Publications by authors named "Amrita Rao"

49 Publications

A disproportionate epidemic: COVID-19 cases and deaths among essential workers in Toronto, Canada.

Ann Epidemiol 2021 Jul 24;63:63-67. Epub 2021 Jul 24.

St. Michael's Hospital, University of Toronto, Toronto, Canada; Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada. Electronic address:

Shelter-in-place mandates and closure of nonessential businesses have been central to COVID19 response strategies including in Toronto, Canada. Approximately half of the working population in Canada are employed in occupations that do not allow for remote work suggesting potentially limited impact of some of the strategies proposed to mitigate COVID-19 acquisition and onward transmission risks and associated morbidity and mortality. We compared per-capita rates of COVID-19 cases and deaths from January 23, 2020 to January 24, 2021, across neighborhoods in Toronto by proportion of the population working in essential services. We used person-level data on laboratory-confirmed COVID-19 community cases and deaths, and census data for neighborhood-level attributes. Cumulative per-capita rates of COVID-19 cases and deaths were 3.3-fold and 2.5-fold higher, respectively, in neighborhoods with the highest versus lowest concentration of essential workers. Findings suggest that the population who continued to serve the essential needs of society throughout COVID-19 shouldered a disproportionate burden of transmission and deaths. Taken together, results signal the need for active intervention strategies to complement restrictive measures to optimize both the equity and effectiveness of COVID-19 responses.
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http://dx.doi.org/10.1016/j.annepidem.2021.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8435380PMC
July 2021

Evaluating the quality of HIV epidemiologic evidence for populations in the absence of a reliable sampling frame: a modified quality assessment tool.

Ann Epidemiol 2021 Jul 24. Epub 2021 Jul 24.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD.

Background: Sampling frames rarely exist for key populations at highest risk for HIV, such as sex workers, men who have sex with men, people who use drugs, and transgender populations. Without reliable sampling frames, most data collection relies on non-probability sampling approaches including network-based methods (e.g. respondent driven sampling) and venue-based methods (e.g. time-location sampling). Quality of implementation and reporting of these studies is highly variable, making wide-ranging estimates often difficult to compare. Here, a modified quality assessment tool, Global.HIV Quality Assessment Tool for Data Generated through Non-Probability Sampling (GHQAT), was developed to evaluate the quality of HIV epidemiologic evidence generated using non-probability methods.

Methods: The GHQAT assesses three main domains: study design, study implementation, and indicator-specific criteria(prevalence, incidence, HIV continuum of care, and population size estimates). The study design domain focuses primarily on the specification of the target and study populations. The study implementation domain is concerned with sampling implementation. Each indicator-specific section contains items relevant to that specific indicator. A random subset of 50 studies from a larger systematic review on epidemiologic data related to HIV and key populations was generated and reviewed using the GHQAT by two independent reviewers. Inter-rater reliability was assessed by calculating intraclass correlation coefficients for the scores assigned to study design, study implementation and each of the indicator-specific criteria. Agreement was categorized as poor(0.00-0.50), fair(0.51-0.70), and good(0.71-1.00). The distribution of good, fair, and poor scores for each section was described.

Results: Overall, agreement between the two independent reviewers was good(ICC >0.7). Agreement was best for the section evaluating the HIV continuum of care(ICC = 0.96). For HIV incidence, perfect agreement was observed, but this is likely due to the small number of studies reviewed that assessed incidence(n = 3). Of the studies reviewed, 2% (n = 1) received a score of "poor" for study design, while 50% (n = 25) received a score of "poor" for study implementation.

Conclusions: Addressing HIV prevention and treatment needs of key populations is increasingly understood to be central to HIV responses across HIV epidemic settings, though data characterizing specific needs remains highly variable with the least amount of information in the most stigmatizing settings. Here, we present an efficient tool to guide HIV prevention and treatment programs as well as epidemiological data collection by reliably synthesizing the quality of available non-probability based epidemiologic information for key populations. This tool may help shed light on how researchers may improve not only the implementation of, but also the reporting on their studies.
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http://dx.doi.org/10.1016/j.annepidem.2021.07.009DOI Listing
July 2021

Curating and translating the evidence about SARS-CoV-2 and COVID-19 for frontline public health and clinical care: The Novel Coronavirus Research Compendium (NCRC).

medRxiv 2021 Apr 27. Epub 2021 Apr 27.

The public health crisis created by the SARS-CoV-2 pandemic has spurred a deluge of scientific research aimed at informing public health and medical response to the COVID-19 pandemic. However, those working in frontline public health and clinical care had insufficient time to parse the rapidly evolving evidence and use it for decision making. Academics in public health and medicine were well-placed to translate the evidence for use by frontline clinicians and public health practitioners. The Novel Coronavirus Research Compendium (NCRC), a group of >50 faculty and trainees, began in March 2020 with the goal to quickly triage and review the large volume of preprints and peer-reviewed publications on SARS-CoV-2 and COVID-19, and to summarize the most important, novel evidence to inform pandemic response. From April 6, 2020 through January 1, 2021, 54,192 papers and preprints were screened by NCRC teams and 527 were selected for review and uploaded to the NCRC website for public consumption. The majority of papers reviewed were peer-reviewed publications (n=395, 75%), published in 102 journals; 25% (n=132) of papers reviewed were of preprints. The NCRC is a successful model of how academics can support practitioners by translating scientific knowledge into action and help to build capacity among students for this work. This approach could be used for health problems beyond COVID-19, but the effort is resource intensive and may not be sustainable over the long term.
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http://dx.doi.org/10.1101/2021.04.26.21255437DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8095230PMC
April 2021

Estimating the contribution of key populations towards HIV transmission in South Africa.

J Int AIDS Soc 2021 01;24(1):e25650

Population Health Sciences, University of Bristol, Bristol, United Kingdom.

Introduction: In generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA).

Methods: We developed the "Key-Pop Model"; a dynamic transmission model of HIV among FSWs, their clients, MSM, and the broader population in SA. The model was parameterized and calibrated using demographic, behavioural and epidemiological data from national household surveys and KP surveys. We estimated the contribution of commercial sex, sex between men and sex among heterosexual partnerships of different sub-groups to HIV transmission over 2010 to 2019. We also estimated the efficiency (HIV infections averted per person-year of intervention) and prevented fraction (% IA) over 10-years from scaling-up ART (to 81% coverage) in different sub-populations from 2020.

Results: Sex between FSWs and their paying clients, and between clients with their non-paying partners contributed 6.9% (95% credibility interval 4.5% to 9.3%) and 41.9% (35.1% to 53.2%) of new HIV infections in SA over 2010 to 2019 respectively. Sex between low-risk groups contributed 59.7% (47.6% to 68.5%), sex between men contributed 5.3% (2.3% to 14.1%) and sex between MSM and their female partners contributed 3.7% (1.6% to 9.8%). Going forward, the largest population-level impact on HIV transmission can be achieved from scaling up ART to clients of FSWs (% IA = 18.2% (14.0% to 24.4%) or low-risk individuals (% IA = 20.6% (14.7 to 27.5) over 2020 to 2030), with ART scale-up among KPs being most efficient.

Conclusions: Clients of FSWs play a fundamental role in HIV transmission in SA. Addressing the HIV prevention and treatment needs of KPs in generalized HIV epidemics is central to a comprehensive HIV response.
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http://dx.doi.org/10.1002/jia2.25650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855076PMC
January 2021

The Relationship Between the Global Burden of Influenza From 2017 to 2019 and COVID-19: Descriptive Epidemiological Assessment.

JMIR Public Health Surveill 2021 03 2;7(3):e24696. Epub 2021 Mar 2.

Department of Medicine, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.

Background: SARS-CoV-2 and influenza are lipid-enveloped viruses with differential morbidity and mortality but shared modes of transmission.

Objective: With a descriptive epidemiological framing, we assessed whether recent historical patterns of regional influenza burden are reflected in the observed heterogeneity in COVID-19 cases across regions of the world.

Methods: Weekly surveillance data reported by the World Health Organization from January 2017 to December 2019 for influenza and from January 1, 2020 through October 31, 2020, for COVID-19 were used to assess seasonal and temporal trends for influenza and COVID-19 cases across the seven World Bank regions.

Results: In regions with more pronounced influenza seasonality, COVID-19 epidemics have largely followed trends similar to those seen for influenza from 2017 to 2019. COVID-19 epidemics in countries across Europe, Central Asia, and North America have been marked by a first peak during the spring, followed by significant reductions in COVID-19 cases in the summer months and a second wave in the fall. In Latin America and the Caribbean, COVID-19 epidemics in several countries peaked in the summer, corresponding to months with the highest influenza activity in the region. Countries from regions with less pronounced influenza activity, including South Asia and sub-Saharan Africa, showed more heterogeneity in COVID-19 epidemics seen to date. However, similarities in COVID-19 and influenza trends were evident within select countries irrespective of region.

Conclusions: Ecological consistency in COVID-19 trends seen to date with influenza trends suggests the potential for shared individual, structural, and environmental determinants of transmission. Using a descriptive epidemiological framework to assess shared regional trends for rapidly emerging respiratory pathogens with better studied respiratory infections may provide further insights into the differential impacts of nonpharmacologic interventions and intersections with environmental conditions. Ultimately, forecasting trends and informing interventions for novel respiratory pathogens like COVID-19 should leverage epidemiologic patterns in the relative burden of past respiratory pathogens as prior information.
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http://dx.doi.org/10.2196/24696DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7927952PMC
March 2021

Exploring the Association Between Depression and Social and Biobehavioral HIV Risk Factors Among Female Sex Workers in Nelson Mandela Bay Municipality, South Africa.

AIDS Res Hum Retroviruses 2021 Sep 17;37(9):666-675. Epub 2021 Feb 17.

Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland, USA.

The aim of this study was to estimate the prevalence of depression among female sex workers (FSW) in an urban coastal city in South Africa, and to explore the relationship between depression and HIV-related social and biobehavioral determinants. A cross-sectional respondent-driven sampling study was conducted with FSW ( = 410), including a sociobehavioral questionnaire, PHQ-9 (Patient Health Questionnaire-9) based assessment of depression, and biological testing for HIV and syphilis. The prevalence of HIV in the sample was 64.1%. The estimated prevalence of depression was 28.8%. Depression was associated with social vulnerability such as living alone [adjusted prevalence ratio 1.82, 95% confidence interval (CI) 1.15-2.90] and food insecurity (aPR 2.19, 95% CI 1.42-3.38). A positive syphilis test result (aPR 1.46, 95% CI 1.02-2.09) and self-reported sexually transmitted disease symptoms (aPR 1.78, 95% CI 1.29-2.46) was associated with depression, but self-reported condom use and HIV status was not. FSW were also less likely to disclose their occupational status to health care providers (aPR 0.61, 95% CI 0.42-0.89) or undergo sexually transmitted infection screening in the last 12 months if they are depressed (aPR 0.64, 95% CI 0.43-0.95). The results demonstrate that the prevalence of depression is high among FSW and that depressive symptoms are associated with social covariates and biobehavioral HIV risk factors.
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http://dx.doi.org/10.1089/AID.2020.0233DOI Listing
September 2021

Perceived Interruptions to HIV Prevention and Treatment Services Associated With COVID-19 for Gay, Bisexual, and Other Men Who Have Sex With Men in 20 Countries.

J Acquir Immune Defic Syndr 2021 05;87(1):644-651

Departments of Epidemiology.

Background: The coronavirus pandemic has necessitated a range of population-based measures to stem the spread of infection. These measures may be associated with disruptions to other health services including for gay, bisexual, and other men who have sex with men (MSM) at risk for or living with HIV. Here, we assess the relationship between stringency of COVID-19 control measures and interruptions to HIV prevention and treatment services for MSM.

Setting: Data for this study were collected between April 16, 2020, and May 24, 2020, as part of a COVID-19 Disparities Survey implemented by the gay social networking app, Hornet. Pandemic control measures were quantified using the Oxford Government Response Tracker Stringency Index: each country received a score (0-100) based on the number and strictness of 9 indicators related to restrictions, closures, and travel bans.

Methods: We used a multilevel mixed-effects generalized linear model with Poisson distribution to assess the association between stringency of pandemic control measures and access to HIV services.

Results: A total of 10,654 MSM across 20 countries were included. Thirty-eight percent (3992/10,396) reported perceived interruptions to in-person testing, 55% (5178/9335) interruptions to HIV self-testing, 56% (5171/9173) interruptions to pre-exposure prophylaxis, and 10% (990/9542) interruptions to condom access. For every 10-point increase in stringency, there was a 3% reduction in the prevalence of perceived access to in-person testing (aPR: 0·97, 95% CI: [0·96 to 0·98]), a 6% reduction in access to self-testing (aPR: 0·94, 95% CI: [0·93 to 0·95]), and a 5% reduction in access to pre-exposure prophylaxis (aPR: 0·95, 95% CI: [0·95 to 0·97]). Among those living with HIV, 20% (218/1105) were unable to access their provider; 65% (820/1254) reported being unable to refill their treatment prescription remotely.

Conclusions: More stringent responses were associated with decreased perceived access to services. These results support the need for increasing emphasis on innovative strategies in HIV-related diagnostic, prevention, and treatment services to minimize service interruptions during this and potential future waves of COVID-19 for gay men and other MSM at risk for HIV acquisition and transmission.
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http://dx.doi.org/10.1097/QAI.0000000000002620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276834PMC
May 2021

Competing Health Risks Associated with the COVID-19 Pandemic and Response: A Scoping Review.

medRxiv 2021 Jan 8. Epub 2021 Jan 8.

Background: COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats. We conducted a scoping review to characterize the impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

Methods: A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1 to October 31 , 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection and mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

Results: A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 12.1% (16/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

Discussion: COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. Data reviewed here suggest that effective strengthening of health systems should include investment in public health with adequate funding to ensure continuity of care for emergent and existing public health threats.
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http://dx.doi.org/10.1101/2021.01.07.21249419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805463PMC
January 2021

Using factor analyses to estimate the number of female sex workers across Malawi from multiple regional sources.

Ann Epidemiol 2021 03 16;55:34-40. Epub 2020 Dec 16.

Department of Statistics, Eberly College of Science, Pennsylvania State University, University Park. Electronic address:

Purpose: Human immunodeficiency virus (HIV) risks are heterogeneous in nature even in generalized epidemics. However, data are often missing for those at highest risk of HIV, including female sex workers. Statistical models may be used to address data gaps where direct, empiric estimates do not exist.

Methods: We proposed a new size estimation method that combines multiple data sources (the Malawi Biological and Behavioral Surveillance Survey, the Priorities for Local AIDS Control Efforts study, and the Malawi Demographic Household Survey). We used factor analysis to extract information from auxiliary variables and constructed a linear mixed effects model for predicting population size for all districts of Malawi.

Results: On average, the predicted proportion of female sex workers among women of reproductive age across all districts was about 0.58%. The estimated proportions seemed reasonable in comparing with a recent study Priorities for Local AIDS Control Efforts II (PLACE II). Compared with using a single data source, we observed increased precision and better geographic coverage.

Conclusions: We illustrate how size estimates from different data sources may be combined for prediction. Applying this approach to other subpopulations in Malawi and to countries where size estimate data are lacking can ultimately inform national modeling processes and estimate the distribution of risks and priorities for HIV prevention and treatment programs.
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http://dx.doi.org/10.1016/j.annepidem.2020.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901797PMC
March 2021

Unsterile injection equipment associated with HIV outbreak and an extremely high prevalence of HCV-A case-control investigation from Unnao, India.

PLoS One 2020 4;15(12):e0243534. Epub 2020 Dec 4.

Indian Council of Medical Research-National AIDS Research Institute, Pune, Maharashtra, India.

The integrated counseling and testing center (ICTC) located in the district hospital, Unnao in the northern state of Uttar Pradesh (UP), India witnessed an increased detection of HIV among its attendees in July 2017. Subsequently, health camps were organized by the UP State AIDS Control Society in the villages and townships contributing to such detection. We conducted a case-control study to identify factors associated with this increased detection; 33 cases and 125 controls were enrolled. Cases were individuals, detected HIV sero-reactive during November 2017-April 2018 from three locations namely Premganj, Karimuddinpur and Chakmeerapur in the Bangarmau block of the district of Unnao. Controls hailed from the same geographical setting and tested HIV sero-nonreactive either in health camps or at ICTC centers from where the cases were detected. Misclassification bias was avoided by confirming HIV sero-status of both cases as well as controls prior to final analysis. Study participants were interviewed on various risk practices and invasive treatment procedures. They were also tested for HIV and other bio-markers reflecting unsafe injecting and sexual exposures such as hepatitis B surface antigen (HBsAg), anti-HCV antibody (HCV Ab), anti-herpes simplex-2 Immunoglobulin G (HSV-2 IgG) and rapid plasma regain (RPR) test for syphilis. Secondary data analysis on three time points during 2015 through 2018 revealed a rising trend of HIV among attendees of the ICTCs (ICTC-Hasanganj, ICTC-Unnao district hospital and ICTC- Nawabganj) catering to the entire district of Unnao. While there was a seven fold rise of HIV among ICTC attendees of Hasanganj (χ2 value for trend 23.83; p < 0.001), the rise in Unnao district hospital was twofold (χ2 value for trend 4.37; p < 0.05) and was tenfold at ICTC-Nawabganj (χ2 value for trend 5.23; p < 0.05) indicating risk of infection prevailing throughout the district. Primary data was generated through interviews and laboratory investigations as mentioned above. The median age of cases and controls was 50 year (minimum 18 -maximum 68; IQR 31-57) and 38 year (minimum 18 -maximum 78; IQR 29-50) respectively. Thirty six percent of the cases and 47% of controls were male. A significantly higher proportion of cases (85%) had HCV Ab compared to controls (56%; OR 4.4, 95% CI 1.5-12.1); none reported injection drug use. However, cases and controls did not differ significantly regarding presence of HSV-2 IgG (6% versus 8% respectively). Neither any significant difference existed between cases and controls in terms of receiving blood transfusion, undergoing invasive surgical procedures, tattooing, tonsuring of head or skin piercing. In multivariate logistic regression model, 'unsafe injection exposure during treatment-seeking'(AOR 6.61, 95% CI 1.80-24.18) and 'receipt of intramuscular injection in last five years' (AOR 7.20, 95% CI 1.48-34.88) were independently associated with HIV sero-reactive status. The monophyletic clustering of HIV sequences from 14 cases (HIV-1 pol gene amplified) indicated a common ancestry. Availability of auto-disabled syringes and needles, empowerment of the local communities and effective regulatory practices across care settings would serve as important intervention measures in this context.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243534PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717531PMC
January 2021

Quantifying the Evolving Contribution of HIV Interventions and Key Populations to the HIV Epidemic in Yaoundé, Cameroon.

J Acquir Immune Defic Syndr 2021 04;86(4):396-405

Department of Infectious Disease Epidemiology, Imperial College London, HPTN Modelling Centre, London, United Kingdom.

Background: Key populations (KP) including men who have sex with men (MSM), female sex workers (FSW), and their clients are disproportionately affected by HIV in Sub-Saharan Africa. We estimated the evolving impact of past interventions and contribution of unmet HIV prevention/treatment needs of key populations and lower-risk groups to HIV transmission.

Setting: Yaoundé, Cameroon.

Methods: We parametrized and fitted a deterministic HIV transmission model to Yaoundé-specific demographic, behavioral, HIV, and intervention coverage data in a Bayesian framework. We estimated the fraction of incident HIV infections averted by condoms and antiretroviral therapy (ART) and the fraction of all infections over 10-year periods directly and indirectly attributable to sex within and between each risk group.

Results: Condom use and ART together may have averted 43% (95% uncertainty interval: 31-54) of incident infections over 1980-2018 and 72% (66-79) over 2009-2018. Most onward transmissions over 2009-2018 stemmed from sex between lower-risk individuals [47% (32-61)], clients [37% (23-51)], and MSM [35% (20-54)] with all their partners. The contribution of commercial sex decreased from 25% (8-49) over 1989-1998 to 8% (3-22) over 2009-2018, due to higher intervention coverage among FSW.

Conclusion: Condom use and recent ART scale-up mitigated the HIV epidemic in Yaoundé and changed the contribution of different partnerships to onward transmission over time. Findings highlight the importance of prioritizing HIV prevention and treatment for MSM and clients of FSW whose unmet needs now contribute most to onward transmission, while maintaining services that successfully reduced transmissions in the context of commercial sex.
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http://dx.doi.org/10.1097/QAI.0000000000002580DOI Listing
April 2021

Acceptability of HIV Oral Self-Test Among Men Having Sex With Men and Transgender Population: A Qualitative Investigation From Pune, India.

Infect Dis (Auckl) 2020 13;13:1178633720962809. Epub 2020 Oct 13.

Indian Council of Medical Research-National AIDS Research Institute (ICMR-NARI), Pune, Maharashtra, India.

Globally HIV-self-test is considered as an important tool to end AIDS. However, several countries, including India, are yet to adopt such a strategy. Against this background, we conducted a qualitative inquiry exploring acceptability of an HIV-oral-self-test (HIVOST) among MSM and TG communities in the district of Pune, India. Discussions were facilitated around an HIVOST kit developed in-country. Most of the participants expressed familiarity with the concept of self-test. They realised that confirmatory diagnostic test would be required following a positive HIVOST screening result. Discrimination from health care workers, crowded environment, lack of privacy and delay in getting reports were hurdles faced during HIV testing at public healthcare facilities. Contrastingly, quick results, painless technique and no-blood-draw were perceived advantages of HIVOST. Innovative suggestions were obtained on how-to-do instruction modalities, kit distribution venues and redressing of apprehensions. Such qualitative responses indicated interest and encouraging level of acceptance around HIVOST among study participants.
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http://dx.doi.org/10.1177/1178633720962809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557648PMC
October 2020

HIV self-test during the time of COVID-19, India.

Authors:
Amrita Rao

Indian J Med Res 2020 Jul & Aug;152(1 & 2):164-167

Division of Clinical Sciences, ICMR-National AIDS Research Institute, Pune 411 026, Maharashtra, India.

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http://dx.doi.org/10.4103/ijmr.IJMR_2521_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7853287PMC
September 2020

A structural equation model of factors associated with HIV risk behaviors and mental health among men who have sex with men in Malawi.

BMC Infect Dis 2020 Aug 10;20(1):591. Epub 2020 Aug 10.

Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.

Background: Men who have sex with men (MSM) bear a disproportionate burden of HIV in Malawi. Early prevention efforts in Malawi have been largely focused on preventing heterosexual and vertical transmission of HIV, and MSM have rarely been the specific benefactors of these efforts, despite facing both higher prevalence of HIV coupled with multiple barriers to prevention and care. To better facilitate the design of culturally relevant HIV prevention programs and prioritize resources among MSM in resource limited settings, the objective of this analysis was to estimate the relationship between social factors and HIV related risk behaviors and mental health.

Methods: 338 MSM were recruited using respondent-driven sampling in Blantyre, Malawi from April 2011 to March 2012. Structural equation models were built to test the association between six latent factors: participation in social activities, social support, stigma and human rights violations, depression symptomatology, condom use, and sexual risk behaviors, including concurrent sexual partnerships and total number of partners.

Results: The mean age of participants was 25 years old. Almost 50% (158/338) of the participants were unemployed and 11% (37/338) were married or cohabiting with women. More than 30% (120/338) of the participants reported sexual behavior stigma and 30% (102/338) reported depression symptomatology. Almost 50% (153/338) of the participants reported any kind of HIV-related risk behaviors and 30% (110/338) participated in one of the recorded social activities. Significant associations were identified between stigma and risk behaviors (β = 0.14, p = 0.03); stigma and depression symptomatology (β = 0.62, p = 0.01); participation in social activities and depression symptomatology (β = 0.17, p = 0.01).

Conclusion: Results suggest MSM reporting stigma are more likely to report sexual risk practices associated with HIV/STI transmission and depressive symptoms, while those reporting participation in social activities related to HIV education are less likely to be depressed. Furthermore, interventions at the community level to support group empowerment and engagement may further reduce risks of HIV transmission and improve mental health outcomes. Taken together, these results suggest the potential additive benefits of mental health services integrated within comprehensive HIV prevention packages to optimize both HIV-related outcomes and general quality of life among MSM in Malawi.
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http://dx.doi.org/10.1186/s12879-020-05310-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7419207PMC
August 2020

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with Men.

AIDS Behav 2021 Feb;25(2):311-321

LGBT Foundation, San Francisco, CA, USA.

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.
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http://dx.doi.org/10.1007/s10461-020-02969-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352092PMC
February 2021

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study.

Glob Health Sci Pract 2020 03 31;8(1):82-99. Epub 2020 Mar 31.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon.

Methods: From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception.

Results: Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use.

Conclusions: Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.
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http://dx.doi.org/10.9745/GHSP-D-19-00330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108938PMC
March 2020

The uptake of population size estimation studies for key populations in guiding HIV responses on the African continent.

PLoS One 2020 26;15(2):e0228634. Epub 2020 Feb 26.

Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.

Background: There has been a heightened emphasis on prioritizing data to inform evidence-based HIV responses, including data focused on both defining the content and scale of HIV programs in response to evidence-based need. Consequently, population size estimation (PSE) studies for key populations have become increasingly common to define the necessary scale of specific programs for key populations. This study aims to assess the research utilization of these size estimates in informing HIV policy and program documents across the African continent.

Methods: This study included two phases; Phase 1 was a review of all PSE for key populations, including men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD), and transgender persons in the 54 countries across Africa published from January 2009-December 2017. Phase 2 was a review of 23 different types of documents released between January 2009 -January 2019, with a focus on the US President's Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria investments, for evidence of stakeholder engagement in PSE studies, as well as key population PSE research utilization to inform HIV programming and international HIV investments.

Results: Of 118 size estimates identified in 39 studies, less than 15% were utilized in PEPFAR Country Operational Plans or national strategic health plan documents, and less than 2% in Global Fund Concept Notes. Of 39 PSE studies, over 50% engaged stakeholders in study implementation and identified target population stakeholders, a third of studies identified policy or program stakeholders, and 15% involved stakeholders in study design.

Conclusion: The past decade has seen an increase in PSE studies conducted for key populations in more generalized HIV epidemic settings which involve significant investments of finances and human resources. However, there remains limited evidence of sustained uptake of these data to guide the HIV responses. Increasing uptake necessitates effective stakeholder engagement and data-oriented capacity building to optimize research utilization and facilitate data-driven and human rights-affirming HIV responses.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228634PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043736PMC
April 2020

Landscape of HIV Implementation Research Funded by the National Institutes of Health: A Mapping Review of Project Abstracts.

AIDS Behav 2020 Jun;24(6):1903-1911

Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

In 2019, the requisite biomedical and behavioral interventions to eliminate new HIV infections exist. "Ending the HIV Epidemic" now becomes primarily a challenge of will and implementation. This review maps the extent to which implementation research (IR) has been integrated into HIV research by reviewing the recent funding portfolio of the NIH. We searched NIH RePORTER for HIV and IR-related research projects funded from January 2013 to March 2018. The 4629 unique studies identified were screened using machine learning and manual methods. 216 abstracts met the eligibility criteria of HIV and IR. Key study characteristics were then abstracted. NIH currently funds HIV studies that are either formally IR (n = 109) or preparatory for IR (n = 107). Few (13%) projects mentioned a guiding implementation model, theory, or framework, and only 56% of all studies explicitly mentioned measuring an implementation outcome. Considering the study aims along an IR continuum, 18 (8%) studies examined barriers and facilitators, 43 (20%) developed implementation strategies, 46 (21%) piloted strategies, 73 (34%) tested a single strategy, and 35 (16%) compared strategies. A higher proportion of formal IR projects involved established interventions (e.g., integrated services) compared to newer interventions (e.g., pre-exposure prophylaxis). Prioritizing HIV-related IR in NIH and other federal funding opportunity announcements and expanded training in implementation science could have a substantial impact on ending the HIV pandemic. This review serves as a baseline by which to compare funding patterns and the sophistication of IR in HIV research over time.
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http://dx.doi.org/10.1007/s10461-019-02764-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220870PMC
June 2020

HIV-Related Implementation Research for Key Populations: Designing for Individuals, Evaluating Across Populations, and Integrating Context.

J Acquir Immune Defic Syndr 2019 12;82 Suppl 3:S206-S216

Key Populations Program, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.

Introduction: Key populations, including men who have sex with men, transgender people, sex workers, people who inject drugs, and incarcerated populations, experience high burdens of HIV and urgently need effective interventions. Yet the evidence base for implementation research (IR) with key populations remains weak and poses specific challenges to epidemiologic inference. We apply the Consolidated Framework for IR to consider specific challenges and recommendations for IR with key populations.

Discussion: Individuals within key populations exist within inner and outer settings-including organizational structures, legal (eg, criminalization), and funding environments-which influence the design, adoption and fidelity of interventions, and the potential sustainability of intervention scale-up. Underlying vulnerabilities and external stressors experienced at the individual level (eg, homelessness, violence) further impact participation and retention in IR. Thus, researchers should account for representation in the research process, beginning with community engagement in IR design and consideration of enumeration/sampling methods for key populations who lack probabilistic sampling frames. Interventions for key populations require substantial adaptation and complexity (eg, individually tailored, multicomponent) to ensure appropriateness; however, there is tension between the need for complexity and challenges to internal validity (fidelity) and external validity (generalizable scale-up). Finally, integrating contextual, sampling, and implementation elements into analytic approaches is critical for effectiveness evaluation.

Conclusions: Translation of efficacious findings at the individual level to effectiveness at the population level requires recognition of risk heterogeneity. Recognizing the nuances of working with key populations is essential to ensure that individuals are represented by design and therefore gains in population health can be achieved.
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http://dx.doi.org/10.1097/QAI.0000000000002191DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6880803PMC
December 2019

Bayesian Estimation of MSM Population Size in Côte d'Ivoire.

Stat Public Policy (Phila) 2019 9;6(1):1-13. Epub 2019 Mar 9.

Department of Epidemiology, Johns Hopkins University, Baltimore, MD.

Côte d'Ivoire has among the most generalized HIV epidemics in West Africa with an estimated half million people living with HIV. Across West Africa, key populations, including gay men and other men who have sex with men (MSM), are often disproportionately burdened with HIV due to specific acquisition and transmission risks. Quantifying population sizes of MSM at the subnational level is critical to ensuring evidence-based decisions regarding the scale and content of HIV prevention interventions. While survey-based direct estimates of MSM numbers are available in a few urban centers across Côte d'Ivoire, no data on MSM population size exists in other areas without any community group infrastructure to facilitate sufficient access to communities of MSM. The data are used in a Bayesian regression setup to produce estimates of the numbers of MSM in areas of Côte d'Ivoire prioritized in the HIV response. Our hierarchical model imputes missing covariates using geo-spatial information and allows for proper uncertainty quantification leading to confidence bounds for predicted MSM population size estimates. This process provided population size estimates where there are no empirical data, to guide the prioritization of further collection of empirical data on MSM and inform evidence-based scaling of HIV prevention and treatment programs for MSM across Côte d'Ivoire.
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http://dx.doi.org/10.1080/2330443X.2018.1546634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6656394PMC
March 2019

The disconnect between individual-level and population-level HIV prevention benefits of antiretroviral treatment.

Lancet HIV 2019 09 19;6(9):e632-e638. Epub 2019 Jul 19.

St Michael's Hospital, Li Ka Shing Knowledge Institute, and Department of Medicine, Division of Infectious Disease, University of Toronto, Toronto, Canada.

In 2019, the HIV pandemic is growing and soon over 40 million people will be living with HIV. Effective population-based approaches to decrease HIV incidence are as relevant as ever given modest reductions observed over the past decade. Treatment as prevention is often heralded as the path to improve HIV outcomes and to reduce HIV incidence. Although treatment of an individual does eliminate onward transmission to serodifferent partners (undetectable=untransmittable or U=U), population-level observational and experimental data have not shown a similar effect with scale-up of treatment on reducing HIV incidence. This disconnect might be the result of little attention given to heterogeneities of HIV acquisition and transmission risks that exist in people at risk for and living with HIV, even in the most broadly generalised epidemics. Available data suggest that HIV treatment is treatment, HIV prevention is prevention, and specificity of HIV treatment approaches towards people at highest risk of onward transmission drives the intersection between the two. All people living with HIV deserve HIV treatment, but both more accurately estimating and optimising the potential HIV prevention effects of universal treatment approaches necessitates understanding who is being supported with treatment rather than a focus on treatment targets such as 90-90-90 or 95-95-95.
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http://dx.doi.org/10.1016/S2352-3018(19)30226-7DOI Listing
September 2019

The disconnect between individual-level and population-level HIV prevention benefits of antiretroviral treatment.

Lancet HIV 2019 09 19;6(9):e632-e638. Epub 2019 Jul 19.

St Michael's Hospital, Li Ka Shing Knowledge Institute, and Department of Medicine, Division of Infectious Disease, University of Toronto, Toronto, Canada.

In 2019, the HIV pandemic is growing and soon over 40 million people will be living with HIV. Effective population-based approaches to decrease HIV incidence are as relevant as ever given modest reductions observed over the past decade. Treatment as prevention is often heralded as the path to improve HIV outcomes and to reduce HIV incidence. Although treatment of an individual does eliminate onward transmission to serodifferent partners (undetectable=untransmittable or U=U), population-level observational and experimental data have not shown a similar effect with scale-up of treatment on reducing HIV incidence. This disconnect might be the result of little attention given to heterogeneities of HIV acquisition and transmission risks that exist in people at risk for and living with HIV, even in the most broadly generalised epidemics. Available data suggest that HIV treatment is treatment, HIV prevention is prevention, and specificity of HIV treatment approaches towards people at highest risk of onward transmission drives the intersection between the two. All people living with HIV deserve HIV treatment, but both more accurately estimating and optimising the potential HIV prevention effects of universal treatment approaches necessitates understanding who is being supported with treatment rather than a focus on treatment targets such as 90-90-90 or 95-95-95.
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http://dx.doi.org/10.1016/S2352-3018(19)30226-7DOI Listing
September 2019

Seroepidemiology of syphilis among men who have sex with men in Burkina Faso, West Africa.

Eur J Clin Microbiol Infect Dis 2019 Oct 15;38(10):1803-1809. Epub 2019 Jun 15.

Université Ouaga I Professeur Joseph KI-ZERBO, Ouagadougou, Ouagadougou, Burkina Faso.

Men who have sex with men (MSM) have a disproportionate risk of acquiring sexually transmitted infections (STIs), such as syphilis. However, prevalence and determinants of syphilis among this population are less known in West Africa. This study aims to estimate syphilis prevalence among MSM in Burkina Faso. We conducted a cross-sectional biological and behavior survey in the two main cities of Burkina Faso, Ouagadougou and Bobo-Dioulasso. MSM were recruited using Respondent Driven Sampling (RDS) methods. Data were collected from January to April 2013 in Ouagadougou and from May to August 2013 in Bobo-Dioulasso. Out of the 657 MSM screened for syphilis, 6.1% (40/657) tested positive for Treponema pallidum antibodies and 1.1% (7/657) for active syphilis. Population-weighted prevalence of active syphilis was 2.1% (95% CI, 01.1-04.4) in Ouagadougou and 0.0% in Bobo-Dioulasso. Serologic markers of syphilis (anti-Treponema antibodies) were found among 7.4% (95% CI 5.0-10.8) of MSM in Ouagadougou and 5.0% (95% CI 3.1-8.0) in Bobo-Dioulasso. No significant differences were found in syphilis serological markers prevalence by participants' sociodemographic and behavioral characteristics. The prevalence of syphilis among MSM is low and comparable to that of other individuals of reproductive age in Burkina Faso. This low prevalence is very encouraging and suggests implementation of effective public health intervention programs which direct resources and services toward MSM to prevent further spread of syphilis infection and to limit HIV transmission in this group.
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http://dx.doi.org/10.1007/s10096-019-03610-2DOI Listing
October 2019

Antenatal care presentation and engagement in the context of sex work: exploring barriers to care for sex worker mothers in South Africa.

Reprod Health 2019 May 29;16(Suppl 1):63. Epub 2019 May 29.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.

Background: Late presentation combined with limited engagement in antenatal care (ANC) increases risk of vertical transmission among mothers living with HIV. Female sex workers (FSW) have more than four times greater burden of HIV than other women of reproductive age in South Africa and the majority of FSW are mothers. For mothers who sell sex and are at increased HIV acquisition risk, timely and routine ANC seeking is especially vital for prevention of vertical transmission. This study represents a mixed-methods study with FSW in Port Elizabeth, South Africa, to characterize factors influencing ANC seeking behaviors in a high HIV prevalence context.

Methods: FSW (n = 410) were recruited into a cross-sectional study through respondent-driven sampling between October 2014 and April 2015 and tested for HIV and pregnancy. A sub-sample of pregnant and postpartum women (n = 30) were invited to participate in in-depth interviews (IDIs) to explore their current or most recent pregnancy experiences. IDIs were coded using a modified grounded theory approach and descriptive analyses assessed the frequency of themes explored in the qualitative analysis among the quantitative sample.

Results: In the quantitative survey, 77% of FSW were mothers (313/410); of these, two-thirds were living with HIV (212/313) and 40% reported being on antiretroviral therapy (ART) (84/212). FSW in the qualitative sub-sample reported unintended pregnancies with clients due to inconsistent contraceptive use; many reported discovering their unintended pregnancies between 4 and 7 months of gestation. FSW attributed delayed ANC seeking and ART initiation in the second or third trimesters to late pregnancy detection. Other factors limiting engagement in ANC included substance and alcohol use and discontent with previous healthcare-related experiences.

Conclusions: Late pregnancy discovery, primarily because pregnancies were unplanned, contributed to late ANC presentation and delayed ART initiation, increasing risks of vertical HIV transmission. Given limited ART coverage among participants, addressing the broader sexual and reproductive health and rights needs of mothers who sell sex has important implications for preventing vertical transmission of HIV. Integrating comprehensive family planning services into FSW programming, as well as providing active linkage to ANC services may reduce barriers to accessing timely ANC, decreasing risks of vertical transmission.
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http://dx.doi.org/10.1186/s12978-019-0716-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6538548PMC
May 2019

Predictors of early childhood HIV testing among children of sex workers living with HIV in Cameroon.

BMC Public Health 2019 May 29;19(Suppl 1):602. Epub 2019 May 29.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA.

Background: Despite recent progress, there exist gaps in the prevention of vertical HIV transmission program access and uptake in Cameroon. Female sex workers (FSW), many of whom are mothers, are disproportionately affected by HIV and have specific barriers to HIV testing and treatment access. Testing for HIV-exposed infants is crucial in monitoring for incident infection and timely intervention. This study explores the level of early childhood testing and also associations between antenatal care (ANC) attendance and other factors and early childhood HIV testing among FSW in Cameroon.

Methods: FSW were recruited to participate in an integrated biobehavioral survey in Cameroon between December 2015 and October 2016. Women were included in these analyses if they were living with HIV and had at least one living child. Both univariate and multivariable logistic regression were used to look at predictors of a child being tested for HIV before age five.

Results: A total of 481/2255 FSW were eligible for these analyses as they were HIV seropositive and had at least one living child at the time of the study. Women included in these analyses had a median age of 35(IQR 30-41). Nearly 70% reported none of their children had been tested for HIV before age five (326/481), and 3.5%(17/481) reported one or more of their children had been diagnosed with HIV. ANC attendance (adjusted OR 2.12, 95% CI: [1.02, 4.55]), awareness of HIV status (aOR 3.70[2.30, 5.93]), pregnancy intentions (aOR 1.89[1.16, 3.08]), and higher education (aOR 2.17[1.01, 4.71]) were all independently associated with increased odds of women having a greater proportion of children tested for HIV before age five. Regional differences in early childhood testing were also observed.

Conclusion: Vertical transmission of HIV remains a challenge in Cameroon, and HIV testing among children of FSW living with HIV was very low. ANC attendance and promotion of the mother's health were associated with increased child HIV testing. For women at high risk of HIV and for whom engagement in the health system is low, strategies to promote and ensure ANC attendance are essential for their health and the health of their children.
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http://dx.doi.org/10.1186/s12889-019-6812-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6538542PMC
May 2019

Evaluating the vertical HIV transmission risks among South African female sex workers; have we forgotten PMTCT in their HIV programming?

BMC Public Health 2019 May 29;19(Suppl 1):605. Epub 2019 May 29.

Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21205, USA.

Background: Female sex workers (FSW) have a greater HIV burden compared to other reproductive-aged women and experience high incidence of pregnancies. However, there are limited data on mother-to-child transmission of HIV in the context of sex work. This study assessed the uptake of prevention of mother-to-child transmission (PMTCT) services to understand the vertical HIV transmission risks among FSW in South Africa.

Methods: FSW ≥18 years were recruited into a cross-sectional study using respondent-driven sampling (RDS) between October 2014-April 2015 in Port Elizabeth, South Africa. An interviewer-administered questionnaire captured information on demographics, reproductive health histories, and HIV care, including engagement in PMTCT care and ART. HIV and pregnancy testing were biologically assessed. This analysis characterizes FSW engagement in HIV prevention and treatment cascades of the four prongs of PMTCT.

Results: Overall, 410 FSW were enrolled. The RDS-weighted HIV prevalence was 61.5% (95% bootstrapped confidence interval 54.1-68.0). A comprehensive assessment of the four PMTCT prongs showed gaps in cascades for each of the prongs. In Prongs 1 and 2, gaps of 42% in consistent condom use with clients among HIV-negative FSW and 43% in long-term high efficacy contraceptive method use among HIV-positive FSW were observed. The analyses for prongs three and four pertained to 192 women with children < 5 years; 101/192 knew their HIV diagnosis prior to the study, of whom 85% (86/101) had their children tested for HIV after birth, but only 36% (31/86) of those who breastfed retested their children post-breastfeeding. A substantial proportion (35%, 42/120) of all HIV-positive women with children < 5 years of age were HIV-negative at their last delivery and seroconverted after delivery. Less than half (45%) of mothers with children < 5 years (45/101) were on ART and 12% (12/101) reported at least one child under five living with HIV.

Conclusion: These findings show significant gaps in engagement in the PMTCT cascades for FSW, evidenced by sub-optimal uptake of HIV prevention and treatment in the peri/post-natal periods and insufficient prevention of unintended pregnancies among FSW living with HIV. These gaps result in elevated risks for vertical transmission among FSW and the need for PMTCT services within FSW programs.
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http://dx.doi.org/10.1186/s12889-019-6811-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6538543PMC
May 2019

Characterising unmet HIV prevention and treatment needs among young female sex workers and young men who have sex with men in Cameroon: a cross-sectional analysis.

Lancet Child Adolesc Health 2019 07 16;3(7):482-491. Epub 2019 May 16.

Johns Hopkins School of Public Health, Department of Epidemiology, Baltimore, MD, USA.

Background: In Cameroon, female sex workers (FSWs) and men who have sex with men (MSM) carry disproportionately high burdens of HIV. Despite specific vulnerabilities and health needs, young key populations remain understudied and underserved in Cameroon owing to legal, ethical, and social challenges. We aimed to assess and compare HIV-related behavioural and structural risks and coverage of HIV prevention and treatment services between young and older key populations to inform implementation strategies.

Methods: FSWs and MSM aged 18 years or older were recruited through respondent-driven-sampling for a biobehavioural survey carried out in five Cameroonian cities. Prevalence of HIV, risk, stigma, and health service engagement were compared between young (18-24 years) and older (≥25 years) key populations. Multivariable Poisson regression models, disaggregated by key population, were constructed to estimate prevalence ratios (PR) by age group for HIV service engagement.

Findings: Participants were recruited between Nov 30, 2015, and Oct 12, 2016. Among FSWs, 724 (32%) of 2255 were aged 18-24 years, and median age of first transactional or compensated sex was 22 years (IQR 19-28). Among MSM, 840 (63%) of 1323 were aged 18-24 years, and median age of first anal sex was 18 years (IQR 17-21). RDS-adjusted HIV prevalence was 8·5% (95% CI 4·7-15·2) among young FSWs and 12·9% (9·5-18·2) among young MSM. HIV viral suppression (<1000 copies per mL) was evident in 24 (43%) of 56 young and 292 (61%) of 479 older FSWs (p=0·0091) and 40 (34%) of 119 of young and 64 (42%) of 153 older MSM (p=0·17). Young FSWs were less likely than older FSWs to report recent peer education (PR 0·65, 95% CI 0·48-0·88), or membership of an FSW community-based organisation (PR 0·69, 0·55-0·86) and were more likely to report untreated sexually transmitted infection symptoms in the past year (PR 1·29, 1·03-1·61). Young MSM were less likely than older MSM to report an HIV test in the past year (PR 0·88, 0·78-0·98), recent peer education (PR 0·77, 0·62-0·95) and receipt of free condoms (PR 0·77, 0·67-0·89). By key population, condom use and recent experiences of stigma and violence were similar between age groups (p>0·05).

Interpretation: Young key populations have similar behavioural and structural risks to older populations but have lower coverage of HIV preventive and treatment services. Achieving an AIDS-free generation in Cameroon and elsewhere in the region necessitates overcoming social and legal challenges and delivering innovative, evidence-based, and human rights-affirming HIV prevention and treatment interventions for young key populations.

Funding: PEPFAR, USAID.
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http://dx.doi.org/10.1016/S2352-4642(19)30123-3DOI Listing
July 2019

Characterizing Multi-level Determinants of HIV Prevalence Among Female Sex Workers in Maseru and Maputsoe, Lesotho.

AIDS Behav 2020 Mar;24(3):714-723

Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA.

Lesotho has a broadly generalized HIV epidemic with nearly one in three reproductive-aged women living with HIV. Given this context, there has been limited research on specific HIV risks. In response, this study aimed to characterize the burden of HIV and multi-level correlates of HIV infection amongst female sex workers (FSW) in Lesotho. Respondent driven sampling was used to recruit 744 FSW from February to September 2014 in Maseru and Maputsoe, Lesotho. Robust Poisson regression was used to model weighted prevalence ratios (PR) for HIV, leveraging a modified social ecological model. The HIV prevalence among participants was 71.9% (534/743), with a mean age of 26.8 (SD 7.2). Both individual and structural determinants involving stigma were significantly associated with HIV. Women with the highest enacted stigma score (≥ 5) had a 26% higher prevalence of HIV than individuals that did not experience any stigma (PR 1.26, 95% CI 1.01, 1.57). These data reinforce the extraordinarily high burden of HIV borne by FSW even in the context of the generalized HIV epidemic observed in Lesotho and across southern Africa. Moreover, stigma represents a structural determinant that is fundamental to an effective HIV response for FSW in Lesotho.
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http://dx.doi.org/10.1007/s10461-019-02495-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821589PMC
March 2020

Female Sex Workers' Experiences Selling Sex during Pregnancy and Post-Delivery in South Africa.

Stud Fam Plann 2019 09 17;50(3):201-217. Epub 2019 Apr 17.

Nearly 75 percent of female sex workers (FSWs) in Port Elizabeth, South Africa are mothers, many of whom engage in sex work during pregnancy or after delivery. We conducted in-depth interviews with 22 postpartum and 8 pregnant FSWs in Port Elizabeth. Interview guides were used to probe women's experiences, challenges, and concerns about selling sex during pregnancy and post-delivery in a high-HIV-prevalence context. Interviews were transcribed, translated, and coded using thematic analysis. FSWs experienced and feared violence by clients during pregnancy, highlighting the need for safe work environments. Further, FSWs expressed concerns about HIV acquisition and vertical transmission during the perinatal period. Physical challenges related to pregnancy affected women's ability to work. Returning to work post-delivery presented barriers to initiating and practicing exclusive breastfeeding. As a result, many FSWs practiced mixed feeding. Interventions, tailored to respond to FSW's challenges and experiences, may offer improved health outcomes in this context.
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http://dx.doi.org/10.1111/sifp.12090DOI Listing
September 2019

Characterizing the Influence of Structural Determinants of HIV Risk on Consistent Condom Use Among Female Sex Workers in Senegal.

J Acquir Immune Defic Syndr 2019 05;81(1):63-71

Department of Epidemiology, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Background: Female sex workers (FSWs) are disproportionately affected by HIV even in the most generalized HIV epidemics. Although structural HIV risks have been understood to affect condom negotiation among FSWs globally, there remain limited data on the relationship between structural determinants of HIV risk, including violence and socioeconomic status, and condom use among FSWs across sub-Saharan Africa. Here, we describe the prevalence of structural determinants and their associations with condom use among FSWs in Senegal.

Methods: In 2015, 758 FSWs >18 years of age were recruited using respondent driven sampling in Senegal. Data on individual, community, network, and structural-level risks were collected through an interviewer-administered questionnaire. Poisson regression with robust variance estimation was used to model the associations of consistent condom use (CCU) and selected structural determinants.

Results: The respondent driven sampling-adjusted prevalence of CCU in the last 10 sexual acts was 76.8% [95% confidence interval (CI): 70.8 to 82.8]. Structural determinants that were significantly associated with lower CCU were as follows: physical violence [adjusted prevalence ratio (aPR): 0.71; 95% CI: 0.52 to 0.98]; working primarily in a hotel or guest house (aPR: 0.85; 95% CI: 0.73 to 0.99); and difficultly accessing condoms (aPR: 0.72; 95% CI: 0.52 to 0.96). High income from sex work (aPR: 1.23; 95% CI: 1.04 to 1.46) was significantly associated with higher CCU.

Conclusions: Taken together, these data highlight the role of structural risk determinants on condom use among FSWs in Senegal. Moreover, these results highlight the need for structural interventions, including safe working spaces and violence mitigation programs, to support condom negotiation and access. Combined with condom distribution programs, structural interventions could ultimately increase condom use among FSWs in Senegal.
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http://dx.doi.org/10.1097/QAI.0000000000001991DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536305PMC
May 2019
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