Developing an implementation science research agenda to improve the treatment and care outcomes among adolescents living with HIV in sub-Saharan Africa

In February 2016, Project SOAR convened a Technical Advisory Network meeting, attended by more than 50 international and domestic thought leaders in adolescent HIV care research and a small group of youth from southern Africa who are living with HIV. To prepare the groundwork for the meeting, SOAR produced a background paper synthesizing the literature on HIV continuum of care outcomes among adolescents living with HIV (ALHIV) in sub-Saharan Africa, where most adolescent cases of HIV are concentrated. This report presents the findings from the literature review and highlights from the Technical Advisory Network meeting. The first section is a summary of the review’s findings, specifically what we know about ALHIV along the care continuum. The second section of the report summarizes the outcomes from the meeting, including a set of priority research questions for the larger HIV community, as well as for Project SOAR, to consider addressing as part of new or ongoing studies

Debe cuidarse en la calle : normative influences on condom use among the steady male partners of female sex workers in the Dominican Republic

Encouragement to use condoms reflects the injunctive norm, or idea that you should use condoms. In our previous research with the regular male partners of female sex workers in the Dominican Republic, we found that encouragement to use condoms with female sex workers from individuals in their personal social networks was not directly associated with condom use. In the current study, we used qualitative interviews to further explore the influence of social network norms on men's sexual risk behaviours. We interviewed eleven steady male partners of female sex workers; participants completed two interviews to achieve greater depth. We analysed data using analytic summaries and systematic thematic coding. All men perceived that the prevailing injunctive norm was that they should use condoms with sex workers. Men received encouragement to use condoms but did not articulate a link between this encouragement and condom use. Additionally, men who did not use condoms lied to their friends to avoid social sanction. Findings highlight that the influence of a pro-condom injunctive norm is not always health promoting and can even be negative. HIV prevention efforts seeking to promote condom use should address the alignment between injunctive and descriptive norms to strengthen their collective influence on behaviour

Peer education and HIV/AIDS: Past experience, future directions

Peer education typically involves training and supporting members of a given group to effect change among members of the same group. Peer education is often used to effect changes in knowledge, attitudes, beliefs, and behaviors at the individual level. However, peer education may also create change at the group or societal level by modifying norms and stimulating collective action that contributes to changes in policies and programs. Worldwide, peer education is one of the most widely used strategies to address the HIV/AIDS pandemic. This report presents findings from a project designed to identify components and principles that influence HIV/AIDS peer education program quality and effectiveness, as well as gaps in and priorities for operations research. The project was coordinated by UNAIDS and the Horizons Project, and implemented with the Jamaican Ministry of Health, PATH, AIDSMark/PSI, IMPACT/FHI, and USAID. The Horizons Project is implemented by the Population Council and partners

Sexual Partnerships, A Qualitative Study in Tanzania.

Concurrent sexual partnerships (CP) have been identified as a potential driver in the HIV epidemic in southern Africa, making it essential to understand motivating factors for engagement in CP. We aimed to assess community attitudes and beliefs about relationship factors that influence men and women in stable relationships to engage in CP in Tanzania. Social exchange theory was used for interpreting the data. Qualitative study with focus group discussions (FGDs). Semiurban/rural communities in four regions across Tanzania (Dar es Salaam, Shinyanga, Iringa and Mbeya). 120 women aged 17-45 years and 111 men aged 18-49 years from four study areas participated in 32 FGDs. FGD participants were asked the following questions about CP: definitions and types, motivations and justifications for engaging or not engaging, cultural factors, gender and socialisation, and local resources and efforts available for addressing CP. Our analysis focused specifically on beliefs about how relationship factors influence engagement in CP. Dissatisfaction with a stable relationship was believed to be a contributing factor for engagement in CP for both men and women. Participants more commonly reported financial dissatisfaction as a contributing factor for women engaging in CP within stable relationships, whereas emotional and sexual dissatisfaction were reported as contributing factors for men and women. Furthermore, participants described how potential outside partners are often evaluated based on what they are able to offer compared with stable partners. Efforts to reach men and women in stable relationships with HIV prevention messages must consider the various dimensions of motivation for engaging in CP, including relationship dynamics

Abriendo Puertas: Baseline Findings from an Integrated Intervention to Promote Prevention, Treatment and Care among FSW Living with HIV in the Dominican Republic

Female sex workers (FSW) are often the focus of primary HIV prevention efforts. However, little attention has been paid to the prevention, treatment, and care needs of FSW living with HIV. Based on formative research, we developed an integrated model to promote prevention and care for FSW living with HIV in Santo Domingo, Dominican Republic, including (1) individual counseling and education; (2) peer navigation; (3) clinical provider training; and (4) community mobilization. We enrolled 268 FSW living with HIV into the intervention and conducted socio-behavioral surveys, sexually transmitted infection (STI) testing, and viral load (VL) assessments. We used multivariate logistic regression to identify behavioral and socio-demographic factors associated with detectable VL (>50 copies/mL) and STI prevalence. Over half of all participants (51.9%) had a detectable VL, even though most received HIV-related care in the last 6 months (85.1%) and were currently on anti-retroviral treatment (ART) (72.4%). Factors positively associated with a detectable VL included being 18–35 years of age (Adjusted Odds Ratio [AOR] 2.46, 95% CI 1.31–4.60), having ever used drugs (AOR 2.34, 95% CI 1.14–4.79), and having ever interrupted ART (AOR 3.09, 95% CI 1.44–6.59). Factors protective against having a detectable VL included being single (AOR 0.45, 95% 0.20–0.98) and being currently on ART (AOR 0.17, 95% CI 0.07–0.41). Nearly one-quarter (23.1%) had an STI, which was associated with being single (AOR 3.21, 95% CI 1.27–8.11) and using drugs in the last 6 months (AOR 3.54, 95% CI 1.32–9.45). Being on ART was protective against STI (AOR 0.51, 95% CI 0.26–1.00). Baseline findings indicate significant barriers to VL suppression and STI prevention among FSW living with HIV and highlight gaps in the continuum of HIV care and treatment. These findings have important implications for both the individual health of FSW and population-level HIV transmission dynamics

Factors related to fertility desire among female sex workers living with HIV in the Dominican Republic

Abstract Background Female sex workers living with HIV are at increased risk for negative health outcomes and multiple levels of stigma. However, there is limited research on female sex workers living with HIV and even less focused on reproductive health. Methods We analyzed data using logistic regression from a cohort of 247 female sex workers of reproductive age living with HIV in Santo Domingo, Dominican Republic to assess factors associated with fertility desire. Results Most participants had children (93.1%; mean: 2.8; range: 1,8) and 28.3% reported fertility desire. Bivariate regression analysis uncovered that participants who desired children were less likely to report being on antiretroviral treatment and more likely to have a detectable viral load. Multivariate regression results showed participants who desired more children were: less likely to be older, have higher levels of HIV-related internalized stigma, have a history of pregnancy loss, have fewer children and have a perception that their partner has negative feelings about pregnancy. Conclusions Individual and interpersonal characteristics were found to be associated with fertility desire in this study. Additional in-depth research is needed to understand how the role of stigma, partner dynamics and reproductive history as it relates to fertility desire, in order to ensure the reproductive health and wellbeing of this population

HIV testing, care, and treatment experiences among the steady male partners of female sex workers living with HIV in the Dominican Republic

Male steady partners of female sex workers (FSW) living with HIV represent a key population for treatment as prevention and/or pre-exposure prophylaxis (PrEP) interventions. This study uses data collected from male steady partners who were referred by FSW living with HIV participating in a multi-level HIV prevention and care intervention in Santo Domingo, Dominican Republic. We conducted a socio-behavioral survey and HIV-testing with all men (n=64) and 16 in-depth interviews with a sub-sample to obtain more depth. Thirty-five of the 64 participants were living with HIV; 27 were previously diagnosed and 8 were diagnosed during our study. As a result, 45% of men were members of a sero-discordant sexual partnerships. Of men with no previous HIV diagnosis (n=37), 15 had never been tested for HIV and 9 had not been tested in the past two years. Ninety-three percent of men previously diagnosed with HIV reported receiving HIV care in the past 6 months and 78% were taking anti-retrovirals. Low HIV testing was partly due to men not feeling at-risk for HIV, despite having an HIV-infected partner. Additionally, a lack of tailored care inhibited engagement in ARV treatment for those infected. HIV testing was low, highlighting a need for test-and-treat strategies. Men not living with HIV would benefit from regular testing and would be good candidates for pre-exposure prophylaxis. While almost all men who had been diagnosed with HIV were engaged in care and adherent to ART, future research should assess whether they are achieving optimal HIV outcomes for their health and prevention of ongoing transmission

Strategies for Recruiting Steady Male Partners of Female Sex Workers for HIV Research

Steady male partners of female sex workers (FSW) are a key population for HIV prevention, but researchers face challenges finding and recruiting this population. We conducted forty in-depth interviews with FSW and steady male partners of FSW in Santo Domingo, Dominican Republic about how to engage steady male partners in HIV research. Participants cautioned that male partners might be unwilling to participate because of discomfort disclosing intimate information and cultural norms of masculinity. They recommended inviting male partners to research offices, instead of venue-based recruitment, because it was more private and trust-promoting. Most participants suggested that FSW could refer their partners or men could refer their friends who have FSW partners. Participants emphasized that referrals could break down trust-related barriers that prevent male partners from participating. Establishing an environment of respect and trust in the research setting can aid referral processes as individuals who participate communicate their positive experiences to their networks

The female condom: Dynamics of use in urban Zimbabwe

In July 1997, Population Services International (PSI), at the request of the Zimbabwe National AIDS Coordination Programme, launched a social marketing program for the female condom in Zimbabwe. To avoid stigma associated with condoms and STI prevention, the female condom was marketed as a family planning product or “contraceptive sheath” under the brand name “Care.” It was initially sold through pharmacies and clinics at a heavily subsidized retail price of US $0.24 for two; distribution has since expanded to other urban outlets, including supermarkets and convenience stores. Approximately one year after the start of the social marketing program, the Horizons Project and PSI conducted a descriptive, cross-sectional study of female condom users, male condom users, and nonusers of either barrier method. The goal is to increase understanding of the patterns and dynamics of female condom use to inform policymakers and program planners involved in decisions about promotion and distribution in Zimbabwe. In total, 493 female condom users, 633 male condom users, and 624 nonusers are included in the analyses upon which this report is based

Amigos and amistades : the role of men's social network ties in shaping HIV vulnerability in the Dominican Republic

While men’s social networks have been identified as a source of influence on sexual behaviour, less is known about the different types of friendship ties within men’s networks. We analysed data from qualitative in-depth interviews with 36 men in Santo Domingo, Dominican Republic who were current or former sexual partners of female sex workers to understand how a) men describe trust and communication with different types of friendship ties, b) characteristics of trust and communication reflect norms of masculinity, and c) these friendship ties influence HIV-related behaviours. We identified a distinction between amistades, social drinking buddies who are not trusted, and amigos, trusted friends. The majority of men lacked any amigos and some had neither amigos nor amistades. In general, men reflected traditional norms of masculinity and said they did not feel they could discuss their relationships or emotional topics with other men. Trust and communication dynamics, and how norms of masculinity shape those dynamics, should be understood and addressed in the design of HIV prevention efforts with men’s social networks as they have implications for the potential effectiveness of such efforts