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Defining the HIV prevention and treatment needs of key populations who have disproportionate HIV acquisition and transmission risks has been particularly difficult in the context of generalized HIV epidemics where less attention has historically been placed on the HIV prevention and treatment needs of these groups. There is a gap in our understanding of the specific needs of—and ultimately the investment case for the added value of supporting—disproportionately burdened key populations in these settings. In response to this gap, Johns Hopkins University under the United States Agency for International Development (USAID)-funded Project SOAR implemented a project in partnership with collaborators, with two primary purposes: synthesizing and assessing the quality of available data for key populations; and leveraging these data to strengthen capacity of a strategic group of governmental, nongovernmental, and community stakeholders to effectively use these data to prioritize rights-based, comprehensive data-collection efforts and programmatic responses. This Project SOAR final report summarizes that work.

This open access book provides a comprehensive overview of the health inequities and human rights issues faced by sex workers globally across diverse contexts, and outlines evidence-based strategies and best practices. Sex workers face severe health and social inequities, largely as the result of structural factors including punitive and criminalized legal environments, stigma, and social and economic exclusion and marginalization. Previous work has largely emphasized the elevated burden and gaps in HIV and sexually transmitted infection (STI) services in sex work. Less attention, however, has been paid to the broader health and human rights concerns faced by sex workers. This contributed volume addresses this gap--back cover.

This open access book provides a comprehensive overview of the health inequities and human rights issues faced by sex workers globally across diverse contexts, and outlines evidence-based strategies and best practices. Sex workers face severe health and social inequities, largely as the result of structural factors including punitive and criminalized legal environments, stigma, and social and economic exclusion and marginalization. Although previous work has largely emphasized an elevated burden and gaps in HIV and sexually transmitted infection (STI) services in sex work, less attention has been paid to the broader health and human rights concerns faced by sex workers. This contributed volume addresses this gap. The chapters feature a variety of perspectives including academic, community, implementing partners, and government to synthesize research evidence as well as lessons learned from local-level experiences across different regions, and are organized under three parts: Burden of health and human rights inequities faced by sex workers globally, including infectious diseases (e.g., HIV, STIs), violence, sexual and reproductive health, and drug use Structural determinants of health and human rights, including legislation, law enforcement, community engagement, intersectoral collaboration, stigma, barriers to health access, im/migration issues, and occupational safety and health Evidence-based services and best practices at various levels ranging from individual and community to policy-level interventions to identify best practices and avenues for future research and interventions Sex Work, Health, and Human Rights is an essential resource for researchers, policy-makers, governments, implementing partners, international organizations and community-based organizations involved in research, policies, or programs related to sex work, public health, social justice, gender-based violence, women's health and harm reduction.

Despite consistent evidence, effective interventions and political declarations to reduce HIV infections among men who have sex with men (MSM), coverage of MSM programmes in sub-Saharan Africa (SSA) remains low. Punitive legal frameworks and hostile social circumstances and inadequate health systems further contribute to the high HIV burden among MSM in SSA. The authors use the Modified Social Ecological Model to discuss economic influences in relation to HIV and MSM in SSA. Nigerian, South African and Ugandan case studies are used to highlight economic factors and considerations related to HIV among MSM. The authors argue that criminalisation of consensual sexual practices among adults increases the frequency of human rights violations contributing to the incidence of HIV infections. Furthermore, marginalisation and disempowerment of MSM limits their livelihood opportunities, increases the prevalence of sex work and drug use and limits financial access to HIV services. Sexual and social networks are complex and ignoring the needs of MSM results in increased risks for HIV acquisition and transmission to all sexual partners with cumulative economic and health implications. The authors recommend a public health and human rights approach that employs effective interventions at multiple levels to reduce the HIV burden among MSM and the general population in SSA.

From publisher: Background Social and structural factors are now well accepted as determinants of HIV vulnerabilities. These factors are representative of social, economic, organizational and political inequities. Associated with an improved understanding of multiple levels of HIV risk has been the recognition of the need to implement multi-level HIV prevention strategies. Prevention sciences research and programming aiming to decrease HIV incidence requires epidemiologic studies to collect data on multiple levels of risk to inform combination HIV prevention packages. Discussion Proximal individual-level risks, such as sharing injection devices and unprotected penile-vaginal or penile-anal sex, are necessary in mediating HIV acquisition and transmission. However, higher order social and structural-level risks can facilitate or reduce HIV transmission on population levels. Data characterizing these risks is often far more actionable than characterizing individual-level risks. We propose a modified social ecological model (MSEM) to help visualize multi-level domains of HIV infection risks and guide the development of epidemiologic HIV studies. Such a model may inform research in epidemiology and prevention sciences, particularly for key populations including men who have sex with men (MSM), people who inject drugs (PID), and sex workers. The MSEM builds on existing frameworks by examining multi-level risk contexts for HIV infection and situating individual HIV infection risks within wider network, community, and public policy contexts as well as epidemic stage. The utility of the MSEM is demonstrated with case studies of HIV risk among PID and MSM. Summary The MSEM is a flexible model for guiding epidemiologic studies among key populations at risk for HIV in diverse sociocultural contexts. Successful HIV prevention strategies for key populations require effective integration of evidence-based biomedical, behavioral, and structural interventions. While the focus of epidemiologic studies has traditionally been on describing individual-level risk factors, the future necessitates comprehensive epidemiologic data characterizing multiple levels of HIV risk. ; The study was funded by amFAR, Foundation for AIDS Research, who supported SB, CB, AG and AW. CL was funded by a Canadian Institutes of Health Research (CIHR) Institute of Gender and Health Training Fellowship.

IntroductionMen who have sex with men (MSM) in Cape Town's townships remain in need of targeted HIV‐prevention services. In 2012, a pilot community‐based HIV‐prevention programme was implemented that aimed to reach MSM in five Cape Town townships, disseminate HIV‐prevention information and supplies, and promote the use of condoms and HIV services.MethodsConvenience sampling was used to recruit self‐identified MSM who were 18 years old or older in five Cape Town townships. The six‐month pilot programme trained five community leaders who, along with staff, provided HIV‐prevention information and supplies to MSM through small‐group meetings, community‐based social activities and inter‐community events. After the completion of the pilot programme, in‐depth interviews and focus group discussions (FGDs) were conducted with a subset of conveniently sampled participants and with each of the community leaders. Qualitative data were then analyzed thematically.ResultsOverall, 98 mostly gay‐identified black MSM consented to participate, 57 community‐based activities were facilitated and 9 inter‐community events were conducted. Following their enrolment, 60% (59/98) of participants attended at least one pilot activity. Of those participants, 47% (28/59) attended at least half of the scheduled activities. A total of 36 participants took part in FGDs, and five in‐depth interviews were completed with community leaders. Participants reported gaining access to MSM‐specific HIV‐prevention information, condoms and water‐based lubricant through the small‐group meetings. Some participants described how their feelings of loneliness, social isolation, self‐esteem and self‐efficacy were improved after taking part.ConclusionsThe social activities and group meetings were viable strategies for disseminating HIV‐prevention information, condoms and water‐based lubricant to MSM in this setting. Many MSM were also able to receive social support, reduce social isolation and improve their self‐esteem. Further research is needed to explore factors affecting attendance and the sustainability of these activities. Perspectives of MSM who did not attend pilot activities regularly were not equally represented in the final qualitative interviews, which could bias the findings. The use of community‐based activities and small‐group meetings should be explored further as components to ongoing HIV‐prevention interventions for MSM in this setting.

IntroductionMen who have sex with men (MSM) are disproportionately burdened by HIV in Senegal, across sub‐Saharan Africa and throughout the world. This is driven in part by stigma, and limits health achievements and social capital among these populations. To date, there is a limited understanding of the feasibility of prospective HIV prevention studies among MSM in Senegal, including HIV incidence and cohort retention rates.MethodsOne hundred and nineteen men who reported having anal sex with another man in the past 12 months were randomly selected from a sampling frame of 450 unique members of community groups serving MSM in Dakar. These men were enrolled in a 15‐month pilot cohort study implemented by a community‐based partner. The study included a structured survey instrument and biological testing for HIV, syphilis and hepatitis B virus at two time points.ResultsBaseline HIV prevalence was 36.0% (43/114), with cumulative HIV prevalence at study end being 47.2% (51/108). The annualized incidence rate was 16% (8/40 at risk for seroconversion over 15 months of follow‐up, 95% confidence interval 4.6–27.4%). Thirty‐seven men were lost to follow up, including at least four deaths. Men who were able to confide in someone about health, emotional distress and sex were less likely to be HIV positive (OR 0.36, p < 0.05, 95% CI 0.13, 0.97).ConclusionsHigh HIV prevalence and incidence, as well as mortality in this young population of Senegalese MSM indicate a public health emergency. Moreover, given the high burden of HIV and rate of incident HIV infections, this population appears to be appropriate for the evaluation of novel HIV prevention, treatment and care approaches. Using a study implemented by community‐based organizations, there appears to be feasibility in implementing interventions addressing the multiple levels of HIV risk among MSM in this setting. However, low retention across arms of this pilot intervention, and in the cohort, will need to be addressed for larger‐scale efficacy trials to be feasible.

AbstractIntroductionAs the HIV field evolves to better serve populations which are diverse in risk and access to services, it is crucial to understand and adapt the conceptual tools used to make sense of the HIV pandemic. In this commentary, we discuss the concept of general population. Using a synthetic and historical review, we reflect on the genesis and usage of the general population in HIV research and programme literature, pointing to its moral connotations and its impact on epidemiologic reasoning.DiscussionFrom the early days of the HIV pandemic, the category of general population has carried implicit normative meanings. General population represented those people considered to be undeserving of HIV acquisition, and therefore deserving of a response. Framing the HIV epidemic in sub‐Saharan Africa as a generalized epidemic primarily affecting the general population has contributed to the exclusion of men who have sex with men from epidemic responses. The usage of this category has also masked heterogeneity among those it includes; the increasing focus on the use of interventions such as circumcision and HIV treatment as general population HIV prevention approaches has been marked by a lack of attention to heterogeneity among beneficiaries.ConclusionsWe recommend that the term general population be retired from the field's lexicon. HIV programmes should strengthen their capacity to describe the heterogeneity of those they serve and plan their interventions accordingly. To increase the efficiency and impact of the HIV response, it is urgent to stratify the category of general population by risk. Sexual networks are a promising basis for this stratification.

IntroductionHIV‐related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response.MethodsWe conducted a systematic review of studies and reports that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 1 January 2002 and 1 March 2013. Databases searched for peer‐reviewed articles included PubMed, Scopus, EBSCO Host –CINAHL Plus, Psycinfo, Ovid, Sociofile and Popline. Reports were obtained from the www.HIVAIDSClearinghouse.eu, USAID Development Experience Clearinghouse, UNESCO HIV and AIDS Education Clearinghouse, Google, WHO and UNAIDS. Ancestry searches for articles included in the systematic review were also conducted. Studies of any design that sought to reduce stigma as a primary or secondary objective and included pre‐ and post‐intervention measures of stigma were included.ResultsOf 2368 peer‐reviewed articles and reports identified, 48 were included in our review representing 14 different target populations in 28 countries. The majority of interventions utilized two or more strategies to reduce stigma and discrimination, and ten included structural or biomedical components. However, most interventions targeted a single socio‐ecological level and a single domain of stigma. Outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult. While the majority of studies were effective at reducing the aspects of stigma they measured, none assessed the influence of stigma or discrimination reduction on HIV‐related health outcomes.ConclusionsOur review revealed considerable progress in the stigma‐reduction field. However, critical challenges and gaps remain which are impeding the identification of effective stigma‐reduction strategies that can be implemented by national governments on a larger scale. The development, validation, and consistent use of globally relevant scales of stigma and discrimination are a critical next step for advancing the field of research in this area. Studies comparing the effectiveness of different stigma‐reduction strategies and studies assessing the influence of stigma reduction on key behavioural and biomedical outcomes are also needed to maximize biomedical prevention efforts.

IntroductionWhile women and girls are disproportionately at risk of HIV acquisition, particularly in low‐ and middle‐income countries (LMIC), globally men and women comprise similar proportions of people living with HIV who are eligible for antiretroviral therapy. However, men represent only approximately 41% of those receiving antiretroviral therapy globally. There has been limited study of men's outcomes in treatment programmes, despite data suggesting that men living with HIV and engaged in treatment programmes have higher mortality rates. This systematic review (SR) and meta‐analysis (MA) aims to assess differential all‐cause mortality between men and women living with HIV and on antiretroviral therapy in LMIC.MethodsA SR was conducted through searching PubMed, Ovid Global Health and EMBASE for peer‐reviewed, published observational studies reporting differential outcomes by sex of adults (≥15 years) living with HIV, in treatment programmes and on antiretroviral medications in LMIC. For studies reporting hazard ratios (HRs) of mortality by sex, quality assessment using Newcastle–Ottawa Scale (cohort studies) and an MA using a random‐effects model (Stata 14.0) were conducted.ResultsA total of 11,889 records were screened, and 6726 full‐text articles were assessed for eligibility. There were 31 included studies in the final MA reporting 42 HRs, with a total sample size of 86,233 men and 117,719 women, and total time on antiretroviral therapy of 1555 months. The pooled hazard ratio (pHR) showed a 46% increased hazard of death for men while on antiretroviral treatment (1.35–1.59). Increased hazard was significant across geographic regions (sub‐Saharan Africa: pHR 1.41 (1.28–1.56); Asia: 1.77 (1.42–2.21)) and persisted over time on treatment (≤12 months: 1.42 (1.21–1.67); 13–35 months: 1.48 (1.23–1.78); 36–59 months: 1.50 (1.18–1.91); 61 to 108 months: 1.49 (1.29–1.71)).ConclusionsMen living with HIV have consistently and significantly greater hazards of all‐cause mortality compared with women while on antiretroviral therapy in LMIC. This effect persists over time on treatment. The clinical and population‐level prevention benefits of antiretroviral therapy will only be realized if programmes can improve male engagement, diagnosis, earlier initiation of therapy, clinical outcomes and can support long‐term adherence and retention.

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