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Bothma R, O'Connor C, Nkusi J, Shiba V, Segale J, Matsebula L, Lawrence JJ, van der Merwe LL, Chersich M, Hill N. Differentiated HIV services for transgender people in four South African districts: population characteristics and HIV care cascade. J Int AIDS Soc 2022; 25 Suppl 5:e25987. [PMID: 36225147 PMCID: PMC9557019 DOI: 10.1002/jia2.25987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 07/30/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Transgender people in South Africa are disproportionately affected by HIV, discrimination and stigma. Access to healthcare and health outcomes are poor. Although integrating gender-affirming healthcare with differentiated HIV prevention, care and treatment services has shown improvement in HIV service uptake and health outcomes among transgender people, evidence is lacking on the implementation of differentiated service delivery models in southern Africa. This article describes a differentiated service delivery model across four South African sites and transgender individuals who access these services. We assess whether hormone therapy (HT) is associated with continued use of pre-exposure prophylaxis (PrEP) and viral load suppression. METHODS In 2019, differentiated healthcare centres for transgender individuals opened in four South African districts, providing gender-affirming healthcare and HIV services at a primary healthcare level. Routine programme data were collected between October 2019 and June 2021. Descriptive statistics summarized patient characteristics and engagement with HIV prevention and treatment services. We conducted a multivariate logistic regression analysis to determine whether HT was associated with viral load suppression and PrEP continued use. RESULTS In the review period, we reached 5636 transgender individuals through peer outreach services; 86% (4829/5636) of them accepted an HIV test and 62% (3535/5636) were linked to clinical services. Among these, 89% (3130/3535) were transgender women, 5% (192/3535) were transgender men and 6% (213/3535) were gender non-conforming individuals. Of those who received an HIV test, 14% (687/4829) tested positive and 91% of those initiated antiretroviral treatment. Viral load suppression was 75% in this cohort. PrEP was accepted by 28% (1165/4142) of those who tested negative. Five percent (161/3535) reported ever receiving HT through the public healthcare system. Service users who received HT were three-fold more likely to achieve viral load suppression. We did not find any association between HT and continued use of PrEP. CONCLUSIONS A differentiated HIV and gender-affirming service delivery model at a primary healthcare level is feasible and can enhance service access in South Africa. HT can improve HIV clinical outcomes for transgender people. As trust is established between the providers and population, uptake of HIV testing and related services may increase further.
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Affiliation(s)
- Rutendo Bothma
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Cara O'Connor
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Jolie Nkusi
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Vusi Shiba
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Jacob Segale
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Luyanda Matsebula
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - J. Joseph Lawrence
- United States Agency for International Development/Southern AfricaCity of TshwaneSouth Africa
| | | | - Matthew Chersich
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
| | - Naomi Hill
- Wits Reproductive Health and HIV Institute (Wits RHI)University of the WitwatersrandJohannesburgSouth Africa
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Bautista-Martínez JS, Mata-Marín JA, Sandoval-Ramírez JL, Chaparro-Sánchez A, Manjarrez-Téllez B, Uribe-Noguez LA, Gaytán-Martínez J, Núñez-Armendáriz M, Cruz-Sánchez A, Núñez-Rodríguez N, Iván MA, Morales-González GS, Álvarez-Mendoza JP, Pérez-Barragán E, Ríos-De Los Ríos J, Contreras-Chávez GG, Tapia-Magallanes DM, Ribas-Aparicio RM, Díaz-López M, Olivares-Labastida A, Gómez-Delgado A, Torres J, Miranda-Duarte A, Zenteno JC, Pompa-Mera EN. Contribution of APOA5, APOC3, CETP, ABCA1 and SIK3 genetic variants to hypertriglyceridemia development in Mexican HIV-patients receiving antiretroviral therapy. Pharmacogenet Genomics 2022; 32:101-110. [PMID: 34693928 DOI: 10.1097/fpc.0000000000000458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the impact of single nucleotide polymorphisms (SNPs) from APOA5, APOC3, CETP, ATP binding cassette transporter A1 and SIK3 genes in the development of hypertriglyceridemia in HIV patients under antiretroviral therapy. MATERIAL AND METHODS A case-control study was developed. Leukocytic genomic DNA was extracted and genotyping for SNPs rs662799, rs964184, rs5128, rs2854116, rs2854117, rs3764261, rs4149310, rs4149267 and rs139961185 was performed by real time-PCR using TaqMan allelic discrimination assays, in Mexican mestizo patients with HIV infection, with hypertriglyceridemia (>1.7 mmol/L) under antiretroviral therapy. Genetic variants were also investigated in a control group of normolipidemic HIV patients (≤ 1.7 mmol/L). Haplotypes and gene interactions were analyzed. RESULTS A total of 602 HIV patients were genotyped (316 cases and 286 controls). Age and antiretroviral regimen based on protease inhibitors were associated with hypertriglyceridemia (P = 0.0001 and P = 0.0002. respectively). SNP rs964184 GG genotype in APOA5 gene exhibited the highest association with hypertriglyceridemia risk (OR, 3.2, 95% CI, 1.7-5.8, P = 0.0001); followed by SNP rs139961185 in SIK3 gene (OR = 2.3; (95% CI, 1.1-4.8; P = 0.03 for AA vs. AG genotype; and APOC3 rs5128 GG genotype, (OR, 2.2; 95% CI, 1.1-4.9; P = 0.04) under codominant models. These associations were maintained in the adjusted analysis by age and protease inhibitors based antiretroviral regimens. CONCLUSIONS This study reveals an association between rs964184 in APOA5; rs5128 in APOC3 and rs139961185 in SIK3 and high triglyceride concentrations in Mexican HIV-patients receiving protease inhibitors. These genetic factors may influence the adverse effects related to antiretroviral therapy.
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Affiliation(s)
- Jonathan Saúl Bautista-Martínez
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional
| | - José Antonio Mata-Marín
- Servicio de Infectología de Adultos, Hospital de Infectología, Centro Médico Nacional "La Raza"
| | | | | | | | | | - Jesús Gaytán-Martínez
- Servicio de Infectología de Adultos, Hospital de Infectología, Centro Médico Nacional "La Raza"
| | | | | | | | - Martínez-Abarca Iván
- Hospital General Regional 72, Instituto Mexicano del Seguro Social, IMSS. Tlalnepantla, Estado de México
| | | | | | | | - Jussara Ríos-De Los Ríos
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
| | - Gerson Gabriel Contreras-Chávez
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
| | - Denisse Marielle Tapia-Magallanes
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
| | - Rosa Maria Ribas-Aparicio
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional
| | - Mónica Díaz-López
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional
| | - Azucena Olivares-Labastida
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
- Departamento de Microbiología, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional
| | - Alejandro Gómez-Delgado
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
| | - Javier Torres
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
| | - Antonio Miranda-Duarte
- Departamento de Medicina Genómica, Instituto Nacional de Rehabilitación "Luis Guillermo Ibarra Ibarra"
| | - Juan C Zenteno
- Department of Genetics, Institute of Ophthalmology "Conde de Valenciana"
- Department of Biochemistry, Faculty of Medicine, UNAM, Mexico City, Mexico
| | - Ericka Nelly Pompa-Mera
- Unidad de Investigación Médica en Enfermedades Infecciosas y Parasitarias, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI. Instituto Mexicano del Seguro Social, IMSS
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Bilardi JE, Hulme-Chambers A, Chen MY, Fairley CK, Huffam SE, Tomnay JE. The role of stigma in the acceptance and disclosure of HIV among recently diagnosed men who have sex with men in Australia: A qualitative study. PLoS One 2019; 14:e0224616. [PMID: 31703087 PMCID: PMC6839846 DOI: 10.1371/journal.pone.0224616] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/17/2019] [Indexed: 01/11/2023] Open
Abstract
Background Our primary study aimed to explore the experiences of men who have sex with men (MSM) recently diagnosed with HIV and their partner notification practices. Themes relating to acceptance, and disclosure of, their HIV status strongly emerged during analysis in our larger study and are reported separately here. Method Fifteen MSM participated in semi-structured interviews by phone or face to face about their experience of a recent HIV diagnosis. In this paper we report on how they received and accepted the diagnosis, who they disclosed their diagnosis to and what is needed to improve support for MSM recently diagnosed with HIV. Results MSM’s reactions to their HIV diagnosis ranged from shock, devastation and anger to a calm acceptance and feeling HIV would not have a significant impact on their lives. MSM who reported strong social support networks, or knew others with HIV, seemed better able to cope with and accept their diagnosis than those with fewer support networks. Due to prevailing stigma around HIV, most MSM were very selective about who they disclosed their status to, often only telling partners perceived to be at risk but no, or only few, close friends. Regardless of how well men accepted their diagnosis, most did not disclose their status to family members for fear of rejection or causing distress due to ideologies based on outdated information about HIV. Conclusion The prevailing stigma around HIV can have a significant impact on MSM’s acceptance of, and willingness to disclose their HIV serostatus to others, and consequently the levels of professional and social support they receive. HIV-related stigma needs to be addressed through community campaigns which better educate the wider population about the current state of HIV prognosis and treatment.
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Affiliation(s)
- Jade E. Bilardi
- Central Clinical School, Monash University, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Victoria, Australia
- Department of General Practice, University of Melbourne, Victoria, Australia
| | - Alana Hulme-Chambers
- Centre for Excellence in Rural Sexual Health, University of Melbourne, Victoria, Australia
| | - Marcus Y. Chen
- Central Clinical School, Monash University, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Victoria, Australia
| | - Christopher K. Fairley
- Central Clinical School, Monash University, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Victoria, Australia
| | - Sarah E. Huffam
- Central Clinical School, Monash University, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Victoria, Australia
| | - Jane E. Tomnay
- Centre for Excellence in Rural Sexual Health, University of Melbourne, Victoria, Australia
- * E-mail:
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Variation in antiretroviral treatment coverage and virological suppression among three HIV key populations. AIDS 2018; 32:2807-2819. [PMID: 30289816 DOI: 10.1097/qad.0000000000002035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES We assessed differences in antiretroviral treatment (ART) coverage and virological suppression across three HIV key populations, as defined by self-reported HIV transmission category: sex between men, injection drug use (IDU) and heterosexual transmission. DESIGN A multinational cohort study. METHODS Within the EuroSIDA study, we assessed region-specific percentages of ART-coverage among those in care and virological suppression (<500 copies/ml) among those on ART, and analysed differences between transmission categories using logistic regression. RESULTS Among 12 872 participants followed from 1 July 2014 to 30 June 2016, the percentages of ART-coverage and virological suppression varied between transmission categories, depending on geographical region (global P for interaction: P = 0.0148 for ART-coverage, P = 0.0006 for virological suppression). In Western [adjusted odds ratio (aOR) 1.41 (95% confidence interval 1.14-1.75)] and Northern Europe [aOR 1.68 (95% confidence interval 1.25-2.26)], heterosexuals were more likely to receive ART than MSM, while in Eastern Europe, there was some evidence that infection through IDU [aOR 0.60 (95% confidence interval 0.31-1.14)] or heterosexual contact [aOR 0.58 (95% confidence interval 0.30-1.10)] was associated with lower odds of receiving ART. In terms of virological suppression, people infected through IDU or heterosexual contact in East Central and Eastern Europe were around half as likely as MSM to have a suppressed viral load on ART, while we observed no differences in virological suppression across transmission categories in Western and Northern Europe. CONCLUSION In our cohort, patterns of ART-coverage and virological suppression among key populations varied by geographical region, emphasizing the importance of tailoring HIV programmes to the local epidemic.
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Schwartz SR, Kavanagh MM, Sugarman J, Solomon SS, Njindam IM, Rebe K, Quinn TC, Toure-Kane C, Beyrer C, Baral S. HIV viral load monitoring among key populations in low- and middle-income countries: challenges and opportunities. J Int AIDS Soc 2018; 20 Suppl 7. [PMID: 29171178 PMCID: PMC5978693 DOI: 10.1002/jia2.25003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 11/08/2022] Open
Abstract
Introduction Key populations bear a disproportionate HIV burden and have substantial unmet treatment needs. Routine viral load monitoring represents the gold standard for assessing treatment response at the individual and programme levels; at the population‐level, community viral load is a metric of HIV programme effectiveness and can identify “hotspots” of HIV transmission. Nevertheless, there are specific implementation and ethical challenges to effectively operationalize and meaningfully interpret viral load data at the community level among these often marginalized populations. Discussion Viral load monitoring enhances HIV treatment, and programme evaluation, and offers a better understanding of HIV surveillance and epidemic trends. Programmatically, viral load monitoring can provide data related to HIV service delivery coverage and quality, as well as inequities in treatment access and uptake. From a population perspective, community viral load data provides information on HIV transmission risk. Furthermore, viral load data can be used as an advocacy tool to demonstrate differences in service delivery and to promote allocation of resources to disproportionately affected key populations and communities with suboptimal health outcomes. However, in order to perform viral load monitoring for individual and programme benefit, health surveillance and advocacy purposes, careful consideration must be given to how such key population programmes are designed and implemented. For example, HIV risk factors, such as particular sex practices, sex work and drug use, are stigmatized or even criminalized in many contexts. Consequently, efforts must be taken so that routine viral load monitoring among marginalized populations does not cause inadvertent harm. Furthermore, given the challenges of reaching representative samples of key populations, significant attention to meaningful recruitment, decentralization of care and interpretation of results is needed. Finally, improving the interoperability of health systems through judicious use of biometrics or identifiers when confidentiality can be maintained is important to generate more valuable data to inform monitoring programmes. Conclusions Opportunities for expanded viral load monitoring could and should benefit all those affected by HIV, including key populations. The promise of the increasing routinization of viral load monitoring as a tool to advance HIV treatment equity is great and should be prioritized and appropriately implemented within key population programmatic and research agendas.
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Affiliation(s)
- Sheree R Schwartz
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Matthew M Kavanagh
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, USA.,O'Neill Institute for National and Global Health Law, Georgetown University, Washington, DC, USA
| | - Jeremy Sugarman
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Sunil S Solomon
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Illiassou M Njindam
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Kevin Rebe
- Anova Health Institute, Cape Town, South Africa
| | - Thomas C Quinn
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Division of Intramural Research, National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Coumba Toure-Kane
- Department of Bacteriology and Virology, CHU Le Dantec, Dakar, Senegal
| | - Chris Beyrer
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Stefan Baral
- Department of Epidemiology, Center for Public Health and Human Rights, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Stevens O, Forrest JI. Thinking upstream: the roles of international health and drug policies in public health responses to chemsex. Sex Health 2018; 15:108-115. [DOI: 10.1071/sh17153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 12/20/2017] [Indexed: 11/23/2022]
Abstract
Chemsex is a growing public health concern in urban centres, and few interventions exist to mitigate the significant sexual, drug-related, and social harms potentially experienced by people who participate in chemsex. In much of the world, these immediate harms are further compounded by the criminalisation and stigmatisation of both homosexuality and drug use, preventing participants fully engaging with treatment services or provision of health care. Gay, bisexual and other men who have sex with men participating in chemsex fall between the traditional definitions of key populations and consequently are poorly provided for by existing drug and sexual health frameworks. Aetiologically complex issues such as chemsex require multifaceted interventions that may fall outside conventional frameworks. Existing interventions have been designed and implemented at the local level. The use of international policy to mitigate these structural barriers, however, has largely been ignored. International policy is broad in nature and its implementation is, in principle, binding for member states. We believe that despite its low international prevalence, international policy can be of use in improving the lives of people who participate in chemsex. Through stimulating a much-needed debate on the interplay between sex and drugs within global health and harm reduction frameworks, this paper aims to address the paucity of substantial discussion surrounding the applicability of international language to chemsex. We analyse international policy aimed at addressing HIV, illicit drugs, harm reduction, and development, and make recommendations for both national advocacy, and advocates working to alter the positions of member states internationally.
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Can differentiated care models solve the crisis in HIV treatment financing? Analysis of prospects for 38 countries in sub-Saharan Africa. J Int AIDS Soc 2017; 20:21648. [PMID: 28770597 PMCID: PMC5577732 DOI: 10.7448/ias.20.5.21648] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Rapid scale-up of antiretroviral therapy (ART) in the context of financial and health system constraints has resulted in calls to maximize efficiency in ART service delivery. Adopting differentiated care models (DCMs) for ART could potentially be more cost-efficient and improve outcomes. However, no study comprehensively projects the cost savings across countries. We model the potential reduction in facility-level costs and number of health workers needed when implementing two types of DCMs while attempting to reach 90-90-90 targets in 38 sub-Saharan African countries from 2016 to 2020. Methods: We estimated the costs of three service delivery models: (1) undifferentiated care, (2) differentiated care by patient age and stability, and (3) differentiated care by patient age, stability, key vs. general population status, and urban vs. rural location. Frequency of facility visits, type and frequency of laboratory testing, and coverage of community ART support vary by patient subgroup. For each model, we estimated the total costs of antiretroviral drugs, laboratory commodities, and facility-level personnel and overhead. Certain groups under four-criteria differentiation require more intensive inputs. Community-based ART costs were included in the DCMs. We take into account underlying uncertainty in the projected numbers on ART and unit costs. Results: Total five-year facility-based ART costs for undifferentiated care are estimated to be US$23.33 billion (95% confidence interval [CI]: $23.3–$23.5 billion). An estimated 17.5% (95% CI: 17.4%–17.7%) and 16.8% (95% CI: 16.7%–17.0%) could be saved from 2016 to 2020 from implementing the age and stability DCM and four-criteria DCM, respectively, with annual cost savings increasing over time. DCMs decrease the full-time equivalent (FTE) health workforce requirements for ART. An estimated 46.4% (95% CI: 46.1%–46.7%) fewer FTE health workers are needed in 2020 for the age and stability DCM compared with undifferentiated care. Conclusions: Adopting DCMs can result in significant efficiency gains in terms of reduced costs and health workforce needs, even with the costs of scaling up community-based ART support under DCMs. Efficiency gains remained flat with increased differentiation. More evidence is needed on how to translate analyzed efficiency gains into implemented cost reductions at the facility level.
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Poteat T, Ackerman B, Diouf D, Ceesay N, Mothopeng T, Odette KZ, Kouanda S, Ouedraogo HG, Simplice A, Kouame A, Mnisi Z, Trapence G, van der Merwe LLA, Jumbe V, Baral S. HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: A cross-sectional analysis. PLoS Med 2017; 14:e1002422. [PMID: 29112689 PMCID: PMC5675306 DOI: 10.1371/journal.pmed.1002422] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 10/02/2017] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Sub-Saharan Africa bears more than two-thirds of the worldwide burden of HIV; however, data among transgender women from the region are sparse. Transgender women across the world face significant vulnerability to HIV. This analysis aimed to assess HIV prevalence as well as psychosocial and behavioral drivers of HIV infection among transgender women compared with cisgender (non-transgender) men who have sex with men (cis-MSM) in 8 sub-Saharan African countries. METHODS AND FINDINGS Respondent-driven sampling targeted cis-MSM for enrollment. Data collection took place at 14 sites across 8 countries: Burkina Faso (January-August 2013), Côte d'Ivoire (March 2015-February 2016), The Gambia (July-December 2011), Lesotho (February-September 2014), Malawi (July 2011-March 2012), Senegal (February-November 2015), Swaziland (August-December 2011), and Togo (January-June 2013). Surveys gathered information on sexual orientation, gender identity, stigma, mental health, sexual behavior, and HIV testing. Rapid tests for HIV were conducted. Data were merged, and mixed effects logistic regression models were used to estimate relationships between gender identity and HIV infection. Among 4,586 participants assigned male sex at birth, 937 (20%) identified as transgender or female, and 3,649 were cis-MSM. The mean age of study participants was approximately 24 years, with no difference between transgender participants and cis-MSM. Compared to cis-MSM participants, transgender women were more likely to experience family exclusion (odds ratio [OR] 1.75, 95% CI 1.42-2.16, p < 0.001), rape (OR 1.95, 95% CI 1.63-2.36, p < 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12-1.52, p < 0.001). Transgender women were more likely to report condomless receptive anal sex in the prior 12 months (OR 2.44, 95% CI 2.05-2.90, p < 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49-2.19, p < 0.001). Overall HIV prevalence was 25% (235/926) in transgender women and 14% (505/3,594) in cis-MSM. When adjusted for age, condomless receptive anal sex, depression, interpersonal stigma, law enforcement stigma, and violence, and the interaction of gender with condomless receptive anal sex, the odds of HIV infection for transgender women were 2.2 times greater than the odds for cis-MSM (95% CI 1.65-2.87, p < 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments. CONCLUSIONS In this study in sub-Saharan Africa, we found that HIV burden and stigma differed between transgender women and cis-MSM, indicating a need to address gender diversity within HIV research and programs.
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Affiliation(s)
- Tonia Poteat
- Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Benjamin Ackerman
- Biostatistics Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Nuha Ceesay
- Joint United Nations Programme on HIV and AIDS Country Office, Mbabane, Swaziland
| | | | - Ky-Zerbo Odette
- Programme d’Appui au Monde Associatif et Communautaire, Ouagadougou, Burkina Faso
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
- Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | - Henri Gautier Ouedraogo
- Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso
- Institut Africain de Santé Publique, Ouagadougou, Burkina Faso
| | | | - Abo Kouame
- Ministère de la Sante et de l’Hygiène Publique, Abidjan, Côte d’Ivoire
| | - Zandile Mnisi
- Health Research Department, Strategic Information Division, Ministry of Health, Mbabane, Swaziland
| | - Gift Trapence
- Centre for the Development of People, Lilongwe, Malawi
| | - L. Leigh Ann van der Merwe
- Social, Health, and Empowerment Feminist Collective of Transgender Women of Africa, East London, South Africa
| | | | - Stefan Baral
- Epidemiology Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Ferro EG, Culbert GJ, Wickersham JA, Marcus R, Steffen AD, Pauls HA, Westergaard RP, Lee CK, Kamarulzaman A, Altice FL. Physician Decisions to Defer Antiretroviral Therapy in Key Populations: Implications for Reducing Human Immunodeficiency Virus Incidence and Mortality in Malaysia. Open Forum Infect Dis 2017; 4:ofw219. [PMID: 28480230 PMCID: PMC5414088 DOI: 10.1093/ofid/ofw219] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/12/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) is recommended for all people living with human immunodeficiency virus (HIV), yet physician attitudes and prescribing behaviors toward members of key risk populations may limit ART access and undermine treatment as prevention strategies. METHODS Physicians in Malaysia (N = 214) who prescribe antiretroviral therapy (ART) responded in an Internet-based survey to hypothetical clinical scenarios of HIV patients, varying by key risk population and CD4+ T-cell count, on whether they would initiate or defer ART compared with a control patient with sexually acquired HIV. RESULTS The proportion of physicians who would defer ART in patients with advanced HIV (CD4 = 17 cells/μL) was significantly higher (P < .0001) for 4 key populations, including people who inject drugs ([PWID] 45.3%) or consume alcohol (42.1%), released prisoners (35.0%), and those lacking social support (26.6%), compared with a control patient (4.2%). People who inject drugs with advanced HIV (CD4 = 17 cells/μL) were 19-fold (adjusted odds ratio [AOR] = 18.9; 95% confidence interval [CI], 9.8-36.5) more likely to have ART deferred compared with the control. This effect was partially mitigated for PWID receiving methadone (AOR = 2.9; 95% CI, 1.5-5.7). At the highest CD4+ T-cell count (CD4 = 470 cells/μL), sex workers (AOR = 0.55; 95% CI, .44-.70) and patients with an HIV-uninfected sexual partner (AOR = 0.43; 95% CI, .34-.57) were significantly less likely to have ART deferred. CONCLUSIONS Physicians who prescribe antiretroviral therapy in Malaysia may defer ART in some key populations including PWID and released prisoners, regardless of CD4+ T-cell count, which may help to explain very low rates of ART coverage among PWID in Malaysia. Reducing HIV incidence and mortality in Malaysia, where HIV is concentrated in PWID and other key populations, requires clinician-level interventions and monitoring physician adherence to international evidence-based treatment guidelines.
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Affiliation(s)
- Enrico G Ferro
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut; University of Illinois at Chicago, College of Nursing
| | | | - Jeffrey A Wickersham
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut; University of Illinois at Chicago, College of Nursing
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Malaysia
| | - Ruthanne Marcus
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut; University of Illinois at Chicago, College of Nursing
| | - Alana D Steffen
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut; University of Illinois at Chicago, College of Nursing
| | | | | | - Christopher K Lee
- Department of Medicine, Hospital Sungai Buloh, Jalan Hospital, Selangor, Malaysia
| | - Adeeba Kamarulzaman
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut; University of Illinois at Chicago, College of Nursing
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Malaysia
| | - Frederick L Altice
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, Connecticut; University of Illinois at Chicago, College of Nursing
- Centre of Excellence for Research in AIDS, Faculty of Medicine, University of Malaya, Malaysia
- Yale University School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut
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Hargreaves JR, Busza J, Mushati P, Fearon E, Cowan FM. Overlapping HIV and sex-work stigma among female sex workers recruited to 14 respondent-driven sampling surveys across Zimbabwe, 2013. AIDS Care 2016; 29:675-685. [PMID: 27998178 DOI: 10.1080/09540121.2016.1268673] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
HIV stigma can inhibit uptake of HIV testing and antiretroviral therapy as well as negatively affect mental health. Efforts to reduce discrimination against people living with HIV (LWH) have contributed to greater acceptance of the infection. Female sex workers (FSW) LWH may experience overlapping stigma due to both their work and HIV status, although this is poorly understood. We examined HIV and sex-work stigma experienced by FSW LWH in Zimbabwe. Using the SAPPH-IRe cluster-randomised trial baseline survey, we analysed the data from 1039 FSW self-reporting HIV. The women were recruited in 14 sites using respondent-driven sampling. We asked five questions to assess internalised and experienced stigma related to working as a sex worker, and the same questions were asked in reference to HIV. Among all FSW, 91% reported some form of sex-work stigma. This was not associated with sociodemographic or sex-work characteristics. Rates of sex-work stigma were higher than those of HIV-related stigma. For example, 38% reported being "talked badly about" for LWH compared with 77% for their involvement in sex work. Those who reported any sex-work stigma also reported experiencing more HIV stigma compared to those who did not report sex-work stigma, suggesting a layering effect. FSW in Zimbabwe experience stigma for their role as "immoral" women and this appears more prevalent than HIV stigma. As HIV stigma attenuates, other forms of social stigma associated with the disease may persist and continue to pose barriers to effective care.
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Affiliation(s)
- J R Hargreaves
- a Department of Social and Environmental Health Research , London School of Hygiene and Tropical Medicine , London , UK
| | - J Busza
- b Department of Population Health , London School of Hygiene and Tropical Medicine , London , UK
| | - P Mushati
- c Centre for Sexual Health and HIV/AIDS Research Zimbabwe , Harare , Zimbabwe
| | - E Fearon
- a Department of Social and Environmental Health Research , London School of Hygiene and Tropical Medicine , London , UK
| | - F M Cowan
- c Centre for Sexual Health and HIV/AIDS Research Zimbabwe , Harare , Zimbabwe.,d Department of Infection and Population Health , University College London , London , UK
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Guise A, Rhodes T, Ndimbii J, Ayon S, Nnaji O. Access to HIV treatment and care for people who inject drugs in Kenya: a short report. AIDS Care 2016; 28:1595-1599. [PMID: 27267309 DOI: 10.1080/09540121.2016.1191606] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
People who inject drugs (PWID) experience a range of barriers to HIV treatment and care access. The Kenyan government and community-based organisations have sought to develop HIV care for PWID. A principal approach to delivery in Kenya is to provide care from clinics serving the general population and for this to be linked to support from community-based organisations providing harm reduction outreach. This study explores accounts of PWID accessing care in Kenya to identify care barriers and facilitators. PWID accounts were collected within a qualitative longitudinal study. In-depth interviews with PWID living with HIV (n = 44) are combined with interviews with other PWID, care providers and community observation. Results show that some PWID are able to access care successfully, whilst other PWID report challenges. The results focus on three principal themes to give insights into these experiences: the hardship of addiction and the costs of care, the silencing of HIV in the community and then discrimination and support in the clinic. Some PWID are able to overcome, often with social and outreach support, barriers to clinic access; for others, the challenges of addiction, hardship, stigma and discrimination are too constraining. We discuss how clinics serving the general population could be further adapted to increase access. Clinic-based care, even with community links, may, however, be fundamentally challenging for some PWID to access. Additional strategies to develop stand-alone care for PWID and also decentralise HIV treatment and care to community settings and involve peers in delivery should be considered.
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Affiliation(s)
- Andy Guise
- a Dept of Global Public Health , University of California San Diego , San Diego , CA , USA.,b Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine , London , UK
| | - Tim Rhodes
- b Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine , London , UK
| | - James Ndimbii
- c Community Action on Harm Reduction Project, Kenya AIDS NGOs Consortium , Nairobi , Kenya
| | - Sylvia Ayon
- c Community Action on Harm Reduction Project, Kenya AIDS NGOs Consortium , Nairobi , Kenya
| | - Obiora Nnaji
- d Mount Sinai Hospital Services, Elmhurst Hospital Centre , Elmhurst , NY , USA
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12
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IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents. J Int Assoc Provid AIDS Care 2015; 14 Suppl 1:S3-S34. [PMID: 26527218 DOI: 10.1177/2325957415613442] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND An estimated 50% of people living with HIV (PLHIV) globally are unaware of their status. Among those who know their HIV status, many do not receive antiretroviral therapy (ART) in a timely manner, fail to remain engaged in care, or do not achieve sustained viral suppression. Barriers across the HIV care continuum prevent PLHIV from achieving the therapeutic and preventive effects of ART. METHODS A systematic literature search was conducted, and 6132 articles, including randomized controlled trials, observational studies with or without comparators, cross-sectional studies, and descriptive documents, met the inclusion criteria. Of these, 1047 articles were used to generate 36 recommendations to optimize the HIV care continuum for adults and adolescents. RECOMMENDATIONS Recommendations are provided for interventions to optimize the HIV care environment; increase HIV testing and linkage to care, treatment coverage, retention in care, and viral suppression; and monitor the HIV care continuum.
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Beckham SW, Shembilu CR, Brahmbhatt H, Winch PJ, Beyrer C, Kerrigan DL. Female sex workers' experiences with intended pregnancy and antenatal care services in southern Tanzania. Stud Fam Plann 2015; 46:55-71. [PMID: 25753059 DOI: 10.1111/j.1728-4465.2015.00015.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Understanding the pregnancy experiences of female sex workers (FSWs), especially in the context of high rates of HIV and sexually transmitted infections (STIs), is essential to tailoring services to meet their needs. This study explores FSWs' experiences with intended pregnancy and access to antenatal care and HIV testing in two regions of Tanzania. Thirty in-depth interviews and three focus group discussions were conducted. FSWs sought to become pregnant to gain respect as mothers, to avoid stigma, and/or to solidify relationships, sometimes posing risks to their own and their partners' health. Pregnant FSWs generally sought antenatal care (ANC) services but rarely disclosed their occupation, complicating provision of appropriate care. Accessing ANC services presented particular challenges, with health care workers sometimes denying all clinic services to women who were not accompanied by husbands. Several participants reported being denied care until delivery. The difficulties participants reported in accessing health care services as both sex workers and unmarried women have potential social and health consequences in light of the high levels of HIV and STIs among FSWs in sub-Saharan Africa.
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Affiliation(s)
- Sarah W Beckham
- Postdoctoral Fellow, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, and can receive mail at P.O. Box 1441, Iringa, Tanzania.
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