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Baltimore Highlands, MD, United States

Similar to other Southern African countries, Swaziland has been severely affected by HIV, with over a quarter of its reproductive-age adults estimated to be living with the virus, equating to an estimate of 170,000 people living with HIV. The last several years have witnessed an increase in the understanding of the potential vulnerabilities among men who have sex with men (MSM) in neighbouring countries with similarly widespread HIV epidemics. To date, there are no data characterizing the burden of HIV and the HIV prevention, treatment and care needs of MSM in Swaziland. In 2011, 324 men who reported sex with another man in the last 12 months were accrued using respondent-driven sampling (RDS). Participants completed HIV testing using Swazi national guidelines as well as structured survey instruments administered by trained staff, including modules on demographics, individual-level behavioural and biological risk factors, social and structural characteristics and uptake of HIV services. Population and individual weights were computed separately for each variable with a data-smoothing algorithm. The weights were used to estimate RDS-adjusted univariate estimates with 95% bootstrapped confidence intervals (BCIs). Crude and RDS-adjusted bivariate and multivariate analyses were completed with HIV as the dependent variable. Overall, HIV prevalence was 17.6% (n=50/284), although it was strongly correlated with age in bivariate- [odds ratio (OR) 1.2, 95% BCI 1.15-1.21] and multivariate-adjusted analyses (adjusted OR 1.24, 95% BCI 1.14-1.35) for each additional year of age. Nearly, 70.8% (n=34/48) were unaware of their status of living with HIV. Condom use with all sexual partners and condom-compatible-lubricant use with men were reported by 1.3% (95% CI 0.0-9.7). Although the epidemic in Swaziland is driven by high-risk heterosexual transmission, the burden of HIV and the HIV prevention, treatment and care needs of MSM have been understudied. The data presented here suggest that these men have specific HIV acquisition and transmission risks that differ from those of other reproductive-age adults. The scale-up in HIV services over the past decade has likely had limited benefit for MSM, potentially resulting in a scenario where epidemics of HIV among MSM expand in the context of slowing epidemics in the general population, a reality observed in most of the world. Source

Beyrer C.,Center for Public Health and Human Rights | Abdool Karim Q.,University of KwaZulu - Natal | Abdool Karim Q.,Columbia University
Current Opinion in HIV and AIDS

PURPOSE OF REVIEW: We sought to review the recent epidemiology of HIV-1 and to identify emerging challenges in HIV surveillance and epidemic control. RECENT FINDINGS: There is increasing evidence that HIV epidemics are in decline among general populations worldwide. Critical exceptions to these trends are HIV epidemics among key populations globally; the HIV epidemics in Eastern Europe and Central Asia in injecting drug using populations; the continued high burden epidemics of sexually transmitted HIV among young women and girls in southern sub-Saharan Africa, and young men who have sex in men (MSM) in the America, Asia, and Africa. In the new era of ART access, prevalence measures over time are less reliable and new approaches to the measurement of incident infection will be critical to assess trends. The implementation of expanded options for HIV prevention, reducing vertical transmission, and treatment as prevention, will shift focus from individuals to population-level impact. Strong surveillance and information systems will be necessary to meet these expanded surveillance needs. SUMMARY: The epidemiology of HIV infection is changing, dynamic, complex, and progress in epidemic control remains markedly uneven. Without addressing the components of global HIV, in which disease rates continue to expand, current efforts are unlikely to succeed. © 2013 Wolters Kluwer Health | Lippincott Williams &Wilkins. Source

Sullivan P.S.,Emory University | Jones J.S.,Emory University | Baral S.D.,Center for Public Health and Human Rights
Current Opinion in HIV and AIDS

PURPOSE OF REVIEW: The epidemiology of HIV epidemics provides the roadmap for prioritization of programmes and serves over time to evaluate broadly the successes and challenges in prevention. The purpose of this review was to summarize recent information about the epidemiology of HIV in high-income countries with concentrated HIV epidemics. RECENT FINDINGS: Data from 26 countries were organized and analysed, and a systematic review of published literature relating to epidemiology in these countries was conducted. Our major findings illustrated strong patterns in epidemiology by mode of HIV acquisition: in most high-income countries, new HIV diagnoses attributable to male-female sex have been stable or decreasing, whereas new HIV diagnoses attributable to male-male sex have been stable or increasing. Late diagnoses of HIV infection are common. Prevalence of HIV in high-income countries has risen over the past 5 years as death rates have been stable or decreasing. Reports of the epidemiology of HIV among sex workers and transgendered persons are rare. SUMMARY: The epidemiology of HIV in high-income countries in 2013 depicts both the successes and challenges of HIV prevention. The stable to decreasing death rates and stable or declining trends in heterosexual populations are likely attributable, at least in part, to the broader availability of effective treatments for HIV and relatively broad availability of antiretroviral treatment in these countries. However, late diagnoses undermine the individual and public health value of antiretroviral treatment, and epidemics of HIV among MSM remain largely uncontrolled despite broad availability and coverage of treatment. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Source

Wirtz A.L.,Center for Public Health and Human Rights
Journal of the International AIDS Society

There are limited data characterizing the burden of HIV among men who have sex with men (MSM) in Malawi. Epidemiologic research and access to HIV prevention, treatment and care services have been traditionally limited in Malawi by criminalization and stigmatization of same-sex practices. To inform the development of a comprehensive HIV prevention intervention for Malawian MSM, we conducted a community-led assessment of HIV prevalence and correlates of infection. From April 2011 to March 2012, 338 MSM were enrolled in a cross-sectional study in Blantyre, Malawi. Participants were recruited by respondent-driven sampling methods (RDS), reaching 19 waves. Trained staff administered the socio-behavioural survey and HIV and syphilis voluntary counselling and testing. Crude HIV and syphilis prevalence estimates were 15.4% (RDS-weighted 12.5%, 95% confidence interval (CI): 7.3-17.8) and 5.3% (RDS-weighted 4.4%, 95% CI: 3.1-7.6), respectively. Ninety per cent (90.4%, unweighted) of HIV infections were reported as being previously undiagnosed. Participants were predominantly gay-identified (60.8%) or bisexually identified (36.3%); 50.7% reported recent concurrent relationships. Approximately half reported consistent condom use (always or almost always) with casual male partners, and proportions were relatively uniform across partner types and genders. The prevalence of perceived and experienced stigma exceeded 20% for almost all variables, 11.4% ever experienced physical violence and 7% were ever raped. Current age >25 years (RDS-weighted adjusted odds ratio (AOR) 3.9, 95% CI: 1.2-12.7), single marital status (RDS-weighted AOR: 0.3; 95% CI: 0.1-0.8) and age of first sex with a man <16 years (RDS-weighted AOR: 4.3, 95% CI: 1.2-15.0) were independently associated with HIV infection. Results demonstrate that MSM represent an underserved, at-risk population for HIV services in Malawi and merit comprehensive HIV prevention services. Results provide a number of priorities for research and prevention programmes for MSM, including providing access to and encouraging regular confidential HIV testing and counselling, and risk reduction counselling related to anal intercourse. Other targets include the provision of condoms and compatible lubricants, HIV prevention information, and HIV and sexually transmitted infection treatment and adherence support. Addressing multiple levels of HIV risk, including structural factors, may help to ensure that programmes have sufficient coverage to impact this HIV epidemic among MSM. Source

Rubenstein L.S.,Center for Public Health and Human Rights

Despite increasing experience in health reconstruction in societies emerging from conflict, the policy basis for investing in the development of equitable and effective health systems in the wake of war remains unsettled. Consideration of post-conflict health reconstruction is almost entirely absent in donor policies on global health. Practically by default, health programmes are seen increasingly as an element of stabilisation and security interventions in the aftermath of armed conflict. That perspective, however, lacks an evidence base and can skew health programmes towards short-term security and stabilisation goals that have a marginal impact and violate the principles of equity, non-discrimination, and quality, which are central to sound health systems and public acceptance of them. A better approach is to ground policy in legitimacy, viewing health both as a core social institution and one that, if developed according to human rights principles, including equity, non-discrimination, participation and accountability, can advance the effectiveness and the quality of governance in the emerging state. © 2011 The Author(s). Disasters © Overseas Development Institute, 2011. Source

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