Protecting the unprotected: mixed-method research on drug use, sex work and rights in Pakistan's fight against HIV/AIDS

HIV prevention and public morality in Pakistan: the secular normativity of development

Religious leaders, development experts and state officials in Pakistan were brought together on shared platforms to negotiate a morally-appropriate but scientifically informed response to HIV. Instead of dialogue and negotiation in line with the secular ideal of development, the moral authority of the religious figure compelled others to forefront the conservative in them, thereby undermining the goal of HIV prevention in the country. The everyday practices of state officials and health experts were already infused with Islamic public morality but the inclusion of religious leaders resulted in acceptance of their conservative position on HIV, gender and sexuality. Through the case study of an Inter-Religious Council on HIV, I argue that intervention strategies which specifically involve religious leaders end up enabling systematic marginalization of those who are already at a greater risk of HIV.

Sexual and gender minority health in the Middle East and North Africa Region: A scoping review

Background

Researchers in studies from multiple countries suggest that sexual and gender minority people experience high rates of violence, stigma, and discrimination, as well as mistrust of health care providers and systems. Despite growing evidence related to sexual and gender minority health in North America and Europe, we know little about the health of this population in the Middle East and North Africa.

Objectives

We aimed to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.

Design

We conducted a scoping review informed by the framework recommended by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.

Data sources

We searched the following databases: PubMed (using Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid). The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority). Each was operationalized using multiple search terms and, where available, controlled vocabulary terms.

Review Methods

Research articles were identified and assessed for inclusion using an explicit strategy. Relevant information was extracted and synthesized to present a descriptive summary of existing evidence.

Results

Research designs of the 98 articles we reviewed included quantitative (n = 73), qualitative (n = 20), and mixed methods (n = 5). Most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23) and focused mainly on gender minority individuals (n = 46) and men who have sex with men (n = 32). Five themes emerged from the review: sexual health (52; 53%); mental health (20; 20%); gender identity (17; 17%); violence and discrimination (7; 7%); and experiences with the healthcare system (2; 2%). Although researchers focused on multiple health outcomes in some studies, we included them under the theme most closely aligned with the main objective of the study.

Conclusion

Although our study is limited to few countries in the Middle East and North Africa region, we found that sexual and gender minority individuals face multiple adverse sexual and mental health outcomes and experience high rates of stigma, discrimination, and violence. More research is needed from countries outside of Lebanon, Pakistan, and Iran, including community-based participatory approaches and multi-level intervention development. Nurses and other healthcare providers in the region need training in providing inclusive care for this population.

Anal human papillomavirus infection among men who have sex with men and transgender women living with and without HIV in Pakistan: findings from a cross-sectional study

OBJECTIVES

The aim of this study was to determine the prevalence of infection, genotypes and risk factors for human papillomavirus (HPV) among men who have sex with men (MSM) and transgender women living with and without HIV in Pakistan. Anal infection with HPV is very common worldwide among MSM, particularly among MSM living with HIV. The high prevalence of HIV among MSM and male-to-female transgendered individuals in Pakistan is a significant health concern since access to screening and health-seeking is often delayed in this stigmatised key population.

DESIGN

This cross-sectional study was conducted between March 2016 and November 2017.

PARTICIPANTS, SETTING AND DATA COLLECTION

This study recruited MSM and transgender-women who self-reported to have had anal sex in the last 6 months, and were at least 18 years of age, from the sexual health and antiretroviral therapy centres. Structured questionnaires were administered, and blood samples were obtained to confirm HIV status. Anal swabs were collected for HPV-DNA detection and typing.

MAIN OUTCOME MEASURES

The primary outcome was the prevalence of 'HPV-DNA infection'. The prevalence ratios (PR) were calculated using Cox proportional hazard model algorithms to analyse the association between exposure variables and HPV-infection.

RESULTS

Complete data were available for 298 MSM and transgender women (HIV +n=131; HIV-n=167). The overall HPV-DNA prevalence was 65.1% and was higher in participants living with HIV as compared with HIV-negative (87% vs 48%; χ²p≤0.001). Likewise, 28.9% of participants living with HIV were infected with two or more than two types of HPV as compared with 18.8% participants without HIV(χ² p≤0.001). The most frequent HPV type was HPV6/11 (46.9%), followed by HPV16 (35.1%), HPV18 (23.2%) and HPV35 (21.1%). HIV status (PR 2.81, 95% CI 2.16 to 3.82) and never condom use (PR 3.08, 95% CI 1.69 to 5.60)) were independently associated with prevalence of 'anal-HPV16 infection' when adjusting for confounding for age, other sexual and behavioural factors, for example, smoking and alcohol consumption.

CONCLUSION

High prevalence of HPV indicates a substantial future risk of anal cancer in Pakistani MSM and transgender women, and particularly in those living with HIV. Current findings support anal Pap-smear HPV screening for this particular group and vaccination efforts for future generations.

Sexual risk-taking among homeless young people in Pakistan

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.

HIV infection predominantly affecting children in Sindh, Pakistan, 2019: a cross-sectional study of an outbreak

BACKGROUND

In April 2019, an HIV screening camp for all ages was established in response to a report of an unusually large number of paediatric HIV diagnoses in Larkana, Pakistan. We aimed to understand the clinical profile of the children who registered for HIV care.

METHODS

In this cross-sectional study, we review the outbreak response from the government, academia, and UN agencies in Larkana, Sindh, Pakistan. We report age-stratified and sex-stratified HIV prevalence estimated among individuals screened. For children who registered for HIV care, clinical history of previous injections and blood transfusions, HIV disease stage, hepatitis B and hepatitis C status, and CD4 count was abstracted from clinical records from Sindh AIDS Control Program HIV Clinic (Shaikh Zayed Childrens Hospital, Larkana, Pakistan) and analysed using percentages, χ2 tests, and weight-for-age Z scores. We also analysed data for parents who were tested for HIV.

FINDINGS

Between April 24, and July 15, 2019, 31 239 individuals underwent HIV testing, of whom 930 (3%) tested positive for HIV. Of these, 763 (82%) were younger than 16 years and 604 (79%) of these were aged 5 years and below. Estimated HIV prevalence was 3% overall; 7% (283 of 3803) in children aged 0-2 years, 6% (321 of 5412) in children aged 3-5 years, and 1% (148 of 11 251) in adults aged 16-49 years. Of the 591 children who registered for HIV care, 478 (81%) were 5 years or younger, 379 (64%) were boys, and 315 (53%) of 590 had a weight-for-age Z score of -3·2. Prevalence of hepatitis B surface antigen was 8% (48 of 574) and hepatitis C antibody positivity was 3% (15 of 574). Of children whose mothers tested for HIV, only 39 (11%) of 371 had HIV-positive mothers. Most children (404 [89%] of 453) reported multiple previous injections and 40 (9%) of 453 reported blood transfusions.

INTERPRETATION

This HIV outbreak is unprecedented among children in Pakistan: a 54% increase in paediatric HIV diagnoses over the past 13 years. The outbreak was heavily skewed towards young children younger than 5 years, with a predominance of boys. Epidemiological and molecular studies are needed to understand the full extent of the outbreak and its drivers to guide HIV control strategies.

FUNDING

None.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

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.

Socio-demographic and sexual practices associated with HIV infection in Kenyan injection and non-injection drug users

Background

Substance use is increasingly becoming prevalent on the African continent, fueling the spread of HIV infection. Although socio-demographic factors influence substance consumption and risk of HIV infection, the association of these factors with HIV infection is poorly understood among substance users on the African continent. The objective of the study was to assess socio-demographic and sexual practices that are associated with HIV infection among injection drug users (IDUs), non-IDUs, and non-drug users (DUs) at an urban setting of coastal Kenya.

Methods

A cross-sectional descriptive study was conducted among 451 adults comprising HIV-infected and -uninfected IDUs (n = 157 and 39); non-IDUs (n = 17 and 48); and non-DUs (n = 55 and 135); respectively at coastal, Kenya. Respondent driven sampling, snowball and makeshift methods were used to enroll IDUs and non-IDUs. Convenience and purposive sampling were used to enroll non-DUs from the hospital’s voluntary HIV testing unit. Participant assisted questionnaire was used in collecting socio-demographic data and sexual practices.

Results

Binary logistic regression analysis indicated that higher likelihood of HIV infection was associated with sex for police protection (OR, 9.526; 95% CI, 1.156-78.528; P = 0.036) and history of sexually transmitted infection (OR, 5.117; 95% CI, 1.924-13.485; P = 0.001) in IDUs; divorced, separated or widowed marital status (OR, 6.315; 95% CI, 1.334-29.898; P = 0.020) in non-IDUs; and unemployment (OR, 2.724; 95% CI, 1.049-7.070; P = 0.040) in non-drug users. However, never married (single) marital status (OR, 0.140; 95% CI, 0.030-0.649; P = 0.012) was associated with lower odds for HIV infection in non-drug users.

Conclusion

Altogether, these results suggest that socio-demographic and sexual risk factors for HIV transmission differ with drug use status, suggesting targeted preventive measures for drug users.

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.

Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence

Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.

Impact of Gender Binarism on Hijras' Life Course and Their Access to Fundamental Human Rights in Pakistan

This study adds to the growing body of knowledge on gender nonconformity aspects of heteronormativity by examining its impact on the life course of hijras and their access to fundamental human rights in Pakistan. Drawing on 50 semistructured interviews conducted in two sites, the findings suggest that the participants' lived experiences associated with gender nonconformity significantly influenced the direction of their life course and their ability to have access to human rights. These experiences spanned from childhood to elderhood across a wide range of settings, such as family, school, guru dera (residence headed by a hijra guru), workplace, and interactions with authorities. The participants' human rights were not recognized, resulting in abuse, social stigma, discrimination against them, and their exclusion from mainstream society. Finally, implications are drawn for public policy and future research on third gender concerns in Pakistan and elsewhere.

Strategies for reducing police arrest in the context of an HIV prevention programme for female sex workers: evidence from structural interventions in Karnataka, South India

Introduction

Female sex workers (FSWs) frequently experience violence in their work environments, violating their basic rights and increasing their vulnerability to HIV infection. Structural interventions addressing such violence are critical components of comprehensive HIV prevention programmes. We describe structural interventions developed to address violence against FSWs in the form of police arrest, in the context of the Bill and Melinda Gates Foundation's India AIDS Initiative (Avahan) in Karnataka, South India. We examine changes in FSW arrest between two consecutive time points during the intervention and identify characteristics that may increase FSW vulnerability to arrest in Karnataka.

Methods

Structural interventions with police involved advocacy work with senior police officials, sensitization workshops, and integration of HIV and human rights topics in pre-service curricula. Programmes for FSWs aimed to enhance collectivization, empowerment and awareness about human rights and to introduce crisis response mechanisms. Three rounds of integrated behavioural and biological assessment surveys were conducted among FSWs from 2004 to 2011. We conducted bivariate and multivariate analyses using data from the second (R2) and third (R3) survey rounds to examine changes in arrests among FSWs over time and to assess associations between police arrest, and the sociodemographic and sex work-related characteristics of FSWs.

Results

Among 4110 FSWs surveyed, rates of ever being arrested by the police significantly decreased over time, from 9.9% in R2 to 6.1% in R3 (adjusted odds ratio (AOR) [95% CI]=0.63 [0.48 to 0.83]). Arrests in the preceding year significantly decreased, from 5.5% in R2 to 2.8% in R3 (AOR [95% CI]=0.59 [0.41 to 0.86]). FSWs arrested as part of arbitrary police raids also decreased from 49.6 to 19.5% (AOR [95% CI]=0.21 [0.11 to 0.42]). Certain characteristics, including financial dependency on sex work, street- or brothel-based solicitation and high client volumes, were found to significantly increase the odds of arrest for participants.

Conclusion

Structural interventions addressing police arrest of FSWs are feasible to implement. Based on our findings, the design of violence prevention and response interventions in Karnataka can be tailored to focus on FSWs, who are disproportionately vulnerable to arrest by police. Context-specific structural interventions can reduce police arrests, create a safer work environment for FSWs and protect fundamental human rights.

Policing practices as a structural determinant for HIV among sex workers: a systematic review of empirical findings

Introduction

Sex workers are disproportionately infected with HIV worldwide. Significant focus has been placed on understanding the structural determinants of HIV and designing related interventions. Although there is growing international evidence that policing is an important structural HIV determinant among sex workers, the evidence has not been systematically reviewed.

Methods

We conducted a systematic review of quantitative studies to examine the effects of policing on HIV and STI infection and HIV-related outcomes (condom use; syringe use; number of clients; HIV/STI testing and access) among cis and trans women sex workers. Databases included PubMed, Embase, Scopus, Sociological Abstracts, Popline, Global Health (OVID), Web of Science, IBSS, IndMed and WHOLIS. We searched for studies that included police practices as an exposure for HIV or STI infection or HIV-related outcomes.

Results

Of the 137 peer-reviewed articles identified for full text review, 14 were included, representing sex workers' experiences with police across five settings. Arrest was the most commonly explored measure with between 6 and 45% of sex workers reporting having ever been arrested. Sexual coercion was observed between 3 and 37% of the time and police extortion between 12 and 28% across studies. Half the studies used a single measure to capture police behaviours. Studies predominantly focused on “extra-legal policing practices,” with insufficient attention to the role of “legal enforcement activities”. All studies found an association between police behaviours and HIV or STI infection, or a related risk behaviour.

Conclusions

The review points to a small body of evidence that confirms policing practices as an important structural HIV determinant for sex workers, but studies lack generalizability with respect to identifying those police behaviours most relevant to women's HIV risk environment.

Effect of Physical Violence on Sexually Transmitted Infections and Treatment Seeking Behaviour among Female Sex Workers in Thane District, Maharashtra, India

BACKGROUND

Violence against sex workers can heighten their vulnerability to HIV and other sexually transmitted infections (STIs). Evidence suggests the risk of acquiring STI/HIV infections among female sex workers (FSWs) who have experienced violence to be almost three-times higher than FSWs, who have not experienced violence. Moreover, an experience of physical and sexual violence makes it difficult for them to negotiate safer sex with their partners and often act as a barrier to utilization of prevention services.

METHODS

This study utilizes data from 2785 FSWs aged 18 years and above who participated in a cross-sectional behavioural study conducted during 2013-14 in Thane district, Maharashtra. A probability-based two-stage cluster sampling method was used for data collection. This study assesses the effect of physical violence on self-reported STI symptoms (any STI and multiple STIs) and treatment seeking for the last STI symptom using propensity score matching method.

RESULTS

About 18% of sampled FSWs reported physical violence at the time of the survey. The likelihood of experiencing such violence was significantly higher among FSWs who solicited clients at public places, engaged in other economic activities apart from sex work, had savings, and reported high client volume per week. FSWs experiencing violence were also inconsistent condom users while engaging in sex with regular partners and clients. The average adjusted effect of violence clearly depicted an increase in the risk of any STI (11%, p<0.05) and multiple STIs (8%, p<0.10) and reduction in treatment seeking (10%, p<0.05).

CONCLUSIONS

This study demonstrates a significant effect of physical violence on reporting of any STI symptom and treatment seeking. Findings call for the immediate inclusion of strategies aimed to address violence related challenges in HIV prevention program currently being provided at Thane district. Such strategies would further help in enhancing the access to tailored STI prevention and care services among FSWs in the district.

Measuring Current Drug Use in Female Sex Workers and Their Noncommercial Male Partners in Mexico: Concordance Between Data Collected From Surveys Versus Semi-Structured Interviews

BACKGROUND

Self-reports are commonly used to assess prevalence and frequency of drug use, but it is unclear whether qualitative methods like semi-structured interviews are as useful at obtaining such information as quantitative surveys.

OBJECTIVES

This study compared drug use occurrence and frequency using data collected from quantitative surveys and qualitative interviews. We also examined whether combining data from both sources could result in significant increases in percentages of current users and whether the concordance between the two sets of data was associated with the type of drug use, age, gender and socioeconomic status.

METHODS

Self- reports of recent marijuana, heroin, crack, cocaine, crystal/methamphetamine, inhalant, and tranquilizer use were collected using both methods from a cohort of Mexican female sex workers and their non-commercial male partners (n = 82).

RESULTS

Participants were significantly less likely to report marijuana, cocaine and tranquilizer use and frequency of use during the qualitative interviews than during the quantitative surveys. Agreement on frequency of drug use was excellent for crystal/methamphetamine, heroin and inhalant use, and weak for cocaine, tranquilizers and marijuana use. Older participants exhibited significantly higher concordance than younger participants in reports of marijuana and methamphetamine use. Higher monthly income was significantly associated with higher concordance in crack use but lower concordance with marijuana use.

CONCLUSIONS

Although use of such data can result in an underreporting of drug use, qualitative data can be quantified in certain circumstances to triangulate and confirm the results from quantitative analyses and provide a more comprehensive view of drug use.

Review of HIV response in Pakistan using a system thinking framework

Pakistan has moved from a 'low prevalence-high risk' to a 'concentrated epidemic' state, yet the forcefulness required for managing this silent escalation of HIV infected numbers is not being highlighted, as it should be. A more comprehensive review of the national strategy for HIV/AIDS would necessitate a system's thinking. For this purpose, the WHO's Health Systems Building Blocks have been discussed to analyse whether this framework can be employed to take some corrective measures. An extensive literature review in this regard helps to understand that the service delivery has to be responsive, but skilled human resources, a robust information system, an uninterrupted supplies and use of latest technology, adequate financing, and above all good governance at operational level are essential ingredients, which call for re-orienting the national programme today. Lack of coordination, capacity, and interventions with questionable sustainability pave a perilous path. Hitherto, the issue can be addressed by involving stakeholders from all levels of the society and managing the void between policy and implementation. Furthermore, interventions that focus on the long-term future are imperative to combat the menace threatening human lives.

Human rights violations against sex workers: burden and effect on HIV

We reviewed evidence from more than 800 studies and reports on the burden and HIV implications of human rights violations against sex workers. Published research documents widespread abuses of human rights perpetrated by both state and non-state actors. Such violations directly and indirectly increase HIV susceptibility, and undermine effective HIV-prevention and intervention efforts. Violations include homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing. Abuses occur across all policy regimes, although most profoundly where sex work is criminalised through punitive law. Protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and wellbeing. Research findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalised population.

Advancing sexual health through human rights: the role of the law

Since the International Conference on Population and Development, definitions of sexuality and sexual health have been greatly elaborated alongside widely accepted recognition that sexual health requires respect, protection and fulfilment of human rights. Considerable progress has also been made in enacting or changing laws that affect sexuality and sexual health, in line with human rights standards. These measures include legal guarantees against non-discrimination and violence, decriminalisation of consensual sexual conduct and guaranteeing availability, accessibility, acceptability and quality of sexual health information and services to all. Such legal actions have had positive effects on health and specifically on sexual health, particularly for marginalised populations. Yet in all regions of the world, laws still exist which jeopardise health, including sexual health, and violate human rights. In order to ensure accountability for the rights and health of their populations, states have an obligation to bring their laws into line with international, regional and national human rights standards. These rights-based legal guarantees, while insufficient alone, are essential for effective systems of accountability, achieving positive sexual health outcomes and the respect and protection of human rights.

Prevalence and correlates of violence against female sex workers in Abuja, Nigeria

BACKGROUND

Few studies in Africa provide detailed descriptions of the vulnerabilities of female sex workers (FSWs) to violence.

OBJECTIVE

To document the prevalence and types of violence experienced by FSWs, identify the risk factors of experiencing violence to women (VAW) and the perpetrators of these acts.

METHODS

An analytical cross sectional survey of 305 brothel-based FSWs and in-depth interview of 20 chairpersons residing in brothels in Abuja, Nigeria was done.

RESULTS

The prevalence of VAW six months preceding the survey was 52.5%. Sexual violence was the commonest type (41.9%) of violence experienced, followed by economic (37.7%), physical violence (35.7%) and psychological (31.9%). The main perpetrators of sexual violence were clients (63.8%) and brothel management (18.7%). Sexual violence was significantly more experienced (aOR 2.23; 95%CI 1.15-4.36) by older FSWs than their younger counterparts, by permanent brothel residents (aOR 2.08; 95%CI 1.22-3.55) and among those who had been in the sex industry for more than five years (aOR 2.01; 95%CI 0.98-4.10). Respondents with good knowledge levels of types of violence were less vulnerable to physical violence (aOR 0.45; 95%CI 0.26-0.77). Psychological violence was more likely among FSWs who smoked (aOR 2.16; 95%CI 1.26-3.81). Risk of economic violence decreased with educational levels (aOR 0.54; 95%CI 0.30-0.99 and aOR 0.42; 95%CI 0.22-0.83 for secondary and post secondary respectively). Consequences of the violence included sexually transmitted infections (20%) and HIV (8.0%).

CONCLUSION

Interventions that educate FSWs on their rights and enable them avoid violence are urgently required. Young women need economic and educational empowerments to enable them avoid sex work.

Prevalence and correlates of client-perpetrated abuse among female sex workers in two Mexico-U.S. border cities

History of abuse has been associated with greater HIV risk among women. This study examined client-perpetrated abuse among female sex workers (FSWs) in two Mexico-U.S. border cities where HIV prevalence is rising. Among 924 FSWs, prevalence of client-perpetrated abuse was 31%. In multivariate logistic regression models, intimate partner violence (IPV), psychological distress, and having drug-using clients were associated with experiencing client-perpetrated abuse. FSWs along the Mexico-U.S. border report frequently experiencing abuse from both clients and intimate partners, which may have serious mental health consequences. Our findings suggest the need for screening and gender-based violence prevention services for Mexican FSWs.

Up-scaling expectations among Pakistan's HIV bureaucrats: entrepreneurs of the self and job precariousness post-scale-up

Existing research has documented how the expansion of HIV programming has produced new subjectivities among the recipients of interventions. However, this paper contends that changes in politics, power and subjectivities may also be seen among the HIV bureaucracy in the decade of scale-up. One year's ethnographic fieldwork was conducted among AIDS control officials in Pakistan at a moment of rolling back a World Bank-financed Enhanced Programme. In 2003, the World Bank convinced the Musharraf regime to scale up the HIV response, offering a multimillion dollar soft loan package. I explore how the Enhanced Programme initiated government employees into a new transient work culture and turned the AIDS control programmes into a hybrid bureaucracy. However, the donor money did not last long and individuals' entrepreneurial abilities were tested in a time of crisis engendered by dependence on aid, leaving them precariously exposed to job insecurity, and undermining the continuity of AIDS prevention and treatment in the country. I do not offer a story of global 'best practices' thwarted by local 'lack of capacity', but an ethnographic critique of the transnational HIV apparatus and its neoliberal underpinning. I suggest that this Pakistan-derived analysis is more widely relevant in the post-scale-up decade.

Realigning government action with public health evidence: the legal and policy environment affecting sex work and HIV in Asia

The HIV epidemic has shed light on how government regulation of sex work directly affects the health and well-being of sex workers, their families and communities. A review of the public health evidence highlights the need for supportive legal and policy environments, yet criminalisation of sex work remains standard around the world. Emerging evidence, coupled with evolving political ideologies, is increasingly shaping legal environments that promote the rights and health of sex workers but even as new legislation is created, contradictions often exist with standing problematic legislation. As a region, Asia provides a compelling example in that progressive HIV policies often sit side by side with laws that criminalise sex work. Data from the 21 Asian countries reporting under the UN General Assembly Special Session on HIV in 2010 were analysed to provide evidence of how countries' approach to sex-work regulation might affect HIV-related outcomes. Attention to the links between law and HIV-related outcomes can aid governments to meet their international obligations and ensure appropriate legal environments that cultivate the safe and healthy development and expression of sexuality, ensure access to HIV and other related services and promote and protect human rights.

Syringe confiscation as an HIV risk factor: the public health implications of arbitrary policing in Tijuana and Ciudad Juarez, Mexico

Female sex workers who inject drugs (FSW-IDUs) face elevated risk for HIV/STIs and constitute a key population for public health prevention. Through direct and indirect pathways including human rights violations, policing practices like syringe confiscation can compound FSW-IDU health risk and facilitate the spread of disease. We studied correlates of experiencing syringe confiscation among FSW-IDUs in northern Mexico, where formal policy allows for syringes to be available over the counter without a prescription, but police practices are often at odds with the law. FSW-IDUs reporting recent syringe sharing and unprotected sex with clients in Tijuana and Ciudad Juarez were administered surveys and HIV/STI testing. Logistic regression was used to identify correlates of syringe confiscation. Among 624 respondent FSW-IDUs, prevalence of syringe confiscation in the last 6 months was 48%. The following factors were positively associated with syringe confiscation: testing positive for HIV (adjusted odds ratio [aOR] = 2.54, 95% confidence interval [CI] = 1.11-5.80), reporting sexual abuse by police (aOR = 12.76, 95% CI = 6.58-24.72), engaging in groin injection (aOR = 1.84, 95% CI = 1.15-2.93), injecting in public (aOR = 1.64; 95% CI = 1.14-2.36), and obtaining syringes from pharmacies (aOR = 1.54; 95% CI = 1.06-2.23). Higher education level was negatively associated with syringe confiscation (aOR = 0.92, 95% CI = 0.87-0.98) as was frequent injection with clients within the last month (aOR = 0.64, 95% CI = 0.44-0.94). This analysis adds to the body of evidence linking unauthorized law enforcement actions targeting high-risk groups with HIV and other adverse health outcomes. Using a public health lens to conceptualize abuse as a structural risk factor, we advocate for multi-prong prevention, systematic monitoring, and evidence-based intervention response to deleterious police practices.

The potential uses of preexposure prophylaxis for HIV prevention among people who inject drugs

PURPOSE OF REVIEW

Oral preexposure prophylaxis (PrEP) has shown HIV preventive efficacy for several key populations at risk for HIV infection including MSM and heterosexual men and women in HIV serodiscordant relationships. An efficacy trial of daily oral tenofovir among people who inject drugs (IDU) is underway in Thailand.

RECENT FINDINGS

Although efficacy data is pending, there is emerging biological and public health plausibility data suggesting the utility of PrEP as an effective component of combination HIV prevention for IDU. Drawing from studies characterizing adherence to antiretroviral therapy for IDU, there are a range of scientific and operational considerations for the potential use of PrEP for IDU. We review here the available literature on the potential use of PrEP for IDU, barriers to uptake and adherence, and potential implementation science questions, which could address, and potently increase, the effectiveness of this intervention.

SUMMARY

IDU remain the most underserved population in the HIV response worldwide, and have a marked gap in prevention services, making PrEP a potentially promising addition to the prevention toolkit for people who use drugs and, for those already living with HIV infection, for their spouses and other sexual partners.

Interdisciplinary mixed methods research with structurally vulnerable populations: case studies of injection drug users in San Francisco

Research with injection drug users (IDUs) benefits from interdisciplinary theoretical and methodological innovation because drug use is illegal, socially sanctioned and often hidden. Despite the increasing visibility of interdisciplinary, mixed methods research projects with IDUs, qualitative components are often subordinated to quantitative approaches and page restrictions in top addiction journals limit detailed reports of complex data collection and analysis logistics, thus minimizing the fuller scientific potential of genuine mixed methods. We present the methodological logistics and conceptual approaches of four mixed-methods research projects that our interdisciplinary team conducted in San Francisco with IDUs over the past two decades. These projects include combinations of participant-observation ethnography, in-depth qualitative interviewing, epidemiological surveys, photo-documentation, and geographic mapping. We adapted Greene et al.'s framework for combining methods in a single research project through: data triangulation, methodological complementarity, methodological initiation, and methodological expansion. We argue that: (1) flexible and self-reflexive methodological procedures allowed us to seize strategic opportunities to document unexpected and sometimes contradictory findings as they emerged to generate new research questions, (2) iteratively mixing methods increased the scope, reliability, and generalizability of our data, and (3) interdisciplinary collaboration contributed to a scientific "value added" that allowed for more robust theoretical and practical findings about drug use and risk-taking.

Sex worker-led structural interventions in India: a case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore

Background & objectives:

Structural interventions have the capacity to improve the outcomes of HIV/AIDS interventions by changing the social, economic, political or environmental factors that determine risk and vulnerability. Marginalized groups face disproportionate barriers to health, and sex workers are among those at highest risk of HIV in India. Evidence in India and globally has shown that sex workers face violence in many forms ranging from verbal, psychological and emotional abuse to economic extortion, physical and sexual violence and this is directly linked to lower levels of condom use and higher levels of sexually transmitted infections (STIs), the most critical determinants of HIV risk. We present here a case study of an intervention that mobilized sex workers to lead an HIV prevention response that addresses violence in their daily lives.

Methods:

This study draws on ethnographic research and project monitoring data from a community-led structural intervention in Mysore, India, implemented by Ashodaya Samithi. Qualitative and quantitative data were used to characterize baseline conditions, community responses and subsequent outcomes related to violence.

Results:

In 2004, the incidence of reported violence by sex workers was extremely high (> 8 incidents per sex worker, per year) but decreased by 84 per cent over 5 years. Violence by police and anti-social elements, initially most common, decreased substantially after a safe space was established for sex workers to meet and crisis management and advocacy were initiated with different stakeholders. Violence by clients, decreased after working with lodge owners to improve safety. However, initial increases in intimate partner violence were reported, and may be explained by two factors: (i) increased willingness to report such incidents; and (ii) increased violence as a reaction to sex workers’ growing empowerment. Trafficking was addressed through the establishment of a self-regulatory board (SRB). The community's progressive response to violence was enabled by advancing community mobilization, ensuring community ownership of the intervention, and shifting structural vulnerabilities, whereby sex workers increasingly engaged key actors in support of a more enabling environment.

Interpretation & conclusions:

Ashodaya's community-led response to violence at multiple levels proved highly synergistic and effective in reducing structural violence.

Mexico's northern border conflict: collateral damage to health and human rights of vulnerable groups

OBJECTIVE

To compare distributions of human rights violations and disease risk; to juxtapose these patterns against demographic and structural environmental variables, and to formulate implications for structural interventions.

METHODS

Female sex workers who inject drugs were surveyed in Tijuana and Ciudad Juarez, Mexico. Structured interviews and testing for sexually transmitted infections (STIs) were conducted (October 2008 to October 2009). Frequencies of individual and environmental factors, including police abuse, risk of HIV infection, and protective behaviors, were compared between sites using univariate logistic regression.

RESULTS

Of 624 women, almost half reported police syringe confiscation despite syringes being legal; 55.6% reported extortion (past 6 months), with significantly higher proportions in Ciudad Juarez (P < 0.001). Reports of recent solicitation of sexual favors (28.5% in Tijuana, 36.5% in Ciudad Juarez, P = 0.04) and sexual abuse (15.7% in Tijuana, 18.3% in Ciudad Juarez) by police were commonplace. Prevalence of STIs was significantly lower in Tijuana than in Ciudad Juarez (64.2% and 83.4%, P < 0.001), paralleling the lower prevalence of sexual risk behaviors there. Ciudad Juarez respondents reported significantly higher median number of monthly clients (6.8 versus 1.5, P < 0.001) and lower median pay per sex act (US$ 10 versus US$ 20, P < 0.001) (in the past month). Relative to Tijuana, security deployment, especially the army's presence, was perceived to have increased more in Ciudad Juarez in the past year (72.1% versus 59.2%, P = 0.001).

CONCLUSIONS

Collateral damage from police practices in the context of Mexico's drug conflict may affect public health in the Northern Border Region. Itinerant officers may facilitate disease spread beyond the region. The urgency for mounting structural interventions is discussed.

Reasons for non- use of condoms and self- efficacy among female sex workers: a qualitative study in Nepal

Background

Heterosexual contact is the most common mode of transmission of sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV) in Nepal and it is largely linked to sex work. We assessed the non-use of condoms in sex work with intimate sex partners by female sex workers (FSWs) and the associated self-efficacy to inform the planning of STI/HIV prevention programmes in the general population.

Methods

This paper is based on a qualitative study of Female Sex Workers (FSWs) in Nepal. In-depth interviews and extended field observation were conducted with 15 FSWs in order to explore issues of safe sex and risk management in relation to their work place, health and individual behaviours.

Results

The main risk factor identified for the non-use of condoms with intimate partners and regular clients was low self efficacy. Non-use of condoms with husband and boyfriends placed them at risk of STIs including HIV. In addition to intimidation and violence from the police, clients and intimate partners, clients' resistance and lack of negotiation capacity were identified as barriers in using condoms by the FSWs.

Conclusion

This study sheds light on the live and work of FSWs in Nepal. This information is relevant for both the Government of Nepal and Non Governmental Organisations (NGO) to help improve the position of FSWs in the community, their general well-being and to reduce their risks at work.

Managing la malilla: Exploring drug treatment experiences among injection drug users in Tijuana, Mexico, and their implications for drug law reform

BACKGROUND

In August 2009, Mexico reformed its drug laws and decriminalized small quantities of drugs for personal use; offenders caught three times will be mandated to enter drug treatment. However, little is known about the quality or effectiveness of drug treatment programs in Mexico. We examined injection drug users' (IDUs) experiences in drug treatment in Tijuana, Mexico, with the goal of informing program planning and policy.

METHODS

We examined qualitative and quantitative data from Proyecto El Cuete, a multi-phased research study on HIV risk among IDUs in Tijuana. Phase I consisted of 20 in-depth interviews and Phase II employed respondent-driven sampling to recruit 222 IDUs for a quantitative survey. We also reviewed national drug policy documents, surveillance data, and media reports to situate drug users' experiences within the broader sociopolitical context.

RESULTS

Participants in the qualitative study were 50% male with a mean age of 32; most injected heroin (85.0%) and methamphetamine (60.0%). The quantitative sample was 91.4% male with a mean age of 35; 98.2% injected heroin and 83.7% injected heroin and methamphetamine together. The majority of participants reported receiving treatment: residential treatment was most common, followed by methadone; other types of services were infrequently reported. Participants' perceptions of program acceptability and effectiveness were mixed. Mistreatment emerged as a theme in the qualitative interviews and was reported by 21.6% of Phase II participants, primarily physical (72.0%) and verbal (52.0%) abuse.

CONCLUSIONS

Our results point to the need for political, economic, and social investment in the drug treatment system before offenders are sentenced to treatment under the revised national drug law. Resources are needed to strengthen program quality and ensure accountability. The public health impact of the new legislation that attempts to bring drug treatment to the forefront of national drug policy should be systematically evaluated.

HIV and risk environment for injecting drug users: the past, present, and future

We systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. We then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. We estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting IDUs' access to HIV prevention and treatment could substantially curtail HIV epidemics.

Epidemiology of HIV infection in the Middle East and North Africa

OBJECTIVE

The Middle East and North Africa (MENA) region continues to be perceived as a region with very limited HIV epidemiological data, raising many controversies about the status of the epidemic in this part of the world. The objective of this review and synthesis was to address the dearth of strategic interpretable data on HIV in MENA by delineating a data-driven overview of HIV epidemiology in this region.

METHODS

A comprehensive systematic review of HIV, sexually transmitted infections (STIs) and risk behavior studies in MENA, irrespective of design, was undertaken. Sources of data included Medline for peer-reviewed publications, Google Scholar for other scientific literature published in nonindexed local and regional journals, international organizations reports and databases, country-level reports and database including governmental and nongovernmental organizations publications, as well as various other institutional documents.

RESULTS

Over 5000 sources of data related to HIV and STIs were identified and reviewed. The quality of data and nature of study designs varied substantially. There was no evidence for a sustainable HIV epidemic in the general population in any of the MENA countries, except possibly for southern Sudan. The general pattern in different countries in MENA points towards emerging epidemics in high-risk populations including injecting drug users, men who have sex with men (MSM) and to a lesser extent female sex workers, with heterogeneity between countries on the relative role of each of these high-risk groups. Exogenous HIV exposures among nationals linked to travel abroad appeared to be the dominant HIV transmission pattern in a few MENA countries with no evidence for much epidemic or endemic transmission. The role of bridging populations in bridging the HIV infection to the general population was found to be very limited.

CONCLUSION

Although they do not provide complete protection against HIV spread, near universal male circumcision and possibly the prevailing sexually conservative cultural norms seemed to have played so far a protective role in slowing and limiting HIV transmission in MENA relative to other regions. If the existing social and epidemiological context remains largely the same, HIV epidemic transmission is likely to remain confined to high-risk populations and their sexual partners, in addition to exogenous exposures. HIV prevention efforts in this region, which continue to be stymied by stigma associated with HIV/AIDS and related risk behaviors, need to be aggressively expanded with a focus on controlling HIV spread along the contours of risk and vulnerability. There is still a window of opportunity to control further HIV transmission among high-risk groups in MENA that, if missed, may entail a health and socioeconomic burden that the region, in large part, is unprepared for.

Multiple risks among male and transgender sex workers in Pakistan

Using data from a qualitative study and a subsequent quantitative survey among 918 male and transgender sex workers (MTSW), we explore the context of multiple risks they face. We show that over one-fifth of MTSW have sex with IDU clients. Combined with high levels of risk behavior and very low levels of risk reduction and knowledge, the extent of sexual networking with men who inject drugs contributes further to the sex workers' health risks. Our findings suggest that isolated interventions with single-risk groups are unlikely to be sufficient to control the spread of the epidemic in Pakistan. We highlight the need for integrated approaches to risk reduction programs among MTSW and IDUs.