The relationship between depression and sexual health service utilization among men who have sex with men (MSM) in Côte d'Ivoire, West Africa.

BACKGROUND: In Cote D'Ivoire, there has been limited coverage of evidence-based sexual health services specifically supporting men who have sex with men (MSM). To date, there has been limited study of the determinants of engagement in these services including multiple intersecting stigmas and depression. METHODS: 1301 MSM aged 18 years and older, were recruited using respondent-driven sampling in Abidjan, Yamoussoukro, Gagnoa and Bouake, Cote d'Ivoire from January 2015 to October 2015. Inclusion criteria included anal sex with another man in the past 12 months were to complete a structured questionnaire including the Patient Health Questionnaire (PHQ)-9 to screen for depression. Chi-Square tests were used to test difference in healthcare utilization across variables, and multiple logistic regression was used to test the association between depression and health care utilization represented by HIV and sexually transmittable infection testing and treatment. RESULTS: Depression (aOR:1.40, 95% CI: 1.07-1.84), being aged 25-29 years (aOR:1.84, 95% CI: 1.11-3.03),unemployed (aOR:0.64, 95% CI: 0.42-0.98), being a student (aOR:0.67, 95% CI: 0.48-0.96), being identified as male (aOR:0.44, 95% CI: 0.29-0.67), and identifying as homosexual (aOR:0.74, 95% CI:0.56-0.99) were significantly associated with utilization of sexual health care services in the final multivariable model. Healthcare enacted stigma (aOR: 1.55, 95% CI: 1.03-2.33) was associated with utilizing sexual health care services, but perceived healthcare stigma, social stigma and family stigma were not. CONCLUSION: Given higher levels of depressive symptomatology among those engaging in sexual health care services, this engagement represents an opportunity for service integration which may have synergistic benefits for both sexual and mental health. Moreover, MSM in Cote D'Ivoire who had engaged in sexual health services were more likely to report having experienced health-care enacted stigma. Taken together, these results reinforce the need for stigma mitigation interventions to support sustained engagement in HIV prevention, treatment and care services as a means of reducing health disparities among MSM in Cote d'Ivoire.

Estimating the contribution of key populations towards the spread of HIV in Dakar, Senegal.

INTRODUCTION: Key populations including female sex workers (FSW) and men who have sex with men (MSM) bear a disproportionate burden of HIV. However, the role of focusing prevention efforts on these groups for reducing a country's HIV epidemic is debated. We estimate the extent to which HIV transmission among FSW and MSM contributes to overall HIV transmission in Dakar, Senegal, using a dynamic assessment of the population attributable fraction (PAF). METHODS: A dynamic transmission model of HIV among FSW, their clients, MSM and the lower-risk adult population was parameterized and calibrated within a Bayesian framework using setting-specific demographic, behavioural, HIV epidemiological and antiretroviral treatment (ART) coverage data for 1985 to 2015. We used the model to estimate the 10-year PAF of commercial sex between FSW and their clients, and sex between men, to overall HIV transmission (defined as the percentage of new infections prevented when these modes of transmission are removed). In addition, we estimated the prevention benefits associated with historical increases in condom use and ART uptake, and impact of further increases in prevention and treatment. RESULTS: The model projections suggest that unprotected sex between men contributed to 42% (2.5 to 97.5th percentile range 24 to 59%) of transmissions between 1995 and 2005, increasing to 64% (37 to 79%) from 2015 to 2025. The 10-year PAF of commercial sex is smaller, diminishing from 21% (7 to 39%) in 1995 to 14% (5 to 35%) in 2015. Without ART, 49% (32 to 71%) more HIV infections would have occurred since 2000, when ART was initiated, whereas without condom use since 1985, 67% (27 to 179%) more HIV infections would have occurred, and the overall HIV prevalence would have been 60% (29 to 211%) greater than what it is now. Further large decreases in HIV incidence (68%) can be achieved by scaling up ART in MSM to 74% coverage and reducing their susceptibility to HIV by two-thirds through any prevention modality. CONCLUSIONS: Unprotected sex between men may be an important contributor to HIV transmission in Dakar, due to suboptimal coverage of evidence-informed interventions. Although existing interventions have effectively reduced HIV transmission among adults, it is crucial that further strategies address the unmet need among MSM.

Using a social ecological framework to characterize the correlates of HIV among men who have sex with men in Lomé, Togo.

In the mixed and concentrated HIV epidemics of West Africa, the relative disproportionate burden of HIV among men who have sex with men (MSM) compared to other reproductive-age men is higher than that observed in Southern and Eastern Africa. Our aim is to describe the correlates of HIV infection among MSM living in Lomé, Togo, using the Modified Social Ecological Model (MSEM). A total of 354 MSM ≥18 years of age were recruited using respondent driven sampling (RDS) for a cross-sectional survey in Lomé, Togo. Participants completed a structured questionnaire and were tested for HIV and syphilis. Statistical analyses included RDS-weighted proportions, bootstrapped confidence intervals (CI), and logistic regression models. Mean age of participants was 22 years; 71.5% were between 18 and 24 years. RDS-weighted HIV prevalence was 9.2% (95% CI=5.4-13.2). In RDS-adjusted (RDSa) bivariate analysis, HIV infection was associated with disclosure of sexual orientation to a family member, discriminatory remarks made by family members, forced sex, ever being blackmailed because of being MSM, community and social stigma and discrimination, and health service stigma and discrimination. In the multivariable model, HIV infection was associated with being 25 years or older (RDSa adjusted OR (aOR)=4.3, 95% CI=1.5-12.2), and having sex with a man before age 18 (RDSa aOR=0.3, 95% CI=0.1-0.9). HIV prevalence was more than seven times higher than that estimated among adults aged 15-49 living in Togo. Using the MSEM, network, community, and policy-level factors were associated with HIV infection among MSM in Lomé, Togo. Through the use of this flexible risk framework, a structured assessment of the multiple levels of HIV risk was characterized, highlighting the need for evidence-based and human-rights affirming combination HIV prevention and treatment programs that address these various risk levels for MSM in Lomé.