The Men Who Have Sex with Men HIV Care Cascade in Rio de Janeiro, Brazil

Mpox severity and associated hospitalizations among people with HIV and related immunosuppression in Brazil

OBJECTIVES

This study aimed to analyze characteristics of mpox hospitalization in a Brazilian cohort, further exploring the impact of HIV on mpox-related outcomes and hospitalization.

DESIGN

We conducted a descriptive analysis, comparing characteristics of individuals diagnosed with mpox according to hospitalization and HIV status, and described the mpox cases among those living with HIV.

METHODS

This was a single-center, prospective cohort study conducted at a major infectious diseases referral center in Rio de Janeiro, Brazil, that enrolled participants older than 18 years of age diagnosed with mpox. Information was collected on standardized forms, including data on sociodemographic, behavioral, clinical and laboratory characteristics. For comparisons, we used chi-squared, Fisher's exact and the Moods median tests whenever appropriate.

RESULTS

From June to December, 2022, we enrolled 418 individuals diagnosed with mpox, of whom 52% were people with HIV (PWH). PWH presented more frequently with fever, anogenital lesions and proctitis. The overall hospitalization rate was 10.5% ( n  = 43), especially for pain control. Among hospitalized participants, PWH had more proctitis and required invasive support. Mpox severity was related to poor HIV continuum of care outcomes and low CD4 + cell counts. All deaths ( n  = 2) occurred in PWH with CD4 + less than 50 cells/μl.

CONCLUSION

HIV-related immunosuppression likely impacts mpox clinical outcomes. This is of special concern in settings of poor adherence and late presentation to care related to socioeconomic inequalities, such as Brazil. The HIV continuum of care must be taken into account when responding to the mpox outbreak.

A systematic review and meta-analysis of the evidence for community-based HIV testing on men's engagement in the HIV care cascade

OBJECTIVE

Men with HIV are less likely than women to know their status, be on antiretroviral therapy, and be virally suppressed. This review examined men's community-based HIV testing services (CB-HTS) outcomes.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched seven databases and conference abstracts through July 2018. We estimated pooled proportions and/or risk ratios (for meta-analyses) for each outcome using random effects models.

RESULTS

188 studies met inclusion criteria. Common testing models included targeted outreach (e.g. mobile testing), home-based testing, and testing at stand-alone community sites. Across 25 studies reporting uptake, 81% (CI: 75-86%) of men offered testing accepted it. Uptake was higher among men reached through CB-HTS than facility-based HTS (RR = 1.39; CI: 1.13-1.71). Over 69% (CI: 64-71%) of those tested through CB-HTS were men, across 184 studies. Across studies reporting new HIV-positivity among men (n = 18), 96% were newly diagnosed (CI: 77-100%). Across studies reporting linkage to HIV care (n = 8), 70% (CI: 36-103%) of men were linked to care. Across 57 studies reporting sex-disaggregated data for CB-HTS conducted among key populations, men's uptake was high (80%; CI: 70-88%) and nearly all were newly diagnosed and linked to care (95%; CI: 94-100%; and 94%; CI: 88-100%, respectively).

CONCLUSION

CB-HTS is an important strategy for reaching undiagnosed men with HIV from the general population and key population groups, particularly using targeted outreach models. When compared to facility-based HIV testing services, men tested through CB-HTS are more likely to uptake testing, and nearly all men who tested positive through CB-HTS were newly diagnosed. Linkage to care may be a challenge following CB-HTS, and greater efforts and research are needed to effectively implement testing strategies that facilitate rapid ART initiation and linkage to prevention services.

Sampling bias in Brazilian studies on transgender and gender diverse populations: the two-step measure for assessing gender identity in surveys

Abstract: Correctly recognizing gender identity in population-based surveys is essential to develop effective public health strategies to improve the living conditions of transgender and gender-diverse populations, as well as to adequately collect data on cisgender individuals. This study aims to present the two-step measure as the best strategy for assessing gender identity in Brazilian surveys, thus we performed two separate analyses. Firstly, we conducted a systematic review concerning HIV-related care among Brazilian transgender and gender-diverse populations to assess the strategy used to identify participants’ gender identity. Secondly, we re-analyzed data from a recent survey that included Brazilian transgender populations, comparing characteristics and health outcomes from the sample identified by single-item and by the two-step measure. Concerning the systematic review, from 6,585 references, Brazilian research teams published seven articles, and only one study used the two-step measure. Regarding this survey, the two-step measure recognized 567 cisgender and 773 transgender and gender diverse participants among the 1,340 participants who answered the questionnaire, whereas the single-item measure was able to recognize only 540 transgender and gender diverse people. Furthermore, 31 transgender women self-identified as “transgender men” on the single-item measure. Therefore, although scarcely used in Brazil, the two-step measure is a more accurate strategy to recognize gender identity.

HIV Treatment Cascade and PrEP Care Continuum Among Serodiscordant Male Couples in the United States

A large proportion of HIV infections among men who have sex with men occur within primary partnerships, however, there is a lack of research focused on serodiscordant male couples. We used baseline data collected as part of Project Stronger Together-a randomized controlled trial to improve treatment outcomes among 155 serodiscordant male couples. We described engagement in HIV care/prevention using the HIV treatment cascade and PrEP care continuum. Among partners living with HIV, 86.5% were linked to care, 77.4% retained in care, 81.3% prescribed ART, 60.7% adherent, and 67.7%virally suppressed. Among HIV-negative partners, 62.6% were willing to take PrEP, 48.4% had ever taken PrEP, and 26.5% were adherent to PrEP. Black partners living with HIV had lower odds of being virally suppressed compared to White partners. Our findings provide evidence to suggest designing programs to address the racial disparities in viral suppression, addressing barriers to HIV prevention/treatment, and improving PrEP education.

Repurposing NGO data for better research outcomes: a scoping review of the use and secondary analysis of NGO data in health policy and systems research

Background

Non-governmental organisations (NGOs) collect and generate vast amounts of potentially rich data, most of which are not used for research purposes. Secondary analysis of NGO data (their use and analysis in a study for which they were not originally collected) presents an important but largely unrealised opportunity to provide new research insights in critical areas, including the evaluation of health policy and programmes.

Methods

A scoping review of the published literature was performed to identify the extent to which secondary analysis of NGO data has been used in health policy and systems research (HPSR). A tiered analytical approach provided a comprehensive overview and descriptive analyses of the studies that (1) used data produced or collected by or about NGOs; (2) performed secondary analysis of the NGO data (beyond the use of an NGO report as a supporting reference); and (3) analysed NGO-collected clinical data.

Results

Of the 156 studies that performed secondary analysis of NGO-produced or collected data, 64% (n = 100) used NGO-produced reports (mostly to a limited extent, as a contextual reference or to critique NGO activities) and 8% (n = 13) analysed NGO-collected clinical data. Of these studies, 55% (n = 86) investigated service delivery research topics and 48% (n = 51) were undertaken in developing countries and 17% (n = 27) in both developing and developed countries. NGOs were authors or co-authors of 26% of the studies. NGO-collected clinical data enabled HPSR within marginalised groups (e.g. migrants, people in conflict-affected areas), albeit with some limitations such as inconsistent and missing data.

Conclusion

We found evidence that NGO-collected and produced data are most commonly perceived as a source of supporting evidence for HPSR and not as primary source data. However, these data can facilitate research in under-researched marginalised groups and in contexts that are hard to reach by academics such as conflict-affected areas. NGO–academic collaboration could help address issues of NGO data quality to facilitate their more widespread use in research. The use of NGO data use could enable relevant and timely research in the areas of programme evaluation and health policy and advocacy to improve health and reduce health inequalities, especially in marginalised groups and developing countries.

An Internet-Based HIV Self-Testing Program to Increase HIV Testing Uptake Among Men Who Have Sex With Men in Brazil: Descriptive Cross-Sectional Analysis

Background

Approximately 30% of people living with HIV worldwide are estimated to be unaware of their infection. HIV self-testing (HIVST) is a strategy recommended by the World Health Organization to increase access to and uptake of testing among key populations who are at high risk for HIV infection.

Objective

This study aimed to describe the development and feasibility of a free, anonymous, internet-based HIVST strategy designed for men who have sex with men in Curitiba, Brazil (electronic testing [e-testing]).

Methods

The project was developed under the scope of the “A Hora é Agora” (The Time is Now) program. Individuals aiming to request an HIVST package (two tests each) answered an anonymous 5-minute questionnaire regarding inclusion criteria and sexual risk behavior. Eligible individuals could receive one package every 6 months for free. Website analytics, response to online questionnaires, package distribution, and return of test results were monitored via a platform-integrated system.

Results

Between February 2015 and January 2016, the website documented 17,786 unique visitors and 3218 completed online questionnaires. Most individuals self-reported being white (77.0%), young (median age: 25 years, interquartile range: 22-31 years), educated (87.3% completed secondary education or more), and previously tested for HIV (62.5%). Overall, 2526 HIVST packages were delivered; of those, 542 (21.4%) reported a result online or by mail (23 reactive and 11 invalid). During the study period, 37 individuals who reported using e-testing visited the prespecified health facility for confirmatory testing (30 positive, 7 negative).

Conclusions

E-testing proved highly feasible and acceptable in this study, thus supporting scale-up to additional centers for men who have sex with men in Brazil.

HIV-related care for transgender people: A systematic review of studies from around the world

RATIONALE

Transgender people face unique challenges, such as structural, interpersonal, and individual vulnerabilities to chronic diseases. Stigma and prejudice may hamper their access to health care and prevent their inclusion in the labor market, as well as cause exposition to violence. Labor market exclusion contributes to engagement in survival sex work, which increases HIV infection vulnerability. HIV continuum of care combines HIV prevention (including antiretroviral pre-exposure prophylaxis (PrEP), antiretroviral post-exposure prophylaxis (PEP) and HIV testing) with linkage to care (that is, initiating, maintaining and monitoring antiretroviral therapy). Currently, many studies evaluate the access barriers and facilitators to HIV care for transgender people.

OBJECTIVE

The present systematic review aimed to provide a clear summary of the current literature on HIV-related care for transgender men, transgender women and gender diverse people.

METHOD

Inclusion criteria were peer-reviewed quantitative studies, published through April 04, 2018, concerning transgender women, transgender men and gender diverse people and HIV-related care, which was any intervention aiming to prevent, treat or alleviate the impact of HIV on these populations.

RESULTS

From 6,585 references, 62 articles were included: Three articles had results on PEP, 18 on PrEP, 29 on HIV-testing, 17 on access to health care, and 13 on adherence to treatment.

CONCLUSIONS

The present study is the first systematic review evaluating HIV-related care for transgender people. Data collection is still scarce regarding transgender men and gender diverse people. Worldwide, testing for HIV infection does not necessarily enable access to the HIV continuum of care for transgender populations or even guarantee awareness of HIV seropositivity.

An urgent need for HIV testing among men who have sex with men and transgender women in Bamako, Mali: Low awareness of HIV infection and viral suppression among those living with HIV

Despite the high HIV prevalence among men who have sex with men (MSM) and transgender women (TGW), there are limited data on progress on their respective HIV antiretroviral treatment (ART) cascades to identify progress and gaps in meeting UNAIDS 90-90-90 targets. We conducted a respondent-driven sampling survey of MSM and TGW in Bamako, Mali from October 2014 to February 2015. We describe the HIV treatment cascade for MSM and TGW, identify correlates of being unaware of HIV-infected status and having unsuppressed viral load levels, and estimate proportion of recent infections. We enrolled 387 MSM and 165 TGW. HIV prevalence was 13.7%. Of those living with HIV, 10.4% were aware of their serostatus, 61.2% of them self-reported being on treatment, and of them, 100% were virally suppressed. In multivariate analysis, factors associated with being unaware of HIV infection included not using free condoms in the last six months (aOR: 5.7, 95% CI: 1.1–29.5) and not having comprehensive knowledge of HIV (aOR: 6.5, 95% CI: 1.4–29.9). Having unsuppressed viral load was associated with identifying as a transgender woman (aOR: 4.8, 95% CI: 1.1–20.7) and not having comprehensive knowledge of HIV (aOR: 6.5, 95% CI: 1.0–40.9). Of the 79 HIV-positive participants, 5.1% had recent infections. While the proportion aware of their HIV status was low despite adjusting for viral load biomarkers, all MSM and TGW on treatment were virally suppressed. Improved testing strategies are urgently needed to achieve the first 90 of the HIV cascade among MSM and TGW in Bamako.

Achieving Viral Suppression in 90% of People Living With Human Immunodeficiency Virus on Antiretroviral Therapy in Low- and Middle-Income Countries: Progress, Challenges, and Opportunities

Although significant progress has been made, the latest data from low- and middle-income countries show substantial gaps in reaching the third "90%" (viral suppression) of the UNAIDS 90-90-90 goals, especially among vulnerable and key populations. This article discusses critical gaps and promising, evidence-based solutions. There is no simple and/or single approach to achieve the last 90%. This will require multifaceted, scalable strategies that engage people living with human immunodeficiency virus, motivate long-term treatment adherence, and are community-entrenched and ‑supported, cost-effective, and tailored to a wide range of global communities.

Comparison of HIV Status Between Transgender Women and Men Who Have Sex with Men: A Meta-Analysis

As key population groups in HIV infection, transgender women (TGW) share the same oral and anal sexual practices with men who have sex with men (MSM). However, the differences in HIV rates between the two groups are still unclear. In our study, relevant publications were electronically searched in three databases. After excluding irrelevant studies based on review of the title, abstract, and full text, a total of 24 studies, including 37,521 cases, were identified. There were no significant differences between TGW and MSM regarding HIV status and condom use. However, TGW had a higher proportion of high-risk behaviors, including exchanges of sex, forced sex, receptive intercourse, and sex work experience. Moreover, most curable sexually transmitted diseases were more prevalent in the TGW group compared to MSM. Although TGW showed a higher proportion of high-risk behavior and sexually transmitted disease incidence, their HIV incidence was the same as that for MSM.

HIV testing and the care continuum among transgender women: population estimates from Rio de Janeiro, Brazil

Introduction: Evidence suggests that, of all affected populations, transgender women (transwomen) may have the heaviest HIV burden worldwide. Little is known about HIV linkage and care outcomes for transwomen. We aimed to estimate population-level indicators of the HIV cascade of care continuum, and to evaluate factors associated with viral suppression among transwomen in Rio de Janeiro, Brazil.

Methods: We conducted a respondent-driven sampling (RDS) study of transwomen from August 2015 to January 2016 in Rio de Janeiro, Brazil and collected data on linkage and access to care, antiretroviral treatment and performed HIV viral load testing. We derived population-based estimates of cascade indicators using sampling weights and conducted RDS-weighted logistic regression analyses to evaluate correlates of viral suppression (viral load ≤50 copies/mL).

Results: Of the 345 transwomen included in the study, 89.2% (95% CI 55–100%) had been previously tested for HIV, 77.5% (95% CI 48.7–100%) had been previously diagnosed with HIV, 67.2% (95% CI 39.2–95.2) reported linkage to care, 62.2% (95% CI 35.4–88.9) were currently on ART and 35.4% (95% CI 9.5–61.4%) had an undetectable viral load. The final adjusted RDS-weighted logistic regression model for viral suppression indicated that those who self-identified as black (adjusted odds ratio [aOR] 0.06, 95% CI 0.01–0.53, p < 0.01), reported earning ≤U$160/month (aOR 0.11, 95% CI 0.16–0.87, p = 0.04) or reported unstable housing (aOR 0.08, 95% CI 0.01–0.43, p < 0.01) had significantly lower odds of viral suppression.

Conclusions: Our cascade indicators for transwomen showed modest ART use and low viral suppression rates. Multi-level efforts including gender affirming care provision are urgently needed to decrease disparities in HIV clinical outcomes among transwomen and reduce secondary HIV transmission to their partners.

Perceptions of HIV Seriousness, Risk, and Threat Among Online Samples of HIV-Negative Men Who Have Sex With Men in Seven Countries

Background

Rates of new HIV infections continue to increase worldwide among men who have sex with men (MSM). Despite effective prevention strategies such as condoms and pre-exposure prophylaxis (PrEP), low usage of both methods in many parts of the world hinder prevention efforts. An individual’s perceptions of the risk of acquiring HIV and the seriousness they afford to seroconversion are important drivers of behavioral risk-taking. Understanding the behavioral factors suppressing the uptake of HIV prevention services is a critical step in informing strategies to improve interventions to combat the ongoing HIV pandemic among MSM.

Objective

The study aimed to examine cross-national perceptions of HIV/AIDS seriousness, risk, and threat and the association between these perceptions and sociodemographic characteristics, relationships, and high-risk sexual behaviors among MSM.

Methods

Participants in Australia, Brazil, Canada, Thailand, South Africa, the United Kingdom, and the United States were recruited for a self-administered survey via Facebook (N=1908). Respondents were asked to rate their perceived seriousness from 1 (not at all serious) to 5 (very serious) of contracting HIV, their perceived risk from 1 (no risk) to 10 (very high risk) of contracting HIV based on their current behavior, and their perception of the threat of HIV—measured as their confidence in being able to stay HIV-negative throughout their lifetimes—on a scale from 1 (will not have HIV by the end of his lifetime) to 5 (will have HIV by the end of his lifetime). Covariates included sociodemographic factors, sexual behavior, HIV testing, drug use, and relationship status. Three ordered logistic regression models, one for each outcome variable, were fit for each country.

Results

Contracting HIV was perceived as serious (mean=4.1-4.6), but perceptions of HIV risk (mean=2.7-3.8) and threat of HIV (mean=1.7-2.2) were relatively low across countries. Older age was associated with significantly lower perceived seriousness of acquiring HIV in five countries (Australia: odds ratio, OR 0.97, 95% CI 0.94-0.99; Brazil: OR 0.95, 95% CI 0.91-0.98; Canada: OR 0.96, 95% CI 0.93-0.98; South Africa: OR 0.96, 95% CI 0.94-0.98; United Kingdom: OR 0.95, 95% CI 0.92-0.98). Being in a male-male sexual relationship was associated with significantly lower perceived risk of HIV in four countries (Australia: OR 0.47, 95% CI 0.30-0.75; Canada: OR: 0.54, 95% CI 0.35-0.86; United Kingdom: OR 0.38, 95% CI 0.24-0.60; United States: OR 0.5, 95% CI 0.31-0.82). Drug use in the previous year was associated with greater threat of contracting HIV in two countries (Canada: OR 1.81, 95% CI 1.13-2.91; United Kingdom: OR 1.7, 95% CI 1.06-2.74).

Conclusions

Few measures of behavioral or sexual risk-taking were significantly associated with perceived HIV seriousness, risk, or threat across countries. Overall, low levels of reported risk were identified, and results illustrate important gaps in the understanding of risk among MSM across societies that could be addressed through culturally-tailored prevention messaging.