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Introduction: Four counties within the Atlanta, Georgia 20‐county eligible metropolitan area (EMA) are currently prioritized by the US "Ending the HIV Epidemic" (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed‐methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative. Methods: We collected 2021 county‐level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web‐based tools (HIV testing and pre‐exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June−December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale‐up or implementation. Results: We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA—particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but <9% of its 177 testing sites and <7% of its 130 PrEP sites. Survey respondents (N = 48; 42% health agency managers/directors) reported high unmet need for HIV self‐testing kits, mobile clinic testing, HIV case management, peer outreach and navigation, integrated care, housing support and transportation services. Respondents highlighted insufficient existing staffing and infrastructure to facilitate the necessary expansion of services, and the need to reduce inequities and address intersectional stigma. Conclusions: Service delivery across all EHE pillars must substantially expand to reach national goals and address HIV disparities in metro Atlanta. High‐resolution geographic data on HIV epidemiology and service delivery with community input can provide targeted guidance to support local EHE efforts. [ABSTRACT FROM AUTHOR]

Introduction: We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation. Methods: A secondary analysis was conducted with a sub‐sample of participants recruited from a 2019 respondent‐driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio‐demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi‐square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation. Results: Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20–26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non‐injection drug use (38.3% vs. 20.2%) than non‐feminine presenting TGW (all p‐value <0.05). Conclusions: Findings suggest that TGW, particularly feminine presenting TGW, experience social and structural inequities which may contribute to HIV vulnerability. Interventions aimed at addressing inequities, including trans competency training for providers and gender‐affirming, psychosocial and legal support services for TGW, might mitigate risk. [ABSTRACT FROM AUTHOR]

Abstract Introduction Four counties within the Atlanta, Georgia 20‐county eligible metropolitan area (EMA) are currently prioritized by the US “Ending the HIV Epidemic” (EHE) initiative which aims for a 90% reduction in HIV incidence by 2030. Disparities driving Atlanta's HIV epidemic warrant an examination of local service availability, unmet needs and organizational capacity to reach EHE targets. We conducted a mixed‐methods evaluation of the Atlanta EMA to examine geographic HIV epidemiology and distribution of services, service needs and organization infrastructure for each pillar of the EHE initiative. Methods We collected 2021 county‐level data (during June 2022), from multiple sources including: AIDSVu (HIV prevalence and new diagnoses), the Centers for Disease Control and Prevention web‐based tools (HIV testing and pre‐exposure prophylaxis [PrEP] locations) and the Georgia Department of Public Health (HIV testing, PrEP screenings, viral suppression and partner service interviews). We additionally distributed an online survey to key local stakeholders working at major HIV care agencies across the EMA to assess the availability of services, unmet needs and organization infrastructure (June−December 2022). The Organizational Readiness for Implementing Change questionnaire assessed the organization climate for services in need of scale‐up or implementation. Results We found racial/ethnic and geographic disparities in HIV disease burden and service availability across the EMA—particularly for HIV testing and PrEP in the EMA's southern counties. Five counties not currently prioritized by EHE (Clayton, Douglas, Henry, Newton and Rockdale) accounted for 16% of the EMA's new diagnoses, but

Abstract Introduction We sought to characterize social and structural drivers of HIV vulnerability for transgender women (TGW) in Zimbabwe, where TGW are not legally recognized, and explore differences in vulnerability by feminine presentation. Methods A secondary analysis was conducted with a sub‐sample of participants recruited from a 2019 respondent‐driven sampling survey that comprised men who have sex with men, TGW and genderqueer individuals assigned male sex at birth, from two cities in Zimbabwe. Survey questionnaires captured information related to socio‐demographics, sexual and substance use behaviours, and social and structural barriers to HIV services. Secondary analyses were restricted to participants who identified as female, transfemale or transwomen (236/1538) and were unweighted. Descriptive statistics were used to calculate sample estimates and chi‐square and Fisher's exact tests were used to assess differences in vulnerability by feminine presentation. Results Among 236 TGW, almost half (45.3%) presented as feminine in the 6 months preceding the survey and 8.5% had ever used hormones to affirm their gender identities. Median age among TGW was 23 years (interquartile range: 20–26). Feminine presenting TGW in our sample had higher prevalence of arrest (15.9% vs. 3.9%), rejection by family/friends (38.3% vs. 14.0%), employment termination (11.2% vs. 3.9%), employment refusal (14.0% vs. 3.9%), denial of healthcare (16.8% vs. 2.3%), physical, sexual or verbal harassment or abuse (59.8% vs. 34.1%), alcohol dependence (32.7% vs. 12.4%), recent transactional sex with a male or TGW partner (30.8% vs. 13.3%) and recent non‐injection drug use (38.3% vs. 20.2%) than non‐feminine presenting TGW (all p‐value

Intimate partner violence (IPV) affects one in three women around the world and is the tenth leading cause of death for women in Africa aged 15 to 29 years. Partner alcohol use, access to social support, and poverty all affect women's likelihood of experiencing violence. We sought to understand how partner alcohol use differentially affected the hypothesized association between a protective role of instrumental social support (in the form of food or financial loans) against IPV for a clinic-based sample of women in the Kingdom of Eswatini (formerly known as Swaziland). We use cross-sectional data from a parent study of women recruited from urban and rural antenatal clinics in Eswatini (n = 393) to calculate the association between experiencing IPV and perception of one's ability access to large cash loans, small cash loans, and food loans-both for the full sample and stratified by partner alcohol use. In fully adjusted models, the perception that one could access loans of food or money was associated with decreased relative risk of IPV for all women. These associations were modified by partner alcohol use. Access to instrumental support (loans of food or money) is associated with decreased risk of IPV, but this association varies according to the type of loan and whether or not a woman's partner drinks alcohol. Economic empowerment interventions to reduce IPV must be carefully tailored to ensure they are appropriate for a woman's specific individual, relationship, and community context.

Abstract Background HIV expansion is controlled by a range of interrelated factors, including the natural history of HIV infection and socio-economical and structural factors. However, how they dynamically interact in particular contexts to drive a transition from concentrated HIV epidemics in vulnerable groups to generalized epidemics is poorly understood. We aim to explore these mechanisms, using Madagascar as a case-study. Methods We developed a compartmental dynamic model using available data from Madagascar, a country with a contrasting concentrated epidemic, to explore the interaction between these factors with special consideration of commercial and transactional sex as HIV-infection drivers. Results The model predicts sigmoidal-like prevalence curves with turning points within years 2020–2022, and prevalence reaching stabilization by 2033 within 9 to 24% in the studied (10 out of 11) cities, similar to high-prevalence regions in Southern Africa. The late/slow introduction of HIV and circumcision, a widespread traditional practice in Madagascar, could have slowed down HIV propagation, but, given the key interplay between risky behaviors associated to young women and acute infections prevalence, mediated by transactional sex, the protective effect of circumcision is currently insufficient to contain the expansion of the disease in Madagascar. Conclusions These results suggest that Madagascar may be experiencing a silent transition from a concentrated to a generalized HIV epidemic. This case-study model could help to understand how this HIV epidemic transition occurs. Graphical abstract

Background: HIV expansion is controlled by a range of interrelated factors, including the natural history of HIV infection and socio-economical and structural factors. However, how they dynamically interact in particular contexts to drive a transition from concentrated HIV epidemics in vulnerable groups to generalized epidemics is poorly understood. We aim to explore these mechanisms, using Madagascar as a case-study. Methods: We developed a compartmental dynamic model using available data from Madagascar, a country with a contrasting concentrated epidemic, to explore the interaction between these factors with special consideration of commercial and transactional sex as HIV-infection drivers. Results: The model predicts sigmoidal-like prevalence curves with turning points within years 2020–2022, and prevalence reaching stabilization by 2033 within 9 to 24% in the studied (10 out of 11) cities, similar to high-prevalence regions in Southern Africa. The late/slow introduction of HIV and circumcision, a widespread traditional practice in Madagascar, could have slowed down HIV propagation, but, given the key interplay between risky behaviors associated to young women and acute infections prevalence, mediated by transactional sex, the protective effect of circumcision is currently insufficient to contain the expansion of the disease in Madagascar. Conclusions: These results suggest that Madagascar may be experiencing a silent transition from a concentrated to a generalized HIV epidemic. This case-study model could help to understand how this HIV epidemic transition occurs. [ABSTRACT FROM AUTHOR]

Introduction: More than 70% of new HIV diagnoses in the United States were among men who have sex with men (MSM) in 2019. Pre‐exposure prophylaxis (PrEP) is a transformative innovation for reducing human immunodeficiency virus (HIV) infections. Structural stigma against sexual minorities, including in the form of state‐level policies, may affect PrEP implementation. We evaluated whether lower structural stigma reflected by earlier year of state same‐sex marriage legalization was associated with increased male PrEP prescriptions and male PrEP‐to‐need ratio (PnR), a ratio of PrEP prescriptions to new HIV diagnoses. Methods: We used 2012−2019 AIDSVu data on male PrEP prescriptions and male PnR in each US state and year. We used generalized estimating equations to evaluate the relationship between the timing of implementing state same‐sex marriage policies and the outcomes of male PrEP prescriptions per 100,000 people and the male PnR. We adjusted for calendar year, Medicaid expansion and the political party of the governor in each state. Results: State implementation of same‐sex marriage policies in earlier, relative to later, periods was associated with increases in the rate of male PrEP prescriptions and in the male PnR. Specifically, implementing state same‐sex marriage policies between 2004 and 2011 and between 2012 and 2013 were each associated with greater rates of male PrEP prescriptions relative to implementing same‐sex marriage policies between 2014 and 2015. Implementing state same‐sex marriage policies between 2004 and 2011 as well as between 2012 and 2013 were both significantly associated with a greater male PnR relative to implementing same‐sex marriage policies between 2014 and 2015. By 2019, the difference in male PrEP prescriptions was 137.9 (97.3−175.5) per 100,000 in states that implemented same‐sex marriage in 2004−2011 and 27.2 (23.3−30.5) per 100,000 in states that implemented same‐sex marriage from 2012 to 2013, relative to states that implemented same‐sex marriage in 2014−2015. Conclusions: Earlier implementation of state same‐sex marriage policies was associated with greater rates of male PrEP prescriptions. Reducing state‐level structural stigma may improve HIV prevention among MSM in the United States. [ABSTRACT FROM AUTHOR]

Abstract Introduction More than 70% of new HIV diagnoses in the United States were among men who have sex with men (MSM) in 2019. Pre‐exposure prophylaxis (PrEP) is a transformative innovation for reducing human immunodeficiency virus (HIV) infections. Structural stigma against sexual minorities, including in the form of state‐level policies, may affect PrEP implementation. We evaluated whether lower structural stigma reflected by earlier year of state same‐sex marriage legalization was associated with increased male PrEP prescriptions and male PrEP‐to‐need ratio (PnR), a ratio of PrEP prescriptions to new HIV diagnoses. Methods We used 2012−2019 AIDSVu data on male PrEP prescriptions and male PnR in each US state and year. We used generalized estimating equations to evaluate the relationship between the timing of implementing state same‐sex marriage policies and the outcomes of male PrEP prescriptions per 100,000 people and the male PnR. We adjusted for calendar year, Medicaid expansion and the political party of the governor in each state. Results State implementation of same‐sex marriage policies in earlier, relative to later, periods was associated with increases in the rate of male PrEP prescriptions and in the male PnR. Specifically, implementing state same‐sex marriage policies between 2004 and 2011 and between 2012 and 2013 were each associated with greater rates of male PrEP prescriptions relative to implementing same‐sex marriage policies between 2014 and 2015. Implementing state same‐sex marriage policies between 2004 and 2011 as well as between 2012 and 2013 were both significantly associated with a greater male PnR relative to implementing same‐sex marriage policies between 2014 and 2015. By 2019, the difference in male PrEP prescriptions was 137.9 (97.3−175.5) per 100,000 in states that implemented same‐sex marriage in 2004−2011 and 27.2 (23.3−30.5) per 100,000 in states that implemented same‐sex marriage from 2012 to 2013, relative to states that implemented same‐sex marriage in 2014−2015. Conclusions Earlier implementation of state same‐sex marriage policies was associated with greater rates of male PrEP prescriptions. Reducing state‐level structural stigma may improve HIV prevention among MSM in the United States.

Intimate partner violence (IPV) affects one in three women around the world and is the tenth leading cause of death for women in Africa aged 15 to 29 years. Partner alcohol use, access to social support, and poverty all affect women's likelihood of experiencing violence. We sought to understand how partner alcohol use differentially affected the hypothesized association between a protective role of instrumental social support (in the form of food or financial loans) against IPV for a clinic-based sample of women in the Kingdom of Eswatini (formerly known as Swaziland). We use cross-sectional data from a parent study of women recruited from urban and rural antenatal clinics in Eswatini (n = 393) to calculate the association between experiencing IPV and perception of one's ability access to large cash loans, small cash loans, and food loans-both for the full sample and stratified by partner alcohol use. In fully adjusted models, the perception that one could access loans of food or money was associated with decreased relative risk of IPV for all women. These associations were modified by partner alcohol use. Access to instrumental support (loans of food or money) is associated with decreased risk of IPV, but this association varies according to the type of loan and whether or not a woman's partner drinks alcohol. Economic empowerment interventions to reduce IPV must be carefully tailored to ensure they are appropriate for a woman's specific individual, relationship, and community context.

Introduction: Street‐connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention‐care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention‐care continuum from healthcare providers, policymakers, community members and SCY in Kenya. Methods: This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in‐depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men. Results: Our analysis resulted in four major themes corresponding to stages in the HIV prevention‐care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient‐centred and responsive to the diversity of their circumstances. The use of pre‐exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer‐based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer‐based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence. Conclusions: This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti‐poverty strategies as cash transfers and provision of food. Peer‐based interventions are a clear option but require SCY‐specific adaptation to be implemented effectively. [ABSTRACT FROM AUTHOR]

The mass incarceration of African Americans is both a driver of racial health inequalities in the USA. Systemic social biases which associate African American men with criminality, violence, and as a particular threat to white women may partially explain their over-representation in the criminal justice system. We combined data from the Washington, DC Metro Police Department (MPD) and the American Community Survey to test whether neighborhood-level gender, race, and economic makeup were associated with elevated drug-related arrest disproportions for African American men. We found that African American men were significantly overrepresented in all drug-related arrests across the District, and that this arrest disproportion was significantly higher in neighborhoods that had a higher percentage of white female residents. The association between race and gender was somewhat attenuated, but not completely eliminated, when we introduced socio-economic variables to our model. Addressing the social determinants of criminal justice disparities must account for the intersection of race, gender, and economics, rather than considering race in isolation.

Introduction : Intimate partner violence (IPV) affects 1 in 3 women and poses a major human rights threat and public health burden, yet there is great variation in risk globally. Whilst individual risk factors are well-studied, less research has focussed on the structural and contextual drivers of IPV and how these co-occur to create contexts of high risk. Methods : We compiled IPV drivers from freely-accessible global country-level data sources and combined gender inequality, natural disasters, conflict, colonialism, socioeconomic development and inequality, homicide and social discrimination in a latent class analysis, and identified underlying 'risk contexts' based on fit statistics and theoretical plausibility (N=5,732 country-years; 190 countries). We used multinomial regression to compare risk contexts according to: proportion of population with disability, HIV/AIDS, refugee status, and mental health disorders; proportion of men with drug use disorders; men's alcohol consumption; and population median age (N=1,654-5,725 country-years). Finally, we compared prevalence of physical and/or sexual IPV experienced by women in the past 12 months across risk contexts (N=3,175 country-years). Results : Three distinct risk contexts were identified: 1) non-patriarchal egalitarian, low rates of homicide; 2) patriarchal post-colonial, high rates of homicide; 3) patriarchal post-colonial conflict and disaster-affected. Compared to non-patriarchal egalitarian contexts, patriarchal post-colonial contexts had a younger age distribution and a higher prevalence of drug use disorders, but a lower prevalence of mental health disorders and a smaller refugee population. IPV risk was highest in the two patriarchal post-colonial contexts and associated with country income classification. Conclusions : Whilst our findings support the importance of gender norms in shaping women's risk of experiencing IPV, they also point towards an association with a history of colonialism. To effectively address IPV for women in high prevalence contexts, structural interventions and policies are needed that address not only gender norms, but also broader structural inequalities arising from colonialism. [ABSTRACT FROM AUTHOR]

Abstract Introduction Street‐connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention‐care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention‐care continuum from healthcare providers, policymakers, community members and SCY in Kenya. Methods This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in‐depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men. Results Our analysis resulted in four major themes corresponding to stages in the HIV prevention‐care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient‐centred and responsive to the diversity of their circumstances. The use of pre‐exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer‐based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer‐based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence. Conclusions This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti‐poverty strategies as cash transfers and provision of food. Peer‐based interventions are a clear option but require SCY‐specific adaptation to be implemented effectively.

Résumé Contexte Les injustices épistémiques sont de plus en plus décriées dans le domaine de la santé mondiale. Cette étude vise à déterminer si la source des connaissances influence la perception de ces connaissances et la volonté de les utiliser. Méthodes L’étude suit un devis expérimental randomisé dans lequel les participant·es ont été assigné·es au hasard à l'une des sept notes politiques conçues avec le même contenu scientifique, mais avec différentes organisations présentées comme autrices. Chaque organisation était représentative d'une autorité financière, scientifique ou morale. Pour chaque type d'autorité, deux organisations étaient proposées : l'une nord-américaine ou européenne, l'autre africaine. Résultats Les résultats montrent que le type d’autorité et la localisation des organisations autrices ne sont pas significativement associés à la qualité perçue et à l’utilisation instrumentale déclarée. Toutefois, des interactions entre le type d’autorité et la localisation étaient significatives. Ainsi, les analyses stratifiées ont mis en évidence que pour la qualité perçue, les notes de politique signées par l'organisme bailleur (autorité financière) africain obtenaient de meilleurs scores que les notes de politique signées par l’organisme bailleur nord-américain / européen. Tant pour la qualité perçue que pour l'utilisation instrumentale déclarée, ces analyses stratifiées ont révélé que les notes de politique signées par l'université africaine (autorité scientifique) étaient associées à des scores plus faibles que les notes de politique signées par l'université nord-américaine/européenne. Interprétation Les résultats confirment l'influence significative des sources sur la perception des connaissances en santé mondiale et rappellent l’intersectionnalité de l’influence des sources d’autorité. Cette analyse nous permet à la fois d'en apprendre davantage sur les organisations qui dominent la scène de la gouvernance mondiale en santé et de réfléchir aux implications pour les pratiques d'application des connaissances.

Introduction: The population of people living with HIV (PLWH) is ageing consequent to effective treatment and a steady stream of new diagnoses among older adults. PLWH experience a greater burden of age‐related comorbidities and poorer social determinants of health compared to their HIV‐negative peers, yet comprehensive requisites for care and support as PLWH age remain poorly understood. Preferences And Needs for Ageing Care among HIV‐positive Elderly people in Ontario, Canada (PANACHE ON), explored the health and community care and social support needs and preferences of a diverse group of older PLWH (age 60+) and described life course experiences among older PLWH that shape these needs and preferences and whether they are met. Methods: PANACHE ON was a qualitative community‐based participatory research study. In‐person focus groups using a semi‐structured interview guide were co‐facilitated by pairs of trained older PLWH from July to October 2019. Purposive sampling bolstered the inclusion of communities disproportionately affected by HIV in Ontario. Descriptive analysis was used to summarize demographic data; participatory data analysis was conducted by a subset of the research team, with transcripts double‐coded and analysed using NVIVO 12 Plus. Results: A total of 73 PLWH participated, 66% identified as men. The mean age was 64 years (range 55–77) and median time living with HIV was 23 years (range 2–37). The current and anticipated needs of older PLWH, many of which were only partially met, included necessities such as food and housing, mobility and sensory aids, in‐home support, social and emotional support, transportation and information. Three experiences—trauma, stigma and uncertainty—intersected in the lives of many of our participants, shaping their needs for care and support, and impacting the ease with which these needs were met. Conclusions: Unmet health and social needs and limited control over the availability and accessibility of ageing‐related care and support due to resource constraints or reduced capacity for self‐advocacy results in anxiety about the future among older PLWH, despite their well‐developed coping strategies and experience navigating systems of care. These study findings will inform the development of the first national needs assessment of older PLWH in Canada. [ABSTRACT FROM AUTHOR]

Introduction: There is strong global commitment to eliminate HIV‐related stigma, and work in this area continues to evolve. Wide variation exists in frameworks and measures used. Methods: Building on the existing knowledge syntheses, we carried out a systematic review to identify frameworks and measures aiming to understand or assess internalized stigma, stigma and discrimination in healthcare, and in law and policy. The review addressed two questions: Which conceptual frameworks have been proposed to assess internalized stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? Which measures of these different types of stigma and discrimination have been proposed and what are their descriptive properties? Searches, completed on 6 May 2021, cover publications from 2008 onwards. The review is registered in PROSPERO (CRD42021249348), the protocol incorporated stakeholder input, and the data are available in the Systematic Review Data Repository. Results and discussion: Sixty‐nine frameworks and 50 measures met the inclusion criteria. Critical appraisal figures and detailed evidence tables summarize these resources. We established a compendium of frameworks and a catalogue of measures of HIV‐related stigma and discrimination. Seventeen frameworks and 10 measures addressed at least two of our focus domains, with least attention to stigma and discrimination in law and policy. The lack of common definitions and variability in scope and structure of HIV‐related frameworks and measures creates challenges in understanding what is being addressed and measured, both in relation to stigma and efforts to mitigate or reduce its harmful effects. Having comparable data is essential for tracking change over time within and between interventions. Conclusions: This systematic review provides an evidence base of current understandings of HIV‐related stigma and discrimination and how further conceptual clarification and increased adaptation of existing tools might help overcome challenges across the HIV care continuum. With people living with HIV at the centre, experts from different stakeholder groups could usefully collaborate to guide a more streamlined approach for the field. This can help to achieve global targets and understand, measure and help mitigate the impact of different types of HIV‐related stigma on people's health and quality of life. [ABSTRACT FROM AUTHOR]

Background: Epistemic injustices are increasingly decried in global health. This study aims to investigate whether the source of knowledge influences the perception of that knowledge and the willingness to use it in francophone African health policy-making context.Methods: The study followed a randomized experimental design in which participants were randomly assigned to one of seven policy briefs that were designed with the same scientific content but with different organizations presented as authors. Each organization was representative of financial, scientific or moral authority. For each type of authority, two organizations were proposed: one North American or European, and the other African.Results: The initial models showed that there was no significant association between the type of authority or the location of the authoring organization and the two outcomes (perceived quality and reported instrumental use). Stratified analyses highlighted that policy briefs signed by the African donor organization (financial authority) were perceived to be of higher quality than policy briefs signed by the North American/European donor organization. For both perceived quality and reported instrumental use, these analyses found that policy briefs signed by the African university (scientific authority) were associated with lower scores than policy briefs signed by the North American/European university.Conclusions: The results confirm the significant influence of sources on perceived global health knowledge and the intersectionality of sources of influence. This analysis allows us to learn more about organizations in global health leadership, and to reflect on the implications for knowledge translation practices. [ABSTRACT FROM AUTHOR]

Introduction: Adolescents living with HIV (ALHIV, ages 10–19) have developmentally specific needs in care, and have lower retention compared to other age groups. Family‐level contexts may be critical to adolescent HIV outcomes, but have often been overlooked. We investigated family‐level factors underlying disengagement and supporting re‐engagement among adolescents disengaged from HIV care. Methods: Semi‐structured interviews were performed with 42 disengaged ALHIV, 32 of their caregivers and 28 healthcare workers (HCW) in the Academic Model Providing Access to Healthcare (AMPATH) program in western Kenya, from 2018 to 2020. Disengaged ALHIV had ≥1 visit within the 18 months prior to data collection at one of two sites and nonattendance ≥60 days following their last scheduled appointment. HCW were recruited from 10 clinics. Transcripts were analysed through thematic analysis. A conceptual model for family‐level domains influencing adolescent HIV care engagement was developed from these themes. Results: Family‐level factors emerged as central to disengagement. ALHIV‐particularly those orphaned by the loss of one or both parents‐experienced challenges when new caregivers or unstable living situations limited support for HIV care. These challenges were compounded by anticipated stigma; resultant non‐disclosure of HIV status to household members; enacted stigma in the household, with overwhelming effects on adolescents; or experiences of multiple forms of trauma, which undermined HIV care engagement. Some caregivers lacked finances or social support to facilitate care. Others did not feel equipped to support adolescent engagement or adherence. Regarding facilitators to re‐engagement, participants described roles for household disclosure; and solidarity from caregivers, especially those also living with HIV. Family‐level domains influencing HIV care engagement were conceptualized as follows: (1) adolescent living situation and contexts; (2) household material resources or poverty; (3) caregiver capacities and skills to support adolescent HIV care; and (4) HIV stigma or solidarity at the household level. Conclusions: Family‐level factors are integral to retention in care for ALHIV. The conceptual model developed in this study for family‐level influences on care engagement may inform holistic approaches to promote healthy outcomes for ALHIV. Developmentally appropriate interventions targeting household relationships, disclosure, HIV stigma reduction, HIV care skills and resources, and economic empowerment may promote adolescent engagement in HIV care. [ABSTRACT FROM AUTHOR]

Rape stigma, both external and self‐stigmatization (self‐blame), is associated with adverse health outcomes. Understanding its origins and resilience factors is critical for reducing and preventing it. We describe the prevalence of rape stigma, the characteristics of women experiencing it and the pathways to experiencing greater stigma. The Rape Impact Cohort Evaluation study enrolled 852 women aged 16–40 years who had been raped from post‐rape care centres in Durban, South Africa. We present a descriptive analysis of the baseline data, a multinomial logistic regression model of factors associated with different levels of stigma and a structural equation model (SEM). Most women reported stigmatizing thoughts or experiences, with self‐stigmatizing thoughts being more prevalent than external stigmatization. The multinomial model showed that experiences of childhood or other trauma, emotional intimate partner violence (IPV), having less gender equitable attitudes and food insecurity were significantly associated with medium or high versus low levels of stigma. Internal and external stigma were significantly associated with each other. Women who had been previously raped reported less stigma. The SEM showed a direct path between food insecurity and rape stigma, with poorer women experiencing more stigma. Indirect paths were mediated by more traditional gender attitudes and childhood trauma experience and other trauma exposure. Our findings confirm the intersectionality of rape stigma, with its structural drivers of food insecurity and gender inequality, as well as its strong association with prior trauma exposure. Rape survivors may benefit from gender‐empowering psychological support that addresses blame and shame. [ABSTRACT FROM AUTHOR]

Background: Labour migrants, who represent over sixty per cent of international migrants globally, frequently have poorer health status than the population of host countries. These health inequities are determined in a large part by structural drivers including political, commercial, economic, normative and social factors, including living and working conditions. Achieving health equity for migrant workers requires structural-level interventions to address these determinants. Methods: We undertook a systematic review of peer-reviewed literature designed to answer the question “what is the evidence for the effectiveness of interventions to address the structural determinants of health for labour migrants?” using the Ovid Medline electronic database. Findings: We found only two papers that evaluated structural interventions to improve the health of labour migrants. Both papers evaluated the impact of insurance – health or social. In contrast, we found 19 evaluations of more proximal, small-scale interventions focused on changing the knowledge, attitudes and behaviours of labour migrants. Interpretation: Despite the rise in international migration, including for work, and evidence that labour migrants have some higher health risks, there is a paucity of research addressing the structural determinants of health inequities in labour migrants. The research community (including funders and academic institutions) needs to pay greater attention to the structural determinants of health – which generally requires working across disciplines and sectors and thinking more politically about health and health inequities. Funding: Wellcome Trust (208712/Z/17/Z).

Introduction: Social protection programmes are considered HIV‐sensitive when addressing risk, vulnerability or impact of HIV infection. Socio‐economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV‐sensitivity of socio‐economic interventions for unemployed and out‐of‐school young women aged 15 to 30 years, in East and Southern Africa, a key population for HIV infection. Methods: We conducted a systematic review using a narrative synthesis method and the Mixed Methods Appraisal Tool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio‐economic outcomes (income, assets, savings, skills, (self‐) employment) and HIV‐related outcomes (behavioural and biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MEDLINE, Scopus, Web of Science and websites of relevant international organizations. Results: We screened 3870 titles and abstracts and 188 full‐text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV‐sensitive social protection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal (n = 2) or informal (n = 5) livelihood training. Eleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio‐economic and HIV‐related outcomes. Most livelihood training contributed positive socio‐economic outcomes, but only two projects showed improved HIV‐related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV‐sensitivity of socio‐economic programmes. Conclusions: A wide variety of livelihood and employability programmes were leveraged to achieve improved socio‐economic and HIV‐related outcomes among unemployed and out‐of‐school young women. To be HIV‐sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Employment support received little attention in this literature. [ABSTRACT FROM AUTHOR]

Abstract Introduction Social protection programmes are considered HIV‐sensitive when addressing risk, vulnerability or impact of HIV infection. Socio‐economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV‐sensitivity of socio‐economic interventions for unemployed and out‐of‐school young women aged 15 to 30 years, in East and Southern Africa, a key population for HIV infection. Methods We conducted a systematic review using a narrative synthesis method and the Mixed Methods Appraisal Tool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio‐economic outcomes (income, assets, savings, skills, (self‐) employment) and HIV‐related outcomes (behavioural and biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MEDLINE, Scopus, Web of Science and websites of relevant international organizations. Results We screened 3870 titles and abstracts and 188 full‐text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV‐sensitive social protection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal (n = 2) or informal (n = 5) livelihood training. Eleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio‐economic and HIV‐related outcomes. Most livelihood training contributed positive socio‐economic outcomes, but only two projects showed improved HIV‐related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV‐sensitivity of socio‐economic programmes. Conclusions A wide variety of livelihood and employability programmes were leveraged to achieve improved socio‐economic and HIV‐related outcomes among unemployed and out‐of‐school young women. To be HIV‐sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Employment support received little attention in this literature.

Abstract In this paper, we draw upon and build on three presentations which were part of the plenary session on ‘Structural Drivers of Health Inequities’ at the National Conference on Health Inequities in India: Transformative Research for Action, organised by the Achutha Menon Centre for Health Science Studies in Trivandrum, India. The three presentations discussed the influential role played by globalisation and neoliberalism in shaping economic, social and political relationships across developed and developing countries. The paper further argues that the twin process of globalisation and liberalisation have been important drivers of health inequities. The first segment of the paper attempts a broader conceptualisation of neoliberalism beyond the economic realm. Using Stephanie Lee Mudge’s conceptualisation (Soc Econ Rev 6:703–3, 2008) we have analysed how the political, bureaucratic and intellectual domains of neoliberalism have intersected and redefined the role of state and commercialised health services leading to inequities. Neoliberal ideas have reconfigured the role and changed the priorities of non-governmental organisations resulting in a fracture within this movement. n the second segment, we focus on the rise of American philanthro-capitalism, and how the two major foundations, the Rockefeller Foundation (early twentieth century) and the Bill and Melinda Gates Foundation (twenty-first century), have shaped the ideology of institutions engaged in international health and influenced the global health agenda. We discuss how the activities of philanthro-capitalists have transformed the architecture of health governance through their top-down organisational culture and deficit of structures to ensure accountability. The third and final segment of the paper focuses on how neoliberalism as a political project and cultural movement has forged alliances with conservative politics and religious fundamentalisms, resulting in negative consequences for women and other marginalised groups. These alliances have resulted in the control of women’s bodies and contributed to the reversal of hard-won rights for health and gender justice in many parts of the world.

Universal Health Coverage (UHC) can only be achieved if people receive good quality care from health workers, yet in Nigeria, as in many other low- and middle-income countries (LMICs), many health workers are absent from work. Absenteeism is a well-known phenomenon but is often considered as the self-serving behaviour of individuals, independent from the characteristics of health systems structures and processes and the broader contexts that enable it. We undertook a qualitative inquiry among 40 key informants, comprising health facility heads and workers, community leaders and state-level health policymakers in Nigeria. We employed a phenomenology approach to examine their lived experiences and grouped findings into thematic clusters. Absenteeism by health workers was found to be a response to structural problems at two levels -midstream (facility-level) and upstream (government level) - rather than being a result of moral failure of individuals. The problems at midstream level pointed to an inconsistent and unfair application of rules and regulations in facilities and ineffective management, while the upstream drivers relate mainly to political interference and suboptimal health system leadership. Reducing absenteeism requires two-pronged interventions that tackle defects in the upstream and midstream rather than just focusing on sanctioning deviant staff (downstream)., (© 2023 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background Deaths from HIV have fallen dramatically with the increasing availability of fully suppressive antiretroviral therapy (ART), and yet HIV remains the ninth leading cause of death in low-income countries. As more people with HIV enter care and receive ART, the focus will need to shift from expanding ART to including long-term program effectiveness and outcomes for people with HIV already engaged in care. Methods We evaluated risk factors for mortality among people with HIV on ART receiving longitudinal care in rural Haiti. We assessed baseline characteristics using a household survey and abstracted clinical characteristics from the electronic record. We used multivariable Cox regression models to identify risk factors for mortality. Results There were 464 people included in this study with a median follow-up (interquartile range [IQR]) of 69 (44–77) months, during which time 37 (8%) were lost to follow-up and 118 (25%) died (median time to death [IQR], 29 [12–53] months). After adjustment, poverty (adjusted hazard ratio [AHR], 1.12 per 10–percentage point increased probability; 95% CI, 1.01–1.24) and single marital status (AHR, 1.59; 95% CI, 1.08–2.36) were associated with increased mortality. Age (AHR, 0.78 per 10-year increase; 95% CI, 0.64–0.94), role function quality of life (AHR, 0.75 per quintile increase; 95% CI, 0.62–0.90), and CD4 count (AHR, 0.66 per 100 cells/μL; 95% CI, 0.58–0.75) were associated with decreased mortality. Conclusions Poverty, marital status, and quality of life were associated with mortality. Social protection should be evaluated as a strategy to reduce mortality for people with HIV in concert with increasing access to ART. [ABSTRACT FROM AUTHOR]

Objectives: Although the benefits of adopting test‐and‐treat antiretroviral therapy (ART) guidelines that recommend initiation of ART regardless of CD4 cell counts have been demonstrated at the individual level, there is uncertainty about how this translates to the population level. Here, we explored whether adopting ART guidelines recommending earlier treatment initiation improves population ART access and viral suppression and reduces overall disease transmission. Methods: Data on ART initiation guidelines and treatment coverage, viral suppression, and HIV incidence from 37 European and Central Asian countries were collected from the European Centre for Disease Prevention and Control and the Global HIV Policy Watch and HIV 90‐90‐90 Watch databases. We used multivariate linear regression models to quantify the association of ART initiation guidelines with population ART access, viral suppression, and HIV incidence, adjusting for potential confounding factors. Results: Test‐and‐treat policies were associated with 15.2 percentage points (pp) [95% confidence interval (CI) 0.8–29.6 pp; P = 0.039] greater treatment coverage (proportion of HIV‐positive people on ART) compared with countries with ART initiation at CD4 cell counts ≤ 350 cells/μL. The presence of test‐and‐treat policies was associated with 15.8 pp (95% CI 2.4–29.1 pp; P = 0.023) higher viral suppression rates (people on ART virally suppressed) compared with countries with treatment initiation at CD4 counts ≤ 350 cells/μL. ART initiation at CD4 counts ≤ 500 cells/μL did not significantly improve ART coverage compared to initiation at CD4 counts ≤ 350 cells/μL but achieved similar degrees of viral suppression as test‐and‐treat. Conclusions: Test‐and‐treat was found to be associated with substantial improvements in population‐level access to ART and viral suppression, further strengthening evidence that rapid initiation of treatment will help curb the spread of HIV. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Qualitative research emphasizes men's experiences of trauma increase HIV risk. We seek to understand associations between experience of traumatic events and HIV-risk behaviors among heterosexual men in 2 trials in urban informal settlements in South Africa. Methods: Cross-sectional surveys among men in Johannesburg and Durban, South Africa, enrolled in intervention trials. Adjusted logistic regression and structural equation modeling assessed associations between men's experiences of poverty and traumatic events, and HIV-risk behaviors (inconsistent condom use, transactional sex, and number of sex partners). We explored mediated pathways from trauma to HIV risk through mental health and alcohol, and gender attitudes. Results: Among 2394 men, in adjusted logistic regression, transactional sex and 4 or more sex partners were associated with witnessing the murder of a family member, witnessing a murder of a stranger, experiencing excessive pain, been kidnapped, and witnessing a rape. More consistent condom use was associated with witnessing the murder of a family member, being kidnapped, and witnessing a rape. In 3 separate structural equation modeling pathways were consistent, trauma directly increased transactional sex, and past year sexual partners, and increased consistent condom use. Risk was increased through mental health pathways, and gender inequitable attitudes and practices. Conclusion: Men's HIV-risk behaviors in this population emerge at the confluence of poverty, traumatic experiences, and gender inequalities. Effective HIV-prevention interventions needs to reduce men's experiences of poverty and trauma, transform gender norms, and reduce the mental health impact of trauma. [ABSTRACT FROM AUTHOR]

HIV criminalization describes the unjust application of criminal and similar laws to people living with HIV ostensibly based on their HIV status, either via HIV-specific criminal statutes or general criminal or other laws. As well as being a human rights issue of global concern, HIV criminalization is a barrier to universal access to HIV prevention, testing, treatment and care [2,3]. Ending unjust HIV criminalization: leave no-one behind. [Extracted from the article]

Abstract: Introduction: The universal test and treat strategy (UTT) was developed to maximize the proportion of all HIV‐positive individuals on antiretroviral treatment (ART) and virally suppressed, assuming that it will lead to a reduction in HIV incidence at the population level. The evolution over time of the cross‐sectional HIV care cascade is determined by individual longitudinal trajectories through the HIV care continuum and underlying population dynamics. The purpose of this paper is to quantify the contribution of each component of population change (in‐ and out‐migration, HIV seroconversion, ageing into the cohort and definitive exit such as death) on the HIV care cascade in the context of the ANRS 12249 Treatment as Prevention (TasP) cluster‐randomized trial, investigating UTT in rural KwaZulu‐Natal, South Africa, between 2012 and 2016. Methods: HIV test results and information on clinic visits, ART prescriptions, viral load and CD4 count, migration and deaths were used to calculate residency status, HIV status and HIV care status for each individual on a daily basis. Position within the HIV care continuum was considered as a score ranging from 0 (undiagnosed) to 4 (virally suppressed). We compared the cascade score of each individual joining or leaving the population of resident adults living with HIV with the average score of their cluster at the time of entry or exit. Then, we computed the contribution of each entry or exit on the average cascade score and their annualized total contribution, by component of change. Results: While the average cascade score increased over time in all clusters, that increase was constrained by population dynamics. Permanent exits and ageing into the people living with HIV cohort had a marginal effect. Both in‐migrants and out‐migrants were less likely to be retained at each step of the HIV care continuum. However, their overall impact on the cross‐sectional cascade was limited as the effect of in‐ and out‐migration balanced each other. The contribution of HIV seroconversions was negative in all clusters. Conclusions: In a context of high HIV incidence, the continuous flow of newly infected individuals slows down the efforts to increase ART coverage and population viral suppression, ultimately attenuating any population‐level impact on HIV incidence. Clinical Trial Number: NCT01509508 (clinicalTrials.gov)/DOH‐27‐0512‐3974 (South African National Clinical Trials Register). [ABSTRACT FROM AUTHOR]

The article provides information on the role of population mobility for achieving HIV infections treatment, transmission and prevention in African countries. Topics discussed include antiretroviral therapy for HIV infections, engagement in the medical care and viral suppression through various randomized controlled trials.

Migration and population mobility has long been regarded as an important structural driver of HIV. Following initial concerns regarding the spatial spread of the disease, mobile populations are viewed to engage in higher levels of risky sexual behaviours than non-mobile groups. However, beyond the case studies of mineworkers and truck drivers, the statistical evidence is inconclusive, suggesting that the relationship between mobility and risk is not well understood. This study investigated how engaging in specific livelihoods that involve mobility influences sexual behaviour and HIV risk. A qualitative research project, including focus groups and in-depth interviews with key mobile groups, was conducted in Northern Tanzania. The findings show that the patterns and conditions of moving related to the requirements of each different economic activity influence the nature of relationships that mobile groups have whilst away, how and where local sexual networks are accessed, and the practicalities of having sex. This has further implications for condom use. Risk behaviours are also shaped by local sexual norms related to transactional sex, emphasising that the roles of mobility and gender are interrelated, overlapping and difficult to disentangle. [ABSTRACT FROM PUBLISHER]

The growth of private rental housing in Australia is important across a range of policy areas, from the administration of housing assistance, to consumer protection, to macroeconomic policy. · This report provides a resource for considering policy settings and institutions relevant to the Australian private rental sector (PRS) by drawing on the international experience of 10 countries in Australasia, Europe and North America. · The report takes a 'system-embedded' approach to comparative housing analysis through interrogating the international experience of housing and impact of broader economic systems, financial settings, landlord and tenancy structures and regulation in the reference countries. · It is not the case that 'everyone in Europe rents'. Most of the European countries surveyed have higher rates of home ownership than Australia. In 9 of the 10 countries including Australia, the PRS is the second largest tenure after owner occupation. In seven countries, the PRS is growing. · Australia's PRS stands out in international comparisons for being less differentiated from the wider housing system in terms of its built form, household types and incomes. This suggests a high degree of integration between the Australian PRS and owner-occupier sectors, which is significant for policymaking. · Finance policy and market settings have undergone remarkable change before and after the global financial crisis (GFC). Particularly in countries that experienced a housing crash, finance settings have driven rapid change in PRS institutions, often without guidance from conventional housing policy objectives. [ABSTRACT FROM AUTHOR]

Many women’s decisions about whether and how to participate in sex work are driven by financial considerations. Despite the recognized importance of economic factors in HIV risk among female sex workers (FSWs), many HIV prevention programs focus narrowly on sexual risk behaviors. We collected data on the financial practices of FSWs in Abidjan, Côte d’Ivoire, to better inform economic strengthening programs for HIV risk reduction with this population. We conducted “walk-along” participant observations (N = 74) during FSWs’ daily non-working routines and analyzed resultant notes using qualitative thematic analysis. We used a financial diary methodology to collect detailed quantitative data on income, spending, savings and lending from a sub-sample of participants (n = 33) over six weeks; these data were analyzed using descriptive statistics. All women in our sample reported sex work as their primary source of earned income. Median weekly income was roughly US $114, with a wide range across the sample and from week to week. Cash expenses related primarily to routine needs (e.g., food, housing, transportation) and accounted, on average, for approximately 90% of weekly spending. Around one-quarter of weekly expenses were directly associated with sex work (e.g., clothing, beauty products, and alcohol). FSWs held “savings” in boxes, mobile money platforms, informal savings groups, or banks, though most withdrew cash from these funds frequently. These findings suggest that this group of FSWs in Abidjan, Côte d’Ivoire, are not cash-poor: median weekly income is greater than the estimated Ivoirian weekly per capita gross national income. Yet the erratic nature of income alongside routine spending needs suggests that effective economic strengthening programs in this context should include financial management education, group-based savings and lending, and links to formal financial institutions. These economic strengthening activities hold promise to empower FSWs financially for downstream HIV-risk reduction benefits by building economic resilience to reduce financially-driven sexual risk decisions. [ABSTRACT FROM AUTHOR]

Introduction: Transgender women are disproportionately impacted by HIV. Transgender women involved in sex work may experience exacerbated violence, social exclusion, and HIV vulnerabilities, in comparison with non-sex work-involved transgender women. Scant research has investigated sex work among transgender women in the Caribbean, including Jamaica, where transgender women report pervasive violence. The study objective was to examine factors associated with sex work involvement among transgender women in Jamaica. Methods: In 2015, we implemented a cross-sectional survey using modified peer-driven recruitment with transgender women in Kingston and Ocho Rios, Jamaica, in collaboration with a local community-based AIDS service organization. We conducted multivariable logistic regression analyses to identify factors associated with paid sex and transactional sex. Exchanging oral, anal or vaginal sex for money only was categorized as paid sex. Exchanging sex for survival needs (food, accommodation, transportation), drugs or alcohol, or for money along with survival needs and/or drugs/alcohol, was categorized as transactional sex. Results: Among 137 transgender women (mean age: 24.0 [SD: 4.5]), two-thirds reported living in the Kingston area. Overall, 25.2% reported being HIV-positive. Approximately half (n = 71; 51.82%) reported any sex work involvement, this included sex in exchange for: money (n = 64; 47.06%); survival needs (n = 27; 19.85%); and drugs/alcohol (n = 6; 4.41%). In multivariable analyses, paid sex and transactional sex were both associated with: intrapersonal (depression), interpersonal (lower social support, forced sex, childhood sexual abuse, intimate partner violence, multiple partners/polyamory), and structural (transgender stigma, unemployment) factors. Participants reporting transactional sex also reported increased odds of incarceration perceived to be due to transgender identity, forced sex, homelessness, and lower resilience, in comparison with participants reporting no sex work involvement. Conclusions: Findings reveal high HIV infection rates among transgender women in Jamaica. Sex work-involved participants experience social and structural drivers of HIV, including violence, stigma, and unemployment. Transgender women involved in transactional sex also experience high rates of incarceration, forced sex and homelessness in comparison with non-sex workers. Taken together, these findings suggest that social ecological factors elevate HIV exposure among sex work-involved transgender women in Jamaica. Findings can inform interventions to advance human rights and HIV prevention and care cascades with transgender women in Jamaica. [ABSTRACT FROM AUTHOR]

In sub-Saharan Africa, young women ages 15–24 have more than twice the risk of acquiring HIV as their male counterparts. A growing body of epidemiological evidence suggests that the practice of “transactional sex” may contribute to this disparity. Over the last 15 years, the social sciences have contributed significantly to understanding the meaning of and motivations for this practice. The findings from these studies are rich, but varied, rendering lessons difficult to navigate for intervention and further research. We therefore contribute a historically-grounded, comprehensive literature review on the nature and motivations for women's participation in transactional sex in sub-Saharan Africa. Drawing from over 300 studies (through 2014), we distill three prominent paradigms observed in the literature that we review toward presenting a unified conceptualization of the practice. “Sex for basic needs,” the first paradigm, positions women as victims in transactional sexual relationships, with implications for interventions that protect girls from exploitation. In contrast, the “sex for improved social status” paradigm positions women as sexual agents who engage in transactional sex toward attaining a middle-class status and lifestyle. Finally, a third paradigm, “sex and material expressions of love,” draws attention to the connections between love and money, and the central role of men as providers in relationships. We find important commonalities in the structural factors that shape the three paradigms of transactional sex including gender inequality and processes of economic change. We suggest that there are three continua stretching across these paradigms: deprivation, agency, and instrumentality. This review proposes a definition of transactional sex and discusses implications for research and interventions aiming to reduce young women's risk of HIV through such relationships. We consider the consequences of drawing from too narrow an understanding of the practice, and highlight the benefits of a broader conceptualization. [ABSTRACT FROM AUTHOR]

We investigate biogeographical, regional and sub-regional-scale responses of scarabaeine dung beetles to late Cenozoic changes in edaphic and climatic character that created a Savanna/Karoo transition zone in the Northern Cape, South Africa. Across a 50 200 km2 study area, the Northern Cape species pool comprised six biogeographical groups defined from distribution across southern Africa. These species groups contributed in different proportions to five regional assemblages defined from structural differences across the transition zone. Towards transition zone peripheries, regional assemblage structure was more strongly correlated to sandiness dating from Miocene to Pliocene deposition (Kalahari), aridity dating from Pliocene to Pleistocene climatic change (Bushmanland Karoo), or cooler temperatures dating from Miocene to Pliocene uplift (Upper Karoo). Correlates of sub-regional assemblages trended to intensification of dominant drivers towards regional peripheries. Drivers of central transition zone, regional assemblages ('Gariep Karoo', 'Gariep Stony Karoo') showed no dominance. Biogeographically, endemism dominates the Northern Cape transition zone: south-west arid groups in Nama Karoo regions; Kalahari plus north-east savanna groups in the Kalahari. Regionally, transition drives assemblage structure: unique variance, 60% in the Kalahari, 21-30% in four Nama Karoo regions; shared variance (overlap), 25-65% between Kalahari and warmer Karoo regions, 11-71% between mainly cooler Karoo regions. [ABSTRACT FROM AUTHOR]

Introduction: Young adolescent women in sub-Saharan Africa are three to four times more likely to be HIV-positive than boys or men. One of the relationship dynamics that is likely to be associated with young women’s increased vulnerability to HIV is transactional sex. There are a range of HIV-related risk behaviours that may drive this vulnerability. However, to date, limited epidemiological data exist on the role of transactional sex in increasing HIV acquisition, especially among young women in sub- Saharan Africa. Our paper presents data on the prevalence of self-reported engagement in transactional sex and explores whether transactional sex is associated with increased risk of HIV infection among a cohort of young, rural, sexually active South African women. We also explore whether this relationship is mediated through certain HIV-related risk behaviours. Methods: We analyzed baseline data from a phase III trial of conditional cash transfers for HIV prevention of 693 sexually active, school-going young women aged 13–20 years in rural South Africa. We examined the association between young women’s engagement in transactional sex and HIV infection. Transactional sex is defined as a non-commercial, non-marital sexual relationship whereby sex is exchanged for money and/or gifts.We explored whether this relationship is mediated by certain HIV-related risk behaviours.We used logistic and multinomial regression and report unadjusted and adjusted odds ratios with 95% CI. Results: Overall, 14% (n=97) of sexually active young women reported engaging in transactional sex. Engagement in transactional sex was associated with an increased risk of being HIV-positive (aOR: 2.5, CI: 95% 1.19–5.25, p=0.01). The effect size of this association remained nearly unchanged when adjusted for certain other dimensions of HIV risk that might help explain the underlying pathways for this relationship. Conclusions: This study provides quantitative support demonstrating that transactional sex is associated with HIV infection in young women. Even though the specific variables tested do not mediate the relationship, a potential explanation for this association may be that the men with whom young women are having sex belong to networks of sexually connected individuals who are at a ‘‘high risk’’ for HIV infection. The results highlight the importance of structural intervention approaches that can alter the context of young women’s HIV risk. [ABSTRACT FROM AUTHOR]

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This paper presents the first empirical results of a long-term project exploring the use of hope as a concept summarising people's experience of the social, economic and cultural world they inhabit. The work has its roots in attempts to understand socio-economic aspects of HIV/AIDS epidemiology through recourse to the term ‘structural drivers’. In this paper, we recognise the distinguished contribution made by that body of work but adopt a different theoretical approach, one based on the idea of emergent social properties. This is an idea derived from the Durkheim's notion of a ‘social current’. One such emergent property is hope and its potential use and applicability as an epidemiological variable is described. The variable is measured using the Snyder scale developed by the late Rick Snyder for quite other purposes in the USA. We use data from the long-standing UK MRC/UVRI General Cohort Study in Uganda together with a smaller study of some fishing communities. The results show that the Snyder scale (1) does measure a real variable, (2) does mean something to Ugandan rural populations and (3) can be used to explore some known risk factors for HIV acquisition. [ABSTRACT FROM PUBLISHER]

Introduction: Female sex workers (FSWs) frequently experience violence, harassment and arrest by the police or their clients, but there is little evidence as to the impact that such factors may have on HIV risk or whether community interventions could mitigate this impact. Methods: As part of the evaluation of the Avahan programme in Karnataka, serial integrated behavioural and biological assessment (IBBA) surveys (four districts) (2005 to 2011) and anonymous polling booth surveys (PBS) (16 districts) (2007 to 2011) were conducted with random samples of FSWs. Logistic regression analysis was used to assess 1) changes in reported violence and arrests over time and 2) associations between violence by non‐partners and police arrest and HIV/STI risk and prevalence. Mediation analysis was used to identify mediating factors. Results: 5,792 FSWs participated in the IBBAs and 15,813 participated in the PBS. Over time, there were significant reductions in the percentages of FSWs reporting being raped in the past year (PBS) (30.0% in 2007, 10.0% in 2011, p <0.001), being arrested in the past year [adjusted odds ratio (AOR) 0.57 (0.35, 0.93), p=0.025] and being beaten in the past six months by a non‐partner (clients, police, pimps, strangers, rowdies) [AOR 0.69 (0.49, 0.95), p=0.024)] (IBBA). The proportion drinking alcohol (during the past week) also fell significantly (32.5% in 2005, 24.9% in 2008, 16.8% in 2011; p<0.001). Violence by non‐partners (being raped in the past year and/or beaten in the past six months) and being arrested in the past year were both strongly associated with HIV infection [AOR 1.59 (1.18, 2.15), p=0.002; AOR 1.91 (1.17, 3.12), p=0.01, respectively]. They were also associated with drinking alcohol (during the past week) [AOR 1.98 (1.54, 2.53), p<0.001; AOR 2.79 (1.93, 4.04), p<0.001, respectively], reduced condom self‐efficacy with clients [AOR 0.36 (0.27, 0.47), p<0.001; AOR 0.62 (0.39, 0.98), p=0.039, respectively], symptomatic STI (during the past year) [AOR 2.62 (2.07, 3.30), p<0.001; AOR 2.17 (1.51, 3.13), p<0.001, respectively], gonorrhoea infection [AOR 2.79 (1.51, 5.15), p=0.001; AOR 2.69 (0.96, 7.56), p=0.060, respectively] and syphilis infection [AOR 1.86 (1.04, 3.31), p=0.036; AOR 3.35 (1.78, 6.28), p<0.001, respectively], but not with exposure to peer education, community mobilization or HIV testing uptake. Mediation analysis suggests that alcohol use and STIs may partially mediate the association between violence or arrests and HIV prevalence. Discussion: Violence by non‐partners and arrest are both strongly associated with HIV infection among FSWs. Large‐scale, comprehensive HIV prevention programming can reduce violence, arrests and HIV/STI infection among FSWs. [ABSTRACT FROM AUTHOR]

Background: Young people particularly women are at increased risk of undesirable sexual and reproductive health (SRH) outcomes. Structural factors have been reported as driving some of these risks. Although several interventions have targeted some of the structural drivers for adolescent's SRH risk, little has been done to consolidate such work. This would provide a platform for coordinated efforts towards adolescent's SRH. We provide a narrative summary of interventions in sub-Saharan Africa (sSA) addressing the structural drivers of adolescents' SRH risk, explore pathways of influence, and highlight areas for further work. Methods: 33 abstracts and summary reports were retrieved and perused for suitability. Fifteen documents met the inclusion criteria and were read in full. Papers and reports were manually reviewed and 15 interventions that met the criteria for inclusion were summarised in a table format. Results: Most of the interventions addressed multiple structural factors, such as social norms, gender inequality, and poverty. Some interventions focused on reducing economic drivers that increased sexual risk behaviours. Others focused on changing social norms and thus sexual risk behaviours through communication. Social norms addressed included gender inequality, gender violence, and child socialisation. The interventions included components on comprehensive sexuality and behaviour change and communication and parenting, using different designs and evaluation methods. Important lessons from the narrative summary included the need for a flexible intervention design when addressing adolescents, the need for coordinated effort among different stakeholders. Conclusion: There are encouraging efforts towards addressing structural drivers among adolescents in (sSA). There is, however, a need for interventions to have a clear focus, indicate the pathways of influence, and have a rigorous evaluation strategy assessing how they work to reduce vulnerability to HIV. There is also a need for coordinated effort among stakeholders working on adolescent vulnerability in sSA. [ABSTRACT FROM AUTHOR]

Introduction: Although biomedical HIV prevention efforts have seen a number of recent promising developments, behavioural interventions have often been described as failing. However, clear lessons have been identified from past efforts, including the need to address influential social, economic and legal structures; to tailor efforts to local contexts; and to address multiple influencing factors in combination. Despite these insights, there remains a pervasive strategy to try to achieve sexual behaviour change through single, decontextualized, interventions or sets of activities. With current calls for structural approaches to HIV as part of combination HIV prevention, though, there is a unique opportunity to define a structural approach to HIV prevention as one which moves beyond these past limitations and better incorporates our knowledge of the social world and the lessons from past efforts. Discussion: A range of interlinked concepts require delineation and definition within the broad concept of a structural approach to HIV. This includes distinguishing between ‘‘structural factors,’’ which can be seen as any number of elements (other than knowledge) which influence risk and vulnerability, and ‘‘structural drivers,’’ which should be reserved for situations where an empirically established relationship to a target group is known. Operationalizing structural approaches similarly can take different paths, either working to alter structural drivers or alternatively working to build individual and community resilience to infection. A ‘‘structural diagnostic approach’’ is further defined as the process one undertakes to develop structural intervention strategies tailored to target groups. Conclusions: For three decades, the HIV prevention community has struggled to reduce the spread of HIV through sexual risk behaviours with limited success, but equally with limited engagement with the lessons that have been learned about the social realities shaping patterns of sexual practices. Future HIV prevention efforts must address the multiple factors influencing risk and vulnerability, and they must do so in ways tailored to particular settings. Clarity on the concepts, terminology and approaches that can allow structural HIV prevention efforts to achieve this is therefore essential to improve the (social) science of HIV prevention. [ABSTRACT FROM AUTHOR]