The realities of HIV prevention. A closer look at facilitators and challenges faced by HIV prevention programmes in Sudan and Yemen

Impact of the COVID-19 pandemic on sexually transmitted infection testing and diagnosis in Lebanon: A retrospective chart review

Background

Social distancing restrictions during the COVID-19 pandemic caused disruptions to sexual health services (SHS) worldwide. During the first year of the pandemic, Lebanon implemented multiple lockdowns during which SHS endured repetitive closures. We explore the impact of the pandemic on SHS delivery and the diagnosis rate of sexually transmitted infections (STIs) among attendees of a large sexual health clinic in Beirut, Lebanon.

Methods

This was a retrospective analysis of the clinic's database, including data on voluntary counseling and testing (VCT) for HIV, syphilis, hepatitis B virus (HBV), and hepatitis C virus (HCV). We compared the number and types of services provided, and the number and rate of positive VCT diagnoses pre- (Mar 2019-Feb 2020) and post- (Mar 2020-Feb 2021) COVID-19 onset.

Results

Men who have sex with men (MSM) comprised 35 % and 40 % of attendees pre- and post- COVID-19 onset, respectively. Post-COVID-19 onset, a total of 1350 VCT services and 406 medical consultations were provided, an overall 45 % decrease compared with pre-COVID-19 onset. The prevalence pre-COVID-19 onset of HIV, syphilis, HBV, and HCV was 0.8 %, 0.3 %, 0.2 %, and 0.1 %, respectively, and post-COVID-19 onset 1.2 %, 0.7 %, 0.3 %, and 0.3 %, respectively. Post-COVID-19 onset, 1.7 % of patients tested positive for any STI compared with 1.1 % pre-COVID-19 onset (OR: 1.5, 95%CI: 0.8-2.7). Close to 90 % of all positive diagnoses were among MSM. The prevalence of HIV, syphilis, HBV, and HCV among MSM in the total sample was 2.1 %, 1.2 %, 0.4 %, and 0.3 %, respectively.

Conclusion

COVID-19 related closures led to substantial reduction in SHS accessibility among clinic attendees. STI positivity rates increased post-COVID-19 onset, although this increase was not statistically significant. Findings suggest that sexual risk behavior was taking place during the pandemic despite the lockdowns and highlight the need to minimize disruptions in provision of SHS during similar crises, particularly to key populations.

Breaking the silence - systematic review of the socio-cultural underpinnings of men's sexual and reproductive health in Middle East and North Africa (MENA): A handful of taboos?

Background

Sociocultural aspects can impact sexual and reproductive health (SRH). Despite this, no study appraised the socio-cultural underpinnings impacting men's SRH in MENA (Middle East and North Africa). The current systematic review undertook this task.

Methods

We searched PubMed and Scopus electronic databases for original articles on socio-cultural aspects of men's SRH published from MENA. Data were extracted from the selected articles and mapped out employing McLeroy's socioecological model. Analyses and data synthesis identified the factors impacting men's experiences of and access to SRH.

Results

A total of 53 articles were included. Five related socio-cultural underpinnings intertwined with taboos were observed that affect three main SRH topics, HIV, reproduction and sexuality across three broad population groups: HCP/health services, school/university students, and the general public/patients. These underpinnings included 1) Challenges to gender equality; 2) Religious prohibitions and misinterpretations; 3) Sexual rights and taboos; 4) Masculinity and manhood ideals; and 5) Large families and consanguinity. In terms of research, a paradox exists, as we found virtually no research on four socio-cultural underpinnings of men's SRH in MENA pertaining to: a) other STI, despite being common; b) other features of reproduction, despite that religio-cultural factors play a critical role; c) sexuality, despite the high prevalence of sexual disorders, and, d) gender-based violence, despite the widespread partner violence.

Conclusions

Socio-cultural underpinnings are deeply rooted across MENA population groups including HCPs, students, general public, and patients with negative impact on the perceptions and dealings pertaining to men's SRH issues including HIV, reproduction and sexuality. The findings call for concerted widespread efforts to enhance the socio-cultural acceptance of these population groups while highlighting any misinterpretations of religious rules pertaining to men's SRH. Moreover, breaking the silence on such issues necessitates more enthusiasm across MENA health systems, with future research examining the effects of such efforts on the socio-cultural aspects of men's SRH in MENA.

Scoping review of sexual and reproductive healthcare for men in the MENA (Middle East and North Africa) region: a handful of paradoxes?

BACKGROUND

No study appraised the knowledge gaps and factors impacting men's sexual and reproductive health (SRH) in MENA (Middle East and North Africa). The current scoping review undertook this task.

METHODS

We searched PubMed and Web of Science (WoS) electronic databases for original articles on men's SRH published from MENA. Data was extracted from the selected articles and mapped out employing the WHO framework for operationalising SRH. Analyses and data synthesis identified the factors impacting on men's experiences of and access to SRH.

RESULTS

A total of 98 articles met the inclusion criteria and were included in the analysis. The majority of studies focused on HIV and other sexually transmissible infections (67%); followed by comprehensive education and information (10%); contraception counselling/provision (9%); sexual function and psychosexual counselling (5%); fertility care (8%); and gender-based violence prevention, support/care (1%). There were no studies on antenatal/intrapartum/postnatal care and on safe abortion care (0% for both). Conceptually, there was lack of knowledge of the different domains of men's SRH, with negative attitudes, and many misconceptions; as well as a deficiency of health system policies, strategies and interventions for SRH.

CONCLUSION

Men's SRH is not sufficiently prioritized. We observed five 'paradoxes': strong focus on HIV/AIDS, when MENA has low prevalence of HIV; weak focus on both fertility and sexual dysfunctions, despite their high prevalence in MENA; no publications on men's involvement in sexual gender-based violence, despite its frequency across MENA; no studies of men's involvement in antenatal/intrapartum/postnatal care, despite the international literature valuing such involvement; and, many studies identifying lack of SRH knowledge, but no publications on policies and strategies addressing such shortcoming. These 'mismatches' suggest the necessity for efforts to enhance the education of the general population and healthcare workers, as well as improvements across MENA health systems, with future research examining their effects on men's SRH.

Status of the HIV epidemic in key populations in the Middle East and north Africa: knowns and unknowns

The Middle East and north Africa is one of only two world regions where HIV incidence is on the rise, with most infections occurring among key populations: people who inject drugs, men who have sex with men, and female sex workers. In this Review, we show a trend of increasing HIV prevalence among the three key populations in the Middle East and north Africa. Although the epidemic continues at a low level in some countries or localities within a country, there is evidence for concentrated epidemics, with sustained transmission at considerable HIV prevalence among people who inject drugs and men who have sex with men in over half of countries in the region with data, and among female sex workers in several countries. Most epidemics emerged around 2003 or thereafter. The status of the epidemic among key populations remains unknown in several countries due to persistent data gaps. The HIV response in Middle East and north Africa remains far below global targets for prevention, testing, and treatment. It is hindered by underfunding, poor surveillance, and stigma, all of which are compounded by widespread conflict and humanitarian crises, and most recently, the advent of COVID-19. Investment is needed to put the region on track towards the target of eliminating HIV/AIDS as a global health threat by 2030. Reaching this target will not be possible without tailoring the response to the needs of key populations, while addressing, to the extent possible, the complex structural and operational barriers to success.

Overcoming Ethical Challenges to Engaging Men Who Have Sex with Women in HIV Research

Men who have sex with women are understudied in HIV research despite the extent to which they experience HIV-related mortality and contribute to the epidemic among women. During our experience of developing and piloting an HIV prevention intervention for men living with HIV in South Africa, and planning to have a child with an HIV-negative woman, ethical questions were posed regarding implementation of a male-centered intervention that did not require female partner participation. Two overarching ethical issues were the potential for (1) compromising women's reproductive and sexual autonomy and (2) increasing HIV-acquisition risks for the woman because the intervention efficacy was unknown. We describe here how these concerns were addressed to facilitate development of a male-centered HIV-prevention intervention. We hope this process manuscript will support researchers, clinicians, and reviewers to engage men who have sex with women in HIV prevention and care.

HIV stigma in the teaching hospitals in Sana'a, Yemen: a conflict and low-resource setting

BACKGROUND

HIV stigma undermines a person's wellbeing and quality of life and hinders HIV control efforts. This study examined the extent and drivers of HIV stigma in the teaching hospitals in Sana'a City, Yemen. The country has low HIV prevalence (4000 (2000-11,000) per 100,000) and limited HIV control funds, worsened by a long conflict and an economic crisis.

METHODS

We conducted a cross-sectional study of 320 Yemeni health professionals in all the four teaching hospitals in Sana'a City. Data were collected anonymously, using an adapted self-completed Arabic version of the Health Policy Project HIV Stigma tool. The questionnaire covered the respondents' background, the stigmatising practices, and potential personal and professional drivers of stigma.

RESULTS

The majority of the participants were: females (68%), 20-39 years old (85%), nurses (84%), and holding a nursing diploma (69%) or a bachelor's degree (27%). None of the hospitals had institutional policies against HIV stigma, and 93% of the participants believed the current infection control measures were inadequate. Less than half of the participants provided care for people living with HIV (PLHIV) (45%), had received HIV training (33%), and were confident that their HIV knowledge was adequate (23%). The majority indicated a preference to test patients for HIV prior to surgical procedures (77%) and disclose positive HIV results to others (99%) without prior knowledge or consent. All the participants had exhibited a form of HIV-related stigmatization, such as avoiding physical contact with PLHIV (87%) or wearing gloves throughout the consultation (96.5%). These practices were significantly correlated with the fear of infection, high perceived risk of infection, and poor work environment (p < 0.05).

CONCLUSION

PLHIV face widespread stigmatizing behaviour in the teaching hospitals in Sana'a City, consistent with the higher level of stigma in low HIV prevalence countries and its links to the fear of infection, poor HIV knowledge, and limited funding for HIV control. Stigma reduction interventions are required at institutional and individual levels. In addition, anti-discrimination policies and structural adjustments are needed, in combination with training on HIV and universal precautions, and action to tackle negative attitudes towards PLHIV and key populations.