Impact of coronavirus disease 2019-related clinic closures on HIV incidence in young adult MSM and transgender women in Kenya.

INTRODUCTION: Little is known about the impact that the COVID-19 pandemic had on risk of HIV acquisition in sub-Saharan Africa. We assessed the impact of COVID-19-related clinic closures on HIV incidence in a cohort of gay, bisexual, and other men who have sex with men (MSM) and transgender women in Kenya. METHODS: MSM and transgender women enrolled in a prospective, multicentre cohort study were followed quarterly for HIV testing, behaviour assessments, and risk. We estimated the HIV incidence rate and its 95% credible intervals (CrI) among participants who were HIV-negative before COVID-19-related clinic closure, comparing incidence rate and risk factors associated with HIV acquisition before vs. after clinic reopening, using a Bayesian Poisson model with weakly informative priors. RESULTS: A total of 690 (87%) participants returned for follow-up after clinic reopening (total person-years 664.3 during clinic closure and 1013.3 after clinic reopening). HIV incidence rate declined from 2.05/100 person-years (95% CrI = 1.22-3.26, n  = 14) during clinic closures to 0.96/100 person-years (95% CrI = 0.41-2.07, n  = 10) after clinic reopening (IRR = 0.47, 95% CrI = 0.20-1.01). The proportion of participants reporting hazardous alcohol use and several sexual risk behaviours was higher during clinic closures than after clinic reopening. In multivariable analysis adjusting for study site and participant characteristics, HIV incidence was lower after clinic reopening (IRR 0.57, 95% CrI = 0.23-1.33). Independent risk factors for HIV acquisition included receptive anal intercourse (IRR 1.94, 95% CrI = 0.88-4.80) and perceived risk of HIV (IRR 3.03, 95% CRI = 1.40-6.24). CONCLUSION: HIV incidence during COVID-19-related clinic closures was moderately increased and reduced after COVID-19 restrictions were eased. Ensuring access to services for key populations is important during public health emergencies.

URCHOICE: Preferences for Pre-Exposure Prophylaxis (PrEP) Options for HIV Prevention Among Kenyan men who have sex with men and Transgender Women in Nairobi, Kisumu and the Coast.

HIV prevention method preferences were evaluated among Kenyan men who have sex with men (MSM) and transgender women (TW) from three sites: Kisumu, Nairobi and the Coast. Information sessions detailing the attributes, duration of protection, route of administration and probable visibility were attended by 464 HIV negative participants, of whom 423 (median age: 24 years) agreed to be interviewed. Across pairwise comparisons daily PrEP was by far the least preferred (1%); quarterly injections (26%) and monthly pills (23%) were most preferred, followed by yearly implant (19%) and condoms (12%). When participants were "forced" to choose their most preferred PrEP option, only 10 (2.4%) chose the daily pill; more (37.1%) chose the quarterly injection than the monthly pill (34.8%) and the yearly implant (25.8%). TW preferred the yearly implant over the quarterly injection. To achieve the rates of PrEP uptake and adherence necessary for protecting large proportions of vulnerable MSM and TW, a variety of long-acting products should be developed and made accessible to appeal to a diversity of preferences.

Challenges with PrEP Uptake and Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kisumu, Kenya.

Data on challenges with pre-exposure prophylaxis (PrEP) uptake and adherence among Kenyan gay, bisexual, and other men who have sex with men (GBMSM) are limited. In this mixed-methods sequential explanatory design study, our quantitative phase followed 157 at-risk, HIV-negative GBMSM who accepted PrEP and enrolled in a cohort with 12-month follow-up. Stored dried blood spots collected at two intervals were batch tested for tenofovir diphosphate (TFV-DP) concentrations at study end. Despite high self-reported adherence, only 14.6% of individuals had protective TFV-DP levels at any visit. Protective TFV-DP levels were positively associated with injection drug use and a self-assessed moderate risk of acquiring HIV, and negatively associated with time since enrolment. In our subsequent qualitative phase, an intensive workshop was conducted with the GBMSM community to identify barriers and facilitators to PrEP uptake and adherence. These data revealed numerous challenges with traditional PrEP programs that must be addressed through community collaborations.

RESUMEN: La evidencia respecto a desafíos existentes con aceptación y adherencia de la profilaxis previa a la exposición (PrEP) de VIH, entre los hombres homosexuales, bisexuales y otros hombres que tienen sexo con hombres (GBMSM) en Kenia es limitada. Condujimos un estudio de métodos mixtos y diseño explicativo secuencial. En la fase cuantitativa seguimos a 157 GBMSM VIH-negativos en riesgo que aceptaron PrEP y se inscribieron en una cohorte con un seguimiento de 12 meses. Analizamos, por lotes y al final del estudio, gotas de sangre seca recolectada a dos intervalos de tiempo y previamente almacenada, para determinar las concentraciones de difosfato de tenofovir (TFV-DP). A pesar de la alta adherencia autoinformada, solo el 14,6% de las personas tenían niveles protectores de TFV-DP en alguna visita. Los niveles protectores de TFV-DP se asociaron positivamente con el uso de drogas inyectables y un riesgo moderado autoevaluado de contraer el VIH, y negativamente con el tiempo transcurrido desde la inscripción. En la fase cualitativa posterior, conversamos con GBMSM de la comunidad para identificar las barreras y los facilitadores para la concientización, aceptación, adherencia y retención a PrEP. Estos datos revelaron numerosos desafíos con los programas tradicionales de PrEP que deben abordarse mediante colaboraciones comunitarias.

Behavior Change and Sexually Transmitted Incidence in Relation to PREP Use Among Men Who Have Sex with Men in Kenya.

We measured change in sexual practices and the incidence of C. trachomatis (CT) and N. gonorrhoeae (NG) within a prospective cohort of Kenyan MSM taking PrEP in Kenya. Over the one year of study participation, CT and NG were diagnosed in urine at baseline, 6- and 12- months. Multivariable Cox regression identified factors associated with incident infection. Sexual practices were assessed at baseline and every 3 months. We evaluated changes over time and in relation to PrEP adherence via generalized estimating equation analysis. From October 2017-January 2018, 158 participants initiated PrEP, having 10.3% baseline CT/NG prevalence (either or both). The incidence was 17.2 cases per 100 person-years (95% CI 11.7-25.5). Incident CT/NG increased with report of: transactional male sex partner (adjusted Hazard Ratio (aHR) = 2.46, p = 0.016, z = 2.40), regular female sex partner (aHR = 2.22, p = 0.051, z = 1.96), greater social support (highest vs. lowest quartile, aHR = 6.24, p = 0.012, z = 2.51), and CT/NG infection prior to enrollment (aHR = 2.90, p = 0.002, z = 3.03). Multiple sex partners, condomless sex, and transactional sex decreased over time and were not associated with PrEP adherence. Urethral CT/NG incidence remained high and there was no evidence of PrEP-related behavioral change. There is need for ongoing etiologic testing, improved understanding of risk from female sex partners, and development of more effective risk reduction interventions.

Enrolment characteristics associated with retention among HIV negative Kenyan gay, bisexual and other men who have sex with men enrolled in the Anza Mapema cohort study.

INTRODUCTION: Most gay, bisexual and other men who have sex with men (GBMSM) live in rights-constrained environments making retaining them in research to be as hard as recruiting them. To evaluate Anza Mapema, an HIV risk-reduction programme in Kisumu, Kenya, we examined the enrolment sociodemographic, behavioural, psychosocial and clinical factors associated with missing two or more follow-up visits for GBMSM participating in Anza Mapema. METHODS: Between August 2015 and November 2017, GBMSM were enrolled and followed in a prospective cohort study with quarterly visits over 12 months. At enrolment, men were tested for HIV and sexually transmitted infections and completed questionnaires via audio computer-assisted self-interview. Because the Kenya Ministry of Health recommends HIV testing every three to six months for GBMSM, the retention outcome in this cross sectional analysis was defined as missing two consecutive follow-up visits (vs. not missing two or more consecutive visits). Multivariable logistic regression estimated the adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the associations of the enrolment characteristics with the binary outcome of retention. RESULTS AND DISCUSSION: Among 609 enrolled HIV-negative GBMSM, the median age was 23 years (interquartile range, 21 to 28 years), 19.0% had completed ≤8 years of education and 4.1% had resided in the study area <1 year at enrolment. After enrolment, 19.7% missed two consecutive follow-up visits. In the final multivariable model, the odds of missing two consecutive follow-up visits were higher for men who: resided in the study area <1 year at enrolment (aOR, 4.14; 95% CI: 1.77 to 9.68), were not living with a male sexual partner (aOR, 1.59; 95% CI: 1.01 to 2.50), and engaged in transactional sex during the last three months (aOR, 1.70; 95% CI: 1.08 to 2.67). CONCLUSIONS: One in five men missed two consecutive follow-up visits during this HIV prevention study despite intensive retention efforts and compensation for travel and participation. Participants with recent community arrival may require special support to optimize their retention in HIV prevention activities. Live-in partners of participants may be enlisted to support greater engagement in prevention programmes, and men who engage in transactional sex will need enhanced counselling and support to stay in longitudinal studies.

Incident gonorrhoea and chlamydia among a prospective cohort of men who have sex with men in Kisumu, Kenya.

OBJECTIVE: STIs disproportionately affect men who have sex with men (MSM) in sub-Saharan Africa. We identified factors associated with incident Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among MSM in the Anza Mapema cohort study in Kisumu, Kenya. METHODS: We enrolled 711 MSM who underwent HIV testing and counselling, medical history and examination, and collection of demographic and behavioural information. They also provided urine and rectal swab specimens for CT and NG testing by qualitative PCR at baseline and at months 6 and 12. Separate multivariable Cox regression models identified factors associated with first incident urethral or rectal infection. RESULTS: Among the 619 men aged 18-54 years included in this analysis, there were 83 first incident urethral CT/NG infections (14.4 cases per 100 person-years (PY)) and 40 first incident rectal infections (6.84 cases per 100 PY), and an overall incidence of 18.0 cases per 100 PY (95% CI 14.8 to 21.8). Most urethral (84%) and rectal (81%) infections were asymptomatic. In the adjusted model, the risk of first incident urethral CT/NG decreased by 4% for each 1-year increase in age and was 41% lower for men who reported their partner used condom at last sexual encounter. Men who were HIV-positive had a 68% less risk of urogenital CT/NG compared with those who were negative. Men who reported being usually receptive or versatile as compared with usually insertive had an 81% increased risk of incident urogenital CT/NG. CONCLUSION: Our study demonstrated a high incidence of urethral CT/NG infection, with somewhat lower incidence of rectal CT/NG infection, despite repeated testing and treatment, highlighting the need for preventive interventions to decrease the burden of CT/NG among Kenyan MSM. Most infections were asymptomatic, and routine aetiological screening for STIs is recommended.

Prevalence and correlates of and a risk score to identify asymptomatic anorectal gonorrhoea and chlamydia infection among men who have sex with men in Kisumu, Kenya.

OBJECTIVES: In settings where laboratory capacity is limited, the WHO recommends presumptive treatment for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in asymptomatic men who have sex with men (MSM) at high risk for these infections. However, little is known about how best to target this intervention. We aimed to identify correlates of anorectal NG/CT infection in Kenyan MSM with and without anorectal symptoms and evaluate the performance of an empirical, model-based risk score to identify cases in asymptomatic men. METHODS: Anorectal NG/CT infections were diagnosed by the Abbott RealTime NG/CT nucleic acid amplification testamong 698 MSM at enrolment into the Anza Mapema study. Multivariable logistic regression was used to identify correlates of anorectal NG/CT infection in men with and without anorectal symptoms. Using coefficients from the final multivariable model for asymptomatic men, we calculated a risk score for each participant. Risk score performance was determined by calculating the sensitivity, specificity and number needed to treat (NNT) to identify one NG/CT infection. RESULTS: Overall anorectal NG/CT infection prevalence was 5.2% (n=36), of which 58.3% (n=21) were asymptomatic. Factors associated with anorectal NG/CT infection in asymptomatic men were aged 18-24 years (aOR=7.6; 95% CI: 1.7 to 33.2), HIV positive serostatus (aOR=6.9; 95% CI: 2.2 to 21.6) and unprotected anal sex in the past 3 months (aOR=3.8; 95% CI: 1.2 to 11.9). Sensitivity and specificity were optimal (81.0% and 66.1%, respectively) at a model-derived risk score cut-point ≥3, and the NNT was 12. CONCLUSIONS: A model-derived risk score based on correlates of anorectal NG/CT infection in asymptomatic participants would be sensitive and efficient (i.e, low NNT) for targeting presumptive treatment. If validated in other settings, this risk score could improve on the WHO algorithm and help reduce the burden of asymptomatic anorectal NG/CT infections among MSM in settings where diagnostic testing is not available.

Depressive symptoms and problematic alcohol and other substance use in 1476 gay, bisexual, and other MSM at three research sites in Kenya.

OBJECTIVE: Information on mental health and substance use challenges among gay, bisexual, and other MSM (GBMSM) is needed to focus resources on these issues and optimize services for HIV prevention and care. We determined factors associated with depressive symptoms and problematic alcohol and other substance use among GBMSM in Kenya. METHODS: Self-identified GBMSM in three HIV research studies in Kenya provided information on depressive symptoms [Patient Health Questionnaire 9 (PHQ-9)], alcohol use [Alcohol Use Disorder Identification Test (AUDIT)], and other substance use [Drug Abuse Screening Test 6 (DAST-6)]. Associations were evaluated using mixed effects Poisson regression. RESULTS: Of 1476 participants, 452 (31%) reported moderate-to-severe depressive symptoms (PHQ-9 ≥ 10), 637 (44%) hazardous alcohol use (AUDIT ≥ 8), and 749 (51%) problematic substance use (DAST-6 ≥ 1). Known HIV-positive status was not associated with these outcomes. Transactional sex was associated with hazardous alcohol use [adjusted prevalence ratio (aPR) 1.34, 95% confidence interval (CI) 1.12-1.60]. Childhood abuse and recent trauma were associated with moderate-to-severe depressive symptoms (aPR 1.43, 95% CI 1.10-1.86 and aPR 2.43, 95% CI 1.91-3.09, respectively), hazardous alcohol use (aPR 1.36, 95% CI 1.10-1.68 and aPR 1.60, 95% CI 1.33-1.93, respectively), and problematic substance use (aPR 1.32, 95% CI 1.09-1.60 and aPR 1.35, 95% CI 1.14-1.59, respectively). CONCLUSION: GBMSM in rights-constrained settings need culturally appropriate services for treatment and prevention of mental health and substance use disorders, in addition to human rights advocacy to prevent abuse. Mental health and substance use screening and treatment or referral should be an integral part of programs, including HIV prevention and treatment programs, providing services to GBMSM.

Factors associated with viral suppression among HIV-positive Kenyan gay and bisexual men who have sex with men.

The UNAIDS 90-90-90 target has prioritized achieving high rates of viral suppression. We identified factors associated with viral suppression among HIV-positive gay, bisexual, and other men who have sex with men (GBMSM) in Kisumu, Kenya. HIV-positive participants in the Anza Mapema study were offered antiretroviral therapy (ART) regardless of CD4 count. HIV viral load was assessed at baseline and after 6 and 12 months of follow-up. Viral suppression was defined as <1,000 copies/mL. Sociodemographic, sexual behaviors, and psychosocial characteristics were assessed via audio computer-assisted self interview. We used generalized estimating equations to estimate the associations between baseline and time-dependent predictors and viral suppression at 6 and 12 months. Seventy-five HIV-positive men were enrolled in the Anza Mapema study, of which 63 had at least one viral load measured during follow-up. Among 52 men with a viral load measure at month 6, 37 (71%) were on ART and virally suppressed. Among 59 men with a viral load measure at month 12, 37 (63%) were on ART and virally suppressed. In the final multivariable model, men who reported receptive or versatile sexual position during anal intercourse with a male partner had reduced odds of viral suppression (aOR = 0.20; 95% CI: 0.08-0.50). Greater levels of coping self-efficacy were associated with increased odds of viral suppression (aOR = 1.10; 95% CI: 1.03-1.16). Despite extensive initiation, retention, and adherence support, the rate of viral suppression in this population did not meet the UNAIDS 90-90-90 target (81% for individuals aware of their HIV status). Pervasive stigma against male-male sex, especially men who practice receptive anal sex, may underlie our findings, which highlight the need for advocacy and stigma reduction efforts. Because coping self-efficacy was a protective factor, efforts to promote resilience in addition to healthy sexual identity development may lead to improved care outcomes among GBMSM in this area.

Depressive Symptoms, Alcohol and Drug Use, and Physical and Sexual Abuse Among Men Who Have Sex with Men in Kisumu, Kenya: The Anza Mapema Study.

Men who have sex with men (MSM) are disproportionately burdened by depressive symptoms and psychosocial conditions including alcohol and substance abuse as well as physical and sexual abuse. We examined sociodemographic and psychosocial factors associated with depressive symptoms at baseline among a cohort of MSM in Kisumu, Kenya. Depressive symptoms were assessed via the Personal Health Questionnaire 9 instrument and examined dichotomously. We performed multivariable modified Poisson regression with robust standard errors for the binary outcome. Among 711 participants: 11.4% reported severe depressive symptoms; 50.1% reported harmful alcohol abuse; 23.8% reported moderate substance abuse; 80.9% reported any childhood physical or sexual abuse; and 39.1% experienced recent trauma due to same-sex behaviors. In the final multivariable model, severe depressive symptoms were more common for men who were ≥ 30 years old, had completed ≤ 8 years of education, had experienced childhood physical or sexual abuse, and had recently experienced trauma due to same-sex behaviors. Our results demonstrate that comprehensive services capable of identifying and addressing depressive symptoms, alcohol and substance abuse, and physical and sexual abuse must be expanded within this sample of MSM.

Factors Associated With Prevalent HIV Infection Among Kenyan MSM: The Anza Mapema Study.

BACKGROUND: To inform future HIV treatment and care programs for men who have sex with men (MSM), we assessed the prevalence of and factors associated with previously diagnosed HIV-positive and out-of-care (PDOC) or newly diagnosed HIV-positive and out-of-care (NDOC) HIV infection among MSM enrolled in the prospective Anza Mapema cohort study. METHODS: Participants were aged 18 years and older, reported oral or anal sex with a man in the past 6 months and were not already in HIV care or taking antiretroviral therapy in the past 3 months. At enrollment, men were tested for HIV infection and completed questionnaires through audio computer-assisted self-interview. Multinomial logistic regression was used to identify associations with PDOC or NDOC HIV infection, relative to HIV-negative status. RESULTS: Among 711 enrolled men, 75 (10.5%) were seropositive including 21 PDOC and 54 NDOC men. In multivariable modeling, PDOC status was more likely than HIV-negative status among men who had experienced upsetting sexual experiences during childhood, had recently experienced MSM trauma, and did not report harmful alcohol use. NDOC infection status was more common among men aged 30 years and older and who had completed ≤8 years of education, relative to HIV-negative status. CONCLUSIONS: Most HIV-positive men were unaware of their infection, indicating that HIV testing and counseling services tailored to this population are needed. To improve linkage to and retention in care, HIV testing and care services for MSM should screen and provide support for those with hazardous alcohol use and those who have experienced childhood sexual abuse or MSM trauma.