Characterising the relationship between migration and stigma affecting healthcare engagement among female sex workers in Lomé, Togo

Migration in West Africa is common and complicates the sustained delivery of comprehensive HIV care programmes for those with specific vulnerabilities to HIV, including female sex workers (FSW). This study evaluated whether migration potentiates the burden of stigma affecting FSW in Lomé, Togo. Respondent driven sampling identified 354 FSW who completed HIV testing and a questionnaire. Multivariable logistic regression was used to identify factors associated with stigma among FSW. Among study participants, 76.3% (270/354) were migrants, with 30.2% (107/354) reporting stigma. Migrant FSW were less likely to report stigma (aOR 0.40; 95% CI:0.22–0.73). FSW who had an abortion (aOR 3.40; 95% CI:1.79–6.30) and were tested for a sexually transmitted infection (STI) or HIV (aOR 2.03; 95% CI:1.16–3.55) were more likely to report stigma. Among FSW, 59.8% (211/353) disclosed selling sex to a health worker. Disclosure was more common among FSW who had been tested for an STI or HIV (36.7%; 77/210), or both (55.7%; 117/210), and resulted in an attenuated but significant association between STI or HIV testing and stigma, indicating that disclosure partially mediated the relationship. These results highlight the need to mitigate healthcare-related stigma affecting FSW, while also considering decentralised HIV testing approaches, including HIV self-testing

Development and reliability of metrics to characterize types and sources of stigma among men who have sex with men and female sex workers in Togo and Burkina Faso

Abstract Background 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. Methods 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. Results 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. Conclusions 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

HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: A cross-sectional analysis

<div><p>Introduction</p><p>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.</p><p>Methods and findings</p><p>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, <i>p <</i> 0.001), rape (OR 1.95, 95% CI 1.63–2.36, <i>p <</i> 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12–1.52, <i>p <</i> 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, <i>p <</i> 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49–2.19, <i>p <</i> 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, <i>p <</i> 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments.</p><p>Conclusions</p><p>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.</p></div

Participant characteristics (<i>N</i> = 4,586).

<p>Participant characteristics (<i>N</i> = 4,586).</p

Multivariable logistic regression of odds of HIV infection.

<p>Multivariable logistic regression of odds of HIV infection.</p

Sexual risk and HIV/STIs among transgender women and cisgender MSM.

<p>Sexual risk and HIV/STIs among transgender women and cisgender MSM.</p

HIV prevalence by country.

<p>HIV prevalence by country.</p