Most-at-risk Populations Research Articles

Modeling time taken to HIV testing and uptake of test results: application of extended PWP model

Improving HIV testing among the most at risk populations (MARP) is one of the first steps to achieve the Sustainable Development Goal target of ending AIDS by 2030. Factors affecting time taken to HIV testing and subsequent clinic visits to uptake the test result are important inputs for development of HIV prevention programmes. This study aims to develop multivariate statistical models to describe HIV testing behavior of MARP. HIV testing data of 5667 Female Sex Workers registered with the National HIV Prevention Programme in 10 districts of Sri Lanka during 2016 and 2017 were modelled using univariate and multivariate survival analysis techniques. Results showed that the Prentice, Williams & Peterson gap time model (PWPGTM), and all univariate Cox Proportional Hazard Models together generated consistent results. However, higher number of effects of the factors and interaction effects were detected in the PWPGTM compared to other models. Further, PWPGTM generated more precise estimates with lower standard errors. In all the models, most of the factors were identified as time dependent covariates. Study concludes that the extended PWPGTM is the more appropriate technique to model time taken to HIV testing and subsequent clinic visit to uptake of test results among MARP.

Knowledge and barriers of PrEP delivery among diverse groups of potential PrEP users in Central Uganda.

BackgroundScale-up of oral pre-exposure prophylaxis (PrEP) for HIV prevention in Uganda began with serodiscordant couples (SDC) and has expanded to other most at-risk populations (MARPs). We explored knowledge, acceptability, barriers and facilitators of PrEP use among potential PrEP users in four MARPs (SDC; men who have sex with men [MSM]; female sex workers [FSW], and fisher folk).MethodsWe administered quantitative surveys to potential PrEP users in multiple settings in Central Uganda at baseline and approximately 9 months after healthcare worker (HCW) training on PrEP.ResultsThe survey was completed by 250 potential PrEP users at baseline and 125 after HCW training; 55 completed both surveys. For these 250 participants, mean age was 28.5 years (SD 6.9), 47% were male and 6% were transgender women, with approximately even distribution across MARPs and recruitment locations (urban, peri-urban, and rural). Most (65%) had not heard about PrEP. After HCW training, 24% of those sampled were aware of PrEP, and the proportion of those who accurately described PrEP as “antiretrovirals to be used before HIV exposure” increased from 54% in the baseline survey to 74% in the second survey (p<0.001). The proportion of participants who reported HCW as a source of PrEP information increased after training (59% vs 91%, p<0.001). In both surveys, nearly all participants indicated they were willing to take PrEP if offered. The most common anticipated barriers to PrEP were stigma, transportation, accessibility, busy schedules, and forgetfulness. Closeness to home was a common facilitator for all participant categories.ConclusionsInitial awareness of PrEP was low, but PrEP knowledge and interest increased among diverse MARPs after HCW training. Demand creation and HCW training will be critical for increasing PrEP awareness among key populations, with support to overcome barriers to PrEP use. These findings should encourage the acceleration of PrEP rollout in Uganda.

Confined vulnerability of HIV infection among pregnant women attending antenatal care clinics in Karnataka, India: Analysis of data from the HIV sentinel surveillance 2017

BackgroundHIV Sentinel Surveillance among pregnant women attending antenatal care clinics, ANC-HSS, is used to estimate HIV prevalence among the general population. Despite the declining trend, HIV prevalence among the general population in Karnataka is still higher than the national average (0.22%), with a recent, noticeable stabilization. Demographic analysis on concentrated HIV infection among pregnant women could be potential indicators for targeted HIV interventions among general population as well as and prevention of parent to child transmission (PPTCT). ObjectivesTo analyse the demographics of HIV-positive pregnant mothers in Karnataka, thereby identifying the most-at-risk populations (MARP) within the general population. MethodsIn total, 24800 eligible pregnant women aged 15–49 attending the ANC clinic for the first time during the surveillance period (Jan–Mar, 2017) were enrolled. Demographic data and blood samples were collected, recorded and tested for HIV. Age-specific factors associated with HIV prevalence, besides the demographics of the HIV positive pregnant women, were analysed to identify the MARP for targeted HIV interventions. ResultsComprehensively, none of the demographic factors was significantly associated with HIV prevalence. Nevertheless, analysis of demographics, HIV test history and ART status of HIV-positive pregnant women reveals prominent prevalence patterns. The epidemic was majorly confined within young, less educated, primigravida and rural mothers of low economic status. ConclusionANC-HSS is designed to estimate the HIV prevalence among general population at national, state and district levels and is not reflective of the concentrated epidemic confined to MARP. Identifying the disease pattern specific to MARP is essential for effective targeted interventions and disease management.

Improving Underestimation of HIV Prevalence in Surveys Using Time-Location Sampling.

We sought to find a method that improves HIV estimates obtained through time-location sampling (TLS) used to recruit most-at-risk populations (MARPs). The calibration on residuals (CARES) method attributes weights to TLS sampled individuals depending on the percentile to which their logistic regression residues belong. Using a real country database, provided by EMIS-2010, with 9591 men who have sex with men (MSM) and an HIV prevalence of 12.1%, we simulated three populations (termed "pseudo-populations") with different levels of HIV. From each pseudo-population, 1000 TLS samples were drawn, and the HIV prevalence estimated by the TLS method and by the CARES method were recorded and compared with the HIV prevalence of the 9591 men. Results showed that the CARES method improves estimates given by the TLS method by getting closer to the real HIV prevalence.

Utilization of safe male circumcision among adult men in a fishing community in rural Uganda.

In Uganda, most-at-riskpopulations(MARPs) such as fishing communities remain vulnerable to preventable HIV acquisition. Safe Male Circumcision (SMC) has been incorporated into Uganda's HIV prevention strategies. This study aimed at determining SMC utilization and associated factors among adult men in a rural fishing community in Uganda. A cross-sectional study was conducted in a rural fishing village in central Uganda. Stratified random sampling of 369 fishermen aged 18-54 yearswas used according to their occupational category; fish monger, boat crew and general merchandise. The dependent variable wasutilization of SMC.A forward fitting multivariable logistic regression model was fitted with variables significant at p≤0.05 controlling for confounding and effect modification. Respondents'mean(SD) age was 30.0(9.3) years. Only8.4%hadSMC and among non-circumcised men, 84.9% had adequate knowledge of SMC benefits while 79.3% did not know were SMC services were offered. Peer support(AOR0.17;95%-CI0.05-0.60) and perceived procedural safety (AOR6.8;95%CI2.16-21.17) were independently associated with SMC utilization. In this rural fishing community, SMC utilization was low. These findings underscore the need to inform HIV preventionstrategies inthecontextof peer support and perceptionsheld by rural dwelling men.

Influence of Profession as Risk of STIs in Intimate Partner Relationship in South Asian Countries

Mixing of sexual partners as part of the profession of female sex workers (FSWs) can be a risk in intimate partner relationship, which is primarily based on love and affection. Sexual relation with one partner provides emotional and psychological support. However, when it is a web of partners, it often results in unprotected sex, consequently creating a pathway for disease and increasing the vulnerability of FSWs to sexually transmitted infections (STIs). This paper analyses the subtleties of sexual behavior of FSWs and their vulnerability toward STIs in intimate partner relationship in South Asian countries. The basic data used in this paper have been taken from 3 countries, 1271 FSWs from Bangladesh, 1404 FSWs from Nepal, and 7399 FSWs from India. The data were collected through modified time location cluster sampling as a part of mapping and size estimation of most-at-risk populations (MARPs) in Nepal and key affected populations (KAPs) in Bangladesh during the period of 2010–2016. The data for India are taken from the integrated behavioral and biological assessment (IBBA), which assesses the prevalence of high risk population in India. The findings reveal that the majority of the FSWs were married, which reveals dynamics of sexual activity placing them at higher risk of STIs. About half of the FSWs had more than 15 coituses in the last 30 days in Nepal, which is a high risk factor. Unprotected sex is reported high across all three countries irrespective of all background characteristics. Condom use during intercourse in Bangladesh is less likely in older FSWs and more likely among educated FSWs who had coital frequency of 7 or more in the last 30 days. Interestingly, unmarried FSWs in Nepal are less likely to use condom in their last sex as against India where FSWs are more likely to use condom in their last sex. The prevalence of STI among uneducated FSWs is found higher in Bangladesh as compared to Nepal and India. The socio-demographic background characteristics showed a significant association with unprotected sex, coital frequency and prevalence of STI across all three countries.

HIV Risk Behaviors and Correlates of Inconsistent Condom Use Among Substance Using Migrants at the Mexico/Guatemala Border.

This study assessed correlates of inconsistent condom use with casual partners and the prevalence of sexual risk behaviors and STIs in the Mexico/Guatemala border region using a sample of 392 migrants (303 men, 85 women) who reported current substance use or problem drinking. We ran separate univariate logistic regression models for men and women, and multivariate logistic regression models for men only. Prevalence of syphilis was 1.2% among women and 2.3% among men; HIV prevalence was 2.4% among women and 1.3% among men. Inconsistent condom use with casual partners was higher in women with greater education and lower among women who sold sex. In men, less access to free condoms, drug use with sexual partners, and drug use before sex were independently associated with inconsistent condom use with casual partners. Sexual and substance use risk behaviors were common, and HIV/STI prevention efforts should target both genders and expand beyond most-at risk populations.

Existing well known and new psychoactive illicit drugs with a broad ranging hazardous potential. A detailed report on one’s experiences

Regarding the prevalence of illicit psychoactive drugs about one third of the adults in Germany are experienced with such kind of drugs. Consumption of classical illegal drugs like heroin and cocaine seems to be unchanged. This article focuses essentially on ‘natural and synthetic drugs’ with respect to (i) injecting drug users (IDU) with the potential of spreading blood borne infections such as, e.g., HBV, HCV and HIV and (ii) people actively participating in sexual exposure settings where psychotropic drugs are concomitantly used. Entactogenic [1,2] drugs are also in demand in these settings especially for sexual stimulation. The addressed issues are to highlight the complexity of the misuse of illicit psychotropic drugs in Germany, and then both targeting directly the individual, temporally limited as well as permanently following hazards of health; furthermore, the indirect consequences are the increasing spread of STIs (sexually transmitted infections) that poses the next relevant issues for public health and social importance. The drugs discussed here are no longer restricted to the most-atrisk populations [3] but have been expanded to include the general population

Identification of gaps for implementation science in the HIV prevention, care and treatment cascade; a qualitative study in 19 districts in Uganda.

BackgroundOver the last 20 years, countries in sub Saharan Africa have made significant strides in the implementation of programs for HIV prevention, care and treatment. Despite, the significant progress made, many targets set by the United Nations have not been met. There remains a large gap between the ideal and what has been achieved. There are several operational issues that may be responsible for this gap, and these need to be addressed in order to achieve the targets. Therefore, the aim of this study was to identify gaps in the HIV prevention, care and treatment cascade, in a large district based HIV implementation program. We aimed to identify gaps that are amenable for evaluation using implementation science, in order to improve the delivery of HIV programs in rural Uganda.MethodsWe conducted key informant (KI) interviews with 60 district health officers and managers of HIV/AIDS clinics and organizations and 32 focus group discussions with exit clients seeking care and treatment for HIV in the 19 districts. The data analysis process was guided using a framework approach. The recordings were transcribed verbatim. Transcripts were read back and forth and codes generated based on the framework.ResultsNine emerging themes that comprise the gaps were identified and these were referral mechanisms indicating several loop holes, low levels of integration of HIV/TB services, low uptake of services for PMTCT services by pregnant women, low coverage of services for most at risk populations (MARPs), poor HIV coordination structures in the districts, poor continuity in the delivery of pediatric HIV/AIDS services, limited community support for orphans and vulnerable (OVC’s), inadequate home based care services and HIV services and support for discordant couples. The themes indicate there are plenty of gaps that need to be covered and have been ignored by current programs.ConclusionsOur study has identified several gaps and suggested several interventions that should be tested before large scale implementation. The implementation of these programs should be adequately evaluated in order to provide field evidence of effectiveness and replicability in similar areas.

Evidence from epidemic appraisals in Nigeria

Although HIV prevalence has increased in most-at-risk populations (MARPs) across Nigeria, effective programming was difficult because Nigeria lacked information for prevention programmes to target interventions that maximise coverage and cost effectiveness. Epidemic appraisals (EA) were conducted in eight states to provide evidence for the planning, implementation and co-ordination of prevention interventions. Component 1: Mapping determined the size, typology and locations of MARPs. Component 2: Venue profiling identified and profiled venues where general populations engaged in high-risk behaviours. Component 3: Rural appraisals provided insights into risk behaviours and sexual networking in villages. States used mapping results to prioritise areas with a MARP coverage of 70% – 80% and then scale up interventions for non-brothel-based female sex workers (FSWs) instead of focusing on brothel-based FSWs. The eight states prioritisedf unding for the high-coverage areas to ensure a minimum coverage level of 70% – 80% of MARPs was reached. The refocused resources led to cost efficiencies. Applying venue profiling results, six states implemented interventions at bars and night clubs – previously not covered. States also maximised intervention coverage for high-risk general populations; this led to the use of resources for general population interventions in a focused way rather than across an entire state. States focused on condom programmes in rural areas. EA results provided the evidence for focusing interventions for high MARP coverage as well as forhigh-risk general populations. The states applied the results and rapidly refocused their interventions, increasing the likelihood of having an impact on HIV transmission in those states. Nigeria is now implementing EAs in the remaining 29 states to effect national-level impact.

P17.13 Evaluating the implementation of couples hiv counselling and testing (chct) among most at risk populations: an experience from bali, indonesia

Introduction A pilot project of couples HIV counselling and testing (CHCT) was conducted among most-at-risk populations (MARP) in Bali from April to September 2013. The project provided financial incentives for outreach workers and counsellors during the implementation. The study evaluated the process of CHCT program and explored the readiness to continue the program implementation. Methods A mixed method study conducted in July–December 2013. The number of couples participated during and after the project were compared. Four focus group discussions were conducted with counsellors and outreach workers, while in-depth interviews conducted with 22 couples (men who have sex with men, female sex workers and their partners). Results There were 100 couples participated during the 6 month project (average: 16–17 couples/month). The number, however, decreased significantly with only 19 couples in the following 5 months (average: 3–4 couples/month). Due to the availability of incentives for staff, they were more active in searching and enrolling clients during the project than after the project. It was revealed that counsellors and outreach workers face more challenges in CHCT than in the individual VCT, particularly the issues of couples’ separation, significantly increased workload, and a limited number of trained counsellors. Interviews with couples show the need of better services and supporting facilities such as after-hour services, treatment support system, computerised data management, one day laboratory service, and more friendly staff. Even though the level of knowledge was generally good, there were some misperceptions among couples regarding the natural history of HIV infection, thus complete information during the counselling process is required. Conclusion CHCT among MARP in Bali can be sustainable, however, some kind of incentives and training for counsellors are needed to motivate staff, while promotion of CHCT and improved facilities are required to attract couples and to provide better services. Disclosure of interest statement The study is funded by National AIDS Commission of Indonesia and HIV Corporation Program for Indonesia (HCPI).

P84 National hiv testing week 3: finding the hard to reach and building on success: Abstract P84 Table 1

<h3>Background/introduction</h3> The third National HIV Testing Week (NHTW) was in November 2014. <h3>Aims</h3> To build on our previous success of testing the most-at-risk populations (MARP), focusing on outreach. <h3>Methods</h3> A third sector organisation, primarily targeting gay communities, provided club and bar outreach and offered point-of-care testing (POCT) on-site and at 2 saunas. A second third sector organisation, targeting African communities, offered POCT at 6 venues, including local markets, an asylum-seeker centre, pharmacies, health centres and an African football match. CASH services offered POCT at 3 clinics across the city. GUM and Leeds City Council staff volunteered to provide outreach and testing support for the 12 different testing sites across the city. <h3>Results</h3> 167 people tested (126 in 2013, 94 in 2012). 71% were from MARPs, unchanged from 2013. 1 female black African and 1 MSM tested HIV+ve, the first HIV diagnoses resulting directly from NHTW initiatives in our city. 74% of people who tested were sensitised through community outreach. Over 90% of people tested were given advice on PEP, repeat testing, STI screening and offered condoms. <h3>Discussion</h3> Two undiagnosed HIV+ve people were identified as a result of NHTW efforts, and both are now in HIV care. A greater population, including those from MARPs tested. Of the MARPs, a higher percentage were testing for the first time. This may reflect decreased overall testing in MARPs, or that our NHTW 2014 campaign was more successful at reaching and testing people who are less likely to attend more traditional testing sites.

Poverty, Denialism, Stigma and Discrimination: Challenges to Alleviating HIV/AIDS in Post-Apartheid South Africa

South Africa is experiencing an HIV/AIDS epidemic whose prevalence remains the highest globally (UNAIDS, 2014). With an estimated 5.7 million HIV-positive persons in South Africa, it is pertinent to develop and sustain a multi-sector strategy for combating the HIV/AIDS epidemic which acknowledges poverty, denialism, stigma, and discrimination as social drivers, acting as deterrents towards treatment and awareness campaigns. These societal drivers are compounded by structural drivers which perpetuate vulnerability to HIV/AIDS. Intersectional stigma and discrimination act as barriers to effective treatment and prevention combination strategies which seek to decrease prevalence, especially amongst the most at risk populations (MARPs): Black women and youth, the LGBTQ community, intravenous drug users, the prison population, orphans, and sex workers (UNAIDS, 2011a; UNAIDS, 2014). These drivers not only perpetuate myths and misconceptions, but directly impact behaviour and decision-making capabilities. Black women and youth in urban and rural areas in South Africa represent one of the MARPs whose prevalence continues to increase, while other vulnerable groups prevalence has decreased or remains stagnant (UNAIDS, 2014). It is imperative to utilize the theory of intersectionality to better comprehend the relationship between poverty, denialism, stigma, and discrimination and its impact on the HIV/AIDS epidemic in South Africa.

Analysis of Health Facility Based Barriers And Facilitators To Use Of Sexual And Reproductive Health Care Services Among Most At Risk Populations (MARPS): Evidence From A Mystery Client Survey In Nigeria

Background: Access to sexual and reproductive health care services for most at risk population (MARPs) is a very important step in stemming the spread of HIV; as HCT and early diagnosis and treatment of STIs can contribute to reduction of the spread of HIV. Within Nigeria and most Sub Saharan African countries, MARPs are highly stigmatized both in the general society and in health care centres. It is important health care facility based facilitators and barriers to MARPs’ access to use of sexual and reproductive health care services by MARPs are identified to guide project design and implementation as well as policy formulation. Methods: Mystery client survey was conducted in thirty three (33) healthcare facilities in Nigeria. For the purpose of the survey, the mystery clients (MARPs) sought only STI consultation and HIV counselling and testing services. Twelve (12) mystery clients visited each facility seeking either STI or HCT service in the facility. Ethical approval was obtained from the Nigeria Institute of Medical Research (NIMR). SPSS version 20 was used for the Bi-variate and multivariate logistic regression analysis. Results: While positive attitude of health care workers was found to be a facilitator of access to health care services, this study shows that perceived quality of services is a very significant variable in MARPs’ use of a health care facility. We also found that MARPs were more willing to refer their community members to facilities that have educational materials promoting non-stigmatizing attitude towards PLWHAs and MARPs. Amazingly, privacy of services provided was not significant. Conclusion: It is recommended that standard of health care practices should be enforced. Training and re training of health care workers on provision of MARP friendly services should be formalized and scaled up. Investment in educational materials (posters) in health facility settings should be promoted.

Providing a gateway to prevention and care for the most at-risk populations in Bhutan: is this being achieved?

Two free-standing urban human immunodeficiency virus (HIV) testing and counselling (HCT) centres in Bhutan offering services to the general population and targeting the most at-risk populations (MARPs). To assess the trend in testing for HIV, hepatitis B and syphilis in both the general population and MARPs, and to determine if sociodemographic and risk behaviour characteristics are associated with HIV, hepatitis B and syphilis seropositivity. Cross-sectional study using client records, 2009 - 2012. Of 7894 clients, 3009 (38%) were from the general population, while 4885 (62%) were from MARPs. Over the 4-year period, testing declined progressively among the general population, while it increased or remained static for MARPs. Of 4885 MARPs, seropositivity was respectively 0.7%, 1.3% and 1.2% for HIV, hepatitis B and syphilis. Female sex workers (FSWs) (relative risk [RR] 4.4, P = 0.03) and partners of person living with HIV (RR 25.9, P < 0.001) had a higher risk of being HIV-positive. FSWs had also a greater risk of being syphilis-positive (RR 9.1, P < 0.001). The increase in uptake of HCT services by MARPs is a welcome finding; however, the relatively static trends call for the introduction of community outreach approaches. The critical gateway being provided to MARPs is an 'opportunity' for the expansion of the current service package.

Can the UNAIDS modes of transmission model be improved?

Objective:The UNAIDS modes of transmission model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplifications inherent in the MoT produce misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity.Methods:We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated.Results:The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40–75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognized risk group, with 16% of infections occurring in this subgroup.Conclusion:The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.

O20.1 Two-Mode Analysis of HIV, HCV and Risk Behaviours: A Place-Based Analysis of Most At-Risk Populations in Winnipeg, Canada

BackgroundThe HIV epidemic has shown a considerable amount of heterogeneity, complicating the design and placement of prevention, intervention and treatment programmes. Place-based analyses providing specific information on pathogen prevalence, risk...

P4.084 Significant Behaviour Change in People Who Inject Drugs (PWID) and Female Sex Workers (FSWs) in Bangladesh

BackgroundThe HIV prevalence in Bangladesh is still low with < 0.1% in general population and < 1% in most at risk populations (MARPs) though all the risk factors prevail like...

Injecting drug users, sex workers and men who have sex with men: a national cross-sectional study to develop a framework and prevalence estimates for national HIV/AIDS programmes in the Republic of Serbia

ObjectiveThe aim of this study was to develop a framework and best estimates of prevalence for the most at risk populations (MARPs) for HIV/AIDS to include sex workers (SW), men...

HIV counseling and testing and access-to-care needs of populations most-at-risk for HIV in Nigeria

Mobile HIV counseling and testing (mHCT) is an effective tool to access hard-to-reach most-at-risk populations (MARPs), but identifying which populations are not accessing services is often a challenge. We compared correlates of human immunodeficiency virus (HIV) infection and awareness of HIV care services among populations tested through mHCT and at testing facilities in Nigeria. Participants in a cross-sectional study completed a questionnaire and HCT between May 2005 and March 2010. Of 27,586 total participants, 26.7% had been previously tested for HIV; among mHCT clients, 14.7% had previously been tested. HIV prevalence ranged from 6.6% among those tested through a facility to 50.4% among brothel-based sex workers tested by mHCT. Among mHCT participants aged 18–24, women were nine times more likely to be infected than men. Women aged 18–24 were also less likely than their male counterparts to know that there were medicines available to treat HIV (63.2 vs. 68.1%; p=0.03). After controlling for gender, age, and other risk factors, those with current genital ulcer disease were more likely to be HIV-infected (ORmHCT=1.65, 1.31–2.09; ORfacility=1.71, 1.37–2.14), while those previously tested were less likely to be HIV-infected (ORmHCT=0.75, 0.64–0.88; ORfacility=0.27, 0.24–0.31). There is an urgent need to promote strategies to identify those who are HIV-infected within MARPs, particularly young women, and to educate and inform them about availability of HIV testing and care services. mHCT, ideally coupled with sexually transmitted infection management, may help to ensure that MARPs access HIV prevention support, and if infected, access care, and treatment.