Sub-Saharan Africa bears more than two-thirds of the worldwide burden of HIV; however, data among transgender women from the region are sparse. Transgender women across the world face significant ...vulnerability to HIV. This analysis aimed to assess HIV prevalence as well as psychosocial and behavioral drivers of HIV infection among transgender women compared with cisgender (non-transgender) men who have sex with men (cis-MSM) in 8 sub-Saharan African countries.
Respondent-driven sampling targeted cis-MSM for enrollment. Data collection took place at 14 sites across 8 countries: Burkina Faso (January-August 2013), Côte d'Ivoire (March 2015-February 2016), The Gambia (July-December 2011), Lesotho (February-September 2014), Malawi (July 2011-March 2012), Senegal (February-November 2015), Swaziland (August-December 2011), and Togo (January-June 2013). Surveys gathered information on sexual orientation, gender identity, stigma, mental health, sexual behavior, and HIV testing. Rapid tests for HIV were conducted. Data were merged, and mixed effects logistic regression models were used to estimate relationships between gender identity and HIV infection. Among 4,586 participants assigned male sex at birth, 937 (20%) identified as transgender or female, and 3,649 were cis-MSM. The mean age of study participants was approximately 24 years, with no difference between transgender participants and cis-MSM. Compared to cis-MSM participants, transgender women were more likely to experience family exclusion (odds ratio OR 1.75, 95% CI 1.42-2.16, p < 0.001), rape (OR 1.95, 95% CI 1.63-2.36, p < 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12-1.52, p < 0.001). Transgender women were more likely to report condomless receptive anal sex in the prior 12 months (OR 2.44, 95% CI 2.05-2.90, p < 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49-2.19, p < 0.001). Overall HIV prevalence was 25% (235/926) in transgender women and 14% (505/3,594) in cis-MSM. When adjusted for age, condomless receptive anal sex, depression, interpersonal stigma, law enforcement stigma, and violence, and the interaction of gender with condomless receptive anal sex, the odds of HIV infection for transgender women were 2.2 times greater than the odds for cis-MSM (95% CI 1.65-2.87, p < 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments.
In this study in sub-Saharan Africa, we found that HIV burden and stigma differed between transgender women and cis-MSM, indicating a need to address gender diversity within HIV research and programs.
Introduction
Transgender women are at high risk for the acquisition and transmission of HIV. However, there are limited empiric data characterizing HIV‐related risks among transgender women in ...sub‐Saharan Africa. The objective of these analyses is to determine what factors, including sexual behaviour stigma, condom use and engagement in sex work, contribute to risk for HIV infection among transgender women across three West African nations.
Methods
Data were collected via respondent‐driven sampling from men who have sex with men (MSM) and transgender women during three‐ to five‐month intervals from December 2012 to October 2015 across a total of six study sites in Togo, Burkina Faso and Côte d'Ivoire. During the study visit, participants completed a questionnaire and were tested for HIV. Chi‐square tests were used to compare the prevalence of variables of interest between transgender women and MSM. A multilevel generalized structural equation model (GSEM) was used to account for clustering of observations within study sites in the multivariable analysis, as well as to estimate mediated associations between sexual behaviour stigma and HIV infection among transgender women.
Results
In total, 2456 participants meeting eligibility criteria were recruited, of which 453 individuals identified as being female/transgender. Transgender women were more likely than MSM to report selling sex to a male partner within the past 12 months (p<0.01), to be living with HIV (p<0.01) and to report greater levels of sexual behaviour stigma as compared with MSM (p<0.05). In the GSEM, sexual behaviour stigma from broader social groups was positively associated with condomless anal sex (adjusted odds ratio (AOR)=1.33, 95% confidence interval (CI)=1.09, 1.62) and with selling sex (AOR=1.23, 95% CI=1.02, 1.50). Stigma from family/friends was also associated with selling sex (AOR=1.42, 95% CI=1.13, 1.79), although no significant associations were identified with prevalent HIV infection.
Conclusions
These data suggest that transgender women have distinct behaviours from those of MSM and that stigma perpetuated against transgender women is impacting HIV‐related behaviours. Furthermore, given these differences, interventions developed for MSM will likely be less effective among transgender women. This situation necessitates dedicated responses for this population, which has been underserved in the context of both HIV surveillance and existing responses.
Introduction
The West and Central Africa (WCA) sub‐region is the most populous region of sub‐Saharan Africa (SSA), with an estimated population of 356 million living in 24 countries. The HIV epidemic ...in WCA appears to have distinct dynamics compared to the rest of SSA, being more concentrated among key populations such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and clients of FSWs. To explore the epidemiology of HIV in the region, a systematic review of HIV literature among key populations in WCA was conducted since the onset of the HIV epidemic.
Methods
We searched the databases PubMed, CINAHL and others for peer‐reviewed articles regarding FSWs, MSM and PWID in 24 countries with no date restriction. Inclusion criteria were sensitive and focused on inclusion of any HIV prevalence data among key populations. HIV prevalence was pooled, and in each country key themes were extracted from the literature.
Results
The search generated 885 titles, 214 s and 122 full articles, of which 76 met inclusion and exclusion criteria providing HIV prevalence data. There were 60 articles characterizing the burden of disease among FSWs, eight for their clients, one for both, six for MSM and one for PWID. The pooled HIV prevalence among FSWs was 34.9% (n=14,388/41,270), among their clients was 7.3% (n=435/5986), among MSM was 17.7% (n=656/3714) and among PWID from one study in Nigeria was 3.8% (n=56/1459).
Conclusions
The disproportionate burden of HIV among FSWs appears to be consistent from the beginning of the HIV epidemic in WCA. While there are less data for other key populations such as clients of FSWs and MSM, the prevalence of HIV is higher among these men compared to other men in the region. There have been sporadic reports among PWID, but limited research on the burden of HIV among these men and women. These data affirm that the HIV epidemic in WCA appears to be far more concentrated among key populations than the epidemics in Southern and Eastern Africa. Evidence‐based HIV prevention, treatment and care programmes in WCA should focus on engaging populations with the greatest burden of disease in the continuum of HIV care.
Objectives
Research indicates that individuals tested for HIV have higher socio‐economic status than those not tested, but less is known about how socio‐economic status is associated with modes of ...testing. We compared individuals tested through provider‐initiated testing and counselling (PITC), those tested through voluntary counselling and testing (VCT) and those never tested.
Methods
Cross‐sectional surveys were conducted at health facilities in Burkina Faso, Kenya, Malawi and Uganda, as part of the Multi‐country African Testing and Counselling for HIV (MATCH) study. A total of 3659 clients were asked about testing status, type of facility of most recent test and socio‐economic status. Two outcome measures were analysed: ever tested for HIV and mode of testing. We compared VCT at stand‐alone facilities and PITC, which includes integrated facilities where testing is provided with medical care, and prevention of mother‐to‐child transmission (PMTCT) facilities. The determinants of ever testing and of using a particular mode of testing were analysed using modified Poisson regression and multinomial logistic analyses.
Results
Higher socio‐economic status was associated with the likelihood of testing at VCT rather than other facilities or not testing. There were no significant differences in socio‐economic characteristics between those tested through PITC (integrated and PMTCT facilities) and those not tested.
Conclusions
Provider‐initiated modes of testing make testing accessible to individuals from lower socio‐economic groups to a greater extent than traditional VCT. Expanding testing through PMTCT reduces socio‐economic obstacles, especially for women. Continued efforts are needed to encourage testing and counselling among men and the less affluent.
Objectifs
La recherche indique que les personnes dépistées pour le VIH ont un statut socioéconomique plus élevé que celles qui ne sont pas dépistées, mais on en sait moins sur la façon dont le statut socioéconomique est associé aux modes de dépistage. Nous avons comparé les individus qui ont été testés à travers l'initiative du prestataire pour le conseil et dépistage (PITC), ceux qui ont été testés à travers le conseil et dépistage volontaire (CDV) et ceux qui n'ont jamais été testés.
Méthodes
Des surveillances transversales ont été menées dans des établissements de santé au Burkina‐Faso, au Kenya, au Malawi et en Ouganda, dans le cadre de l’étude MATCH (Conseil et Dépistage du VIH Multi‐pays Africain). 3.659 personnes ont été interrogées sur le statut du test, le type d’établissement pour le test le plus récent et le statut socioéconomique. Deux mesures de résultats ont été analysées: jamais testé pour le VIH et le mode de dépistage. Nous avons comparé le CDV dans les établissements autonomes et le PITC, qui comprend des établissements intégrés où le test est fourni avec des soins médicaux, et les établissements PTME (prévention de la transmission de la mère à l'enfant). Les déterminants pour n'avoir jamais été testé et pour l'utilisation d'un mode particulier de dépistage ont été analysés en utilisant la régression de Poisson modifiée et des analyses logistiques multinomiales.
Résultats
Le statut socioéconomique plus élevé a été associé à la probabilité de tester à travers le mode CDV plutôt qu’à travers d'autres établissements ou ne pas tester. Il n'y avait pas de différences significatives dans les caractéristiques socioéconomiques entre ceux testés à travers le PITC (établissements intégrés PTME) et ceux non testés.
Conclusions
Les modes de dépistage à l'initiative du prestataire permettent l'accès au dépistage aux personnes appartenant aux groupes socioéconomiques inférieurs dans une plus grande mesure que le CDV traditionnel. Etendre le dépistage par la PTME réduit les obstacles socioéconomiques, en particulier pour les femmes. Des efforts continus sont nécessaires pour encourager le conseil et le dépistage chez les hommes et les moins nantis.
ObjetivosInvestigaciones previas indican que los individuos que se realizan la prueba del VIH tienen un mayor estatus socioeconómico que aquellos que no se la hacen, pero se conoce menos acerca de cómo están asociados el estatus socioeconómico con las diferentes formas de hacerse la prueba. Hemos comparado a individuos que se han realizado la prueba a través de un programa de aconsejamiento y prueba iniciado por el proveedor (APIP), aquellos que se la han hecho siguiendo un aconsejamiento y prueba voluntarios (APV), y aquellos que nunca se han hecho la prueba.
Métodos
Se realizaron estudios croseccionales en centros sanitarios de Burkina Faso, Kenia, Malawi y Uganda, como parte del estudio MATCH (por sus siglas en inglés “Multi‐country African Testing and Counselling for HIV”). Se preguntó a 3,659 personas si se habían realizado o no la prueba de VIH, el tipo de centro en el que se habían realizado la última prueba y su estatus socioeconómico. Se analizaron dos parámetros: si se habían sometido a no alguna vez a la prueba del VIH y el tipo de prueba al que se habían sometido. Comparamos el APV en centros independientes y el APIP, incluyendo a centros sanitarios integrados, en donde la prueba se ofrece con cuidados médicos y prevención de la transmisión vertical (madre‐hijo). El análisis de los determinantes de haberse realizado la prueba alguna vez y de utilizar una forma particular de prueba se hizo mediante la regresión modificada de Poisson y la regresión logística multinomial.
ResultadosEl tener un mayor estatus socioeconómico estaba asociado con la probabilidad de realizarse la prueba mediante APV comparado con utilizar otros centros o no hacerse la prueba. No había diferencias significativas entre las características socioeconómicas de aquellos que se realizaban la prueba en APIP (centros integrados y centros de prevención de la transmisión vertical) y quienes no se habían realizado nunca a la prueba.
ConclusionesLa opción de APIP hace que la prueba sea asequible a individuos pertenecientes a grupos con un menor estatus socioeconómico, mucho más que el APV tradicional. Expandir la realización de pruebas mediante programas de prevención de la transmisión vertical reduce los obstáculos socioeconómicos, especialmente para las mujeres. Se requiere de esfuerzos continuados para promover el aconsejamiento y prueba entre los hombres y los menos adinerados.
Ambitious UN goals to reduce the mother-to-child transmission of HIV have not been met in much of Sub-Saharan Africa. This paper focuses on the quality of information provision and counseling and ...disclosure patterns in Burkina Faso, Kenya, Malawi and Uganda to identify how services can be improved to enable better PMTCT outcomes.
Our mixed-methods study draws on data obtained through: (1) the MATCH (Multi-country African Testing and Counseling for HIV) study's main survey, conducted in 2008-09 among clients (N = 408) and providers at health facilities offering HIV Testing and Counseling (HTC) services; 2) semi-structured interviews with a sub-set of 63 HIV-positive women on their experiences of stigma, disclosure, post-test counseling and access to follow-up psycho-social support; (3) in-depth interviews with key informants and PMTCT healthcare workers; and (4) document study of national PMTCT policies and guidelines. We quantitatively examined differences in the quality of counseling by country and by HIV status using Fisher's exact tests.
The majority of pregnant women attending antenatal care (80-90%) report that they were explained the meaning of the tests, explained how HIV can be transmitted, given advice on prevention, encouraged to refer their partners for testing, and given time to ask questions. Our qualitative findings reveal that some women found testing regimes to be coercive, while disclosure remains highly problematic. 79% of HIV-positive pregnant women reported that they generally keep their status secret; only 37% had disclosed to their husband.
To achieve better PMTCT outcomes, the strategy of testing women in antenatal care (perceived as an exclusively female domain) when they are already pregnant needs to be rethought. When scaling up HIV testing programs, it is particularly important that issues of partner disclosure are taken seriously.
The ATLAS programme aims to promote and implement HIV self-testing (HIVST) in three West African countries: Côte d'Ivoire, Mali, and Senegal. During 2019-2021, in close collaboration with the ...national AIDS implementing partners and communities, ATLAS plans to distribute 500,000 HIVST kits through eight delivery channels, combining facility-based, community-based strategies, primary and secondary distribution of HIVST. Considering the characteristics of West African HIV epidemics, the targets of the ATLAS programme are hard-to-reach populations: key populations (female sex workers, men who have sex with men, and drug users), their clients or sexual partners, partners of people living with HIV and patients diagnosed with sexually transmitted infections and their partners. The ATLAS programme includes research support implementation to generate evidence for HIVST scale-up in West Africa. The main objective is to describe, analyse and understand the social, health, epidemiological effects and cost-effectiveness of HIVST introduction in Côte d'Ivoire, Mali and Senegal to improve the overall HIV testing strategy (accessibility, efficacy, ethics).
ATLAS research is organised into five multidisciplinary workpackages (WPs): Key Populations WP: qualitative surveys (individual in-depth interviews, focus group discussions) conducted with key actors, key populations, and HIVST users. Index testing WP: ethnographic observation of three HIV care services introducing HIVST for partner testing. Coupons survey WP: an anonymous telephone survey of HIVST users. Cost study WP: incremental economic cost analysis of each delivery model using a top-down costing with programmatic data, complemented by a bottom-up costing of a representative sample of HIVST distribution sites, and a time-motion study for health professionals providing HIVST. Modelling WP: Adaptation, parameterisation and calibration of a dynamic compartmental model that considers the varied populations targeted by the ATLAS programme and the different testing modalities and strategies.
ATLAS is the first comprehensive study on HIV self-testing in West Africa. The ATLAS programme focuses particularly on the secondary distribution of HIVST. This protocol was approved by three national ethic committees and the WHO's Ethical Research Committee.
Consultations for sexually transmitted infection (STI) provide an opportunity to offer HIV testing to both patients and their partners. This study describes the organisation of HIV self-testing ...(HIVST) distribution during STI consultations in Abidjan (Côte d'Ivoire) and analyse the perceived barriers and facilitators associated with the use and redistribution of HIVST kits by STI patients.
A qualitative study was conducted between March and August 2021 to investigate three services providing HIVST: an antenatal care clinic (ANC), a general health centre that also provided STI consultations, and a dedicated STI clinic. Data were collected through observations of medical consultations with STI patients (N = 98) and interviews with both health professionals involved in HIVST distribution (N = 18) and STI patients who received HIVST kits for their partners (N = 20).
In the ANC clinic, HIV testing was routinely offered during the first prenatal visit. HIVST was commonly offered to women who had been diagnosed with an STI for their partner's use (27/29 observations). In the general health centre, two parallel pathways coexisted: before the consultation, a risk assessment tool was used to offer HIV testing to eligible patients and, after the consultation, patients who had been diagnosed with an STI were referred to a care assistant for HIVST. Due to this HIV testing patient flow, few offers of HIV testing and HIVST were made in this setting (3/16). At the dedicated STI clinic, an HIVST video was played in the waiting room. According to the health professionals interviewed, this video helped reduce the time required to offer HIVST after the consultation. Task-shifting was implemented there: patients were referred to a nurse for HIV testing, and HIVST was commonly offered to STI patients for their partners' use (28/53). When an HIVST was offered, it was generally accepted (54/58). Both health professionals and patients perceived HIVST positively despite experiencing a few difficulties with respect to offering HIVST to partners and structural barriers associated with the organisation of services.
The organisation of patient flow and task-shifting influenced HIV testing and offers of HIVST kits. Proposing HIVST is more systematic when HIV testing is routinely offered to all patients. Successful integration requires improving the organisation of services, including task-shifting.
HIV epidemics in Western and Central Africa (WCA) remain concentrated among key populations, who are often unaware of their status. HIV self-testing (HIVST) and its secondary distribution among key ...populations, and their partners and relatives, could reduce gaps in diagnosis coverage. We aimed to document and understand secondary HIVST distribution practices by men who have sex with men (MSM), female sex workers (FSW), people who use drugs (PWUD); and the use of HIVST by their networks in Côte d'Ivoire, Mali, and Senegal.
A qualitative study was conducted in 2021 involving (a) face-to-face interviews with MSM, FSW, and PWUD who received HIVST kits from peer educators (primary users) and (b) telephone interviews with people who received kits from primary contacts (secondary users). These individual interviews were audio-recorded, transcribed, and coded using Dedoose software. Thematic analysis was performed.
A total of 89 participants, including 65 primary users and 24 secondary users were interviewed. Results showed that HIVST were effectively redistributed through peers and key populations networks. The main reported motivations for HIVST distribution included allowing others to access testing and protecting oneself by verifying the status of partners/clients. The main barrier to distribution was the fear of sexual partners' reactions. Findings suggest that members of key populations raised awareness of HIVST and referred those in need of HIVST to peer educators. One FSW reported physical abuse. Secondary users generally completed HIVST within two days of receiving the kit. The test was used half the times in the physical presence of another person, partly for psychological support need. Users who reported a reactive test sought confirmatory testing and were linked to care. Some participants mentioned difficulties in collecting the biological sample (2 participants) and interpreting the result (4 participants).
The redistribution of HIVST was common among key populations, with minor negative attitudes. Users encountered few difficulties using the kits. Reactive test cases were generally confirmed. These secondary distribution practices support the deployment of HIVST to key populations, their partners, and other relatives. In similar WCA countries, members of key populations can assist in the distribution of HIVST, contributing to closing HIV diagnosis gaps.
Stigma is a multifaceted concept that potentiates Human Immunodeficiency Virus and sexually transmitted infection acquisition and transmission risks among key populations, including men who have sex ...with men (MSM) and female sex workers (FSW). Despite extensive stigma literature, limited research has characterized the types and sources of stigma reported by key populations in Sub-Saharan Africa.
This study leveraged data collected from 1356 MSM and 1383 FSW in Togo and Burkina Faso, recruited via respondent-driven sampling. Participants completed a survey instrument including stigma items developed through systematic reviews and synthesis of existing metrics. Using exploratory factor analysis with promax oblique rotation, 16 items were retained in a stigma metric for MSM and 20 in an FSW stigma metric. To assess the measures' convergent validity, their correlations with expected variables were examined through bivariate logistic regression models.
One factor, experienced stigma, included actions that were carried out by multiple types of perpetrators and included being arrested, verbally harassed, blackmailed, physically abused, tortured, or forced to have sex. Other factors were differentiated by source of stigma including healthcare workers, family and friends, or police. Specifically, stigma from healthcare workers loaded on two factors: experienced healthcare stigma included being denied care, not treated well, or gossiped about by healthcare workers and anticipated healthcare stigma included fear of or avoiding seeking healthcare. Stigma from family and friends included feeling excluded from family gatherings, gossiped about by family, or rejected by friends. Stigma from police included being refused police protection and items related to police confiscation of condoms. The Cronbach's alpha ranged from 0.71-0.82. Median stigma scores, created for each participant by summing the number of affirmative responses to each stigma item, among MSM were highest in Ouagadougou and among FSW were highest in both Ouagadougou and Bobo-Dioulasso. Validation analyses demonstrated higher stigma was generally significantly associated with suicidal ideation, disclosure of involvement in sex work or same-sex practices, and involvement in organizations for MSM or FSW.
Taken together, these data suggest promising reliability and validity of metrics for measuring stigma affecting MSM and FSW in multiple urban centers across West Africa.
Many men who have sex with men (MSM) are at significant risk for HIV infection. The objective of this study was to determine the prevalence and correlates of HIV infection among MSM in Burkina Faso.
...A cross-sectional biological and behavioral survey was conducted from January to August 2013 among MSM in Ouagadougou and Bobo-Dioulasso. MSM 18 years old and above were recruited using respondent driven sampling (RDS). A survey was administered to study participants followed by HIV testing. Population prevalence estimates and 95% confidence intervals (CI) adjusted for the RDS design were produced using the RDS Analysis Tool version 6.0.1 (RDS, Inc., Ithaca, NY).
A total of 662 MSM were enrolled in Ouagadougou (n = 333) and Bobo-Dioulasso (n = 329). The majority were unmarried, with an average age of 22.1 ± 4.4 years old in Ouagadougou and 23.1 ± 4.7 years old in Bobo-Dioulasso. RDS-adjusted HIV prevalence was 1.7% (95% CI: 0.9-3.1) in Ouagadougou and 2.7% (95% CI: 1.6-4.6) in Bobo-Dioulasso. HIV prevalence among MSM under 25 years old was 1.3% (95% CI: 0.6-2.8) and 0.9% (95% CI: 0.4-2.5) respectively in Ouagadougou and Bobo-Dioulasso, compared to 5.4% (95% CI: 2.2-12.5) and 6.6% (95% CI: 3.4-12.3) among those 25 years old or older in these cities (p = 0.010 and p < 0.001).
Results from this first biological and behavioral survey among MSM in Burkina Faso suggest a need for programs to raise awareness among MSM and promote safer sex, particularly for young MSM to prevent HIV transmission. These programs would need support from donors for innovative actions such as promoting and providing pre-exposure prophylaxis, condoms and water-based lubricants, HIV counseling, testing, early treatment initiation and effective involvement of the MSM communities.
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