Non-uptake of HIV testing among trans men and trans women: cross-sectional study of client records from 2017 to 2019 in a community-based transgender health center in Metro Manila, Philippines.

BACKGROUND: Transgender individuals are considered at high risk of contracting HIV infection. Integrating HIV testing and counseling (HTC) services into current transgender health programs is necessary to increase its uptake. Our study aimed to describe the characteristics of trans men (TM) and trans women (TW) who accessed HTC services in a community-based transgender health center in Metro Manila, Philippines, and to examine the relationship between gender identity and their non-uptake of HIV testing.  METHODS: We conducted a cross-sectional study of TM and TW seeking care from 2017 to 2019. Medical records of clients were reviewed to ascertain their age, gender identity, year and frequency of clinic visits, lifestyle factors, and non-uptake of HIV testing. The effect of gender identity on the non-uptake of HIV testing was estimated using a generalized linear model with Poisson distribution, log link function, and a robust variance, adjusted for confounding variables.  RESULTS: Five hundred twenty-five clients were included in the study, of which about 82.3% (432/525) of the clients declined the HTC services being offered. In addition, the prevalence of non-uptake of HIV testing was 48% higher (Adjusted Prevalence Ratio: 1.48; 95% Confidence Interval: 1.31-1.67) among TM compared to TW. Approximately 3.7% (1/27) and 10.6% (7/66) of the TM and TW, respectively, who accessed the HTC services were reactive. Moreover, most reactive clients were on treatment 87.5% (7/8); three were already virally suppressed, four were on ART but not yet virally suppressed, and one TW client was lost to follow up. CONCLUSION: The non-uptake of HTC service of TM and TW is high. HIV program implementers should strategize solutions to reach this vulnerable population for increased and better HTC service uptake and linkage to care.

"She Just Told Me Not To Cry": A Qualitative Study of Experiences of HIV Testing and Counseling (HTC) Among Pregnant Women Living with HIV in Tanzania.

HIV testing and counseling (HTC) in antenatal care is extremely effective at identifying women living with HIV and linking them to HIV care. However, retention is suboptimal in this population. We completed qualitative interviews with 24 pregnant women living with HIV in Tanzania to explore perceptions of HTC. Participants described intense shock and distress upon testing positive, including concerns about HIV stigma and disclosure; however, these concerns were rarely discussed in HTC. Nurses were generally kind, but relied on educational content and brief reassurances, leaving some participants feeling unsupported and unprepared to start HIV treatment. Several participants described gaps in HIV knowledge, including the purpose of antiretroviral therapy and the importance of medication adherence. Targeted nurse training related to HIV disclosure, stigma, and counseling skills may help nurses to more effectively communicate the importance of care engagement to prevent HIV transmission and support the long-term health of mother and child.

RESUMEN: Las pruebas de VIH y la orientación (HTC) en el cuidado prenatal son métodos extremadamente efectivos para identificar a mujeres viviendo con VIH y referirlas al cuidado que necesitan. Sin embargo, la retención en los programas de cuidado es un obstáculo en esta población. Completamos entrevistas cualitativas en Tanzania con 24 mujeres embarazadas que viven con el VIH para identificar sus reacciones al HTC. Las participantes describieron un sentido de conmoción intensa y angustia al dar positivo, además de las preocupaciones sobre el estigma del VIH y el temor a divulgar ser positivas. Sin embargo, estas preocupaciones rara vez se discutieron durante el proceso de HTC. Por lo general, las enfermeras fueron amables, pero se dependían del material educativo y ofrecían pequeñas consolaciones, los cuales dejaban a algunas participantes sintiéndose sin apoyo y sin preparación para comenzar el tratamiento contra el VIH. Varias participantes describieron poco conocimiento del VIH, como el propósito de la terapia antirretroviral y la importancia de la adherencia terapéutica. Un entrenamiento específico para las enfermeras en relación a la divulgación, el estigma y la orientación sobre el VIH podrían ayudar a las enfermeras a comunicar de manera más efectiva la importancia de la participación en el cuidado de la condición para así prevenir la transmisión del VIH y fomentar la salud a largo plazo del la madre y la criatura.

Does the use of HIV testing and counseling services influence condom use among low-paid female sex workers in Guangxi, China?

HIV testing and counseling (HTC) are increasingly used in China during routine medical care visits to health facilities. However, limited data are available regarding the association between the utilization of HTC services and condom use among low-paid female sex workers (FSWs) who are at high risk of HIV infection but are hard to reach. A cross-sectional study was conducted among 794 low-paid FSWs in a city of Guangxi Zhuang Autonomous Region in 2011. Results showed that 71.7% of low-paid FSWs had utilized HTC services in the previous year and 65.7% reported having used a condom during the last sexual intercourse with their clients. Multivariate logistic regression analysis showed that utilizing HTC services was significantly and positively associated with the condom use. It also indicated that low-paid FSWs who were older, married, had higher education, earned less money, had high number of clients, had a history of sexually transmitted diseases, or had little or no HIV knowledge were less likely to use a condom during the last sexual encounter. The study suggests that HTC services need to be scaled up and made more accessible for this vulnerable population.

Understanding male involvement in antenatal care in the Kilimanjaro region of Tanzania: Barriers, facilitators, and opportunities for engagement.

BACKGROUND: Male engagement in antenatal care (ANC) has been recommended by the World Health Organization to improve maternal and newborn health outcomes, but implementation challenges remain. This study explored barriers, facilitators, and opportunities to improve male attendance and engagement in ANC. METHODS: In-depth interviews were conducted individually with pregnant women and male partners attending a first ANC visit at two public health facilities in Moshi, Tanzania. Interviews examined factors influencing male ANC attendance and male experiences during the clinic visit. Interviews were recorded, transcribed verbatim, and translated from Swahili into English. Transcripts were coded thematically in NVivo. MAIN FINDINGS: Constructions of masculinity both positively and negatively influenced male involvement in ANC. Individual-level barriers included a fear of HIV testing, perceptions of pregnancy as the woman's responsibility, and discomfort with ANC as a predominantly female space. Structural barriers included inability to take time off from work and long clinic wait times. The primary facilitator to male involvement was the preferential care given in the ANC clinic to women who present with a male partner. Additionally, some men desired to learn about their family's health status and felt that attending ANC was a sign of respect and love for their partner. CONCLUSIONS: Opportunities exist to improve male involvement in ANC, namely training providers to engage men beyond HIV testing and counseling. Peer programs that promote men's engagement in pregnancy could prove useful to reduce apprehension around HIV testing and dispel conceptions of ANC as only a women's healthcare space.

The development of Maisha, a video-assisted counseling intervention to address HIV stigma at entry into antenatal care in Tanzania.

HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for "Life"), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.

Initiation of antiretroviral therapy and viral suppression after home HIV testing and counselling in KwaZulu-Natal, South Africa, and Mbarara district, Uganda: a prospective, observational intervention study.

OBJECTIVE: Antiretroviral therapy (ART) significantly decreases HIV-associated morbidity, mortality, and HIV transmission through HIV viral load suppression. In high HIV prevalence settings, outreach strategies are needed to find asymptomatic HIV positive persons, link them to HIV care and ART, and achieve viral suppression. METHODS: We conducted a prospective intervention study in two rural communities in KwaZulu-Natal, South Africa, and Mbabara district, Uganda. The intervention included home HIV testing and counseling (HTC), point-of-care CD4 count testing for HIV positive persons, referral to care, and one month then quarterly lay counselor follow-up visits. The outcomes at 12 months were linkage to care, and ART initiation and viral suppression among HIV positive persons eligible for ART (CD4≤350 cells/µL). FINDINGS: 3,393 adults were tested for HIV (96% coverage), of whom 635 (19%) were HIV positive. At baseline, 36% of HIV positive persons were newly identified (64% were previously known to be HIV positive) and 40% were taking ART. By month 12, 619 (97%) of HIV positive persons visited an HIV clinic, and of 123 ART eligible participants, 94 (76%) initiated ART by 12 months. Of the 77 participants on ART by month 9, 59 (77%) achieved viral suppression by month 12. Among all HIV positive persons, the proportion with viral suppression (<1,000 copies/mL) increased from 50% to 65% (p=<0.001) at 12 months. INTERPRETATION: Community-based HTC in rural South Africa and Uganda achieved high testing coverage and linkage to care. Among those eligible for ART, a high proportion initiated ART and achieved viral suppression, indicating high adherence. Implementation of this HTC approach by existing community health workers in Africa should be evaluated to determine effectiveness and costs.