Organisation of testing services, structural barriers and facilitators of routine HIV self-testing during sexually transmitted infection consultations: a qualitative study of patients and providers in Abidjan, Côte d'Ivoire.

BACKGROUND: Consultations for sexually transmitted infection (STI) provide an opportunity to offer HIV testing to both patients and their partners. This study describes the organisation of HIV self-testing (HIVST) distribution during STI consultations in Abidjan (Côte d'Ivoire) and analyse the perceived barriers and facilitators associated with the use and redistribution of HIVST kits by STI patients. MATERIALS AND METHODS: A qualitative study was conducted between March and August 2021 to investigate three services providing HIVST: an antenatal care clinic (ANC), a general health centre that also provided STI consultations, and a dedicated STI clinic. Data were collected through observations of medical consultations with STI patients (N = 98) and interviews with both health professionals involved in HIVST distribution (N = 18) and STI patients who received HIVST kits for their partners (N = 20). RESULTS: In the ANC clinic, HIV testing was routinely offered during the first prenatal visit. HIVST was commonly offered to women who had been diagnosed with an STI for their partner's use (27/29 observations). In the general health centre, two parallel pathways coexisted: before the consultation, a risk assessment tool was used to offer HIV testing to eligible patients and, after the consultation, patients who had been diagnosed with an STI were referred to a care assistant for HIVST. Due to this HIV testing patient flow, few offers of HIV testing and HIVST were made in this setting (3/16). At the dedicated STI clinic, an HIVST video was played in the waiting room. According to the health professionals interviewed, this video helped reduce the time required to offer HIVST after the consultation. Task-shifting was implemented there: patients were referred to a nurse for HIV testing, and HIVST was commonly offered to STI patients for their partners' use (28/53). When an HIVST was offered, it was generally accepted (54/58). Both health professionals and patients perceived HIVST positively despite experiencing a few difficulties with respect to offering HIVST to partners and structural barriers associated with the organisation of services. CONCLUSION: The organisation of patient flow and task-shifting influenced HIV testing and offers of HIVST kits. Proposing HIVST is more systematic when HIV testing is routinely offered to all patients. Successful integration requires improving the organisation of services, including task-shifting.

"I take it and give it to my partners who will give it to their partners": Secondary distribution of HIV self-tests by key populations in Côte d'Ivoire, Mali, and Senegal.

INTRODUCTION: HIV epidemics in Western and Central Africa (WCA) remain concentrated among key populations, who are often unaware of their status. HIV self-testing (HIVST) and its secondary distribution among key populations, and their partners and relatives, could reduce gaps in diagnosis coverage. We aimed to document and understand secondary HIVST distribution practices by men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD); and the use of HIVST by their networks in Côte d'Ivoire, Mali, and Senegal. METHODS: A qualitative study was conducted in 2021 involving (a) face-to-face interviews with MSM, FSW, and PWUD who received HIVST kits from peer educators (primary users) and (b) telephone interviews with people who received kits from primary contacts (secondary users). These individual interviews were audio-recorded, transcribed, and coded using Dedoose software. Thematic analysis was performed. RESULTS: A total of 89 participants, including 65 primary users and 24 secondary users were interviewed. Results showed that HIVST were effectively redistributed through peers and key populations networks. The main reported motivations for HIVST distribution included allowing others to access testing and protecting oneself by verifying the status of partners/clients. The main barrier to distribution was the fear of sexual partners' reactions. Findings suggest that members of key populations raised awareness of HIVST and referred those in need of HIVST to peer educators. One FSW reported physical abuse. Secondary users generally completed HIVST within two days of receiving the kit. The test was used half the times in the physical presence of another person, partly for psychological support need. Users who reported a reactive test sought confirmatory testing and were linked to care. Some participants mentioned difficulties in collecting the biological sample (2 participants) and interpreting the result (4 participants). CONCLUSION: The redistribution of HIVST was common among key populations, with minor negative attitudes. Users encountered few difficulties using the kits. Reactive test cases were generally confirmed. These secondary distribution practices support the deployment of HIVST to key populations, their partners, and other relatives. In similar WCA countries, members of key populations can assist in the distribution of HIVST, contributing to closing HIV diagnosis gaps.

Willingness to use and distribute HIV self-test kits to clients and partners: A qualitative analysis of female sex workers' collective opinion and attitude in Côte d'Ivoire, Mali, and Senegal.

BACKGROUND: In West Africa, female sex workers are at increased risk of HIV acquisition and transmission. HIV self-testing could be an effective tool to improve access to and frequency of HIV testing to female sex workers, their clients and partners. This article explores their perceptions regarding HIV self-testing use and the redistribution of HIV self-testing kits to their partners and clients. METHODS: Embedded within ATLAS, a qualitative study was conducted in Côte-d'Ivoire, Mali, and Senegal in 2020. Nine focus group discussions were conducted. A thematic analysis was performed. RESULTS: A total of 87 participants expressed both positive attitudes toward HIV self-testing and their willingness to use or reuse HIV self-testing. HIV self-testing was perceived to be discreet, confidential, and convenient. HIV self-testing provides autonomy from testing by providers and reduces stigma. Some perceived HIV self-testing as a valuable tool for testing their clients who are willing to offer a premium for condomless sex. While highlighting some potential issues, overall, female sex workers were optimistic about linkage to confirmatory testing following a reactive HIV self-testing. Female sex workers expressed positive attitudes toward secondary distribution to their partners and clients, although it depended on relationship types. They seemed more enthusiastic about secondary distribution to their regular/emotional partners and regular clients with whom they had difficulty using condoms, and whom they knew enough to discuss HIV self-testing. However, they expressed that it could be more difficult with casual clients; the duration of the interaction being too short to discuss HIV self-testing, and they fear violence and/or losing them. CONCLUSION: Overall, female sex workers have positive attitudes toward HIV self-testing use and are willing to redistribute to their regular partners and clients. However, they are reluctant to promote such use with their casual clients. HIV self-testing can improve access to HIV testing for female sex workers and the members of their sexual and social network.

Is it possible to recruit HIV self-test users for an anonymous phone-based survey using passive recruitment without financial incentives? Lessons learned from a pilot study in Côte d'Ivoire.

BACKGROUND: Due to the discreet and private nature of HIV self-testing (HIVST), it is particularly challenging to monitor and assess the impacts of this testing strategy. To overcome this challenge, we conducted a study in Côte d'Ivoire to characterize the profile of end users of HIVST kits distributed through the ATLAS project (AutoTest VIH, Libre d'Accéder à la connaissance de son Statut). Feasibility was assessed using a pilot phone-based survey. METHODS: The ATLAS project aims to distribute 221300 HIVST kits in Côte d'Ivoire from 2019 to 2021 through both primary (e.g., direct distribution to primary users) and secondary distribution (e.g., for partner testing). The pilot survey used a passive recruitment strategy-whereby participants voluntarily called a toll-free survey phone number-to enrol participants. The survey was promoted through a sticker on the HIVST instruction leaflet and hotline invitations and informal promotion by HIVST kit-dispensing agents. Importantly, participation was not financially incentivized, even though surveys focussed on key populations usually use incentives in this context. RESULTS: After a 7-month period in which 25,000 HIVST kits were distributed, only 42 questionnaires were completed. Nevertheless, the survey collected data from users receiving HIVST kits via both primary and secondary distribution (69% and 31%, respectively). CONCLUSION: This paper provides guidance on how to improve the design of future surveys of this type. It discusses the need to financial incentivize participation, to reorganize the questionnaire, the importance of better informing and training stakeholders involved in the distribution of HIVST, and the use of flyers to increase the enrolment of users reached through secondary distribution.

Strengthening equitable health systems in West Africa: The regional project on governance research for equity in health systems.

The West African Health Organization (WAHO) supported an innovative regional initiative that contributes to building effective decision making, community and researcher partnerships to strengthen equitable health systems and influence local programmes and policies. Four projects were funded in Nigeria, Sierra Leone, Burkina Faso and Senegal, supported by a Regional Advisory Committee of experts and local Steering Committees. Based on a framework drawn from WAHO objectives, we reviewed documents, conducted 56 project stakeholder interviews and undertook thematic analysis. A diverse range of stakeholders perceived that the projects were in line with national priorities, were well managed and were equitably implemented. The projects generated evidence that could increase access to and improve quality maternal health services. Sustainable partnerships were formed and stakeholder and research team capacity were strengthened. Our study provides insight into project implementation in West Africa, bearing in mind context-specific issues.

Enthusiasm for Introducing and Integrating HIV Self-Testing but Doubts About Users: A Baseline Qualitative Analysis of Key Stakeholders' Attitudes and Perceptions in Côte d'Ivoire, Mali and Senegal.

Since 2019, the ATLAS project, coordinated by Solthis in collaboration with national AIDS programs, has introduced, promoted and delivered HIV self-testing (HIVST) in Côte d'Ivoire, Mali and Senegal. Several delivery channels have been defined, including key populations: men who have sex with men, female sex workers and people who use injectable drugs. At project initiation, a qualitative study analyzing the perceptions and attitudes of key stakeholders regarding the introduction of HIVST in their countries and its integration with other testing strategies for key populations was conducted. The study was conducted from September to November 2019 within 3 months of the initiation of HIVST distribution. Individual interviews were conducted with 60 key informants involved in the project or in providing support and care to key populations: members of health ministries, national AIDS councils, international organizations, national and international non-governmental organizations, and peer educators. Semi structured interviews were recorded, translated when necessary, and transcribed. Data were coded using Dedoose© software for thematic analyses. We found that stakeholders' perceptions and attitudes are favorable to the introduction and integration of HIVST for several reasons. Some of these reasons are held in common, and some are specific to each key population and country. Overall, HIVST is considered able to reduce stigma; preserve anonymity and confidentiality; reach key populations that do not access testing via the usual strategies; remove spatial barriers; save time for users and providers; and empower users with autonomy and responsibility. It is non-invasive and easy to use. However, participants also fear, question and doubt users' autonomy regarding their ability to use HIVST kits correctly; to ensure quality secondary distribution; to accept a reactive test result; and to use confirmation testing and care services. For stakeholders, HIVST is considered an attractive strategy to improve access to HIV testing for key populations. Their doubts about users' capacities could be a matter for reflective communication with stakeholders and local adaptation before the implementation of HIVST in new countries. Those perceptions may reflect the West African HIV situation through the emphasis they place on the roles of HIV stigma and disclosure in HIVST efficiency.

Challenges of HIV Self-Test Distribution for Index Testing When HIV Status Disclosure Is Low: Preliminary Results of a Qualitative Study in Bamako (Mali) as Part of the ATLAS Project.

Context: The rate of HIV status disclosure to partners is low in Mali, a West African country with a national HIV prevalence of 1.2%. HIV self-testing (HIVST) could increase testing coverage among partners of people living with HIV (PLHIV). The AutoTest-VIH, Libre d'accéder à la connaissance de son Statut (ATLAS) program was launched in West Africa with the objective of distributing nearly half a million HIV self-tests from 2019 to 2021 in Côte d'Ivoire, Mali, and Senegal. The ATLAS program integrates several research activities. This article presents the preliminary results of the qualitative study of the ATLAS program in Mali. This study aims to improve our understanding of the practices, limitations and issues related to the distribution of HIV self-tests to PLHIV so that they can offer the tests to their sexual partners. Methods: This qualitative study was conducted in 2019 in an HIV care clinic in Bamako. It consisted of (i) individual interviews with eight health professionals involved in the distribution of HIV self-tests; (ii) 591 observations of medical consultations, including social service consultations, with PLHIV; (iii) seven observations of peer educator-led PLHIV group discussions. The interviews with health professionals and the observations notes have been subject to content analysis. Results: HIVST was discussed in only 9% of the observed consultations (51/591). When HIVST was discussed, the discussion was almost always initiated by the health professional rather than PLHIV. HIVST was discussed infrequently because, in most of the consultations, it was not appropriate to propose partner HIVST (e.g., when PLHIV were widowed, did not have partners, or had delegated someone to renew their prescriptions). Some PLHIV had not disclosed their HIV status to their partners. Dispensing HIV self-tests was time-consuming, and medical consultations were very short. Three main barriers to HIVST distribution when HIV status had not been disclosed to partners were identified: (1) almost all health professionals avoided offering HIVST to PLHIV when they thought or knew that the PLHIV had not disclosed their HIV status to partners; (2) PLHIV were reluctant to offer HIVST to their partners if they had not disclosed their HIV-positive status to them; (3) there was limited use of strategies to support the disclosure of HIV status. Conclusion: It is essential to strengthen strategies to support the disclosure of HIV+ status. It is necessary to develop a specific approach for the provision of HIV self-tests for the partners of PLHIV by rethinking the involvement of stakeholders. This approach should provide them with training tailored to the issues related to the (non)disclosure of HIV status and gender inequalities, and improving counseling for PLHIV.

Describing, analysing and understanding the effects of the introduction of HIV self-testing in West Africa through the ATLAS programme in Côte d'Ivoire, Mali and Senegal.

BACKGROUND: The ATLAS programme aims to promote and implement HIV self-testing (HIVST) in three West African countries: Côte d'Ivoire, Mali, and Senegal. During 2019-2021, in close collaboration with the national AIDS implementing partners and communities, ATLAS plans to distribute 500,000 HIVST kits through eight delivery channels, combining facility-based, community-based strategies, primary and secondary distribution of HIVST. Considering the characteristics of West African HIV epidemics, the targets of the ATLAS programme are hard-to-reach populations: key populations (female sex workers, men who have sex with men, and drug users), their clients or sexual partners, partners of people living with HIV and patients diagnosed with sexually transmitted infections and their partners. The ATLAS programme includes research support implementation to generate evidence for HIVST scale-up in West Africa. The main objective is to describe, analyse and understand the social, health, epidemiological effects and cost-effectiveness of HIVST introduction in Côte d'Ivoire, Mali and Senegal to improve the overall HIV testing strategy (accessibility, efficacy, ethics). METHODS: ATLAS research is organised into five multidisciplinary workpackages (WPs): Key Populations WP: qualitative surveys (individual in-depth interviews, focus group discussions) conducted with key actors, key populations, and HIVST users. Index testing WP: ethnographic observation of three HIV care services introducing HIVST for partner testing. Coupons survey WP: an anonymous telephone survey of HIVST users. Cost study WP: incremental economic cost analysis of each delivery model using a top-down costing with programmatic data, complemented by a bottom-up costing of a representative sample of HIVST distribution sites, and a time-motion study for health professionals providing HIVST. Modelling WP: Adaptation, parameterisation and calibration of a dynamic compartmental model that considers the varied populations targeted by the ATLAS programme and the different testing modalities and strategies. DISCUSSION: ATLAS is the first comprehensive study on HIV self-testing in West Africa. The ATLAS programme focuses particularly on the secondary distribution of HIVST. This protocol was approved by three national ethic committees and the WHO's Ethical Research Committee.

Effects of traumatic events on sex workers' mental health and suicide intentions in Burkina Faso: a trauma-informed approach.

Background Data from other settings suggest that female sex workers (FSWs) are regularly exposed to violence and risks of psychological and physical trauma, although less is known about the effects of this violence. The objective of this study was to understand the experiences of violence and relationships with mental health symptomatology among FSWs. METHODS: A mixed-methods design was used to explore the contexts and social perceptions of violence and mental health effects among FSW in Burkina Faso in 2013. RESULTS: In all, 696 FSWs were recruited via respondent-driven sampling and enrolled in the study in Ouagadougou and Bobo-Dioulasso, Burkina Faso. Seventy participants were also recruited into qualitative research. Nearly two-thirds of quantitative respondents (61.7%) reported experiencing lifetime physical violence, of whom 77.4% reported experiencing violence after initiating sex work. Further, 40.9% of participants reported forced non-consensual sex, most of which occurred after they had started sex work (73.0%). In some cases, the male perpetrator used physical force to force non-consensual sex. Forced non-consensual sex was often without condoms. Among quantitative participants, 41.8% reported ever having feelings of depression; there was also a high prevalence of suicide ideation in this group. Qualitative participants also described feelings of depression, alienation, and suicide ideation. Some qualitative participants described using protective methods to avoid violence and to promote social protection among FSWs. CONCLUSIONS: The findings suggest that stigma and physical and sexual abuse are prevalent among FSWs. Within this context of sex work, lifetime experiences of physical and sexual violence were highly correlated with self-reported mental health symptoms.

Seroepidemiology of syphilis among men who have sex with men in Burkina Faso, West Africa.

Men who have sex with men (MSM) have a disproportionate risk of acquiring sexually transmitted infections (STIs), such as syphilis. However, prevalence and determinants of syphilis among this population are less known in West Africa. This study aims to estimate syphilis prevalence among MSM in Burkina Faso. We conducted a cross-sectional biological and behavior survey in the two main cities of Burkina Faso, Ouagadougou and Bobo-Dioulasso. MSM were recruited using Respondent Driven Sampling (RDS) methods. Data were collected from January to April 2013 in Ouagadougou and from May to August 2013 in Bobo-Dioulasso. Out of the 657 MSM screened for syphilis, 6.1% (40/657) tested positive for Treponema pallidum antibodies and 1.1% (7/657) for active syphilis. Population-weighted prevalence of active syphilis was 2.1% (95% CI, 01.1-04.4) in Ouagadougou and 0.0% in Bobo-Dioulasso. Serologic markers of syphilis (anti-Treponema antibodies) were found among 7.4% (95% CI 5.0-10.8) of MSM in Ouagadougou and 5.0% (95% CI 3.1-8.0) in Bobo-Dioulasso. No significant differences were found in syphilis serological markers prevalence by participants' sociodemographic and behavioral characteristics. The prevalence of syphilis among MSM is low and comparable to that of other individuals of reproductive age in Burkina Faso. This low prevalence is very encouraging and suggests implementation of effective public health intervention programs which direct resources and services toward MSM to prevent further spread of syphilis infection and to limit HIV transmission in this group.

Development and reliability of metrics to characterize types and sources of stigma among men who have sex with men and female sex workers in Togo and Burkina Faso.

BACKGROUND: Stigma is a multifaceted concept that potentiates Human Immunodeficiency Virus and sexually transmitted infection acquisition and transmission risks among key populations, including men who have sex with men (MSM) and female sex workers (FSW). Despite extensive stigma literature, limited research has characterized the types and sources of stigma reported by key populations in Sub-Saharan Africa. METHODS: This study leveraged data collected from 1356 MSM and 1383 FSW in Togo and Burkina Faso, recruited via respondent-driven sampling. Participants completed a survey instrument including stigma items developed through systematic reviews and synthesis of existing metrics. Using exploratory factor analysis with promax oblique rotation, 16 items were retained in a stigma metric for MSM and 20 in an FSW stigma metric. To assess the measures' convergent validity, their correlations with expected variables were examined through bivariate logistic regression models. RESULTS: One factor, experienced stigma, included actions that were carried out by multiple types of perpetrators and included being arrested, verbally harassed, blackmailed, physically abused, tortured, or forced to have sex. Other factors were differentiated by source of stigma including healthcare workers, family and friends, or police. Specifically, stigma from healthcare workers loaded on two factors: experienced healthcare stigma included being denied care, not treated well, or gossiped about by healthcare workers and anticipated healthcare stigma included fear of or avoiding seeking healthcare. Stigma from family and friends included feeling excluded from family gatherings, gossiped about by family, or rejected by friends. Stigma from police included being refused police protection and items related to police confiscation of condoms. The Cronbach's alpha ranged from 0.71-0.82. Median stigma scores, created for each participant by summing the number of affirmative responses to each stigma item, among MSM were highest in Ouagadougou and among FSW were highest in both Ouagadougou and Bobo-Dioulasso. Validation analyses demonstrated higher stigma was generally significantly associated with suicidal ideation, disclosure of involvement in sex work or same-sex practices, and involvement in organizations for MSM or FSW. CONCLUSIONS: Taken together, these data suggest promising reliability and validity of metrics for measuring stigma affecting MSM and FSW in multiple urban centers across West Africa.

Human immunodeficiency virus (HIV) among men who have sex with men: results of the first integrated biological and behavioral survey in Burkina Faso, West Africa.

BACKGROUND: Many men who have sex with men (MSM) are at significant risk for HIV infection. The objective of this study was to determine the prevalence and correlates of HIV infection among MSM in Burkina Faso. METHODS: A cross-sectional biological and behavioral survey was conducted from January to August 2013 among MSM in Ouagadougou and Bobo-Dioulasso. MSM 18 years old and above were recruited using respondent driven sampling (RDS). A survey was administered to study participants followed by HIV testing. Population prevalence estimates and 95% confidence intervals (CI) adjusted for the RDS design were produced using the RDS Analysis Tool version 6.0.1 (RDS, Inc., Ithaca, NY). RESULTS: A total of 662 MSM were enrolled in Ouagadougou (n = 333) and Bobo-Dioulasso (n = 329). The majority were unmarried, with an average age of 22.1 ± 4.4 years old in Ouagadougou and 23.1 ± 4.7 years old in Bobo-Dioulasso. RDS-adjusted HIV prevalence was 1.7% (95% CI: 0.9-3.1) in Ouagadougou and 2.7% (95% CI: 1.6-4.6) in Bobo-Dioulasso. HIV prevalence among MSM under 25 years old was 1.3% (95% CI: 0.6-2.8) and 0.9% (95% CI: 0.4-2.5) respectively in Ouagadougou and Bobo-Dioulasso, compared to 5.4% (95% CI: 2.2-12.5) and 6.6% (95% CI: 3.4-12.3) among those 25 years old or older in these cities (p = 0.010 and p < 0.001). CONCLUSIONS: Results from this first biological and behavioral survey among MSM in Burkina Faso suggest a need for programs to raise awareness among MSM and promote safer sex, particularly for young MSM to prevent HIV transmission. These programs would need support from donors for innovative actions such as promoting and providing pre-exposure prophylaxis, condoms and water-based lubricants, HIV counseling, testing, early treatment initiation and effective involvement of the MSM communities.

Syphilis among Female Sex Workers: Results of Point-of-Care Screening during a Cross-Sectional Behavioral Survey in Burkina Faso, West Africa.

BACKGROUND: Syphilis among female sex workers (FSW) remains a public health concern due to its potential impact on their health and the possibility of transmission to their clients, partners, and children. Recent data on the prevalence of syphilis in the population in West Africa are scarce. The objective of this study was to measure the seroprevalence of syphilis serological markers among female sex workers in Burkina Faso. METHODS: We conducted a cross-sectional survey among FSW between February 2013 and May 2014. Participants were recruited using respondent-driven sampling (RDS) methods in five cities of Burkina Faso (Ouagadougou, Bobo-Dioulasso, Koudougou, Ouahigouya, and Tenkodogo). FSW were enrolled and screened for syphilis using a syphilis serological rapid diagnostic test. Data from all cities were analyzed with Stata version 14.0. RESULTS: A total of 1045 FSW were screened for syphilis. Participants' mean age was 27.2 ± 0.2 years. The syphilis serological markers were detected in 5.6% (95% CI: 4.4-7.2) of the participants whereas active syphilis was seen in 1.4% (95% CI: 0.9-2.4). RDS weighted prevalence of syphilis serological markers and active syphilis by city were, respectively, estimated to be 0.0% to 11.0% (95% CI: 8.1-14.7) and 0.0% to 2.2% (95% CI: 1.1-4.4). No syphilis markers were found among Ouahigouya FSW. Low education level and high number of clients were factors associated with syphilis markers among the FSW. CONCLUSION: The prevalence of syphilis markers was high during this study among FSW. This highlights the need to reinforce the comprehensive preventive measures and treatment of syphilis in this population.

Stigma as a barrier to health care utilization among female sex workers and men who have sex with men in Burkina Faso.

PURPOSE: The aim of this study is to examine the prevalence and correlates of perceived health care stigma among female sex workers (FSWs) and men who have sex with men (MSM), including other stigma types, suicidal ideation, and participation in social activities. METHODS: FSWs (N = 350) and MSM (N = 330) aged ≥18 were recruited in Bobo-Dioulasso, Burkina Faso. Perceived health care stigma was defined as either ever being afraid of or avoiding health care services because someone might find out the participant has sex with men (for MSM) or sells sex (for FSW). Correlates of perceived health care stigma were examined using multivariable logistic regression. RESULTS: The prevalence of perceived health care stigma was 14.9% (52/350) and 24.5% (81/330) in FSWs and MSM, respectively. Among FSWs, experienced or social stigma, including verbal harassment (adjusted odds ratio [aOR] = 3.59, 95% confidence interval [CI] 1.48-8.71), feeling rejected by friends (aOR = 2.30, 95% CI 1.14-4.64), and feeling police refused to protect them (aOR = 2.58, 95% CI 1.27-5.25), was associated with perceived health care stigma. Among MSM, experiencing verbal harassment (aOR = 1.95, 95% CI 1.09-3.50) and feeling scared to walk in public (aOR = 2.93, 95% CI 1.47-5.86) were associated with perceived health care stigma. CONCLUSIONS: In these key populations, perceived health care stigma was prevalent and associated with experienced and social stigmas. To increase coverage of effective HIV services, interventions should incorporate approaches to comprehensively mitigate stigma.

HIV among Female Sex Workers in Five Cities in Burkina Faso: A Cross-Sectional Baseline Survey to Inform HIV/AIDS Programs.

BACKGROUND: Female sex workers (FSWs) are considered a vulnerable population for HIV infection and a priority for HIV/AIDS response programs. This study aimed to determine HIV prevalence among FSWs in five cities in Burkina Faso. METHODS: FSWs aged 18 and older were recruited using respondent driven sampling (RDS) in five cities (Ouagadougou, Bobo-Dioulasso, Koudougou, Ouahigouya, and Tenkodogo) in Burkina Faso from 2013 to 2014. HIV testing was performed using the HIV testing national algorithm. We conducted bivariate and multivariate logistic regression analysis to assess correlates of HIV in all cities combined (not RDS-adjusted). RESULTS: Among Ouagadougou, Koudougou, and Ouahigouya FSWs, RDS-adjusted HIV prevalence was 13.5% (95% Confidence Interval [CI]: 9.6-18.7), 13.3% (95% CI: 7.6-22.4), and 13.0% (95% CI: 7.6-21.3), respectively, compared to 30.1% (95% CI: 25.5-35.1) among Bobo-Dioulasso FSWs. Factors associated with HIV infection were age (adjusted odds ratio [aOR] = 7.84 95% CI: 3.78-16.20), being married or cohabitating (aOR = 2.43, 95% CI: 1.31-4.49), and history of pregnancy (aOR = 5.24, 95% CI: 1.44-18.97). CONCLUSION: These results highlight the need to strengthen HIV prevention among FSWs, through behavior change strategies, and improve access to sexual and reproductive health services.

Reproductive health needs of female sex workers and opportunities for enhanced prevention of mother-to-child transmission efforts in sub-Saharan Africa.

INTRODUCTION: HIV infection and pregnancy are both common among female sex workers (FSW), indicating the need for prevention of mother-to-child transmission (PMTCT) among FSW. METHODS: FSW were enrolled into studies in Swaziland, Burkina Faso and Togo using respondent-driven sampling. Women completed interview-administered socio-behavioural surveys and HIV counselling and testing. This secondary analysis describes contraceptive use and attempted pregnancy among reproductive-aged FSW (16-49 years). Robust Poisson regression with generalised estimating equations to account for clustering within recruitment networks was used to separately estimate associations between current unmet contraceptive need and attempted pregnancy among FSW. RESULTS: Overall 1666 FSW were enrolled, 1372 (82.4%) of whom had ever been pregnant. In Togo and Burkina Faso, 83 FSW reported a prior HIV diagnosis and having a child, of which 12.1% (10/83) reported a child known to be HIV-positive. Twenty-five per cent of FSW had an unmet need for contraception; 9% of FSW employed dual contraception, including highly effective non-barrier methods and consistent condom use. Consistent condom use varied substantially by partner type and was higher with clients than non-paying partners. Nineteen per cent (n=313/1666) of FSW were trying to conceive. HIV-positive, undiagnosed FSW were more likely to be trying to conceive as compared to HIV-negative FSW; among 98 HIV-positive women trying to conceive, 25.5% were on antiretroviral therapy. CONCLUSIONS: FSW have varying reproductive goals and contraceptive usage. Efforts to improve coverage of comprehensive family planning - including efforts to increase HIV testing and engagement in treatment among FSW trying to conceive - are necessary for PMTCT.

Suicidal ideation among MSM in three West African countries: Associations with stigma and social capital.

BACKGROUND: Suicidal ideation is understudied among men who have sex with men (MSM) across Sub-Saharan Africa. AIMS: This study aimed to explore social capital and sexual behavior stigma associated with suicidal ideation among MSM in the West African nations of The Gambia, Burkina Faso and Togo. METHODS: Participants were recruited using respondent-driven sampling and snowball sampling across multiple cities (n = 1555) from July 2011 to August 2013. During a single study visit, participants completed a survey. Logistic regression models were used to assess bivariate and multivariable associations with suicidal ideation. RESULTS: The prevalence of lifetime suicidal ideation was 13% overall and ranged 6%-17% across study sites. After adjusting for potential confounders, MSM who reported stigma as a result of having sex with men were more likely to report suicidal ideation. Physical and sexual violence was strongly associated with suicidal ideation, including being physically harmed (adjusted odds ratio (aOR) = 2.94, 95% confidence interval (CI) = 1.91, 4.52), tortured (aOR = 3.86, 95% CI = 2.17, 6.86) and raped (aOR = 3.07, 95% CI = 2.05, 4.60). In contrast, increasing social participation with the broader community was associated with decreased report of suicidal ideation (aOR = 0.91, 95% CI = 0.85, 0.99). CONCLUSION: Sexual behavior stigma should be addressed to improve mental health among MSM in Western Sub-Saharan Africa.

Characterizing the HIV risks and potential pathways to HIV infection among transgender women in Côte d'Ivoire, Togo and Burkina Faso.

INTRODUCTION: Transgender women are at high risk for the acquisition and transmission of HIV. However, there are limited empiric data characterizing HIV-related risks among transgender women in sub-Saharan Africa. The objective of these analyses is to determine what factors, including sexual behaviour stigma, condom use and engagement in sex work, contribute to risk for HIV infection among transgender women across three West African nations. METHODS: Data were collected via respondent-driven sampling from men who have sex with men (MSM) and transgender women during three- to five-month intervals from December 2012 to October 2015 across a total of six study sites in Togo, Burkina Faso and Côte d'Ivoire. During the study visit, participants completed a questionnaire and were tested for HIV. Chi-square tests were used to compare the prevalence of variables of interest between transgender women and MSM. A multilevel generalized structural equation model (GSEM) was used to account for clustering of observations within study sites in the multivariable analysis, as well as to estimate mediated associations between sexual behaviour stigma and HIV infection among transgender women. RESULTS: In total, 2456 participants meeting eligibility criteria were recruited, of which 453 individuals identified as being female/transgender. Transgender women were more likely than MSM to report selling sex to a male partner within the past 12 months (p<0.01), to be living with HIV (p<0.01) and to report greater levels of sexual behaviour stigma as compared with MSM (p<0.05). In the GSEM, sexual behaviour stigma from broader social groups was positively associated with condomless anal sex (adjusted odds ratio (AOR)=1.33, 95% confidence interval (CI)=1.09, 1.62) and with selling sex (AOR=1.23, 95% CI=1.02, 1.50). Stigma from family/friends was also associated with selling sex (AOR=1.42, 95% CI=1.13, 1.79), although no significant associations were identified with prevalent HIV infection. CONCLUSIONS: These data suggest that transgender women have distinct behaviours from those of MSM and that stigma perpetuated against transgender women is impacting HIV-related behaviours. Furthermore, given these differences, interventions developed for MSM will likely be less effective among transgender women. This situation necessitates dedicated responses for this population, which has been underserved in the context of both HIV surveillance and existing responses.

Examining the Correlates of Sexually Transmitted Infection Testing Among Men Who Have Sex With Men in Ouagadougou and Bobo-Dioulasso, Burkina Faso.

BACKGROUND: Men who have sex with men (MSM) are a population at risk for HIV acquisition and transmission and other sexually transmitted infections (STIs). In Burkina Faso, the prevalence of HIV among MSM is higher than that of other reproductive-aged adults. Early and frequent STI testing and treatment can help prevent HIV acquisition and transmission and may improve linkage to care. METHODS: A cross-sectional study used respondent-driven sampling of MSM in the urban centers of Ouagadougou and Bobo-Dioulasso, Burkina Faso, to complete a questionnaire and HIV and syphilis testing. The binary-dependent variable in these analyses was self-reported prior STI testing in the past 12 months. Independent variables included sociodemographic characteristics, sexual behaviors, and psychosocial factors, selected according to the modified social ecological model. Bivariate associations at the P<0.05 level were used to create a manual forward stepwise multivariable logistic regression. RESULTS: Seventy-six percent of participants (511/672) did not test for STIs in the last 12 months. Testing for STIs was associated with STI symptoms (odds ratio [OR], 2.56; 95% confidence interval [95% CI], 1.39-4.76) and independently associated with depressive symptoms (adjusted OR, 1.49; 95% CI, 1.01-2.20) and discussing HIV and STIs with main male partners (adjusted OR, 1.73; 95% CI, 1.23-1.76). CONCLUSIONS: These data suggest that periodic targeted STI screening for MSM in Burkina Faso may represent an important component of comprehensive HIV prevention programming. The relationship between depression and STI risks is well established, and these data further indicate that screening for depression may be warranted during these clinical encounters.

Mothers who sell sex: a potential paradigm for integrated HIV, sexual, and reproductive health interventions among women at high risk of HIV in Burkina Faso.

BACKGROUND: Antenatal care is a point of entry into the health system for women across Africa and may facilitate the uptake of HIV services among female sex workers (FSWs). This study aimed to evaluate the determinants of motherhood among FSWs, their sexual risks, and their engagement in health care. METHODS: A cross-sectional study was conducted from January to July 2013 among FSWs in Ouagadougou and Bobo-Dioulasso, Burkina Faso. The study used respondent-driven sampling for HIV testing and behavioral data collection. Predictors of motherhood and the association of motherhood and sex work dynamics were assessed separately using logistic regression. RESULTS: Of the 696 women enrolled, the majority of participants (76.6%, n = 533) had at least 1 biological child. Mothers were more likely to have a nonpaying partner [adjusted odds ratio (aOR), 1.73; 95% confidence interval (CI): 1.20 to 2.49], and significantly less likely to currently desire to conceive (aOR, 0.21; 95% CI: 0.13 to 0.33). Motherhood was predictive of having reduced condomless vaginal or anal sex with a new client [age-adjusted odds ratio (aaOR), 0.80; 95% CI: 0.65 to 0.97] in the past 30 days, and increased condomless vaginal or anal sex with a nonpaying partner (aaOR, 1.49; 95% CI: 1.13 to 1.96). Motherhood was prognostic of a higher likelihood of ever being tested for HIV (aaOR, 1.89; 95% CI: 1.55 to 2.31). Motherhood was predictive of reporting limited difficulty when accessing health services (aaOR, 0.15; 95% CI: 0.67 to 0.34). CONCLUSIONS: Motherhood is common among FSWs. The results indicate that FSWs who are mothers may have more exposure to health care because of seeking antenatal/perinatal services, presenting important opportunities for inclusion in the HIV continuum of care and to prevent vertical transmission.