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Objectives: Globally, cisgender men who have sex with men experience sexual stigma, but limited investigation of cross-population scale performance hinder comparisons. As measurement invariance is a necessary but seldom-established criterion of valid cross-cultural comparisons, we assessed invariance in scales of stigma related to sexual behavior across 9 countries., Methods: This secondary analysis used data collected from adult (mean age=29.6, standard deviation=12.5) cisgender men who have sex with men (n=8,669) in studies from 6 West African, 2 Southern African, and 1 North American country from 2012-2016. A common item set assessed 2 sexual behavior stigma domains. A sequential process was used to test the factor structure and measurement invariance, which included multigroup confirmatory factor analyses (CFA). Individual countries, items, living with HIV, and disclosure were explored as possible sources of noninvariance., Results: Goodness-of-fit statistics indicated adequate fit of the same 2-factor model in 7 of the 9 countries. The chi 2 difference test comparing a constrained and unconstrained 7-country model in which loadings and thresholds were freely estimated was significant ( p <0.001), indicating metric and scalar noninvariance, but removing the US provided evidence of invariance and freeing certain items led to a finding of partial invariance. Sexuality disclosure exhibited a direct relationship with select stigma items in several countries., Conclusions: Our findings point to the utility of the two stigma scale dimensions in making cross-country comparisons, but also to the necessity of assessing invariance with explicit attention to several factors including differential disclosure of sexuality across contexts to ensure valid comparisons.

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: 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.)

Gender-based violence (GBV) is that perpetrated based on sex, gender identity, or perceived adherence to socially defined gender norms. This human rights violation is disproportionately experienced by HIV key populations including female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM). Consequently, addressing GBV is a global priority in HIV response. There is limited consensus about optimal interventions and little known about effectiveness. Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in International Prospective Register of Systematic Reviews. Peer-reviewed and non-peer-reviewed literature were searched for articles that described a GBV prevention or response intervention specifically for key populations including FSW, PWID, and MSM. Results were organized by level(s) of implementation and pillars of a comprehensive GBV response: prevention, survivor support, and accountability/justice. Of 4,287 articles following removal of duplicates, 32 unique interventions (21 FSW, seven PWID, and nine MSM, not mutually exclusive) met inclusion criteria, representing 13 countries. Multisectoral interventions blended empowerment, advocacy, and crisis response with reductions in violence. Individual-level interventions included violence screening and response services. Violence-related safety promotion and risk reduction counseling within HIV risk reduction programming reduced violence. Quantitative evaluations were limited. Violence prevention and response interventions for FSW, PWID, and MSM span individual, community, and multisectoral levels with evidence of promising practices at each level. The strongest evidence supported addressing violence in the context of sexually transmitted infection/HIV risk reduction. As interventions continue to emerge, the rigor of accompanying evaluations must simultaneously advance to enable clarity on the health and safety impact of GBV prevention and response programming.

Background: For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma., Methods: We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senegal, Côte d'Ivoire, Lesotho, and eSwatini to assess associations between disclosure and sexual behavior stigma in healthcare contexts; we used logistic regressions to analyze country-specific data., Results: Compared to participants who had not disclosed to either family or HCWs, those who had disclosed only to family were more likely to have been gossiped about by HCWs (aOR = 1.70, CI = 1.18, 2.45); the association between having disclosed to family and having felt mistreated in a health center approached, but did not achieve, statistical significance (aOR = 1.56, CI = 0.94, 2.59). Those who had disclosed only to HCWs were more likely to have feared to seek health services (aOR = 1.60, CI = 1.14, 2.25), avoided health services (aOR = 1.74, CI = 1.22, 2.50), and felt mistreated in a health center (aOR = 2.62, CI = 1.43, 4.81). Those who had disclosed to both were more likely to have feared to seek health services (aOR = 1.71, CI = 1.16, 2.52), avoided health services (aOR = 1.59, CI = 1.04, 2.42), been gossiped about by HCWs (aOR = 3.78, CI = 2.38, 5.99), and felt mistreated in a health center (aOR = 3.39, CI = 1.86, 6.20). Country-specific analyses suggested that data from Cameroon drove several of these associations., Conclusions: Research to determine the factors driving disclosure's differential effect on healthcare stigma across contexts is needed. Ultimately, supportive environments enabling safe disclosure is critical to understanding HIV-acquisition risks and informing differentiated HIV-prevention, treatment, and testing services for MSM across SSA., (© 2021. The Author(s).)

Background: The COVID-19 pandemic indirectly impacts HIV epidemiology in Central/West Africa. We estimated the potential impact of COVID-19-related disruptions to HIV prevention/treatment services and sexual partnerships on HIV incidence and HIV-related deaths among key populations including female sex workers (FSW), their clients, men who have sex with men, and overall., Setting: Yaoundé (Cameroon) and Cotonou (Benin)., Methods: We used mathematical models of HIV calibrated to city population-specific and risk population-specific demographic/behavioral/epidemic data. We estimated the relative change in 1-year HIV incidence and HIV-related deaths for various disruption scenarios of HIV prevention/treatment services and decreased casual/commercial partnerships, compared with a scenario without COVID-19., Results: A 50% reduction in condom use in all partnerships over 6 months would increase 1-year HIV incidence by 39%, 42%, 31%, and 23% among men who have sex with men, FSW, clients, and overall in Yaoundé, respectively, and 69%, 49%, and 23% among FSW, clients, and overall, respectively, in Cotonou. Combining a 6-month interruption of ART initiation and 50% reduction in HIV prevention/treatment use would increase HIV incidence by 50% and HIV-related deaths by 20%. This increase in HIV infections would be halved by a simultaneous 50% reduction in casual and commercial partnerships., Conclusions: Reductions in condom use after COVID-19 would increase infections among key populations disproportionately, particularly FSW in Cotonou, who need uninterrupted condom provision. Disruptions in HIV prevention/treatment services have the biggest impacts on HIV infections and deaths overall, only partially mitigated by equal reductions in casual/commercial sexual partnerships. Maintaining ART provision must be prioritized to minimize short-term excess HIV-related deaths., Competing Interests: K.M.M. has received an honorarium from Gilead for speaking, outside the submitted work. The remaining authors have conflicts of interest to disclose., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

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.)

Overcoming stigma affecting gay, bisexual, and other men who have sex with men (MSM) is a foundational element of an effective response to the human immunodeficiency virus (HIV) pandemic. Quantifying the impact of stigma mitigation interventions necessitates improved measurement of stigma for MSM around the world. In this study, we explored the underlying factor structure and psychometric properties of 13 sexual behavior stigma items among 10,396 MSM across 8 sub-Saharan African countries and the United States using cross-sectional data collected between 2012 and 2016. Exploratory factor analyses were used to examine the number and composition of underlying stigma factors. A 3-factor model was found to be an adequate fit in all countries (root mean square error of approximation = 0.02-0.05; comparative fit index/Tucker-Lewis index = 0.97-1.00/0.94-1.00; standardized root mean square residual = 0.04-0.08), consisting of "stigma from family and friends," "anticipated health-care stigma," and "general social stigma," with internal consistency estimates across countries of α = 0.36-0.80, α = 0.72-0.93, and α = 0.51-0.79, respectively. The 3-factor model of sexual behavior stigma cut across social contexts among MSM in the 9 countries. These findings indicate commonalities in sexual behavior stigma affecting MSM across sub-Saharan Africa and the United States, which can facilitate efforts to track progress on global stigma mitigation interventions., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2020.)

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: Key populations bear a disproportionate HIV burden and have substantial unmet treatment needs. Routine viral load monitoring represents the gold standard for assessing treatment response at the individual and programme levels; at the population-level, community viral load is a metric of HIV programme effectiveness and can identify "hotspots" of HIV transmission. Nevertheless, there are specific implementation and ethical challenges to effectively operationalize and meaningfully interpret viral load data at the community level among these often marginalized populations., Discussion: Viral load monitoring enhances HIV treatment, and programme evaluation, and offers a better understanding of HIV surveillance and epidemic trends. Programmatically, viral load monitoring can provide data related to HIV service delivery coverage and quality, as well as inequities in treatment access and uptake. From a population perspective, community viral load data provides information on HIV transmission risk. Furthermore, viral load data can be used as an advocacy tool to demonstrate differences in service delivery and to promote allocation of resources to disproportionately affected key populations and communities with suboptimal health outcomes. However, in order to perform viral load monitoring for individual and programme benefit, health surveillance and advocacy purposes, careful consideration must be given to how such key population programmes are designed and implemented. For example, HIV risk factors, such as particular sex practices, sex work and drug use, are stigmatized or even criminalized in many contexts. Consequently, efforts must be taken so that routine viral load monitoring among marginalized populations does not cause inadvertent harm. Furthermore, given the challenges of reaching representative samples of key populations, significant attention to meaningful recruitment, decentralization of care and interpretation of results is needed. Finally, improving the interoperability of health systems through judicious use of biometrics or identifiers when confidentiality can be maintained is important to generate more valuable data to inform monitoring programmes., Conclusions: Opportunities for expanded viral load monitoring could and should benefit all those affected by HIV, including key populations. The promise of the increasing routinization of viral load monitoring as a tool to advance HIV treatment equity is great and should be prioritized and appropriately implemented within key population programmatic and research agendas., (© 2017 The Authors. Journal of the International AIDS Society published by John Wiley & sons Ltd on behalf of the International AIDS Society.)

Background/objectives: Female sex workers (FSWs) are at risk for HIV and physical and sexual gender-based violence (GBV). We describe the prevalence of lifetime GBV and its associations with HIV risk behaviour, access to health services and barriers in accessing justice among FSWs in Cameroon., Methods: FSWs (n=1817) were recruited for a cross-sectional study through snowball sampling in seven cities in Cameroon. We examined associations of lifetime GBV with key outcomes via adjusted logistic regression models., Results: Overall, 60% (1098/1817) had experienced physical or sexual violence in their lifetime. GBV was associated with inconsistent condom use with clients (adjusted OR (AOR) 1.49, 95% CI 1.18 to 1.87), being offered more money for condomless sex (AOR 2.09, 95% CI 1.56 to 2.79), having had a condom slip or break (AOR 1.53, 95% CI 1.25 to 1.87) and difficulty suggesting condoms with non-paying partners (AOR 1.47, 95% CI 1.16 to 1.87). Violence was also associated with fear of health services (AOR 2.25, 95% CI 1.61 to 3.16) and mistreatment in a health centre (AOR 1.66, 95% CI 1.01 to 2.73). Access to justice was constrained for FSWs with a GBV history, specifically feeling that police did not protect them (AOR 1.41, 95% CI 1.12 to 1.78)., Discussion: Among FSWs in Cameroon, violence is prevalent and undermines HIV prevention and access to healthcare and justice. Violence is highly relevant to FSWs' ability to successfully negotiate condom use and engage in healthcare. In this setting of criminalised sex work, an integrated, multisectoral GBV-HIV strategy that attends to structural risk is needed to enhance safety, HIV prevention and access to care and justice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)