Lessons learnt from assessing and improving accuracy and positive predictive value of the national HIV testing algorithm in Nigeria.

Background: HIV testing remains an entry point into HIV care and treatment services. In 2007, Nigeria adopted and implemented a two-test rapid HIV testing algorithm of three HIV rapid test kits, following the sequence: Alere Determine (first test), UnigoldTM (second test), and STAT-PAK® as the tie-breaker. Sub-analysis of the 2018 Nigeria HIV/AIDS Indicator and Impact Survey data showed significant discordance between the first and second tests, necessitating an evaluation of the algorithm. This manuscript highlights lessons learnt from that evaluation. Intervention: A two-phased evaluation method was employed, including abstraction and analysis of retrospective HIV testing data from January 2017 to December 2019 from 24 selected sites supported by the United States President's Emergency Plan for AIDS Relief programme. A prospective evaluation of HIV testing was done among 2895 consecutively enrolled and consented adults, aged 15-64 years, accessing HIV testing services from three selected sites per state across the six geopolitical zones of Nigeria between July 2020 and September 2020. The prospective evaluation was performed both in the field and at the National Reference Laboratory under controlled laboratory conditions. Stakeholder engagements, strategic selection and training of study personnel, and integrated supportive supervision were employed to assure the quality of evaluation procedures and outcomes. Lessons learnt: The algorithm showed higher sensitivity and specificity in the National Reference Laboratory compared with the field. The approaches to quality assurance were integral to the high-quality study outcomes. Recommendations: We recommend comparison of testing algorithms under evaluation against a gold standard. What this study adds: This study provides context-specific considerations in using World Health Organization recommendations to evaluate the Nigerian national HIV rapid testing algorithm.

Risk Compensation After Initiation of Daily Oral Pre-exposure Prophylaxis Among Sexual and Gender Minorities in Nigeria.

Pre-exposure prophylaxis (PrEP) use may be associated with risk compensation. We enrolled and provided PreP to sexual and gender minorities (SGM) in Abuja, Nigeria between April 2018 and May 2019. Behavioral information and samples for urogenital and anorectal Chlamydia trachomatis and Neisseria gonorrhoeae sexually transmitted infections (STIs) were collected at baseline. Blood samples for PrEP assay and self-reported adherence were collected at three-monthly follow-up visits. STIs were detected using Aptima Combo2 assay. We estimated the odds ratios (ORs) of PCR-diagnosed bacterial STIs and self-reported behavioral outcomes (condomless anal intercourse [CAI] and concurrent sexual relationships) with conditional logistic regression. Of 400 SGM who initiated PrEP, 206 were eligible for analysis, and had a median age of 24 years (IQR 22-27). In multivariable analysis, participants in the PrEP period had decreased odds of CAI (adjusted OR: 0.49, 95% CI 0.28, 0.84). PrEP use was not associated with risk compensation.

Effects of the COVID-19 pandemic on HIV service delivery and viral suppression: Findings from the SHARP program in Northern Nigeria.

During the COVID-19 pandemic, HIV programs scaled up differentiated service delivery (DSD) models for people living with HIV (PLHIV). We evaluated the effects of COVID-19 on HIV service delivery and viral suppression in facilities in Northern Nigeria, and determined factors associated with viral suppression among adolescents and adults. We analysed a cross-sectional survey data from facility heads, and retrospective, routinely collected patient data from 63 facilities for PLHIV ≥10 years old in care between April 2019-March 2021, defining study periods as "pre-COVID-19" (before April 2020) and "during COVID-19" (after April 2020). For the pre-COVID and the COVID-19 periods we compared uptake of antiretroviral therapy (ART) refills of ≥3 months (MMD3), and ≥6 months (MM6), missed appointments, viral load (VL) testing, VL testing turnaround time (TAT) and viral suppression among those on ART for ≥6 months using two proportions Z-test and t-tests. We fit a multivariable logistic regression model to determine factors associated with maintaining or achieving viral suppression. Of 84,776 patients, 58% were <40 years, 67% were female, 55% on ART for >5 years, 93% from facilities with community-based ART refill, a higher proportion were on MMD3 (95% versus 74%, p<0.001) and MMD6 (56% versus 22%, p<0.001) during COVID-19 than pre-COVID-19, and a higher proportion had VL testing during COVID-19 (55,271/69,630, [84%]) than pre-COVID-19 (47,747/68,934, [73%], p<0.001). Viral suppression was higher during COVID-19 pandemic compared to the pre-COVID era (93% [51,196/55,216] versus 91% [43,336/47,728], p<0.001), and there was a higher proportion of missed visits (40% [28,923/72,359] versus 39% [26,304/67,365], p<0.001) and increased VL TAT (mean number of days: 38 versus 36, p<0.001) during COVID-19 pandemic and pre-COVID period respectively. Factors associated with maintaining or achieving suppression during COVID-19 were receiving MMD3 and MMD6 refills (OR: 2.8 [95% CI: 2.30-3.47] and OR: 6.3 [95% CI: 5.11-7.69], respectively) and attending clinics with community-based ART refill (OR: 1.6 [95% CI: 1.39-1.87]). The program in Northern Nigeria demonstrated resilience during the COVID-19 pandemic and adoption of MMD had a positive impact on HIV care. Though VL TAT and missed clinic visits slightly increased during the pandemic, VL testing improved and viral suppression moved closer to 95%. Adoption of MMD and community-based models of care at scale are recommended for future pandemic preparedness.

Is Internalised Homonegativity associated with HIV testing and HIV risk behaviours of men who have sex with men: a multilevel cross-sectional study of sub-Saharan African countries.

OBJECTIVES: This study assessed the associations of Internalised Homonegativity (IH) with HIV testing and risk behaviours of adult men who have sex with men (MSM) in sub-Saharan Africa (SSA) and effect modification by the legal climate. DESIGN: We used data from the cross-sectional 2019 Global Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI+) Internet survey study. SETTING AND PARTICIPANTS: Overall, the 2019 Global LGBTI Internet Survey collected data from 46 SSA countries. In this secondary analysis, we included data from 3191 MSM in 44 SSA countries as there were no eligible MSM responses in the 2 countries excluded. OUTCOME MEASURES: Our response variables were self-reported binary indicators of ever tested for HIV, recently tested in the past 6 months (from those who reported ever testing), transactional sex (paying for and being paid for sex in the past 12 months), and unprotected anal sex (that is without a condom or pre-exposure prohylaxis (PrEP)) with a non-steady partner (in the past 3 months). RESULTS: Our findings showed high levels of IH (range 1-7) in MSM across SSA (mean (SD)=5.3 (1.36)). We found that MSM with higher IH levels were more likely to have ever (adjusted OR (aOR) 1.18, 95% CI 1.03 to 1.35) and recently tested (aOR 1.19, 95% CI 1.07 to 1.32) but no evidence of an association with paying for sex (aOR 1.00, 95% CI 0.89 to 1.12), selling sex (aOR 1.06, 95% CI 0.95 to 1.20) and unprotected sex (aOR 0.99, 95% CI 0.89 to 1.09). However, we observed that a favourable legal climate modifies the associations of IH and paying for sex (aOR 0.75, 95% CI 0.60 to 0.94). Increasing levels of IH had a negative association with paying for sex in countries where same-sex relationships are legal. We found no associations of IH with unprotected anal sex in the population surveyed. CONCLUSIONS: We confirm that IH is widespread across SSA but in countries that legalise same-sex relationships, MSM were less likely to engage in transactional sex compared with those in countries where homosexuality is criminalised.

Effect of Test and Treat on clinical outcomes in Nigeria: A national retrospective study.

BACKGROUND: In Nigeria, results from the pilot of the Test and Treat strategy showed higher loss to follow up (LTFU) among people living with HIV compared to before its implementation. The aim of this evaluation was to assess the effects of antiretroviral therapy (ART) initiation within 14 days on LTFU at 12 months and viral suppression. METHODS: We conducted a retrospective cohort study using routinely collected de-identified patient-level data hosted on the Nigeria National Data Repository from 1,007 facilities. The study population included people living with HIV age ≥15. We used multivariable Cox proportional frailty hazard models to assess time to LTFU comparing ART initiation strategy and multivariable log-binomial regression for viral suppression. RESULTS: Overall, 26,937 (38.13%) were LTFU at 12 months. Among individuals initiated within 14 days, 38.4% were LTFU by 12 months compared to 35.4% for individuals initiated >14 days (p<0.001). In the adjusted analysis, individuals who were initiated ≤14 days after HIV diagnosis had a higher hazard of being LTFU (aHR 1.15, 95% CI 1.10-1.20) than individuals initiated after 14 days of HIV diagnosis. Among individuals with viral load results, 86.2% were virally suppressed. The adjusted risk ratio for viral suppression among individuals who were initiated ≤14 days compared to >14 days was not statistically significant. CONCLUSION: LTFU was higher among individuals who were initiated within 14 days compared to greater than 14 days after HIV diagnosis. There was no difference for viral suppression. The provision of early tailored interventions to support newly diagnosed people living may contribute to reducing LTFU.

Determinants of Preexposure Prophylaxis Cascade Among Sexual and Gender Minorities in Nigeria.

BACKGROUND: Preexposure prophylaxis (PrEP) is effective in preventing human immunodeficiency virus (HIV) infection among sexual and gender minorities (SGMs). We evaluated the characteristics associated with engagement in 7 steps of the PrEP cascade among SGMs in Nigeria. METHODS: Sexual and gender minorities without HIV from the Abuja site of TRUST/RV368 cohort who were surveyed on awareness of and willingness to use PrEP were approached for PrEP initiation upon availability of oral daily PrEP. To understand gaps in the uptake of oral daily PrEP, we categorized the HIV PrEP cascade as (i) education about PrEP, (ii) interest in PrEP, (iii) successful contact, (iv) appointment scheduled, (v) appointment attendance, (vi) PrEP initiation, and (vii) plasma protective levels of tenofovir disoproxil fumarate. Multivariable logistic regression models were used to determine factors associated with each of the 7 steps in the HIV PrEP cascade. RESULTS: Of 788 participants, 718 (91.1%) showed interest in taking oral daily PrEP every day and/or after a sexual act, 542 (68.8%) were successfully contacted, 433 (54.9%) scheduled an appointment, 409 (51.9%) attended a scheduled appointment, 400 (50.8%) initiated oral daily PrEP, and 59 (7.4%) had protective levels of tenofovir disoproxil fumarate. Of initiators of PrEP, 23 (5.8%) seroconverted at a rate of 13.9 cases/100 person-years. Better social support, larger network density, and higher education were associated with engagement in 4 to 5 components of the cascade. CONCLUSIONS: Our data highlight a gap between willingness and actual PrEP use. Despite PrEP's effectiveness in preventing HIV, the optimal impact of PrEP for SGMs in sub-Saharan Africa will require multifaceted approaches that combine social support, education, and destigmatization.

From Paper Files to Web-Based Application for Data-Driven Monitoring of HIV Programs: Nigeria's Journey to a National Data Repository for Decision-Making and Patient Care.

BACKGROUND: Timely and reliable data are crucial for clinical, epidemiologic, and program management decision making. Electronic health information systems provide platforms for managing large longitudinal patient records. Nigeria implemented the National Data Repository (NDR) to create a central data warehouse of all people living with human immunodeficiency virus (PLHIV) while providing useful functionalities to aid decision making at different levels of program implementation. OBJECTIVE: We describe the Nigeria NDR and its development process, including its use for surveillance, research, and national HIV program monitoring toward achieving HIV epidemic control. METHODS: Stakeholder engagement meetings were held in 2013 to gather information on data elements and vocabulary standards for reporting patient-level information, technical infrastructure, human capacity requirements, and information flow. Findings from these meetings guided the development of the NDR. An implementation guide provided common terminologies and data reporting structures for data exchange between the NDR and the electronic medical record (EMR) systems. Data from the EMR were encoded in extensible markup language and sent to the NDR over secure hypertext transfer protocol after going through a series of validation processes. RESULTS: By June 30, 2021, the NDR had up-to-date records of 1,477,064 (94.4%) patients receiving HIV treatment across 1,985 health facilities, of which 1,266,512 (85.7%) patient records had fingerprint template data to support unique patient identification and record linkage to prevent registration of the same patient under different identities. Data from the NDR was used to support HIV program monitoring, case-based surveillance and production of products like the monthly lists of patients who have treatment interruptions and dashboards for monitoring HIV test and start. CONCLUSION: The NDR enabled the availability of reliable and timely data for surveillance, research, and HIV program monitoring to guide program improvements to accelerate progress toward epidemic control.

Brief Report: Prevalence and Predictors of Concern About Anal Cancer Among Sexual and Gender Minorites Living With HIV in Abuja, Nigeria.

BACKGROUND: Anal cancer rates are rising among sexual and gender minorities (SGM) who live with HIV and engage in anal sex. Given that secondary cancer prevention programs for nonanal cancers are underutilized in sub-Saharan Africa, our objective was to assess concerns for anal cancer and hesitancy with cancer prevention among at-risk Nigerian SGM. METHODS: Within 4 weeks, SGM living with HIV were surveyed on levels of worry and hesitancy in engaging with a future anal cancer screening and treatment study. Worry was measured on a 5-point Likert scale (0%, 25%, 50%, 75%, 100%) and categorized as low ≤25%, moderate 50%, and high ≥75%. Ordinal logistic regression identified factors associated with worry by estimating unadjusted and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). RESULTS: Of 800 enrolled SGM, median age was 32 (interquartile range: 25-38) years, 99.2% were on antiretroviral therapy, of which 78.5% reported ≥95% pill adherence. The prevalence of moderate and high worry was 46.9% and 39.5%, respectively. Increasing worry was associated with reporting as a bottom for sexual position (aOR: 3.12; 95% CI: 2.04 to 4.80), top or bottom for sexual position (aOR: 2.94; 95% CI: 1.92 to 4.52), or knowing anyone with anal cancer (aOR: 2.99; 95% CI: 1.36 to 6.57). Participants aged ≥35 years were less worried (aOR: 0.72; 95% CI: 0.59 to 0.95). Ninety-nine percent of participants provided contact information for a future cancer prevention study. DISCUSSION: SGM who heard about and engaged in at-risk practices for anal cancer were willing to access secondary prevention. Addressing biopsychosocial factors such as age could foster future engagement.

Food and Water Insecurity in Sexual and Gender Minority Groups Living With HIV in Lagos, Nigeria.

BACKGROUND: Food and water insecurity are associated with poor health outcomes that may be exacerbated by social marginalization and barriers to health care experienced by sexual and gender minorities (SGM) in resource-limited settings. We explored factors associated with food and water insecurity in SGM with HIV. SETTING: A longitudinal study of 357 men who have sex with men, transgender women, and other gender-identifying people in Lagos, Nigeria. METHODS: Laboratory testing, interviews, food and water assessments, and anthropometry were performed quarterly. Robust Poisson regression with generalized estimating equations was used to evaluate factors potentially associated with food and water insecurity. RESULTS: From 2014 to 2018, 357 SGM with HIV completed either the food or water assessments. At baseline, participants identified as cisgender men who have sex with men 265 (74.2%), transgender women 63 (17.7%), or as nonbinary/other gender 29 (8.1%). Food insecurity and water insecurity were reported by 63/344(18.3%) and 113/357(31.7%), respectively, at any visit. Food and water insecurity each decreased with ongoing study participation. Food insecurity was associated with nonpartnered relationship status, CD4 count <500 cells/mm 3 , and lack of access to piped water. Water insecurity was associated with age 25 years or older, living with a man, transactional sex, and food insecurity. CONCLUSIONS: Food and water insecurity were common among SGM in Nigeria and decreased with continued study participation, suggesting amenability to intervention when SGM are successfully engaged in care. Targeted interventions to support food and water security may improve HIV-related outcomes, such as CD4 count.

Correlates of self-reported and biomarker based adherence to daily oral HIV pre-exposure prophylaxis among a cohort of predominantly men who have sex with men in Nigeria.

INTRODUCTION: HIV pre-exposure prophylaxis (PrEP) significantly reduces the risk of HIV acquisition. However, studies have demonstrated discordance between self-reported measures and biomedical benchmarks of PrEP adherence. We estimated the correlation between self-reported PrEP adherence and PrEP biomarkers and explored factors associated with adherence among men who have sex with men (MSM) in Nigeria. METHODS: TRUST-PrEP, an open-label, prospective study; conducted in Abuja between April 2018 and May 2019. MSM ≥ 18 years with substantial HIV risk were enrolled. Participants reported PrEP adherence in the last month using a 4-point scale from "poor" to "perfect" and serum samples for PrEP biomarkers were collected at months 3 and 9. Serum tenofovir concentration was measured by liquid chromatography-tandem mass spectrometry and considered protective for adherence if ≥ 4.2 ng/ml. Spearman's rank correlation was used to estimate correlation between self-reported adherence and measured tenofovir levels. Generalized estimating equations with a logit link was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between self-reported adherence and laboratory-measured adherence. RESULTS: A total of 219 MSM with median age 23 (interquartile range 20-27) years had at least one PrEP biomarker assay. Only 66/219 (30%) had at least one record of protective tenofovir concentration. Correlation between tenofovir and self-reported adherence at 3 and 9 months were 0.1 and 0.02 respectively. Furthermore, 17/219 (8%,) and 49/219 (22%) had serum tenofovir of 4.2-35.4 ng/mL and ≥ 35.5 ng/mL, corresponding to at least 4 and 7 days' PrEP use in a week, respectively. PrEP adherence was higher among participants introduced to PrEP in the clinics compared with communities (aOR: 8.35, 95%CI: [3.24, 21.5]) and those with same-sex practices family disclosure (aOR: 3.60 95% CI: [1.73, 7.51]). CONCLUSION: Self-reported PrEP adherence poorly correlated with biomarkers. Facilitating clinic-based PrEP introduction and disclosure of same-sex practices to family among MSM may improve PrEP adherence.

Herpes Simplex Virus Type 2 Prevalence and Association with Inflammatory Cytokines Among Sexual and Gender Minorities Living With and Without HIV-1 from Lagos, Nigeria.

Herpes simplex virus type 2 (HSV-2) is common globally and contributes significantly to the risk of acquiring HIV-1, yet these two sexually transmitted infections have not been sufficiently characterized for sexual and gender minorities (SGM) across Sub-Saharan Africa. To help fill this gap, we performed a retrospective study using plasma and serum samples from 183 SGM enrolled at the Lagos site of the TRUST/RV368 cohort in Nigeria, assayed them for HSV-2 antibodies with the Kalon ELISA and plasma cytokines and chemokines with Luminex, and correlated the findings with HIV-1 viral loads (VLs) and CD4 counts. We found an overall HSV-2 prevalence of 36.6% (49.5% and 23.9% among SGM with and without HIV-1, respectively, p < .001). Moreover, HSV-2-positive status was associated with high circulating concentrations of CCL11 among antiretroviral therapy-treated (p = .031) and untreated (p = .015) participants, and with high concentrations of CCL2 in the untreated group (p = .004), independent of VL. Principal component analysis revealed a strong association of cytokines with HIV-1 VL independent of HSV-2 status. In conclusion, our study finds that HSV-2 prevalence among SGM with HIV-1 is twice as high than HSV-2 prevalence among SGM without HIV-1 in Lagos and suggests that this is associated with higher levels of certain systemic cytokines. Additional work is needed to further characterize the relationship between HSV-2 and HIV-1 in SGM and help develop targeted therapies for coinfected individuals.

Depression and Sexual Stigma Are Associated With Cardiometabolic Risk Among Sexual and Gender Minorities Living With HIV in Nigeria.

BACKGROUND: People living with HIV are vulnerable to cardiometabolic diseases. We assessed the prevalence of cardiometabolic risk factors (CMRF) and associations with sexual stigma and depression among sexual and gender minorities (SGM) in Abuja and Lagos, Nigeria. METHODS: The TRUST/RV368 study enrolled SGM between March 2013 and February 2020. Participants were assessed for depression, sexual stigma, and CMRF. Robust multinomial logistic regression was used to estimate adjusted odds ratio (aORs) and 95% confidence intervals (CIs) for associations of depression, sexual stigma, and other factors with increasing numbers of CMRF. RESULTS: Among 761 SGM, the mean age was 25.0 ± 6.0 years; 580 (76%) identified as cisgender men, 641 (84%) had ≥1 CMRF, 355 (47%) had mild-severe depression, and 405 (53%) reported moderate-high sexual stigma. Compared with individuals without depression, those with mild (aOR 8.28; 95% CI: 4.18 to 16.40) or moderate-severe depression (aOR 41.69; 95% CI: 9.60 to 181.04) were more likely to have 3-5 CMRF. Individuals with medium (aOR 3.17; 95% CI: 1.79 to 5.61) and high sexual stigma (aOR 14.42; 95% CI: 2.88 to 72.29) compared with those with low sexual stigma were more likely to have 3-5 CMRF. Participants age 25-34 years were less likely to have 3-5 CMRF (aOR 0.41; 95% CI: 0.23 to 0.73) compared with participants age younger than 25 years. CONCLUSION: CMRF increased with severity of depression and sexual stigma, potentially predisposing SGM living with HIV to cardiometabolic diseases. Integrating interventions that address depression and sexual stigma in HIV care programs for SGM may improve cardiometabolic outcomes.

Associations of gender identity with sexual behaviours, social stigma and sexually transmitted infections among adults who have sex with men in Abuja and Lagos, Nigeria.

INTRODUCTION: Sexual and gender minority populations are disproportionately affected by the global syndemic of HIV and other sexually transmitted infections (STIs). We hypothesized that transgender women (TGW) and non-binary individuals in Nigeria have more STIs than cis-gender men who have sex with men (cis-MSM), and that experiences of stigma and sexual practices differ between these three groups. METHODS: From 2013 to 2020, TRUST/RV368 enrolled adults assigned male sex at birth who reported anal sex with men in Abuja and Lagos, Nigeria. Participants were tested for STIs and completed questionnaires about sexual behaviours and social stigma every 3 months. Participants were categorized as cis-MSM, TGW or non-binary/other based on self-reported gender identity. Gender group comparisons were made of HIV, gonorrhoea and chlamydia prevalence and incidence; stigma indicators; and condom use during anal sex. RESULTS: Among 2795 participants, there were 2260 (80.8%) cis-MSM, 284 (10.2%) TGW and 251 (9.0%) non-binary/other individuals with median age of 23 years (interquartile range 20-27). HIV prevalence among cis-MSM, TGW and non-binary/other participants was 40.8%, 51.5% and 47.6%, respectively (p = 0.002). HIV incidence was 8.7 cases per 100 person-years (PY) (95% confidence interval [CI] 6.9-10.8), 13.1 cases/100 PY (95% CI 6.5-23.4) and 17.6 cases/100 PY (95% CI 9.8-29.0, p = 0.025), respectively. Anorectal gonorrhoea incidence was lower in cis-MSM than TGW (22.2 [95% CI 19.6-25.0] vs. 35.9 [95% CI 27.3-46.3]). TGW were more likely than cis-MSM to report being affected by stigma, including assault (47.2% vs. 32.3%), fear of walking around (32.4% vs. 19.2%) and healthcare avoidance (25.0% vs. 19.1%; all p < 0.05). TGW were more likely to report always using condoms than non-binary/other individuals (35.3% vs. 26.2%, p = 0.041) during receptive anal sex. CONCLUSIONS: Sexual and gender minorities in Nigeria have heterogeneous sexual behaviours and experiences of social stigma that may influence the vulnerability to HIV and other STIs. There is a need for tailored interventions that acknowledge and are informed by gender. Further research is needed, particularly among understudied non-binary individuals, to better understand disparities and inform tailored interventions to improve outcomes among these communities.

Operationalizing the distribution of oral HIV self-testing kits to men who have sex with men (MSM) in a highly homophobic environment: the Nigerian experience.

BACKGROUND: Self-care health interventions are innovative approaches for improving health and achieving the sustainable development goals (SDGs). Men who have sex with men (MSM) have been disproportionately affected by Human Immunodeficiency Virus (HIV). In spite of this, stigma from healthcare workers has reportedly prevented MSM from accessing HIV testing in health facilities. This paper explored the operationalization of using key opinion leaders (KOLs) to distribute HIVST (HIV self-test) kits to MSM. This qualitative survey used a combination of in-depth interviews (IDI) with HIVST users and focus group discussions (FGDs) with KOLs to collect data three months after the distribution of the test kits by the KOLs. Thematic analysis of the data was carried out. RESULT: Three themes were generated namely: KOLs serve as a trusted resource to promote and support HIVST for the MSM community; Skills and qualifications required for KOLs to effectively distribute and promote uptake of HIVST; and Effective strategies used to create demand and promote uptake of HIVST. CONCLUSION: This study showed the practical steps involved in operationalizing KOL support system distribution of HIVST that positively influenced the testing experience for the participants irrespective of the HIV status and engagement in care. KOLs are a reliable resource to leverage for ensuring that HIV self-test kit is utilized and HIV positive individuals are linked to treatment and care in homophobic environments.

Re-Engagement into HIV Care: A Systematic Review.

Identifying evidence-based interventions that can optimize the re-engagement into care of people living with HIV is necessary to achieve and sustain HIV epidemic control. We conducted a systematic review of interventions for re-engagement into HIV care to examine the accumulated evidence and to identify similarities and differences across studies. Between January and March 2020, we searched MEDLINE, Embase, CINAHL, and PsycINFO databases for publications from 1996 to 2020. We screened 765 references and selected 125 publications for full-text review. For the nine included studies, the intervention centered on (1) integration of clinic and HIV surveillance data; (2) additional or different levels of support provided by healthcare workers; or (3) multi-component intervention. Irrespective of the interventions, mixed results were found for re-engagement into care or ART re-initiation. None of the studies led to an improvement in viral suppression. Re-engagement in HIV care is critical for longitudinal HIV and national program success. Standardizing definitions for out-of-care and re-engagement would facilitate the comparison of interventions. Rigorous study designs to assess strategies to enhance HIV re-engagement are warranted.

Prevalence and factors associated with anogenital warts among sexual and gender minorities attending a trusted community health center in Lagos, Nigeria.

Anogenital warts caused by human papillomavirus are common in sexual and gender minorities (SGM). The prevalence of, and factors associated with warts were described for SGM with a high burden of HIV in Nigeria. Individuals who reported anal sex with men were enrolled in the TRUST/RV368 cohort. Participants completed an interviewer-led survey, provided biological samples, and had a physical examination. Specific to the Lagos site, clinic staff offered standardized warts treatment services. RDS-weighted multivariable logistic regression was used to estimate the adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for factors potentially associated with anogenital warts. Of 672 enrolled SGM, 478 (71%) engaged in warts services and had complete data. The median age (interquartile range) was 22 (20-26) years, 272 (52%) initiated sex before age 18, and 347 (79%) were cisgender men. Multiple male sexual partners in the previous year were reported by 448 (90%) of the participants, and 342 (66%) were living with HIV. Warts were diagnosed in 252 (54%), including anal warts in 234 (43%) and penile warts in 44 (8%); 26 (5%) had both anal and penile warts. Factors independently associated with warts included HIV (AOR:2.97; CI:1.44-6.14), engaging in receptive anal sex (AOR:3.49; CI:1.25-9.75), having multiple male sexual partners (AOR:7.26; CI:2.11-24.87), age at sexual debut (AOR:0.53; CI:0.28-0.98), and non-binary gender identity (AOR:0.20; CI:0.05-0.71). Warts were common among SGM in Nigeria, particularly those living with HIV. Administration of HPV vaccination before sexual debut or as a catch-up vaccination may prevent HPV-associated complications.

Evaluation of the Nigeria national HIV rapid testing algorithm.

Human Immunodeficiency Virus (HIV) diagnosis remains the gateway to HIV care and treatment. However, due to changes in HIV prevalence and testing coverage across different geopolitical zones, it is crucial to evaluate the national HIV testing algorithm as false positivity due to low prevalence could be detrimental to both the client and the service delivery. Therefore, we evaluated the performance of the national HIV rapid testing algorithm using specimens collected from multiple HIV testing services (HTS) sites and compared the results from different HIV prevalence levels across the six geopolitical zones of Nigeria. The evaluation employed a dual approach, retrospective, and prospective. The retrospective evaluation focused on a desktop review of program data (n = 492,880) collated from patients attending routine HTS from six geopolitical zones of Nigeria between January 2017 and December 2019. The prospective component utilized samples (n = 2,895) collected from the field at the HTS and tested using the current national serial HIV rapid testing algorithm. These samples were transported to the National Reference Laboratory (NRL), Abuja, and were re-tested using the national HIV rapid testing algorithm and HIV-1/2 supplementary assays (Geenius to confirm positives and resolve discordance and multiplex assay). The retrospective component of the study revealed that the overall proportion of HIV positives, based on the selected areas, was 5.7% (28,319/492,880) within the study period, and the discordant rate between tests 1 and 2 was 1.1%. The prospective component of the study indicated no significant differences between the test performed at the field using the national HIV rapid testing algorithm and the re-testing performed at the NRL. The comparison between the test performed at the field using the national HIV rapid testing algorithm and Geenius HIV-1/2 supplementary assay showed an agreement rate of 95.2%, while that of the NRL was 99.3%. In addition, the comparison of the field results with HIV multiplex assay indicated a sensitivity of 96.6%, the specificity of 98.2%, PPV of 97.0%, and Kappa Statistic of 0.95, and that of the NRL with HIV multiplex assay was 99.2%, 99.4%, 99.0%, and 0.99, respectively. Results show that the Nigeria national serial HIV rapid testing algorithm performed very well across the target settings. However, the algorithm's performance in the field was lower than the performance outcomes under a controlled environment in the NRL. There is a need to target testers in the field for routine continuous quality improvement implementation, including refresher trainings as necessary.

Individual and partnership characteristics associated with consistent condom use in a cohort of cisgender men who have sex with men and transgender women in Nigeria.

BACKGROUND: This study reports on the individual and partnership characteristics that influence consistent condom use in cisgender men who have sex with men (MSM) and transgender women (TGW) attending trusted community centers that provide HIV prevention and treatment services in Nigeria. METHODS: Adults assigned male at birth who reported anal sex with male partners who enrolled between March 2013-2019 and had information about at least one male sexual partner were included in these analyses. At enrollment and follow-up visits every 3 months for up to 18 months, participants were administered detailed questionnaires that collected information about demographics, sexual practices, HIV risk behaviors, and characteristics and behaviors of their partners in the previous year (at enrollment) or the preceding 3 to 6-months (at follow-up visits). Logistic regression models with generalized estimating equations were used to assess the odds ratio (OR) and 95% confidence intervals (CI) of individual, partner, and partnership characteristics associated with consistent condom use (CCU). A participant was defined as consistently using condom if they reported always using condoms all the time they had insertive, receptive or both types of anal sex with a male partner. RESULTS: At the individual level, CCU was positively associated with higher education, disclosure of key population status to a healthcare worker and negatively associated with poor access to condoms. At the partner and partnership level, CCU was associated with partners with higher education (aOR: 1.36; 95% CI: 1.07-1.72), casual relationships (aOR: 1.22; 95% CI: 1.11-1.34) and relationships in which partners encouraged the participant to use condoms with other partners (aOR: 1.14; 95% CI: 1.02-1.28). Relationships in which the partner was married to a woman and/or the partner's HIV status positive or unknown were negatively associated with CCU. CONCLUSIONS: These findings suggest that individuals in relationships where partners were more open and encouraged safer sex were more likely to consistently use condoms. HIV prevention programs should consider leveraging communication to sexual partners to encourage condom use as this may support condom use with other sexual partners. Given sustained and growing HIV and STI epidemics among MSM and TGW, even with pre-exposure prophylaxis scale-up, it is crucial to continue to study optimal implementation strategies to increase condom use.

Patterns of financial incentives in primary healthcare settings in Nigeria: implications for the productivity of frontline health workers.

OBJECTIVE: This study was designed to explore the patterns of financial incentives received by some frontline health workers (including nurses, midwives as well as community health workers in paid employment) and the implications for their productivity within rural settings in Nigeria. A cross-sectional quantitative design in two States in Nigeria was adopted. Structured interviews were conducted with 114 frontline health workers. Bivariate analysis and multivariate regression analysis were carried out to explore relationships between the satisfaction of frontline health workers with the financial incentives received and their productivity in rural settings as well as the extent of any such relationships. RESULTS: Bivariate analysis demonstrated a statistically significant relationship (P = 0.013) between satisfaction with incentives received by frontline health workers and their productivity in rural settings. When other predictors were controlled for within a multivariate regression model, those who received incentives and were satisfied with the incentives were about three times more likely to be more productive at work than those who were unsatisfied with incentives (AOR: 3.3; P = 0.009, 95% CI = 1.3-8.2). In conclusion, the determination of type and content of incentives should be done in consultation with all relevant stakeholders, including possibly a cross-section of health workers themselves.

Disclosure of Same-Sex Sexual Practices to Family and Healthcare Providers by Men Who Have Sex with Men and Transgender Women in Nigeria.

Disclosure of same-sex sexual practices by men who have sex with men (MSM) and transgender women (TGW) may facilitate appropriate healthcare engagement, including risk assessment for HIV and other sexually transmitted infections (STIs), and negotiation of condom use with partners. However, disclosure may also generate stigma. In these cross-sectional analyses, MSM and TGW were categorized based on self-report of disclosure to family members and healthcare providers (HCP) at enrollment into the TRUST/RV368 study of comprehensive HIV and STI care programs in Abuja and Lagos, Nigeria. Multivariable Poisson regression models with robust error variance were used to estimate relative risk of disclosure with 95% confidence intervals. Pearson's chi-squared test was used to compare condom use and stigma indicators by disclosure status. Of 2557 participants who answered baseline questions about disclosure, 384 (15.0%) had ever disclosed to a family member and 733 (28.7%) to HCP, including 192 (7.5%) who disclosed to both. Higher education, prevalent HIV infections, and residence in Lagos were each associated with increased likelihood of disclosure to family and HCP. Older participants were more likely to disclose to HCP but not family. Participants who made a disclosure to family or HCP were more likely to report condom use during anal sex as well as perceived and experienced stigma that included healthcare avoidance, blackmail, assault, and sexual violence as compared to participants who had not disclosed. Improved disclosure practices within safe spaces may enhance engagement of MSM and TGW in healthcare and HIV prevention services.