Zambia.

INTRODUCTION: Optimizing uptake of pre-exposure prophylaxis (PrEP) for individuals at risk of HIV acquisition has been challenging despite clear scientific evidence and normative guidelines, particularly for key populations (KPs) such as men who have sex with men (MSM), female sex workers (FSWs), transgender (TG) people and persons who inject drugs (PWID). Applying an iterative Programme Science cycle, building on the effective programme coverage framework, we describe the approach used by the Centre for Infectious Disease Research in Zambia (CIDRZ) to scale up PrEP delivery and address inequities in PrEP access for KP in Lusaka, Zambia. METHODS: In 2019, CIDRZ partnered with 10 local KP civil society organizations (CSOs) and the Ministry of Health (MOH) to offer HIV services within KP-designated community safe spaces. KP CSO partners led KP mobilization, managed safe spaces and delivered peer support; MOH organized clinicians and clinical commodities; and CIDRZ provided technical oversight. In December 2021, we introduced a community-based intervention focused on PrEP delivery in venues where KP socialize. We collected routine programme data from September 2019 to June 2023 using programme-specific tools and the national electronic health record. We estimated the before-after effects of our intervention on PrEP uptake, continuation and equity for KP using descriptive statistics and interrupted time series regression, and used mixed-effects regression to estimate marginal probabilities of PrEP continuity. RESULTS: Most (25,658) of the 38,307 (67.0%) Key Population Investment Fund beneficiaries were reached with HIV prevention services at community-based venues. In total, 23,527 (61.4%) received HIV testing services, with 15,508 (65.9%) testing HIV negative and found PrEP eligible, and 15,241 (98.3%) initiating PrEP. Across all programme quarters and KP types, PrEP uptake was >90%. After introducing venue-based PrEP delivery, PrEP uptake (98.7% after vs. 96.5% before, p < 0.001) and the number of initiations (p = 0.014) increased significantly. The proportion of KP with ≥1 PrEP continuation visit within 6 months of initiation was unchanged post-intervention (46.7%, 95% confidence interval [CI]: 45.7%, 47.6%) versus pre-intervention (47.2%, 95% CI: 45.4%, 49.1%). CONCLUSIONS: Applying Programme Science principles, we demonstrate how decentralizing HIV prevention services to KP venues and safe spaces in partnership with KP CSOs enabled successful community-based PrEP delivery beyond the reach of traditional facility-based services.

Defining community-led monitoring and its role in programme-embedded learning: lessons from the Citizen Science Project in Malawi and South Africa.

INTRODUCTION: Programme Science (PS) and community-led monitoring (CLM) intersect in unexpected and promising ways. This commentary examines a CLM initiative in Malawi and South Africa to highlight the crucial role of CLM in bolstering the PS framework. By leveraging data sources often overlooked by conventional research and evaluation approaches, CLM emerges as a pivotal element in enhancing programme effectiveness. This paper delineates the fundamental principles of CLM, presents programme outcomes derived from CLM methodologies and contextualizes these findings within the broader framework of PS. DISCUSSION: The Citizen Science Project implements CLM continuously at 33 health facilities: 14 in Malawi (eight in Kasungu District and six in Dedza District), and 19 in South Africa (all in the West Rand District), representing a total catchment area of 989,848 people. Monitoring indicators are developed in an iterative process with community groups. The indicators are unique to each country, but both focus on the uptake of health services (quantitative) and barriers to access (qualitative). Monthly clinic records surveys capture 34 indicators in Malawi and 20 in South Africa and are supplemented by qualitative interviews with care recipients and healthcare workers. Qualitative interviews provide additional granularity and help confirm and explain the more macro trends in service coverage as described in quantitative data. The resulting data analysis reveals key themes that help stakeholders and decision-makers to solve problems collaboratively. Noteworthy outcomes include a substantial increase in multi-month dispensing of antiretroviral therapy (ART) during COVID-19 (from 6% to 31%) with a subsequent recovery surpassing of HIV service benchmarks in Malawi post-pandemic. CONCLUSIONS: While quantifying direct impact remains challenging due to the project's design, CLM proves to be a robust methodology that generates credible data and produces impactful outcomes. Its potential extends beyond the health sector, empowering community leadership and fostering interventions aligned with community needs. As CLM continues to evolve, its integration into PS promises to improve relevance, quality and impact across diverse disciplines.

" because the social work never ends": a qualitative study exploring how NGOs responded to emerging needs while upholding responsibility to HIV prevention and treatment during the war in Ukraine.

INTRODUCTION: Since the onset of the Russian invasion on 24 February 2022, the health system in Ukraine has been placed under tremendous pressure, with damage to critical infrastructure, large losses of human resources, restricted mobility and significant supply chain interruptions. Based on a longstanding partnership between the Ukrainian Institute for Social Research after Oleksandr Yaremenko (UISR after O. Yaremenko) and the Institute for Global Public Health at the University of Manitoba, we explore the impact of the full-scale war on non-governmental organizations (NGOs, including charitable organizations) providing services for key population groups in Ukraine. METHODS: We conducted in-depth qualitative interviews with key representatives from NGOs working with key population groups (i.e., people living with HIV, sex workers, men who have sex with men, people who inject drugs and transgender people) throughout Ukraine. Members of the UISR after O. Yaremenko research team recruited participants from organizations working at national, regional and local levels. The research team members conducted 26 interviews (22 with women and four with men) between 15 May and 7 June 2023. Interviews were conducted virtually in Ukrainian and interpretively analysed to draw out key themes. RESULTS: Applying Roels et al.'s notion of "first responders", our findings explore how the full-scale war personally and organizationally impacted workers at Ukrainian NGOs. Despite the impacts to participants' physical and mental health, frontline workers continued to support HIV prevention and treatment while also responding to the need for humanitarian aid among their clients and the wider community. Furthermore, despite inadequate pay and compensation for their work, frontline workers assumed additional responsibilities, thereby exceeding their normal workload during the extraordinary conditions of war. CONCLUSIONS: NGOs play a vital role as responders, adapting their services to meet the emergent needs of communities during structural shocks, such as war. There is an urgent need to support NGOs with adequate resources for key population service delivery and to increase support for their important role in humanitarian aid.

An implementation evaluation of the Breaking Down human rights barriers to HIV services initiative in Ukraine.

INTRODUCTION: Globally, stark inequities exist in access to HIV treatment and prevention. The eastern European and central Asian region is experiencing the sharpest rise in new HIV acquisition and deaths in the world, with low rates of treatment and prevention services, especially for key and vulnerable populations who face a range of human rights-related barriers to HIV prevention and treatment. METHODS: An implementation learning evaluation approach was used to examine the implementation of the Breaking Down Barriers initiative targeting key and vulnerable populations in Ukraine. Between September 2022 and April 2023, researchers conducted 23 key informant interviews with individuals from the Ukrainian government, implementing organizations and human rights experts. Using a concurrent triangulation design, researchers and key informants, in a process of co-creation, sought to describe programme accomplishments, challenges and innovations in implementation, between 2021 and 2023, including periods before and after Russia's February 2022 full-scale invasion. RESULTS: Eight rights-based interventions related to HIV were identified in Global Fund programme documents and key informant interviews as making up the core of the Breaking Down Barriers initiative in Ukraine. These included programmes seeking to: eliminate stigma and discrimination; ensure the non-discriminatory provision of medical care; promote rights-based law enforcement practices; expand legal literacy ("know your rights"); increase access to justice; improve laws, regulations and policies; reduce gender discrimination, harmful gender norms and violence against women and girls; and mobilize communities for advocacy. These programmes received US$5.9 million in funding. Key informants reported that significant progress had been made addressing human rights barriers and scaling up interventions, both before and after Russia's invasion. Programme implementors adopted innovative approaches, including using paralegals, hotlines and other community-led interventions, to ensure that key and vulnerable populations, including displaced individuals, were able to access prevention and care. CONCLUSIONS: An implementation learning evaluation approach examining programmes addressing human rights barriers to HIV services, designed as a process of co-creation between researchers, programme implementors, government officials and human rights experts, can provide a robust assessment of programme outputs, outcomes and evidence of impact, despite a challenging operational environment.

Capturing the HIV-related social exclusion practices experienced by key populations through photovoice: an interpretative phenomenological study.

BACKGROUND: Key populations are defined as groups that are susceptible to HIV, including Men Sex with Men (MSM), Transgender (TG), Persons who Inject Drug (PID), and Female Sex Worker (FSW). These key populations groups are among the fastest-growing populations in Indonesia. These vulnerable groups are ostracized by society and health services, which makes it difficult to get treatment. This project was carried out to investigate the different experiences and perspectives of these key populations in facing and addressing social and spiritual exclusion. METHODS: A qualitative phenomenological study using photovoice was carried out from July to December 2022. Key populations comprising MSM, TG, PID, and FSW were recruited from community-based peer groups in West Bandung Regency using snowball sampling. This was followed by the Photovoice stages, from workshops to focus group discussions and interviews with audio recordings. Furthermore, thematic data analysis was carried out by interpretative participant narratives and photographs supported by Atlas.ti software. RESULT: Eighteen participants comprising four MSM, five TG, four PIDs, and five FSWs participated in this research. Among these eighteen participants, six were HIV-negative, including 3 PIDs and 3 FSWs, while the remaining were positive. The analysis of the collected data identified four main themes: 1) limited access like unequal treatment, disadvantage, and harassment, 2) social and spiritual impact, 3) coping mechanisms, and 4) self-reflection through photovoice. These results showed that social exclusion occurred in an environment where community values, beliefs, and norms dehumanised these key populations, and where removal of support and care was prominent. Despite these challenges, participant resilience was evidenced by using internal resources and peer support as coping mechanisms. The participants considered photovoice as a tool to foster self-confidence and self-awareness through a reflective process. CONCLUSIONS: The findings of this study highlight the emphasis on participants' openness in sharing their experiences, which can build empathy and promote a more inclusive community in HIV prevention efforts. This research findings can be used to inform HIV policy and practice and inclusion of these key populations in the community. We advocate making the photovoice efforts accessible to a wider audience through exhibitions and various media.

Lived experience, social support, and challenges to health service use during the COVID-19 pandemic among HIV key populations in Indonesia.

The COVID-19 pandemic has greatly affected the lives, health, and social well-being of people globally including presenting special challenges in low to middle income countries for people living with HIV. This study investigates the pandemic experiences of the four key HIV-positive populations in Indonesia: men who have sex with men, transgender women, female sex workers, and people who use drugs. In-depth interviews were conducted with a convenience sample of 22 key population members recruited through 9 nongovernment HIV agencies in Jakarta and Bali, Indonesia. Indonesia's Large-scale Social Restrictions Policy mandating physical distancing and stay-at-home orders had been in effect for 7-10 months at the time of the interviews. The interviews were audio-recorded, transcribed, and coded using NVivo™ (R1.7) software. A grounded theory approach identified key concepts along with similarities, differences, and reoccurring patterns of COVID-19 lived experience among participants. Participants recounted the impact of both the pandemic and the Restriction Policy on their interpersonal, financial, medical, and psychosocial well-being. When in need, they turned to formal and informal sources of financial and social support plus their own resourcefulness. Along with other factors, HIV medication shortages, HIV and COVID-19 related stigma, and fear of acquiring COVID-19 negatively impacted their antiretroviral adherence and the use of health services. The results point to the latent consequences of government attempts to curb a pandemic through public health lockdowns and enforced policies of physical separation. Its findings reveal the importance of ensuring that public safety nets for HIV key populations are available to supplement more informal personal sources of needed support.

Investigating the effectiveness of web-based HIV self-test distribution and linkage to HIV treatment and PrEP among groups at elevated risk of HIV in Viet Nam provinces: a mixed-methods analysis of implementation from pilot to scale-up.

INTRODUCTION: In Viet Nam, key populations (KPs) face barriers accessing HIV services. Virtual platforms can be leveraged to increase access for KPs, including for HIV self-testing (HIVST). This study compares reach and effectiveness of a web-based HIVST intervention from pilot to scale-up in Viet Nam. METHODS: A mixed-methods explanatory sequential design used cross-sectional and thematic analysis. The pilot launched in Can Tho in November 2020, followed by Hanoi and Nghe An in April 2021. Scale-up included Can Tho and Nghe An, with 21 novel provinces from April to December 2022. After risk assessment, participants registered on the website, receiving HIVST (OraQuick®) by courier, peer educator or self-pick-up. Test result reporting and completing satisfaction surveys were encouraged. Intervention reach was measured through numbers accessing the testing, disaggregated by demographics, and proportion of individuals reporting self-testing post-registration. Effectiveness was measured through numbers reporting self-test results, testing positive and linking to care, and testing negative and using HIVST to manage pre-exposure prophylaxis (PrEP) use. Thematic content analysis of free-text responses from the satisfaction survey synthesized quantitative outcomes. RESULTS: In total, 17,589 participants registered on the HIVST website; 11,332 individuals ordered 13,334 tests. Participants were generally young, aged <25 years (4309/11,332, 38.0%), male (9418/11,332, 83.1%) and men who have sex with men (6437/11,332, 56.8%). Nearly half were first-time testers (5069/11,332, 44.9%). Scale-up participants were two times more likely to be assigned female at birth (scale-up; 1595/8436, 18.9% compared to pilot; 392/3727, 10.5%, p < 0.001). Fewer test results were reported in scale-up compared with pilot (pilot: 3129/4140, 75.6%, scale-up: 5811/9194, 63.2%, p < 0.001). 6.3% of all tests were reactive (pilot: 176/3129, 5.6% reactive compared to scale-up: 385/5811, 6.6% reactive, p = 0.063); of which most linked to care (509/522, 97.5%). One-fifth of participants with a negative test initiated or continued PrEP (pilot; 19.8%, scale-up; 18.5%, p = 0.124). Thematic analysis suggested that community delivery models increased programmatic reach. Live chat may also be a suitable proxy for staff support to increase result reporting. CONCLUSIONS: Web-based self-testing in Viet Nam reached people at elevated risk of HIV, facilitating uptake of anti-retroviral treatment and direct linkage to PrEP initiations. Further innovations such as the use of social-network testing services and incorporating features powered by artificial intelligence could increase the effectiveness and efficiency of the approach.

Living a private lie: intersectional stigma, depression and suicidal thoughts for selected young key populations living with HIV in Zambia.

BACKGROUND: Limited research has been conducted on the forms, manifestations and effects of intersectional stigma among young HIV-positive men who have sex with men (MSM) and transgender women (TGW) in Zambia. In this study, we aimed to address this gap by elucidating the experiences of these in a small group of young, HIV + MSM and TGW in Zambia. METHODS: We applied a mixed-methods design. Data were collected from January 2022 to May 2022. Qualitative data were collected using in-depth interviews while quantitative data were collected using a questionnaire. Qualitative transcripts were coded using thematic analysis while paper-based questionnaire data were entered into Kobo Connect. Descriptive statistics, using chi-squared tests were calculated using Excel. In this paper, we provide a descriptive profile of the sample and then focus on the qualitative findings on intersectional stigma, depression, and contemplation of suicide. RESULTS: We recruited 56 participants from three sites: Lusaka, Chipata, and Solwezi districts. Participants' mean age was 23 years. The study found that 36% of all participants had moderate to significant symptoms of depression, 7% had major depression, 30% had moderate signs of anxiety, 11% had high signs of anxiety, 4% had very high signs of anxiety and 36% had contemplated suicide at least once. A greater proportion of TGW had moderate to significant symptoms of depression (40%) or major depression (10%) compared to MSM, at 33% and 6%, respectively (X2 = 0.65; p = 0.42). Similarly, more TGW (55%) had contemplated suicide than MSM peers (36%, X2=1.87; p = 0.17). In the qualitative data, four emergent themes about the forms, manifestations, and effects of intersectional stigma were (1) HIV, sexual orientation, and gender identity disclosure; (2) Dual identity; (3) Challenges of finding and maintaining sexual partners; (4) Coping and resilience. Overall, having to hide both one's sexuality and HIV status had a compounding effect and was described as living "a private lie." CONCLUSION: Effectively addressing stigmas and poor mental health outcomes among young HIV-positive MSM and TGW will require adopting a socio-ecological approach that focuses on structural interventions, more trauma-informed and identity-supportive care for young people with HIV, as well as strengthening of authentic community-informed public health efforts.

HIV seroconversion among female sex workers: retrospective cohort study from a large-scale HIV prevention and sexual and reproductive health program in Tanzania.

Introduction: In 2016, UNAIDS set ambitious targets to reduce global HIV infections by 75% by 2020 and 90% by 2030, based on the 2.1 million new infections reported in 2010. However, by 2022, new HIV infections had only decreased by 38%, from 2.1 million in 2010 to 1.3 million in 2022, raising concerns about reaching the 2030 goal. Female sex workers (FSWs) in sub-Saharan Africa face a disproportionately high risk of HIV acquisition, contributing 5%-20% of all new infections in several countries in the region. This analysis investigates HIV seroconversion and associated factors among FSWs, offering insights into critical interventions for preventing HIV transmission in this population and advancing the goal of ending the HIV pandemic by 2030. Methods: We conducted a retrospective cohort study involving 17,977 FSWs who initially tested HIV negative upon enrollment in the Sauti project between October 2016 and September 2018. HIV incidence rates were calculated by dividing the number of new HIV cases by observed person-time within the cohort. Cox regression analysis identified factors associated with seroconversion. Results: The study revealed an HIV incidence rate of 8.6 per 100 person-years among FSWs [95% confidence interval (CI): 8.1-9.1]. Factors independently associated with HIV seroconversion included age 35 years or older [adjusted hazard ratio (aHR): 2.53; 95% CI: 2.03-3.14], unprotected sex (aHR: 1.27; 95% CI: 1.13-1.42), STI symptoms (aHR: 1.99; 95% CI: 1.67-2.38), and alcohol consumption before sex (aHR: 1.20; 95% CI: 1.07-1.34). Conclusion: Targeted interventions are vital in curbing HIV transmission among FSWs, with a focus on expanding access to primary HIV prevention services, particularly for older FSWs who face heightened risk. Tailored sexual health education programs are imperative to encourage consistent condom use and enable informed decision-making. Accessible and timely STI screening and treatment services are crucial to mitigate HIV transmission risk. Collaborative partnerships between healthcare providers, community organizations, and government agencies are essential in implementing these interventions among FSWs.