Review of sampling hard-to-reach and hidden populations for HIV surveillance

Novel methods to construct a representative sample for surveying California's unhoused population: the California Statewide Study of People Experiencing Homelessness

Existing literature on people experiencing homelessness (PEH) draws on nonrepresentative samples from service providers, populations with comorbidities, or areas with disproportionately high amounts of sheltered homelessness, leading to bias. Nearly one-third of PEH in the United States and more than half of unsheltered PEH live in California. We designed a rigorous state-representative survey of PEH to investigate the antecedents of homelessness, understand health, and inform policy solutions. The multistage design randomized at 3 levels: county, venue, and individual. Stratifying the state into 8 regions, we sampled 1 county per region to reflect statewide demographics. Within counties, sampled venues matched the expected proportion of sheltered and unsheltered residents. Within venues, interviewers randomly sampled individuals. We adjusted for nonresponse and incorporated poststratification to benchmarks. In parallel, respondent-driven sampling reached subpopulations through social networks who may otherwise have been undersampled. Our community-engaged study yielded 3200 quantitative surveys. We purposively sampled 365 participants for qualitative interviews. Demographic estimates match those found in the PIT with the added strength of statistical inference. To our knowledge, this is the first large representative study of PEH, beyond a single county, to draw inference on a large population that did not depend on service utilization. Our methods may inform future efforts to understand homelessness.

Viability of Web-Based Respondent-Driven Sampling of Belgian Men Who Have Sex With Men: Process Evaluation

BACKGROUND

Obtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men Web-based respondent-driven sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research, it remains unclear whether WEB RDS is suitable for sampling hidden populations such as men who have sex with men.

OBJECTIVE

This study aims to evaluate how viable the WEB RDS methodology is for obtaining a nationwide sample of men who have sex with men, suitable for population inference of sexual health characteristics, in Belgium.

METHODS

We adapted the Medical Resource Council process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing "WEB RDS" as a complex intervention with respondent-driven recruitment as the aim, we evaluated indicators of context, implementation, mechanisms of impact, and performance. We analyzed the data using a mixed methods approach that integrated findings from quantitative analysis, such as RDS diagnostics, and qualitative thematic analysis.

RESULTS

Sampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). A visual examination of the convergence and bottleneck plots indicates that many more waves of recruitment would be needed for population estimates to become independent of the seeds. However, producing further waves was impeded by challenges inherent to the research context and process. Men who have sex with men and their community organization representatives indicated that, in Belgium, men who have sex with men are overresearched, with low motivation for the topic of sexual health and digital etiquette dictating not sharing survey links. A moderate reward of €10-€30 (US $11.2-$33.6) with a dual incentive structure was insufficient to overcome these barriers.

CONCLUSIONS

This study indicates that WEB RDS, even with a moderate incentive, is not a viable sampling strategy for obtaining valid population estimates of sexual health traits of men who have sex with men in Belgium. The study emphasizes the need to understand men who have sex with men research motivation and topic saliency. Additionally, the study highlights the importance of digital etiquette. Finally, the study showcases the use of the adapted Medical Research Council framework for evaluating WEB RDS methodology.

Australian immigration detention health study protocol: a prospective, mixed-methods cohort study examining the physical and mental health of refugees and asylum seekers

INTRODUCTION

Globally, studies have consistently demonstrated the harmful mental and physical health impacts of immigration detention, with high levels of distress documented among detained asylum seekers and refugees (ASR). However, the consequences of immigration detention over time on the psychological and physical health of ASR are unclear and poorly quantified.

METHODS AND ANALYSIS

This prospective, mixed-methods cohort study will recurrently assess and describe the health profiles of adult ASR with an experience of Australian Government-sponsored immigration detention greater than 28 days. ASR ≥18 years old released from immigration detention will be assessed at 0, 3, 6 and 12 months and annually thereafter for up to 10 years, contingent on resourcing. Five self-report scales and a structured psychiatric interview will assess the primary outcome of depression, anxiety, post-traumatic stress, pain intensity and severity, somatic symptoms, functional impairment, physical health conditions associated with detention and engagement in available treatment of this cohort. Additionally, pre-existing health records will be accessed to identify current and previous health status and assess changes in these health indices. Quantitative findings will be triangulated with a qualitative phenomenological thematic analysis of interviews to determine additional psychosocial factors associated with the outcomes.

ETHICS AND DISSEMINATION

The study protocol was approved by the Monash Health Human Research Ethics Committee (HREC/73614/MonH-2021-251322). Results will be reported at conferences, in peer-reviewed publications and to all relevant stakeholder groups.

Growing up in the shadow of HIV: post-AIDS generation of HIV-negative men who have sex with men in Sweden and their perceptions of HIV and stigma

Despite growing understanding and acceptance of the concept of Undetectable = Untransmittable (U = U) among gay men, HIV stigma remains a burden for people living with HIV. This study explored perceptions of HIV among HIV seronegative gay men in Sweden in this new context. Using snowball sampling, 15 gay men born between 1980 and 2000 were recruited to the study. Semi-structured interviews were conducted and data were subjected to reflexive thematic analysis. Men grew up experiencing gay stigma and were repeatedly informed by parents, schools, communities, peers, and popular culture about the dangers of HIV, and that gay men were a high-risk group. As men grew older, and the premise of HIV shifted dramatically due to U = U, some remained emotionally anchored to the pre-U = U era, while others realigned their perceptions, often after a process of reconciling emotional responses (e.g. HIV = death) with the logical-rational claims made about U = U. The study highlights key areas for future efforts, namely establishing a balance between HIV education strategies and stigma reduction initiatives. Study findings underscore the need to care for the memory of those lost during the crisis years, while also addressing the stigma faced by those currently living with HIV.

Incorporating Epidemiological Data into the Genomic Analysis of Partially Sampled Infectious Disease Outbreaks

Pathogen genomic data are increasingly being used to investigate transmission dynamics in infectious disease outbreaks. Combining genomic data with epidemiological data should substantially increase our understanding of outbreaks, but this is highly challenging when the outbreak under study is only partially sampled, so that both genomic and epidemiological data are missing for intermediate links in the transmission chains. Here, we present a new dynamic programming algorithm to perform this task efficiently. We implement this methodology into the well-established TransPhylo framework to reconstruct partially sampled outbreaks using a combination of genomic and epidemiological data. We use simulated datasets to show that including epidemiological data can improve the accuracy of the inferred transmission links compared with inference based on genomic data only. This also allows us to estimate parameters specific to the epidemiological data (such as transmission rates between particular groups), which would otherwise not be possible. We then apply these methods to two real-world examples. First, we use genomic data from an outbreak of tuberculosis in Argentina, for which data was also available on the HIV status of sampled individuals, in order to investigate the role of HIV coinfection in the spread of this tuberculosis outbreak. Second, we use genomic and geographical data from the 2003 epidemic of avian influenza H7N7 in the Netherlands to reconstruct its spatial epidemiology. In both cases, we show that incorporating epidemiological data into the genomic analysis allows us to investigate the role of epidemiological properties in the spread of infectious diseases.

Inferring bivariate associations with continuous data from studies using respondent-driven sampling

Respondent-driven sampling (RDS) is a link-tracing sampling design that was developed to sample from hidden populations. Although associations between variables are of great interest in epidemiological research, there has been little statistical work on inference on relationships between variables collected through RDS. The link-tracing design, combined with homophily, the tendency for people to connect to others with whom they share characteristics, induces similarity between linked individuals. This dependence inflates the Type 1 error of conventional statistical methods (e.g. t-tests, regression, etc.). A semiparametric randomization test for bivariate association was developed to test for association between two categorical variables. We directly extend this work and propose a semiparametric randomization test for relationships between two variables, when one or both are continuous. We apply our method to variables that are important for understanding tuberculosis epidemiology among people who smoke illicit drugs in Worcester, South Africa.

Cost-effectiveness of health insurance among women engaged in transactional sex and impacts on HIV transmission in Cameroon: a mathematical model

INTRODUCTION

HIV prevalence disproportionately affects high-risk populations, particularly female sex workers in Africa. Women and girls engaging in transactional sex (WGTS) face similar health risks from unsafe practices, economic vulnerabilities and stigma. However, they are not recognised.

METHODS

Using existing literature and data from the POWER randomised controlled trial, we developed a deterministic compartmental model to assess HIV dynamics among WGTS, their sugar daddies and low-risk populations. We evaluated the cost-effectiveness of a new structural intervention to prevent HIV among WGTS in urban Cameroon by reducing the financial need to engage in transactional sex in the case of illness and injury shocks to the household. The intervention provided free healthcare to WGTS and their economic dependents through a zero-cost health insurance package. We explored the cost-effectiveness of this intervention considering various population coverage levels (0%, 25%, 50%, 75% and 100%). We calculated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life-year (DALY) and HIV infections averted, employing both univariable and global sensitivity analyses. Probabilistic sensitivity analyses considered all parameters, including the insurance effect in reducing HIV, comparing simulated ICERs to willingness-to-pay thresholds. We also compared the health insurance strategy with expanding pre-exposure prophylaxis (PrEP) coverage. All costs were evaluated in 2023 UK pounds (£) using a 3% discount rate, with Cameroon's gross domestic product (GDP) per capita recorded at £1239.

RESULTS

Implementing health insurance coverage levels of 25%, 50%, 75% and 100% yielded ICERs/DALY averted of £2795 (£2483-£2824), £2541 (£2370-£2592), £2263 (£2156-£2316) and £1952 (£1891-£1998), respectively, compared with 0% coverage. Probabilistic sensitivity analysis indicated an ICER=£2128/DALY averted at 100% coverage, with 58% of simulations showing ICERs

CONCLUSION

A comprehensive health insurance scheme for women in Cameroon could significantly reduce HIV infections and DALYs, promoting a more inclusive and targeted healthcare policy for women at high risk of HIV.

Collapse

Key Words

• HIV
• Health economics
• Health insurance
• Mathematical modelling

Collapse

MESH Headings

• Humans
• Cameroon/epidemiology
• HIV Infections/prevention & control
• HIV Infections/transmission
• HIV Infections/economics
• HIV Infections/epidemiology
• Cost-Benefit Analysis
• Female
• Sex Workers/statistics & numerical data
• Insurance, Health/economics
• Models, Theoretical
• Adult

Collapse

Grants

• MRC/ESRC
• Dr Aurélia Lépine

Collapse

Affiliation(s)

Kasim Allel University College London, London, UK Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
Henry Cust University College London, London, UK Duke University, Durham, North Carolina, USA
Iliassou Mfochive John Hopkins Cameroon Program, Yaounde, Cameroon
Sandie Szawlowski University College London, London, UK
Emile Nitcheu John Hopkins Cameroon Program, Yaounde, Cameroon
Eric Defo Tamgno John Hopkins Cameroon Program, Yaounde, Cameroon
Stephanie Moyoum John Hopkins Cameroon Program, Yaounde, Cameroon
Julienne Noo John Hopkins Cameroon Program, Yaounde, Cameroon
Serge Billong University of Yaounde, Yaoundé, Cameroon
Ubald Tamoufe John Hopkins Cameroon Program, Yaounde, Cameroon
Aurelia Lepine University College London, London, UK

Collapse

Healthcare access barriers and utilization among the Arab Bedouin population in Israel: a cross-sectional study

BACKGROUND

The Arab Bedouin Muslim minority in Israel, is one of the country's most vulnerable groups. They are residents of the Israeli geographical and social periphery. Bedouin's healthcare service utilization is shaped by its sociocultural and environmental characteristics. This study explores healthcare access barriers and utilization patterns among the Arab Bedouin population, focusing on two types of legal status locality: a legally recognized Bedouin town and the surrounding unrecognized villages.

METHODS

We conducted a cross-sectional study among Arab Bedouin adults (N = 246) residing in a Bedouin recognized town and unrecognized villages. Using an anonymous, self-administered questionnaire in Arabic. We collected information about healthcare visits, types of services accessed, access barriers and the factors influencing healthcare-seeking behavior. Multivariate linear regression was conducted to examine the predictors of healthcare services utilization.

RESULTS

Of the 246 participants, 60% resided in a recognized Bedouin town and 40% resided in unrecognized villages. Most participants were female (61%) and the mean age was 37.8 ± 13.9 years. The findings showed that barriers to seeking care differed based on the residence town's legal status. While residents of unrecognized villages face significant physical access barriers, they also show a notable reliance on cross-border healthcare providers, particularly in the Palestinian Authority. Chronic medical conditions (B = 1.147, p < 0.001), gender (B = -0.459, p < 0.01), and parental status (B = 0.667, p = 0.001) have been identified as strong predictors of healthcare service utilization.

CONCLUSION

This study offers new insights regarding the complexity of healthcare access and utilization in the Arab Bedouin population in Israel, emphasizing that barriers are not only structural but also deeply intertwined with cultural and linguistic factors. The study highlights the universal message of addressing both physical and systemic barriers to healthcare access, ensuring that healthcare services are culturally and linguistically tailored to the specific needs of marginalized populations locally and globally. These findings provide actionable insights for policymakers emphasizing the need to improve health equity by addressing the access barriers faced by the Arab Bedouin population, including structural, cultural, and linguistic challenges, and ensuring targeted interventions for marginalized communities both locally and globally.

Sero-Kinship: How Young People Living With HIV/AIDS Survive in Southeast Nigeria

Research on the lived experiences of HIV survivors, including young people living with HIV, has primarily emphasized broader sociocultural concerns, such as stigmatization and cultural attitudes toward sexuality and gender, while giving less attention to the interconnectedness of these issues with the mental well-being of those affected by the illness. This study, drawing on relational ethnography including observations and interviews at four antiretroviral-administering healthcare facilities in Enugu State, southeast Nigeria, explores how young people living with HIV strive toward viral suppression and how they develop collaborative psychosocial support along with the global efforts in eradicating the HIV epidemic. We found that, in and between themselves, young people living with HIV weave for themselves a network of relationships, though discreetly, to foster and encourage survivorship. Such relatedness, where mutual trust and support have emerged and rebuilt HIV survivors' faith in a livable life, forms what we conceptualize as "sero-kinship." That is, sero-kinship, which focuses on how people create and change meanings in their everyday lives that ultimately contribute to controlling HIV and treatment management, forms an essential foundation on which a life with HIV becomes thinkable, bearable, then manageable, and acceptable.

HIV and Hepatitis C Among People Who Inject Drugs in Memphis, Tennessee: an Intersectional Risk Environment Analysis of the Social Determinants of Health

BACKGROUND

The Southern US is confronting bourgeoning HIV and hepatitis C virus (HCV) epidemics among people who inject drugs (PWID), yet little is known about shared and unique risk factors across the region. We applied an intersectional risk environment framework to understand infectious disease outcomes for sub-groups of PWID that experience multiple axes of social marginalization related to racial and ethnic identity and social and economic vulnerability.

METHODS

HIV and HCV prevalence was estimated from the first iteration of the CDC's National HIV Behavioral Surveillance respondent driven sample of PWID in Shelby County, Tennessee in 2018. We ran adjusted multinomial models to test main and interaction effects of race/ethnicity and structural factors on the prevalence of a three-level outcome: HIV-only, HCV-only, and no infection.

RESULTS

A total of 564 PWID participated, 558 (99%) completed HIV testing, and 540 (96%) HCV testing. Thirty (5%) were HIV-positive, 224 (40%) HCV-positive, and less than 1% were co-infected. Descriptive differences by race/ethnicity and levels of structural vulnerability for HIV and HCV subpopulations were present; however, there was no evidence for statistical interaction. In the final main effects model, HIV status was positively associated with non-Hispanic Black identity (aRR 4.95, 95% CI 1.19, 20.6), whereas HCV status was associated with non-white identity (aRR 0.11 95% CI 0.07, 0.18). Factors associated with HCV infection were higher scores of structural vulnerability (aRR 2.19 95% CI 1.10, 4.35), and criminal legal involvement (aOR 1.99 95% CI 1.18, 3.37).

CONCLUSION

This is the first study to implement local population-based survey data to evaluate distinctive intersections of ethnic/racial and social factors associated with HIV and HCV status among PWID in the Memphis region. Findings come at an opportune time as harm reduction programs are in development in the South and shed light to the need for socially equitable race conscious resource investment.

Factors associated with the completion of syphilis treatment among transgender women and travestis, in five Brazilian capitals, 2019-2021: a multicenter cross-sectional study

OBJECTIVE

To assess the previous history of syphilis in transgender women and travestis (TWTs) and identify factors associated with treatment incompleteness.

METHODS

: This was a multicenter cross-sectional study conducted between 2019 and 2021, with participants recruited through respondent-driven sampling, in five Brazilian capitals. Dependent variable: "reported syphilis treatment in the last year", "no/incomplete" or "complete". A multivariate-logistic model was used to identify factors associated with completeness.

RESULTS

: Of the 1,317 participants, 16.0% reported previous history of syphilis. Of these, 68.9% were Black, 54.6% earned up to 1 minimum wage and 61.1% completed the treatment. Treatment completion was lower in São Paulo (42.7%) and among those who experienced verbal abuse (53.6%; ORa 0.46; 95%CI 0.25;0.85).

CONCLUSION

In this sample, both the prevalence of self-reported syphilis and the proportion of participants who reported not having started/completed treatment were high. It is essential to identify the barriers faced by TWTs that hinder healthcare access, and identify their needs in order to ensure adequate diagnosis and treatment.

MAIN RESULTS

Of the 16% of participants who reported a previous diagnosis of syphilis, only one-third completed the treatment. Residents of São Paulo were less likely to complete it compared to those from other cities, and those who had experienced verbal abuse.

IMPLICATIONS FOR SERVICES

There is a need for healthcare professionals to receive training focused on specific needs of TWTs , including respect for their social names, extended opening hours, point-of-care strategy and alternatives for the administration of intramuscular benzathine penicillin injections.

PERSPECTIVES

It is crucial to develop new, more effective therapeutic methods for syphilis treatment and deepen research on the impacts of discrimination and stigma on transgender women and travestis' access to healthcare, especially diagnosis and treatment of sexually transmitted infections.

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.

Feasibility and Acceptability of a Prospective Syphilis Sexual Network Study for Sexual Minority Men

BACKGROUND

In preparation for a prospective syphilis network study of sexual minority men, we conducted a mixed-methods formative study with the following objectives: ( a ) assess acceptability of respondent-driven sampling, ( b ) assess acceptability of study procedures, ( c ) social network seed selection, and ( d ) pilot an ecological momentary assessment (EMA) study to assess social networking, sexual, and substance use behaviors.

METHODS

We conducted in-depth interviews with 8 providers serving sexual minority men and 5 focus group discussions with 34 sexual minority men, prioritizing 4 target populations: (1) young Black sexual minority men, (2) on preexposure prophylaxis, (3) living with HIV, and (4) not engaged in care. The 4-week EMA pilot was conducted with 40 sexual minority men. Ecological momentary assessment survey responses were analyzed to evaluate how different compensation levels influenced response rates. Brief exit surveys were used to assess EMA app acceptability.

RESULTS

Primary themes identified through qualitative data collection: (1) importance of developing trust and maintaining confidentiality during proposed recruitment activities, (2) importance of compensating participants appropriately for study activities, and (3) cultural considerations for increasing visibility and participation of young Black sexual minority men. All EMA participants reported being "completely comfortable" reporting sexual behavior through the app. Most (78%) preferred the app to in-person interviews. Several participants identified technical issues with the app, including not receiving push notifications and spontaneous closure.

CONCLUSIONS

This mixed-methods formative study allowed for adjustments to and tailoring of the planned network study, including recruitment protocols, compensation type and amount, and EMA survey wording and response items.

'Public prostitutes and private prostitutes': A study of women's perceptions of transactional sex in Cameroon

CONTEXT

Although AIDS-related deaths continue to decline, there are more people living with HIV than ever before. Sub-Saharan Africa remains disproportionately affected by the epidemic, with women aged 15-24 being over three times as likely to acquire HIV than their male counterparts. One reason for this disparity is that those engaging in 'transactional sex' do not benefit from governmental HIV prevention efforts. Transactional sex is both less well understood than sex work and more common, suggesting the need for further research.

METHOD

To this end, we interviewed eighteen women engaging in transactional sex in Yaoundé, Cameroon using snowball sampling. Participants were recruited using respondent-driven sampling, with the help of a nongovernmental organisation that works with women engaging in transactional sex. The objective of this study is to understand how transactional sex differs from commercial sex according to women engaging in transactional sex.

RESULTS

We found that participants distinguished themselves from sex workers, but only in a limited sense. They referred to themselves as 'private prostitutes', meaning those who sell sex in all but name. 'Private prostitutes' avoid red-light districts and do not wear revealing clothing, but exchange sex for money all the same. They are no less profit-oriented than their 'public' counterparts (i.e., sex workers), reminding us that the two activities have a lot of similarities in as far as public health is concerned.

DISCUSSION

Women engaging in transactional sex would require equal attention than FSWs in terms of HIV prevention. Like FSWs, they have multiple sexual partners and unprotected sex. They should be considered a 'key population' for HIV prevention. This would improve public health outcomes, suggesting the need to target women engaging in transactional sex on a greater scale than previously attempted in Sub-Saharan Africa.

Adherence to and predictors of iron-folate acid supplementation among pregnant women in a pastoral population in Ghana: a community-based cross-sectional study

BACKGROUND

Iron-Folate Acid Supplementation (IFAS) interventions have been recognized globally as key in reducing the burden of anemia among pregnant women. However, adherence to and determinants of IFAS remain indistinct, as it is the main constraint with supplementation therapy, particularly among minority populations. Hence, this study sought to determine the adherence to and predictors of IFAS among nomadic Fulani pregnant women in the West Gonja Municipality of Ghana.

METHODS

A community-based cross-sectional design was employed to involve 130 respondents between February to July, 2022 in the West Gonja Municipality of Ghana. Fulani pregnant women aged 15-49 years, possessing maternal and child health record book and were given iron-folate supplements within 16 weeks and resided within the study area ≥ 6 months before/during the data collection period were included in the study. Multivariable logistic regression was used to determine independent predictors of IFAS using SPSS version 25.0 (p ≤ 0.05 deemed statistically significant across all models). ResultsUptake of and adherence to IFAS was 47.7% and 35.5% respectively. Major barriers to IFAS uptake were forgetfulness (25.7%) and unavailability (20.0%). About 65.4% of the respondents revealed poor knowledge of IFAS. Spousal occupation (AOR = 0.17, p = 0.010), spousal income (AOR = 4.125, p = 0.050) and knowledge on IFAS (AOR = 0.259, p = 0.039) were predictors of IFAS.

CONCLUSIONS

Poor adherence to and knowledge on IFAS were noted in the study and highlighted as a grave public health concern. Thus, nutrition and antenatal educational programs should give necessary attention to adherence to IFAS during pregnancy, particularly among nomadic and other vulnerable and minority populations to limit the burden of illnesses.

Self-reported lifetime Hepatitis B virus testing, and vaccination uptake among people who inject drugs in Iran: a nationwide study in 2020

BACKGROUND

Hepatitis B virus (HBV) infection is a silent epidemic among people who inject drugs (PWID). HBV testing and vaccination are important for PWID to reduce the risk of infection, prevent chronic complications and contribute to public health efforts in addressing HBV transmission. Our objective was to assess the self-reported lifetime uptake of HBV testing and vaccination among PWID in Iran and their associated factors.

METHOD

This cross-sectional study was conducted among 2,684 PWID in 11 large cities from July 2019 to March 2020 using a respondent-driven sampling method. Participants were interviewed face-to-face and asked about their lifetime experience of HBV testing and vaccination uptake as the outcome. Logistic regression models were built to identify related factors for reporting HBV testing and vaccination uptake.

RESULTS

The prevalence of HBV testing and vaccination uptake among PWID was 14.2% (95% confidence intervals [CI]: 12.8-15.6) and 16.4% (95% CI: 14.9-18.1), respectively. Shared needles, syringes, or equipment in the past 12 months decreased the odds of reporting lifetime HBV testing uptake (Adjusted odds ratio [AOR]:0.46, 95% CI: 0.29-0.72). However, having an academic education (AOR: 1.89, 95% CI: 1.09-3.30) and lifetime experience of homelessness (AOR: 1.58, 95% CI: 1.21-2.06) increased the odds of reporting lifetime HBV vaccination uptake.

CONCLUSION

Our study highlighted the low prevalence of HBV testing and vaccination uptake among PWID in Iran. It is essential to understand and address the obstacles preventing PWID from getting tested and vaccinated for HBV. Addressing these barriers could significantly reduce the burden of HBV among this socio-economically marginalized population.

The effect of protecting women against economic shocks to fight HIV in Cameroon, Africa: The POWER randomised controlled trial

BACKGROUND

Women in sub-Saharan Africa are disproportionately affected by the HIV epidemic. Young women are twice as likely to be living with HIV as men of the same age and account for 64% of new HIV infections among young people. Many studies suggest that financial needs, alongside biological susceptibility, are a leading cause of the gender disparity in HIV acquisition. New robust evidence suggests women adopt risky sexual behaviours to cope with economic shocks, the sudden decreases in household's income or consumption power, enhancing our understanding of the link between poverty and HIV. We investigated if health insurance protects against economic shocks, reducing the need for vulnerable women to engage in risky sexual behaviours and reducing HIV and sexually transmitted infection (STI) incidence.

METHOD AND FINDINGS

We conducted a randomised controlled trial to test the effectiveness of a formal shock coping strategy to prevent HIV among women at high risk of HIV (registration number: ISRCTN 22516548). Between June and August 2021, we recruited 1,508 adolescent girls and women over age 15 years who were involved in transactional sex (n = 753) or commercial sex (n = 755), using snowball sampling. Participants were randomly assigned (1:1) to receive free health insurance for themselves and their economic dependents for 12 months either at the beginning of the study (intervention; n = 579; commercial sex n = 289, transactional sex n = 290) from November 2021 or at the end of the study 12 months later (control; n = 568; commercial sex n = 290, transactional sex n = 278). We collected data on socioeconomic characteristics of participants. Primary outcomes included incidence of HIV and STIs and were measured at baseline, 6 months after randomisation, and 12 months after randomisation. We found that study participants who engaged in transactional sex and were assigned to the intervention group were less likely to become infected with HIV post-intervention (combined result of 6 months post-intervention or 12 months post-intervention, depending on the follow-up data available; odds ratio (OR) = 0.109 (95% confidence interval (CI) [0.014, 0.870]); p = 0.036). There was no evidence of a reduction in HIV incidence among women and girls involved in commercial sex. There was also no effect on STI acquisition among both strata of high-risk sexual activity. The main limitations of this study were the challenges of collecting reliable STI incidence data and the low incidence of HIV in women and girls involved in commercial sex, which might have prevented detection of study effects.

CONCLUSION

The study provides to our knowledge the first evidence of the effectiveness of a formal shock coping strategy for HIV prevention among women who engage in transactional sex in Africa, reinforcing the importance of structural interventions to prevent HIV.

TRIAL REGISTRATION

The trial was registered with the ISRCTN Registry: ISRCTN 22516548. Registered on 31 July 2021.

Using an anti-racist research framework to design studies of oral human papillomavirus and oropharyngeal cancer in San Francisco: rationale and protocol for the Health Equity and Oral Health in People living with HIV (HEOHP) qualitative study

INTRODUCTION

The goal of our research programme is to develop culturally appropriate patient-specific interventions for primary and secondary prevention of human papillomavirus (HPV)-related oropharyngeal cancer (OPC) among people living with HIV (PLWH); PLWH are at a higher risk for OPC than the general population and, as with many cancers, there are disparities in OPC health outcomes by race and ethnicity. Our study incorporates an anti-racist research framework that proposes considering racism as a foundational sociocultural system that causes ill health. We expand the framework to include biases due to gender, sexual orientation, HIV status and membership in other non-dominant groups. Our research programme focuses on HPV-related OPC among people living with PLWH, and on how intersecting identities may impact an individual's experience with oral health, obtaining regular and appropriate oral healthcare, knowledge and perceptions of oral HPV infection, risk factors for OPC and HPV vaccination.

METHODS AND ANALYSIS

We will follow a grounded theory (GT) qualitative research methodology using focus group discussions (FGDs) to collect data. We will invite PLWH with intersecting identities to participate in one of 12-18 FGDs with 5-8 participants per group. Focus groups will be formed based on self-reported domains, including race, ethnicity, gender identity, sexual orientation and other identities that could impact oral health, such as smoking status, experience with homelessness or experience with drug use disorders. We do not know which aspects of intersecting identities are most salient to accessing oral healthcare. Using FGDs will allow us to gain this knowledge in a setting where participants can build on and reinforce shared understandings about oral healthcare. Following our GT methodology, analysis will occur concurrently with data collection, and emerging concepts or theories may result in changes to focus group guide questions. Initial focus group questions will be organised around our main objectives: (1) to identify individual, interpersonal and structural health equity factors that serve as barriers or facilitators to oral health status and care; (2) to explore knowledge and perceptions about causes, risk factors, prevention and screening for oral or OPC and (3) to elicit recommendations for improving access to regular and appropriate oral healthcare and suggestions on engaging PLWH from diverse identity groups in prevention interventions.

ETHICS AND DISSEMINATION

All methods and procedures were approved by the University of California, San Francisco, Institutional Review Board (approval number: 23-39307) and are in accordance with the Declaration of Helsinki of 1975, as revised in 2000. Participants are required to provide informed consent. The results of this study will be presented at scholarly meetings and published in peer-reviewed journals. In addition, a lay summary of results will be created and distributed to our participants and community through our website and social media.

TRIAL REGISTRATION NUMBER

NCT06055868.

Syphilis infection prevalence in the Middle East and North Africa: a systematic review and meta-analysis

Background

Syphilis is a sexually transmitted infection (STI) that can be prevented and effectively treated; yet it continues to be a cause of morbidity and mortality worldwide. There is a limited understanding of the epidemiology of syphilis in the Middle East and North Africa (MENA) region.

Methods

A systematic review conducted up to April 30, 2024 assessed the prevalence of syphilis and followed PRISMA guidelines, without language and date restrictions. Syphilis infection was categorized based on the diagnostic test type, distinguishing between current and lifetime infections. Pooled mean prevalence estimates were determined through random-effects meta-analyses. Random-effects meta-regression analyses were conducted to investigate sources of heterogeneity between studies and identify factors associated with syphilis prevalence.

Findings

The review identified 643 studies based on close to 38 million syphilis tests in the 24 MENA countries. The pooled prevalence for probable current syphilis infection was 0.004% (95% CI: 0.001%-0.025%) among blood donors, 0.48% (95% CI: 0.22%-0.82%) in the general population (pregnant women and other general population groups), 2.76% (95% CI: 1.51%-4.35%) in populations at intermediate risk, 4.18% (95% CI: 2.08%-6.89%) among STI clinic attendees, 12.58% (95% CI: 8.45%-17.35%) among female sex workers, and 22.52% (95% CI: 12.73%-34.06%) among men who have sex with men and transgender people. Meta-regression analyses explained 62% of the prevalence variation and indicated a hierarchical pattern in prevalence by population group, higher prevalence among men, considerable subregional variability, and an annual decline of 3% in prevalence among general population groups and 8% among populations at high risk.

Interpretation

Syphilis prevalence in MENA is comparable to global levels, emphasizing a considerable yet often overlooked disease burden with implications for reproductive health and social well-being. The observed rate of decline in syphilis prevalence and the current response fall short of the global targets. Action is required to control syphilis and mitigate its impact, especially in most affected populations.

Funding

Qatar Research, Development, and Innovation Council (ARG01-0524-230273); Qatar National Research Fund (NPRP grant number 9-040-3-008).

The Development and the Assessment of Sampling Methods for Hard-to-Reach Populations in HIV Surveillance

Due to stigma or legal issues, populations with higher HIV risk are often hard to reach, which impedes accurate population estimation of HIV burden. To better sample hard-to-reach populations (HTRPs) for HIV surveillance, various sampling methods have been designed and/or used since HIV epidemic following the first reported AIDS cases in 1981. This paper describes the development and the assessment (i.e., validity and reproducibility) of approximately eight sampling methods (e.g., convenience sampling, snowball sampling, time location sampling, and respondent-driven sampling) for HTRPs in HIV surveillance, with a focus on respondent-driven sampling (RDS). Compared to other methods, RDS has been greatly assessed. However, current evidence is still inadequate for RDS to be considered the best option for sampling HTRPs. The field must continue to assess RDS and to develop new sampling approaches or modifications to existing approaches.

Recruiting Black and Latina/Hispanic Transgender Women for HIV Research: Implementation of Respondent-Driven Sampling and Factors Associated with Peer Recruitment

Purpose

We aim to examine if respondent-driven sampling (RDS) is a feasible and efficient method to recruit Black and Latina/Hispanic transgender women into HIV research.

Methods

As part of the National HIV Behavioral Surveillance Study among transgender women in New York City in 2019, RDS was implemented with a focus on recruiting Black and Latina/Hispanic transgender women. We identified factors independently associated with (1) peer recruitment and (2) presenting to the study with a photo coupon.

Results

A total of 269 transgender women were enrolled, 94% of whom were Black or Latina/Hispanic. In terms of peer recruitment, 47% recruited at least one eligible peer. Compared with those who were aged 18-29 years, those aged 30-39 years (adjusted prevalence ratio [aPR]: 2.04; 95% confidence interval [CI]: 1.35-3.07) and those aged 50 years or older (aPR: 1.97; 95% CI: 1.32-2.94) were more likely to recruit an eligible peer. Peer recruitment was also associated with utilizing HIV prevention services in the past 12 months (aPR: 1.62; 95% CI: 1.18-2.23). We did not find any differences in presenting the study with a photo recruitment coupon versus a physical recruitment coupon.

Conclusion

RDS was feasible and efficient in recruiting Black and Latina/Hispanic transgender women. Providing gender-affirming environments as well as allowing peer recruitment through photo coupons may have facilitated peer recruitment and study participation. Our findings regarding factors associated with peer recruitment could aid in future study design and may help in addressing the lack of HIV research among Black and Latina/Hispanic transgender women.

Using Respondent-Driven Sampling (RDS) to Identify the Healthcare Needs among Women of Reproductive Age Who Migrated from Venezuela to Brazil, 2018-2021

In 2021, an RDS survey was conducted among Venezuelan migrant women of reproductive age who migrated to two Brazilian cities (Manaus and Boa Vista) from 2018 to 2021. To start the RDS recruitment, we chose seeds non-randomly in both cities. The study variables were age, educational level, self-rated health, pregnancy, migratory status and use of health services. We estimated the prevalence, confidence intervals and homophily effects by variable category. We used a multivariate logistic regression model to identify the main factors associated with healthcare use. A total of 761 women were recruited in Manaus and 1268 in Boa Vista. Manaus showed more irregular migrants than Boa Vista. The main reasons for using health services were as follows: illness, disease prevention and prenatal care. The logistic regression model showed the use of health services was associated with educational level and healthcare needs but not with migratory status. The social inclusion of Venezuelan migrants is extremely relevant, although many challenges must be overcome. The strategy of the Brazilian Federal Government for providing humanitarian assistance to Venezuelan migrants should be expanded to include and facilitate their integration into labor markets, access to healthcare and education, benefiting both migrants and the Brazilian people by reducing social inequality.

Dynamics and features of transmission clusters of HIV-1 subtypes in the state of São Paulo, Brazil

Background

Molecular epidemiology techniques allow us to track the HIV-1 transmission dynamics. Herein, we combined genetic, clinical and epidemiological data collected during routine clinical treatment to evaluate the dynamics and characteristics of transmission clusters of the most prevalent HIV-1 subtypes in the state of São Paulo, Brazil.

Methods

This was a cross-sectional study conducted with 2,518 persons living with HIV (PLWH) from 53 cities in São Paulo state between Jan 2004 to Feb 2015. The phylogenetic tree of protease/reverse transcriptase (PR/RT) regions was reconstructed by PhyML and ClusterPicker used to infer the transmission clusters based on Shimodaira-Hasegawa (SH) greater than 90% (phylogenetic support) and genetic distance less than 6%.

Results

Of a total of 2,518 sequences, 2,260 were pure subtypes at the PR/RT region, being B (88%), F1 (8.1%), and C (4%). About 21.2% were naïve with a transmitted drug resistance (TDR) rate of 11.8%. A total of 414 (18.3%) of the sequences clustered. These clusters were less evident in subtype B (17.7%) and F1 (15.1%) than in subtype C (40.2%). Clustered sequences were from PLWH at least 5 years younger than non-clustered among subtypes B (p < 0.001) and C (p = 0.037). Men who have sex with men (MSM) predominated the cluster in subtype B (51%), C (85.7%), and F1 (63.6%; p < 0.05). The TDR rate in clustered patients was 15.4, 13.6, and 3.1% for subtypes B, F1, and C, respectively. Most of the infections in subtypes B (80%), C (64%), and F1 (59%) occurred within the state of São Paulo. The metropolitan area of São Paulo presented a high level of endogenous clustering for subtypes B and C. The São Paulo city had 46% endogenous clusters of subtype C.

Conclusion

Our findings showed that MSM, antiretroviral therapy in Treatment-Naive (ART-naïve) patients, and HIV1-C, played an important role in the HIV epidemic in the São Paulo state. Further studies in transmission clusters are needed to guide the prevention intervention.

Trends in HIV Prevalence, Sexual Behavior, and Pre-Exposure Prophylaxis Willingness Among Transgender Women: An Analysis of Three Cross-Sectional Studies Conducted Mainly in Shenyang, China, 2014-2019

Purpose

Although transgender women (TGW) bear the highest HIV burden worldwide, routine surveillance of this group is rare. We aimed to evaluate the trends in health characteristics of Chinese TGW.

Methods

Three cross-sectional studies using snowball sampling were conducted in 2014, 2017, and 2019, primarily in Shenyang, China. A questionnaire and voluntary HIV testing were used to obtain information on background characteristics, sexual behaviors, pre-exposure prophylaxis (PrEP) willingness, and HIV status.

Results

There were 220 respondents in 2014, 198 in 2017, and 247 in 2019 (average age 31.1±7.6 to 33.5±9.6 years). HIV prevalence significantly decreased from 29.5% (95% confidence interval [CI]: 25.3-38.4%) in 2014 to 19.4% (95% CI: 14.7-24.9%) in 2019 (p<0.05). The proportion of participants reporting condomless anal intercourse (CAI) with any partner fluctuated from 30.8% (95% CI: 25.1-36.1%) to 53.0% (95% CI: 45.8-60.1%). The proportion of participants willing to use PrEP decreased from 86.4% (95% CI: 81.1-90.6%) in 2014 to 62.8% (95% CI: 56.4-68.8%) in 2019. Factors significantly associated with HIV infection were CAI with any partner (multivariate odds ratio [ORm]: 3.58, 95% CI: 1.55-8.29 in 2017; ORm: 3.18, 95% CI: 1.56-6.46 in 2019) and PrEP willingness (ORm: 0.26, 95% CI: 0.12-0.58 in 2017).

Conclusion

HIV prevalence and associated risk factors remain substantial among Chinese TGW. There is an urgent need to strengthen HIV surveillance in this population, and develop trans-friendly and effective interventions to minimize HIV prevalence and transmission.

Acceptability and feasibility of tests for infection, serological testing, and photography to define need for interventions against trachoma

BACKGROUND

Trachoma causes blindness due to repeated conjunctival infection by Chlamydia trachomatis (Ct). Transmission intensity is estimated, for programmatic decision-making, by prevalence of the clinical sign trachomatous inflammation-follicular (TF) in children aged 1-9 years. Research into complementary indicators to field-graded TF includes work on conjunctival photography, tests for ocular Ct infection, and serology. The perceived acceptability and feasibility of these indicators among a variety of stakeholders is unknown.

METHODOLOGY

Focus group discussions (FGDs) with community members and in-depth interviews (IDIs) with public health practitioners in Tanzania were conducted. FGDs explored themes including participants' experience with, and thoughts about, different diagnostic approaches. The framework method for content analysis was used. IDIs yielded lists of perceived strengths of, and barriers to, implementation for programmatic use of each indicator. These were used to form an online quantitative survey on complementary indicators distributed to global stakeholders via meetings, mailing lists, and social media posts.

RESULTS

Sixteen FGDs and 11 IDIs were conducted in October-November 2022. In general, all proposed sample methods were deemed acceptable by community members. Common themes included not wanting undue discomfort and a preference for tests perceived as accurate. Health workers noted the importance of community education for some sample types. The online survey was conducted in April-May 2023 with 98 starting the questionnaire and 81 completing it. Regarding barriers to implementing diagnostics, the highest agreement items related to feasibility, rather than acceptability. No evidence of significant differences was found in responses pertaining to community acceptability based on participant characteristics.

CONCLUSIONS

All of the indicators included were generally deemed acceptable by all stakeholders in Tanzania, although community education around the benefits and risks of different sample types, as well as addressing issues around feasibility, will be key to successful, sustainable integration of these indicators into trachoma programs.

Prevalence of common risk factors of major noncommunicable diseases among sexual and gender minorities in Kathmandu valley, Nepal

Four noncommunicable diseases (NCDs): cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, account for 71% of global deaths. However, little is known about the NCDs risk profile of sexual and gender minorities (SGMs). This study aimed to determine the prevalence of NCDs risk factors among the SGMs of Kathmandu valley, Nepal. A cross-sectional study was conducted among SGMs in the Kathmandu valley, Nepal. We recruited 140 participants using the snowball sampling method. A face-to-face interview was done using a structured questionnaire adapted from World Health Organization Step Wise Approach to Surveillance (STEPS instruments V2.2 2019) along with blood pressure and anthropometric measurements. Data were analyzed using Statistical Package for Social Science (SPSS.v20). More than two-thirds of the participants, 96 (68.6%), had co-occurrence of NCDs risk factors. The prevalence of insufficient fruits and vegetables consumption, current smoking, harmful alcohol consumption, overweight/obesity, and hypertension were 95.7%, 40.0%, 32.9%, 28.5%, and 28.6%, respectively. There was a significant association between hypertension, harmful alcohol consumption, and overweight/obesity with the participants' age, employment status, and marital status, respectively. Study findings indicated a higher prevalence of NCDs risk factors among SGMs. National-level NCDs surveillance, policy planning, prevention, and targeted health interventions should prioritize the SGMs.

HIV stigma and other barriers to COVID-19 vaccine uptake among Georgian people living with HIV/AIDS: A mixed-methods study

We conducted a study in Georgia to examine behavioral insights and barriers to COVID-19 vaccine uptake among people living with HIV (PLWH). Between December 2021-July 2022, we collected quantitative data to evaluate participants' demographics, COVID-19 knowledge, attitude, perception, and HIV stigma as potential covariates for being vaccinated against COVID-19. We conducted a multivariate analysis to define the factors independently associated with COVID-19 vaccination among PLWH. We collected qualitative data to explore individual experiences of their positive or negative choices, main barriers, HIV stigma, and preferences for receiving vaccination. Of the total 85 participants of the study, 52.9% were vaccinated; 61.2% had concerns with the disclosure of HIV status at the vaccination site. Those who believed they would have a severe form of COVID-19 were more likely to be vaccinated (OR = 23.8; 95% CI: 5.1-111.7). The association stayed significant after adjusting for sex, age, education level, living area, health care providers' unfriendly attitudes, and their fear of disclosing HIV status at vaccination places. Based on the qualitative study, status disclosure was a significant barrier to receiving care; therefore, PLWH prefer to receive COVID-19 vaccination integrated in HIV services. Conclusions: In this study, around half of the participants were not vaccinated against COVID-19. The main reasons for not being vaccinated included stigma, misleading health beliefs, and low awareness about COVID-19. An integrated service delivery model may improve vaccination uptake among PLWH in Georgia.

Peers plus mobile app for treatment in HIV (PATH): protocol for a randomized controlled trial to test a community-based integrated peer support and mHealth intervention to improve viral suppression among Hispanic and Black people living with HIV

BACKGROUND

Significant disparities continue to exist in the HIV care continuum, whereby Hispanic and Black people living with HIV (PLWH) are less likely to achieve viral suppression compared to their White counterparts. Studies have shown that intervention approaches that involve peer navigation may play an important role in supporting patients to stay engaged in HIV care. However, implementation may be challenging in real-world settings where there are limited resources to support peer navigators. Combining a peer navigation approach with scalable mobile health (mHealth) technology may improve impact and implementation outcomes.

METHODS

We combined a peer navigation intervention with a mHealth application and are conducting a randomized controlled trial (RCT) to test the efficacy of this integrated "Peers plus mobile App for Treatment in HIV" (PATH) intervention to improve HIV care engagement, and ultimately sustained viral suppression, among Hispanic and Black PLWH. We will enroll up to 375 PLWH into a two-arm prospective RCT, conducting follow-up assessments every 3 months up to 12 months post-baseline. Participants randomized to the control arm will continue to receive usual care Ryan White Program case management services. Individuals randomized to receive the PATH intervention will receive usual care plus access to two main intervention components: (1) a peer navigation program and (2) a mHealth web application. The primary outcome is sustained HIV viral suppression (undetectable viral load observed at 6- and 12-month follow-up). Secondary outcomes are retention in HIV care, gaps in HIV medical visits, and self-reported ART adherence. Recruitment for the RCT began in November 2021 and will continue until June 2024. Follow-up assessments and medical chart abstractions will be conducted to collect measurements of outcome variables.

DISCUSSION

The efficacy trial of PATH will help to fill gaps in our scientific understanding of how a combined peer navigation and mHealth approach may produce effects on HIV care outcomes while addressing potential implementation challenges of peer navigation in Ryan White-funded clinics.

TRIAL REGISTRATION

The PATH trial is registered at the United States National Institutes of Health National Library of Medicine (ClinicalTrials.gov) under ID # NCT05427318 . Registered on 22 June 2022.

The Dark Tetrad: analysis of profiles and relationship with the Big Five personality factors

The Dark Tetrad (DT) is composed of the traits of Narcissism, Machiavellianism, Psychopathy, and Sadism. Most studies analyzing the DT have employed a variable-centered approach, analyzing the traits separately. In the present study, we treat DT as a whole, adopting a person-centered approach. We analyzed different homogeneous subgroups of individuals characterized by specific DT profiles, aiming to examine their relationship with Big Five personality factors. A sample of 1149 participants (50.1% women, 18-79 years) completed The Short Dark Triad and the Assessment of Sadistic Personality instrument to assess DT, while the Mini-IPIP was used to assess the Big Five personality factors. Cluster analysis yielded five groups: Narcissism, Machiavellianism, Mean DT, Low DT, and High DT group. The main results showed that the High DT group was distinguished by higher levels of extraversion and lower levels of agreeableness and conscientiousness (compared with the Low DT group). Moreover, the Narcissism group was characterized by higher scores on emotional stability, openness to experience, and extraversion. Finally, distribution according to gender varied across DT groups (more men than women in the High DT group and the opposite in the Low DT group). Limitations and future lines of research are discussed.

Impact of COVID-19 on the mental health of adolescents and youth in Nairobi, Kenya

Objective

To report on the mental health status of adolescents and youth in relation to the COVID-19 pandemic in Nairobi County, Kenya.

Methodology

This was a mixed-methods study with cross-sectional quantitative and qualitative components conducted in Nairobi County, Kenya from August to September 2020. The quantitative survey involved phone interviews of n = 1,217 adolescents and youth. Qualitative components included virtual focus group discussions (FGDs) with adolescents and youth (n = 64 unmarried youths aged 16-25 years, across 8 FGDs) and youth-serving stakeholders (n = 34, across 4 FGDs), key informant interviews (n = 12 higher-level stakeholders from Ministries of Health, Gender, and Education), and in-depth interviews with youth (n = 20) so as to examine the COVID-19 impact on mental health.

Results

Among the participants, 26.6% of young men and 30.0% of young women reported probable depressive symptoms, of whom 37.7% of young men and 38.9% of young women reported little interest or pleasure in doing various activities. Hopelessness and feeling down nearly every day was additionally reported by 10.7% of young women and 6.3% of young men. Further, about 8.8% of young men and 7.6% of young women reported they could not get the emotional help and support they may need from people in their life. Multivariable regression results showed an association between depressive symptoms and reduced working hours due to COVID-19 and increased intimate partner violence. Additionally, the results show that respondents with higher emotional help and support were less likely to report depressive symptoms. Qualitative results confirm the quantitative findings and exemplify the negative behavior arising from the impact of adherence to COVID-19 prevention measures.

Conclusion

Mental health issues were common among adolescents and youth and may have been augmented by isolation and economic hardships brought about by COVID-19 restrictions. There is a need for concerted efforts to support adolescents and young people to meet their mental health needs, while considering the unique variations by gender. There is need to urgently strengthen the mental health system in Kenya, including via integrating psychosocial support services in communities, schools, and healthcare services, to ensure adolescents and young persons are not left behind.

Surgical leadership in a culture of safety: An inter-professional study of metrics and tools for improving clinical practice

BACKGROUND

Leadership in a safety culture environment is essential in avoiding patient harm. However, leadership in surgery is not routinely taught or assessed. This study aims to identify a framework, metrics and tools to improve surgical leadership and safety outcomes.

METHODS

Qualitative interviews were performed with leadership experts from safety-critical professions. Non-probability-based sampling was undertaken in major international airlines. Data underwent thematic analysis and clinical adaptation by multiple surgeon-analysts using the framework method.

RESULTS

583 codes were synthesised into 10 themes. Leaders were identified as 'threat and error managers' who placed safety first. Their core attribute was humble confidence. This allowed them to set the tone for high standards of practice, whilst empowering individuals to speak up about safety issues. Safety-oriented leaders assumed complete responsibility and applied their authority discerningly to obtain optimal outcomes. Finally, effective leaders rallied support for their mission by instilling confidence, building collaborations and managing conflict.

CONCLUSIONS

Surgical leadership requires the ability to manage risk, opportunity and people. The study provides an assessment matrix and deliverable tools for improving surgical safety.

Overview and Methodology of the National HIV Behavioral Surveillance Among Transgender Women - Seven Urban Areas, United States, 2019-2020

Transgender women, especially transgender women of color, are disproportionately affected by HIV. However, no surveillance system collects data on HIV risk factors among this population. To address this gap, CDC developed a surveillance system entitled National HIV Behavioral Surveillance Among Transgender Women (NHBS-Trans) to assess behavioral and contextual data through systematic biobehavioral surveillance to monitor behavioral risk factors, prevention usage, and HIV prevalence among transgender women. NHBS-Trans used respondent-driven sampling in seven urban areas in the United States. Trained interviewers used a standardized, anonymous questionnaire to collect information on HIV-related behavioral risk factors, HIV testing, and use of prevention services. Each of the seven participating project areas recruited approximately 200 eligible transgender women and offered anonymous HIV testing. Overall, in the seven project areas, 1,757 participants completed the eligibility screener for NHBS-Trans during 2019-2020; of these, 6.6% were seeds (i.e., a limited number of initial participants who were chosen by referrals from persons and community-based organizations who knew or were part of the local population of transgender women). A total of 1,637 (93.2%) participants were eligible, consented, and completed the interview. Of these, 1,624 (99.2%) agreed to HIV testing. Of the total 1,637 participants, 29 participants did not report identity of woman or transgender woman, resulting in a final sample of 1,608 transgender women. NHBS-Trans project area staff members (n = 14) reported that the survey was timely and addressed a critical need for HIV surveillance in a population that is often overlooked. The MMWR supplement includes this overview report on NHBS-Trans, which describes the methods (history, participant eligibility criteria, questionnaire, data collection, and HIV testing) as well as evaluation of project implementation and the performance of the questionnaire content, specifically the acceptability for transgender women. The other NHBS-Trans reports in the supplement include information on pre-exposure prophylaxis use, psychosocial syndemic conditions and condomless anal intercourse, nonprescription hormone use, homelessness, discrimination and the association between employment discrimination and health care access and use, and social support and the association between certain types of violence and harassment (gender-based verbal and physical abuse or harassment, physical intimate partner abuse or harassment, and sexual violence) and suicidal ideation. NHBS-Trans provides important data related to the goals of the Ending the HIV Epidemic in the U.S. initiative. Findings from NHBS-Trans can help guide community leaders, clinicians, and public health officials in improving access to and use of HIV prevention and treatment services by transgender women.

Ethno-racial variations in mental health symptoms among sexually-active gay, bisexual, and other men who have sex with men in Vancouver, Canada: a longitudinal analysis

BACKGROUND

Minority stress from racism and heterosexism may uniquely interact to impact the mental health of racialized sexual minorities. We examined variations in anxiety and depressive symptoms by reported by ethno-racial identity among gay, bisexual, and other men who have sex with men (gbMSM) in Vancouver, Canada.

METHODS

We recruited gbMSM aged ≥ 16 years from February 2012 to February 2015 using respondent-driven sampling (RDS). Participants completed computer assisted self-interviews (CASI) at enrollment and every 6 months until February 2017. We examined factors associated with moderate/severe anxiety and depression scores (> 10) on the Hospital Anxiety and Depression Scale (HADS) and differences in key explanatory variables including sociodemographic, psychosocial, and substance use factors. We used multivariable mixed effects models to assess whether moderate/severe scores were associated with ethno-racial identity across all visits.

RESULTS

After RDS-adjustment, of 774 participants, 79.9% of participants identified as gay. 68.6% identified as white, 9.2% as Asian, 9.8% as Indigenous, 7.3% as Latin American, and 5.1% as other ethno-racial identities. Participants contributed a median of 6 follow-up visits (Q1-Q3: 4-7). In the multivariable analysis, Asian participants had decreased odds of moderate/severe anxiety scores compared to white participants (aOR = 0.39; 95% CI: 0.18-0.86), and Latin American participants had decreased odds of moderate/severe depression scores compared to both white (aOR = 0.17; 95% CI: 0.08-0.36) and Asian (aOR = 0.07; 95% CI: 0.02-0.20) participants.

CONCLUSION

Asian and Latino gbMSM reported decreased mental health symptoms compared to white participants. Asian and Latino gbMSM in Vancouver appear to manage multiple minority stressors without adversely affecting their mental health.

The Concordance of Electronic Health Record Diagnoses and Substance use Self-Reports Among Reproductive Aged Women Enrolled in a Community-Based Addiction Reduction Program

Substance use disorders among reproductive aged women are a major public health issue. There is little work investigating the validity and reliability of electronic health record (EHR) data for measuring substance use in this population. This study examined the concordance of self-reported substance use with clinical diagnoses of substance use, substance abuse and substance use disorder in EHR data. Reproductive age women enrolled in the Community-Based Addiction Reduction (CARE) program were interviewed by peer recovery coaches (PRC) at enrollment. That survey data was linked with EHR data (n = 102). Concordance between self-reported substance use and clinical diagnoses in the EHR was examined for opioids, cannabis/THC, and cocaine. Cohen's kappa, sensitivity, and specificity were calculated. The survey captured a higher number of women who use substances compared to the EHR. The concordance of self-report with EHR diagnosis varied by substance and was higher for opioids (17.6%) relative to cannabis/THC (8.8%), and cocaine (3.0%). Additionally, opioids had higher sensitivity (46.2%) and lower specificity (76.2%) relative to cannabis/THC and cocaine. Survey data collected by PRCs captured more substance use than EHRs, suggesting that EHRs underestimate substance use prevalence. The higher sensitivity and lower specificity of opioids was due to a larger number of women who had a diagnosis of opioid use in the EHR who did not self-report opioid use in the self-report survey relative to cannabis/THC and cocaine. Opioid self-report and diagnosis may be influenced by research setting, question wording, or receipt of medication for opioid use disorder.

Characterizing prescription opioid, heroin, and fentanyl initiation trajectories: A qualitative study

We understand the current crisis of overdose deaths to be driven by widespread opioid use, characterized by distinct 'waves' of drug use. The first wave was driven by prescription opioids, the second by heroin, and the third by illicit, non-pharmaceutical fentanyl and fentanyl analogues (henceforth, fentanyl). The purpose of this study is to describe opioid initiation within each of the three waves from the perspective of people who use illicit opioids, with a focus on emerging pathways into fentanyl use. The authors recruited sixty people reporting past-30-day illicit opioid use in Dayton, Ohio. Participants completed a brief survey and a semi-structured in-depth qualitative interview, conducted from March to November 2020 with a total of 13 in-person and 47 virtual interviews. The qualitative interviews were transcribed in their entirety and analyzed thematically using NVivo 12. We noted supply-side changes as influencing trajectories in all three waves. However, we also noted differences in the experiences of prescription opioid and heroin initiation, with these trajectories influenced by pharmacological effects, pain management, curiosity, intergenerational use, pricing, and peers. In comparison, most participants were unaware that they were initiating fentanyl, and many reported overdosing with their first use of fentanyl. We identified a trajectory into fentanyl with limited to no prior heroin use among a few participants. The increased risk of overdose with initiation into fentanyl use further emphasizes the need for an expansion of naloxone distribution and the implementation of more comprehensive measures, such as overdose prevention centers, drug testing, and a safer supply. Further research on the dynamics of the ongoing overdose death crisis in the era of fentanyl and the 4th wave of the overdose crisis is critical in developing responsive prevention and intervention strategies.

Trading HIV for sheep: Risky sexual behavior and the response of female sex workers to Tabaski in Senegal

We use a cohort of female sex workers (FSWs) in Senegal to show how large anticipated economic shocks lead to increased risky sexual behavior. Exploiting the exogenous timing of interviews, we study the effect of Tabaski, the most important Islamic festival celebrated in Senegal, in which most households purchase an expensive animal for sacrifice. Condom use, measured robustly via the list experiment, falls by between 27.3 percentage points (pp) (65.5%) and 43.1 pp (22.7%) in the 9 days before Tabaski, or a maximum of 49.5 pp (76%) in the 7 day period preceding Tabaski. The evidence suggests the economic pressures from Tabaski are key to driving the behavior change observed through the price premium for condomless sex. Those most exposed to the economic pressure from Tabaski were unlikely to be using condoms at all in the week before the festival. Our findings show that Tabaski leads to increased risky behaviors for FSWs, a key population at high risk of HIV infection, for at least 1 week every year and has implications for FSWs in all countries celebrating Tabaski or similar festivals. Because of the scale, frequency, and size of the behavioral response to shocks of this type, policy should be carefully designed to protect vulnerable women against anticipated shocks.

More than mateship: exploring how Australian male expatriates, longer-term and frequent travellers experience social support

PURPOSE

Those travelling overseas for work or leisure including male expatriates, longer-term and frequent travellers (ELoFTs) may be at heightened risk for a range of health and wellbeing issues. Social support may mediate this risk. However, from a public health perspective, little is written about how ELoFTs access health information and support and the role of their social networks in facilitating health and wellbeing outcomes. This research was part of a study examining social network processes of Australian male ELoFTs travelling, living, or working in Southeast Asia (SEA).

METHODS

Symbolic Interactionism and Grounded Theory were the conceptual framework and methodology supporting semi-structured, in-depth interviews (n = 25) conducted in Australia and Thailand with Australian male ELoFTs to SEA, aged 18 years or older.

RESULTS

Findings highlight supports that assist ELoFT transition and adjustment to country of destination or manage their transnational experience. Influential places, people, and points in the migration journey mediated engagement with social support.

CONCLUSIONS

ELoFT social networks and the support provided within them may provide a mechanism for intervention across a range of public health issues. Findings may support the development of policy and practice across industries charged with supporting successful ELoFT adjustment.

National health surveys: overview of sampling techniques and data collected using complex designs

This article aimed to present an overview of national health surveys, sampling techniques, and components of statistical analysis of data collected using complex sampling designs. Briefly, surveys aimed at assessing the nutritional status of Brazilians and maternal and child health care were described. Surveys aimed at investigating access to and use of health services and funding, those aimed at surveillance of chronic noncommunicable diseases and associated behaviors, and those focused on risk practices regarding sexually transmitted infections were also addressed. Health surveys through social networks, including online networks, deserved specific attention in the study. The conclusion is that the development of health surveys in Brazil, in different areas and using different sampling methodologies, has contributed enormously to the advancement of knowledge and to the formulation of public policies aimed at the health and well-being of the Brazilian population.

The contribution of active case detection to malaria elimination in Thailand

INTRODUCTION

Thailand's malaria surveillance system complements passive case detection with active case detection (ACD), comprising proactive ACD (PACD) methods and reactive ACD (RACD) methods that target community members near index cases. However, it is unclear if these resource-intensive surveillance strategies continue to provide useful yield. This study aimed to document the evolution of the ACD programme and to assess the potential to optimise PACD and RACD.

METHODS

This study used routine data from all 6 292 302 patients tested for malaria from fiscal year 2015 (FY15) to FY21. To assess trends over time and geography, ACD yield was defined as the proportion of cases detected among total screenings. To investigate geographical variation in yield from FY17 to FY21, we used intercept-only generalised linear regression models (binomial distribution), allowing random intercepts at different geographical levels. A costing analysis gathered the incremental financial costs for one instance of ACD per focus.

RESULTS

Test positivity for ACD was low (0.08%) and declined over time (from 0.14% to 0.03%), compared with 3.81% for passive case detection (5.62%-1.93%). Whereas PACD and RACD contributed nearly equal proportions of confirmed cases in FY15, by FY21 PACD represented just 32.37% of ACD cases, with 0.01% test positivity. Each geography showed different yields. We provide a calculator for PACD costs, which vary widely. RACD costs an expected US$226 per case investigation survey (US$1.62 per person tested) or US$461 per mass blood survey (US$1.10 per person tested).

CONCLUSION

ACD yield, particularly for PACD, is waning alongside incidence, offering an opportunity to optimise. PACD may remain useful only in specific microcontexts with sharper targeting and implementation. RACD could be narrowed by defining demographic-based screening criteria rather than geographical based. Ultimately, ACD can continue to contribute to Thailand's malaria elimination programme but with more deliberate targeting to balance operational costs.

Validation of the Patient Health Questionnaire-9 for Suicide Screening in Transgender Women

Purpose

High prevalence of depression in transgender women highlights the importance of validating the measure to assess depression. Moreover, depression is significantly associated with suicide across research studies. The aims of the current study were to validate a Chinese-language version of the Patient Health Questionnaire-9 (PHQ-9) and to assess operating characteristics of the PHQ-9 for suicide screening in transgender women.

Methods

With the approval of an Institutional Review Board (IRB), a total of 198 transgender women living in Shenyang, China, were recruited, and asked to complete the PHQ-9, including measures of their suicidal ideation, planning and attempt.

Results

A one-factor model of the PHQ-9 was supported in the current sample, showing good reliability and validity. The best cutoff point for the PHQ-9 in suicidal ideation was 17, with a sensitivity/specificity of 77.78%; the best cutoff point for PHQ-9 in suicidal planning was 17, with a sensitivity of 81.82% and a specificity of 73.26%; and the best cutoff point for PHQ-9 in suicidal attempt was 20, with a sensitivity of 75% and a specificity of 90.21%.

Conclusion

Findings supported the validity of the PHQ-9. With potential clinical or research application, the PHQ-9 can be an efficient instrument for suicide screening in transgender women.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

BACKGROUND

Adverse socio-cultural factors compromise the implementation of HIV prevention strategies among displaced youth. While condoms are an affordable and effective HIV prevention strategy for youth, stigma and inequitable gender norms may constrain condom self-efficacy (i.e., knowledge, intentions, and relationship dynamics that facilitate condom negotiation) and use. Further, knowledge of contextually appropriate HIV prevention approaches are constrained by limited understanding of the socio-cultural conditions that affect condom self-efficacy and use among displaced youth. Guided by syndemics theory, we examine independent and joint effects of adverse socio-cultural factors associated with condom self-efficacy and use among displaced youth living in urban slums in Kampala, Uganda.

METHODS

We conducted a community-based cross-sectional survey of displaced youth aged 16-24 years living in five slums in Kampala. We used multivariable logistic regression and multivariate linear regression to assess independent and two-way interactions among adverse socio-cultural factors (adolescent sexual and reproductive health-related stigma [A-SRH stigma], perceived HIV-related stigma, and beliefs in harmful inequitable gender norms) on condom self-efficacy and recent consistent condom use. We calculated the prevalence and co-occurrence of adverse socio-cultural factors; conducted regression analyses to create unique profiles of adverse socio-cultural factors; and then assessed joint effects of adverse socio-cultural factors on condom self-efficacy and practices.

RESULTS

Among participants (mean age: 19.59 years; SD: 2.59; women: n = 333, men: n = 112), 62.5% were sexually active. Of these, only 53.3% reported recent consistent condom use. Overall, 42.73% of participants reported two co-occurring adverse socio-cultural factors, and 16.63% reported three co-occurring exposures. We found a joint effect of beliefs in harmful inequitable gender norms with high A-SRH stigma (β = - 0.20; p < 0.05) and high A-SRH stigma with high perceived HIV stigma (β = - 0.31; p < 0.001) on reduced condom self-efficacy. We found a multiplicative interaction between high A-SRH stigma with high perceived HIV stigma (aOR = 0.52; 95% CI 0.28, 0.96) on recent consistent condom use. Additionally, we found that condom self-efficacy (aOR = 1.01; 95% CI 1.05, 1.16) and safer sexual communication (aOR = 2.12; 95% CI 1.54, 2.91) acted as protective factors on inconsistent condom use.

CONCLUSIONS

Displaced youth living in urban slums exhibited low consistent condom use. Intersecting stigmas were associated with lower condom self-efficacy-a protective factor linked with increased consistent condom use. Findings highlight the importance of gender transformative and intersectional stigma reduction approaches to increase sexual agency and safer sex practices among Kampala's slum-dwelling displaced youth.

Victimization among adolescents of female sex workers: findings from the children of at-risk parents (CARP) study in Uganda

BACKGROUND

Female sex workers (FSWs) live and work in high-risk environments, experience high levels of adversity, and have multigenerational trauma that can negatively affect their children. Yet not much is known about the prevalence of victimization (i.e., exposure to maltreatment and trauma) among children of FSWs. This study compared the prevalence of lifetime victimization among adolescents of FSWs and adolescents of non-FSWs in Gulu City, Northern Uganda.

METHODS

A comparative cross-sectional study was conducted among adolescents (10-17 years) enrolled in the Children of At-Risk Parents (CARP) study. This study included 147 adolescents of FSWs and 147 adolescents of non-FSWs selected for comparison in Gulu City, Northern Uganda. The adolescents of FSWs were identified through their mothers using respondent-driven sampling. Data on the residence of FSWs guided a proportionate stratified sampling of adolescents of non-FSWs. Using the Juvenile Victimization Questionnaire, we screened for 34 different types of victimization during participants' lifetimes. Percentage point differences within groups of adolescents and comparison between adolescents of FSWs and non-FSWs were calculated using STATA version 14.1. Statistical significance was set to p < 0.05.

RESULTS

99.3% of the participants experienced at least one form of lifetime victimization. The median number of lifetime victimizations was 12.4. Overall, lifetime victimization was higher among adolescents of FSWs than non-FSWs (13.4 vs. 11.5), male vs. female adolescents (13.4 vs. 11.9), and older [14-17 years] vs. younger (10-13 years) adolescents (14.0 vs. 11.7). Further, more adolescents of FSWs experienced lifetime victimization in the following domains and subdomains, all of which were statistically significant: kidnap (15.8% vs. 4.8%), emotional abuse (65.8% vs. 50.0%), emotional neglect (37.4% vs. 21.1%), physical intimidation (10.2% vs. 4.1%), relational aggression (36.4% vs. 18.4%), verbal aggression (68.7% vs. 46.9%), sexual victimization (31.3% vs. 17.7%), verbal sexual harassment (20.4% vs. 5.4%), exposure to murder scene (42.9% vs. 26.5%), witness to domestic violence (39.5% vs. 26.5%), and witness to the murder of relatives (31.3% vs. 21.1%). Conversely, more adolescents of non-FSWs experienced caregiver victimization than the adolescents of FSWs (98.0 vs. 92.5; p < 0.05).

CONCLUSIONS

Childhood victimization is highly prevalent in Northern Uganda and disproportionately affects the adolescents of FSWs. Therefore, government and development partners should urgently develop policies and interventions targeting prevention, early detection, and timely management of victimization in this vulnerable population.

Black Women's Perceptions Towards Infant and Child Male Circumcision

OBJECTIVE

The objective of this article was to analyse women's perceptions of ICMC and to propose a framework for ICMC decision-making that can inform ICMC policies.

METHOD

Using qualitative interviews, this study investigated twenty-five Black women's perceptions of ICMC decisionmaking in South Africa. Black women who had opted not to circumcise their sons, were selected through purposive and snowball sampling. Underpinned by the Social Norms Theory, their responses were analysed through in-depth interviews and a framework analysis. We conducted the study in the townships of Diepsloot and Diepkloof, Gauteng, South Africa.

RESULTS

Three major themes emerged: medical mistrust, inaccurate knowledge leading to myths and misconceptions, and cultural practices related to traditional male circumcision. Building Black women's trust in the public health system is important for ICMC decision-making.

CONCLUSIONS FOR PRACTICE

Policies should address misinformation through platforms that Black women share. There should be an acknowledgement of the role that cultural differences play in the decision-making process. This study developed an ICMC perception framework to inform policy.

Fertility and contraceptive dynamics amidst COVID-19: who is at greatest risk for unintended pregnancy among a cohort of adolescents and young adults in Nairobi, Kenya?

OBJECTIVES

Among youth in Nairobi, we (1) characterised fertility and contraceptive use dynamics by gender; (2) estimated pregnancy prevalence over the pandemic; and (3) assessed factors associated with unintended pandemic pregnancy for young women.

DESIGN

Longitudinal analyses use cohort data collected at three timepoints prior to and during the COVID-19 pandemic: June to August 2019 (pre-pandemic), August to October 2020 (12-month follow-up) and April to May 2021 (18-month follow-up).

SETTING

Nairobi, Kenya.

PARTICIPANTS

At initial cohort recruitment, eligible youth were aged 15-24 years, unmarried and residing in Nairobi for at least 1 year. Within-timepoint analyses were restricted to participants with survey data per round; trend and prospective analyses were restricted to those with complete data at all three timepoints (n=586 young men, n=589 young women).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes comprised fertility and contraceptive use for both genders, and pregnancy for young women. Unintended pandemic pregnancy (assessed at 18-month follow-up) was defined as a current or past 6-month pregnancy with intent to delay pregnancy for more than 1 year at 2020 survey.

RESULTS

While fertility intentions remained stable, contraceptive dynamics varied by gender-young men both adopted and discontinued coital-dependent methods, whereas young women adopted coital-dependent or short-acting methods at 12-month follow-up (2020). Current pregnancy was highest at 2020 (4.8%), and approximately 2% at 2019 and 2021. Unintended pandemic pregnancy prevalence was 6.1%, with increased odds for young women recently married (adjusted OR (aOR)=3.79; 95% confidence interval (CI) 1.83-7.86); recent contraceptive use was protective against unintended pandemic pregnancy (aOR=0.23; 95% CI 0.11-0.47).

CONCLUSIONS

Current pregnancy in Nairobi was highest at the height of the COVID-19 pandemic (2020), and subsided to pre-pandemic levels by 2021 data collection; however, requires further monitoring. New marriages posed considerable risk for unintended pandemic pregnancy. Contraceptive use remains a crucial preventive strategy to averting unintended pregnancy, particularly for married young women.

Associations between HIV stigma, gender, and depression among people living with HIV in Hyderabad, India

The goal of this study was to explore the association between HIV stigma and depression and whether gender moderated this relationship. The theoretical framework for the study combined an adapted version of Goffman's conceptualization of stigma with gender role theory. We surveyed 150 individuals living with HIV in Hyderabad, India (51 cisgender women, 49 cisgender men, and 50 third gender people) on their experiences with HIV stigma. While third gender people had statistically higher scores for HIV stigma over their cisgender counterparts, the association between each of three different forms of stigma (internalized stigma, perceived stigma, and experienced stigma) on depression was negatively moderated by third gender status. This demonstrates that third gender research participants who experienced certain forms of HIV stigma were less likely to be depressed than cisgender participants. These findings indicate resilience amongst third gender people living with HIV and can be used to better tailor social policies and gender-affirming HIV care programs in south India.

Atypical Sexual Interests in Compulsive Sexual Behavior: Results From a Phallometric Study

The link between Compulsive Sexual Behavior (CSB) and atypical sexual interests is elusive. This study aimed to provide preliminary insights into the relationship between both aspects. The study sample comprised 61 self-identified straight men. CSB was measured through a composite self-report index assessing symptoms of CSB, whereas sexual interests -atypical and normophilic- were assessed objectively through penile plethysmography. The CSB index had small, non-significant correlation with greater sexual response to different sexual stimuli (r_{general sexual responsiveness}=.127 [95% CI: -.137, .384]). In terms of overall sexual interest, increased scores on the CSB index had small, non-significant correlation with a higher preference for younger sexual stimuli (r = -.098 [95% CI: -.499, .215]) and persuasive sex (r = .10 [95% CI: -.168, .316]). Finally, CSB had a moderate correlation with sexual response when presented with stimuli depicting "female toddler coercive" (r = .27 [95% CI: -.083, .544]). We conclude that our findings do not support the hypotheses that CSB is significantly related to an increased arousability across sexual stimuli. The study findings also suggest that CSB may be, to a small degree, predisposed to experience sexual attraction toward children. Given the preliminary nature of the study, these conclusions warrant further research. Alternative explanations for the study findings related to the particular components of CSB that may be related to typical and atypical sexual interests are also considered.

Application of the network scale-up method to estimate the sizes of key populations for HIV in Singapore using online surveys

INTRODUCTION

Singapore lacks robust data on the sizes of the key populations that are most at risk for HIV. Using the network scale-up method for hidden or hard-to-reach populations, we estimate the sizes of five key populations-male clients of female sex workers (MCFSW), men who have sex with men (MSM), female sex workers (FSW), people who inject drugs (PWID) and transgender people-and profile the ages and ethnicities of respondents with the high-risk contacts they report knowing.

METHODS

We conducted a cross-sectional online survey between March and May 2019 (n = 2802) using a network scale-up instrument previously developed for Singapore. Participants were recruited using an existing panel and online advertising, and the sample reweighted by age, sex, ethnicity and education attained to represent the general adult population. We built a Bayesian hierarchical model to estimate the sizes of the five key populations for HIV in Singapore.

RESULTS

After adjustment, the sizes of the at-risk populations are estimated to be: 76,800 (95% credible interval [CI]: 64,200-91,800) MCFSW; 139,000 (95% CI: 120,000-160,000) MSM; 8030 (95% CI: 3980-16,200) FSW; 3470 (95% CI: 1540-7830) PWID and 18,000 (95% CI: 14,000-23,200) transgender people. Generally, men reported knowing more people in all the high-risk groups; older people reported knowing more MCFSW, FSW and transgender people; and younger people reported knowing more MSM. There was a bimodal effect of age on those who reported knowing more PWIDs: people in their 20s and 60s reported more contacts.

CONCLUSIONS

This study demonstrates that a size estimation study of hidden populations is quickly and efficiently scalable through using online surveys in a socially conservative society, like Singapore, where key populations are stigmatized or criminalized. The approach may be suitable in other countries where stigma is prevalent and where barriers to surveillance and data collection are numerous.

The Use of Adaptive Sampling to Reach Disadvantaged Populations for Immunization Programs and Assessments: A Systematic Review

Vaccines prevent 4-5 million deaths every year, but inequities in vaccine coverage persist among key disadvantaged subpopulations. Under-immunized subpopulations (e.g., migrants, slum residents) may be consistently missed with conventional methods for estimating immunization coverage and assessing vaccination barriers. Adaptive sampling, such as respondent-driven sampling, may offer useful strategies for identifying and collecting data from these subpopulations that are often "hidden" or hard-to-reach. However, use of these adaptive sampling approaches in the field of global immunization has not been systematically documented. We searched PubMed, Scopus, and Embase databases to identify eligible studies published through November 2020 that used an adaptive sampling method to collect immunization-related data. From the eligible studies, we extracted relevant data on their objectives, setting and target population, and sampling methods. We categorized sampling methods and assessed their frequencies. Twenty-three studies met the inclusion criteria out of the 3069 articles screened for eligibility. Peer-driven sampling was the most frequently used adaptive sampling method (57%), followed by geospatial sampling (30%), venue-based sampling (17%), ethnographic mapping (9%), and compact segment sampling (9%). Sixty-one percent of studies were conducted in upper-middle-income or high-income countries. Data on immunization uptake were collected in 65% of studies, and data on knowledge and attitudes about immunizations were collected in 57% of studies. We found limited use of adaptive sampling methods in measuring immunization coverage and understanding determinants of vaccination uptake. The current under-utilization of adaptive sampling approaches leaves much room for improvement in how immunization programs calibrate their strategies to reach "hidden" subpopulations.

"The Drug Sellers Were Better Organized than the Government": A Qualitative Study of Participants' Views of Drug Markets during COVID-19 and Other Big Events

"Big events", such as wars, economic crises, pandemics, or natural disasters, affect the risk environment in which people use drugs. While the impact of big events on injection risk behaviors and access to drug-treatment services is well documented, less is known about the effects of big events on drug markets. Based on self-reporting data on drug availability among people who use drugs (PWUD) in the aftermath of Hurricane Maria in Puerto Rico and during the COVID-19 lockdown in a Midwestern US state, this study aims to document the effects of big events on drug markets. Qualitative data on the effects of Hurricane Maria on drug markets are based on participants' self-reporting (N = 31). Data collection started after the hurricane and ended in 2020. Data on changes to the drug supply during the COVID-19 lockdown were collected based on semi-structured interviews with PWUD (N = 40) in a Midwestern US state. Findings show that while the drug markets might have initially been affected by big events, most effects were temporary. Drug availability, pricing, and quality might have suffered some initial fluctuations but stabilized as the drug markets absorbed the initial shocks caused by the hurricane and the lockdown measures. In preparation for increasingly more frequent and virulent pandemics and natural disasters, health infrastructures should be strengthened to prevent not only overdose episodes and deaths but also drug-related harms.

HIV self-testing for men who have sex with men in Sweden. A cross-sectional study concerning interest to use HIV self-tests

Background

HIV self-testing (HIVST) has been found to have high acceptability among men who have sex with men (MSM) internationally and might contribute to increase testing frequencies, but many countries, including Sweden, lack policies for using HIVST.

Objective

To examine interest to use and willingness to pay for HIVST, and associated factors, among MSM attending HIV testing venues in Sweden.

Method

This cross-sectional study analyzed data from a self-administered survey, consisting of 33 questions, collected at six HIV testing venues in Sweden in 2018. The sample consisted of sexually active men who have sex with men, aged ≥ 18 years, and not diagnosed with HIV. Data were analyzed descriptively and by univariable and multivariable logistic regression.

Result

Among 663 participants (median age 33 years), 436 respondents (65.8%) expressed interest to use HIVST. Among those interested, less than half, 205 (47.0%), were willing to pay for HIVST. Being interested in HIVST was found to be negatively associated with being in the 55 years or older age group (AOR 0.31, CI 0.14–0.71), and having had syphilis, rectal chlamydia, or rectal gonorrhea in the preceding 12 months (AOR 0.56, CI 0.32–0.99). In the sample of MSM interested in HIVST, willingness to pay was positively associated with being in the age groups 35–44 years (AOR 2.94, CI 1.40–6.21), 45–54 years (AOR 2.82, CI 1.16–6.90), and 55 years or above (AOR 3.90, CI 1.19–12.81), and negatively associated with being single (AOR 0.56, CI 0.36–0.88).

Conclusion

This study found high interest for HIVST in a sample of MSM in Sweden. However, HIVST offered at a cost is likely to negatively affect uptake among MSM broadly, compared with free availability.