Sexual minority men (SMM) and transgender women in South Africa engage in HIV care at lower rates than other persons living with HIV and may experience population-specific barriers to HIV treatment and viral suppression (VS). As part of a pilot trial of an SMM-tailored peer navigation (PN) intervention in Ehlanzeni district, South Africa, we assessed factors associated with ART use and VS among SMM at trial enrolment. A total of 103 HIV-positive SMM and transgender women enrolled in the pilot trial. Data on clinical visits and ART adherence were self-reported. VS status was verified through laboratory analysis (<1000 copies/ml). We assessed correlates of VS at baseline using Poisson generalized linear model (GLM) with a log link function, including demographic, psychosocial, clinical, and behavioral indicators. Among participants, 52.4% reported ART use and only 42.2% of all participants had evidence of VS. Of the 49.5% who reported optimal engagement in HIV care (consistent clinic visits with pills never missed for ≥ 4 consecutive days) in the past 3-months, 56.0% were virally suppressed. In multivariable analysis, SMM were significantly more likely to be virally suppressed when they were ≥ 25 years of age (Adjusted prevalence ratio [APR] = 2.0, CI 95%:1.0-3.8); in a relationship but not living with partner, as compared to married, living together, or single (APR = 1.7, CI 95%:1.0-2.7), and optimally engaged in care (APR = 2.1, 95% CI:1.3-3.3). Findings indicate a need for targeted treatment and care support programming, especially for SMM and transgender women who are young and married/living with their partners to improve treatment outcomes among this population.

ABSTRACT Introduction The ability to objectively measure chronic stress has important implications for research, prevention, and treatment. Cortisol is currently the most used biological marker in the investigation of stress and can be measured via blood, saliva, and urine; however, these methods have disadvantages. The measurement of cortisol in hair is a more recently developed method that quantifies the cumulative production of cortisol over longer periods of time. Given the potential benefits of hair as a chronic stress biometric, research with this novel method is burgeoning, yet rarely involves transgender (“trans”) populations, despite high levels of reported stress among trans people due to experiences of stigma and discrimination. Since hair is a key part of gender presentation, trans people might be less likely than cisgender people to donate hair for research. To explore the feasibility and acceptability of hair collection for use as a stress biometric with trans women, we nested a study into an ongoing clinical trial in São Paulo, Brazil, “Manas por Manas” (Sisters for Sisters). Here, we describe the hair biometric substudy protocol, as well as the feasibility and acceptability of collecting hair in the study cohort. Methods We randomly selected a subsample (n = 180) from the Manas por Manas cohort (n = 392), all of whom are trans women, age 18 or older. We messaged participants via phone, WhatsApp, or social media for at least three attempted contacts. Study visits included four components: (1) video introduction, including a demonstration of hair sampling; (2) informed consent; (3) a brief survey with the validated Short Stress Overload Scale (translated to Portuguese) and questions on hair care that could moderate stress hormone results; and (4) hair sample collection. Hair samples were collected and stored using validated protocols. Participants were reimbursed for travel costs. Results Between April and December 2022, we messaged with 143 individuals out of the 180 sampled (79%) and invited them to participate in the study. Of those invited to participate, we scheduled study visits with 102 people (71.3% of those invited to participate), of whom 100 attended their study visits and completed all activities. Two people did not attend their study visits and stopped communication. Of those who were invited to participate and declined a study visit, four individuals declined due to the hair sample collection procedures (2.8% of those invited to participate). Other reasons for declining to participate included having moved (n = 7), lack of time (n = 11), not interested in research participation (n = 8), or unknown/stopped responding to messages (n = 11). Most participants reported that they chemically treated their hair to bleach, color, or straighten it, which could impact laboratory assays. Conclusion We found hair sampling for stress measurement to be feasible and acceptable to our participants. We successfully completed all study activities for our desired sample size, and most recruited individuals volunteered to participate. Reasons provided for declining study participation reflected general barriers to research participation, with only four people declining due to hair sample collection procedures.

We assessed the uptake of COVID-19 vaccination in a community-recruited sample of people who inject drugs (PWID) in San Francisco in 2022. Overall, 72.4% (95% CI 64.6-80.3) were vaccinated for COVID-19. Independent predictors of vaccination were age 65 years and older (adjusted odds ratio [AOR] 9.7, 95% CI 2.2-28.7) and ever testing positive for COVID-19 (AOR 2.0, 95% CI 1.2-3.5). Homelessness was associated with lower COVID-19 vaccination (AOR 0.5, 95% CI 0.3-0.8). Our study underscores the urgent need for targeted interventions to address unique challenges faced by PWID in accessing COVID-19 vaccination, particularly for those experiencing homelessness and who are younger.

Clinical trials provide evidence that pre-exposure prophylaxis (PrEP) prevents HIV acquisition including through sharing of injection equipment among people who inject drugs (PWID). However, uptake among many populations at risk for HIV has been slow, particularly among PWID. We examined data from the National HIV Behavioral Surveillance (NHBS) from San Francisco in 2022 to measure PrEP uptake and identify factors associated with PrEP awareness among PWID. Of 479 PWID with HIV-negative or unknown HIV status, 54.9% were aware of PrEP, 5.9% had discussed PrEP with a healthcare provider, and 1.5% had used PrEP in the past year. Lack of PrEP awareness was associated with being age 50 years and older (adjusted odds ratio [aOR] 0.40, 95% CI 0.27-0.60), being men who have sex with women (vs. men who have sex with men, aOR 0.47, 95% CI 0.24-0.92), having a disability (aOR 0.58, 95% CI 0.35-0.95), using heroin as their most frequently injected drug (aOR 0.51, 95% CI, 0.34-0.78), not having tested for HIV, HCV, or an STD in the past year (aOR 0.43, 95% CI 0.28-0.64), and not having access to new sterile needles in the past year (aOR 0.28, 95%CI 0.08-1.00). We found negligible change in the awareness and uptake of PrEP among PWID since previously measured in NHBS in 2018. Low PrEP use among PWID may be addressed by increasing provider discussion of PrEP with their PWID patients and clients during routine care, expanding testing for injection-related infections among PWID, and integrating PrEP access into harm reduction programs.

In generalized epidemic settings, there is insufficient understanding of how the unmet HIV prevention and treatment needs of key populations (KPs), such as female sex workers (FSWs) and men who have sex with men (MSM), contribute to HIV transmission. In such settings, it is typically assumed that HIV transmission is driven by the general population. We estimated the contribution of commercial sex, sex between men, and other heterosexual partnerships to HIV transmission in South Africa (SA).

BACKGROUND:South African men who have sex with men (MSM) have a high burden of undiagnosed HIV infection and HIV-testing rates incommensurate with their risk. HIV self-testing (HIVST) may increase testing uptake, frequency, and earlier HIV detection and treatment. SETTING:Gert Sibande and Ehlanzeni districts, Mpumalanga Province, South Africa. METHODS:We conducted a longitudinal HIVST study among MSM between June 2015 and May 2017. Overall 127 HIV-negative MSM were provided with up to 9 test kits of their choice-oral fluid or blood fingerstick-to use themselves and distribute to their networks. Surveys conducted 3- and 6-month post-enrollment elicited information on HIVST experiences, preferences, acceptability, utilization, and distribution. We used generalized estimating equations to assess changes in testing frequency. RESULTS:Ninety-one percent of participants self-tested. All participants who self-tested reported being likely to self-test again, with over 80% preferring HIVST to clinic-based testing. Fingerstick was preferred to oral fluid tests by approximately 2:1. Returning participants distributed 728 tests to sexual partners (18.5% of kits), friends (51.6%), and family (29.8%). Six participants seroconverted during the study, and 40 new diagnoses were reported among test recipients. Frequent (semi-annual) testing increased from 37.8% before the study to 84.5% at follow-up (P < 0.001), and participants reported anticipated frequent testing of 100% if HIVST were available compared with 84% if only clinic-testing were available in the coming year (P < 0.01). CONCLUSIONS:HIVST use and network distribution is acceptable and feasible for MSM in South Africa and can increase testing uptake and frequency, potentially improving early detection among MSM and their networks.

Background Robust population size estimates of female sex workers and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators. This has, consequently, challenged the appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-2014 integrated biological and behavioral surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among female sex workers in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation methods. Objective The objective of our study was to present the selected population size estimation methods used in an IBBS survey and the subsequent participatory process used to estimate the number of female sex workers in three South African cities. Methods In 2013-2014, we used respondent-driven sampling to recruit independent samples of female sex workers for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based population size estimation methods into the survey, from which investigators calculated weighted estimates and ranges of population size estimates for each city’s female sex worker population. Following data analysis, investigators consulted civil society stakeholders to present survey results and size estimates and facilitated stakeholder vetting of individual estimates to arrive at consensus point estimates with upper and lower plausibility bounds. Results In total, 764, 650, and 766 female sex workers participated in the survey in Johannesburg, Cape Town, and eThekwini, respectively. For size estimation, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey and presented these to a civil society-convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, ensuring inclusion only of plausible point estimates in median calculation. After vetting, stakeholders adopted three consensus point estimates with plausible ranges: Johannesburg 7697 (5000-10,895); Cape Town 6500 (4579-9000); eThekwini 9323 (4000-10,000). Conclusions Using several population size estimates methods embedded in an IBBS survey and a participatory stakeholder consensus process, the South Africa Health Monitoring Survey produced female sex worker size estimates representing approximately 0.48%, 0.49%, and 0.77% of the adult female population in Johannesburg, Cape Town, and eThekwini, respectively. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically based size estimates procedures to ensure adoption and utilization of data-informed size estimates for coordinated national and subnational benchmarking. It also has the potential to increase coherence in national and key population-specific HIV responses and to decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around estimates and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available, as these additional data points may minimize the impact of the known and unknown biases inherent in any single, investigator-calculated method.

Introduction Recent HIV key populations (KP) surveillance studies in South Africa, including female sex workers (FSW) and men who have sex with men (MSM), demonstrate the disproportionate burden of HIV they bear compared to the general population. The national response for KP has lagged due to relatively scarce KP data focused narrowly on urban areas. We adopted a participatory data triangulation approach with stakeholders to overcome the challenges of KP program planning in KP data-scarce districts. Here we describe our methodology for achieving consensus on population size estimates (PSE) and treatment cascade indicator estimates derived from FSW and MSM surveillance data and applied across the country. Methods The South African National AIDS Council (SANAC) convened the group; technical advisors from the University of California San Francisco (UCSF) facilitated; and stakeholders from government, non-government, academic, and KP-led advocacy organizations involved in program implementation and research provided input through three in-person meetings covering four phases of work: surveillance data analysis; cascades data extraction; presentation for feedback; and data extrapolation. Results Technical advisors presented eight cascades (three FSW, five MSM) to stakeholders, recommending data-informed extrapolation factors for each population. Stakeholders adopted recommendations by consensus with few adjustments. FSW cascades displayed high awareness of HIV status and steep breakpoints towards ART uptake; MSM cascades displayed less HIV status awareness, but relatively good ART uptake, with metropolitan areas displaying better uptake than rural districts. Conclusion The participatory process enabled KP stakeholders to vet disparate data sources against programmatic experience and recommend consistency in cascades data; participatory triangulation of additional surveillance and program data will follow. The considerable time and resource investments in this process had downstream benefits, including consistency in sub-national HIV implementation plans. We recommend this consensus-based approach as a transparent, consistent, and sound methodology for cascades construction in KP data-scarce environments.

Robust population size estimates (PSEs) for female sex workers (FSW) and other key populations in South Africa face multiple methodological limitations, including inconsistencies in surveillance and programmatic indicators; this has consequently challenged appropriate allocation of resources and benchmark-setting necessary to an effective HIV response. A 2013-14 Integrated Biological and Behavioral Surveillance (IBBS) survey from South Africa showed alarmingly high HIV prevalence among FSW in South Africa’s three largest cities of Johannesburg (71.8%), Cape Town (39.7%), and eThekwini (53.5%). The survey also included several multiplier-based population size estimation (PSE) methods. To present the selected PSE methods used in an IBBS survey and subsequent participatory process used to estimate the number of FSW in three South African cities. In 2013-14 we used respondent driven sampling (RDS) to recruit independent samples of FSW for IBBS surveys in Johannesburg, Cape Town, and eThekwini. We embedded multiple multiplier-based PSE methods into the survey, from which investigators calculated a range of PSEs for each city’s FSW population. Following data analysis, investigators consulted civil society stakeholders to present survey results and PSEs and facilitated stakeholder vetting of individual PSEs to arrive at consensus point estimates with upper and lower plausibility bounds. A total of 2,180 FSW participated in the SAHMS survey. To perform the size estimate exercise, investigators calculated preliminary point estimates as the median of the multiple estimation methods embedded in the IBBS survey, and presented these to a civil-society convened stakeholder group. Stakeholders vetted all estimates in light of other data points, including programmatic experience, to ensure that only plausible point estimates were included in the calculation of the median. After vetting, stakeholders adopted three consensus point estimates with plausible ranges (PR): Johannesburg 7,697 (plausible range (PR) 5,000 - 10,895); Cape Town 6,500 (PR 4,579-9,000); eThekwini 9,323 (PR 4,000-10,000). Through the use of several PSE methods embedded in an IBBS survey and a participatory stakeholder consensus process, SAHMS produced FSW size estimates representing approximately 0.48%, 0.49% and 0.77% of the adult female population in Johannesburg, Cape Town and eThekwini. In data-sparse environments, stakeholder engagement and consensus is critical to vetting of multiple empirically-based PSE procedures to ensure adoption and utilization of data-informed PSEs for coordinated national and sub-national benchmarking. Incorporating stakeholder consensus in PSE methodology has the potential to increase coherence in national and key populations-specific HIV responses, and decrease the likelihood of duplicative and wasteful resource allocation. We recommend building cooperative and productive academic-civil society partnerships around PSE and other strategic information dissemination and sharing to facilitate the incorporation of additional data as it becomes available in order to increase accuracy and precision over time, and decrease biases inherent in any single, investigator calculated method.

Introduction: Power imbalances within sexual relationships have significant implications for HIV prevention in sub-Saharan Africa. Little is known about how power influences the quality of a relationship, which could be an important pathway leading to healthy behavior around HIV/AIDS.Methods: This paper uses data from 448 heterosexual couples (896 individuals) in rural KwaZulu-Natal, South Africa who completed baseline surveys from 2012 to 2014 as part of a couples-based HIV intervention trial. Using an actor-partner interdependence perspective, we assessed: (1) how both partners' perceptions of power influences their own (i.e., actor effect) and their partner's reports of relationship quality (i.e., partner effect); and (2) whether these associations differed by gender. We examined three constructs related to power (female power, male equitable gender norms, and shared power) and four domains of relationship quality (intimacy, trust, mutually constructive communication, and conflict).Results: For actor effects, shared power was strongly and consistently associated with higher relationship quality across all four domains. The effect of shared power on trust, mutually constructive communication, and conflict were stronger for men than women. The findings for female power and male equitable gender norms were more mixed. Female power was positively associated with women's reports of trust and mutually constructive communication, but negatively associated with intimacy. Male equitable gender norms were positively associated with men's reports of mutually constructive communication. For partner effects, male equitable gender norms were positively associated with women's reports of intimacy and negatively associated with women's reports of conflict.Conclusions: Research and health interventions aiming to improving HIV-related behaviors should consider sources of shared power within couples and potential leverage points for empowerment at the couple level. Efforts solely focused on empowering, women should also take the dyadic environment and men's perspectives into account to ensure positive relationship outcomes. (C) 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Cross-sectional studies among African men who have sex with men (MSM) populations demonstrate high HIV prevalence, but few incidence estimates exist. The Mpumalanga Men's Study in Gert Sibande, Mpumalanga province, South Africa, involved 3 serial cross-sectional surveys of MSM recruited through respondent-driven sampling between 2012 and 2015. Successive surveys recaptured a nested cohort of 179, contributing 144.3 person-years (PY) of observation. We observed 18 seroconversions, or incidence of 12.5/100 (PY) (95% confidence interval CI: 8.1 to 19.2/100 PY). Presumptions of high incidence among MSM were confirmed and demonstrate an urgent need for biomedical prevention and treatment programming for MSM in South Africa.

The Mpumalanga Men's Study (MPMS) is the assessment of the Project Boithato HIV prevention intervention for South African MSM. Boithato aims to increase consistent condom use, regular testing for HIV-negative MSM, and linkage to care for HIV-positive MSM. The MPMS baseline examined HIV prevalence and associated risk behaviors, and testing, care, and treatment behaviors among MSM in Gert Sibande and Ehlanzeni districts in Mpumalanga province, South Africa in order to effectively target intervention activities. We recruited 307 MSM in Gert Sibande and 298 in Ehlanzeni through respondentdriven sampling (RDS) between September 2012-March 2013. RDS-adjusted HIV prevalence estimates are 28.3% (95% CI 21.1%-35.3%) in Gert Sibande, and 13.7% (95% CI 9.1%-19.6%) in Ehlanzeni. Prevalence is significantly higher among MSM over age 25 [ 57.8% (95% CI 43.1%-72.9%) vs. 17.9% (95% CI 10.6%-23.9%), P < 0.001 in Gert Sibande; 34.5% (95% CI 20.5%-56.0%) vs. 9.1% (95% CI 4.6%-13.9%), P < 0.001 in Ehlanzeni]. In Gert Sibande, prevalence is higher among self-identified gay and transgender MSM vs. other MSM [39.3% (95% CI, 28.3%-47.9%), P < 0.01], inconsistent condom users [38.1% (18.1%64.2%), P < 0.05], those with a current regular male partner [35.0% (27.1%-46.4%), P < 0.05], and those with lifetime experience of intimate partner violence with men [40.4%, (95% CI 28.9%-50.9%), P < 0.05]. Prevalence of previous HIV testing was 65.8% (95% CI 58.8%-74.0%) in Gert Sibande, and 69.3% (95% CI 61.9%-76.8%) in Ehlanzeni. Regular HIV testing was uncommon [(34.6%, (95% CI 27.9%-41.4%) in Gert Sibande; 31.0% (95% CI 24.9%-37.8%) in Ehlanzeni]. Among HIV-positive participants, few knew their status (28.1% in Gert Sibande and 14.5% in Ehlanzeni), or were appropriately linked to care (18.2% and 11.3%, respectively), or taking antiretroviral therapy (13.6% and 9.6% respectively). MPMS results demonstrate the importance of implementing interventions for MSM to increase consistent condom use, regular HIV testing, and linkage and engagement in care for HIV-infected MSM.