Health Provider Views on Improving Antiretroviral Therapy Adherence Among Men Who Have Sex with Men in Coastal Kenya

HIV self-management and associated factors among people living with HIV in Hunan, China: a nine-year longitudinal study

Self-management refers to the behaviors and strategies individuals employ to manage their health conditions. For people living with HIV (PLWH), it encompasses medication adherence, health monitoring, symptom management, lifestyle maintenance and seeking emotional support. While previous studies on the factors influencing self-management in PLWH are predominantly cross-sectional, longitudinal studies are scarce. This nine-year longitudinal study aimed to investigate the trajectories of psychosocial characteristics in PLWH and their effects on self-management. A total of 265 PLWH were assessed for psychosocial factors, including stigma, depression, anxiety, and social support, at baseline and at one-, five- and nine-year follow-ups. Self-management was evaluated at the nine-year follow-up. Psychosocial trajectories were identified using latent growth trajectory models (LGMM), and associations with self-management were analyzed via multiple linear regression. The majority of participants exhibited a low-level decline in depression (79.6%) and rising social support (54.3%). The high-level decline depression group demonstrated the lowest self-management scores (b = -4.67, 95% CI: -8.166 to -1.175). Multivariate analysis revealed significant associations between self-management and exercise (b = 5.360, 95% CI: 3.934-6.786), depressive symptoms (b = -0.168, 95% CI: -0.305 to -0.031) and social support (b = 0.182, 95% CI: 0.101-0.264). These findings emphasize the need for continuous monitoring and targeted interventions to improve self-management in PLWH.

Barriers and facilitators to uptake and persistence on prep among key populations in Southern Province, Zambia: a thematic analysis

BACKGROUND

Especially in high HIV prevalence contexts, such as Zambia, effective biomedical prevention tools are needed for priority populations (PPs), including key populations (KPs), who are at higher risk. HIV pre-exposure prophylaxis (PrEP) has been scaled up nationally in Zambia, but little is known about barriers to PrEP use among specific PPs to date.

METHODS

To understand barriers and facilitators to PrEP use in Zambia, we conducted a qualitative case study of PrEP services to PPs including sero-discordant couples (SDCs), female sex workers (FSWs), and men who have sex with men (MSM) in Livingstone. The study conducted in 2021 included in-depth interviews (n = 43) guided by the socio-ecological model, and focus group discussions (n = 4) with clinic and community-based providers and PrEP-eligible clients including users and non-users across PP groups. We used thematic analysis to analyze data using codes derived both deductively and inductively.

RESULTS

We found multilevel barriers and facilitators to PrEP use. Cross-cutting barriers shared across PP groups included amplifying effects of PrEP being mistaken for antiretroviral drugs used to treat HIV, including anticipated stigma, and concerns about side-effects based on both misinformation and experience. In addition, stigmatized identities, particularly that of MSM, served as a barrier to PrEP use. The fear of being mislabeled as having HIV was of greatest concern for FSWs. Facilitators to PrEP use primarily included the importance of confidential, KP-sensitive services, and the role of informed, supportive family, friends, and peers. Participants across all PP groups urged expanded education efforts to increase awareness of PrEP within the general population toward mitigating concerns of being mislabeled as living with HIV.

CONCLUSION

To our knowledge, this is the first qualitative study of the PrEP cascade among multiple PPs in Zambia. This study provides important explanation for the low rates of PrEP continuation found in earlier demonstration trials among KPs in Zambia. The study also offers recommendations for programming efforts going forward such as inclusive PrEP awareness campaigns, expanded KP sensitivity training, and related efforts to thwart PrEP stigma while expanding access.

'I take the drugs… to make the sickness to move out of me': key populations' and service provider perspectives about facilitators and barriers to ART adherence and retention in care in Nigeria

BACKGROUND

Adherence to antiretroviral therapy (ART) has individual and public health benefits and is critical to improving life expectancy, achieving viral suppression, and reducing the risk of HIV transmission. This qualitative study explored the experience of receiving care as well as perceived facilitators and barriers of treatment initiation, retention in ART care, and adherence to treatment.

METHODS

In-depth interviews were conducted among 28 men who have sex with men (MSM) and female sex workers (FSWs) receiving ART services in Lagos and Benue states. Key informant interviews were also conducted among 16 service providers engaged in counselling, clinical care, and ART treatment for MSM and FSWs. The Social Ecology Model guided the exploration of perceived barriers and facilitators of treatment initiation, retention in ART care and adherence to treatment. Qualitative data analysis was managed using NVIVO 11 software and themes were analysed using thematic analysis.

RESULTS

We found that the key barriers to ART adherence were low motivation to comply with medication regimen, work commitments, socioeconomic factors, stigma, negative provider attitude and distance to health facilities. Facilitators of adherence identified include the desire to live a productive life, strong family support and participation in support group programs. Comprehensive adherence counselling, support group programs and an effective follow-up system were factors identified by service providers as key to facilitating adherence.

CONCLUSION

To be effective, ART programs must address the unique challenges key populations face in accessing treatment and achieving optimal adherence regarding establishing a strong support system and follow-up. Community level interventions that support a stigma-free environment are critical to sustaining engagement in care.

Stigmatizing clinical setting erodes physician-patient interaction quality for sexual minority men through perceived HIV stigma and HIV infection concerns in Zambia

This study investigated whether perceived HIV stigma and HIV infection concerns among healthcare providers (HCPs) mediate the association between stigmatizing clinical setting and their interaction quality with sexual minority men (SMM) patients in Zambia. In 2021, a cross-sectional survey was conducted with 91 HCPs offering HIV-related services to SMM in Zambia. Path analysis was conducted to examine the potential mediation effect of "perceived HIV stigma" and "HIV infection concern" among HCPs in the association between "stigmatizing clinical setting" and their "interaction quality with SMM". Mediators i.e., "perceived HIV stigma" and "HIV infection concern" among HCPs, were associated positively with the stigmatizing clinical setting (β = 0.329, p < .01, β = 0.917, p < 0.01), and negatively with physician-patient interaction quality (β = -0.167, p = 0.051; β = -0.126, p < 0.05). Stigmatizing clinical setting had a significant and negative indirect effect on HCPs interaction quality with SMM through increased perceived HIV stigma (z = -1.966, p < 0.05) and increased HIV infection concern (z = -1.958, p = 0.050). To improve physician-patient interaction quality, stigma reduction interventions among HCPs, who serve SMM in Zambia, should target development of development of inclusive policies and the cultivation of cultural norms that are supportive and respectful to SMM, and protection of HCPs from enacted stigma due to offering care to SMM.

Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia

HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (β = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (β = 0.039, z = 5.121, p < 0.001) and current PrEP use (β = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (β = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (β = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.

Do Peer Navigators Improve Initiation and Retention in HIV/VH/STI Treatment Programs for People From Key Populations? A Systematic Review of Effectiveness, Values and Preferences, and Cost

BACKGROUND

Key populations are disproportionately affected by HIV, viral hepatitis (VH), and sexually transmitted infections (STIs) and face barriers to care. Peer navigation programs are widely used, but evidence supporting their use has not been synthesized.

SETTING

Peer navigation programs for sex workers, men who have sex with men, people who inject drugs, prisoners, and trans and gender diverse people globally.

METHODS

To inform World Health Organization guidelines, we conducted a systematic review of effectiveness, values and preferences, and cost studies published between January 2010 and May 2021. We searched CINAHL, PsycINFO, PubMed, and EMBASE; screened abstracts; and extracted data in duplicate. The effectiveness review included randomized controlled trials and comparative observational studies evaluating time to diagnosis or linkage to care, treatment initiation, treatment retention/completion, viral load, cure, or mortality. We assessed risk of bias and summarized findings in GRADE evidence profiles. Values and preferences and cost data were summarized descriptively.

RESULTS

Four studies evaluated the effectiveness of peer navigators for key populations. All were focused on HIV; none were designed for VH or STIs. These studies showed mixed effects on linkage to care, treatment retention/completion, and viral load; no studies measured treatment initiation, cure, or mortality. Two values and preferences studies with community-based organization staff and health workers suggested peer navigators for key populations were acceptable and valued, although continued challenges remained. No cost studies were identified.

CONCLUSIONS

Although limited, available studies provide moderate certainty evidence for benefits of HIV/VH/STI peer navigation programs for key populations. Further evaluations are needed.

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.

"I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia

ABSTRACT

Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.

Pre-exposure prophylaxis uptake concerns in the Democratic Republic of the Congo: Key population and healthcare workers perspectives

Key populations (KP) in the Democratic Republic of the Congo (DRC), including female sex workers (SW), are disproportionally affected by HIV. Quantitative feedback surveys were conducted at seven health facilities in DRC with 70 KP clients enrolled in pre-exposure prophylaxis (PrEP) services to measure benefits and concerns. The surveys also assessed satisfaction with PrEP services and experiences of stigma at the health facilities. Thirty healthcare workers (HCW) were surveyed to measure attitudes, beliefs, and acceptability of providing services to KP. KP client survey participants were primarily female SW. KP clients reported that the primary concern about taking PrEP was fear of side effects (67%) although few KP reported having experienced side effect (14%). HCW concurred with clients that experienced and anticipated side effects were a primary PrEP uptake concern, along with costs of clinic visits.

The Impacts of Stigma Against Sexual Minority Men Within and Between Various Socioecological Levels: Breaking the Vicious Cycle in Zambia

Sexual minority men (SMM) face persistent stigma in Zambia. From a holistic perspective, we aim to explore its impacts within and between multiple socioecological levels, demonstrating how their interactions create a vicious cycle of barriers to the well-being of SMM. In-depth interviews were conducted with 20 purposively recruited SMM from Lusaka, Zambia. All interviews were audio-recorded, after written consent, transcribed verbatim, and iteratively coded employing inductive (i.e., data-driven) approaches for thematic analysis using NVivo. Results suggest three key themes: (1) interpersonal socially perpetuated sexual minority stigma (SMS); (2) multidirectional interactions between psychosocial well-being and risk-taking behaviors; and (3) institutionally perpetuated SMS as a barrier to seeking and receiving health care. SMS permeates across all levels of the socioecological model to negatively impact the psychosocial well-being of SMM while acting also as a barrier to accessing HIV prevention and care. Our study necessitates structural public health intervention to decrease stigma and discrimination against SMM in Zambia, in efforts to increase their psychosocial well-being as well as their access to and utilization of HIV care by breaking the vicious cycle of SMS that pervades through the intrapersonal, interpersonal, and institutional levels of the socioecological model.

Assessing awareness and use of HIV self-testing kits after the introduction of a community-based HIV self-testing programme among men who have sex with men in Kenya

Men who have sex with men (MSM) bear a disproportionate burden of new HIV infections in Kenya, while experiencing discrimination, leading to suboptimal levels of HIV care. HIV self-testing (HIVST) is a tool to increase HIV screening and earlier diagnosis; however, questions remain regarding how best to scale-up HIVST to MSM in Kenya. The main objective of this study was to examine changes in knowledge and use of HIVST after implementation of a community-led HIVST project. Participants were MSM recruited from Kisumu, Mombasa, and Kiambu counties. Data were collected from two rounds (Round 1: 2019; Round 2: 2020) of serial cross-sectional integrated biological and behavioural assessments (IBBA), pre-, and post-project implementation. Two main outcomes were measured: 1) whether the respondent had ever heard of HIVST; and 2) whether they had ever used HIVST kits. Changes in outcomes between IBBA rounds were examined using modified multivariable Poisson regression models; adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) are reported. A total of 2,328 respondents were included in main analyses. The proportion of respondents who had heard of HIVST increased from 75% in Round 1 to 94% in Round 2 (aPR: 1.2, 95% CI: 1.2-1.3), while those reporting using an HIVST kit increased from 20% to 53% (aPR: 2.3, 95% CI: 2.0-2.6). Higher levels of education and HIV programme awareness were associated with both outcomes. Awareness and use of HIVST kits increased after implementation of a community-led HIVST implementation project, demonstrating the importance of integration with existing community groups.

A Qualitative Study of the Benefits and Utility of Brief Motivational Interviewing to Reduce Sexually Transmitted Infections among Men Who Have Sex with Men

Several studies have demonstrated the effectiveness of motivational interviewing (MI) in reducing sexual risk behaviors. However, limited information is available on the acceptability of brief MI among men who have sex with men (MSM) in poor resource settings like sub-Saharan Africa. The objective of this study was to assess the views of MSM about the benefits and utility of brief MI (bMI) in changing their risky behavior. A qualitative study among men who have sex with men (MSM) who were enrolled in a longitudinal observational study between December 2021 and May 2023. The setting was in Tshwane North and participants were scheduled for baseline, 6-month, and 12-month visits. All participants received 20 min one-on-one face-to-face brief motivational interview (bMI) sessions during their follow-up visits. At month 12, an exit interview was conducted with consenting conveniently sampled participants (n = 23) who had completed all scheduled visits and received three bMI sessions. The findings indicated that the most recalled conversation was related to multiple sexual partners, having sex under the influence of alcohol, and MSM learned more about sexually transmitted diseases. Many expressed being comfortable with the sessions because the counselor was respectful and non-judgmental. Most found the bMI sessions to have a positive impact on changing and reducing risky sexual behaviors, particularly it reportedly increased their use of condoms and reduced the number of multiple partners. MSM found the bMI to be useful and acceptable in reducing sexual risk behaviors among MSM.

Five different ways of reasoning: Tanzanian healthcare workers' ideas about how to improve HIV prevention among same-sex attracted men

BACKGROUND

Same-sex attracted men in Tanzania and globally carry a disproportionate burden of HIV. Drawing on qualitative research, this article explores healthcare providers' ideas and recommendations regarding how to improve HIV prevention among same-sex attracted men.

METHODS

We carried out a qualitative study among healthcare workers in the cities of Dar es Salaam and Tanga in Tanzania between August 2018 and October 2019. Data were collected using qualitative methods of data collection, specifically in-depth interviews, focus group discussions, and participant observation. Study participants were recruited through a purposive sampling strategy that aimed to ensure variation in age, education, and work experience. Forty-eight interviews with 24 healthcare workers, six focus group discussions, and participant observation were conducted. A total of 64 persons participated in the study.

RESULTS

This paper describes five different "ways of reasoning" that were identified among healthcare workers regarding how to strengthen HIV prevention among same-sex attracted men. One held that punitive measures should be taken to prevent HIV transmission, another that health services needed to become more friendly towards men who have sex with men, a third that healthcare workers should reach out to provide more education to this population, a fourth called for strengthened collaboration between healthcare providers and same-sex attracted men in healthcare delivery, and the fifth proposed that activistic efforts be taken to remove structural barriers for same-sex attracted men to access healthcare.

CONCLUSION

When reflecting on what is needed to strengthen HIV prevention among men who have sex with men, healthcare workers described six different ideas. One was that restrictive and punitive measures ought to be taken to prevent HIV transmission through same-sex sex. The remaining five promoted understanding of and support for same-sex attracted men. They prescribed more healthcare education, measures to improve attitudes among healthcare workers, healthcare delivery with user involvement, and political action to achieve law reform. Finally, some study participants raised concerns about the implementation of the national comprehensive package for key populations.

Exploring Malaysian Physicians' Intention to Discriminate Against Gay, Bisexual, and Other Men Who Have Sex with Men Patients

Purpose: Gay, bisexual, and other men who have sex with men (MSM) experience high levels of stigma and discrimination. Minimizing the stigma and discrimination is critical to fostering an inclusive environment for care and optimizing health outcomes. This study aimed at exploring the factors related to physicians' intention to discriminate against MSM in Malaysia. Methods: Physicians (N = 542) from two university-affiliated hospitals in Kuala Lumpur, Malaysia, completed an online cross-sectional survey between January and March 2016. Measures included sociodemographic and clinical characteristics, intention to discriminate against MSM, and several stigma-related constructs. Bivariate and multivariable linear regressions were used to evaluate independent correlates of discrimination intent against MSM. Results: Physicians' intention to discriminate against MSM was low (mean [M] = 1.9, standard deviation [SD] = 0.7), but most physicians (70.6%) had a mean score greater than 1.0, indicating that most physicians expressed some degree of intention to discriminate against MSM. A minority of physicians (10.7%), however, had a score of 3.0 or higher, revealing some physicians holding a moderate to high level of discrimination intent toward MSM. The multivariable model demonstrated that physicians who expressed greater prejudice (B = 0.30, p < 0.01), had more MSM-related shame (B = 0.19, p < 0.01), and fear about MSM (B = 0.31, p < 0.01) were more likely to have the intention to discriminate against MSM. Conclusion: Stigma-related constructs including prejudice, MSM-related shame, and fear were independently correlated with increases in a physician's intention to discriminate against MSM. Therefore, implementing interventions to reduce physicians' stigma toward MSM may promote equitable and stigma-free access to health care.

Outcomes of a community-based antiretroviral therapy programme for key populations living with HIV in Benue State, Nigeria: protocol for a realist evaluation

INTRODUCTION

Key populations (KP) living with HIV are underserved and often face social and health system barriers to HIV care. To optimise access to quality HIV services among KP, the WHO recommended community-based approaches to HIV service delivery for KP. However, to inform the successful rollout and scale-up of community-based antiretroviral therapy service delivery models for KP (KP-CBART), there is a need to study the programme implementation. This study aims to evaluate the outcomes of KP-CBART in Benue State Nigeria using a realist impact evaluation approach. Our evaluation question is: what are the mechanisms and context conditions that drive successful community-based implementation and how do these lead to better retention in care, treatment adherence and viral suppression among which categories of KP?

METHODS AND ANALYSIS

This study will be conducted in three phases, relying on a mixed-method design and following the realist evaluation cycle. The first phase is the development of the initial programme theory grounded in a scoping review, programme and policy document review and in-depth interviews with key stakeholders. In phase 2, findings from case studies of KP-CBART programme implementation in one Nigerian state are used to test the initial programme theory and to refine it. The quantitative part is a retrospective cohort study. All HIV-positive KP clients enrolled into the KP-CBART between 2016 and 2020 will be included in the study. While maximum variation and data saturation will inform sample size for the qualitative part, an estimated 90 purposively selected study participants will be interviewed. In phase 3, findings will be synthesised into a middle-range theory through cross-case analysis. The heuristic intervention, context, agents, mechanisms and outcomes (ICAMO) tool will be used to refine the initial programme theory.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Boards of APIN Public Health Initiatives (IRB022-FR), Institute of Tropical Medicine Antwerp (1503/21), and the Benue State Ministry of Health and Human Services (MOH/STA/204/VOL1/154). Written informed consent will be obtained from all study participants. Study results will be disseminated through stakeholders meeting, peer-reviewed journals and conferences.

Peer community health workers improve HIV testing and ART linkage among key populations in Zambia: retrospective observational results from the Z-CHECK project, 2019-2020

INTRODUCTION

Zambia has made tremendous progress towards HIV epidemic control; however, gaps remain among key populations (KPs), such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and people in prisons and enclosed settings due to cultural, social and legal barriers. The University of Maryland, Baltimore Zambia Community HIV Epidemic Control for Key Populations (Z-CHECK) project aimed to improve HIV case-finding, linkage and treatment adherence at the community level for KPs in Zambia. We describe Z-CHECK strategies and examine HIV positivity yield and antiretroviral therapy (ART) linkage among KPs to inform ongoing programme improvement.

METHODS

Z-CHECK recruited, trained and deployed peer community health workers (CHWs) for KP groups, with ongoing mentorship in community engagement. CHWs offered HIV testing in safe spaces and escorted newly HIV-diagnosed clients for same-day ART initiation. Z-CHECK also reached out to KP community leaders and gatekeepers for KP mobilization and trained healthcare workers (HCWs) on KP services and sensitivity. We conducted a retrospective observational review of routinely collected aggregate data for KPs aged ≥15 years at high risk for HIV transmission across five districts in Zambia from January 2019 to December 2020.

RESULTS

Z-CHECK provided HIV testing for 9211 KPs, of whom 2227 were HIV positive (positivity yield, 24%). Among these, 1901 (85%) were linked to ART; linkage for MSM, FSW, PWID and people in prisons and enclosed settings was 95%, 89%, 86% and 65%, respectively. Programme strategies that contributed to high positivity yield and linkage included the use of peer KP CHWs, social network testing strategies and opportunities for same-day ART initiation. Challenges to programme implementation included stigma and discrimination among HCWs, as well as KP CHW attrition, which may be explained by high mobility.

CONCLUSIONS

Peer CHWs were highly effective at reaching KP communities, identifying persons living with HIV and linking them to care. Engaging KP community gatekeepers resulted in high diffusion of health messages and increased access to health resources. The mobility of CHWs and HCWs is a challenge for programme implementation. Innovative interventions are needed to support PWID and people in prisons and enclosed settings.

Perceptions of Sexual Healthcare Provision in Tanzania: a Key Informant Qualitative Study

INTRODUCTION

Sexual health care services must be standard and unbiased, guided by a structured health care system. There is a scarcity of data on how sexual health care is delivered in Tanzania.

METHODS

To address this gap, in July 2019 we interviewed eleven key informants: cultural and public health experts, and political, religious, and community leaders, selected from different organizations in Dar es Salaam, Tanzania. Participants were asked for their opinions about clinical practices of health care professionals when providing care to patients, with an emphasis on sexual health.

RESULTS

Participants' responses were classified into three subcategories: strengths, barriers, and gaps in sexual health care. Availability of services, service delivery to adults, and code of conduct were among the strengths observed in clinical care services. Barriers included the health care provider's attitudes, moral values, and inadequacy in health policies and treatment guidelines. Vulnerable populations including youth were frequently reported to face most challenges when seeking sexual health care services. In terms of gaps, informants emphasized gender equity in sexual health services provision within care settings.

CONCLUSION AND IMPLICATION

Data indicate that lack of training in sexual health and guidelines for dealing with sexual issues are a barrier to comprehensive health care. These findings can inform the main areas for curriculum developers to focus on, when developing an Afro-centric sexual health curriculum suitable for students in health care professional courses. Moreover, these findings can be useful when developing treatment guidelines and policies that are beneficial to the sexual health wellbeing of individuals.

Sexual health behavior, health status, and knowledge among queer womxn and trans men in Kenya: An online cross-sectional study

Introduction

Little research has been conducted on the sexual health needs and risk behaviors of queer womxn and trans men, making it difficult to identify specific health needs and disparities. This is especially the case in the Global South, where their needs are poorly understood. This study presents findings on demographics, sources of information, sexual (risk) behaviors, and substance use in Kenyan queer womxn and trans men.

Methods

An online survey among 335 Kenyan queer womxn and trans men was used to collect data on sexual health, risk behavior, health information sources, and substance use. The participants needed to have had at least one self-identified female sexual partner.

Results

The sample presented young, highly-educated queer womxn and trans men. A high incidence of childhood sexual trauma found was found. Risk behaviors included sexual activities with partners of multiple genders, violence, and low use of barrier methods. One in three participants had been treated for an STD in the previous year. The incidences of smoking and drinking were high, and a quarter of participants indicated having taken drugs at least once a month or more. The internet was either the first or second most important source of sexual health information for 44.1% of the participants, followed by schools (30.9%).

Discussion and conclusion

Our findings indicate that queer womxn and trans men are at risk of negative sexual health outcomes due to a lack of appropriate information, risk behavior, substance use, and low uptake of sexual health services. Kenya’s Penal Code still criminalizes consensual same-sex activities and may play a role in perpetuating barriers that prohibit them from making healthier choices. Developing tailored programming and policies require local, national, and global stakeholders to engage with the inclusion of queer womxn and trans men’s sexual health needs within strategic planning and healthcare delivery.

Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis

INTRODUCTION

Men are missing along the HIV care continuum. However, the estimated proportions of men in sub-Saharan Africa meeting the UNAIDS 95-95-95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95-95-95 goals across studies in sub-Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement.

METHODS

We systematically searched PubMed and Embase for peer-reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95-95-95 goal in sub-Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion-Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta-synthesis.

RESULTS AND DISCUSSION

We screened 14,896 studies and included 129 studies in the meta-analysis, compiling data over the data collection period. Forty-seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41-0.58; range, 0.09-0.97]) or not being on treatment (0.58 [95% CI, 0.51-0.65; range, 0.07-0.97]), while over three-quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77-0.81; range, 0.39-0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta-synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty.

CONCLUSIONS

Psychosocial and systems-level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.

Cultural adaptation and validation of a measure of prejudice against men who have sex with men among healthcare providers in western Kenya

Sexual prejudice toward men who have sex with men (MSM) is a pressing concern in sub-Saharan Africa (SSA). Given the high HIV infection risk among this population, sexual prejudice perpetuated by healthcare providers, affects access to and willingness of MSM to seek HIV care services. However, data on healthcare providers' attitudes towards MSM in SSA are limited, and there are no locally-adapted measures of sexual prejudice. We adapted a scale to measure sexual prejudice with a sample of 147 healthcare providers in western Kenya. Results from exploratory factor analysis revealed a single-factor structure. The scale demonstrated high internal consistency with Cronbach's α = 0.91. Healthcare providers who had prior interpersonal contact with MSM, had ever been trained on counselling MSM, and had higher knowledge about MSM health needs reported lower sexual prejudice scores, compared with peers who lacked these experiences (p < 0.001). In contrast, healthcare providers who had experienced secondary stigma (negative judgments from peers and community) for providing care to MSM reported higher scores of sexual prejudice scale (p < 0.001) compared with providers who had not experienced secondary stigma. The scale provides a contextualised tool to assess healthcare providers' attitudes toward MSM in Kenya and countries in SSA with similar cultural norms.

Testing for saturation in qualitative evidence syntheses: An update of HIV adherence in Africa

Background

A systematic review of randomised trials may be conclusive signalling no further research is needed; or identify gaps requiring further research that may then be included in review updates. In qualitative evidence synthesis (QES), the rationale, triggers, and methods for updating are less clear cut. We updated a QES on adherence to anti-retroviral treatment to examine if thematic saturation renders additional research redundant.

Methods

We adopted the original review search strategy and eligibility criteria to identify studies in the subsequent three years. We assessed studies for conceptual detail, categorised as ‘rich’ or ‘sparse’, coding the rich studies. We sought new codes, and appraised whether findings confirmed, extended, enriched, or refuted existing themes. Finally, we examined if the analysis impacted on the original conceptual model.

Results

After screening 3895 articles, 301 studies met the inclusion criteria. Rich findings from Africa were available in 82 studies; 146 studies were sparse, contained no additional information on specific populations, and did not contribute to the analysis. New studies enriched our understanding on the relationship between external and internal factors influencing adherence, confirming, extending and enriching the existing themes. Despite careful evaluation of the new literature, we did not identify any new themes, and found no studies that refuted our theory.

Conclusions

Updating an existing QES using the original question confirmed and sometimes enriched evidence within themes but made little or no substantive difference to the theory and overall findings of the original review. We propose this illustrates thematic saturation. We propose a thoughtful approach before embarking on a QES update, and our work underlines the importance of QES priority areas where further primary research may help, and areas where further studies may be redundant.

'Fighting an uphill battle': a qualitative study of the challenges encountered by pharmacy workers when providing services to men who have sex with men in Dar es Salaam, Tanzania

Background

Previous research suggests that Tanzanian MSM might prefer consulting pharmacies and drugstores, rather than public healthcare services, when in need of STI medicines and treatment. Yet, few studies have explored the experiences of providing services to MSM clients among those working at pharmacies and drugstores and examined what challenges they encounter in providing these services.

Objective

To gain increased knowledge and understanding of the perceived challenges encountered by pharmacists and drugstore workers when providing STI services to MSM clients in Dar es Salaam, Tanzania.

Method

In early 2016, 16 semi-structured interviews were conducted with persons working at private pharmacies and drugstores in Dar es Salaam. Data were interpreted through qualitative content analysis.

Results

The overarching theme that emerged was labelled ‘Fighting an uphill battle’, which reflected the challenges pharmacy workers experienced during interactions with MSM clients, and in particular service provision. Pharmacy workers tried to act upon the best of their knowledge to meet the needs of clients, given their understanding of risks and obstacles that MSM faced. Yet, the lack of educational and professional preparedness and insufficient financial and human resources, regarded as necessary to meet the needs of a stigmatised client group, formed barriers for effective service delivery.

Conclusions

In order to support pharmacists and drug-store workers in Tanzania to address perceived challenges for service delivery to MSM clients, systematic and continuous training on MSM’s sexual health is required. Furthermore, inter-professional cooperation that harnesses provider involvement from all tiers in the healthcare system is essential to offer complementary services to ensure proper STI care and treatment. Thus, interventions that focus on inter-professional communication and interaction between pharmacists and physicians could have a positive impact on timely referrals of suspected STI cases among marginalised populations.

Building self-advocacy in HIV care: the use of role-play to examine healthcare access for HIV-positive MSM in rural South Africa

There is high HIV prevalence and low rates of viral suppression for men who have sex with men (MSM) in South Africa, with few MSM-centered interventions to address these outcomes along the HIV treatment cascade. Participatory interventions may support community building among HIV-positive MSM through which they can share approaches of self-advocacy that are contextually grounded. We conducted a pilot study to assess the use of role-plays in influencing social isolation while also updating our understanding of MSM healthcare experiences in Mpumalanga, South Africa. The study was conducted with 21 MSM leaders who were HIV-positive. There were three groups of seven participants each who created and performed role-plays based on their healthcare experiences, with a focus group discussion (FGD) conducted afterward. Audio-recordings were transcribed, translated, and analyzed using a constant comparison approach. We found that MSM described role-play as cathartic and a future HIV care educational tool for other MSM, and that they outlined points of self-advocacy during HIV care in clinics. Our study suggests that future research should utilize role-play so to integrate contextual factors influencing HIV treatment, especially in high HIV prevalence settings.

Increasing HIV treatment access, uptake and use among men who have sex with men in urban Indonesia: evidence from a qualitative study in three cities

Men who have sex with men make up one of four key populations identified as critical to a successful HIV response in Indonesia. Despite international policies supporting HIV treatment in low- and middle-income countries, Indonesia is one of the few countries experiencing low coverage of HIV treatment and little decrease in HIV incidence. There is poor retention in care and low viral suppression rates among key populations such as men who have sex with men. The national government has committed to increasing treatment access and uptake for people with HIV but little is known about how these men themselves view, use and experience these medications. Drawing on qualitative data collected in 2015-16 from 24 HIV-positive men who have sex with men living in three Indonesian cities, we observed multiple intersecting social and contextual factors that can influence effective HIV treatment use. Although shared stories of strong side effects and fear of unwanted disclosure inhibited treatment uptake, social support from 'buddies' helped to navigate healthcare systems and sharing medication among peers enabled adherence. In order to improve treatment uptake and adherence among Indonesian men who have sex with men living with HIV, these divergent effects of the social meanings and practices associated with HIV treatments in Indonesia must be better acknowledged. A more comprehensive understanding of social and community practices within key populations can strengthen national efforts to improve treatment access and increase adherence. Ongoing decentralization of healthcare in Indonesia, and differentiated care models that enable initiation of treatment in community settings and involve non-medical, community-based organizations in the provision of treatment services have the potential to address the needs of individuals who fall into a key population category such as men who have sex with men.

A more responsive, multi-pronged strategy is needed to strengthen HIV healthcare for men who have sex with men in a decentralized health system: qualitative insights of a case study in the Kenyan coast

INTRODUCTION

HIV healthcare services for men who have sex with men (MSM) in Kenya have not been openly provided because of persistent stigma and lack of healthcare capacity within Kenya's decentralized health sector. Building on an evaluation of a developed online MSM sensitivity training programme offered to East and South African healthcare providers, this study assessed views and responses to strengthen HIV healthcare services for MSM in Kenya.

METHODS

The study was conducted between January and July 2017 in Kilifi County, coastal Kenya. Seventeen policymakers participated in an in-depth interview and 59 stakeholders, who were purposively selected from three key groups (i.e. healthcare providers, implementing partners and members of MSM-led community-based organizations) took part in eight focus group discussions. Discussions aimed to understand gaps in service provision to MSM from different perspectives, to identify potential misconceptions, and to explore opportunities to improve MSM HIV healthcare services. Interviews and focus group discussions were recorded, transcribed verbatim and analysed using Braun and Clarke's thematic analysis.

RESULTS

Participants' responses revealed that all key groups navigated diverse challenges related to MSM HIV health services. Specific challenges included priority-setting by county government staff; preparedness of leadership and management on MSM HIV issues at the facility level; data reporting at the implementation level and advocacy for MSM health equity. Strong power inequities were observed between policy leadership, healthcare providers and MSM, with MSM feeling blamed for their sexual orientation. MSM agency, as expressed in their actions to access HIV services, was significantly constrained by county context, but can potentially be improved by political will, professional support and a human rights approach.

CONCLUSIONS

To strengthen HIV healthcare for MSM within a decentralized Kenyan health system, a more responsive, multi-pronged strategy adaptable and relevant to MSM's healthcare needs is required. Continued engagement with policy leadership, collaboration with health facilities, and partnerships with different community stakeholders are critical to improve HIV healthcare services for MSM.

Strategies to improve access for MSM in low-income and middle-income countries

PURPOSE OF REVIEW

HIV prevention and treatment interventions for MSM are not well studied or reported from low-income and middle-income countries (LMIC) in comparison to those targeting gender-conforming populations. Some evidence-based strategies to engage MSM in appropriate healthcare have recently reported on their experiences and impact. Novel recruitment strategies have been developed for treatment and preexposure prophylaxis (PrEP) for MSM, leveraging new community engagement strategies and social media technologies.

RECENT FINDINGS

Despite publication of several new guidelines, there is little recent evidence available to guide MSM health programs in LMIC, highlighting the need for ongoing research and publication. Some important PrEP pilot study results have recently been published, such as the PrEP Brazil and Princess PrEP programmes, which could guide the scale-up of MSM PrEP. The novel use of technology and online platforms to strengthen MSM health delivery and support is particularly important.

SUMMARY

Providing healthcare to MSM requires consideration of context, broad stakeholder engagement, implementation of best practice guidelines and ongoing situational assessment and integration of novel community engagement methods that are evidence-based. Implementation of improved antiretroviral programmes and the access to PrEP for MSM are vital.

A Randomized Controlled Trial of the Shikamana Intervention to Promote Antiretroviral Therapy Adherence Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya: Feasibility, Acceptability, Safety and Initial Effect Size

Gay, bisexual, and other men who have sex with men (GBMSM) living with HIV in rights-constrained settings need support for antiretroviral therapy (ART) adherence due to barriers including stigma. The Shikamana intervention combined modified Next Step Counseling by providers with support from trained peers to improve adherence among GBMSM living with HIV in Kenya. A randomized controlled trial with 6-month follow-up was used to determine feasibility, acceptability, safety, and initial intervention effects. Generalized estimating equations examined differences in self-reported adherence and virologic suppression. Sixty men enrolled, with 27 randomly assigned to the intervention and 33 to standard care. Retention did not differ by arm, and no adverse events occurred. Feedback on feasibility and acceptability was positive based on exit interviews. After adjustment for baseline viral suppression and confounding, the intervention group had a sixfold increased odds of viral suppression during follow-up. A larger trial of a scaled-up intervention is needed.

"It is always better for a man to know his HIV status" - A qualitative study exploring the context, barriers and facilitators of HIV testing among men in Nairobi, Kenya

HIV testing services are an important component of HIV program and provide an entry point for clinical care for persons newly diagnosed with HIV. Although uptake of HIV testing has increased in Kenya, men are still less likely than women to get tested and access services. There is, however, limited understanding of the context, barriers and facilitators of HIV testing among men in the country. Data are from in-depth interviews with 30 men living with HIV and 8 HIV testing counsellors that were conducted to gain insights on motivations and drivers for HIV testing among men in the city of Nairobi. Men were identified retroactively by examining clinical CD4 registers on early and late diagnosis (e.g. CD4 of ≥500 cells/mm, early diagnosis and <500 cells/mm, late diagnosis). Analysis involved identifying broad themes and generating descriptive codes and categories. Timing for early testing is linked with strong social support systems and agency to test, while cost of testing, choice of facility to test and weak social support systems (especially poor inter-partner relations) resulted in late testing. Minimal discussions occurred prior to testing and whenever there was dialogue it happened with partners or other close relatives. Interrelated barriers at individual, health-care system, and interpersonal levels hindered access to testing services. Specifically, barriers to testing included perceived providers attitudes, facility location and set up, wait time/inconvenient clinic times, low perception of risk, limited HIV knowled ge, stigma, discrimination and fear of having a test. High risk perception, severe illness, awareness of partner's status, confidentiality, quality of services and supplies, flexible/extended opening hours, and pre-and post-test counselling were facilitators. Experiences between early and late testers overlapped though there were minor differences. In order to achieve the desired impact nationally and to attain the 90-90-90 targets, multiple interventions addressing both barriers and facilitators to testing are needed to increase uptake of testing and to link the positive to care.

Access to health services for men who have sex with men and transgender women in Beira, Mozambique: A qualitative study

OBJECTIVES

HIV prevalence and incidence are higher among key populations including Men who have Sex with Men (MSM) and transgender women in low and middle income countries, when compared to the general population. Despite World Health Organisation guidelines on the provision of services to key populations recommending an evidence-based, culturally relevant and rights-based approach, uptake of HIV services in many resource-limited and rights-constrained settings remains low. Médecins Sans Frontières (MSF) has been offering health services for MSM and transgender women in Beira, Mozambique since 2014 using a peer-educator driven model, but uptake of services has not been as high as expected. This qualitative study aimed to learn more about these key populations in Beira, their experiences of accessing MSM- and transgender-friendly services and their use of face-to-face and virtual networks, including social media, for engagement with health care.

METHODS

In-depth interviews were carried out with MSM and transgender women who were 1) enrolled in, 2) disengaged from or 3) never engaged in MSF's programme. Purposive and snowball sampling were used to recruit the different groups of interviewees. Interviews were conducted in Portuguese, transcribed and translated into English before being coded and manually analysed using a thematic network framework.

RESULTS

Nine transgender women and 18 cisgender MSM participated in the study. Interviewees ranged in age from 19 to 47 years, with a median age of 29. Three main themes emerged from the data: perceptions of stigma and discrimination, experiences of the peer-educator driven model and the use of face-to-face and virtual platforms for communication and engagement, including social media. Interviewees reported experiencing stigma and discrimination because of their gender or sexual identity. HIV-related stigma and health-care setting discrimination, including gossip and breach of confidentiality, were also reported. Although the presence of the peer-educators and their outreach activities were appreciated, they had limited visibility and an over-focus on health and HIV. The face-to-face networks of MSM and transgender women were small and fragmented. Virtual networks such as Facebook were mainly used for flirting, dating and informal communication. Most interviewees were at ease using social media and would consider it as a means of engaging with health messaging.

CONCLUSIONS

MSM and transgender women have challenges in accessing health services due to being stigmatised because of their gender identity and their sexual behaviour, and often experience stigma at home, in health-care facilities and in their communities. Peer-driven models of engagement were appreciated but have limitations. There is an untapped potential for further expansion and engagement with face-to-face and virtual platforms to reach MSM and transgender women in settings with a high HIV burden, and to provide them with essential information about HIV and their health.

'My Tablets are on Top of the Fridge': The Roles of Relationship Desire and Medical Mistrust in ART Adherence for HIV-Positive MSM and Transgender Women Living in Rural South Africa

Given the high HIV prevalence for men who have sex with men (MSM) and transgender women in South Africa, there is limited understanding of social determinants that influence antiretroviral treatment (ART) adherence. Although universal testing and treatment (UTT) is available, ART adherence remains suboptimal. We conducted focus groups with MSM and transgender women in order to understand factors influencing their ART adherence in Mpumalanga, South Africa. All focus groups were audio-recorded, transcribed and translated for analysis using a constant comparison approach, guided by the concept of Therapeutic Citizenship. We found there is medical mistrust of ART based on differing interpretations of HIV cure that may influence treatment adherence behaviors within social networks, and relationship desire had a significant influence on optimal ART adherence. Our findings suggest that clinics must provide interventions that integrate HIV disclosure and relationship skill-building to support optimal ART adherence for MSM and transgender women under UTT.

Barriers to HIV Treatment Adherence: A Qualitative Study of Discrepancies Between Perceptions of Patients and Health Providers in Tanzania and Uganda

Previous qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers-particularly in low-income countries-who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.

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.

Healthcare providers' attitudes towards care for men who have sex with men (MSM) in Malawi

BACKGROUND

Men who have sex with men (MSM) are a priority group in Malawi's national response to Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). There are limited data on service providers' acceptability to deliver appropriate sexual health services in relation to HIV prevention, care and treatment targeting the MSM. We assessed attitudes of healthcare providers already working, health professions students and faculty at health professions training institutions regarding the provision of MSM focused HIV related health services.

METHODS

We conducted a qualitative study between April and May 2017 in Lilongwe, Malawi. We purposively recruited 15 participants (5 health service providers, 5 health professions students and 5 faculty of tertiary health training institutions) among whom individual in-depth interviews were conducted. Interviews were audio recorded, transcribed and analysed thematically.

RESULTS

Participants recognized MSM as having health needs and rights. Participants generally expressed willingness to deliver appropriate healthcare because they perceived this as their professional responsibility. Participants suggested that it was the responsibility for MSM to disclose their sexual orientation and or preferences when they access care such that healthcare providers better anticipate their care needs. They suggested a need to increase the availability of MSM-centered and friendly health services as well as trained providers that are non-judgmental, non-discriminatory and have respect for people's right to health care access.

CONCLUSION

Despite widespread poor attitudes against MSM in Malawi, health service providers and health professions students and faculty accepted and were willing to provide MSM-focused health services. The acceptability and willingness of health service providers, health professions students and faculty to provide health services to MSM offer hope and scope for efforts to strengthen the delivery of health services and quality of care to MSM in Malawi.

Characteristics and early clinical outcomes of key populations attending comprehensive community-based HIV care: Experiences from Nasarawa State, Nigeria

Background

Despite a call for differentiated care, there are limited data from sub-Saharan Africa on comprehensive community-based HIV care for key populations (KP), including commercial sex workers (CSW), men who have sex with men (MSM), and people who inject drugs (PWID). In Nigeria, a programme was implemented that liaised with community-based organizations and offered HIV testing, same-day ART initiation, and ART follow-up to KP. Here we characterize KP and their partners enrolled on ART. Our objective is to assess the early treatment outcomes and to estimate predictors of attrition among KP.

Method

This is a retrospective cohort study of routinely collected data in a community-based HIV program for KP in Nasarawa state, Nigeria from August 2016 to November 2017. Variables of interest were socio-demographic, KP types, treatment outcomes, ART adherence, WHO stage, TB status and viral load. Summary statistics, logistic and Cox proportional hazard regression were used to describe the characteristics of KP and estimate predictors of attrition (patients either lost to follow-up (LTFU) or dead).

Result

Seven hundred and ten (710) KP and their partners were enrolled into this study, 77.3% (549) of study participants were female and the median age was 30 years (IQR: 24–35). Respectively, 74.2%, 4.5%, 1.1% and 20% were FSW, MSM, PWID and their partners. Of 710 KP who started ART, 13.9% (99/710) discontinued after the first visit. After a median follow-up time of 7 months on ART 73.2% of patients were retained, 23.4% were LTFU, and 3.4% were dead. Lack of formal education (aHR 1.8; 95% CI 1.3–2.6) and unemployment (aHR 1.8; 95% CI 1.2–2.6) were significantly associated with attrition.

Conclusion

Comprehensive community-based HIV care, including HIV testing and same-day ART is feasible. However, ART initiation on the same day of confirmatory HIV testing resulted in a high uptake of ART, but possibly inflated early attrition on ART. To mitigate early attrition among KP after same-day ART initiation, the psychosocial readiness of clients should be assessed better. We strongly recommend further studies to understand factors contributing to high attrition among the KP.

Identifying MSM-competent physicians in China: a national online cross-sectional survey among physicians who see male HIV/STI patients

Background

Men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) infection and sexually transmitted infection (STI) in China. Inadequate clinical services and poor clinical competency among physicians are major barriers to improving the sexual health of MSM. This study aims to understand physician clinical competency in providing MSM health services in China.

Methods

We conducted an online cross-sectional survey among Chinese physicians who have seen male patients for STI complaints in the past year. We obtained information on individual demographics, clinical practice, attitudes toward MSM, and interest in contributing to MSM clinical services. We defined an MSM-competent physician as one who asked male patients about sexual orientation, sexual practices, and recommended HIV/ STI testing during a clinic visit. We conducted multivariable logistic regression to identify factors associated with MSM competency.

Results

In total, 501 physicians completed the survey. The most common subspecialties were dermatovenereology (33.1%), urology (30.1%), and general medicine (14.4%). Roughly half (n = 267, 53.3%) reported seeing MSM in the past 12 months. Among physicians who saw MSM in the past 12 months, 60.3% (n = 161) met criteria as MSM-competent physicians, and most (n = 234, 87.6%) MSM-competent physicians reported positive or neutral attitudes towards MSM. Over 60% of all physicians were willing to participate in activities for improving MSM services, such as training and being on a list of physicians willing to serve MSM. MSM-competent physicians showed no sociodemographic differences compared with non MSM-competent physicians. MSM-competent physicians were more willing to have their medical institution named on a public clinic list capable of serving MSM (aOR: 1.70, 95%CI: 1.01–2.86) and being on a public physician list capable of serving MSM (aOR: 1.77, 95%CI: 1.03–3.03).

Conclusions

MSM-competent physicians included a broad range of individuals that practiced in diverse clinical settings. Most physicians were interested in improving and expanding MSM clinical services, despite having neutral attitudes toward same-sex behavior. Future interventions should focus on developing MSM clinical competency and expanding services that meet the needs of MSM.

Stigma and Healthcare-Seeking Practices of Men Who Have Sex with Men in Western Kenya: A Mixed-Methods Approach for Scale Validation

In sub-Saharan Africa, men who have sex with men (MSM) experience high HIV prevalence, in part, due to stigma and discrimination creating barriers to engagement in prevention and care services. We examined the reliability and validity of measures of stigma and satisfaction with healthcare providers, as well as explored whether scores on the factors varied across sociodemographic variables among MSM in western Kenya. A mixed-methods design using a sequential triangulation approach was adopted, involving a survey of 89 MSM and 10 key informant interviews. Reliability and correlation analyses, exploratory factor analyses, t-tests, and ANOVAs (analyses of variances) were conducted to test the scale's psychometric properties and examine differences in mean scores by demographics. Thematic analysis with qualitative data was used to validate the meaning of scales and explore how stigma influences and relates to satisfaction with healthcare providers. Of 89 participants, 50% identified as homosexual, 52% had college degree, 45% were above 25 years, and 72% had ever been married. Three subscales measuring enacted stigma, internalized stigma, and mistrust of healthcare providers showed good reliability (α = 0.80, α = 0.90, and α = 0.90). Men who identified as homosexual reported higher mean scores of enacted stigma and distrust of healthcare providers compared to heterosexual/bisexual identified (p < 0.001). Qualitative data revealed perceptions that healthcare providers were not knowledgeable to handle MSM needs. Study provides preliminary evidence for the reliability and validity of measures of stigma and mistrust of healthcare providers in Kenya. Quantitative and qualitative findings highlight the need for interventions to reduce stigma and create a more inclusive health system.

Impact of a massive earthquake on adherence to antiretroviral therapy, mental health, and treatment failure among people living with HIV in Nepal

INTRODUCTION

The April 2015 Nepal earthquake resulted in more than 8,700 deaths and 22,000 casualties including damage to health facilities. The impact of this situation on chronic conditions such as human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV/AIDS) may become a long-lasting public health threat. Therefore, the objectives of this study were i) to assess the association of antiretroviral therapy (ART) adherence with mental health problems, and social behaviors, ii) to examine factors affecting treatment failure, and iii) to investigate changes in ART adherence and post-traumatic stress disorder (PTSD) among people living with HIV 6 and 12 months after the disaster.

METHODS

Study was conducted 6 months after the earthquake in 2015 with a sample size of 305 earthquake victims with HIV and followed after 12 months of the earthquake. A logistic regression analysis was used to examine relationships, while a paired t-test analysis was conducted to assess changes in adherence to ART and PTSD level at 6 months and 12 months after earthquake.

RESULTS

In the earthquake, 5.2% of the participants lost their family member. Approximately 44% of participants had earthquake-PTSD symptoms and 50% experienced HIV stigma. PTSD and HIV status disclosure were significantly associated with adherence to ART, while HIV stigma and religion were associated with treatment failure. PTSD and adherence levels to ART were significantly improved over the 6-month period.

CONCLUSION

Awareness programs for general public to eliminate HIV stigma; promote psychosocial counseling to earthquake victims living with HIV in order to reduce PTSD will contribute to maintaining optimal ART adherence and to prevent treatment failure.

HIV viral load monitoring among key populations in low- and middle-income countries: challenges and opportunities

Introduction

Key populations bear a disproportionate HIV burden and have substantial unmet treatment needs. Routine viral load monitoring represents the gold standard for assessing treatment response at the individual and programme levels; at the population‐level, community viral load is a metric of HIV programme effectiveness and can identify “hotspots” of HIV transmission. Nevertheless, there are specific implementation and ethical challenges to effectively operationalize and meaningfully interpret viral load data at the community level among these often marginalized populations.

Discussion

Viral load monitoring enhances HIV treatment, and programme evaluation, and offers a better understanding of HIV surveillance and epidemic trends. Programmatically, viral load monitoring can provide data related to HIV service delivery coverage and quality, as well as inequities in treatment access and uptake. From a population perspective, community viral load data provides information on HIV transmission risk. Furthermore, viral load data can be used as an advocacy tool to demonstrate differences in service delivery and to promote allocation of resources to disproportionately affected key populations and communities with suboptimal health outcomes. However, in order to perform viral load monitoring for individual and programme benefit, health surveillance and advocacy purposes, careful consideration must be given to how such key population programmes are designed and implemented. For example, HIV risk factors, such as particular sex practices, sex work and drug use, are stigmatized or even criminalized in many contexts. Consequently, efforts must be taken so that routine viral load monitoring among marginalized populations does not cause inadvertent harm. Furthermore, given the challenges of reaching representative samples of key populations, significant attention to meaningful recruitment, decentralization of care and interpretation of results is needed. Finally, improving the interoperability of health systems through judicious use of biometrics or identifiers when confidentiality can be maintained is important to generate more valuable data to inform monitoring programmes.

Conclusions

Opportunities for expanded viral load monitoring could and should benefit all those affected by HIV, including key populations. The promise of the increasing routinization of viral load monitoring as a tool to advance HIV treatment equity is great and should be prioritized and appropriately implemented within key population programmatic and research agendas.