Faran Emmanuel

AIDS in South Asia : understanding and responding to a heterogenous epidemic

South Asias HIV epidemic is highly heterogeneous. As a result, informed, prioritized, and effective responses necessitate an understanding of the epidemic diversity between and within countries. Further spread of HIV in South Asia is preventable. The future size of South Asias epidemic will depend on an effective two-pronged approach: firstly, on the scope and effectiveness of HIV prevention programs for sex workers and their clients, injecting drug users and their sexual partners, and men having sex with men and their other sexual partners; and secondly, on the effectiveness of efforts to address the underlying socio-economic determinants of the epidemic, and to reduce stigma and discrimination towards people engaging in high risk behaviors, often marginalized in society, as well as people living with HIV and AIDS.

The HIV/AIDS Surveillance Project mapping approach: an innovative approach for mapping and size estimation for groups at a higher risk of HIV in Pakistan.

Objective:We developed a mapping approach to gather data on distribution, number of settings, operational typologies and estimated size of female sex workers (FSWs), male sex workers, hijra sex workers and injection drug users in Pakistan. Methods:Data were collected across 12 major cities in Pakistan. Broader methodological steps involved dividing each target city into smaller geographical units and collecting data within each zone from secondary and tertiary key informants, also known as level 1. Level 2 ensured involvement of the communities themselves in validating these estimates, followed by triangulation of the finalized results. Rates for each subgroup per 1000 adult men or women were computed and rolled up into provincial estimates to be summed up into national estimates. Results:FSWs formed the largest group reported, with estimates of 79 127 and five different subtypologies. Injection drug users were the second largest group, followed by male sex workers and hijra sex workers with estimates of 31 555, 19 320 and 14 702, respectively. We estimated approximately 167 501 FSWs in Pakistan, with an overall national rate of 4. 4 FSWs per 1000 adult women. A total of 71 911 male sex workers in addition to 39 262 hijra sex workers were calculated with rates of 1.7 and 0.9 per 1000 men, whereas injection drug users had an overall estimate of 102 042. Conclusion:This relatively simple methodology provides a scientific and systematic approach, which can be used in the region to estimate population sizes, understand geographical distribution of these groups and recognize the various operational typologies and dynamics of these populations for developing effective prevention strategies.

An Appraisal of Female Sex Work in Nigeria - Implications for Designing and Scaling Up HIV Prevention Programmes

Background The HIV epidemic in Nigeria is complex with diverse factors driving the epidemic. Accordingly, Nigerias National Agency for the Control of AIDS is coordinating a large-scale initiative to conduct HIV epidemic appraisals across all states. These appraisals will help to better characterize the drivers of the epidemic and ensure that the HIV prevention programmes match the local epidemic context, with resources allocated to interventions that have the greatest impact locally. Currently, the mapping and size estimation of Female Sex Workers (FSWs) - a major component of the appraisal has been completed in seven states. These states are using the data generated to plan, prioritize and scale-up sub-national HIV prevention programmes. Methodology It involved a two-level process of identifying and validating locations where FSWs solicit and/or meet clients (“hotspots”). In the first level, secondary key informants were interviewed to collect information about the geographic location and description of the hotspots. For the second level, FSWs were interviewed at each hotspot and information on population size estimates, typologies and operational dynamics of the FSWs were collected. Results Across the seven states, a total of 17,266 secondary key informants and 5,732 FSWs were interviewed. 10,233 hotspots were identified with an estimated 126,489 FSWs ranging from 5,920 in Anambra to 46,691 in Lagos. The most common hotspots were bars/nightclubs (30%), hotels/lodges (29.6%), streets (16.6%), and brothels (14.6%). Furthermore, the population density of FSWs (per thousand adult men) across the states ranged from 2 in Anambra to 17 in the Federal Capital Territory. Conclusion FSW populations in Nigeria are large and diverse, with substantial differences between and within states. Improved understanding of the location, population size, density, organizational typologies and clients of sex work has informed and is central to Nigerias planning process for scaling up focused HIV prevention programmes.

Factors associated with an explosive HIV epidemic among injecting drug users in Sargodha, Pakistan.

Background:During a routine surveillance round, an extremely high prevalence of 51.3% was found among injecting drug users (IDUs) in Sargodha, a small town in Pakistan. This sharp increase of HIV among this group warranted an urgent need to explore the factors leading toward this explosion of HIV infection among IDUs at this very location to direct the policy makers in designing preventive activities, especially in the context of HIV prevention. Methods:In 2007, 400 current IDUs were recruited through multistage cluster sampling based on mapping studies. Participants provided dried blood spot samples for HIV testing and completed a questionnaire on demographic characteristics and sexual/drug injecting behaviors. Logistic regression was used to examine the independent association of multiple variables with HIV infection. Results:Of the 400 IDUs tested, 205 (51.3%) were HIV positive confirmed through enzyme-linked immunosorbent assay and Western blot. In multivariate analysis, geographical location of IDUs [adjusted odds ratio (aOR) 2.4 for IDUs located in the northern zone vs southern zone, 95% confidence interval (CI) 1.5 to 3.7], injected in groups (aOR 1.8, 95% CI 1.1 to 3.1), and sharing injecting paraphernalia with other IDUs (aOR 1.5, 95% CI 1.0 to 2.4) were strong correlates of HIV infection. Conclusions:Effective outreach programs need to be developed to provide a comprehensive package of HIV prevention services to IDUs not reached by existing services, entry into drug abuse treatment and medical care needs to be facilitated, and essential legal and social services need to be provided with community participation.

The descriptive epidemiology of male sex workers in Pakistan: a biological and behavioural examination

Objectives There is a dearth of published information on the characteristics of sex workers in Pakistan. This study sought to characterise and compare hijra and non-hijra sex workers from eight large cities in Pakistan. Design χ2 and Kruskal–Wallis tests, and multivariable logistic regression were used where appropriate. Methods Study respondents were described on demographic, sex-work, and risk behaviour variables using a cross-sectional integrated biological and behavioural quantitative survey. Results A total of 3350 respondents were surveyed, of which 2694 were included in the study. The average age of respondents was 24.1 years (SD 6.3), and the average duration of sex work was 7.5 years (SD 5.9). Respondents averaged 30.9 (SD 2.7) paid receptive anal sex acts in the month prior to their interview, while 21.5% reported using a condom during their last occurrence of paid anal sex. Of those surveyed, HIV prevalence was 5.4 per 1000; notably, no HIV-positive respondents reported any injection drug use. Finally, intercity heterogeneity was observed on demographic, sex work and risk behaviour characteristics, with almost all characteristics differing at the p<0.01 level. Conclusions Low levels of education, high volume of sex acts and suboptimal condom use makes for a potentially volatile situation. Information provided by this study can play an important role in designing effective prevention programmes, particularly in capturing heterogeneity in sex work between cities, and as evidence is accumulating that a shift in epidemic phase, as well as affected populations is occurring in Pakistan.

Second-generation surveillance for HIV/AIDS in Pakistan: results from the 4th round of Integrated Behavior and Biological Survey 2011-2012.

Objectives In an effort to fully analyse and understand the HIV situation and its epidemiology in Pakistan, a bilateral collaboration between the National AIDS Control Program and the Canadian International Development Agency resulted in the establishment of an effective second-generation surveillance (SGS) system for HIV/AIDS between 2004 and 2012 in accordance with the published guidelines. This paper presents findings from the 4th round of SGS. Methods A mapping exercise was initially conducted for size estimations of the key vulnerable populations: people who inject drugs (PWIDs), male sex workers (MSWs), hijra sex workers (HSWs), and female sex workers (FSWs), followed by an Integrated Behavioral and Biological Surveillance in 20 selected cities across Pakistan. Results The estimated sizes of the four key populations mapped in the 20 cities were 89 178 FSWs, 46 351 PWIDs, 23 317 HSWs and 19 119 MSWs. The HIV sero-prevalence among PWIDs was the highest among all key populations surveyed at 37.8% (CI 37.3 to 38.3) nationally, followed by a prevalence of 7.2% (CI 6.8 to 7.5) among HSWs, 3.1% (CI 2.8 to 3.4) among MSWs and 0.8% (CI 0.4 to 1.0) for FSWs. Various key risk behaviours, that is, sharing of syringes by PWIDs and inconsistent use of condoms by sex workers, were documented. Conclusions Pakistans HIV epidemic that once was characterised primarily by transmission among PWIDs is now increasingly characterised by significant sexual transmission, and all types of sex workers (male, hijra and female) exhibit epidemiological proportions of infection. There is a need to develop concrete strategic plans for each vulnerable subpopulation, initially focusing prevention resources on those with a higher risk or vulnerability.

Sexual behaviour, structural vulnerabilities and HIV prevalence among female sex workers in Pakistan

Background We sought to describe differences in individual and structural vulnerabilities faced by female sex workers (FSWs) in Pakistan between 2006 and 2011, and to characterise risk factors for inconsistent condom use and HIV prevalence in this population. Methods To describe differences in vulnerabilities, we analysed behavioural data from serial cross-sectional surveys conducted across nine cities in 2006 and 2011. Using data from 12 cities in 2011, we used logistic regression to characterise risk factors for (a) inconsistent condom use in the past month (N=6987), and (b) HIV (N=4301). Results Compared to FSWs in 2006, FSWs in 2011 were significantly more likely to solicit clients via cell phones, and to report a larger client volume and anal sex with clients, but also consistent condom use with clients (30.0% vs 23.6% in 2006). In 2011, independent risk factors for inconsistent condom use with clients included: recent sexual violence, recent sex with a person who injects drugs, and absence of programme exposure. HIV prevalence was 0.63% (95% CI 0.43% to 0.92%) in 2011, and was associated with a recent history of injection drug use and absence of programme exposure. Conclusions While condom use with clients was higher in 2011, protective behaviours remained low and vulnerabilities related to sex work may have risen. HIV is emerging in this population and an adaptive HIV prevention programme that addresses different vulnerabilities and the intersection of sexual networks with injection drug use is needed.

Patterns and trends in Pakistan's heterogeneous HIV epidemic

Background Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan. Methods The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana. Results The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17–22% among MSWs/HSWs in Karachi, 44–49% among IDUs in Lahore and 46–66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65–75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana. Conclusions There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.

Heterogeneity of characteristics structure and dynamics of male and hijra sex workers in selected cities of Pakistan.

Background We sought to describe the characteristics and operational dynamics of male sex workers (MSW) and hijra sex workers (HSWs) in 11 cities across Pakistan in 2011. Methods We report descriptive statistics of self-reported sexual behaviour data from cross-sectional mapping and biological and behavioural surveys conducted among 1431 MSWs and 1415 HSWs in four cities across Pakistan in 2011. Results While Karachi had the largest numbers of MSWs and HSWs, Quetta had the largest relative population sizes, with 3.6 MSWs per 1000 male adults and 3.3 HSWs per 1000 male adults. There was considerable variability in the proportion of HSWs who operate through deras, ranging from 2.2% in Peshawar to 62.7% in Karachi. The number of HSWs per guru varies by city, from 1.5 in Quetta to 16.5 HSWs per guru in Karachi. Among HSWs, the use of mobile phones for solicitation ranged from 37.6% in Quetta to 83% in Peshawar and among MSWs the use of mobile phones ranged from 27% in Karachi to 52% in Quetta. In Quetta, a large proportion of HSWs (41%) find clients through gurus. Client volume tended to be higher among HSWs and among both MSWs and HSWs in Quetta and Peshawar. Condom use with clients was most consistent in Quetta, with 31% of MSWs and 41% of HSWs reporting always using condoms with clients. Peshawar had the greatest proportion reporting never using condoms. Conclusions There is considerable geographic heterogeneity in the characteristics and operational dynamics of MSWs and HSWs across Pakistan.

Using geographical mapping of key vulnerable populations to control the spread of HIV epidemics

Even in countries experiencing widely established HIV epidemics among the general population, available epidemiological evidence suggests that certain key populations form the major driver of the epidemic [1]. These populations mainly comprise of female sex workers, men having sex with men and people who inject drugs (PWID) [2]. Their engagement in behaviors that are considered illegal leads to their dissociation from social programs and services, meaning that they remain hidden and extremely hard to reach, which adds to the complexities of planning a prevention response. Over recent years, a large emphasis has been placed on developing an understanding of the key drivers of HIV transmission locally and allocating resources where they are needed the most [3]. The UNAIDS Practical Guidelines for Intensifying HIV Prevention recommend that HIV program planners use strategic information to define the key populations and risk settings, and then match prevention measures according to their epidemic scenario for strategic allocation of resources and placement of the prevention interventions [4]. The approach poses policymakers and program planners with a great challenge of quantifying the size of these populations, understanding their subtypes and identifying locations where they can be found. A lack of reliable knowledge about these populations including their size estimates remains a major information gap identified in various countries globally [5].