Marina Rifkin, TB/Care Association

1. Burden of HIV and Research Gaps among
Key Populations in sub-Saharan Africa
Marina Rifkin
TB/HIV Care Association
CFAR Biannual Meeting
6-7 December, 2013
Cape Town, South Africa
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2. Key Populations
• Sometimes referred to as a most-at-risk populations (MARPs) or
Key Population include sex workers, men who have sex with
men, people who inject drugs.
• Due to various biological, behavioral and structural factors key
populations are at increased risk of acquiring and transmitting
the virus to others.
• Key populations are important in establishing, accelerating,
sustaining or curbing the HIV epidemic.
– Key populations are likely to be the first to get HIV infection in a new
epidemic
– Key populations are often the first to experience a decline in prevalence
and/or incidence following prevention interventions.
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3. 14
Behavioural risk factors
Guiding Framework
The risk of HIV infection is determined by the total number of unprotected sex acts with an HIV-infected partner
and the e ciency of HIV transmission (Fiure 2).
Risk of HIV
acquisition
=
E ciency of HIV
transmission
x
Number of HIV-infected
partners
x
Number of unprotected
sex acts with each
partner
F • 2. F
igure Untreated STIs
ramework of biomedical and behavioural risk factors for HIV acquisition
• Vaginal practices (use of drying agents)
• Anal sex
number of clients, duration of sex work, and inconsistent condom use.36 A high background prevalence of STI,
• Injection drug use
which increases transmission e ciency, places sex workers and clients at higher risk for HIV acquisition and of
transmitting STI and HIV. The risk of acquiring HIV is also in uenced by the type of sexual activity. The e ciency
• Multiple concurrent sexual partners
of HIV transmission varies with anal, oral and vaginal sex.
• Group injecting
Data are presented here from behavioural surveys and studies in sex work settings, which assessed sexual
• Low or inconsistent condom use
behaviours that in uence the risk of HIV transmission.
• Needle sharing and syringe re-use
Proxy markers of this equation have been shown to be associated with HIV infection. These include higher
1.4.1
U
nprotected sex, including unprotected paid sex
There is a large body of evidence from sub-Saharan Africa, which shows that the risk for HIV infection is
lower among sex workers who use condoms consistently.36,44 Availability of condoms among sex workers has
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4. Structural Barriers
–
–
–
–
Laws and legislation that criminalize KP behavior
Stigma and discrimination
Lack of general acceptance in society Lack of political will
Sexual/physical violence against KPs
Same-sex/homosexuality laws
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5. HIV prevalence among female sex workers in low-income and
middle-income countries
•
•
•
•
1.7% - Middle East/North Africa
5.2% - Asia
6.1% - Latin America/Caribbean
10.9% - Eastern Europe
• 36.9% Sub-Saharan Africa
Stefan Baral, Chris Beyrer, Kathryn Muessig, Tonia Poteat, Andrea L Wirtz, Michele R Decker, Susan G Sherman, Deanna
Kerrigan. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and metaanalysis. Lancet Infect Dis 2012; 12: 538–49.
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6. HIV burden among Female Sex Workers in sub-Saharan
Africa
• Pooled HIV prevalence among adult women in SSA: 7.42%
• Pooled HIV prevalence among FSW in SSA: 36.9%
• Sex workers were 12 times more likely to be HIV infected than
adult women [OR: 12.4 (95% CI: 8.9–17.2].
• SW size estimates in SSA vary considerably and are generally
higher in urban areas, port cities and along major
transportation corridors.
Stefan Baral, Chris Beyrer, Kathryn Muessig, Tonia Poteat, Andrea L Wirtz, Michele R Decker, Susan G Sherman, Deanna
Kerrigan. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and
meta-analysis. Lancet Infect Dis 2012; 12: 538–49.
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7. HIV Prevalence among FSW and Reproductive Age Women in
SSA
Sample
size
Prevalence among female sex
workers (95% CI)
Female
populationn
prevalence
OR (95% CI)
% Female HIV
infections among
female sex workers
Kenya, 2007-2011
7544
45.1% (44.0–46.2)
7.72%
9.8 (9.4–10.3)
32.2
Uganda, 2011
1027
37.2% (34.2-40.2)
8.51%
6.4 (5.6-7.2)
15.7
South Africa, 2008
775
59.6% (56.2–63 .1)
25.32%
4.4 (3.8–5.0)
5.7
Togo, 2009
1311
36.2% (33.6-38.8)
4.2%
12.7 (11.4-14.2)
76.7
Senegal, 2007/2009
1656
19.9% (18.0 –21.9)
1.04%
23.7 (21.0-26.7)
11.5
Malawi, 2007
273
70.7% (65.3–76.1)
13.33%
15.7 (12.1–20.4)
12.7
Nigeria, 2008/2009
3477
33.7% (32.1–35.3)
4.54%
10.7 (10.0-11.5)
4.5
Mauritius, 2010
291
32.6% (27.3–38.0)
0.71%
67.4 (52.6–86.4)
9.1
Country
Baral et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and metaanalysis. Lancet Infect Dis 2012.
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8. Global burden of HIV among MSM, studies
published 2007-2011
Chris Beyrer et al. Global Epidemiology of HIV infection in men who have sex with men. Lancet 2012.
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9. HIV burden among MSM in sub-Saharan Africa
• The HIV epidemic among MSM is occurring within a widespread
heterosexual epidemic; HIV rates among MSM reflect the
overall high burden of HIV disease.
• The first MSM survey in SSA was conducted in Senegal in 2005.
• Approx. 20 countries have either implemented or plan to
implement surveillance and surveys focusing on MSM.
– South Africa: Reported HIV prevalence rates among South African MSM range from 9% to
34%.
– Namibia: MSM in Windhoek found to have an HIV prevalence of 12.4%.
– In 2011, Kenya reported an annual incidence of over 20% among a sample of MSM in
Mombasa.
Baral et al. 2009; Lane et al. 2009; Sanders et al. 2011
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10. IBBS Botswana
• Many MSM have multiple partners, including female partners (51% in
Namibia; 54% in
SA), which serve as a bridge for STI and HIV transmission to the ge
neral population.
• Concurrent partnerships: Nearly 40% of MSM reporting to be in more
than one ongoing sexual relationship at the time of survey.
• Some MSM are selling sex and others are buying sex from FSWs.
• Most MSM
were not aware that anal sex carries an increased risk of HIV transm
ission
• Excessive alcohol consumption and limited availability of condoms and
lubricant was reported as a barrier to consistent condom use.
Botswana Ministry of Health. 2012 Mapping, Size Estimation & Behavioral and Biological Surveillance Survey (BBSS) of HIV/STI Among
Select High-Risk Sub-Populations in Botswana.
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11. MSM and STIs
• 2012 IBBS in Botswana, 11.3% tested positive
for chlamydia, including 5.9% infected with
chlamydia of the anus.
• In FGD, MSM expressed feeling uncomfortable
discussing rectal STIs with health care
providers – need for sensitization, specialized
training and MSM-appropriate services.
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12. HIV burden among PWID in sub-Saharan Africa
• Concentrated PWID epidemics in Mauritius and Zanzibar
• PWID epidemics occurring within generalized epidemics in Kenya,
mainland Tanzania and southern Africa.
• Studies in Tanzania have estimated an overall HIV prevalence of
42% among PWID, compared with an estimated prevalence of 6% in
the general population.
• A 2011 integrated bio-biological surveillance survey in Nairobi
found an HIV prevalence of 30.2% among PWID sharing syringes
and 5.4% among non-sharing PWID.
• Heroin is the most widely injected drug across the countries, except
in Mauritius, where 80% of PWID currently inject buprenorphine.
• High risk injection practices often co-occur with high-risk sexual
practices.
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13. Modes of Transmission: Proportion of new HIV infections by risk
category in five countries in Southern and East Africa
UNAIDS. Regional Support Team for Eastern and Southern Africa – modes of transmission.
http://www.unaidsrstesa.org/hiv-prevention-modes-of-transmission
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14. It is “estimated” that KPs and their sex partners
account for +30% of new infections in South Africa
Key Population
Percent of new HIV
infections, group only
CSW
5.5%
Percent of new infections,
group and their
partners/clients
19.8%
PWID
1.1%
1.3%
MSM
7.9%
9.2%
Total
14.5%
30.3%
SACEMA June 1 2010 Discussion Draft of “South African HIV epidemic, policy and response synthesis”

15. Importance of KPs in a stabilizing epidemic
• As HIV epidemics appear to be stabilizing in the region in the general
population, the relative importance of key populations increases.
– Key populations have an unequal risk of acquiring disease.
– Populations at higher risk require specific services.
– These services must differ in intensity and type from services that target
groups at lower risk.
– Stigmatized, marginalize and often deprioritized by MOH
• Combination prevention for KPs
– Behavioral interventions
– Biomedical interventions
– Structural interventions
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16. Behavioral Intervention Components
• Peer education and
outreach
• Sexual health screening,
risk reduction counseling
and skills building
• Promotion,
demonstration, provision
of condoms and lube
• Screening and treatment
for alcohol and drug
abuse
• Promotion of health
seeking behaviors
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17. Biomedical Intervention Components
•
•
•
•
•
•
•
•
•
•
•
•
•
•
HIV counseling and testing
STI screening and treatment
TB screening and treatment
HIV care and treatment (including ART)
Condoms and compatible lubricants
Sexual and reproductive health services
Medical male circumcision
Post-exposure prophylaxis
Needle and syringe exchange
OST/MAT
Hep B screening and vaccination
HPV screening and vaccination
Periodic presumptive treatment of STIs
Pre-exposure prophylaxis
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18. Structural Intervention Components
• Services to mitigate
sexual violence
• Sensitization of HCWs,
police, etc.
• Implementation of
policies that safeguard
health and human rights
• Capacity
building/empowerment
of KP groups and
individuals
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19. Key Points
• In SSA, the burden of HIV among key populations is
disproportionately high compared with that of the general
population.
• Key populations in most countries still have a high unmet
need for HIV services.
• Despite strong evidence-base supporting the effectiveness of
currently available interventions in preventing HIV acquisition
and transmission, access to and coverage of HIV interventions
among KPs remain low.
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20. Research Gaps
• Bio-behavioral surveillance/size estimation data are needed to
establish baselines/denominators
• Poor indices to measure and monitor coverage, cost and
impact of HIV services for KPs
• Need for demonstration project that provide KPs with access
to new biomedical tools
• Limited inclusion/recruitment of KPs in HIV prevention
research
• Limited inclusion of male and transgender sex workers,
women who inject drugs, and non-urban KPs in research and
surveillance.
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21. Potential NIH/CFAR Research Priorities
Implementation science/operations research opportunities
• Assessing network level risk for various KPs and sub-populations of
KPs in sub-Saharan Africa
• Innovative methods of accessing and targeting sub-populations of
previous hard-to-reach KPs using mobile and web-based technologies
• Role of bisexuality among MSM in prevention research (eg, MMC)
• Role of risk compensation in KP prevention research
• Role of seroadaptation among MSM in prevention research
• Interventions to optimize acceptability, uptake, adherence and
retention (HCT, PEP, ART, health-seeking, etc. )
• Role of super infection/VL spikes among KPs
• Models of service delivery: stand-alone, mobile-linked, integrated
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22. Potential NIH/CFAR Research Priorities
HIV Test
Retain in Care
Adherence to ART
Link to Care
Pre-ART Care
ART Eligible
Viral Suppression
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23. Potential NIH/CFAR Research Priorities
Treatment as Prevention
• Following on HPTN052 results, what about TasP for KPs?
• High rates of client change, the potential for onward transmission of HIV
from an infected sex worker to other clients or partners may be more than
100 times greater than from other people living with HIV.
• What evidence is needed to better inform MOH/DOH and policy makers?
• Feasibility/acceptability
• Optimizing adherence
• Costing
• Modeling to determine impact of TasP for KPs on incidence in the
general population
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