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

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

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

Brief interventions to prevent sexually transmitted infections suitable for in-service use: a systematic review

Background: Sexually transmitted infections (STIs) are more common in young people and men who have sex with men (MSM) and effective in-service interventions are needed. Methods: A systematic review of randomized control trials (RCTs) of waiting-room delivered,self-delivered and brief healthcare-provider-delivered interventions designed to reduce STIs, increase use of home-based STI testing, or reduce STI-risk behaviour was conducted. Six databases were searched between January 2000 to October 2014. Results: 17,916 articles were screened. 23 RCTs of interventions for young people met our inclusion criteria. Significant STI reductions were found in four RCTs of interventions using brief one-to-one counselling (2 RCTs), video (1 RCT) and a STI home-testing kit (1 RCT). Increase in STI test uptake was found in five studies using video (1 RCT), one-to-one counselling (1 RCT), home test kit (2 RCTs) and a web-based intervention (1 RCT). Reduction in STI-risk behaviour was found in seven RCTs of interventions using digital online (web-based) and offline (computer software) (3 RCTs), printed materials (1 RCT) and video (3 RCTs). Ten RCTs of interventions for MSM met our inclusion criteria. Three tested for STI reductions but none found significant differences between intervention and control groups. Increased STI test uptake was found in two studies using brief one-to-one counselling (1 RCT) and an online web-based intervention (1 RCT. Reduction in STI-risk behaviour was found in six studies using digital online (web-based) interventions (4 RCTs) and brief one-to one counselling (2 RCTs. Conclusion: A small number of interventions which could be used, or adapted for use, in sexual health clinics were found to be effective in reducing STIs among young people and in promoting self-reported STI-risk behaviour change in MSM

Exploring the views and experiences of HIV positive patients treated for cancer: a systematic review of the literature

A systematic review of the literature was conducted to find out what is known about patients’ experiences of a dual diagnosis of HIV and cancer. We systematically searched the following databases; MEDLINE (Ovid Version); CINAHL Plus; PsycINFO and EMBASE from inception to June 2016 for studies that included patients with a dual diagnosis of cancer and HIV and focused on patient experiences. Studies with a focus on one illness rather than a dual diagnosis, those that focused on treatment strategies and medical management, epidemiology and pathology studies and comparison studies were all excluded. The full text of the included studies were reviewed. Information on location, sample size, study design and a narrative summary of findings were extracted using a standardised format. Studies were combined thematically. 1777 records were screened by title and abstract using the selection criteria described in the methods. Eight records were reviewed in depth in full text and seven selected as eligible. The selected studies suggest that a dual diagnosis of HIV and cancer has a powerful impact on individuals’ behaviour. The experience of stigma was a consistent factor in all patient accounts and the strategy of selective disclosure to access support reveals how patient agency can interplay with stigma. This is an area largely unexplored in the published literature; further research into patients’ experiences of a dual diagnosis of HIV and cancer will provide relevant knowledge in order to tailor and improve services

'This is what is going to help me': Developing a co-designed and theoretically informed harm reduction intervention for mobile youth in South Africa and Uganda

Young migrants in sub-Saharan Africa are particularly vulnerable to HIV-acquisition. Despite this, they are consistently under-served by services, with low uptake and engagement. We adopted a community-based participatory research approach to conduct longitudinal qualitative research among 78 young migrants in South Africa and Uganda. Using repeat in-depth interviews and participatory workshops we sought to identify their specific support needs, and to collaboratively design an intervention appropriate for delivery in their local contexts. Applying a protection-risk conceptual framework, we developed a harm reduction intervention which aims to foster protective factors, and thereby nurture resilience, for youth ‘on the move’ within high-risk settings. Specifically, by establishing peer supporter networks, offering a ‘drop-in’ resource centre, and by identifying local adult champions to enable a supportive local environment. Creating this supportive edifice, through an accessible and cohesive peer support network underpinned by effective training, supervision and remuneration, was considered pivotal to nurture solidarity and potentially resilience. This practical example offers insights into how researchers may facilitate the co-design of acceptable, sustainable interventions

Opportunities for technologically driven dialogical health communication for participatory interventions: Perspectives from male peer navigators in rural South Africa

There is increasing interest in the potential to deliver participatory dialogical HIV and intimate partner violence (IPV) prevention interventions via digital platforms, though the majority of mHealth interventions have been didactic in approach. We undertook 10 in-depth interviews with male Peer Navigators (PNs) who had been extensively trained and working on a larger intervention promoting young people's sexual and reproductive rights, in rural KwaZulu-Natal. Interviews focused on their, and their peers', use of technology in their everyday lives. Data were transcribed and translated, and subjected to thematic analysis. PNs described structural barriers to the use of technology, including poor connectivity, high data costs, and erratic electricity. They primarily used Facebook and WhatsApp for communication and highlighted how reading messages asynchronously was important to overcome connectivity challenges. PNs shared how groups were primarily for information sharing, they also discussed 'sensitive' issues online. Privacy was a concern, especially for conversations, and there was recognition of how confidentiality could be breached. It was also felt that WhatsApp could potentially support greater openness in discussions. We reflect on the potential for online interventions to support dialogical health communication, highlighting how dialogical health communication may be enabled through information provision, the asynchronous communication enhancing the potential for reflection, and greater participation in discussion by those who are shyer. Despite this potential there remain important risks around privacy of discussions and how to implement these approaches online