Characterizing social cohesion and gender identity as risk determinants of HIV among cisgender men who have sex with men and transgender women in Côte d'Ivoire

Marriage and Steady Relationships with Women in Men Who Have Sex with Men in Sub-Saharan Africa: A Mixed-Method Systematic Review and Meta-analyses

High HIV prevalence in Sub-Saharan African (SSA) in men who have sex with men (MSM) leads to greater risk for their wives and other steady female partners because of prolonged exposure. To provide insights into the context possibly contributing to the risk of HIV transmission from MSM to women, our mixed-method synthesis about MSM' marriage and steady relationships with cisgender women aimed to: (i) assess the extent of engagement in steady relationships with women and in risky behaviors with these women across SSA's four regions; (ii) explore the underlying dynamics within these relationships by gathering qualitative information. We used quantitative and qualitative data specifically pertaining to related to marriage or other steady relationships with women from a systematic review on men who have sex with both men and women (MSMW) in SSA (PROSPERO-CRD42021237836). Meta-analyses were performed on quantitative data for each region. Pooled proportions were calculated using random-effects models. Qualitative data were analyzed using thematic synthesis. Data were selected from 125 studies. For Southern, East and West Africa, the estimated pooled proportions of married MSM were 4% (95% CI 2-8%; n = 10 studies; 4183 MSM), 8% (6-11%; 19; 7070), and 7% (6-9%; 13; 4705). In Southern Africa, 29% (11-56%; 5; 1667) of MSM had steady female partners. In East Africa, 34% (14-61%; 5; 2003) were currently or previously married to women. Motives to marry women included a desire to have children, and to conform to heteronormative social norms and family pressure. Marriage was seen as a means to discontinue homosexual behaviors or, conversely, a way to secretly continue same-sex behaviors more freely. Procreative intentions and a desire for secrecy often deterred MSM from using HIV prevention methods with their wives. For some MSM, steady relationships with women provided them with mutual support. However, these relationships could also lead to stressful and conflict-ridden situations, potentially resulting in psychosocial and HIV-related risks for the MSM as well as their male and steady female partners. Steady relationships with women are common in MSM in SSA. Sexuality concealment strategies with steady female partners depend on the circumstances that lead MSM to enter into these relationships, and have various implications on sexual behaviors with both male and female partners. Community-based support, HIV research, prevention, and care programs should be adapted to MSM's different life situations to reduce direct HIV transmission risk to steady female partners.

Men who have sex with men perceiving that sex with women carries the greatest risk of HIV acquisition: results from a mixed-methods systematic review in sub-Saharan Africa

INTRODUCTION

In sub-Saharan Africa (SSA), men who have sex with men (MSM) often have female sexual partners. Their overall risk of acquiring HIV is higher with male partners. Risk perception is associated with HIV knowledge, sexual risk and preventive behaviours. This synthesis aimed to summarize existing data about HIV knowledge and perceived HIV acquisition risk regarding sex with men and with women in MSM in SSA.

METHODS

We conducted a systematic literature review of MSM's relationships with women in SSA (PROSPERO-CRD42021237836). Quantitative and qualitative data related to MSM's perceived risk from sex with men and with women and HIV knowledge (published up to 2021) were selected and synthesized.

RESULTS

Twenty studies were selected. More MSM perceived that the greatest risk of HIV acquisition came from heterosexual/vaginal sex than from homosexual/anal sex (53% vs. 15%; 51% vs. 39%; 42% vs. 8%; 27% vs. 25%; 43% vs. 11%; 23% vs. 13%; 35% vs. 16%, cumulative sample n = 4396, six countries). A higher proportion of MSM received preventive information on heterosexual HIV transmission than on homosexual transmission (79% vs. 22%; 94% vs. 67%; 54% vs. 19%; cumulative sample n = 1199, four countries). The qualitative synthesis (eight studies) highlighted biology- and behaviour-based misconceptions leading MSM to perceive lower or negligible HIV risk from sex with men, compared to sex with women. These misconceptions were partly fuelled by the predominant focus on heterosexual and vaginal HIV transmission in HIV prevention information.

DISCUSSION

Common misconceptions regarding sexual risk between men remain unaddressed by the heteronormative messaging of HIV prevention. Underestimation by MSM of their HIV acquisition risk with male partners can pose significant barriers to effective HIV preventive behaviours and strengthen the transmission risk from MSM to their female partners.

CONCLUSIONS

Improving access of MSM to tailored HIV prevention information and tools that address their practices with male and female partners is crucial. Integrating messages about anal sex into broader public health initiatives, including sexual health programmes targeting the general population, is essential. Further research in diverse settings in SSA is necessary to gain a greater understanding of the drivers and implications of HIV risk perception in MSM.

Sexual behaviours and risk with women in MSM in sub-Saharan Africa

In sub-Saharan Africa (SSA), MSM - a high HIV prevalence group - experience strong social stigma and pressure to have female partners. Accordingly, they could constitute a bridging group for HIV transmission to cisgender women. We developed a multilevel summary of MSM sexual behaviors and risk with women in various SSA regions. Following PRISMA guidelines, we conducted a mixed-method systematic review of data of sex with women in MSM in SSA. We performed meta-analyses on quantitative data (i.e. percent of recent sex and condomless sex with women) for each SSA region (when proportions reported in ≥4 studies). Pooled proportions were calculated using random-effects models. Qualitative data were analyzed using the three-step thematic synthesis methodology. The pooled proportion of MSM who had sex with women was 58% (33-83%) in East Africa (in the previous 3 months), and 27% (13-48%) in Southern Africa and 50% (95% CI 39-62%) in West Africa (in the previous 6 months); 23% (16-32%) of MSM in West Africa had condomless sex with a woman (during the most recent encounter). Approximately one quarter of MSM had recent multiple female partners. MSM reported having sex with women because of heteronormative pressure, erotic/romantic attraction, or financial needs leading to transactional sex. MSM may act as a bridging population to women in SSA, as they commonly practice sex with women and risky sexual behaviors with them. HIV programmes and community-based support for MSM should be adapted to this population to reduce this risk.

Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa

OBJECTIVES

Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations.

DESIGN

Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews.

DATA SOURCES

Public health and regional databases were searched in 2020 and 2022.

ELIGIBILITY CRITERIA

Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA.

DATA EXTRACTION AND SYNTHESIS

Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed.

RESULTS

Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors.

CONCLUSION

Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.

Men Who Have Sex with Both Men and Women in West Africa: Factors Associated with a High Behavioral Risk of Acquiring HIV from Male Partners and Transmission to Women (CohMSM ANRS 12324-Expertise France)

HIV is highly prevalent in men who have sex with men (MSM) in West Africa. Many MSM in the region also have sex with women (MSMW). Accordingly, they are a potential bridge subpopulation for HIV transmission to women. We aimed to evaluate the proportions and characteristics of West African MSMW at high behavioral risk of acquiring HIV from male partners and transmitting it to female partners (HBRMF). The cohort ANRS-12324 CohMSM Study included 630 HIV-negative MSM in Burkina Faso, Cote d'Ivoire, Mali, and Togo. Among MSMW (i.e., with ≥ 1 female partner) in the cohort, HBRMF was identified using trajectory models based on seven at-risk sexual practices with male and female partners, including inconsistent condom use, multiple partnerships, and receptive same-sex anal intercourse. To assess the relevance of using trajectory models, we compared the proportions of participants who seroconverted during the cohort follow-up among those at HBRMF and those not at HBRMF. Factors associated with HBRMF were identified using a generalized estimation equation logistic regression model accounting for longitudinal data. Approximately half (47%) of the 304 MSMW (22% of all CohMSM study participants) were at HBRMF. This group accounted for 75% of the 28 HIV seroconversions observed during follow-up (p = 0.001). HBRMF was positively associated with being aged < 25 years (aOR 95% CI 1.67 [1.23-2.27]), being sexually attracted only to men (1.97 [1.38-2.78]), feelings of loneliness (1.92 [1.38-2.65]), and homonegative violence score (1.22 [1.05-1.41]). HBRMF was negatively associated with having had both stable and casual female partners in the previous 6 months (0.34 [0.20-0.60] vs. only a stable female partner). HBRMF tended to be negatively associated with having ≥ 4 sexual intercourses with female partners in the previous four weeks (0.54 [0.27-1.06] vs. no intercourse). Establishing official relationships with women might be a strategy for young and/or stigmatized MSMW to comply with social pressure to display a heterosexual lifestyle. However, this seems to increase the risk of HIV transmission to female partners. In the present study, almost half of MSMW were at HBRMF. This result stresses the need to adapt HIV research and prevention to MSMW and their female partners.

Sentiment Grading and Evaluation of Network Resources of Ideological and Political Education in Colleges and Universities: A Research Based on Artificial Intelligence

The current new round of scientific and technological revolution represented by artificial intelligence is rapidly driving a new wave of development of the times, and the rapid iterative update of science and technology is triggering new changes in educational concepts and educational thinking methods. Only by deeply understanding the reshaping of education concept, teaching concept, and learning concept by the new generation of scientific and technological revolution, as well as the major opportunities and challenges brought to education, can we understand the future direction of the development of ideological and political education for college students. This study takes the ideological and political education and teaching of college students as the research object. It begins by defining artificial intelligence and the ideological and political education of college students and analyzes the new concepts of precise individualization, intelligent teaching, and evaluation brought by artificial intelligence to the ideological and political education of college students. Then, it selects the students who have studied ideological and political education network resources as the empirical objects, designs a questionnaire based on the emotional characteristics of the resources, implements a questionnaire survey, uses the Stata software to conduct a correlation analysis on the acceptance of the students, and finally verifies the resources. Combined with empirical results, this article analyzes the influence of emotional characteristics of resources on students' acceptance, reveals the carrier role of ideological and political network resources in school emotional education and students through mirror theory and student response theory, respectively, and establishes the principle of graded reading guidance.

Indices and Indicators Developed to Evaluate the "Strengthening Community Actions" Mechanism of the Ottawa Charter for Health Promotion: A Scoping Review

OBJECTIVE

To determine 1) the indexes/indicators used for evaluating the "strengthening community actions" mechanism of the Ottawa Charter for Health Promotion and 2) to extract the characteristics and key components of the indexes/indicators using a scoping review.Data Source:In May 2020, the search was conducted across three databases: Medline (via PubMed), Embase, and Scopus.Inclusion and Exclusion Criteria: All primary studies relating to development, identification, and measurement of health promotion indices/indicators associated to the "strengthening community actions" were included. The review articles were excluded.

DATA EXTRACTION

The data were extracted to a data-charting form that was developed by the research team. Two authors reviewed the extracted data.

DATA SYNTHESIS

To summarize and report the data, a descriptive numerical analysis and a narrative descriptive synthesizing approach were used.

RESULTS

In total, 93 study articles were included. A majority of studies (82%) were conducted in developed countries. Different types of recognized indices were categorized into seven groups: social cohesion (n = 3), community capacity (n = 1), community participation (n = 7), social capital (n = 6), social network (n = 3), social support (n = 1), and others (n = 5).

CONCLUSIONS

Having a collection of "strengthening community actions" indices/indicators in hand, health policymakers and health promotion specialists might be able to do their best in considering, selecting, and applying the most appropriate indices/indicators while evaluating community health promotion interventions in different settings.

Stigma, Social Cohesion, and HIV Risk Among Sexual and Gender Minorities in Two Cities in Zimbabwe

Though stigma is a recognized contributor to the disproportionate HIV burden among sexual and gender minorities (SGM) in sub-Saharan Africa, data describing this association among Zimbabwean SGM are limited. We examined relationships between SGM stigma and HIV and the potential for social cohesion to moderate the association among Zimbabwean men who have sex with men, transgender women, and genderqueer individuals. Consenting participants (n = 1511) recruited through respondent-driven sampling for a biobehavioral survey in Harare and Bulawayo completed structured interviews and received HIV testing. Reported SGM stigma was common (68.9% in Harare and 65.3% in Bulawayo) and associated with HIV infection in Harare (adjusted prevalence ratio [aPR] = 1.82, 95% confidence interval [CI] = 1.27–2.62) and Bulawayo (aPR = 1.51, 95% CI = 1.15–2.00) in relative risk regression. Social cohesion did not moderate these relationships. Findings demonstrate stigma’s association with HIV vulnerability among Zimbabwean SGM, highlighting the need for stigma-mitigation to reduce HIV transmission in this population.

Solidarity and HIV Testing Willingness During the COVID-19 Epidemic: A Study Among Men Who Have Sex With Men in China

Background: Solidarity, such as community connectedness and social cohesion, may be useful in improving HIV testing uptake among men who have sex with men (MSM). This study aimed to evaluate the impact of solidarity on HIV testing before the coronavirus disease 2019 (COVID-19) and HIV testing willingness during COVID-19 among MSM in China. Materials and Methods: An online survey was conducted to collect sociodemographic, sexual behavioral, and solidarity items' information from the participants. We first used factor analysis to reveal the principal component of the solidarity items and then used logistic regression to study the impact of solidarity on HIV testing, by adjusting the possible confounding factors, such as age and education. Results: Social cohesion and community connectedness were revealed by the factor analysis. MSM with high community connectedness were more willing to undergo HIV testing before the epidemic adjusted by age [odds ratio (OR): 1.07, 95% CI: 1.01-1.13]. The community connectedness was also related to the willingness of HIV testing during the epidemic, with adjustments of 1.09 (95% CI: 1.03-1.15). People who did not test for HIV before the COVID-19 epidemic were more willing to have the HIV test during the epidemic, which was correlated with the community connectedness, and the OR value was 1.14 (95%: 1.03-1.25). Conclusion: A high level of community connectedness helped to increase the HIV testing rate before COVID-19 and the willingness of HIV testing during the epidemic among MSM. Strategies can strengthen the role of the community in the management and service of MSM.

Disclosure of same-sex practices and experiences of healthcare stigma among cisgender men who have sex with men in five sub-Saharan African countries

BACKGROUND

For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma.

METHODS

We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d'Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data.

RESULTS

Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations.

CONCLUSIONS

Research to determine the factors driving disclosure's differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA.

"I've Learned to Value Myself More": Piloting an Adapted Multilevel Intervention for Transgender Women Sex Workers Living with HIV in the Dominican Republic

Purpose: Transgender (trans) women living with HIV experience suboptimal care and treatment outcomes. We adapted a multilevel intervention to improve HIV outcomes and overall well-being among trans women sex workers living with HIV. The intervention, called Abriendo Puertas (AP; Opening Doors), included: individual counseling, peer navigation, and community mobilization "open houses." The purpose of this article is to describe acceptability and initial outcomes of the adapted AP pilot and explore intervention experiences to inform recommendations for improvement. Methods: After an iterative adaptation process, we recruited 30 trans women sex workers living with HIV to participate in the pilot. We conducted baseline and endline (12-months) surveys to compare HIV care and treatment outcomes and qualitative interviews to assess intervention experiences with a subsample (n=20). Results: Intervention retention was high, with 86.7% of participants (n=26/30) completing both baseline and endline surveys. At endline, there was a significant increase in current anti-retroviral therapy (ART) use (70.0% to 84.6%, p<0.03) and positive, but not significant, trends in missed care appointments in the past 6 months (34.5% to 20.0%, p<0.39) and not having missed any ART doses in the past 4 days (85.7% to 95.5%, p<0.50). Intervention acceptability was high across all components: individual counseling (96.1%), peer navigation (80.8%), and open houses (84.6%). Participants emphasized that trust and being treated with respect allowed them to relax and improve their self-esteem. Limited trust and cohesion among trans women, however, limited more extensive engagement with peer navigation and community mobilization components. Conclusion: Future efforts to strengthen the AP intervention with trans women sex workers should continue to address emotional, instrumental, and informational support needs related to living with HIV through individual counseling, peer navigation, and open houses while also enhancing group-level activities to build trust and generate a collective commitment to promote the well-being of the community.