HIV prevention while bulldozers roll: developing evidence based HIV prevention intervention for female sex workers following the demolition of Goa’s redlight area

Background: Interventions targeting female sex workers (FSWs) are pivotal to HIV prevention in India. Societal factors and legislation around sex-work are potential barriers to achieving this. In recent years several high profile closures of red-light areas and dance bars in India have occurred. In this thesis I describe the effects of the demolition of Goa’s red-light area on the organsiation of sex-work, HIV risk environment, and implications for evidence-based HIV prevention. Methods: The pre-demolition phase was a detailed ethnographic study. The early post-demolition phase included rapid ethnographic mapping of sex-work in the immediate aftermath. The late post-demolition phase was a cross-sectional survey supplemented by an in-depth qualitative study. 326 FSWs were recruited throughout Goa using respondent-driven-sampling, and completed interviewer-administered questionnaires. They were tested for sexually transmitted infections (STIs) and HIV. Results: The homogeneous brothel-based sex-work in Goa evolved into heterogeneous, clandestine and dispersed types of sex-work. The working environment was higher risk and less conducive to HIV prevention. Infections were common with 25.7% prevalence of HIV and 22.5% prevalence of curable STIs. Women who had never worked in Baina, young women, and those who had recently started sex-work were particularly likely to have curable STIs, a marker of recent sexual risk. STIs were independently associated with young age, lack of schooling, no financial autonomy, deliberate-self-harm, sexual-abuse, regular customers, streetbased sex-work, Goan ethnicity, and being asymptomatic. Having knowledge about HIV, access to free STI services, and having an intimate partner were associated with a lower likelihood of STIs. HIV was independently associated with being Hindu, recent migration to Goa, lodge or brothel-based sex work, and dysuria. Conclusions: Tackling structural and gender-based determinants of HIV are integral to HIV prevention strategies. Prohibition and any form of criminalisation of sex-work reduce the sex workers’ agency and create barriers to effective HIV prevention

Exploring people’s candidacy for mobile health–supported HIV testing and care services in rural Kwazulu-Natal, South Africa: qualitative study

BACKGROUND: The use of mobile communication technologies (mHealth: mobile health) in chronic disease management has grown significantly over the years. mHealth interventions have the potential to decentralize access to health care and make it convenient, particularly in resource-constrained settings. It is against this backdrop that we aimed to codevelop (with potential users) a new generation of mobile phone-connected HIV diagnostic tests and Web-based clinical care pathways needed for optimal delivery of decentralized HIV testing, prevention, and care in low- and middle-income countries. OBJECTIVE: The aim of this study was to understand ways in which an mHealth intervention could be developed to overcome barriers to existing HIV testing and care services and promote HIV self-testing and linkage to prevention and care in a poor, HIV hyperendemic community in rural KwaZulu-Natal, South Africa. METHODS: A total of 54 in-depth interviews and 9 focus group discussions were conducted with potential users (including health care providers) in 2 different communities. Theoretically informed by the candidacy framework, themes were identified from the interview transcripts, manually coded, and thematically analyzed. RESULTS: Participants reported barriers, such as fear of HIV identity, stigma, long waiting hours, clinic space, and health care workers' attitudes, as major impediments to effective uptake of HIV testing and care services. People continued to reassess their candidacy for HIV testing and care services on the basis of their experiences and how they or others were treated within the health systems. Despite the few concerns raised about new technology, mobile phone-linked HIV testing was broadly acceptable to potential users (particularly men and young people) and providers because of its privacy (individual control of HIV testing over health provider-initiated testing), convenience (individual time and place of choice for HIV testing versus clinic-based testing), and time saving. CONCLUSIONS: Mobile phone-connected HIV testing and Web-based clinical care and prevention pathways have the potential to support access to HIV prevention and care, particularly for young people and men. Although mHealth provides a way for individuals to test their candidacy for HIV services, the barriers that can make the service unattractive at the clinic level will also need to be addressed if potential demand is to turn into actual demand

Global elective breast- and colorectal cancer surgery performance backlogs, attributable mortality and implemented health system responses during the COVID-19 pandemic: A scoping review

Globally, 28.4 million non-emergent ('elective') surgical procedures have been deferred during the COVID-19 pandemic. This study evaluated the impact of the COVID-19 pandemic on elective breast- or colorectal cancer (CRC) procedure backlogs and attributable mortality, globally. Further, we evaluated the interaction between procedure deferrals and health systems, internationally. Relevant articles from any country, published between December 2019-24 November 2022, were identified through searches of online databases (MEDLINE, EMBASE) and by examining the reference lists of retrieved articles. We organised health system-related findings thematically per the Structures-Processes-Outcomes conceptual model by Donabedian (1966). Of 337 identified articles, we included 50. Eleven (22.0%) were reviews. The majority of included studies originated from high-income countries (n = 38, 76.0%). An ecological, modelling study elucidated that global 12-week procedure cancellation rates ranged from 68.3%-73%; Europe and Central Asia accounted for the majority of cancellations (n = 8,430,348) and sub-Saharan Africa contributed the least (n = 520,459). The percentage reduction in global, institutional elective breast cancer surgery activity ranged from 5.68%-16.5%. For CRC, this ranged from 0%-70.9%. Significant evidence is presented on how insufficient pandemic preparedness necessitated procedure deferrals, internationally. We also outlined ancillary determinants of delayed surgery (e.g., patient-specific factors). The following global health system response themes are presented: Structural changes (i.e., hospital re-organisation), Process-related changes (i.e., adapted healthcare provision) and the utilisation of Outcomes (i.e., SARS-CoV-2 infection incidence among patients or healthcare personnel, postoperative pulmonary complication incidence, hospital readmission, length of hospital stay and tumour staging) as indicators of health system response efficacy. Evidence on procedure backlogs and attributable mortality was limited, partly due to insufficient, real-time surveillance of cancer outcomes, internationally. Elective surgery activity has decreased and cancer services have adapted rapidly, worldwide. Further research is needed to understand the impact of COVID-19 on cancer mortality and the efficacy of health system mitigation measures, globally

Pre-exposure prophylaxis (PrEP) uptake and adherence experiences of gay and bisexual men who engage in chemsex: A qualitative study

BACKGROUND: Pre-exposure prophylaxis (PrEP) is the use of HIV antiretroviral medications to reduce the risk of HIV acquisition. PrEP is highly effective when used during periods of potential HIV exposure. Gay and bisexual men (GBM) who engage in unprotected chemsex (without condoms or PrEP) are at high-risk of acquiring HIV. Substance use has been shown to detrimentally impact on the effective use of HIV treatment among GBM living with HIV. This study aims to qualitatively explore PrEP uptake and adherence among GBM who engage in chemsex in the United Kingdom. METHODS: Nineteen semi-structured in-depth telephone interviews were conducted with self-identifying HIV-negative GBM who reported recently engaging in chemsex and currently using or had recently used PrEP. We explored the ways in which chemsex influenced GBM's motivation to use, access to and effective use of PrEP. Interviews were audio recorded, transcribed, and coded using thematic analysis. RESULTS: Most of the men identified as gay, were of white ethnicity and had a median age of 41. Eighteen men were still using PrEP at the time of the interview and most used daily dosing. The perception of being at high risk of HIV acquisition was a key factor influencing PrEP initiation and after initiation, continued to influence high levels of adherence which was reported by the majority of participants. The few individuals who reported sub-optimal adherence, explained that psychosocial stressors or periods of impaired mental health led to more frequent or intense chemsex sessions, which in turn contributed to occasional non-adherence. Most participants used a variety of strategies to help them adhere, which included restricting the amount or intensity of chemsex they engaged in, strategic placement of PrEP and external triggers to remind them to take PrEP. CONCLUSIONS: In this study, the majority of GBM who engaged in chemsex, initiated PrEP in recognition of their potential risk of HIV acquisition and reported high levels of PrEP adherence. They used multiple strategies to support effective PrEP access and adherence. These findings support a growing body of evidence that PrEP is a viable prevention tool for GBM who engage in chemsex, and that chemsex does not negatively impact PrEP adherence

HIV positive and treated for cancer: The convergence of pressures "invisible" in HIV and "visible" in cancer

OBJECTIVE: An increasing number of people living with HIV are living longer and experiencing a dual diagnosis of HIV and cancer. Little is known of their experience and quality of care. This paper presents the findings of a study exploring experiences of cancer care, from the perspectives of both patients and healthcare professionals. METHODS: Thematic analysis of participant narratives provided in longitudinal, semi-structured interviews with 17 people, recruited from three London sites between 2015 and 2017. Focused ethnography comprising 27 hr of participant observation and seven semi-structured interviews with healthcare professionals. RESULTS: Both HIV and cancer have a powerful, combined impact; in cancer, the impact is visible; in HIV, it is generally hidden. Patients and staff experienced particular challenges in the cancer setting. Patients felt responsible for their HIV management and described being excluded from clinical trials. Both staff and patients encountered difficulties around the management of information relating to HIV. CONCLUSION: This dual diagnosis has a profound and negative effect on patients' experiences and potential outcomes. Improvement depends on interventions that acknowledge the shared social narrative and impact of HIV-related stigma so that this burden is not carried by the patient alone

HIV infection significantly reduces lipoprotein lipase which remains low after 6 months of antiretroviral therapy

Purpose of the study Fractional clearance rate of apolipoprotein B100-containing lipoproteins is reduced in HIV infection before and after antiretroviral (ARV) treatment [1]. We compared lipoprotein lipase (LPL) activity and gene expression in HIV-positive subjects before and 6 months after ARV with HIV-negative controls. Methods Fasting blood post heparin total and hepatic lipase activity,adiponectin, leptin, insulin, glucose, and lipid measurementswere made in 32 HIV-infected and 15 HIVnegative controls. LPL was estimated by subtractinghepatic lipase from total lipase. Adiponectin, LPL andhormone sensitive lipase (HSL) gene expression weremeasured from iliac crest subcutaneous fat biopsies.Patients were tested before, and 6 months after randomisation to AZT/3TC (n = 15) or TDF/FTC (n = 17) with EFV.Between-group comparison was by Mann-Whitney andpaired samples by the Wilcoxon signed rank tests. Summary of results There were no differences in gender, ethnicity, baseline BMI, regional fat distribution (whole body DEXA) and visceral (VAT) and subcutaneous fat (SAT) measured by abdominal CT scans between controls and patients. Trunk fat/BMI ratio, VAT and VAT:SAT ratio significantly increased after 6-month ARV therapy (p = 0.01). There were no differences between groups in serum NEFA,HOMA and leptin levels. Selected other results are shown in Table 1. Conclusion Post heparin lipoprotein lipase activity is reduced in HIV and does not return to control levels after 6 months of ARV therapy. AZT-containing regimens are associated with a greater increase in LPL, LPL gene expression and plasma adiponectin than TDF

Community perceptions of the socio-economic structural context influencing HIV and TB risk, prevention and treatment in a high prevalence area in the era of antiretroviral therapy

Following calls for targeted HIV prevention interventions in so-called “hotspots”, we explored subjective perceptions of community members in places considered to be high HIV and tuberculosis (TB) transmission areas and those with low prevalence. Although more people now have access to antiretroviral therapy (ART), some areas are still experiencing high HIV transmission rates, presenting a barrier to the elimination of HIV. A rapid qualitative assessment approach was used to access a sample of 230 people who contributed narratives of their experiences and perceptions of transmission, treatment and prevention of HIV and TB in their communities. Theoretical propositions case study strategy was used to inform and guide the thematic analysis of the data with Research Department of Epidemiology & Public Health, University College London, London, UK. Our results support the concept of linking perceived control to health through the identification of structural factors that increase communities’ sense of agency. People in these communities did not feel they had the efficacy to effect change in their milieu. The few socio-economic opportunities promote social mobility in search of better prospects which may have a negative impact on community cohesion and prevention strategies. Communities were more concerned with improving their immediate social and economic situations and prioritised this above the prevention messages. Therefore approaches that focus on changing the structural and environmental barriers to prevention may increase people’s perceived control. Multifaceted strategies that address the identified constructs of perceived control may influence the social change necessary to make structural interventions successful

Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review

Objective: In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA. // Design: Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach. // Data sources: A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021. // Eligibility criteria: Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10–24 years. // Data extraction and synthesis: We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants. // Results: Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes. // Conclusions: The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts. // PROSPERO registration number: CRD42021258826

Community perceptions of the socio-economic structural context influencing HIV and TB risk, prevention and treatment in a high prevalence area in the era of antiretroviral therapy.

Following calls for targeted HIV prevention interventions in so-called "hotspots", we explored subjective perceptions of community members in places considered to be high HIV and tuberculosis (TB) transmission areas and those with low prevalence. Although more people now have access to antiretroviral therapy (ART), some areas are still experiencing high HIV transmission rates, presenting a barrier to the elimination of HIV. A rapid qualitative assessment approach was used to access a sample of 230 people who contributed narratives of their experiences and perceptions of transmission, treatment and prevention of HIV and TB in their communities. Theoretical propositions case study strategy was used to inform and guide the thematic analysis of the data with Research Department of Epidemiology & Public Health, University College London, London, UK. Our results support the concept of linking perceived control to health through the identification of structural factors that increase communities' sense of agency. People in these communities did not feel they had the efficacy to effect change in their milieu. The few socio-economic opportunities promote social mobility in search of better prospects which may have a negative impact on community cohesion and prevention strategies. Communities were more concerned with improving their immediate social and economic situations and prioritised this above the prevention messages. Therefore approaches that focus on changing the structural and environmental barriers to prevention may increase people's perceived control. Multifaceted strategies that address the identified constructs of perceived control may influence the social change necessary to make structural interventions successful