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Quaife M, Diallo M, Jaye A, Martinez-Alvarez M. Partnership preferences, economic drivers, and health consequences of Gambian men's interactions with foreign tourists: A mixed methods study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001115. [PMID: 36962966 PMCID: PMC10021562 DOI: 10.1371/journal.pgph.0001115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/22/2022] [Indexed: 03/04/2023]
Abstract
The Gambia has a thriving tourist industry, but in recent decades has developed a reputation as a destination for older, female tourists to seek sexual relationships with young Gambian men. During partnerships or in return for sex, Gambian men may receive financial support or in some cases the opportunity to travel to Europe with a partner. There has been little previous research among these men on sexual risk behaviours, physical and mental health, and health service utilisation. This study describes the economic drivers and health implications of interactions between Gambian men and foreign tourists near tourist resorts in The Gambia. We conducted simultaneous mixed method data collection among Gambian men who regularly interact with tourists: a cross-sectional quantitative survey and discrete choice experiment (DCE) with 242 respondents, three focus group discussions, and 17 in-depth interviews. The survey asked questions on demographic characteristics, sexual history and health-seeking, the DCE elicited trade-offs between partnership characteristics, and qualitative data explored individual and group experiences in depth. We found that sexual activity between Gambian men and tourists was prevalent with 50% of the sample reporting ever having sex with a tourist. Condom use at last sex was significantly higher with tourist (63%) than with Gambian partners (40%, p<0.01). Condom use, money, and opportunity to travel to Europe were most important to respondents in the DCE. Qualitative data validated and explained quantitative findings, notably pressures to engage in unprotected sex and potential travel to Europe. Although men's physical health needs were broadly met, mental health, substance use and sexual health needs were not. Young men working on the beaches of The Gambia face substantial health risks, including from STIs and mental health issues. The health system needs to understand barriers to existing health services, and how they can meet the needs of these vulnerable men.
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Affiliation(s)
- Matthew Quaife
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mareme Diallo
- MRC Unit The Gambia at LSHTM, London School of Hygiene and Tropical Medicine, Serrekunda, The Gambia
| | - Assan Jaye
- MRC Unit The Gambia at LSHTM, London School of Hygiene and Tropical Medicine, Serrekunda, The Gambia
| | - Melisa Martinez-Alvarez
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- MRC Unit The Gambia at LSHTM, London School of Hygiene and Tropical Medicine, Serrekunda, The Gambia
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Ruderman LW, Ochwal P, Marcus N, Napierala S, Thirumurthy H, Agot K, Maman S. 'When I have these kits … I have confidence' - HIV self-testing provides agency for women in their sexual decision-making. Glob Public Health 2022; 17:3735-3746. [PMID: 35770697 PMCID: PMC9800639 DOI: 10.1080/17441692.2022.2092176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 05/10/2022] [Indexed: 02/06/2023]
Abstract
Oral fluid-based HIV self-testing (HIVST) has emerged as a promising approach to increasing HIV testing coverage, particularly among high-risk populations. Understanding the experiences of women using self-tests and offering them to their sexual partners (secondary distribution) is crucial for determining the potential of HIVST. Qualitative in-depth interviews were conducted among 32 women at high risk of HIV infection, including women who engage in transactional sex, who participated in a cluster randomised trial of a secondary distribution strategy in western Kenya. Interviews explored how women used self-tests within relationships and how this affected their sexual decision-making. Three key themes emerged: women used HIVST to assess risk prior to engaging in sex with partners; HIVST provided women with increased agency to engage in or end relationships; and women appreciated these benefits and urged expanded access to self-tests. HIVST has the potential to support HIV prevention objectives in settings with high prevalence of HIV.Trial registration: ClinicalTrials.gov identifier: NCT03135067.
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Affiliation(s)
- Lucy W. Ruderman
- Gillings School of Global Public Health Department of Health Behaviour, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Perez Ochwal
- Impact Research and Development Organization, Kisumu, Kenya
| | - Noora Marcus
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Sue Napierala
- Women’s Global Health Imperative, RTI International, Berkeley, CA, USA
| | - Harsha Thirumurthy
- Perelman School of Medicine, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Suzanne Maman
- Gillings School of Global Public Health Department of Health Behaviour, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Shi L, Luo J, Chen Y, Chen L, Hu H, Qiu T, Liu X, Xu X, Chen Y, Zhang Z, Zhou Y, Lu J, Fu G. Prevalence of syphilis and chlamydia trachomatis infection among female sex workers in Jiangsu, China: Results from a multicenter cross-sectional and venue-based study. Front Public Health 2022; 10:1018724. [PMID: 36388309 PMCID: PMC9659951 DOI: 10.3389/fpubh.2022.1018724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/14/2022] [Indexed: 01/28/2023] Open
Abstract
Background Female sex workers (FSWs) are considered highly vulnerable to sexually transmitted infections (STIs), but available data on the prevalence of STIs among FSWs in China is limited at a provincial level. This study aimed to evaluate the prevalence of STIs and risk factors among FSWs in Jiangsu, China. Methods We conducted a multicenter cross-sectional study in seven cities of Jiangsu to investigate the prevalence and risk factors associated with HIV and other STIs. Blood and urine were collected to test for HIV, syphilis, Hepatitis C (HCV), Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infections. Results We enrolled 3,580 FSWs. The overall prevalence of bacterial STIs was 6.2% (5.4%-7.0%). The prevalence of HIV, syphilis infection, HCV, NG and CT were 0.1% (95%CI, 0.0-0.2), 1.8% (95%CI, 1.4-2.3), 0.3% (95%CI, 0.1-0.5), 0.3% (95%CI, 0.2-0.5) and 4.3% (95%CI, 3.6-5.0), respectively. Most FSWs (85.6%) reported consistent condom use with clients in the past month. Only 10.6% of FSWs reported group sex, and 68.3% self-reported HIV testing in the previous year. According to the multivariable model, having group sex in the past year (aOR, 2.521, 95%CI: 1.366-4.651) and HIV infection (aOR, 26.260, 95%CI: 2.432-283.563) were associated with a higher risk of syphilis infection. Migrants (aOR, 1.669, 95%CI: 1.163-2.395), having a history of STIs in the past year (aOR, 4.601, 95%CI: 1.003-21.118), and NG infection (aOR, 38.549, 95%CI: 11.214-132.514) were associated with a higher risk of CT infection. On the contrary, FSWs aged older than 25 were associated with lower risk of syphilis infection (25-34: aOR, 0.339, 95%CI: 0.151-0.763) and CT infection (25-34: aOR, 0.503, 95%CI: 0.316-0.802; ≥35: aOR, 0.578, 95%CI: 0.362-0.925). Conclusion This study's prevalence rates of syphilis and CT infections show the need to promote comprehensive STIs control and prevention strategies, including behavioral intervention and STIs screening, especially in younger high-risk populations. With the increasing coverage of HIV testing, integrating other STIs screening with HIV testing may be a reasonable way to implement comprehensive STIs control and prevention.
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Affiliation(s)
- Lingen Shi
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China,Jiangsu Key Laboratory of Molecular Medicine, Medical School, Nanjing University, Nanjing, China
| | - Jun Luo
- Department of Clinical Central Laboratory, Jiangsu Health Vocational College, Nanjing, China
| | - Yuheng Chen
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Liping Chen
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Haiyang Hu
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Tao Qiu
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Xiaoyan Liu
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Xiaoqin Xu
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Yunting Chen
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Zhi Zhang
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Ying Zhou
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Jing Lu
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Gengfeng Fu
- Institute for STIs and HIV Control and Prevention, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China,*Correspondence: Gengfeng Fu
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Kazungu J, Richter M, Luchters S, Chersich MF, Quaife M. The economics of sex work and major sporting events: Learning from the 2010 FIFA World Cup in South Africa. SOCIAL SCIENCES & HUMANITIES OPEN 2022; 5:100251. [PMID: 35516462 PMCID: PMC8976284 DOI: 10.1016/j.ssaho.2022.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 12/03/2021] [Accepted: 12/17/2021] [Indexed: 11/19/2022]
Abstract
Risk-taking in sex work is related to financial gains from condom-protected and condomless-acts alongside vulnerabilities, including socio-economic factors, which influence the safety of sex workers. Large international sporting events have been shown to significantly impact the economies of host countries, but there is a dearth of studies that examine how major sporting events may affect the economics of sex work and the risks taken by sex workers and clients. This study examines the determinants of the price of commercial sex alongside the price premium for and correlates of, condomless sex before, during and after the 2010 world cup in South Africa. We analysed data from three phases of repeated cross-sectional surveys with sex workers. Bivariate and multivariable logistic regression models were fitted to examine the predictors of condomless sex. We also fitted fixed-effect regression models to examine the determinants of the price of commercial sex across each survey phase. Findings suggest that the price of sex was higher during the world cup compared to before and after, whilst the price premium for condomless-sex increased from 36% before the world cup to 40% (p-value<0.001) and 57% (p-value<0.001) during and after the world cup, respectively. Across the survey phases, anal, oral or masturbation sex were more likely to be supplied without a condom compared to vaginal sex. The type of sex was the primary determinant of the price of sex across all phases. We show indicative evidence that the 2010 world cup was associated with an increase in the price of sex and supply of condomless-sex. Although these findings should be interpreted as associations rather than causal relationships, we recommend that countries with substantial sex-worker populations that host major events shouldexplicitly consider the context and structures of sex work, and promote client-focused safe-sex-interventions that explicitly consider the economic pressures faced by sexworkers to provide riskier acts, to minimise health impacts.
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Affiliation(s)
- Jacob Kazungu
- Health Economics Research Unit, KEMRI | Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
- Corresponding author. Health Economics Research Unit, KEMRI, Wellcome Trust Research Programme, P.O. Box 43640 – 00100, Nairobi, Kenya.
| | - Marlise Richter
- African Centre for Migration & Society, University of the Witwatersrand, Johannesburg, South Africa
- Alan J Flisher Centre for Public Mental Health, University of Cape Town, Cape Town, South Africa
| | - Stanley Luchters
- Department of Population Health, Aga Khan University, Nairobi, Kenya
- Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Matthew F. Chersich
- Wits Reproductive Health and HIV Institute, Faculty of Health Science, University of the Witwatersrand, South Africa
| | - Matthew Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
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Hirsch-Moverman Y, Strauss M, George G, Mutiti A, Mafukidze A, Shongwe S, Dube GS, El Sadr WM, Mantell JE, Howard AA. Paediatric tuberculosis preventive treatment preferences among HIV-positive children, caregivers and healthcare providers in Eswatini: a discrete choice experiment. BMJ Open 2021; 11:e048443. [PMID: 34686549 PMCID: PMC8543650 DOI: 10.1136/bmjopen-2020-048443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 09/02/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Isoniazid preventive therapy initiation and completion rates are suboptimal among children. Shorter tuberculosis (TB) preventive treatment (TPT) regimens have demonstrated safety and efficacy in children and may improve adherence but are not widely used in high TB burden countries. Understanding preferences regarding TPT regimens' characteristics and service delivery models is key to designing services to improve TPT initiation and completion rates. We examined paediatric TPT preferences in Eswatini, a high TB burden country. DESIGN We conducted a sequential mixed-methods study utilising qualitative methods to inform the design of a discrete choice experiment (DCE) among HIV-positive children, caregivers and healthcare providers (HCP). Drug regimen and service delivery characteristics included pill size and formulation, dosing frequency, medication taste, treatment duration and visit frequency, visit cost, clinic wait time, and clinic operating hours. An unlabelled, binary choice design was used; data were analysed using fixed and mixed effects logistic regression models, with stratified models for children, caregivers and HCP. SETTING The study was conducted in 20 healthcare facilities providing TB/HIV care in Manzini, Eswatini, from November 2018 to December 2019. PARTICIPANTS Ninety-one stakeholders completed in-depth interviews to inform the DCE design; 150 children 10-14 years, 150 caregivers and 150 HCP completed the DCE. RESULTS Despite some heterogeneity, the results were fairly consistent among participants, with palatability of medications viewed as the most important TPT attribute; fewer and smaller pills were also preferred. Additionally, shorter waiting times and cost of visit were found to be significant drivers of choices. CONCLUSION Palatable medication, smaller/fewer pills, low visit costs and shorter clinic wait times are important factors when designing TPT services for children and should be considered as new paediatric TPT regimens in Eswatini are rolled out. More research is needed to determine the extent to which preferences drive TPT initiation, adherence and completion rates.
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Affiliation(s)
- Yael Hirsch-Moverman
- ICAP at Columbia University, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Michael Strauss
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Anthony Mutiti
- ICAP at Columbia University, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Arnold Mafukidze
- ICAP at Columbia University, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Siphesihle Shongwe
- ICAP at Columbia University, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Gloria Sisi Dube
- Eswatini National TB Control Programme, Eswatini Ministry of Health, Mbabane, Hhohho, Swaziland
| | - Wafaa M El Sadr
- ICAP at Columbia University, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Joanne E Mantell
- Department of Psychiatry, Gender, Sexuality and Health Area, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Andrea A Howard
- ICAP at Columbia University, Columbia University Mailman School of Public Health, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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Trends in Reported Sexual Behavior and Y-Chromosomal DNA Detection Among Female Sex Workers in the Senegal Preexposure Prophylaxis Demonstration Project. Sex Transm Dis 2021; 47:314-320. [PMID: 32187172 PMCID: PMC7213512 DOI: 10.1097/olq.0000000000001175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A study among female sex workers in Senegal found no evidence of increased sexual risk behavior after preexposure prophylaxis initiation as measured by self-report or Y-chromosomal DNA detection. Supplemental digital content is available in the text. Background Preexposure prophylaxis (PrEP) can reduce HIV acquisition among female sex workers (FSWs). However, changes in condomless sex frequency after PrEP initiation could reduce PrEP effectiveness when PrEP adherence is suboptimal as well as increase the risk of acquiring other sexually transmitted infections. Objective measures of condomless sex may be more accurate for determining changes in sexual behavior than self-reported measures. Methods We longitudinally measured self-reported condom use, number of clients, and presence of Y-chromosomal DNA (Yc-DNA) in vaginal swabs among 267 FSWs accessing PrEP at 4 clinics in Senegal between 2015 and 2016. We assessed trends in sexual behavior over time since PrEP initiation using generalized estimating equations and evaluated predictors of Yc-DNA detection. Results We found no increase in self-reported condomless sex with clients (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.89–1.00), main partners (OR, 0.99; 95% CI, 0.96–1.02), or Yc-DNA detection (OR, 0.99; 95% CI, 0.90–1.08) over time since initiation. Y-chromosomal DNA was detected in 34 (22%) of 154 swabs tested and in 15 (26%) of 58 swabs from FSW reporting consistent condom use among both clients and main partners. Self-reported condom use with clients or main partners did not predict Yc-DNA detection. Conclusions In a FSW PrEP demonstration project in Senegal, we found no evidence of risk compensation among FSWs on PrEP as measured by self-reported behavior or through Yc-DNA detection. Y-chromosomal DNA detection was frequently detected among FSWs reporting consistent condom use, highlighting limitations of self-reported sexual behavioral measures.
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Quaife M, Terris-Prestholt F, Mukandavire Z, Vickerman P. Modelling the effect of market forces on the impact of introducing human immunodeficiency virus pre-exposure prophylaxis among female sex workers. HEALTH ECONOMICS 2021; 30:659-679. [PMID: 33377250 DOI: 10.1002/hec.4211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 10/06/2020] [Accepted: 11/22/2020] [Indexed: 06/12/2023]
Abstract
Pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) enables female sex workers (FSWs) to protect themselves from HIV without relying on clients using condoms. Yet, because PrEP reduces HIV risk, financial incentives to not use condoms may lead to risk compensation: reductions in condom use and/or increases in commercial sex, and may reduce the price of unprotected sex. In this analysis, we integrate market forces into a dynamic HIV transmission model to assess how risk compensation could change the impact of PrEP among FSWs and clients. We parameterise how sexual behavior may change with PrEP use among FSWs using stated preference data combined with economic theory. Our projections suggest the impact of PrEP is sensitive to risk compensatory behaviors driven by changes in the economics of sex work. Condom substitution could reduce the impact of PrEP on HIV incidence by 55%, while increases in the frequency of commercial sex to counter decreases in the price charged for unprotected sex among PrEP users could entirely mitigate the impact of PrEP. Accounting for competition between PrEP users and nonusers exacerbates this further. Alternative scenarios where increases in unprotected sex among PrEP users are balanced by decreases in non-PrEP users have the opposite effect, resulting in PrEP having much greater impact. Intervention studies need to determine how HIV prevention products may change the economics of sex work and provision of unprotected sex to enable a better understanding of their impact.
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Affiliation(s)
- Matthew Quaife
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Zindoga Mukandavire
- School of Computing, Electronics and Mathematics, Coventry University, Coventry, UK
- Center for Data Science, Coventry University, Coventry, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
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Eliciting Preferences for HIV Prevention Technologies: A Systematic Review. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:151-174. [PMID: 33319339 PMCID: PMC7884379 DOI: 10.1007/s40271-020-00486-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 01/10/2023]
Abstract
Background Many human immunodeficiency virus (HIV) prevention technologies (pre-exposure prophylaxis, microbicides, vaccines) are available or in development. Preference elicitation methods provide insight into client preferences that may be used to optimize products and services. Given increased utilization of such methods in HIV prevention, this article identifies and reviews these methods and synthesizes their application to HIV prevention technologies. Methods In May 2020, we systematically searched peer-reviewed literature in PubMed, CINAHL, and Web of Science for studies employing quantitative preference elicitation methods to measure preferences for HIV prevention technologies among populations of any age, sex, or location. Quality assessment used an existing checklist (PREFS) and a novel adaptation of the Newcastle–Ottawa Scale (PROSPERO #CRD42018087027). Results We screened 5022 titles and abstracts, reviewed 318 full texts, and included 84 studies. Common methods employed were discrete-choice experiment (33%), conjoint analysis (25%), and willingness-to-participate/try/accept (21%). Studies were conducted in 25 countries and had a mean of 768 participants (range = 26–7176), two-thirds of them male. Common HIV prevention technologies included pre-exposure prophylaxis (23%), voluntary testing and counseling (19%), HIV self-testing (17%), vaccines (15%), and topical microbicides (9%). Most attributes focused on product design (side effects, frequency), service design (provider type, location), acceptability or willingness to accept/pay; results are summarized in these categories, by prevention type. Mean quality-adapted Newcastle–Ottawa Scale score was 4.5/8 (standard deviation = 2.1) and mean PREFS scores was 3.47/5 (standard deviation = 0.81). Conclusions This review synthesizes extant literature on quantitative measurement of preferences for HIV prevention technologies. This can enable practitioners to improve prevention products and interventions, and ultimately reduce HIV incidence.
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iSAY (incentives for South African youth): Stated preferences of young people living with HIV. Soc Sci Med 2020; 265:113333. [PMID: 32896799 DOI: 10.1016/j.socscimed.2020.113333] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 01/13/2023]
Abstract
High adherence to antiretroviral therapy (ART) is essential for achieving viral suppression and preventing HIV transmission. Yet adherence is suboptimal among adolescents who face unique adherence challenges. Little is known about the role of conditional economic incentives (CEIs) for increasing ART adherence in this population. During 2017-2019, we conducted a mixed-methods discrete choice experiment in Cape Town, South Africa to inform the optimal design of a CEI intervention for ART adherence among youth. In-depth interviews were conducted with n = 35 adolescents (10-19 years old) living with HIV and prescribed ART, to identify attributes of a youth-centered CEI intervention for ART adherence. A discrete choice experiment was subsequently conducted with N = 168 adolescents to elicit preferences for intervention components. A rank-ordered mixed logit model was used for main results; marginal willingness-to-accept (mWTA) was then estimated. Five attributes emerged from the qualitative research as important for a CEI-based intervention for youth ART adherence: (1) incentive amount, (2) incentive format, (3) incentive recipient, (4) delivery mode, and (5) program participants. Youth had a high probability of acceptance of any incentives program (88-100%), yet they did not have a strong preference of a quarterly over a monthly program. From a maximum incentive amount of R1920 (~US$115), youth were willing to forgo up to R126 per year (~US$9) if the incentive was given in cash (versus fashion vouchers); R274 (~US$19.6) if it was open to both previously adherent and non-adherent youth (instead of non-adherent only); and up to R91 (~US$6.5) to receive incentives at a clinic setting (instead of electronically). The use of incentives over the short term during the critical age- and developmental-transition, when adolescents begin to take sole responsibility for their medication-taking behaviors, holds great promise for habituating adherence into adulthood.
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Ortblad KF, Stalter RM, Bukusi EA, Ngure K, Mujugura A, Celum C, Baeten JM, Heffron R. No Evidence of Sexual Risk Compensation Following PrEP Initiation Among Heterosexual HIV Serodiscordant Couples in Kenya and Uganda. AIDS Behav 2020; 24:1365-1375. [PMID: 31696370 PMCID: PMC7156350 DOI: 10.1007/s10461-019-02720-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recent studies among men who have sex with men suggest that sexual behaviors associated with risk of sexually transmitted infections increase following initiation of pre-exposure prophylaxis (PrEP) for HIV prevention. We used longitudinal data from HIV-uninfected participants (n = 1013) enrolled in an open-label study of PrEP delivered to Ugandan and Kenyan heterosexual HIV serodiscordant couples to understand the association between PrEP initiation and HIV risk-related sexual behaviors among these couples. In the month following PrEP initiation, the mean number of monthly sex acts within couples decreased from 7.9 to 6.9 (mean difference: - 1.1; 95% CI - 1.5, - 0.7) and the proportion of couples having condomless sex decreased from 65% to 32% (percentage point change: - 33%; 95% CI - 37%, - 30%); these behaviors then remained relatively constant over 2 years. We found no evidence of sexual risk compensation following PrEP initiation within African serodiscordant couples. However, roughly a third of couples continued to engage in condomless sex during follow up, emphasizing the importance of continued PrEP use to sustain HIV protection.
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Affiliation(s)
- Katrina F Ortblad
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA.
| | - Randy M Stalter
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Andrew Mujugura
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Connie Celum
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Epidemiology, University of Washington, Seattle, USA
- Department of Medicine, University of Washington, Seattle, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, 908 Jefferson St, 12th floor, Seattle, WA, 98104, USA
- Department of Medicine, University of Washington, Seattle, USA
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Bowring AL, Schwartz S, Lyons C, Rao A, Olawore O, Njindam IM, Nzau J, Fouda G, Fako GH, Turpin G, Levitt D, Georges S, Tamoufe U, Billong SC, Njoya O, Zoung-Kanyi AC, Baral S. Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:82-99. [PMID: 32234842 PMCID: PMC7108938 DOI: 10.9745/ghsp-d-19-00330] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 02/28/2020] [Indexed: 12/19/2022]
Abstract
Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs. Background: Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon. Methods: From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception. Results: Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use. Conclusions: Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.
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Affiliation(s)
- Anna L Bowring
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Burnet Institute, Melbourne, Australia
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie Lyons
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amrita Rao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oluwasolape Olawore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Iliassou Mfochive Njindam
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Metabiota, Yaounde, Cameroon
| | | | | | | | - Gnilane Turpin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Ubald Tamoufe
- Metabiota, Yaounde, Cameroon.,Johns Hopkins Cameroon Program, Yaounde, Cameroon
| | - Serge C Billong
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Oudou Njoya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Anne-Cécile Zoung-Kanyi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon.,Division of Operations Research, Ministry of Health, Yaounde, Cameroon
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bowring AL, Ampt FH, Schwartz S, Stoové MA, Luchters S, Baral S, Hellard M. HIV pre-exposure prophylaxis for female sex workers: ensuring women's family planning needs are not left behind. J Int AIDS Soc 2020; 23:e25442. [PMID: 32064765 PMCID: PMC7025091 DOI: 10.1002/jia2.25442] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/28/2019] [Accepted: 12/05/2019] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs. DISCUSSION FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed. CONCLUSIONS As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights.
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Affiliation(s)
- Anna L Bowring
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
- Burnet InstituteMelbourneVictoriaAustralia
| | - Frances H Ampt
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Sheree Schwartz
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Mark A Stoové
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Stanley Luchters
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Population HealthAga Khan UniversityNairobiKenya
- International Centre for Reproductive HealthDepartment of Public Health and Primary CareGhent UniversityGhentBelgium
| | - Stefan Baral
- Department of EpidemiologyJohns Hopkins School of Public HealthBaltimoreMDUSA
| | - Margaret Hellard
- Burnet InstituteMelbourneVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of Infectious DiseasesThe Alfred HospitalMelbourneVictoriaAustralia
- Doherty Institute and Melbourne School of Population and Global HealthUniversity of MelbourneMelbourneVictoriaAustralia
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Ortblad KF, Musoke DK, Chanda MM, Ngabirano T, Velloza J, Haberer JE, McConnell M, Oldenburg CE, Bärnighausen T. Knowledge of HIV Status Is Associated With a Decrease in the Severity of Depressive Symptoms Among Female Sex Workers in Uganda and Zambia. J Acquir Immune Defic Syndr 2020; 83:37-46. [PMID: 31633611 PMCID: PMC6898780 DOI: 10.1097/qai.0000000000002224] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 09/25/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Knowledge of HIV-positive status may result in depressive symptoms, which may be a concern to scaling novel HIV testing interventions that move testing outside the health system and away from counselor support. SETTING Uganda and Zambia. METHODS We used longitudinal data from 2 female sex worker (FSW) cohorts in Uganda (n = 960) and Zambia (n = 965). Over 4 months, participants had ample opportunity to HIV testing using standard-of-care services or self-tests. At baseline and 4 months, we measured participants' perceived knowledge of HIV status, severity of depressive symptoms (continuous PHQ-9 scale, 0-27 points), and prevalence of likely depression (PHQ-9 scores ≥10). We estimated associations using individual fixed-effects estimation. RESULTS Compared with unknown HIV status, knowledge of HIV-negative status was significantly associated with a decrease in depressive symptoms of 1.06 points in Uganda (95% CI -1.79 to -0.34) and 1.68 points in Zambia (95% CI -2.70 to -0.62). Knowledge of HIV-positive status was significantly associated with a decrease in depressive symptoms of 1.01 points in Uganda (95% CI -1.82 to -0.20) and 1.98 points in Zambia (95% CI -3.09 to -0.88). The prevalence of likely depression was not associated with knowledge of HIV status in Uganda but was associated with a 14.1% decrease with knowledge of HIV-negative status (95% CI -22.1% to -6.0%) and a 14.3% decrease with knowledge of HIV-positive status (95% CI -23.9% to -4.5%) in Zambia. CONCLUSIONS Knowledge of HIV status, be it positive or negative, was significantly associated with a decrease in depressive symptoms in 2 FSW populations. The expansion of HIV testing programs may have mental health benefits for FSWs.
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Affiliation(s)
| | | | | | | | - Jennifer Velloza
- Department of Global Health, University of Washington, Seattle, WA
| | | | - Margaret McConnell
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Catherine E. Oldenburg
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology & Biostatistics, University of California, San Francisco, CA
| | - Till Bärnighausen
- Department of Global Health, University of Washington, Seattle, WA
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa; and
- Heidelberg Institute of Public Health, Heidelberg University, Heidelberg, Germany
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