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Background: The eastern European and central Asian (EECA) region has the fastest growing HIV epidemic globally. We aimed to identify how HIV resources could be allocated for maximum health impact., Methods: Between Aug 1 and Dec 23, 2022, allocative efficiency analyses were undertaken for 12 countries in the EECA region (Albania, Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kosovo, Kyrgyzstan, Moldova, Serbia, Tajikistan, and Uzbekistan) using HIV epidemic models developed with Optima HIV. Country models were calibrated to demographic, epidemiological, and programmatic data and validated by national teams. Three scenarios were projected from 2023 to 2030: status quo (continued 2021 spending on HIV programmes); optimised allocation of different spending envelopes to minimise HIV infections and deaths; and achieving 95-95-95 UNAIDS targets by 2030., Findings: Aggregated across the 12 models, HIV infections attributable to sexual transmission were estimated to surpass those attributable to transmission through injecting drugs in 2018, with male-to-male sexual transmission accounting for a continuously increasing share. In the status quo scenario, there were an estimated 111 520 (95% CI 28 960-208 270) new HIV infections and 34 530 (17 280-57 410) HIV-related deaths between 2023 and 2030. Aggregated optimisation results suggest that 35 860 (32%) of 111 520 new HIV infections and 9170 (27%) of 34 530 HIV-related deaths could be averted from 2023 to 2030 compared with the status quo, by prioritising antiretroviral therapy and targeted key population programmes. For ten countries, achieving 95% diagnosis was projected to not be possible with the current budget envelope, and for seven countries, this target could require more than three times the current spending. Compared with the status quo, achieving 95-95-95, or as close as possible, could avert 70 880 (64%) of 111 520 new HIV infections and 18 890 (55%) of 34 530 HIV-related deaths from 2023 to 2030., Interpretation: Targeted key population programmes should remain high priorities in the EECA region. Achieving 95-95-95 will require more emphasis on implementing appropriate modes of service delivery that reduce the gap in diagnosis and treatment coverage for people living with HIV., Funding: The Global Fund to Fight AIDS, Tuberculosis and Malaria., Translation: For the Russian translation of the summary see Supplementary Materials section., Competing Interests: Declaration of interests SZ and CM are employed by the funder of this study (The Global Fund to Fight AIDS, Tuberculosis and Malaria). All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Many adolescents under 18 years old who sell sex are at elevated risk for sexually transmitted infection (STI) acquisition, which may persist into adulthood. There has been limited study of the burden of the risks and vulnerabilities among women who started selling sex as adolescents across Sub-Saharan Africa. In this study, a Adult female sex workers (FSW) recruited through respondent-driven sampling in five cities in Cameroon from December 2015 to October 2016 completed a questionnaire and human immunodeficiency virus (HIV) and syphilis testing. Multivariable logistic regression analysis controlling for age was used to identify factors associated with reporting selling sex before age 18. Selling sex before age 18 was reported by 11.5% (256/2,220) of FSW. Initiation of selling sex as an adolescent was positively associated with experiencing dysuria (adjusted odds ratio [aOR]:1.50, 95% confidence interval [CI]:1.08-2.10) or genital warts (aOR:1.78, 95% CI:1.08-2.94) and negatively associated with prior recent testing for HIV (aOR:0.71, 95% CI:0.53-0.96) or STIs (aOR:0.65, 95% CI:0.44-0.96). Consistent condom use with clients was negatively associated with early initiation of selling sex (aOR:0.58, 95% CI:0.42-0.80), while experience of recent sexual violence was positively associated with early initiation (aOR:1.74, 95% CI:1.15-2.63). There were no independent significant differences in HIV (24.5%) or syphilis (8.3%) prevalence. Given the limited use of HIV and STI testing services by women who sold sex as adolescents, the prevalence of forced sex, condomless sex, and STI symptoms were high. Programs serving FSW should more vigorously aim to serve adolescents and adults who began selling sex early., (© 2023. The Author(s).)

Introduction: Globally, resources for health spending, including HIV and tuberculosis (TB), are constrained, and a substantial gap exists between spending and estimated needs. Optima is an allocative efficiency modelling tool that has been used since 2010 in over 50 settings to generate evidence for country-level HIV and TB resource allocation decisions. This evaluation assessed the utilisation of modelling to inform financing priorities from the perspective of country stakeholders and their international partners., Methods: In October to December 2021, the World Bank and Burnet Institute led 16 semi-structured small-group virtual interviews with 54 representatives from national governments and international health and funding organisations. Interviews probed participants' roles and satisfaction with Optima analyses and how model findings have had been used and impacted resource allocation. Interviewed stakeholders represented nine countries and 11 different disease programme-country contexts with prior Optima modelling analyses. Interview notes were thematically analysed to assess factors influencing the utilisation of modelling evidence in health policy and outcomes., Results: Common influences on utilisation of Optima findings encompassed the perceived validity of findings, health system financing mechanisms, the extent of stakeholder participation in the modelling process-including engagement of funding organisations, sociopolitical context and timeliness of the analysis. Using workshops can facilitate effective stakeholder engagement and collaboration. Model findings were often used conceptually to localise global evidence and facilitate discussion. Secondary outputs included informing strategic and financial planning, funding advocacy, grant proposals and influencing investment shifts., Conclusion: Allocative efficiency modelling has supported evidence-informed decision-making in numerous contexts and enhanced the conceptual and practical understanding of allocative efficiency. Most immediately, greater involvement of country stakeholders in modelling studies and timing studies to key strategic and financial planning decisions may increase the impact on decision-making. Better consideration for integrated disease modelling, equity goals and financing constraints may improve relevance and utilisation of modelling findings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Men who have sex with men (MSM) are consistently burdened by HIV at higher levels than other adults. While HIV prevention programs for MSM are growing in coverage and quality, HIV incidence remains high. In response, pre-exposure prophylaxis (PrEP) was introduced in 2019 to support HIV risk reduction among MSM in Cameroon. Understanding how PrEP initiation programs will change the HIV prevalence among MSM in Cameroon is important to developing effective programs., Methods: This study uses a mathematical model to simulate population-level HIV transmission among MSM in the cities of Yaoundé and Douala, Cameroon. PrEP is incorporated into the model at rates that equal 25%, 50%, or 75% coverage after twenty years to assess the potential effects on HIV prevalence among MSM, requiring annual initiation rates of 2.5%, 6.8%, and 17.2% for Yaoundé and 2.2%, 5.6%, and 13.4% for Douala, respectively. The data utilized for this model are from a cross sectional study which recruited MSM through respondent-driven sampling of MSM in two major cities in Cameroon: Yaoundé and Douala., Results: The model estimated an HIV prevalence of 43.2% among MSM, annual HIV diagnoses of 300 per 10,000 MSM and antiretroviral therapy (ART) coverage of 53.9% in Yaoundé. In Douala, estimated prevalence is 26.5% among MSM, 167 per 10,000 MSM annual diagnoses and ART coverage of 72.0%. Standalone PrEP interventions aimed at 50% coverage at the end of a 20-year program would reduce the prevalence from 43.2% to 35.4% in Yaoundé and from 26.5 to 20.1% in Douala. Combining PrEP with a 10% increase in HIV testing would decrease the number of MSM living with HIV and unaware of their status from 9.8 to 6.0% in Yaoundé and from 8.7 to 4.6% in Douala., Conclusions: PrEP would be beneficial in reducing prevalence even at varying initiation and coverage levels. Combination of PrEP and increased HIV testing further decreased the number of undiagnosed MSM. This study supports the utility of implementing PrEP as part of comprehensive HIV prevention programming among MSM in Cameroon., (© 2022. The Author(s).)

Introduction: Pre-exposure prophylaxis (PrEP) is proven to be a highly effective HIV prevention method for key populations. However, its scale-up in resource-limited settings remains suboptimal. This paper seeks to describe PrEP initiation and continuation among key populations in Cameroon., Methodology: From June 2019 through October 2020, we collected routine program data on PrEP uptake and continuation among female sex workers (FSWs) and men who have sex with men (MSM) in the Continuum of prevention, care and treatment of HIV/AIDS with Most-at-risk Populations (CHAMP) program in Cameroon. PrEP was offered to clients who tested negative for HIV and were assessed to potentially benefit from PrEP. Using survival analysis, we identified factors associated with PrEP discontinuation over time with significance set at 5%., Results: Overall, 27,750 clients were sensitized for PrEP of whom 3,138 persons were eligible to start PrEP and 1,409 (45%; FSW: 691 and MSM: 718) initiated PrEP. The PrEP continuation rate was 37% at 3 months, 28% at 6 months and 19% at 12 months. PrEP discontinuation was significantly higher among FSW than MSM [adjusted hazard ratio (aHR) 1.5 (95% CI: 1.2 to 1.9)] in Yaounde [aHR 1.5 (95% CI: 1.2 to 1.9)] and Bafoussam/Bertoua [aHR 3.1 (2.2-4.5)] relative to Douala. Discontinuation was lower among those with moderate [aHR 0.3 (0.3-0.4)] or good adherence [aHR 0.4 (0.3-0.6)] compared with poor adherence (all P < 0.001)., Conclusion: Differentiated approaches to deliver PrEP, create demand, and provide more intensive support for adherence and continuation may support scale-up of PrEP in Cameroon for equitable and prolonged impact on HIV prevention., Competing Interests: A.L.B., W.P., D.C. and S.B. disclose that they received payments through their institutions for their efforts in this study. The other authors have no conflict of interest to disclose., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: High vaccine uptake requires strong public support, acceptance, and willingness., Methods: A longitudinal cohort study gathered survey data every four weeks between 1 October 2020 and 9 November 2021 in Victoria, Australia. Data were analysed for 686 participants aged 18 years and older., Results: Vaccine intention in our cohort increased from 60% in October 2020 to 99% in November 2021. Vaccine intention increased in all demographics, but longitudinal trends in vaccine intention differed by age, employment as a healthcare worker, presence of children in the household, and highest qualification attained. Acceptance of vaccine mandates increased from 50% in October 2020 to 71% in November 2021. Acceptance of vaccine mandates increased in all age groups except 18-25 years; acceptance also varied by gender and highest qualification attained. The main reasons for not intending to be vaccinated included safety concerns, including blood clots, and vaccine efficacy., Conclusion: COVID-19 vaccination campaigns should be informed by understanding of the sociodemographic drivers of vaccine acceptance to enable socially and culturally relevant guidance and ensure equitable vaccine coverage. Vaccination policies should be applied judiciously to avoid polarisation.

Background: Gay and bisexual men (GBM) are a key population affected by human immunodeficiency virus (HIV) and hepatitis C virus (HCV) coinfection. We aimed to measure HCV treatment effectiveness and to determine the population impact of treatment scale-up on HCV prevalence and incidence longitudinally among GBM., Methods: The co-EC Study (Enhancing Care and Treatment Among HCV/HIV Coinfected Individuals to Eliminate Hepatitis C Transmission) was an implementation trial providing HCV direct-acting antiviral treatment in Melbourne, Australia, during 2016-2018. Individuals with HCV/HIV coinfection were prospectively enrolled from primary and tertiary care services. HCV viremic prevalence and HCV antibody/viremic incidence were measured using a statewide, linked, surveillance system., Results: Among 200 participants recruited, 186 initiated treatment during the study period. Sustained virological response in primary care (98% [95% confidence interval {CI}, 93%-100%]) was not different to tertiary care (98% [95% CI, 86%-100%]). From 2012 to 2019, between 2434 and 3476 GBM with HIV infection attended our primary care sites annually, providing 13 801 person-years of follow-up; 50%-60% received an HCV test annually, and 10%-14% were anti-HCV positive. Among those anti-HCV positive, viremic prevalence declined 83% during the study (54% in 2016 to 9% in 2019). HCV incidence decreased 25% annually from 1.7/100 person-years in 2012 to 0.5/100 person-years in 2019 (incidence rate ratio, 0.75 [95% CI, .68-.83]; P < .001)., Conclusions: High treatment effectiveness by nonspecialists demonstrates the feasibility of treatment scale-up in this population. Substantial declines in HCV incidence and prevalence among GBM provides proof-of-concept for HCV microelimination., Clinical Trials Registration: NCT02786758., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Key populations (KP) including men who have sex with men (MSM), female sex workers (FSW), and their clients are disproportionately affected by HIV in Sub-Saharan Africa. We estimated the evolving impact of past interventions and contribution of unmet HIV prevention/treatment needs of key populations and lower-risk groups to HIV transmission., Setting: Yaoundé, Cameroon., Methods: We parametrized and fitted a deterministic HIV transmission model to Yaoundé-specific demographic, behavioral, HIV, and intervention coverage data in a Bayesian framework. We estimated the fraction of incident HIV infections averted by condoms and antiretroviral therapy (ART) and the fraction of all infections over 10-year periods directly and indirectly attributable to sex within and between each risk group., Results: Condom use and ART together may have averted 43% (95% uncertainty interval: 31-54) of incident infections over 1980-2018 and 72% (66-79) over 2009-2018. Most onward transmissions over 2009-2018 stemmed from sex between lower-risk individuals [47% (32-61)], clients [37% (23-51)], and MSM [35% (20-54)] with all their partners. The contribution of commercial sex decreased from 25% (8-49) over 1989-1998 to 8% (3-22) over 2009-2018, due to higher intervention coverage among FSW., Conclusion: Condom use and recent ART scale-up mitigated the HIV epidemic in Yaoundé and changed the contribution of different partnerships to onward transmission over time. Findings highlight the importance of prioritizing HIV prevention and treatment for MSM and clients of FSW whose unmet needs now contribute most to onward transmission, while maintaining services that successfully reduced transmissions in the context of commercial sex., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon., Methods: From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception., Results: Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use., Conclusions: Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights., (© Bowring et al.)

Introduction: Female sex workers (FSWs) experience overlapping burdens of HIV, sexually transmitted infections and unintended pregnancy. Pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. It represents a promising strategy to reduce HIV acquisition risks among FSWs specifically given complex social and structural factors that challenge consistent condom use. However, the potential impact on unintended pregnancy has garnered little attention. We discuss the potential concerns and opportunities for PrEP to positively or negatively impact the sexual and reproductive health and rights (SRHR) of FSWs., Discussion: FSWs have high unmet need for effective contraception and unintended pregnancy is common in low- and middle-income countries. Unintended pregnancy can have enduring health and social effects for FSWs, including consequences of unsafe abortion and financial impacts affecting subsequent risk-taking. It is possible that PrEP could negatively impact condom and other contraceptive use among FSWs due to condom substitution, normalization, external pressures or PrEP provision by single-focus services. There are limited empirical data available to assess the impact of PrEP on pregnancy rates in real-life settings. However, pregnancy rates are relatively high in PrEP trials and modelling suggests a potential two-fold increase in condomless sex among FSWs on PrEP, which, given low use of non-barrier contraceptive methods, would increase rates of unintended pregnancy. Opportunities for integrating family planning with PrEP and HIV services may circumvent these concerns and support improved SRHR. Synergies between PrEP and family planning could promote uptake and maintenance for both interventions. Integrating family planning into FSW-focused community-based HIV services is likely to be the most effective model for improving access to non-barrier contraception among FSWs. However, barriers to integration, such as provider skills and training and funding mechanisms, need to be addressed., Conclusions: As PrEP is scaled up among FSWs, there is growing impetus to consider integrating family planning services with PrEP delivery in order to better meet the diverse SRHR needs of FSWs and to prevent unintended consequences. Programme monitoring combined with research can close data gaps and mobilize adequate resources to deliver comprehensive SRHR services respectful of all women's rights., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

HIV Self-Testing (HIVST) aims to increase HIV testing coverage and can facilitate reaching the UNAIDS 90-90-90 targets. In Senegal, key populations bear a disproportionate burden of HIV and report limited uptake of HIV testing given pervasive stigma and criminalization. In these contexts, HIVST may represent a complementary approach to reach populations reporting barriers to engagement with existing and routine HIV testing services. In this study, 1839 HIVST kits were distributed in Senegal, with 1149 individuals participating in a pre-test questionnaire and 817 participating in a post-test questionnaire. Overall, 46.9% (536/1144) were first-time testers and 26.2% (300/1144) had tested within the last year; 94.3% (768/814) reported using the HIVST, and 2.9% (19/651) reported a reactive result which was associated with first-time testers (p = 0.024). HIVST represents an approach that reached first-time testers and those who had not tested recently. Implementation indicators suggest the importance of leveraging existing community structures and programs for distribution.

Background: In Cameroon, female sex workers (FSWs) and men who have sex with men (MSM) carry disproportionately high burdens of HIV. Despite specific vulnerabilities and health needs, young key populations remain understudied and underserved in Cameroon owing to legal, ethical, and social challenges. We aimed to assess and compare HIV-related behavioural and structural risks and coverage of HIV prevention and treatment services between young and older key populations to inform implementation strategies., Methods: FSWs and MSM aged 18 years or older were recruited through respondent-driven-sampling for a biobehavioural survey carried out in five Cameroonian cities. Prevalence of HIV, risk, stigma, and health service engagement were compared between young (18-24 years) and older (≥25 years) key populations. Multivariable Poisson regression models, disaggregated by key population, were constructed to estimate prevalence ratios (PR) by age group for HIV service engagement., Findings: Participants were recruited between Nov 30, 2015, and Oct 12, 2016. Among FSWs, 724 (32%) of 2255 were aged 18-24 years, and median age of first transactional or compensated sex was 22 years (IQR 19-28). Among MSM, 840 (63%) of 1323 were aged 18-24 years, and median age of first anal sex was 18 years (IQR 17-21). RDS-adjusted HIV prevalence was 8·5% (95% CI 4·7-15·2) among young FSWs and 12·9% (9·5-18·2) among young MSM. HIV viral suppression (<1000 copies per mL) was evident in 24 (43%) of 56 young and 292 (61%) of 479 older FSWs (p=0·0091) and 40 (34%) of 119 of young and 64 (42%) of 153 older MSM (p=0·17). Young FSWs were less likely than older FSWs to report recent peer education (PR 0·65, 95% CI 0·48-0·88), or membership of an FSW community-based organisation (PR 0·69, 0·55-0·86) and were more likely to report untreated sexually transmitted infection symptoms in the past year (PR 1·29, 1·03-1·61). Young MSM were less likely than older MSM to report an HIV test in the past year (PR 0·88, 0·78-0·98), recent peer education (PR 0·77, 0·62-0·95) and receipt of free condoms (PR 0·77, 0·67-0·89). By key population, condom use and recent experiences of stigma and violence were similar between age groups (p>0·05)., Interpretation: Young key populations have similar behavioural and structural risks to older populations but have lower coverage of HIV preventive and treatment services. Achieving an AIDS-free generation in Cameroon and elsewhere in the region necessitates overcoming social and legal challenges and delivering innovative, evidence-based, and human rights-affirming HIV prevention and treatment interventions for young key populations., Funding: PEPFAR, USAID., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Female sex workers (FSWs) are disproportionately affected by HIV even in the most generalized HIV epidemics. Although structural HIV risks have been understood to affect condom negotiation among FSWs globally, there remain limited data on the relationship between structural determinants of HIV risk, including violence and socioeconomic status, and condom use among FSWs across sub-Saharan Africa. Here, we describe the prevalence of structural determinants and their associations with condom use among FSWs in Senegal., Methods: In 2015, 758 FSWs >18 years of age were recruited using respondent driven sampling in Senegal. Data on individual, community, network, and structural-level risks were collected through an interviewer-administered questionnaire. Poisson regression with robust variance estimation was used to model the associations of consistent condom use (CCU) and selected structural determinants., Results: The respondent driven sampling-adjusted prevalence of CCU in the last 10 sexual acts was 76.8% [95% confidence interval (CI): 70.8 to 82.8]. Structural determinants that were significantly associated with lower CCU were as follows: physical violence [adjusted prevalence ratio (aPR): 0.71; 95% CI: 0.52 to 0.98]; working primarily in a hotel or guest house (aPR: 0.85; 95% CI: 0.73 to 0.99); and difficultly accessing condoms (aPR: 0.72; 95% CI: 0.52 to 0.96). High income from sex work (aPR: 1.23; 95% CI: 1.04 to 1.46) was significantly associated with higher CCU., Conclusions: Taken together, these data highlight the role of structural risk determinants on condom use among FSWs in Senegal. Moreover, these results highlight the need for structural interventions, including safe working spaces and violence mitigation programs, to support condom negotiation and access. Combined with condom distribution programs, structural interventions could ultimately increase condom use among FSWs in Senegal.

Background: Female sex workers (FSW) are disproportionately affected by HIV in Cameroon, with an estimated 23.6% HIV prevalence. Given the unavailability of HIV incidence data, to better understand associations with acquiring HIV we assessed the prevalence and associations with new HIV diagnoses among FSW in Cameroon., Methods: In 2016, FSW were recruited through respondent-driven sampling from 5 cities for a biobehavioral survey. Participants self-reporting living with HIV or with an indeterminate test status were excluded from analysis. New diagnoses were defined as testing HIV-positive when participants self-reported HIV-negative or unknown status. A multivariable modified Poisson regression model was developed to assess determinants of new HIV diagnosis (referent group: HIV-negative) using key covariates; adjusted prevalence ratios (aPR) are reported if statistically significant (P < 0.05)., Results: Overall 2255 FSW were recruited. Excluding participants who self-reported living with HIV (n = 297) and indeterminate test results (n = 7), 260/1951 (13.3%) FSW were newly diagnosed with HIV. Variables significantly associated with new HIV diagnosis were: no secondary/higher education [aPR: 1.56, 95% confidence interval (CI): 1.12 to 2.15], 5+ dependents compared with none (aPR: 2.11, 95% CI: 1.01 to 4.40), 5+ years involved in sex work compared with <1 year (aPR: 2.84, 95% CI: 1.26 to 6.42), history of incarceration (aPR: 2.13, 95% CI: 1.13 to 3.99), and low social capital (aPR: 1.53, 95% CI: 1.12 to 2.10). Higher monthly income (>250,000 FCFA vs. <50,000 FCFA) was associated with lower prevalence of new HIV diagnosis (aPR: 0.22, 95% CI: 0.05 to 0.86)., Conclusions: There are significant sociostructural factors that seem to potentiate risk of HIV infection and delay diagnosis among FSW in Cameroon. Initiatives to build social capital and integrate services such as pre-exposure prophylaxis and HIV self-testing into HIV programs may reduce new infections and decrease time to diagnosis and treatment.

Issue Addressed: Young people have a high burden of sexual and reproductive health (SRH) problems, and it is important to reach this group through health promotion initiatives. We conducted a systematic review of reviews to identify successful elements of health promotion programs for improving SRH of young people., Methods: We identified and collated systematic reviews published in 2005-2015 which focused on young people (10-24 years), reported on SRH outcomes (pregnancy, sexually transmissible infections, condoms/contraceptive use, risky sexual behaviour, sexual healthcare access or intimate partner violence), and included primary studies predominantly conducted in high-income countries. This report focuses on features of successful SRH programs identified in the interpretation and discussion of included systematic reviews., Results: We identified 66 systematic reviews, of which 37 reported on program features which were anecdotally or statistically associated with improved program effectiveness and success. Common features of effective interventions were: longer term or repeated implementation; multi-setting and multi-component; parental involvement; culturally/gender/age appropriate; and inclusion of skills-building. SO WHAT?: There is marked consistency of features improving SRH program effectiveness for young people despite the wide variation in interventions reviewed. There is a need to better implement this knowledge in future programs, and our findings provide useful guidance for optimising the design of SRH interventions for young people., (© 2017 Australian Health Promotion Association.)

Identification of priority populations such as men who have sex with men (MSM) is important in surveillance systems to monitor trends of sexually transmitted infections (STIs). We explored using routinely collected non-behavioural data as a means to establish MSM status in surveillance by assessing anorectal swab as a marker of male-to-male sexual exposure. We used chlamydia testing data from a sexual health clinic, 2007-2012. Men reporting any male sexual partner(s) in the previous 12 months were considered MSM. The dataset was split into development and validation samples to develop a univariate predictive model and assess the model fit. The dataset included 30 358 individual men and 48 554 episodes of STI testing; 45% were among reported MSM and an anorectal swab was performed in 40% of testing episodes. Anorectal swabbing had good diagnostic performance as a marker for MSM status (sensitivity = 87%, specificity = 99%, positive predictive value = 98·6%, negative predictive value = 90·3%). The model showed good fit against the internal validation sample (area under the curve = 0·93). Anorectal swabs are a valid marker of MSM behaviour in surveillance data from sexual health clinics, and they are likely to be particularly useful for monitoring STI trends among MSM with higher risk behaviour.

People engaging in transactional sex are considered a key population for HIV prevention. Prior quantitative surveys demonstrated that behaviorally bisexual men in Vientiane, Laos commonly transact sex. In 2013, we conducted a qualitative study to explore behaviorally bisexual men's experience, motivations, and perceptions related to transactional sex in Vientiane. Behaviorally bisexual men were recruited from bars, nightclubs, and dormitories for five focus group discussions (FGDs) and 11 in-depth interviews (n = 31). Additionally, young women were recruited from a university, garment factory, and nightclub for four FGDs (n = 22). Transcripts were translated and thematically coded. Bisexual male participants most commonly described being paid for sex by male-to-female transgender people and buying sex from women. Both male and female participants reported that older, single women pay younger men for sex. Negotiation and direction of sexual transactions are influenced by age, attraction, and wealth. Common motivations for selling sex included the need for money to support family or fund school fees, material gain, or physical pleasure. Transactional sex was often opportunistic. Some behaviorally bisexual men reported selling sex in order to pay another more desirable sex partner or to buy gifts for their regular sex partner. Participants perceived high risk associated with intercourse with female sex workers but not with other transactional sex partners. Health interventions are needed to improve knowledge, risk perception, and health behaviors, but must recognize the diversity of transactional sex in Vientiane. Both physical and virtual settings may be appropriate for reaching behaviorally bisexual men and their partners.

We performed a systematic review to estimate the proportion of men who have sex with men (MSM) in Asia who are bisexual and compare prevalence of HIV and sexual risk between men who have sex with men and women (MSMW) and men who have sex with men only (MSMO). Forty-eight articles based on 55 unique samples were identified from nine countries in Asia. Bisexual behaviour was common among MSM (pooled prevalence 32.8 %). Prevalence of HIV (pooled OR 0.90; 95 % CI 0.77-1.05), recent syphilis infection (pooled OR 0.99; 95 % CI 0.93-1.06) and unprotected anal intercourse (pooled OR 0.80; 95 % CI 0.57-1.11) were similar between MSMW and MSMO, but heterogeneity was high. MSMW had lower odds of reporting a prior HIV test than MSMO (OR 0.82; 95 % CI 0.70-0.95; p = 0.01, I(2) = 0 %). Targeted interventions are needed to increase uptake of HIV testing among MSMW. Increased reporting of disaggregated data in surveillance and research will help improve understanding of risk in MSMW and inform targeted interventions.

Background: Heteronormativity describes a set of norms and assumptions pertaining to heterosexual identities and binary gender. In 2015, we conducted our annual Sex, Drugs and Rock'n'Roll study, an online health survey of over 1000 Victorians aged 15-29 years. Feedback from participants suggested that our survey contained heteronormative language. In response to this, we aimed to make inclusive changes to our survey via consultation with young gender and sexually diverse (GSD) people., Methods: We conducted two semi-structured focus groups in Melbourne with a total of 16 participants (age range: 21-28 years). Participants were mostly cisgender women, and there were two transgender participants and one non-binary participant. Participants also had a range of sexual identities including lesbian, queer, bisexual, pansexual, and asexual. Focus group discussions were transcribed verbatim and analysed thematically., Results: Most participants indicated heteronormativity affects their lives in multiple ways, noting its impacts on access to sexual healthcare, invalidating sexual experiences and miscommunication in forms and surveys. Overall, participants emphasised the need for sexual health research to avoid assumptions about behaviour, to be clear and eliminate question ambiguity and avoiding treating gender as binary. Participants also discussed how the Sex, Drugs and Rock'n'Roll survey could address a range of sexual behaviours and experiences, rather than focusing on penetrative sex, which many participants found invalidating., Conclusions: Our findings have important implications for future health surveys aimed at general populations. We present recommendations that encourage research to be more inclusive to ensure data collection from GSD participants is respectful and rigorous.

In Laos, men who have sex with men (MSM) are disproportionately affected by HIV, and bisexual behavior among men is common. We conducted a qualitative study to explore access and influences on sexual health care seeking among bisexual men in Vientiane. In 2013, behaviorally bisexual men were recruited from bars, clubs and dormitories for 5 focus group discussions and 11 in-depth interviews. Participants (aged 18-35 years) commonly reported high-risk sexual behaviors, yet most had never been tested for HIV, and none reported testing for sexually transmitted infections. Common barriers to testing were low perception of risk, expectation of symptoms, fear of HIV, shyness, perceived stigma, confidentiality concerns, and waiting times. Many men were unaware of available services. Most clinics cannot provide comprehensive HIV and sexually transmitted infection services. Strategies are needed to generate demand for testing, improve the capacity of sexual health care providers, and promote available services among behaviorally bisexual men in Vientiane., (© 2015 APJPH.)

Unlabelled: Background Transactional sex may increase risk of HIV and sexually transmissible infections (STIs). In Laos, men who have sex with men are disproportionately affected by HIV, and bisexual behaviour among men is relatively common. The occurrence of transactional sex among behaviourally bisexual men in Vientiane, Laos was explored., Methods: In 2010, behaviourally bisexual men were recruited through enhanced snowball sampling to complete a behavioural survey. Reports of transactional sex partners (anal/vaginal sex) in the previous year, by direction of payment and partner gender, is described., Results: Of 88 participating behaviourally bisexual men (median age 22 years), 17 (19%) reported only selling sex, eight (9%) reported only paying for sex and nine (10%) reported both selling and paying for sex. Men reporting any transactional sex reported a median of four transactional sex partners and reported a higher number of total sex partners in the previous 12 months (median: 18.5 partners) than men reporting no transactional sex partners (median: 6 partners). Of 26 men who reported selling sex, 15 (58%) were paid by females, 15 (58%) were paid by males and 14 (55%) were paid by transgender sex partner(s); 11 (42%) reported consistent condom use (CCU) when selling sex. Of 17 men who reported paying for sex, 13 (76%) paid females, six (35%) paid males and two (12%) paid transgender partner(s); eight (47%) reported CCU when paying for sex., Conclusions: Young behaviourally bisexual men engaging in transactional sex may be at increased risk of HIV and STIs. Prevention interventions should consider the transient and informal nature of transactional sex in this population.

In 2009, the Australian Government's National Sexually Transmitted Infection Prevention Program launched a multi-million dollar sexual health campaign targeting young people. We assessed campaign recognition among a community sample of young people. Individuals aged 16-29 years self-completed a questionnaire at a music festival. Participants were asked whether they recognised the campaign image and attempted to match the correct campaign message. Recognition of two concurrent campaigns, GlaxoSmithKline's The Facts genital herpes campaign (targeting young women) and the Drama Downunder campaign (targeting gay men) were assessed simultaneously. Among 471 participants, just 29% recognised the National Sexually Transmitted Infection Prevention Program campaign. This compared to 52% recognising The Facts and 27% recognising Drama Downunder. Of 134 who recognised the National Sexually Transmitted Infection Prevention Program campaign, 27% correctly recalled the campaign messages compared to 61% of those recognising the Facts campaign, and 25% of those recognising the Drama Downunder campaign. There was no difference in National Sexually Transmitted Infection Prevention Program campaign recognition by gender or age. Campaign recognition and message recall of the National Sexually Transmitted Infection Prevention Program campaign was comparatively low. Future mass media sexual health campaigns targeting young people can aim for higher recognition and recall rates than that achieved by the National Sexually Transmitted Infection Prevention Program campaign. Alternative distribution channels and message styles should be considered to increase these rates., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Young people who are same-sex attracted report higher rates of substance use, sexual risk behaviour, and mental health problems. Numerous studies have shown that sexual identity, sexual behaviour and sexual attraction do not always correspond, particularly among young people. We describe sexual identity, sexual partners, and associations between sexual identity and risk in a community-based sample of young people., Methods: From 2011 to 2013, young people (16-29 years) were recruited at a music festival in Melbourne, Australia to self-complete a questionnaire. We describe sexual identity and gender of anal/vaginal sex partners in the past year. Secondly, we assess associations between risk behaviours, health outcomes and gay/lesbian/bisexual/queer/questioning (GLBQQ)-identity using multivariable logistic regression., Results: Among 3793 (91%) participants with complete data, 115 (9%) males and 266 (11%) females were GLBQQ-identifying. Among GLBQQ-identifying males, 23% reported only same-sex partners, 34% reported both sex partners, 26% reported only opposite-sex partners, 5% reported no sex partners in the past year, and 12% had never had sex. Among GLBQQ-identifying females, 10% reported only same-sex partners, 22% reported both sex partners, 48% reported only opposite-sex partners, 3% reported no sex partners in the past year, and 17% had never had sex. Controlling for age and sex, significant (p<0.05) associations with GLBQQ-identity included: recent drug use (adjusted odds ratio [AOR] 1.7, 95%CI 1.3-2.2); ever injected drugs (AOR 5.7, 95%CI 3.3-9.7); young age at first sex (AOR 1.8, 95%CI 1.3-2.3); ≥11 lifetime sex partners (AOR 1.5, 95%CI 1.1-2.0); multiple sex partners in the past year (AOR 1.9, 95%CI 1.5-2.5); and rating mental health as fair/poor (AOR 3.0, 95%CI 1.9-4.6)., Conclusion: Young people with GLBQQ-identity commonly engage in high risk behaviours and are more at risk relative to their heterosexual-identifying peers. Targeted interventions to promote the health and wellbeing of this group should account for the complexities of identity and behaviour., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Behaviorally bisexual men (BBM) in Vientiane, Laos report high-risk sexual behaviors. We explore settings for meeting sex partners and associated risk behaviors among BBM in Laos. BBM and their sexual partners were recruited in Vientiane Capital using modified snowball sampling (2010). Settings for usually meeting sex partners and associations with risk behaviors were assessed. Among 88 BBM, the most common settings for men meeting male, kathoey, and female sex partners were private residences (48%, 37%, 51%, respectively) and hospitality settings (39%, 31%, 40%, respectively). Hospitality settings were more commonly reported by heterosexual-identifying BBM, and private residences more commonly reported by bisexual/homosexual-identifying BBM. Inconsistent condom use was high across partners and settings. Meeting partners in hospitality settings was associated with reporting a high number of female sex partners and frequently drinking alcohol before sex. Our results suggest that targeted health promotion initiatives in bars, clubs, and beer-shops could reach a high proportion of high-risk bisexual men, particularly heterosexual-identifying BBM.

Unlabelled: Background Age at first sex (AFS) is associated with adverse outcomes. We explore associated factors and correlates of 'early' AFS (<16 years)., Methods: In 2009-11, participants (16-29 years) were recruited. Multivariate Cox regression explored correlates of AFS. Logistic regression analysis explored associations between early AFS and risk behaviours., Results: Of 3563 participants, 79% were sexually active. Median AFS was 17 years. Compared with those aged 25-29 years, younger participants reported younger AFS [16-17 years: adjusted hazard ratio (AHR)=1.87, P<0.01; 18-19 years: AHR=1.47, P<0.01, 20-24 years: AHR=1.19, P<0.01]. Of those sexually active, 29% reported early AFS. Early AFS was associated with being male [adjusted odds ratio (AOR)=1.25, P<0.05], being younger (16-17 years: AOR=11.10, P<0.01; 18-19 years: AOR=3.60, P<0.01; 20-24 years: AOR=1.83, P<0.01; compared with 25-29 years), having no education after high school (AOR=1.52, P<0.01), living alone (AOR=1.84, P<0.01) or with a partner (AOR=1.57, P=0.01), having more than five lifetime sex partners (AOR=3.22, P=0.01), inconsistent condom use in the past 12 months (AOR=1.43, P<0.01), ever using illicit drugs (AOR=1.69, P<0.01) and ever injecting drugs (AOR=3.45, P<0.01)., Conclusions: The results highlight the importance of comprehensive sex education.

Unlabelled: Background Clinical guidelines commonly recommend annual chlamydia (Chlamydia trachomatis) testing in young people. General practice (GP) clinics can play an important role in annual testing, as a high proportion of young people attend these clinics annually; however, little is known about the timing of attendance and testing in this setting., Methods: The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmitted Infections and Blood-Borne Viruses system extracted consultation and pathology data on 16-29-year-olds attending 25 GP clinics in 2007-10. We calculated the proportion of individuals with an initial negative test that reattended at 12 months (±3 months) and retested at 12 months (±3 months). Individuals with an initial positive test were excluded, as guidelines recommend retesting at 3 months., Results: Among 3852 individuals who had an initial negative test, 2201 (57.1%) reattended at ~12 months; reattendance was higher among females (60.8%) than males (44.1%; P<0.001) and higher among 16-19-year-olds (64.2%) than 25-29-year-olds (50.8%; P<0.001). Of 2201 individuals who reattended at 12 months, 377 had a chlamydia test (retesting rate of 9.8%); retesting was higher among females (10.8%) than males (6.1%; P<0.01) and higher among 16-19-year-olds (13.3%) than 25-29-year-olds (7.5%; P<0.001)., Conclusion: Although over half of young people reattended their GP clinic ~1 year after a negative chlamydia baseline test, only 9.8% were retested at this visit. Strategies are needed to promote regular attendance and testing to both patients and clinicians.

Men who have sex with both men and women (behaviorally bisexual men) may be at increased risk of HIV acquisition and transmission due to risky sexual behaviors. We recruited a sexual network comprised of behaviorally bisexual men and their sexual partners in Vientiane, Lao PDR in 2010 to inform our understanding of the potential for HIV transmission among heterosexual, homosexual, and bisexual networks. Participants completed a sexual behavior questionnaire and referred < 5 sexual partners. A total of 298 people were recruited, including 63 behaviorally bisexual men. Behaviorally bisexual men reported riskier sexual behaviors (number of sexual partners in the previous 12 months and consistent condom use) than behaviorally homosexual and heterosexual men. Using social network diagrammatic representation, heterosexual, homosexual, and bisexual networks are shown to be interlinked. This study demonstrates that behaviorally bisexual men are potential key drivers of HIV epidemics and require a targeted approach to sexual health promotion.

Background: The 10-item Alcohol Use Disorders Identification Test (AUDIT-10) is commonly used to monitor harmful alcohol consumption among high-risk groups, including young people. However, time and space constraints have generated interest for shortened versions. Commonly used variations are the AUDIT-C (three questions) and the Fast Alcohol Screening Test (FAST) (four questions), but their utility in screening young people in non-clinical settings has received little attention., Methods: We examined the performance of established and novel shortened versions of the AUDIT in relation to the full AUDIT-10 in a community-based survey of young people (16-29 years) attending a music festival in Melbourne, Australia (January 2010).Among those reporting drinking alcohol in the previous 12 months, the following statistics were systematically assessed for all possible combinations of three or four AUDIT items and established AUDIT variations: Cronbach's alpha (internal consistency), variance explained (R2) and Pearson's correlation coefficient (concurrent validity). For our purposes, novel shortened AUDIT versions considered were required to represent all three AUDIT domains and include item 9 on alcohol-related injury., Results: We recruited 640 participants (68% female) reporting drinking in the previous 12 months. Median AUDIT-10 score was 10 in males and 9 in females, and 127 (20%) were classified as having at least high-level alcohol problems according to WHO classification.The FAST scored consistently high across statistical measures; it explained 85.6% of variance in AUDIT-10, correlation with AUDIT-10 was 0.92, and Cronbach's alpha was 0.66. A number of novel four-item AUDIT variations scored similarly high. Comparatively, the AUDIT-C scored substantially lower on all measures except internal consistency., Conclusions: Numerous abbreviated variations of the AUDIT may be a suitable alternative to the AUDIT-10 for classifying high-level alcohol problems in a community-based population of young Australians. Four-item AUDIT variations scored more consistently high across all evaluated statistics compared to three-item combinations. Novel AUDIT versions may be more effective than many established shortened versions as an alternative screening tool to the AUDIT-10 to measure hazardous or harmful alcohol consumption in this population.

Introduction: National guidelines recommend opportunistic chlamydia screening of sexually active 16- to 29-year-olds and encourage retesting 3-12 months after a diagnosed chlamydia (Chlamydia trachomatis) infection. We assessed chlamydia testing patterns at five Australian family planning clinics (FPCs)., Methods: Using routine clinic data from 16- to 29-year-olds, we calculated chlamydia testing and positivity rates in 2008-2009. Reattendance, retesting and positivity rates at retesting within 1.5-4 and 1.5-12 months of a positive result were calculated., Results: Over 2 years, 13?690 individuals aged 16-29 years attended five FPCs (93% female). In 2008, 3159 females (41.4%,) and 263 males (57.0%) were tested for chlamydia; positivity was 8% and 19%, respectively. In 2009, 3178 females (39.6%) and 295 males (57.2%) were tested; positivity was 8% and 23%, respectively. Of 7637 females attending in 2008, 38% also attended in 2009, of which 20% were tested both years. Within 1.5-4 months of a positive test, 83 (31.1%) females reattended; the retesting rate was 13% and 12% retested positive. Within 1.5-12 months of a positive test, 96 (57.5%) females reattended; the retesting rate was 36% and 13% retested positive., Conclusions: Approximately 40% of young people attending FPCs were tested for chlamydia but a smaller proportion were tested annually or were retested following chlamydia infection. High positivity rates emphasise that FPCs see a high-risk population. To maximise testing opportunities, clinical prompts, patient reminder systems and non-clinic testing strategies may be needed.

Background: Injecting drug use (IDU) is a growing concern in Tanzania compounded by reports of high-risk injecting and sexual risk behaviours among people who inject drugs (PWID). These behaviours have implications for transmission of blood-borne viruses, including HIV and hepatitis C (HCV)., Methods: We recruited 267 PWID (87% male) from Temeke District, Dar-es-Salaam through snowball and targeted sampling. A behavioural survey was administered alongside repeated rapid HIV and HCV antibody testing. HIV and HCV prevalence estimates with 95% confidence intervals (CIs) were calculated., Results: Among PWID, 34.8% (95%CI 29.1-40.9) tested HIV positive (29.9% of males and 66.7% of females); 27.7% (95%CI 22.0-34.0) tested HCV antibody positive. Almost all (97%) participants were aware of HIV and 34% of HCV. 45% of male and 64% of female PWID reported a previous HIV test; only five (2%) PWID reported a previous HCV test. Of HIV and HCV positive tests, 73% and 99%, respectively, represented newly diagnosed infections., Conclusion: High prevalence of HIV and HCV were detected in this population of PWID. Rapid scale-up of targeted primary prevention and testing and treatment services for PWID in Tanzania is needed to prevent further transmission and consequent morbidities., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Self-reported anthropometric data are commonly used to estimate prevalence of obesity in population and community-based studies. We aim to: 1) Determine whether survey participants are able and willing to self-report height and weight; 2) Assess the accuracy of self-reported compared to measured anthropometric data in a community-based sample of young people., Methods: Participants (16-29 years) of a behaviour survey, recruited at a Melbourne music festival (January 2011), were asked to self-report height and weight; researchers independently weighed and measured a sub-sample. Body Mass Index was calculated and overweight/obesity classified as ≥25 kg/m². Differences between measured and self-reported values were assessed using paired t-test/Wilcoxon signed ranks test. Accurate report of height and weight were defined as <2 cm and <2 kg difference between self-report and measured values, respectively. Agreement between classification of overweight/obesity by self-report and measured values was assessed using McNemar's test., Results: Of 1405 survey participants, 82% of males and 72% of females self-reported their height and weight. Among 67 participants who were also independently measured, self-reported height and weight were significantly less than measured height (p=0.01) and weight (p<0.01) among females, but no differences were detected among males. Overall, 52% accurately self-reported height, 30% under-reported, and 18% over-reported; 34% accurately self-reported weight, 52% under-reported and 13% over-reported. More females (70%) than males (35%) under-reported weight (p=0.01). Prevalence of overweight/obesity was 33% based on self-report data and 39% based on measured data (p=0.16)., Conclusions: Self-reported measurements may underestimate weight but accurately identified overweight/obesity in the majority of this sample of young people.

Introduction and Aims: Young people are at high risk of alcohol-related harm and injury. This study assessed awareness of the 2009 Australian Guidelines to Reduce Health Risks from Drinking Alcohol, understanding of alcohol-related risks and drinking behaviours among young people., Design and Methods: We recruited participants (16-29 years) from a music festival in Melbourne, Australia, January 2010. Participants self-completed a risk behaviour questionnaire which included questions regarding the 2009 guidelines. Characteristics associated with awareness of the guidelines and accurate understanding of a 'safe' number of drinks to avoid long-term harm and injury (defined as a maximum of two drinks daily and four drinks on a single occasion, respectively) were examined using multivariable logistic regression., Results: Of 1381 participants, only 32% were aware of the 2009 guidelines, but the majority had an accurate understanding of the safe number of drinks to avoid long-term harm (74%) and injury (71%). Nonetheless, many reported drinking behaviour with risk of long-term harm (22%) or injury (54%). Participants with lower-risk drinking behaviours were more likely to have an accurate understanding of the safe number of drinks to avoid harm. Males and participants without post-high school education were significantly less likely to be aware of the guidelines and/or have an accurate understanding of alcohol-related risks (P < 0.05)., Discussion and Conclusions: Although raising awareness of alcohol-related risks may promote reduced alcohol consumption, many young people reported consuming alcohol at harmful levels despite having an accurate understanding of alcohol-related risks. Multiple approaches to reducing alcohol-related harm in young people should be considered., (© 2011 Australasian Professional Society on Alcohol and other Drugs.)