Increasing Testing Options for Key Populations in Burundi Through Peer-Assisted HIV Self-Testing: Descriptive Analysis of Routine Programmatic Data.

BACKGROUND: In Burundi, given the low testing numbers among key populations (KPs), peer-assisted HIV self-testing (HIVST) was initiated for female sex workers (FSWs), men who have sex with men (MSM), and transgender people to provide another testing option. HIVST was provided by existing peer outreach workers who were trained to provide support before, during, and after the administration of the test. People who screened reactive were referred and actively linked to confirmatory testing, and those confirmed positive were linked to treatment. Standard testing included HIV testing by clinical staff either at mobile clinics in the community or in facilities. OBJECTIVE: This study aims to improve access to HIV testing for underserved KPs, improve diagnoses of HIV serostatus among key populations, and link those who were confirmed HIV positive to life-saving treatment for epidemic control. METHODS: A descriptive analysis was conducted using routine programmatic data that were collected during a 9-month implementation period (June 2018 to March 2019) for peer-assisted HIVST among FSWs, MSM, and transgender people in 6 provinces where the US Agency for International Development-and US President's Emergency Plan for AIDS Relief-funded LINKAGES (Linkage across the Continuum of HIV Services for KP Affected by HIV) Burundi project was being implemented. Chi-square tests were used to compare case-finding rates among individuals who were tested through HIVST versus standard testing. Multivariable logistic regression was performed to assess factors that were independently associated with HIV seropositivity among FSWs and MSM who used HIVST kits. RESULTS: A total of 2198 HIVST kits were administered (FSWs: 1791/2198, 81.48%; MSM: 363/2198, 16.52%; transgender people: 44/2198, 2%). HIV seropositivity rates from HIVST were significantly higher than those from standard testing for FSWs and MEM and nonsignificantly higher than those from standard testing for transgender people (FSWs: 257/1791, 14.35% vs 890/9609, 9.26%; P<.001; MSM: 47/363, 12.95% vs 90/2431, 3.7%; P<.001; transgender people: 10/44, 23% vs 6/36, 17%; P=.50). Antiretroviral therapy initiation rates were significantly lower among MSM who were confirmed to be HIV positive through HIVST compared to those among MSM who were confirmed to be HIV positive through standard testing (40/47, 85% vs 89/90, 99%; P<.001). No significant differences in antiretroviral therapy initiation rates were found between the FSW and transgender groups. Multivariable analyses among FSWs who used HIVST kits showed that being aged ≥25 years (adjusted odds ratio 1.9, 95% CI 1.4-2.6) and having >8 clients per week (adjusted odds ratio 1.3, 95% CI 1.0-1.8) were independently associated with HIV seropositivity. CONCLUSIONS: The results demonstrate the potential effectiveness of HIVST in newly diagnosing underserved KPs and linking them to treatment.

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d'Ivoire: Program Data Analysis.

BACKGROUND: In the context of the mostly generalized HIV epidemic in Côte d'Ivoire, key populations bear a higher burden of HIV than that borne by the general reproductive-aged population. Mathematical models have demonstrated the significant potential impact and cost-effectiveness of improving the coverage of HIV prevention and treatment services for key populations in Côte d'Ivoire. However, in 2019, coverage of these services remained limited by multiple intersecting stigmas affecting key populations, necessitating the study of innovative implementation strategies to better meet the needs of those most marginalized. Here, we leverage programmatic data to compare the effectiveness of the enhanced and traditional peer outreach approaches in reaching and providing community HIV testing to female sex workers not readily engaged in HIV prevention and treatment services in Côte d'Ivoire. OBJECTIVE: The aim of this study was to describe the characteristics of female sex workers reached by the LINKAGES project in Côte d'Ivoire with enhanced peer outreach and traditional peer outreach and to compare HIV-related outcomes between the women reached by both strategies. METHODS: Deidentified routine programmatic data collected as part of LINKAGES Côte d'Ivoire between October 2017 and April 2018 were used in these analyses. Demographic characteristics and HIV indicators including HIV testing history, HIV case-finding, linkage to HIV treatment, and treatment initiation were assessed using descriptive statistics. Differences in these indicators were compared by outreach strategy using Pearson chi-square tests. RESULTS: There were 9761 women reached with enhanced peer outreach and routine peer outreach included in these analyses. The overall case-finding rate in the sample was 7.8% (698/8851). Compared with women reached by routine outreach, those reached by enhanced peer outreach were more likely to have previously been tested for HIV (enhanced: 1695/2509, 67.6%; routine: 4302/7252, 60.0%; χ21=43.8; P=.001). The enhanced peer outreach approach was associated with a higher HIV case-finding rate (enhanced: 269/2507 10.7%; routine: 429/6344, 6.8%; χ21=32.3; P=.001), higher proportion of linkage to treatment (enhanced: 258/269, 95.9%; routine: 306/429, 71.3%; χ21=64.4; P=.001), and higher proportion of treatment initiation (enhanced: 212/269, 78.8%; routine: 315/429, 73.3%; χ21=2.6; P=.11). Women reached by both approaches were categorized as high risk for HIV-related behaviors such as condomless sex and number of sex acts in the previous week. CONCLUSIONS: These analyses suggest that the novel peer-referral strategy, the enhanced peer outreach approach, was effective in reaching female sex workeres in Côte d'Ivoire with demonstrated acquisition risks for HIV and who had not been effectively engaged by routine outreach approaches. Scaling up novel strategies such as enhanced peer outreach in the context of differentiated service models may be needed to optimize HIV prevention and treatment outcomes for key populations in Côte d'Ivoire.

Reaching the unreached: Performance of an enhanced peer outreach approach to identify new HIV cases among female sex workers and men who have sex with men in HIV programs in West and Central Africa.

Finding new HIV-positive cases remains a priority to achieve the UNAIDS goals. An enhanced peer outreach approach (EPOA) was implemented to expand the delivery of HIV services to female sex workers (FSWs) and men who have sex with men (MSM) in three countries in West and Central Africa. The aim of EPOA is to identify new HIV-positive cases. EPOA was implemented in Burundi among FSWs, and in Cote d'Ivoire and Democratic Republic of the Congo (DRC) among both FSWs and MSM. Implementation ranged from five to nine weeks and was nested within a three-month reporting period. Standard outreach was suspended for the duration of EPOA implementation but was resumed thereafter. Summary service statistics were used to compare HIV seropositivity during standard outreach and EPOA. Trends were analyzed during the quarter in which EPOA was implemented, and these were compared with the two preceding quarters. Differences in proportions of HIV seropositivity were tested using Pearson's chi-square test; p-values of less than 0.05 were considered statistically significant. Overall, EPOA resulted in a higher proportion of new HIV-positive cases being found, both within and between quarters. In Burundi, HIV seropositivity among FSWs was significantly higher during EPOA than during standard outreach (10.8% vs. 4.1%, p<0.001). In Cote d'Ivoire, HIV seropositivity was significantly higher during EPOA among both populations (FSWs: 5.6% vs. 1.81%, p<0.01; MSM: 15.4% vs. 5.9%; p<0.01). In DRC, HIV seropositivity was significantly higher during EPOA among MSM (6.9% vs. 1.6%; p<0.001), but not among FSWs (5.2% vs. 4.3%; p = 0.08). Trends in HIV seropositivity during routine outreach for both populations were constant during three successive quarters but increased with the introduction of EPOA. EPOA is a public health approach with great potential for reaching new populations and ensuring that they are aware of their HIV status.

Think global, act local: the experience of Global Fund and PEPFAR joint cascade assessments to harmonize and strengthen key population HIV programmes in eight countries.

INTRODUCTION: The Global Fund and the US President's Emergency Plan for AIDS Relief (PEPFAR) are major donors to HIV services with key populations (KPs) to achieve the UNAIDS 95-95-95 epidemic control goals. The programmes they fund are not always well aligned or coordinated, decreasing their effectiveness. Joint assessments are designed and led by LINKAGES, a project funded by PEPFAR and the US Agency for International Development, to improve coordination among donors and on-the-ground implementation of KP HIV programmes. Joint assessments help identify barriers that prevent KPs from accessing interventions along the cascade of prevention, diagnosis and treatment services, and provide recommendations to improve and align programmes. Detailed reports from eight assessments in Malawi, Cameroon, Swaziland, Haiti, Angola, Nepal, Côte d'Ivoire and Botswana were analysed for thematic challenges, and recommendations are presented. The purpose of the paper is to identify commonalities across KP HIV programmes that were found through the assessments so others can learn and then strengthen their programmes to become more effective. DISCUSSION: The joint cascade assessments offered countries feedback on HIV programme challenges and recommendations for strengthening them at national, subnational and local levels. Shared intervention areas included: (1) robust population size estimates to inform service delivery targets and to budget resources for KP outreach; (2) accessible and KP-friendly services most relevant to individuals to increase retention in the HIV cascade; (3) decentralized, community-based services for HIV testing and antiretroviral therapy, and new approaches including self-testing and PrEP; (4) addressing structural issues of stigma, discrimination and violence against KPs to create a more enabling environment; and (5) more effective and continual tracking of KPs across the cascade, and coordinated, harmonized monitoring tools and reporting systems between donor-funded and national programmes. CONCLUSIONS: The assessment teams and country stakeholders viewed the assessments as a best practice for coordinating donor-funded programmes that may overlap or inefficiently serve KPs. Global and national HIV programmes need investments of time, resources, and commitment from stakeholders to continually course-correct to align and improve programmes for sustained impact. The type of continued partnership demonstrated by the joint assessments is key to address HIV among KPs globally.

Kenyan in-school youths' level of understanding of abstinence, being faithful, and consistent condom use terms: implications for HIV-prevention programs.

The HIV-prevention behaviors of "abstinence" from sex, "being faithful" to one sexual partner, and "condom use" (ABC) are the focus of many international HIV interventions. Kenyan in-school youth ages 13-19 years (N = 1,375) were surveyed before the intended HIV-prevention intervention was implemented. As part of the survey, students wrote their definitions of the terms in a space provided. These definitions were qualitatively analyzed by determining recurrent themes, developing a codebook, and having two coders code the responses. The entire definition was assigned an overall fully comprehended, partly comprehended, did not comprehend, or no response code in comparison to the conventional definition of the term. Overall, 48% fully comprehended abstinence, 20% fully comprehended being faithful, and 7% fully comprehended consistent condom use. This suggests that these terms, and the meanings behind them, need additional clarification and discussion if they are to be used appropriately in HIV-prevention programs.

Injection drug users' strategies to manage perceptions of personal risk: how do IDUs see HIV as having affected them?

The U.S. public health community is in its 3rd decade of seeking to prevent and treat HIV/AIDS. Injection drug users (IDUs) are central to targeted HIV prevention interventions as approximately one third of new U.S. infections are attributable to injection drug use (Santibanez et al.,Journal of Urban Health, 83[1], 86-100, 2006). Targeted behavior change efforts are often explicitly built upon the risk perception of targeted individuals. In this article, we consider the efficacy of behavior change based on IDUs' perceptions of elevated risk. Our qualitative analysis of 28 interviews with HIV negative IDUs in inner city Baltimore suggests that participants did not see themselves as personally affected by HIV. Rather, respondents constructed accounts in which they differentiated themselves from the type of people who are so affected, thereby creating a less stigmatizing identity. We argue that effective HIV prevention should explicitly acknowledge and address the stigmatized IDU identity, rather than assuming readiness for behavior change.