Understanding and Addressing HIV Risks in Key Populations

1. Enhancing Benefits or Increasing HarmsCommunity Responses for HIV Among key populations Stefan Baral, MD MPH FRCPC Center for Public Health and Human Rights, Johns Hopkins School of Public Health

2. Acknowledgements • Coauthors • Claire Holland, Kate Shannon, Carmen Logie, Paul Semugoma, Bhekie Sithole, Erin Papworth, Fatou Drame, Chris Beyrer • Acknowledgements • Beth Mallalieu • Lynn Van Lith

3. Outline • Background • Key Populations • Female Sex Workers • Men who have Sex with Men • People who Inject Drugs • Transgender People • Community Level Determinants of HIV • Search Protocol Methods • Results • Conclusions and Moving Forward

4. Most At Risk or Key Populations • Populations that have specific acquisition and transmission risk factors for HIV • Three Universal Key Populations • Sex workers (SW) and their clients • Gay Men and other Men who have sex with Men (MSM) • People who Use Drugs (PUD) • Country Specific Key Populations • Migrant populations • Fisherfolk, Truckers • Often clients of sex workers

5. Levels of HIV Acquisition and Transmission Risks Source: Baral, Logie, et al. Modified Social Ecological Model of HIV Risk. BMC Public Health. 2013

6. Map of HIV prevalence among female sex workers in low-income and middle-income countries, 2007-2011 • Pooled OR for HIV infection among FSW compared to other reproductive age women • 13.49 (95% CI 10.04-18.12)

7. Global HIV prevalence among MSM, 2007-2011 Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012

8. HIV Prevalence among MSM in Africa 6.2% (267) Egypt 21.5% (463) 21.8% (501) 9.3% (713) 4.9% (1,778) 7.3% (406) 4.4% (90) Tunisia Morocco 25.0% (N/A) 13.4% (1,125) Senegal Sudan 5.7% (259) 5.9% (262) Nigeria 24.6% (285) Ghana 17.2% (1,291) Legend 13.3% (215) Kenya The Gambia 13.2% (306) Tanzania 19.0% (563) 12.3% (509) Uganda 21.4% (201) 2002 2003 12.4% (218) Malawi 2004 19.7% (117) 2005 Namibia 28.9% (249) 40.7% (285) 2006 Botswana 2007 25.0% (200) Soweto 2008 10.6% (538) Cape Town (Township) 2009 2010 Cape Town 2011 Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009

9. Map of HIV prevalence among transgender women, 2000-2011 • Pooled OR for HIV infection among TGW compared to other reproductive people. • 48.8 (95% CI 31.2-76.3)

10. HIV prevalence among PWID in 2011 Source: Mathers, et, al, Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet, 2008

11. PrEP • Many ongoing & planned Phase III/IV research & feasibility/demonstration projects • ≥ 17 studies with GMT • Feasibility studies in FSW in Nigeria, Kenya, RSA, Benin, Senegal supported by BMGF

12. PrEP

13. Oral PrEP – Dosing/Regimens Study

14. Topical PrEP – Ongoing Research

15. Acute Infection/Universal ART Study

16. Universal Coverage of ART

17. Studies for Transgender Women • NIH Funded Studies • Feasibility study of an anti-stigma intervention among health care providers in Mumbai, India to improve access to HIV services for hijra • Feasibility study of a telemedicine approach to improving engagement in care among TGW of color in Washington, DC • RCT of the LifeSkills program (a six session, peer-led, group intervention for sexually active TGW ages 16-24 years) in Boston and Chicago. • RCT of T-Talk, a peer-led harm reduction and social support intervention for TGW in New York City • Pilot RCT of Sheroes, a 5-session group intervention based on gender affirmation in the USA.

18. Community Level Determinants • Reinforce stigma and discrimination • Stigmas • Sexual stigma, transphobia, HIV-related stigma • Intersecting/layered stigmas • Pejorative public discourse limits the effectiveness of health communication programs for these populations • Promote health and well-being • Social Capital • Inclusion, Participation, and Cohesion

19. Objective • Synthesize the evidence characterizing the community-level determinants that potentiate or mitigate HIV-related outcomes for key populations

20. Search protocol • Search Strategy • Medical subject headings (MeSH)/key terms • HIV • Sex workers, gay men/MSM, transgender women, and people who inject drugs • Community- or social-level determinants • Inclusion Criteria • Peer-reviewed literature review from 2000 to 2014 • Low and middle income countries (LMIC) • Contained community- or social-level associations with HIV and HIV related risk (ie sexual behaviours)

21. Search Results • 1191 unique articles were obtained from the search • 132 articles were included in the full text review • 22 articles contained community- or social-level associations with HIV or HIV-related outcomes

22. Map of low-income and middle-income countries reporting community level measurements for HIV risk among key populations, 2000-2014

23. Results Men who have Sex with Men • Mitigating HIV Risks • Participating in HIV Prevention Programs in Beijing • OR 2.3 (95% CI 1.3-4.0) knowing 10 or more MSM • Potentiating HIV Risks • Prevalent HIV infections in Kampala, Uganda • OR 4.3 (95% CI 1.3-14.0) exposure to homophobic abuse Sources: Ma W, Raymond HF, Wilson EC, et al. Participation of HIV prevention programs among men who have sex with men in two cities of China—a mixed method study. BMC Public Health. 2012; HladikW, Barker J, Ssenkusu JM, et al. HIV infection among men who have sex with men in Kampala, Uganda—a respondent driven sampling survey. PLoS One. 2012.

24. Results Female sex workers • Studies regularly focused on measuring social participation and cohesion among FSW • Consistent condom use with all partners • Swaziland • OR 2.3 (95% CI 1.3-3.9) social cohesion • China • OR 1.2 (p<.01) peer support for condom use Sources: Fonner VA, Kerrigan D, Mnisi Z, et al. Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland. PloS One. 2014; Correlates of consistent condom use among female entertainment workers in Shanghai, China: a repeated measures analysis. Int J STD AIDS. 2013.

25. Results Transgender people • Limited studies in LMIC focused on this population • Consistent condom use with a paying partner in India • OR 1.9 (95% CI 1.5-2.3) collective efficacy among high-risk MSM and transgender women Source: Saggurti N, Mishra RM, Proddutoor L, et al. Community collectivization and its association with consistent condom use and STI treatment seekingbehaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India. Aids Care. 2013.

26. Results People who inject drugs • Limited data measuring community- and social-level determinants among PWID • Highly criminalized population • Avoiding HIV testing in Bangkok, Thailand • OR 6.7 (95% CI 3.1-14.7) ever been refused health care services Source: Ti L, Hayashi K, Kaplan K, et al. HIV test avoidance among people who inject drugs in Thailand. AIDS Behavior. 2013.

27. Conclusions • Predominant majority of epidemiologic and surveillance studies have focused on individual-level determinants of HIV risk among key populations • Community determinants • Contextualize HIV-related risk behaviors among key populations • Affect the coverage of HIV prevention, treatment, and care services by mitigating both the provision and uptake of services

28. Ways Forward • Epidemiology and Prevention Programs • Increased measurement and characterizations of community-level determinants of HIV risk is needed to • Characterize barriers to service provision and uptake for key populations • Translate efficacious HIV prevention interventions to effective and scalable HIV prevention, treatment, and care programs • Policy • Failure to address each level of HIV risk will cost lives, harm communities, and undermine the gains of the HIV response