The Effect of Family Wealth on Physical Function Among Older Adults in Mpumalanga, South Africa: A Causal Network Analysis.

Objectives: The aging of the South African population could have profound implications for the independence and overall quality of life of older adults as life expectancy increases. While there is evidence that lifetime socio-economic status shapes risks for later function and disability, it is unclear whether, and how, the wealth of family members shapes these outcomes. We investigated the relationship between outcomes activities of daily living (ADL), grip strength, and gait speed, and the household wealth of non-coresident family members. Methods: Using data from Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) and the Agincourt Health and Demographic Surveillance System (AHDSS), we examined the relationship between physical function and household and family wealth in the 13 preceding years. HAALSI is a cohort of 5,059 adults who were 40 years or older at baseline in 2014. Using auto-g-computation-a recently proposed statistical approach to quantify causal effects in the context of a network of interconnected units-we estimated the effect of own and family wealth on the outcomes of interest. Results: We found no evidence of effects of family wealth on physical function and disability. Conclusion: Further research is needed to assess the effect of family wealth in early life on physical function and disability outcomes.

Impact of family networks on uptake of health interventions: evidence from a community-randomized control trial aimed at increasing HIV testing in South Africa.

INTRODUCTION: While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network. METHODS: The "Home-Based Intervention to Test and Start" (HITS) was a 2×2 factorial community-randomized controlled trial in Umkhanyakude, KwaZulu-Natal, South Africa, embedded in the Africa Health Research Institute's population-based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro-incentive and a male-targeted HIV-specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro-incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co-residents, a socio-centric family network was constructed among HITS-eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level. RESULTS: Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3-7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9-22.3). The difference in efficacy was statistically significant (21.1-6.5 = 14.6%; 95% CI: 9.3-19.9). CONCLUSIONS: Micro-incentives appear to have synergistic effects when distributed within family networks. These effects support family network-based approaches for the design of health interventions.

Associations between punitive policies and legal barriers to consensual same-sex sexual acts and HIV among gay men and other men who have sex with men in sub-Saharan Africa: a multicountry, respondent-driven sampling survey.

BACKGROUND: Few assessments of associations between structural-level factors and HIV among gay men and other men who have sex with men (MSM) have been conducted, especially in sub-Saharan Africa. Our objective was to examine HIV testing history, HIV status, and stigmas among MSM living in ten countries with heterogeneous legal environments. METHODS: This study used pooled data from ten country-specific, cross-sectional studies done in 25 sites in Burkina Faso, Cameroon, Côte d'Ivoire, The Gambia, Guinea-Bissau, Nigeria, Senegal, Eswatini, Rwanda, and Togo. MSM were recruited by respondent-driven sampling and were eligible if they met country-specific requirements for age, area of residence, and self reported being assigned male sex at birth and having anal sex with a man in the past 12 months. Policy related to same-sex sexual behaviour for each country was categorised as not criminalised or criminalised. Countries were also categorised on the basis of recent reports of prosecutions related to same-sex sexual acts. Legal barriers were defined as those that legally prevented registration or operation of sexual orientation related civil society organisations (CSOs). Individual data on HIV testing history, HIV status, and stigma were collected via interviewer-administered sociobehavioural questionnaires and HIV testing. Multilevel logistic regression with random intercepts was used to assess the association between policies, recent prosecutions, legal barriers to CSOs, and HIV-related factors with adjusted odds ratios (aORs) and 95% CIs. FINDINGS: Between Aug 3, 2011, and May 27, 2020, we recruited 8047 MSM with a median age of 23 years (IQR 21-27). 4886 (60·7%) lived in countries that criminalise same-sex sexual acts. HIV prevalence among MSM was higher in criminalised settings than non-criminalised settings (aOR 5·15, 95% CI 1·12-23·57); higher in settings with recent prosecutions than in settings without prosecutions (12·06, 7·19-20·25); and higher in settings with barriers to CSOs than without barriers to CSOs (9·83, 2·00-48·30). HIV testing or status awareness was not associated with punitive policies or practices. Stigma was associated with HIV status but did not consistently vary across legal environments. Disparities in HIV prevalence between MSM and other adult men were highest in punitive settings. INTERPRETATION: Structural risks including discriminatory country-level policies, prosecutions, and legal barriers might contribute to higher HIV prevalence among MSM. Taken together, these data highlight the importance of decriminalisation and decreasing enforcement, alongside stigma reduction, as central to effective control for HIV. FUNDING: National Institutes of Health. TRANSLATION: For the French translation of the abstract see Supplementary Materials section.

Monkeypox Virus Infection in Humans across 16 Countries - April-June 2022.

BACKGROUND: Before April 2022, monkeypox virus infection in humans was seldom reported outside African regions where it is endemic. Currently, cases are occurring worldwide. Transmission, risk factors, clinical presentation, and outcomes of infection are poorly defined. METHODS: We formed an international collaborative group of clinicians who contributed to an international case series to describe the presentation, clinical course, and outcomes of polymerase-chain-reaction-confirmed monkeypox virus infections. RESULTS: We report 528 infections diagnosed between April 27 and June 24, 2022, at 43 sites in 16 countries. Overall, 98% of the persons with infection were gay or bisexual men, 75% were White, and 41% had human immunodeficiency virus infection; the median age was 38 years. Transmission was suspected to have occurred through sexual activity in 95% of the persons with infection. In this case series, 95% of the persons presented with a rash (with 64% having ≤10 lesions), 73% had anogenital lesions, and 41% had mucosal lesions (with 54 having a single genital lesion). Common systemic features preceding the rash included fever (62%), lethargy (41%), myalgia (31%), and headache (27%); lymphadenopathy was also common (reported in 56%). Concomitant sexually transmitted infections were reported in 109 of 377 persons (29%) who were tested. Among the 23 persons with a clear exposure history, the median incubation period was 7 days (range, 3 to 20). Monkeypox virus DNA was detected in 29 of the 32 persons in whom seminal fluid was analyzed. Antiviral treatment was given to 5% of the persons overall, and 70 (13%) were hospitalized; the reasons for hospitalization were pain management, mostly for severe anorectal pain (21 persons); soft-tissue superinfection (18); pharyngitis limiting oral intake (5); eye lesions (2); acute kidney injury (2); myocarditis (2); and infection-control purposes (13). No deaths were reported. CONCLUSIONS: In this case series, monkeypox manifested with a variety of dermatologic and systemic clinical findings. The simultaneous identification of cases outside areas where monkeypox has traditionally been endemic highlights the need for rapid identification and diagnosis of cases to contain further community spread.

Understanding the differential impacts of COVID-19 among hospitalised patients in South Africa for equitable response.

BACKGROUND: There are limited in-depth analyses of COVID-19 differential impacts, especially in resource-limited settings such as South Africa (SA). OBJECTIVES: To explore context-specific sociodemographic heterogeneities in order to understand the differential impacts of COVID-19. METHODS: Descriptive epidemiological COVID-19 hospitalisation and mortality data were drawn from daily hospital surveillance data, National Institute for Communicable Diseases (NICD) update reports (6 March 2020 - 24 January 2021) and the Eastern Cape Daily Epidemiological Report (as of 24 March 2021). We examined hospitalisations and mortality by sociodemographics (age using 10-year age bands, sex and race) using absolute numbers, proportions and ratios. The data are presented using tables received from the NICD, and charts were created to show trends and patterns. Mortality rates (per 100 000 population) were calculated using population estimates as a denominator for standardisation. Associations were determined through relative risks (RRs), 95% confidence intervals (CIs) and p-values <0.001. RESULTS: Black African females had a significantly higher rate of hospitalisation (8.7% (95% CI 8.5 - 8.9)) compared with coloureds, Indians and whites (6.7% (95% CI 6.0 - 7.4), 6.3% (95% CI 5.5 - 7.2) and 4% (95% CI 3.5 - 4.5), respectively). Similarly, black African females had the highest hospitalisation rates at a younger age category of 30 - 39 years (16.1%) compared with other race groups. Whites were hospitalised at older ages than other races, with a median age of 63 years. Black Africans were hospitalised at younger ages than other race groups, with a median age of 52 years. Whites were significantly more likely to die at older ages compared with black Africans (RR 1.07; 95% CI 1.06 - 1.08) or coloureds (RR 1.44; 95% CI 1.33 - 1.54); a similar pattern was found between Indians and whites (RR 1.59; 95% CI 1.47 - 1.73). Women died at older ages than men, although they were admitted to hospital at younger ages. Among black Africans and coloureds, females (50.9 deaths per 100 000 and 37 per 100 000, respectively) had a higher COVID-19 death rate than males (41.2 per 100 000 and 41.5 per 100 000, respectively). However, among Indians and whites, males had higher rates of deaths than females. The ratio of deaths to hospitalisations by race and gender increased with increasing age. In each age group, this ratio was highest among black Africans and lowest among whites. CONCLUSIONS: The study revealed the heterogeneous nature of COVID-19 impacts in SA. Existing socioeconomic inequalities appear to shape COVID-19 impacts, with a disproportionate effect on black Africans and marginalised and low socioeconomic groups. These differential impacts call for considered attention to mitigating the health disparities among black Africans.

Understanding the differential impacts of COVID-19 among hospitalised patients in South Africa for equitable response

Background. There are limited in-depth analyses of COVID-19 differential impacts, especially in resource-limited settings such as South Africa (SA).Objectives. To explore context-specific sociodemographic heterogeneities in order to understand the differential impacts of COVID-19. Methods. Descriptive epidemiological COVID-19 hospitalisation and mortality data were drawn from daily hospital surveillance data, National Institute for Communicable Diseases (NICD) update reports (6 March 2020 - 24 January 2021) and the Eastern Cape Daily Epidemiological Report (as of 24 March 2021). We examined hospitalisations and mortality by sociodemographics (age using 10-year age bands, sex and race) using absolute numbers, proportions and ratios. The data are presented using tables received from the NICD, and charts were created to show trends and patterns. Mortality rates (per 100 000 population) were calculated using population estimates as a denominator for standardisation. Associations were determined through relative risks (RRs), 95% confidence intervals (CIs) and p-values <0.001. Results. Black African females had a significantly higher rate of hospitalisation (8.7% (95% CI 8.5 - 8.9)) compared with coloureds, Indians and whites (6.7% (95% CI 6.0 - 7.4), 6.3% (95% CI 5.5 - 7.2) and 4% (95% CI 3.5 - 4.5), respectively). Similarly, black African females had the highest hospitalisation rates at a younger age category of 30 - 39 years (16.1%) compared with other race groups. Whites were hospitalised at older ages than other races, with a median age of 63 years. Black Africans were hospitalised at younger ages than other race groups, with a median age of 52 years. Whites were significantly more likely to die at older ages compared with black Africans (RR 1.07; 95% CI 1.06 - 1.08) or coloureds (RR 1.44; 95% CI 1.33 - 1.54); a similar pattern was found between Indians and whites (RR 1.59; 95% CI 1.47 - 1.73). Women died at older ages than men, although they were admitted to hospital at younger ages. Among black Africans and coloureds, females (50.9 deaths per 100 000 and 37 per 100 000, respectively) had a higher COVID-19 death rate than males (41.2 per 100 000 and 41.5 per 100 000, respectively). However, among Indians and whites, males had higher rates of deaths than females. The ratio of deaths to hospitalisations by race and gender increased with increasing age. In each age group, this ratio was highest among black Africans and lowest among whites.Conclusions. The study revealed the heterogeneous nature of COVID-19 impacts in SA. Existing socioeconomic inequalities appear to shape COVID-19 impacts, with a disproportionate effect on black Africans and marginalised and low socioeconomic groups. These differential impacts call for considered attention to mitigating the health disparities among black Africans.

From general to specific: moving past the general population in the HIV response across sub-Saharan Africa.

INTRODUCTION: As the HIV field evolves to better serve populations which are diverse in risk and access to services, it is crucial to understand and adapt the conceptual tools used to make sense of the HIV pandemic. In this commentary, we discuss the concept of general population. Using a synthetic and historical review, we reflect on the genesis and usage of the general population in HIV research and programme literature, pointing to its moral connotations and its impact on epidemiologic reasoning. DISCUSSION: From the early days of the HIV pandemic, the category of general population has carried implicit normative meanings. General population represented those people considered to be undeserving of HIV acquisition, and therefore deserving of a response. Framing the HIV epidemic in sub-Saharan Africa as a generalized epidemic primarily affecting the general population has contributed to the exclusion of men who have sex with men from epidemic responses. The usage of this category has also masked heterogeneity among those it includes; the increasing focus on the use of interventions such as circumcision and HIV treatment as general population HIV prevention approaches has been marked by a lack of attention to heterogeneity among beneficiaries. CONCLUSIONS: We recommend that the term general population be retired from the field's lexicon. HIV programmes should strengthen their capacity to describe the heterogeneity of those they serve and plan their interventions accordingly. To increase the efficiency and impact of the HIV response, it is urgent to stratify the category of general population by risk. Sexual networks are a promising basis for this stratification.

Blue-Ribbon Boys: factors associated with PrEP use, ART use and undetectable viral load among gay app users across six regions of the world.

INTRODUCTION: Gay social networking apps have grown in popularity among men who have sex with men offering opportunities for rapid and confidential collection of vital data as well as social connection. The goal of our study was to explore factors associated with utilization of pre-exposure prophylaxis (PrEP) and antiretroviral treatment (ART), and self-reported undetectable viral load (UVL) using data collected by the gay social networking app Hornet. METHODS: In 2016, the Global Forum on MSM & HIV (MSMGF) partnered with Hornet, to support an educational initiative called Blue-Ribbon Boys. One aspect of the initiative prompts Hornet users to answer a short series of yes-no questions about their sexual health. Using survey responses, we evaluated factors associated with PrEP and ART use as well as self-reported UVL by fitting separate multivariable generalized estimating equation models. RESULTS: In total, 16,008 unique Hornet users started the survey, of which 12,126 (76%) provided sufficient data for analyses. Of the 10,774 HIV-negative men, 13% reported PrEP use in the past year. PrEP use was associated with a recent sexually transmitted infection (STI) test or treatment (aOR = 2.19, CI = 1.49 to 3.21); and taking steps to protect oneself from HIV (aOR = 1.41, CI = 1.13 to 1.76). Among HIV-positive Hornet users (n = 1243), ART use was associated with older age (each year increase aOR = 1.02, CI = 1.01 to 1.04), a recent STI test or treatment (aOR = 4.54, CI = 2.65 to 7.78); and awareness of unlikely HIV transmission with UVL (aOR = 1.53, CI = 1.03 to 2.26). UVL was associated with older age (each year increase aOR = 1.03, CI = 1.01 to 1.04), a recent STI test or treatment (aOR = 4.84, CI = 2.74 to 8.55), and awareness of unlikely HIV transmission with UVL (aOR = 1.98, CI = 1.37 to 2.85). CONCLUSIONS: Study findings underscore the importance of STI testing and treatment as well as information about HIV transmissibility for encouraging PrEP and ART use. Our findings also reveal age disparities, which can undermine incidence reduction among gay men. Gay social networking apps can be effectively used for rapid data collection and sexual health promotion with men who have sex with men. STI testing and treatment programmes offer important opportunities for encouraging PrEP and ART use. Information about HIV transmissibility with consistent ART use should be incorporated into prevention messaging tailored to various age groups.

Developing and implementing national health identifiers in resource limited countries: why, what, who, when and how?

Many resource-limited countries are scaling up health services and health-information systems (HISs). The HIV Cascade framework aims to link treatment services and programs to improve outcomes and impact. It has been adapted to HIV prevention services, other infectious and non-communicable diseases, and programs for specific populations. Where successful, it links the use of health services by individuals across different disease categories, time and space. This allows for the development of longitudinal health records for individuals and de-identified individual level information is used to monitor and evaluate the use, cost, outcome and impact of health services. Contemporary digital technology enables countries to develop and implement integrated HIS to support person centred services, a major aim of the Sustainable Development Goals. The key to link the diverse sources of information together is a national health identifier (NHID). In a country with robust civil protections, this should be given at birth, be unique to the individual, linked to vital registration services and recorded every time that an individual uses health services anywhere in the country: it is more than just a number as it is part of a wider system. Many countries would benefit from practical guidance on developing and implementing NHIDs. Organizations such as ASTM and ISO, describe the technical requirements for the NHID system, but few countries have received little practical guidance. A WHO/UNAIDS stake-holders workshop was held in Geneva, Switzerland in July 2016, to provide a 'road map' for countries and included policy-makers, information and healthcare professionals, and members of civil society. As part of any NHID system, countries need to strengthen and secure the protection of personal health information. While often the technology is available, the solution is not just technical. It requires political will and collaboration among all stakeholders to be successful.

Availability and Use of Substance Abuse Treatment Programs Among Substance-Using Men Who Have Sex With Men Worldwide.

BACKGROUND: Substance use is common among men who have sex with men (MSM) worldwide, and epidemiologic data suggest that alcohol/substance-using MSM are at greater risk for HIV. However, there are scarce data on substance abuse treatment programs (SATPs) for substance-using MSM. OBJECTIVES: We examined proportions of substance use as well as SATP availability and use. We used multivariable regression models, controlling for potential confounders, to examine behavioral and demographic correlates of SATP availability and use. METHODS: This is a cross-sectional study of a multi-region, online sample of substance-using MSM. RESULTS: In this sample, 75% were substance-using MSM of whom 36% reported at-least-weekly use. Substance use was most prevalent among respondents from Eastern Europe/Central Asia (86%) and Latin America (79%). Among substance-using MSM, 96% and 33% reported alcohol intoxication and other substance use, respectively; 11% reported having high SATP availability; and 5% reported using SATPs. Controlling for global region of origin and age, high SATP availability was associated with high access to HIV risk-reduction education (aOR = 3.19; CI = 1.48-6.89), mental health services (aOR = 2.53; CI = 1.32-4.83), and medical care (aOR = 2.32; CI = 1.12-4.80); less than college-level education (aOR = 0.32; CI = 0.18-0.54); and higher comfort levels with providers (aOR = 1.75; CI = 1.30-2.37). Controlling for substance use frequency and personal income additionally, using SATPs was associated with higher levels of connection to the gay community (aOR = 2.76; CI = 1.22-6.22). CONCLUSION: In this global sample of MSM, we found high alcohol intoxication and other substance use proportions. Few substance-using MSM report SATP availability, highlighting the need to develop novel substance use programs outside traditional treatment settings.

Reductions in access to HIV prevention and care services are associated with arrest and convictions in a global survey of men who have sex with men.

OBJECTIVES: Men who have sex with men (MSM) are disproportionately impacted by HIV. Criminalisation of homosexuality may impede access to HIV services. We evaluated the effect of the enforcement of laws criminalising homosexuality on access to services. METHODS: Using data from a 2012 global online survey that was published in a prior paper, we conducted a secondary analysis evaluating differences in perceived accessibility to health services (ie, 'how accessible are ____' services) between MSM who responded 'yes'/'no' to: 'have you ever been arrested or convicted for being gay/MSM?' RESULTS: Of the 4020 participants who completed the study and were included in the analysis, 8% reported ever being arrested or convicted under laws relevant to being MSM. Arrests and convictions were most common in sub-Saharan Africa (23.6% (58/246)), Eastern Europe/Central Asia (18.1% (123/680)), the Caribbean (15% (15/100)), Middle East/North Africa (13.2% (10/76)) and Latin America (9.7% (58/599)). Those arrested or convicted had significantly lower access to sexually transmitted infection treatment (adjusted OR (aOR)=0.81; 95% CI 0.67 to 0.97), condoms (aOR=0.77; 95% CI 0.61 to 0.99) and medical care (aOR=0.70; 95% CI 0.54 to 0.90), compared with other MSM, while accounting for clustering by country and adjusting for age, HIV status, education and country-level income. CONCLUSIONS: Arrests and convictions under laws relevant to being MSM have a strong negative association with access to HIV prevention and care services. Creating an enabling legal and policy environment, and increasing efforts to mitigate antihomosexuality stigma to ensure equitable access to HIV services are needed, along with decriminalisation of homosexuality, to effectively address the public health needs of this population.

Towards Equity in Service Provision for Gay Men and Other Men Who Have Sex with Men in Repressive Contexts.

Chris Beyrer and colleagues reflect on an underappreciated trend in multiple African, Asian, and Caribbean settings, in which the provision of HIV and other essential health services for sexual and gender minorities is expanding despite challenging legal and social environments.

Inequities in access to HIV prevention services for transgender men: results of a global survey of men who have sex with men.

INTRODUCTION: Free or low-cost HIV testing, condoms, and lubricants are foundational HIV prevention strategies, yet are often inaccessible for men who have sex with men (MSM). In the global context of stigma and poor healthcare access, transgender (trans) MSM may face additional barriers to HIV prevention services. Drawing on data from a global survey of MSM, we aimed to describe perceived access to prevention services among trans MSM, examine associations between stigma and access, and compare access between trans MSM and cisgender (non-transgender) MSM. METHODS: The 2014 Global Men's Health and Rights online survey was open to MSM (inclusive of trans MSM) from any country and available in seven languages. Baseline data (n=3857) were collected from July to October 2014. Among trans MSM, correlations were calculated between perceived service accessibility and anti-transgender violence, healthcare provider stigma, and discrimination. Using a nested matched-pair study design, trans MSM were matched 4:1 to cisgender MSM on age group, region, and HIV status, and conditional logistic regression models compared perceived access to prevention services by transgender status. RESULTS: About 3.4% of respondents were trans men, of whom 69 were included in the present analysis. The average trans MSM participant was 26 to 35 years old (56.5%); lived in western Europe, North America, or Oceania (75.4%); and reported being HIV-negative (98.6%). HIV testing, condoms, and lubricants were accessible for 43.5, 53.6, and 26.1% of trans MSM, respectively. Ever having been arrested or convicted due to being trans and higher exposure to healthcare provider stigma in the past six months were associated with less access to some prevention services. Compared to matched cisgender controls, trans MSM reported significantly lower odds of perceived access to HIV testing (OR=0.57, 95% CI=0.33, 0.98) and condom-compatible lubricants (OR=0.54, 95% CI=0.30, 0.98). CONCLUSIONS: This first look at access to HIV prevention services for trans MSM globally found that most reported inadequate access to basic prevention services and that they were less likely than cisgender MSM to have access to HIV testing and lubricants. Results indicate the need to enhance access to basic HIV prevention services for trans MSM, including MSM-specific services.

Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide.

Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3,340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.