Piloting a Social Networks Strategy to Increase HIV Testing and Counseling Among Men Who Have Sex with Men in Greater Accra and Ashanti Region, Ghana

Social network strategy (SNS) for HIV testing: a new approach for identifying individuals with undiagnosed HIV infection in Tanzania

Social network strategy (SNS) testing uses network connections to refer individuals at high risk to HIV testing services (HTS). In Tanzania, SNS testing is offered in communities and health facilities. In communities, SNS testing targets key and vulnerable populations (KVP), while in health facilities it complements index testing by reaching unelicited index contacts. Routine data were used to assess performance and trends over time in PEPFAR-supported sites between October 2021 and March 2023. Key indicators included SNS social contacts tested, and new HIV-positives individuals identified. Descriptive and statistical analysis were conducted. Univariable and multivariable analysis were applied, and variables with P-values <0.2 at univariable analysis were considered for multivariable analysis. Overall, 121,739 SNS contacts were tested, and 7731 (6.4%) previously undiagnosed individuals living with HIV were identified. Tested contacts and identified HIV-positives were mostly aged ≥15 years (>99.7%) and females (80.6% of tests, 79.4% of HIV-positives). Most SNS contacts were tested (78,363; 64.7%) and diagnosed (6376; 82.5%) in communities. SNS tests and HIV-positives grew 11.5 and 6.1-fold respectively, from October-December 2021 to January-March 2023, with majority of clients reached in communities vs. facilities (78,763 vs. 42,976). These results indicate that SNS testing is a promising HIV case-finding approach in Tanzania.

Programme science in action: lessons from an observational study of HIV prevention programming for key populations in Lusaka, Zambia

INTRODUCTION

Optimizing uptake of pre-exposure prophylaxis (PrEP) for individuals at risk of HIV acquisition has been challenging despite clear scientific evidence and normative guidelines, particularly for key populations (KPs) such as men who have sex with men (MSM), female sex workers (FSWs), transgender (TG) people and persons who inject drugs (PWID). Applying an iterative Programme Science cycle, building on the effective programme coverage framework, we describe the approach used by the Centre for Infectious Disease Research in Zambia (CIDRZ) to scale up PrEP delivery and address inequities in PrEP access for KP in Lusaka, Zambia.

METHODS

In 2019, CIDRZ partnered with 10 local KP civil society organizations (CSOs) and the Ministry of Health (MOH) to offer HIV services within KP-designated community safe spaces. KP CSO partners led KP mobilization, managed safe spaces and delivered peer support; MOH organized clinicians and clinical commodities; and CIDRZ provided technical oversight. In December 2021, we introduced a community-based intervention focused on PrEP delivery in venues where KP socialize. We collected routine programme data from September 2019 to June 2023 using programme-specific tools and the national electronic health record. We estimated the before-after effects of our intervention on PrEP uptake, continuation and equity for KP using descriptive statistics and interrupted time series regression, and used mixed-effects regression to estimate marginal probabilities of PrEP continuity.

RESULTS

Most (25,658) of the 38,307 (67.0%) Key Population Investment Fund beneficiaries were reached with HIV prevention services at community-based venues. In total, 23,527 (61.4%) received HIV testing services, with 15,508 (65.9%) testing HIV negative and found PrEP eligible, and 15,241 (98.3%) initiating PrEP. Across all programme quarters and KP types, PrEP uptake was >90%. After introducing venue-based PrEP delivery, PrEP uptake (98.7% after vs. 96.5% before, p < 0.001) and the number of initiations (p = 0.014) increased significantly. The proportion of KP with ≥1 PrEP continuation visit within 6 months of initiation was unchanged post-intervention (46.7%, 95% confidence interval [CI]: 45.7%, 47.6%) versus pre-intervention (47.2%, 95% CI: 45.4%, 49.1%).

CONCLUSIONS

Applying Programme Science principles, we demonstrate how decentralizing HIV prevention services to KP venues and safe spaces in partnership with KP CSOs enabled successful community-based PrEP delivery beyond the reach of traditional facility-based services.

Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana's slums-BSGH-005

Despite significant progress in Ghana's HIV response, disparities in HIV prevalence persist among different populations. Gays, bisexuals, and other men who have sex with men (GBMSM) in the country remain vulnerable to HIV infection due to high levels of stigma and discrimination, limited access to healthcare services, and low HIV knowledge levels. While limited studies focus on HIV prevention and care in the Ghanaian GBMSM context, we did not find studies on GBMSM in slums. We, therefore, explored stigma and motivations of HIV testing among GBMSM in slums. In collaboration with our community partners, we recruited and conducted face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi, Ghana. Our multiple-reviewer summative content analysis identified the following: under HIV stigma, we identified two categories, avoidance of GBMSM living with HIV and fear of testing positive for HIV. Under motivations for HIV testing, we identified three categories; HIV vulnerability, knowing one's HIV status, and positive messaging about HIV. Our findings provide valuable insights into stigma and motivations for HIV testing among GBMSM in Ghanaian slums. They also highlight the importance of targeted HIV education interventions to empower GBMSM to take responsibility for their sexual health and address the unique challenges they face accessing HIV testing services.

"One pastor advised him to stop taking HIV medication": Promoters and barriers to HIV care among gay, bisexual, and men who have sex with men living with HIV in Ghana

Introduction

Few studies examine Ghanaian gay, bisexual, and other men who have sex with men (GBMSM) experience with HIV diagnoses and linkage to care. This article provides qualitative accounts of promoters and barriers to care among GBMSM living with HIV in Ghana.

Methods

We recruited and interviewed 10 GBMSM living with HIV in two Ghanaian cities. We transcribed the interviews, coded the data, and used thematic content analysis.

Results

We found that community and healthcare facility (HCF) level HIV and sexual stigma, confidentiality issues, alternative medicine, and substance use remain the key barriers to care. Other barriers include healthcare system issues such as long wait times and economic problems (e.g., health insurance and financial difficulties). Nonetheless, HCF-level factors such as positive experiences with providers, HIV counseling, and detailed medication information facilitate adherence to care among GBMSM.

Conclusion

This study highlights the need for interventions that address linkage to care issues, especially substance use, disinformation, and misinformation among GBMSM and other Ghanaian communities.

HIV Testing Strategies, Types of Tests, and Uptake by Men Who have Sex with Men and Transgender Women: A Systematic Review and Meta-analysis

This systematic review and meta-analysis investigated the effectiveness of strategies and types of tests on HIV testing uptake by men who have sex with men (MSM) and transgender women (TGW), and in reaching PLWH. Articles published up to July 2020 were identified from major electronic databases and grey literature. Data were extracted and assessed for risk of bias. Estimates were pooled using random-effect meta-analysis while heterogeneity was evaluated by Cochran's Q test and I². This study is registered with PROSPERO (CRD42020192740). Of 6820 titles, 263 studies (n = 67,288 participants) were included. The testing strategies reported in most studies were community- (71.2%) and facility-based (28.8%). Highest uptake, with facility-based testing, occurred and reached more PLWH while with standard laboratory tests, it occurred with the highest HIV prevalence among MSM. However, urine test showed a highest rate of new HIV infection. Multiple test combinations had the highest uptake and reached more PLWH among TGW. Various testing strategies, considering barriers and regional differences, and different test types, need be considered, to increase uptake among MSM and TGW.

Reaching transgender populations in Zambia for HIV prevention and linkage to treatment using community-based service delivery

INTRODUCTION

Transgender and gender-diverse communities in Zambia are highly vulnerable and experience healthcare differently than cisgender persons. The University of Maryland, Baltimore (UMB) supports projects in Zambia to improve HIV case-finding, linkage and antiretroviral treatment (ART) for Zambia's transgender community. We describe programme strategies and outcomes for HIV prevention, testing and ART linkage among transgender communities.

METHODS

UMB utilizes a differentiated service delivery model whereby community health workers (CHWs) recruited from key populations (KPs) reach community members through a peer-to-peer approach, with the support of local transgender civil society organizations (CSOs) and community gatekeepers. Peer CHWs are trained and certified as HIV testers and psychosocial counsellors to offer counselling with HIV testing and prevention services in identified safe spaces. HIV-negative people at risk of HIV infection are offered pre-exposure prophylaxis (PrEP), while those who test positive for HIV are linked to ART services. CHWs collect data using the standardized facility and community tools and a dedicated DHIS2 database system. We conducted a descriptive analysis examining HIV testing and prevention outcomes using proportions and comparisons by time period and geographic strata.

RESULTS

From October 2020 to June 2021, across Eastern, Lusaka, Western and Southern Provinces, 1860 transgender persons were reached with HIV prevention messages and services. Of these, 424 (23%) were tested for HIV and 78 (18%) tested positive. Of the 346 HIV-negative persons, 268 (78%) eligible transgender individuals were initiated on PrEP. ART linkage was 97%, with 76 out of the 78 transgender individuals living with HIV initiating treatment. Programme strategies that supported testing and linkage included peer CHWs, social network strategy testing, same-day ART initiation and local KP CSO support. Challenges included non-transgender-friendly environments, stigma and discrimination, the high transiency of the transgender community and the non-availability of transgender-specific health services, such as hormonal therapy.

CONCLUSIONS

Peer KP CHWs were able to reach many members of the transgender community, providing safe HIV testing, PrEP services and linkage to care. Focusing on community gatekeepers and CSOs to disburse health messages and employ welcoming strategies supported high linkage to both PrEP and ART for transgender people in Zambia.

Individual level peer interventions for gay and bisexual men who have sex with men between 2000 and 2020: A scoping review

BACKGROUND

Peer-led interventions are central to the global HIV response for gay and bisexual men who have sex with men [GBMSM]. Since the year 2000, technological advancements in HIV and an increased response to the health disparities faced by GBMSM outside of HIV, have contributed to the expanding scope of their content and delivery. This review sets out to characterise the evidence base for individual level peer interventions for GBMSM, overview approaches to implementing and evaluating them and identify future priorities for their delivery and evaluation.

METHODS

A scoping review methodology was applied and evaluations of peer programs for GBMSM published in peer reviewed journals were identified via subject heading and keyword searches across five electronic databases. Titles and abstracts were reviewed, and full texts were assessed against eligibility criteria. A coding framework was used to extract data from included studies against intervention implementation and evaluation components.

RESULTS

A total of 38 studies evaluating peer led interventions against effectiveness outcomes were deemed eligible for inclusion and coded into four intervention modalities; peer counselling [n = 6], groupwork programs [n = 15], peer navigation [n = 7] and peer education [n = 10]. Most addressed HIV [n = 32] and across intervention modalities, evaluations demonstrated compelling evidence of significant effect. Intervention effects on broader indicators of psychosocial wellbeing were not extensively evaluated. Expertise regarding the implementation and evaluation of peer interventions addressing HIV among GBMSM ought to be leveraged to expand the scope of peer intervention to meet the diverse health and wellbeing needs of GBMSM.

A Systematic Review of HIV Testing Implementation Strategies in Sub-Saharan African Countries

HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa.

Sexual Partner Referral for HIV Testing Through Social Networking Platforms: Cross-sectional Study

Background

Men who have sex with men (MSM) who undergo voluntary HIV counseling and testing (VCT) often report condomless anal sexual intercourse, having many sexual partners, and being exposed to risky sexual networks. Limited research has discussed the application of motivational interviewing and convenience referral platforms to facilitate the referral of sexual partners for HIV testing among MSM.

Objective

This study aimed to evaluate the effects of VCT referral by sexual partners through social networking platforms and the test results after elicited interviews with MSM; compare the characteristics and risk behaviors among MSM tested without referral, index subjects, and referred sexual partners; and explore unknown sexual affiliations through visualizing and quantifying the social network graph.

Methods

This was a cross-sectional study. Purposeful sampling was used to recruit index subjects from a community HIV screening station frequented by MSM in Taipei City on Friday and Saturday nights. Respondent-driven sampling was used to recruit sexual partners. Partner-elicited interviews were conducted by trained staff before VCT to motivate MSM to become index subjects and refer sexual partners via the Line app, or to disclose the accounts and profiles of sexual partners on relevant social networking platforms. Referred sexual partners received rapid HIV testing, and the recruitment process was repeated until leads were exhausted.

Results

After the interviews, 28.2% (75/266) of MSM were successfully persuaded to become index subjects in the first wave, referring 127 sexual partners via the Line app for rapid HIV testing and disclosing 40 sexual partners. The index subjects and tested sexual partners had more sexual partners (F₂=3.83, P=.02), more frequent anal intercourse (F₂=10.10, P<.001), and higher percentages of those who had not previously received HIV testing (χ²₁=6.1, P=.047) compared with MSM tested without referrals. The new HIV-seropositivity rate among tested sexual partners was 2.4%, which was higher than the rate in the other 2 groups. The social network analysis revealed the following 4 types of sexual affiliation: chain, Y, star, and complicated. Among the HIV-negative sexual partners, 26.9% (43/160) had sexual affiliations with HIV-positive nodes, and 40% (10/25) were untested sexual partners with a direct sexual affiliation with an HIV-positive node. Four transmission bridges were found in the network graph.

Conclusions

Partner-elicited interviews can effectively promote referral for HIV testing and case identification via Line, and can clarify unknown sexual affiliations of MSM to facilitate the development of a tailored prevention program. Social network analysis is needed for an insightful understanding of the different network structures.

HIV Testing Approaches to Optimize Prevention and Treatment for Key and Priority Populations in Malawi

Background

Despite progress in improving antiretroviral therapy (ART) for people with HIV in Malawi, the burden of HIV infections and HIV treatment outcomes among key populations is suboptimal. Client-centered differentiated service delivery approaches may facilitate addressing HIV prevention and treatment needs of key populations in Malawi.

Methods

De-identified program data routinely collected as part of the LINKAGES project–Malawi were assembled from October 2017 to September 2019. HIV case finding was compared across different testing modalities for each population. Poisson regression was used to estimate the association between testing modalities and ART initiation.

Results

Of the 18 397 people included in analyses, 10627 (58%) were female sex workers (FSWs), 2219 (12%) were men who have sex with men (MSM), and 4970 (27%) were clients of FSWs. HIV case finding varied by modality and population, with index testing and enhanced peer outreach demonstrating high yield despite reaching relatively few individuals. FSWs who tested positive through risk network referral testing were more likely to initiate ART within 30 days compared with those who tested positive through clinic-based testing (adjusted risk ratio [aRR], 1.50; 95% CI, 1.23–1.82). For MSM, index testing (aRR, 1.45; 95% CI, 1.06–2.00) and testing through a drop-in center (aRR, 1.82; 95% CI, 1.19–2.78) were associated with 30-day ART initiation.

Conclusions

These data suggest that differentiated HIV testing and outreach approaches tailored to the needs of different key populations may facilitate improved ART initiation in Malawi. Achieving 0 new infections by 2030 suggests the need to adapt treatment strategies given individual and structural barriers to treatment for key populations with HIV in high-prevalence settings.

HIV testing and ART initiation among partners, family members, and high-risk associates of index clients participating in the CommLink linkage case management program, Eswatini, 2016-2018

To help diagnose and initiate antiretroviral therapy (ART) for ≥95% of all persons living with HIV (PLHIV), the World Health Organization (WHO) recommends offering HIV testing to biological children, and sexual and needle-sharing partners of all PLHIV (index-client testing, ICT). Many index clients, however, do not identify or have contactable partners, and often substantially fewer than 95% of HIV-positive partners initiate ART soon after index testing. To help improve early HIV diagnosis and ART initiation in Eswatini (formerly Swaziland), we implemented a community-based HIV testing and peer-delivered, linkage case management program (CommLink) that provided ICT as part of a comprehensive package of WHO recommended linkage services. CommLink was implemented June 2015 -March 2017 (Phase I), and April 2017 -September 2018 (Phase II). In addition to biological children and partners, HIV testing was offered to adult family members (Phases I and II) and high-risk associates including friends and acquaintances (Phase II) of CommLink index clients. Compared with Phase I, in Phase II proportionally more CommLink clients disclosed their HIV-infection status to a partner or family member [94% (562/598) vs. 75% (486/652)], and had ≥1 partners, family members, or high-risk associates (contacts) tested through CommLink [41% (245/598) vs. 18% (117/652)]. Of 537 contacts tested, 253 (47%) were HIV-positive and not currently in HIV care, including 17% (17/100) of family members aged <15 years, 42% (78/187) of non-partner family members aged ≥15 years, 60% (73/121) of sexual partners, and 66% (85/129) of high-risk associates. Among 210 HIV-positive contacts aged ≥15 years who participated in CommLink, nearly all received recommended linkage services including treatment navigation (95%), weekly telephone follow-up (93%), and ≥3 counseling sessions (94%); peer counselors resolved 76% (306/404) of identified barriers to care (e.g., perceived wellness); and 200 (95%) initiated ART at a healthcare facility, of whom 196 (98%) received at least one antiretroviral refill before case-management services ended. To help countries achieve ≥90% ART coverage among all PLHIV, expanding ICT for adult family members and high-risk associates of index clients, and providing peer-delivered linkage case management for all identified PLHIV, should be considered.

HIV Education, Empathy, and Empowerment (HIVE3): A Peer Support Intervention for Reducing Intersectional Stigma as a Barrier to HIV Testing among Men Who Have Sex with Men in Ghana

Men who have sex with men (MSM) in Ghana remain at heightened risk of HIV infection, and face challenges in accessing HIV prevention and care services. Previous research in Ghana shows that MSM face intersectional stigma across ecological levels (family, peers, healthcare settings, and community level) and the criminalization of same-gender sexual behaviors in the country. To protect their wellbeing from exposure to stigma, many MSM avoid interactions with healthcare systems and services, which inadvertently inhibits their opportunities for early detection and treatment of HIV. Consequently, MSM in Ghana carry a disproportionate burden of HIV prevalence (18%) compared to the general population (2%), highlighting the need for culturally relevant processes in HIV/STI prevention, and care communication to optimize sexual health and wellness among MSM in Ghana. To this effect, we collaborated with community partners to use the Assessment, Decision, Adaptation, Production, Topical Experts, Training, Testing (ADAPT-ITT) model to modify a theory-driven smartphone-based peer support intervention to enhance its focus on intersectional stigma reduction, and improve HIV health-seeking behaviors among MSM, including HIV testing and linkage to care. We used the Dennis Peer Support Model to develop the peer support components (emotional, informational, and appraisal support) to increase peer social support, decrease social isolation, and minimize intersectional stigma effects on HIV-related healthcare-seeking behaviors. This paper shows the preliminary acceptability and effectiveness of employing culturally relevant techniques and communication strategies to provide secure peer support to improve HIV prevention and care among key populations in highly stigmatized environments.

Improved HIV case finding among key populations after differentiated data driven community testing approaches in Zambia

Introduction

Open Doors, an HIV prevention project targeting key populations in Zambia, recorded low HIV positivity rates (9%) among HIV testing clients, compared to national adult prevalence (12.3%), suggesting case finding efficiency could be improved. To close this gap, they undertook a series of targeted programmatic and management interventions. We share the outcomes of these interventions, specifically changes in testing volume, HIV positivity rate, and total numbers of key populations living with HIV identified.

Methods

The project implemented a range of interventions to improve HIV case finding using a Total Quality Leadership and Accountability (TQLA) approach. We analyzed program data for key populations who received HIV testing six months before the interventions (October 2017–March 2018) and 12 months after (April 2018–March 2019). Interrupted time series analysis was used to evaluate the impact on HIV positivity and total case finding and trends in positivity and case finding over time, before and after the interventions.

Results

While the monthly average number of HIV tests performed increased by only 14% post-intervention, the monthly average number of HIV positive individuals identified increased by 290%. The average HIV positivity rate rose from 9.7% to 32.4%. Positivity rates and case finding remained significantly higher in all post-intervention months. Similar trends were observed among FSW and MSM.

Conclusions

The Open Doors project was able to reach large numbers of previously undiagnosed key populations by implementing a targeted managerial and technical intervention, resulting in a significant increase in the HIV positivity rate sustained over 12 months. These results demonstrate that differentiated, data-driven approaches can help close the 95-95-95 gaps among key populations.

Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial

BACKGROUND

Men with have sex with men (MSM) in Africa face high levels of stigma due to elevated HIV exposure (actual or perceived), same-sex practices, and gender non-conformity. These stigmas are documented barriers to HIV prevention and treatment. Most stigma-reduction interventions have focused on single-level targets (e.g., health care facility level [HCF]) and addressed one type of stigma (e.g., HIV), without engaging the multiple intersecting stigmas that MSM encounter. Determining the feasibility and acceptability of multi-level intervention of reducing intersectional stigma and estimating its efficacy on increasing HIV testing are needed.

METHODS

We proposed a mixed method study among MSM in Ghana. First, we will develop the intervention protocol using the Convergence Framework, which combines three interventions that were previously implemented separately in Ghana for reducing stigma at the HCF-level, increasing HIV testing at the peer group-level, and increasing peer social support at the individual-level. Then, we will conduct a cluster randomized controlled trial with four pairs of HCFs matched on staff size. HCFs within each pair are randomized to the HCF-level stigma-reduction intervention or control arm. MSM (n = 216) will be randomized to receive the group-level and individual-level interventions or standard of care control arm. MSM will be assigned to receive HIV testing at one of the HCFs that match their study assignment (intervention or control facility). The frequency of HIV testing between MSM in the study arms at 3 and 6 months will be compared, and the predictors of HIV testing uptake at the HCF, peer group and individual-levels will be assessed using multi-level regression models.

DISCUSSION

These findings from this study will provide important evidence to inform a hybrid implementation-effectiveness trial of a public health intervention strategy for increasing HIV case detection among key populations in sub-Saharan African communities. Accurate information on HIV prevalence can facilitate epidemic control through more precise deployment of public health measures aimed at HIV treatment and viral load suppression, which eliminates risk of transmission.

TRIAL REGISTRATION

This study was prospectively registered on ClinicalTrials.gov, Identifier: NCT04108078, on September 27, 2019.

Community-Based Interventions as Opportunities to Increase HIV Self-Testing and Linkage to Care Among Men Who Have Sex With Men - Lessons From Ghana, West Africa

MSM in Ghana encounter challenges in accessing HIV services and may experience barriers to HIV self-testing due to multiple forms of stigma present in health care settings. We worked with community-based organization partners to implement three interventions that successfully engaged and retained MSM which provides an opportunity for linkage to self-testing and medical care. These interventions were (1) Many Men Many Voices (3MV) a locally-led culturally grounded group-level HIV prevention program, (2) Auntie's Corner: a mobile-app based connecting MSM to health monitoring by a registered nurse and (3) HIV Education, Empathy, & Empowerment (HIVE3): a mobile-app based peer support intervention for MSM living with HIV. The 3MV intervention may be effective in improving HIV self-testing due to its effectiveness in engaging MSM, increasing HIV testing, and improving MSM understanding of the need for HIV testing. The utilization of apps like Auntie's Corner could positively impact HIV self-testing among MSM because it increases contact with nurses and reporting of symptoms. In HIVE3, participants expressed appreciation of the security and privacy that protects their identities as MSM and the peer mentors' abilities to make referrals to the nurses in Auntie's Corners. The confidentiality component has proven key among MSM and connecting MSM to self-testing through apps to report their process and receive care could increase utilization. Together, we show the efficacy of using the community-engaged process in reaching and engaging highly stigmatized populations like Ghana and sub-Saharan Africa, and its potential in increasing HIV self-testing and linkage to HIV care.

Gaps in HIV Testing and Treatment Among Female Sex Workers in Lae and Mt. Hagen, Papua New Guinea

We conducted biobehavioral surveys among female sex workers (FSW) in Lae and Mt. Hagen, Papua New Guinea (January-December 2017). Respondent-driven sampling was used to recruit FSW aged ≥ 12 years, who were assigned female sex at birth, who spoke English or Tok Pisin, and who sold or exchanged sex for money, goods, or services in the last 6 months. When adjusted for viral suppression, 48.9% of FSW Lae and 61.9% in Mt. Hagen were aware of their HIV positive status. Of these women, 95.3% in Lae and 98.9% in Mt. Hagen were on antiretroviral therapy, and of these, 83.5% in Lae and 87.0% in Mt. Hagen had suppressed viral load. Renewed efforts are needed to increase HIV testing among FSW and provide support to FSW on treatment in both cities to attain viral suppression.

High HIV and syphilis prevalence among female sex workers in Juba, South Sudan

HIV prevalence is estimated to be 2.7% in South Sudan; however, little is known about the young country’s epidemic. We conducted a respondent-driven sampling biobehavioral survey in Juba of female sex workers (FSW) aged ≥15 years who sold or exchanged sex in the last 6 months to learn more about this population. We enrolled 838 FSW from November 2015 to March 2016 and estimated HIV prevalence to be 37.8%. Prevalence of active syphilis was 7.3%. FSW were from South Sudan and most neighboring countries. Comprehensive knowledge of HIV was 11.1% and 64.2% of FSW had never spoken with an outreach worker. In multivariable analysis, HIV was associated with being from Uganda (aOR: 3.3, 95% CI: 1.7–6.1) or Kenya (aOR: 4.3, 95% CI: 1.5–13.0) versus from South Sudan. Our survey suggests that FSW may play a critical role in South Sudan’s HIV epidemic and highlights the importance of tailoring services to the unique needs of FSW of all nationalities in Juba.

Acceptability of pre-exposure prophylaxis for HIV prevention: facilitators, barriers and impact on sexual risk behaviors among men who have sex with men in Benin

BACKGROUND

In Benin, men who have sex with men (MSM) do not always use condoms during anal sex. Pre-exposure prophylaxis (PrEP) using Truvada® (tenofovir disoproxil fumarate / emtricitabine) may be a complementary HIV prevention measure for MSM. This study aimed at identifying the potential facilitators and barriers to the use of PrEP.

METHODS

This was a cross-sectional study conducted in 2018 among male-born MSM aged 18 years or older who reported being HIV-negative or unaware of their HIV status. The participants were recruited by the RDS technique (respondent driven sampling) in six cities of Benin. Logistic regression analyses, adapted to RDS statistical requirements, were performed to identify the factors associated with PrEP acceptability.

RESULTS

Mean age of the 400 MSM recruited was 26.2 ± 5.0 years. PrEP was known by 50.7% of respondents. The intention to use PrEP was expressed by 90% of MSM. If PrEP effectiveness were 90% or more, 87.8% of the respondents thought they would decrease condom use. In multivariate analysis, the facilitators associated with PrEP acceptability were: not having to pay for PrEP (odds ratio (OR) = 2.39, 95% CI: 1.50-4.46) and its accessibility within MSM networks (OR = 9.82, 95% CI: 3.50-27.52). Only one barrier was significant: the concern that taking PrEP be perceived as marker of adopting HIV risky behaviors (OR = 0.11, 95% CI: 0.04-0.30).

CONCLUSION

In Benin, not all MSM know about PrEP. But once well informed, the majority seems willing to use it if made available. The free availability of the drug and its accessibility in the MSM networks are important facilitators. The possibility of decrease in condom use should not be a barrier to the prescription of PrEP if made available.

Comparison of the prevalence rates of HIV infection between men who have sex with men (MSM) and men in the general population in sub-Saharan Africa: a systematic review and meta-analysis

Background

According to the 2015 report of the Joint United Nations Program on Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), the prevalence rates of HIV infection among men who have sex with men (MSM) varied from 6 to 37% depending on the country, far exceeding the national prevalence rates. The present study on HIV infection among men who have sex with men in sub-Saharan Africa was conducted to describe the different sampling methods used to identify this target population and compare the prevalence rates of HIV infection among MSM to that of men in the general population.

Methods

The selection of studies to be included was carried out in the principal electronic databases. The 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) directives were used throughout the entire process. Bias evaluation was performed using the Mixed Methods Appraisal Tool. For each country, HIV prevalence values in both groups were calculated. A prevalence ratio was also calculated to compare the prevalence rates of the two groups.

Results

Seventeen articles were selected. Most of the studies (82.35%) used the Respondent-Driven Sampling method. The average prevalence rate was 17.81% (range: 3.7–33.46) for MSM and 6.15% (range: 0.5–19.7) for men in the general population. Overall, the human HIV prevalence rate was 4.94 times higher among MSM than among men in the general population (95%CI: 2.91–8.37). The western and central regions of Africa, as well as low-prevalence countries (prevalence < 1%), had very high prevalence ratios: 14.47 (95% CI: 9.90–21.13) and 28.49 (95% CI: 11.47–72.71), respectively.

Conclusion

MSM are at higher risk of HIV infection than men in the general population. The prevalence ratios are particularly elevated in West and Central Africa as well as in low-prevalence countries. Close monitoring of the situation, research and preventive measures are essential to control the epidemic amongst MSM.

HIV testing and engagement with the HIV treatment cascade among men who have sex with men in Africa: a systematic review and meta-analysis

BACKGROUND

HIV disproportionately affects gay, bisexual, and other men who have sex with men (MSM) in Africa, where many countries criminalise same-sex behaviour. We assessed changes in the engagement of African MSM with HIV testing and treatment cascade stages over time, and the effect of anti-LGBT legislation and stigma.

METHODS

We systematically searched Embase, Global Health, MEDLINE, Scopus, and Web of Science for peer-reviewed cross-sectional or longitudinal studies recruiting at least ten MSM, published from Jan 1, 1980, to Oct 10, 2018. We extracted or derived estimates of HIV testing, engagement with the HIV treatment cascade, or both among African MSM from published reports. We derived pooled estimates using inverse-variance random-effects models. We used subgroup and meta-regression analysis to assess associations between testing and status awareness outcomes and study and participant characteristics, including the severity of country-level anti-LGBT legislation.

FINDINGS

Our searches identified 75 independent eligible studies that provided estimates for 44 993 MSM across one or more of five testing and treatment cascade outcomes. HIV testing increased significantly over time overall, with pooled proportions of MSM ever tested for HIV of 67·3% (95% CI 62·1-72·3; 44 estimates) and tested in the past 12 months of 50·1% (42·4-57·8, 31 estimates) after 2011, which were 14·8 percentage points and 17·9 percentage points higher than before 2011, respectively. After 2011, ever testing was highest in southern Africa (80·0%), and lowest in northern Africa (34·4%), with the greatest increase in western Africa (from 42·4% to 70·9%). Levels of testing ever, in the past 12 months, and status awareness were statistically significantly lower in countries with the most severe anti-LGBT legislation compared with countries with the least severe legislation (57·4% vs 71·6%, p=0·0056; 35·5% vs 49·3%, p=0·010; 6·7% vs 22·0%, p=0·0050). Few estimates were available for later stages of the treatment cascade. Available data after 2011 suggest that the pooled proportion of MSM HIV-positive aware has remained low (18·5%, 12·5-25·3; 28 estimates), whereas proportions of current antiretroviral therapy (ART) use were 23·7% (15·5-33·0; 13 estimates) among all MSM living with HIV and 60·1% (48·6-71·1; five estimates) among MSM HIV-positive aware of their status. Pooled levels of viral suppression among MSM currently on ART were 75·6% (64·4-85·5; four estimates), but only 24·7% (18·8-31·2; four estimates) among all MSM living with HIV.

INTERPRETATION

Despite improvements in HIV testing among MSM in Africa, HIV status awareness, ART coverage, and viral suppression remain much lower than required to achieve UNAIDS 90-90-90 targets. Further studies are urgently needed to provide more accurate estimates of levels of status awareness, engagement in care, ART coverage, and viral suppression among MSM to inform prevention efforts aimed at improving access to HIV services for MSM. Severe anti-LGBT legislation might be associated with lower HIV testing and status awareness; therefore, further research is needed to assess the effect of such legislation on HIV testing and engagement with the HIV treatment cascade among MSM.

FUNDING

US National Institutes of Health, UK Medical Research Council.

Effectiveness of community outreach HIV prevention programs in Vietnam: a mixed methods evaluation

BACKGROUND

In 2014, Vietnam was the first Southeast Asian country to commit to achieving the World Health Organization's 90-90-90 global HIV targets (90% know their HIV status, 90% on sustained treatment, and 90% virally suppressed) by 2020. This pledge represented further confirmation of Vietnam's efforts to respond to the HIV epidemic, one feature of which has been close collaboration with the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Starting in 2004, PEPFAR supported community outreach programs targeting high-risk populations (people who inject drugs, men who have sex with men, and sex workers). To provide early evidence on program impact, in 2007-2008 we conducted a nationwide evaluation of PEPFAR-supported outreach programs in Vietnam. The evaluation focused on assessing program effect on HIV knowledge, high-risk behaviors, and HIV testing among high-risk populations-results relevant to Vietnam's push to meet global HIV goals.

METHODS

We used a mixed-methods cross-sectional evaluation design. Data collection encompassed a quantitative survey of 2199 individuals, supplemented by 125 in-depth interviews. Participants were members of high-risk populations who reported recent contact with an outreach worker (intervention group) or no recent contact (comparison group). We assessed differences in HIV knowledge, risky behaviors, and HIV testing between groups, and between high-risk populations.

RESULTS

Intervention participants knew significantly more about transmission, prevention, and treatment than comparison participants. We found low levels of injection drug-use-related risk behaviors and little evidence of program impact on such behaviors. In contrast, a significantly smaller proportion of intervention than comparison participants reported risky sexual behaviors generally and within each high-risk population. Intervention participants were also more likely to have undergone HIV testing (76.1% vs. 47.0%, p < 0.0001) and to have received pre-test (78.0% vs. 33.7%, p < 0.0001) and post-test counseling (80.9% vs. 60.5%, p < 0.0001). Interviews supported evidence of high impact of outreach among all high-risk populations.

CONCLUSIONS

Outreach programs appear to have reduced risky sexual behaviors and increased use of HIV testing services among high-risk populations in Vietnam. These programs can play a key role in reducing gaps in the HIV care cascade, achieving the global 90-90-90 goals, and creating an AIDS-free generation.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

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

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

"Too Much Sex and Alcohol": Beliefs, Attitudes, and Behaviors of Male Adolescents and Young Men Who have Sex with Men in Ghana

Background

Research suggests that men who have sex with men (MSM) often engage in high-risk sex and use illicit substances.

Objective

To increase understanding of HIV knowledge and vulnerability among adolescent and young adult MSM, with a focus on alcohol and drug use and transactional sex.

Methods

We conducted in-depth interviews and Focus Group Discussions (FGDs) with adolescent (aged 15-17 years) and young adult (aged 18-29 years) MSM in Kumasi, Ghana. MSM who reported recent alcohol and/or substance use or engagement in transactional sex were eligible. Questions covered HIV-related knowledge, experiences with substance-use and transactional sex, and attitudes regarding sexual risk-taking and HIV-related services. Data were analyzed thematically using NVivo 10.0 software.

Results

Ninety-nine MSM participated in 44 interviews and 8 FGDs. Most were attending or had completed secondary school. HIV knowledge was high, but with major gaps. Most consumed alcohol; one-fourth used drugs. Alcohol and substances were consumed to enhance pleasure during sex with another man. Transactional sex was common and positively viewed. Half of the participants used condoms inconsistently or never, and self-perceived HIV risk was high. Nearly half faced stigma-related barriers to accessing HIV-related services.

Conclusion

As Ghana strives to achieve the UNAIDS's 90-90-90 global targets (90% of people living with HIV know their status, 90% who know their status are on sustained treatment, and 90% of those on treatment are virally suppressed), we recommend enhancing MSM-targeted prevention programs, improving care options, and increasing use of critical clinical HIV-services by ensuring that MSM receive unbiased, confidential care.

Strategies to Increase HIV Testing Among MSM: A Synthesis of the Literature

More than 30 years into the HIV epidemic, men who have sex with men (MSM) continue to be disproportionately impacted. It is estimated that worldwide nearly half of MSM infected with HIV are unaware of their status, making HIV testing along with early linkage to care crucial to HIV prevention efforts. However, there remain significant barriers to HIV testing among MSM, due largely to complex issues of layered stigma that deter MSM from accessing traditional, clinic-based testing. We conducted a review and synthesis of the literature on strategies to increase uptake of HIV testing among MSM. We found that social network-based strategies, community-based testing, HIV self-testing, and modifications to the traditional clinic-based model can effectively reach a subset of MSM, but success was often context-specific and there are significant gaps in evidence. We provide recommendations for increasing HIV testing rates and status awareness among MSM.

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

INTRODUCTION

The Global Fund and the US President's Emergency Plan for AIDS Relief (PEPFAR) are major donors to HIV services with key populations (KPs) to achieve the UNAIDS 95-95-95 epidemic control goals. The programmes they fund are not always well aligned or coordinated, decreasing their effectiveness. Joint assessments are designed and led by LINKAGES, a project funded by PEPFAR and the US Agency for International Development, to improve coordination among donors and on-the-ground implementation of KP HIV programmes. Joint assessments help identify barriers that prevent KPs from accessing interventions along the cascade of prevention, diagnosis and treatment services, and provide recommendations to improve and align programmes. Detailed reports from eight assessments in Malawi, Cameroon, Swaziland, Haiti, Angola, Nepal, Côte d'Ivoire and Botswana were analysed for thematic challenges, and recommendations are presented. The purpose of the paper is to identify commonalities across KP HIV programmes that were found through the assessments so others can learn and then strengthen their programmes to become more effective.

DISCUSSION

The joint cascade assessments offered countries feedback on HIV programme challenges and recommendations for strengthening them at national, subnational and local levels. Shared intervention areas included: (1) robust population size estimates to inform service delivery targets and to budget resources for KP outreach; (2) accessible and KP-friendly services most relevant to individuals to increase retention in the HIV cascade; (3) decentralized, community-based services for HIV testing and antiretroviral therapy, and new approaches including self-testing and PrEP; (4) addressing structural issues of stigma, discrimination and violence against KPs to create a more enabling environment; and (5) more effective and continual tracking of KPs across the cascade, and coordinated, harmonized monitoring tools and reporting systems between donor-funded and national programmes.

CONCLUSIONS

The assessment teams and country stakeholders viewed the assessments as a best practice for coordinating donor-funded programmes that may overlap or inefficiently serve KPs. Global and national HIV programmes need investments of time, resources, and commitment from stakeholders to continually course-correct to align and improve programmes for sustained impact. The type of continued partnership demonstrated by the joint assessments is key to address HIV among KPs globally.

High Prevalence of Concurrent Male-Male Partnerships in the Context of Low Human Immunodeficiency Virus Testing Among Men Who Have Sex With Men in Bamako, Mali

BACKGROUND

Concurrent male-male sexual partnerships have been understudied in sub-Saharan Africa and are especially important because human immunodeficiency virus (HIV) prevalence and acquisition probability are higher among men who have sex with men (MSM) than among heterosexual men and women.

METHODS

We conducted a respondent-driven sampling survey of 552 men who have sex with men in Bamako, Mali from October 2014 to February 2015. Eligibility criteria included 18 years or older, history of oral or anal sex with another man in the last 6 months, residence in or around Bamako in the last 6 months, ability to communicate in French.

RESULTS

HIV prevalence was 13.7%, with 86.7% of MSM with HIV unaware of their infection. Concurrent male-male sexual partnerships were common, with 60.6% of MSM having a concurrent male sexual partnerships or believing their sex partner did in the last 6 months, and 27.3% having a concurrent male sexual partnerships and believing their sex partner did in the last 6 months. Over half (52.5%) of MSM had sex with women, and 30.8% had concurrent male partnerships and sex with a woman in the last 6 months. Concurrency was more likely among MSM with limited education, telling only MSM of same-sex behaviors, high social cohesion, and not knowing anyone with HIV.

CONCLUSIONS

The high proportion of HIV-infected MSM in Bamako who are unaware of their HIV infection and the high prevalence of concurrent partnerships could further the spread of HIV in Bamako. Increasing testing through peer educators conducting mobile testing could improve awareness of HIV status and limit the spread of HIV in concurrent partnerships.

Participants' accrual and delivery of HIV prevention interventions among men who have sex with men in sub-Saharan Africa: a systematic review

Background

Across sub-Saharan Africa (SSA), HIV disproportionately affects men-who-have-sex-with-men (MSM) compared with other men of the same age group in the general population. Access to HIV services remains low among this group although several effective interventions have been documented. It is therefore important to identify what has worked well to increase the reach of HIV services among MSM.

Methods

We searched MEDLINE, POPLINE and the Web of Science databases to collect published articles reporting HIV interventions among MSM across sub-Saharan Africa. Covidence was used to review the articles. The review protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) - CRD42017060808.

Results

The search identified 2627 citations, and following removal of duplicates and inclusion and exclusion criteria, only 15 papers were eligible for inclusion in the review. The articles reported various accrual strategies, namely: respondent driven sampling, known peers identified through hotspot or baseline surveys, engagement with existing community-based organizations, and through peer educators contacting MSM in virtual sites. Some programs, however, combined some of these accrual strategies. Peer-led outreach services were indicated to reach and deliver services to more MSM. A combination of peer outreach and mobile clinics increased uptake of health information and services. Health facilities, especially MSM-friendly facilities attract access and use of services by MSM and retention into care.

Conclusions

There are various strategies for accrual and delivering services to MSM across SSA. However, each of these strategies have specific strengths and weaknesses necessitating combinations of interventions and integration of the specific context to inform implementation. If the best of intervention content and implementation are used to inform these services, sufficient coverage and impact of HIV prevention and treatment programs for MSM across SSA can be optimized.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5303-2) contains supplementary material, which is available to authorized users.

Potential Impact of Integrated Stigma Mitigation Interventions in Improving HIV/AIDS Service Delivery and Uptake for Key Populations in Senegal

BACKGROUND

Men who have sex with men (MSM) and female sex workers (FSW) are consistently shown to have a higher burden of HIV compared with other adults in Senegal. This study, HIV Prevention 2.0, evaluates the impact of the 3-tiered integrated stigma mitigation interventions (ISMIs) approach to optimizing HIV service delivery for key populations in Senegal.

METHODS

Baseline assessment includes a questionnaire and biological testing for HIV. A proportion of participants enrolled into a 24-month longitudinal cohort with questionnaires and biological testing every 3 months. In these preliminary analyses, ISMIs are evaluated from participants in the cohort through uptake of HIV services and implementation outcomes.

RESULTS

Overall, 724 MSM and 758 FSW participated in the baseline assessment. HIV prevalence is 30.2% (n = 219/724) among MSM and 5.3% (n = 40/758) among FSW. Fear of seeking health services among MSM is 17.7% (n = 128/724) at baseline, 10.5% (n = 18/172) at month 3, and 9.8% (n = 10/102) at month 6 (P < 0.004); and among FSW is 21.9% (n = 166/758) at baseline, 8.1% (n = 15/185) at month 3, and 10.7% (n = 18/168) at month 6 (P < 0.001). Overall, 63.9% (n = 62/97) of MSM and 82.5% (n = 118/143) of FSW agreed that the intervention is effective in addressing stigma; however, loss to follow-up was 41.1% among MSM and 10% among FSW.

CONCLUSION

Baseline data reinforce the need for stigma mitigation interventions, combined with enhanced linkage and retention to optimize HIV treatment. Preliminary results show high levels of HIV-related risk determinants and suggest the potential utility of the ISMI to decrease perceived stigma relating to engagement in HIV prevention, treatment, and care services among key populations in Senegal.

Using Peer-Referral Chains with Incentives to Promote HIV Testing and Identify Undiagnosed HIV Infections Among Crack Users in San Salvador

In El Salvador, crack users are at high risk for HIV but they are not targeted by efforts to promote early HIV diagnosis. We evaluated the promise of peer-referral chains with incentives to increase HIV testing and identify undiagnosed HIV infections among networks of crack users in San Salvador. For 14 months, we offered HIV testing in communities with a high prevalence of crack use. For the following 14 months, we promoted chains in which crack users from these communities referred their peers to HIV testing and received a small monetary incentive. We recorded the monthly numbers of HIV testers, and their crack use, sexual risk behaviors and test results. After launching the referral chains, the monthly numbers of HIV testers increased significantly (Z = 6.90, p < .001) and decayed more slowly (Z = 5.93, p < .001), and the total number of crack-using testers increased nearly fourfold. Testers in the peer-referral period reported fewer HIV risk behaviors, but a similar percentage (~5 %) tested HIV positive in both periods. More women than men received an HIV-positive diagnosis throughout the study (χ(2)(1, N = 799) = 4.23, p = .040). Peer-referral chains with incentives can potentially increase HIV testing among networks of crack users while retaining a focus on high-risk individuals.