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.

INTRODUCTION: 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. METHODS AND FINDINGS: 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, p < 0.001), rape (OR 1.95, 95% CI 1.63-2.36, p < 0.001), and depressive symptoms (OR 1.30, 95% CI 1.12-1.52, p < 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, p < 0.001) and to be currently living with HIV (OR 1.81, 95% CI 1.49-2.19, p < 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, p < 0.001). Limitations of the study included sampling strategies tailored for cis-MSM and merging of datasets with non-identical survey instruments. CONCLUSIONS: 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.

Suicidal ideation among MSM in three West African countries: Associations with stigma and social capital.

BACKGROUND: Suicidal ideation is understudied among men who have sex with men (MSM) across Sub-Saharan Africa. AIMS: This study aimed to explore social capital and sexual behavior stigma associated with suicidal ideation among MSM in the West African nations of The Gambia, Burkina Faso and Togo. METHODS: Participants were recruited using respondent-driven sampling and snowball sampling across multiple cities (n = 1555) from July 2011 to August 2013. During a single study visit, participants completed a survey. Logistic regression models were used to assess bivariate and multivariable associations with suicidal ideation. RESULTS: The prevalence of lifetime suicidal ideation was 13% overall and ranged 6%-17% across study sites. After adjusting for potential confounders, MSM who reported stigma as a result of having sex with men were more likely to report suicidal ideation. Physical and sexual violence was strongly associated with suicidal ideation, including being physically harmed (adjusted odds ratio (aOR) = 2.94, 95% confidence interval (CI) = 1.91, 4.52), tortured (aOR = 3.86, 95% CI = 2.17, 6.86) and raped (aOR = 3.07, 95% CI = 2.05, 4.60). In contrast, increasing social participation with the broader community was associated with decreased report of suicidal ideation (aOR = 0.91, 95% CI = 0.85, 0.99). CONCLUSION: Sexual behavior stigma should be addressed to improve mental health among MSM in Western Sub-Saharan Africa.

Correlates of condom use among female sex workers in The Gambia: results of a cross-sectional survey.

Objectives. This study examined correlates of condom use among 248 female sex workers (FSW) in The Gambia. Methods. Between July and August 2011, FSW in The Gambia who were older than 16 years of age, the age of consent in The Gambia, were recruited for the study using venue-based sampling and snowball sampling, beginning with seeds who were established clients with the Network of AIDS Services Organizations. To be eligible, FSW must have reported selling sex for money, favors, or goods in the past 12 months. Bivariate and multivariate logistic regressions were used to determine associations and the relative odds of the independent variables with condom use. Four different condom use dependent variables were used: consistent condom use in the past six months during vaginal or anal sex with all clients and partners; consistent condom use in the past month during vaginal sex with new clients; consistent condom use in the past month during vaginal sex with nonpaying partners (including boyfriends, husbands, or casual sexual partners); and condom use at last vaginal or anal sex with a nonpaying partner. Results. Many FSW (67.34%, n = 167) reported it was not at all difficult to negotiate condom use with clients in all applicable situations, and these FSW were more likely to report consistent condom use with all clients and partners in the past 6 months (aOR 3.47, 95% CI [1.70-7.07]) compared to those perceiving any difficulty in condom negotiation. In addition, FSW were more likely to report using condoms in the past month with new clients (aOR 8.04, 95% CI [2.11-30.65]) and in the past month with nonpaying partners (aOR 2.93, 95% CI [1.09-7.89]) if they had been tested for HIV in the past year. Women who bought all their condoms were less likely than those who received all of their condoms for free (aOR 0.38, 95% CI [0.15-0.97]) to have used a condom at last vaginal or anal sex with a nonpaying partner. Conclusions. HIV and sexually transmitted infection (STI) prevention interventions for FSW should aim to improve condom negotiation self-efficacy since women who report less difficulty negotiating condom use are more likely to use condoms with clients. Interventions should also be aimed at structural issues such as increasing access to free condoms and HIV testing since these were positively associated with condom use among FSW.

Sexual violence against female sex workers in The Gambia: a cross-sectional examination of the associations between victimization and reproductive, sexual and mental health.

BACKGROUND: Female sex workers (FSW) are a vulnerable population for sexual violence and poor sexual and reproductive health outcomes. Sexual violence against FSW has not been widely studied in The Gambia. This study will report the prevalence of and evaluate the health issues correlated with forced sex perpetrated by clients against FSW in The Gambia, and will secondly aim to inform future research and efforts to improve health outcomes for survivors of violence. METHODS: A cross-sectional survey was administered among 251 FSW accrued through a combination of chain referral and venue-based sampling in The Gambia. Eligibility criteria included being over 16 years old and having exchanged sex for money, goods, or favors in the past 12 months. RESULTS: There is a high prevalence of sexual violence against FSW in The Gambia, with 29% (n = 70) of participants reporting a client forced them to have sex in their lifetime. Women who reported forced sex by a client were more likely to report symptoms of depression (aOR 2.15, CI: 1.10-4.16 p < 0.05), unwanted pregnancy (aOR: 2.69, CI: 1.12-6.49 p < 0.05) and report "no", "difficult" or "somewhat difficult" access to condoms (aOR: 3.31, CI: 1.76-6.26 p < .01) compared to women who did not report forced sex. Client-perpetrated forced sex was also negatively associated with receiving any sexually transmitted infection (STI) test in the past 12 months (aOR: 0.49, CI: .26-.91 p < .05). CONCLUSION: FSW who experience sexual violence by a client are more likely to experience poor sexual, reproductive and mental health outcomes. Responding to sexual violence among FSW, including providing survivors with access to post-exposure prophylaxis, emergency contraception, and mental health services, must be a priority given the prevalence of forced sex and links with poor health outcomes. Efforts to reduce sexual violence against FSW is a vital strategy to improve the health and safety of FSW as well as impact the spread of HIV/STIs in The Gambia.

Associations of stigma with negative health outcomes for people living with HIV in the Gambia: implications for key populations.

BACKGROUND: The HIV epidemic in the Gambia is concentrated among stigmatized key populations. This study explores the relationship between 3 types of HIV-related stigma and 3 health outcomes among people living with HIV (PLHIV) in the Gambia. METHODS: Three hundred seventeen PLHIV from PLHIV support groups in the Gambia were surveyed using the PLHIV Stigma Index. RESULTS: Enacted stigma in health care settings was significantly associated with avoiding or delaying seeking care [adjusted odds ratio (aOR) = 3.03, 95% confidence interval (CI) = 1.24 to 7.89]; enacted stigma in the household or community (aOR = 1.21, 95% CI = 0.98 to 1.49) and internal stigma (aOR = 1.47, 95% CI = 0.96 to 2.22) were marginally associated. Enacted stigma in health care settings was significantly associated with non-use of antiretroviral therapy (aOR = 0.52, 95% CI = 0.31 to 0.88), whereas internal stigma and enacted stigma in the household or community were not. Enacted stigma in the household or community (aOR = 0.75, 95% CI = 0.64 to 0.87) and internal stigma (aOR = 0.69, 95% CI = 0.50 to 0.93) were significantly associated with poorer self-reported health status, whereas enacted stigma in health care settings was not. CONCLUSIONS: PLHIV in the Gambia face stigma regardless of identity as members of key populations, who may face dual stigma. Stigma mitigation represents a potentially important component of a comprehensive package of services to improve the HIV care continuum in the Gambia. Targeted interventions that address stigma with health care workers could facilitate antiretroviral therapy use and timely care seeking for PLHIV. Interventions to address internal stigma and enacted stigma in the household and community may yield additional dividends for the overall health of PLHIV. Examining only 1 domain of stigma may not be sufficient to understand the effect of stigma on a specific health outcome.

A cross-sectional evaluation of the prevalence and associations of HIV among female sex workers in the Gambia.

To determine HIV prevalence among female sex workers in the Gambia and HIV risk factors, we accrued participants (n = 251) through peer-referral and venue-based recruitment. Blood samples were screened for HIV and participants were administered a questionnaire. Bivariate and multivariate logistic regression identified factors associated with HIV status. Forty respondents (15.9%) were HIV-positive: 20 (8.0%) were infected with HIV-1 only, 10 (4.0%) with HIV-2 only, and 10 (4.0%) with both HIV-1 and HIV-2; 12.5% (n = 5/40) knew their status. Condom usage at last sex was 97.1% (n = 170/175) with new clients and 44.2% (n = 53/120) with non-paying partners. Having a non-paying partner, living with relatives or friends, having felt scared to walk in public, selling sex in multiple locations, and recent depressive symptoms were positively associated with HIV under multivariate regression. Female sex workers have a higher prevalence of HIV compared to the general Gambian population. Interventions should be rights-based, promote safer sex practices and regular testing for female sex workers and linkage to HIV treatment and care with adherence support for those living with HIV. In addition, service providers should consider non-paying partners of female sex workers, improve knowledge and availability of condoms and lubricant, and address safety and mental health needs.

Epidemiology of HIV among female sex workers, their clients, men who have sex with men and people who inject drugs in West and Central Africa.

INTRODUCTION: The West and Central Africa (WCA) sub-region is the most populous region of sub-Saharan Africa (SSA), with an estimated population of 356 million living in 24 countries. The HIV epidemic in WCA appears to have distinct dynamics compared to the rest of SSA, being more concentrated among key populations such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and clients of FSWs. To explore the epidemiology of HIV in the region, a systematic review of HIV literature among key populations in WCA was conducted since the onset of the HIV epidemic. METHODS: We searched the databases PubMed, CINAHL and others for peer-reviewed articles regarding FSWs, MSM and PWID in 24 countries with no date restriction. Inclusion criteria were sensitive and focused on inclusion of any HIV prevalence data among key populations. HIV prevalence was pooled, and in each country key themes were extracted from the literature. RESULTS: The search generated 885 titles, 214 abstracts and 122 full articles, of which 76 met inclusion and exclusion criteria providing HIV prevalence data. There were 60 articles characterizing the burden of disease among FSWs, eight for their clients, one for both, six for MSM and one for PWID. The pooled HIV prevalence among FSWs was 34.9% (n=14,388/41,270), among their clients was 7.3% (n=435/5986), among MSM was 17.7% (n=656/3714) and among PWID from one study in Nigeria was 3.8% (n=56/1459). CONCLUSIONS: The disproportionate burden of HIV among FSWs appears to be consistent from the beginning of the HIV epidemic in WCA. While there are less data for other key populations such as clients of FSWs and MSM, the prevalence of HIV is higher among these men compared to other men in the region. There have been sporadic reports among PWID, but limited research on the burden of HIV among these men and women. These data affirm that the HIV epidemic in WCA appears to be far more concentrated among key populations than the epidemics in Southern and Eastern Africa. Evidence-based HIV prevention, treatment and care programmes in WCA should focus on engaging populations with the greatest burden of disease in the continuum of HIV care.

A cross-sectional analysis of population demographics, HIV knowledge and risk behaviors, and prevalence and associations of HIV among men who have sex with men in the Gambia.

HIV epidemics in West Africa appear far more concentrated among key populations including men who have sex with men (MSM) and female sex workers (FSW) as compared to the more generalized epidemics of Southern and Eastern Africa. Since there has been no prior quantitative assessment of HIV risk among MSM in the Gambia, this study aims to describe the burden of HIV and associations of HIV infections. A total of 207 study participants reporting anal sex with another man in the previous 12 months were accrued using snowball sampling for this cross-sectional study and were administered an anonymous structured questionnaire. Bivariate and multivariate logistic regression models were used to identify factors associated with prevalent HIV infections. HIV prevalence was 9.8% (20/205) and the highest HIV prevalence age group was among the participants who were older than 25 years with 22.9% (8/35) living with HIV. Less than 10% of participants reported always using condoms with male partners (19/201) while 33.8% (69/204) of men reported no access to condoms and 82.5% (146/177) reported no access to latex condom-compatible lubricants (CCL). Knowledge of HIV risks was low with 3.5% (7/200) knowing that receptive anal intercourse was the highest risk sexual practice and CCL were the safest to use. This study highlighted that, similar to other West Africa countries, MSM are a high risk and underserved population for HIV prevention, treatment, and care services in the Gambia. Multilateral efforts including government, service providers, and community are needed to achieve reductions in HIV incidence and eventually prevalence among MSM in the Gambia.