Evelyn Kim

HIV risk and the overlap of injecting drug use and high-risk sexual behaviours among men who have sex with men in Zanzibar (Unguja), Tanzania.

BACKGROUND Men who have sex with men and inject drugs (MSM-IDU) are particularly vulnerable to HIV infection and have the potential to transmit HIV across multiple populations through their male and female sexual partners and injection drug-using partners. METHODS Respondent-driven sampling was used to recruit men who reported engaging in anal sex with another man in the past 3 months, aged ≥15 years, and living in Unguja, Zanzibar. Participants responded to a face-to-face interview about their HIV and injecting risk behaviours and were tested for HIV, Hepatitis B (HBV) and C (HCV) and syphilis. RESULTS Among the 509 MSM who enrolled in the survey, 14% (n=66) reported injecting drugs in the past 3 months among which 66% used heroin, 60% used a needle after someone else had and 68% passed a needle to someone else after using it. MSM-IDU were significantly more likely to have two or more non-paying male receptive sex partners and to have engaged in group sex in the past month, to have symptoms of a sexually transmitted infection in past 6 months, to have been arrested or beaten in the past 12 months and to be infected with HIV and co-infected with HIV and HCV compared to MSM who did not inject drugs. MSM-IDU were less likely to have used a condom at last sex with a non-paid female partner, to know where to get a confidential HIV test and to have ever been tested for HIV compared to MSM who did not inject drugs. CONCLUSION MSM-IDU, and MSM in general, in Unguja practice multiple high-risk behaviours that put them at risk for blood-borne and sexual transmission of HIV and HCV infection. Targeted interventions for MSM-IDU must account for the overlap of high-risk sexual and drug-using networks and integrate injection drug use and HIV services.

A Systematic Review of Published Respondent-Driven Sampling Surveys Collecting Behavioral and Biologic Data

Reporting key details of respondent-driven sampling (RDS) survey implementation and analysis is essential for assessing the quality of RDS surveys. RDS is both a recruitment and analytic method and, as such, it is important to adequately describe both aspects in publications. We extracted data from peer-reviewed literature published through September, 2013 that reported collected biological specimens using RDS. We identified 151 eligible peer-reviewed articles describing 222 surveys conducted in seven regions throughout the world. Most published surveys reported basic implementation information such as survey city, country, year, population sampled, interview method, and final sample size. However, many surveys did not report essential methodological and analytical information for assessing RDS survey quality, including number of recruitment sites, seeds at start and end, maximum number of waves, and whether data were adjusted for network size. Understanding the quality of data collection and analysis in RDS is useful for effectively planning public health service delivery and funding priorities.

Sexually transmitted infections associated with alcohol use and HIV infection among men who have sex with men in Kampala, Uganda

Objectives Few studies have been conducted in Africa to assess prevalence of sexually transmitted infections (STIs) and risk factors among men who have sex with men (MSM). We report findings from the first behavioural survey to include STI testing among MSM in Kampala, Uganda. Methods Respondent-driven sampling (RDS) was used to recruit MSM for a biobehavioural survey. Eligible participants were men who reported anal sex with another man in the previous 3 months, were 18 years or older, and resided in Kampala. Information was collected on demographics, sexual behaviour, alcohol and drug use, and STI symptoms. Blood, urine and rectal specimens were tested for syphilis, HIV, rectal and urethral gonorrhoea, and chlamydia. Analyses weighted for RDS were conducted to assess associations with STI diagnosis. Results A total of 295 MSM participated in the survey. Almost half (weighted percentage: 47.3%) reported STI symptoms in the last 6 months and 12.9% tested HIV-positive. Prevalence of non-HIV STI was 13.5%; syphilis prevalence was 9.0%. Adjusting for age and education, STI was associated with HIV (adjusted OR (AOR)=3.46, 95% CI 1.03 to 11.64), alcohol use before sex (AOR=4.99, 95% CI 1.86 to 13.38) and having sold sex in the last 3 months (AOR=3.17, 95% CI 1.25 to 8.07), and inversely associated with having anonymous sex partners (AOR=0.20, 95% CI 0.07 to 0.61). Conclusions We observed high levels of self-reported STI symptoms and STI prevalence associated with alcohol use and HIV among MSM in Kampala. Public health interventions supporting MSM are needed to address STI risk and facilitate access to diagnosis and treatment services.

Performance and comparison of self-reported STI symptoms among high-risk populations – MSM, sex workers, persons living with HIV/AIDS – in El Salvador

Summary Resource-limited countries have limited laboratory capability and rely on syndromic management to diagnose sexually transmitted infections (STIs). We aimed to estimate the sensitivity, specificity and positive predictive value (PPV) of STI syndromic management when used as a screening method within a study setting. Men who have sex with men (MSM), female sex workers (FSWs) and people living with HIV/AIDS (PLWHA) participated in a behavioural surveillance study. Data were obtained on demographics, sexual behaviours, STI history and service utilisation. Biological specimens were tested for genital inflammatory infections (Neisseria gonorrhoeae [GC], Chlamydia trachomatis [CT], Mycoplasma genitalium [MG], Trichomonas vaginalis [TV]) and genital ulcerative infection (syphilis and Herpes simplex virus-2). There was a high prevalence of Herpes simplex virus-2 (MSM 48.1%, FSW 82.0% and PLWHA 84.4%). Most participants reported no ulcerative symptoms and the majority of men reported no inflammatory symptoms. Sensitivity and PPV were poor for inflammatory infections among PLWHA and MSM. Sensitivity in FSWs for inflammatory infections was 75%. For ulcerative infections, sensitivity was poor, but specificity and PPV were high. Reliance on self-reported symptoms may not be an effective screening strategy for these populations. STI prevention studies should focus on symptom recognition and consider routine screening and referral for high-risk populations.

Male circumcision programmes in Kenya: lessons from the Kenya AIDS Indicator Survey 2007

OBJECTIVE To provide guidance for male circumcision programmes in Kenya by estimating the population of uncircumcised men and investigating the association between circumcision and infection with the human immunodeficiency virus (HIV), with particular reference to uncircumcised, HIV-uninfected men. METHODS Data on men aged 15 to 64 years were derived from the 2007 Kenya AIDS Indicator Survey, which involved interviews and blood collection to test for HIV and herpes simplex virus 2 (HSV-2). The prevalence of HIV infection and circumcision in Kenyan provinces was calculated and the demographic characteristics and sexual behaviour of circumcised and uncircumcised, HIV-infected and HIV-uninfected men were recorded. FINDINGS The national prevalence of HIV infection in uncircumcised men was 13.2% (95% confidence interval, CI: 10.8-15.7) compared with 3.9% (95% CI: 3.3-4.5) among circumcised men. Nyanza province had the largest estimated number of uncircumcised, HIV-uninfected men (i.e. 601 709), followed by Rift Valley, Nairobi and Western Province, respectively, and most belonged to the Luo ethnic tribe. Of these men, 77.8% did not know their HIV status and 33.2% were HSV-2-positive. In addition, 65.3% had had unprotected sex with a partner of discordant or unknown HIV status in the past 12 months and only 14.7% consistently used condoms with their most recent partner. However, only 21.8% of the uncircumcised, HIV-uninfected men aged 15 to 19 years were sexually active. CONCLUSION The Kenyan male circumcision strategy should focus on the provinces with the highest number of uncircumcised, HIV-uninfected men and target young men before or shortly after sexual debut.

Defining and surveying key populations at risk of HIV infection: Towards a unified approach to eligibility criteria for respondent-driven sampling HIV biobehavioral surveys:

Substantial resources are invested in human immunodeficiency virus biobehavioral surveys using respondent-driven sampling for measuring progress towards the UNAIDS 90–90–90 goals and to obtain other essential data on key populations. Survey data are used to meet country needs as well those of development partners, whose data needs may sometimes diverge. Surveys using differing eligibility criteria impede comparisons across surveys. With scant literature and guidelines on how to approach eligibility criteria, diverse criteria are used within and across countries. We conducted a review of peer-reviewed human immunodeficiency virus respondent-driven sampling biobehavioral survey literature published through December 2013. We describe eligibility criteria of 137 articles representing 214 surveys. Reporting on age, risk behavior, and reference period of risk behavior was nearly universal; however, reporting on gender, geography, and language was less common. Multiple definitions were used for each criterion, making comparisons challenging. We provide a framework for how to approach defining eligibility to improve consistency and comparability across surveys.