Published on February 26, 2014
Burden of HIV and Research Gaps among Key Populations in sub-Saharan Africa Marina Rifkin TB/HIV Care Association CFAR Biannual Meeting 6-7 December, 2013 Cape Town, South Africa 1
Key Populations • Sometimes referred to as a most-at-risk populations (MARPs) or Key Population include sex workers, men who have sex with men, people who inject drugs. • Due to various biological, behavioral and structural factors key populations are at increased risk of acquiring and transmitting the virus to others. • Key populations are important in establishing, accelerating, sustaining or curbing the HIV epidemic. – Key populations are likely to be the first to get HIV infection in a new epidemic – Key populations are often the first to experience a decline in prevalence and/or incidence following prevention interventions. 2
14 Behavioural risk factors Guiding Framework The risk of HIV infection is determined by the total number of unprotected sex acts with an HIV-infected partner and the e ciency of HIV transmission (Fiure 2). Risk of HIV acquisition = E ciency of HIV transmission x Number of HIV-infected partners x Number of unprotected sex acts with each partner F • 2. F igure Untreated STIs ramework of biomedical and behavioural risk factors for HIV acquisition • Vaginal practices (use of drying agents) • Anal sex number of clients, duration of sex work, and inconsistent condom use.36 A high background prevalence of STI, • Injection drug use which increases transmission e ciency, places sex workers and clients at higher risk for HIV acquisition and of transmitting STI and HIV. The risk of acquiring HIV is also in uenced by the type of sexual activity. The e ciency • Multiple concurrent sexual partners of HIV transmission varies with anal, oral and vaginal sex. • Group injecting Data are presented here from behavioural surveys and studies in sex work settings, which assessed sexual • Low or inconsistent condom use behaviours that in uence the risk of HIV transmission. • Needle sharing and syringe re-use Proxy markers of this equation have been shown to be associated with HIV infection. These include higher 1.4.1 U nprotected sex, including unprotected paid sex There is a large body of evidence from sub-Saharan Africa, which shows that the risk for HIV infection is lower among sex workers who use condoms consistently.36,44 Availability of condoms among sex workers has 3
Structural Barriers – – – – Laws and legislation that criminalize KP behavior Stigma and discrimination Lack of general acceptance in society Lack of political will Sexual/physical violence against KPs Same-sex/homosexuality laws 4
HIV prevalence among female sex workers in low-income and middle-income countries • • • • 1.7% - Middle East/North Africa 5.2% - Asia 6.1% - Latin America/Caribbean 10.9% - Eastern Europe • 36.9% Sub-Saharan Africa Stefan Baral, Chris Beyrer, Kathryn Muessig, Tonia Poteat, Andrea L Wirtz, Michele R Decker, Susan G Sherman, Deanna Kerrigan. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and metaanalysis. Lancet Infect Dis 2012; 12: 538–49. 5
HIV burden among Female Sex Workers in sub-Saharan Africa • Pooled HIV prevalence among adult women in SSA: 7.42% • Pooled HIV prevalence among FSW in SSA: 36.9% • Sex workers were 12 times more likely to be HIV infected than adult women [OR: 12.4 (95% CI: 8.9–17.2]. • SW size estimates in SSA vary considerably and are generally higher in urban areas, port cities and along major transportation corridors. Stefan Baral, Chris Beyrer, Kathryn Muessig, Tonia Poteat, Andrea L Wirtz, Michele R Decker, Susan G Sherman, Deanna Kerrigan. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infect Dis 2012; 12: 538–49. 6
HIV Prevalence among FSW and Reproductive Age Women in SSA Sample size Prevalence among female sex workers (95% CI) Female populationn prevalence OR (95% CI) % Female HIV infections among female sex workers Kenya, 2007-2011 7544 45.1% (44.0–46.2) 7.72% 9.8 (9.4–10.3) 32.2 Uganda, 2011 1027 37.2% (34.2-40.2) 8.51% 6.4 (5.6-7.2) 15.7 South Africa, 2008 775 59.6% (56.2–63 .1) 25.32% 4.4 (3.8–5.0) 5.7 Togo, 2009 1311 36.2% (33.6-38.8) 4.2% 12.7 (11.4-14.2) 76.7 Senegal, 2007/2009 1656 19.9% (18.0 –21.9) 1.04% 23.7 (21.0-26.7) 11.5 Malawi, 2007 273 70.7% (65.3–76.1) 13.33% 15.7 (12.1–20.4) 12.7 Nigeria, 2008/2009 3477 33.7% (32.1–35.3) 4.54% 10.7 (10.0-11.5) 4.5 Mauritius, 2010 291 32.6% (27.3–38.0) 0.71% 67.4 (52.6–86.4) 9.1 Country Baral et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and metaanalysis. Lancet Infect Dis 2012. 7
Global burden of HIV among MSM, studies published 2007-2011 Chris Beyrer et al. Global Epidemiology of HIV infection in men who have sex with men. Lancet 2012. 8
HIV burden among MSM in sub-Saharan Africa • The HIV epidemic among MSM is occurring within a widespread heterosexual epidemic; HIV rates among MSM reflect the overall high burden of HIV disease. • The first MSM survey in SSA was conducted in Senegal in 2005. • Approx. 20 countries have either implemented or plan to implement surveillance and surveys focusing on MSM. – South Africa: Reported HIV prevalence rates among South African MSM range from 9% to 34%. – Namibia: MSM in Windhoek found to have an HIV prevalence of 12.4%. – In 2011, Kenya reported an annual incidence of over 20% among a sample of MSM in Mombasa. Baral et al. 2009; Lane et al. 2009; Sanders et al. 2011 9
IBBS Botswana • Many MSM have multiple partners, including female partners (51% in Namibia; 54% in SA), which serve as a bridge for STI and HIV transmission to the ge neral population. • Concurrent partnerships: Nearly 40% of MSM reporting to be in more than one ongoing sexual relationship at the time of survey. • Some MSM are selling sex and others are buying sex from FSWs. • Most MSM were not aware that anal sex carries an increased risk of HIV transm ission • Excessive alcohol consumption and limited availability of condoms and lubricant was reported as a barrier to consistent condom use. Botswana Ministry of Health. 2012 Mapping, Size Estimation & Behavioral and Biological Surveillance Survey (BBSS) of HIV/STI Among Select High-Risk Sub-Populations in Botswana. 10
MSM and STIs • 2012 IBBS in Botswana, 11.3% tested positive for chlamydia, including 5.9% infected with chlamydia of the anus. • In FGD, MSM expressed feeling uncomfortable discussing rectal STIs with health care providers – need for sensitization, specialized training and MSM-appropriate services. 11
HIV burden among PWID in sub-Saharan Africa • Concentrated PWID epidemics in Mauritius and Zanzibar • PWID epidemics occurring within generalized epidemics in Kenya, mainland Tanzania and southern Africa. • Studies in Tanzania have estimated an overall HIV prevalence of 42% among PWID, compared with an estimated prevalence of 6% in the general population. • A 2011 integrated bio-biological surveillance survey in Nairobi found an HIV prevalence of 30.2% among PWID sharing syringes and 5.4% among non-sharing PWID. • Heroin is the most widely injected drug across the countries, except in Mauritius, where 80% of PWID currently inject buprenorphine. • High risk injection practices often co-occur with high-risk sexual practices. 12
Modes of Transmission: Proportion of new HIV infections by risk category in five countries in Southern and East Africa UNAIDS. Regional Support Team for Eastern and Southern Africa – modes of transmission. http://www.unaidsrstesa.org/hiv-prevention-modes-of-transmission 13
It is “estimated” that KPs and their sex partners account for +30% of new infections in South Africa Key Population Percent of new HIV infections, group only CSW 5.5% Percent of new infections, group and their partners/clients 19.8% PWID 1.1% 1.3% MSM 7.9% 9.2% Total 14.5% 30.3% SACEMA June 1 2010 Discussion Draft of “South African HIV epidemic, policy and response synthesis”
Importance of KPs in a stabilizing epidemic • As HIV epidemics appear to be stabilizing in the region in the general population, the relative importance of key populations increases. – Key populations have an unequal risk of acquiring disease. – Populations at higher risk require specific services. – These services must differ in intensity and type from services that target groups at lower risk. – Stigmatized, marginalize and often deprioritized by MOH • Combination prevention for KPs – Behavioral interventions – Biomedical interventions – Structural interventions 15
Behavioral Intervention Components • Peer education and outreach • Sexual health screening, risk reduction counseling and skills building • Promotion, demonstration, provision of condoms and lube • Screening and treatment for alcohol and drug abuse • Promotion of health seeking behaviors 16
Biomedical Intervention Components • • • • • • • • • • • • • • HIV counseling and testing STI screening and treatment TB screening and treatment HIV care and treatment (including ART) Condoms and compatible lubricants Sexual and reproductive health services Medical male circumcision Post-exposure prophylaxis Needle and syringe exchange OST/MAT Hep B screening and vaccination HPV screening and vaccination Periodic presumptive treatment of STIs Pre-exposure prophylaxis 17
Structural Intervention Components • Services to mitigate sexual violence • Sensitization of HCWs, police, etc. • Implementation of policies that safeguard health and human rights • Capacity building/empowerment of KP groups and individuals 18
Key Points • In SSA, the burden of HIV among key populations is disproportionately high compared with that of the general population. • Key populations in most countries still have a high unmet need for HIV services. • Despite strong evidence-base supporting the effectiveness of currently available interventions in preventing HIV acquisition and transmission, access to and coverage of HIV interventions among KPs remain low. 19
Research Gaps • Bio-behavioral surveillance/size estimation data are needed to establish baselines/denominators • Poor indices to measure and monitor coverage, cost and impact of HIV services for KPs • Need for demonstration project that provide KPs with access to new biomedical tools • Limited inclusion/recruitment of KPs in HIV prevention research • Limited inclusion of male and transgender sex workers, women who inject drugs, and non-urban KPs in research and surveillance. 20
Potential NIH/CFAR Research Priorities Implementation science/operations research opportunities • Assessing network level risk for various KPs and sub-populations of KPs in sub-Saharan Africa • Innovative methods of accessing and targeting sub-populations of previous hard-to-reach KPs using mobile and web-based technologies • Role of bisexuality among MSM in prevention research (eg, MMC) • Role of risk compensation in KP prevention research • Role of seroadaptation among MSM in prevention research • Interventions to optimize acceptability, uptake, adherence and retention (HCT, PEP, ART, health-seeking, etc. ) • Role of super infection/VL spikes among KPs • Models of service delivery: stand-alone, mobile-linked, integrated 21
Potential NIH/CFAR Research Priorities HIV Test Retain in Care Adherence to ART Link to Care Pre-ART Care ART Eligible Viral Suppression 22
Potential NIH/CFAR Research Priorities Treatment as Prevention • Following on HPTN052 results, what about TasP for KPs? • High rates of client change, the potential for onward transmission of HIV from an infected sex worker to other clients or partners may be more than 100 times greater than from other people living with HIV. • What evidence is needed to better inform MOH/DOH and policy makers? • Feasibility/acceptability • Optimizing adherence • Costing • Modeling to determine impact of TasP for KPs on incidence in the general population 23
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HIV epidemic among key populations in west Africa on ResearchGate, the professional network for scientists.
Burden of HIV and Research Gaps Among Key Populations in Sub-Saharan Africa. Posted on December 07, 2013. Speaker(s): Marina Rifkin
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