The size and distribution of key populations at greater risk of HIV in Pakistan: implications for resource allocation for scaling up HIV prevention programmes

Adequate funding of comprehensive community-based programs for key populations needed now more than ever to reach and sustain HIV targets

Introduction

Globally, over half of the estimated new HIV infections now occur among key populations, including men who have sex with men, sex workers, people who inject drugs, transgender individuals, and people in prisons and other closed settings, and their sexual partners. Reaching epidemic control will, for many countries, increasingly require intensified programming and targeted resource allocation to meet the needs of key populations and their sexual partners. However, insufficient funding, both in terms of overall amounts and the way the funding is spent, contributes to the systematic marginalization of key populations from needed HIV services.

Discussion

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently highlighted the urgent need to take action to end inequalities, including those faced by key populations, which have only been exacerbated by the COVID‐19 pandemic. To address these inequalities and improve health outcomes, key population programs must expand the use of a trusted access platform, scale up differentiated service delivery models tailored to the needs of key populations, rollout structural interventions and ensure service integration. These critical program elements are often considered “extras,” not necessities, and consequently costing studies of key population programs systematically underestimate the total and unitary costs of services for key populations. Findings from a recent costing study from the LINKAGES project suggest that adequate funding for these four program elements can yield benefits in program performance. Despite this and other evidence, the lack of data on the true costs of these elements and the costs of failing to provide them prevents sufficient investment in these critical elements.

Conclusions

As nations strive to reach the 2030 UNAIDS goals, donors, governments and implementers should reconsider the true, but often hidden costs in future healthcare dollars and in lives if they fail to invest in the community‐based and community‐driven key population programs that address structural inequities. Supporting these efforts contributes to closing the remaining gaps in the 95‐95‐95 goals. The financial and opportunity cost of perpetuating inequities and missing those who must be reached in the last mile of HIV epidemic control must be considered.

Transitions: Novel Study Methods to Understand Early HIV Risk Among Adolescent Girls and Young Women in Mombasa, Kenya, and Dnipro, Ukraine

Transitions aims to understand the human immunodeficiency virus (HIV) risk at critical transition points in the sexual life course of adolescent girls and young women (AGYW) who engage in casual sex, transactional sex, and sex work. In this article, we present the Transitions study methods. The Transitions study has the following objectives: (1) to describe how the characteristics and length of the transition period and access gap vary across two epidemiological contexts (Mombasa, Kenya, and Dnipro, Ukraine); (2) to understand how the risk of HIV varies by length and characteristics of the transition period and access gap across epidemiologic contexts; and (3) to assess the extent to which HIV infections acquired during the transition period and access gap could mitigate the population-level impact of focused interventions for female sex workers and explore the potential marginal benefit of expanding programs to reach AGYW during the transition period and access gap. Cross-sectional biobehavioral data were collected from young women aged 14 to 24 years who were recruited from locations in Mombasa County, Kenya, and Dnipro, Ukraine, where sex work took place. Data are available for 1,299 Kenyan and 1,818 Ukrainian participants. The survey addressed the following areas: timing of transition events (first sex, first exchange of sex for money or other resources, self-identification as sex workers, entry into formal sex work, access to prevention program services); sexual behaviors (condom use, anal sex, sex under the influence of drugs or alcohol); partnerships (regular and first-time clients, regular and first-time transactional sex partners, and husbands and boyfriends); alcohol use; injection and non-injection illicit drug use; experience of violence; access to HIV prevention and treatment program; testing for sexually transmitted and blood-borne infections and HIV; and reproductive health (pregnancies, abortions, contraceptives). HIV and hepatitis C virus prevalence data were based on rapid test results. Mathematical modeling will be used to generate projections of onward HIV transmission at specific transition points in the sexual life course of AGYW. Taken together, these data form a novel data resource providing comprehensive behavioral, structural, and biological data on a high-risk group of AGYW in two distinct sociocultural and epidemiologic contexts.

HIV-1 phylodynamic analysis among people who inject drugs in Pakistan correlates with trends in illicit opioid trade

Pakistan is considered by the World Health Organization to currently have a "concentrated" HIV-1 epidemic due to a rapid rise in infections among people who inject drugs (PWID). Prevalence among the country's nearly 105,000 PWID is estimated to be 37.8% but has been shown to be higher in several large urban centers. A lack of public health resources, the common use of professional injectors and unsafe injection practices are believed to have fueled the outbreak. Here we evaluate the molecular characteristics of HIV-1 sequences (n = 290) from PWID in several Pakistani cities to examine transmission dynamics and the association between rates of HIV-1 transmission with regards to regional trends in opioid trafficking. Tip-to-tip (patristic) distance based phylogenetic cluster inferences and BEAST2 Bayesian phylodynamic analyses of time-stamped data were performed on HIV-1 pol sequences generated from dried blood spots collected from 1,453 PWID as part of a cross-sectional survey conducted in Pakistan during 2014/2015. Overall, subtype A1 strains were dominant (75.2%) followed by CRF02_AG (14.1%), recombinants/unassigned (7.2%), CRF35_AD (2.1%), G (1.0%) and C (0.3%). Nearly three quarters of the PWID HIV-1 sequences belonged to one of five distinct phylogenetic clusters. Just below half (44.4%) of individuals in the largest cluster (n = 118) did seek help injecting from professional injectors which was previously identified as a strong correlate of HIV-1 infection. Spikes in estimated HIV-1 effective population sizes coincided with increases in opium poppy cultivation in Afghanistan, Pakistan's western neighbor. Structured coalescent analysis was undertaken in order to investigate the spatial relationship of HIV-1 transmission among the various cities under study. In general terms, our analysis placed the city of Larkana at the center of the PWID HIV-1 epidemic in Pakistan which is consistent with previous epidemiological data.

Rising HIV seroconversion rates & associated risks among employees of organization 'X': A case control study, Pakistan, 2017

Background and Objectives:

In 2004 Pakistan escalated from ‘low-prevalence’ to ‘concentrated’ phase of HIV epidemic. Despite global decline in HIV incidence since 1997, rate of HIV infections in Pakistan is persistently rising since 1990. Available literature focusses on key populations or localized outbreaks limited by short study duration and regional applicability of results. We studied HIV seroconversion trends over a period of 8 years in a geographically diverse population and evaluated associated risk factors.

Methods:

A desk review of HIV surveillance data from 2010 to 2017 was carried out at Armed Forces Institute of Pathology. A case was defined as any adult employed in organization ‘X’, initially screened for HIV but later seroconverted on ELISA and western blot. Case-control study was conducted on cases diagnosed in 2017. Age and sex matched controls were identified from same population sub-group. Structured telephonic interviews were conducted and statistical analysis done at 5% margin of error.

Results:

The annual HIV diagnosis rate remained relatively stable till 2015 (< 40 /100,000/yr) after which it rose sharply to 60/100,000/yr in 2016 .Upward trend continued in 2017 to reach 125/100,000/yr (>200% increase from baseline). Acquisition of HIV was significantly associated with commercial sex activities (OR=9; 95% CI: 1.25-395).

Conclusion:

HIV seroconversion rates among employees of organization X have increased significantly in the past two years. Unlike HIV outbreaks previously reported from Pakistan, sexual route seems to be the predominant mode of transmission. Focus is mandated on prevention of sexual transmission of HIV at national level as well for all vulnerable populations.

Assessing the influence of conflict on the dynamics of sex work and the HIV and HCV epidemics in Ukraine: protocol for an observational, ethnographic, and mathematical modeling study

BACKGROUND

Armed conflict erupted in eastern Ukraine in 2014 and still continues. This conflict has resulted in an intensification of poverty, displacement and migration, and has weakened the local health system. Ukraine has some of the highest rates of HIV and Hepatitis C (HCV) in Europe. Whether and how the current conflict, and its consequences, will lead to changes in the HIV and HCV epidemic in Ukraine is unclear. Our study aims to characterize how the armed conflict in eastern Ukraine and its consequences influence the pattern, practice, and experience of sex work and how this affects HIV and HCV rates among female sex workers (FSWs) and their clients.

METHODS

We are implementing a 5-year mixed methods study in Dnipro, eastern Ukraine. Serial mapping and size estimation of FSWs and clients will be conducted followed by bio-behavioral cross-sectional surveys among FSWs and their clients. The qualitative component of the study will include in-depth interviews with FSWs and other key stakeholders and participant diaries will be implemented with FSWs. We will also conduct an archival review over the course of the project. Finally, we will use these data to develop and structure a mathematical model with which to estimate the potential influence of changes due to conflict on the trajectory of HIV and HCV epidemics among FSW and clients.

DISCUSSION

The limited data that exists on the effect of conflict on disease transmission provides mixed results. Our study will provide rigorous, timely and context-specific data on HIV and HCV transmission in the setting of conflict. This information can be used to inform the design and delivery of HIV and HCV prevention and care services.

Political and Governance Challenges to Achieving Global HIV Goals with Injecting Drug Users: The Case of Pakistan

Background: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has recently set the ambitious "90-90-90 target" of having 90% of people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve viral suppression by 2020. This ambitious new goal is occurring in a context of global "scale-down" following nearly a decade of heightened investment in HIV prevention and treatment efforts. Arguably international goals spur action, however, setting unrealistic goals that do not take weak health systems and variations in the nature of the epidemic across countries into consideration may set them up for failure in unproductive ways that lead to a decline in confidence in global governance institutions. This study explores how policy actors tasked with implementing HIV programs navigate the competing demands placed upon them by development targets and national politics, particularly in the current context of waning international investments towards HIV.

Methods: To examine these questions, we interviewed 29 key informants comprising health experts in donor organizations and government employees in HIV programs in Pakistan, a country where HIV programs must compete with other issues for attention. Themes were identified inductively through an iterative process and findings were triangulated with various data sources and existing literature.

Results: We found both political and governance challenges to achieving the target, particularly in the context of the global HIV scale-down. Political challenges included, low and heterogeneous political commitment for HIV and a conservative legal environment that contributed towards a ban on opiate substitution therapy, creating low treatment coverage. Governance challenges includedstrained state and non-governmental organization (NGO) relations creating a hostile service delivery environment, weak bureaucratic and civil society capacity contributing to poor regulation of the health infrastructure, and resource mismanagement on both the part of the government and NGOs.

Conclusion: Our findings suggest that in a context of waning international attention to HIV, policy actors on the ground face a number of practical hurdles to achieving the ambitious targets set out by international agencies. Greater attention to the political and governance challenges of implementing HIV programs in low- and middle-income countries (LMICs) could help technical assistance agencies to develop more realistic implementation plans.

Mapping and size estimates of female sex workers in Cameroon: Toward informed policy for design and implementation in the national HIV program

Background

Due to high HIV prevalence among Female Sex Workers (FSWs) in Cameroon (36.5%), this population is especially vulnerable to HIV acquisition and transmission nationwide. Though being prioritized in the national HIV response, it would be relevant to generate statistics on the number of FSWs in order to guide HIV interventions among FSWs. Our objective was to estimate the size of FSWs within hotspots of Cameroon.

Methods

A cross-sectional study was conducted from September-November 2015 in selected cities in Cameroon: Bafoussam, Bamenda, Bertoua, Buea, Douala, Kribi, Limbé, and Yaoundé. A programmatic mapping was used, consisting of interviews with secondary key informants (KI) to identify hotspots of FSWs and their respective estimated numbers. Validation of size estimates was done by interviews with FSW at each hotspot. Size estimations in the councils mapped were extended to others not mapped using a Poisson regression model.

Results

A total of 2,194 hotspots were identified: Douala (760), Yaoundé (622), Bamenda (263), Bafoussam (194), Kribi (154), Bertoua (140), Limbé (35), and Buea (26). The estimated total number (range) of FSWs was 21,124 (16,079–26,170), distributed per city as follows: Douala 7,557 (5,550–9,364), Yaoundé 6,596 (4,712–8,480), Bafoussam 2,458 (1,994–2,923), Bamenda 1,975 (1,605–2,345), Kribi 1,121 (832–1,408), Bertoua 1,044 (891–1,198), Buea 225 (185–266), and Limbé 148 (110–148). The variability of estimates among cities was also observed within the councils of each city. The national predicted estimate of FSW population was 112,580 (103,436–121,723), covering all councils of Cameroon. An estimate of 1.91% (112,580/5,881,526; 0.47%-3.36%) adult female population in Cameroon could be sex workers.

Conclusion

There are considerable numbers of FSW in major cities in Cameroon. There is a need to prioritize interventions for HIV prevention toward this population in order to limit the burden of HIV sexual transmission nationwide.

Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data

BACKGROUND

Assessing patterns and trends in new infections is key to better understanding of HIV epidemics, and is best done through monitoring changes in incidence over time. In this study, we examined disparities in geographical trends of HIV epidemics among people who inject drugs (PWIDs), female sex workers (FSWs) and hijra/transgender/male sex workers (H/MSWs), in Pakistan.

METHODS

The UNAIDS Estimation and Projection Package (EPP) mathematical model was used to explore geographical trends in HIV epidemics. Four rounds of mapping and surveillance data collected among key populations (KPs) across 20 cities in Pakistan between 2005-2011 was used for modeling. Empirical estimates of HIV prevalence of each KP in each city were used to fit the model to estimate prevalence and incidence over time.

RESULTS

HIV incidence among PWIDs in Pakistan reached its peak in 2011, estimated at 45.3 per 1000 person-years. Incidence was projected to continue to rise from 18.9 in 2015 to 24.3 in 2020 among H/MSWs and from 3.2 in 2015 to 6.3 in 2020 among FSWs. The number of people living with HIV in Pakistan was estimated to steadily increase through at least 2020. HIV incidence peak among PWIDs ranged from 16.2 in 1997 in Quetta to 71.0 in 2010 in Faisalabad (per 1000 person-years). Incidence among H/MSWs may continue to rise through 2020 in all the cities, except in Larkana where it peaked in the early 2000s. In 2015, model estimated incidence among FSWs was 8.1 in Karachi, 6.6 in Larkana, 2.0 in Sukkur and 1.2 in Lahore (per 1000 person-years).

CONCLUSIONS

There exists significant geographical heterogeneity in patterns and trends of HIV sub-epidemics in Pakistan. Focused interventions and service delivery approaches, different by KP and city, are recommended.

Revisiting the AIDS Epidemic in Pakistan: Where We Stand and What We Must Aim For

Human immunodeficiency virus type 1 (HIV-1) is the major cause of acquired immunodeficiency syndrome (AIDS) in humans, where the immune system totally succumbs to the virus. A large proportion of the AIDS infected belong to developing countries and AIDS prevalence is intensified by severe poverty, malnutrition, and famine; fatal illnesses with a scorn shortage of medical amenities complemented with the lack of education and development. Current Pakistani health system setting is in a dire need of improvement. Low literacy rates, high birth rates, and associated maternal mortality plus a lack of clean drinking water and appropriate sanitation system have a serious impact on general living conditions contributing to a relatively short lifespan. HIV is, therefore, becoming a growing health concern in Pakistan with a rapid rise in the reported cases. AIDS is most prevalent among injection drug users (IDUs), male/female sex workers, and unchecked deported migrant workforce. To combat this virus, the Pakistan Government has been working hard over the past few years with local bodies and international organizations in an effort to combat this menace. This review aims to discuss the risk factors for the rise of this epidemic in the country and the recommendations, efforts to be done to address this alarming issue.

An appraisal of female sex work in Nigeria--implications for designing and scaling up HIV prevention programmes

Background

The HIV epidemic in Nigeria is complex with diverse factors driving the epidemic. Accordingly, Nigeria's National Agency for the Control of AIDS is coordinating a large-scale initiative to conduct HIV epidemic appraisals across all states. These appraisals will help to better characterize the drivers of the epidemic and ensure that the HIV prevention programmes match the local epidemic context, with resources allocated to interventions that have the greatest impact locally. Currently, the mapping and size estimation of Female Sex Workers (FSWs) - a major component of the appraisal has been completed in seven states. These states are using the data generated to plan, prioritize and scale-up sub-national HIV prevention programmes.

Methodology

It involved a two-level process of identifying and validating locations where FSWs solicit and/or meet clients (“hotspots”). In the first level, secondary key informants were interviewed to collect information about the geographic location and description of the hotspots. For the second level, FSWs were interviewed at each hotspot and information on population size estimates, typologies and operational dynamics of the FSWs were collected.

Results

Across the seven states, a total of 17,266 secondary key informants and 5,732 FSWs were interviewed. 10,233 hotspots were identified with an estimated 126,489 FSWs ranging from 5,920 in Anambra to 46,691 in Lagos. The most common hotspots were bars/nightclubs (30%), hotels/lodges (29.6%), streets (16.6%), and brothels (14.6%). Furthermore, the population density of FSWs (per thousand adult men) across the states ranged from 2 in Anambra to 17 in the Federal Capital Territory.

Conclusion

FSW populations in Nigeria are large and diverse, with substantial differences between and within states. Improved understanding of the location, population size, density, organizational typologies and clients of sex work has informed and is central to Nigeria's planning process for scaling up focused HIV prevention programmes.