Kimberly Green

It's all about making a life: poverty, HIV, violence, and other vulnerabilities faced by young female sex workers in Kumasi, Ghana

Objectives:This study aimed to identify social, economic, structural, and individual-level vulnerabilities of female adolescents who sell sex in Kumasi, Ghana. Methods:Twenty-four in-depth interviews and 4 focus group discussions were conducted with female sex workers of age 18–20 years who had been involved in sex work for at least 2 years. Total sample size was 48. Findings:One-third of participants started sex work before age 15. Knowledge of HIV was accurate and most reported having intentions to use condoms consistently with clients; however, factors such as higher payments, drug and/or alcohol use, fear of violence, and police harassment affected condom use. They perceived violence and rape at the hands of clients as their greatest risk. They also reported abuse and exploitation by police. Respondents voiced strong concerns that girls and teens involved in sex work are at higher risk of unsafe sex, exploitation, and abuse than their older and more experienced counterparts. Unprotected sex with boyfriends was also common. Discussion:The pathway to sex work followed a similar pattern for many study participants who left their rural homes for Kumasi in search of economic opportunity. While adolescents who sell sex appear to be abundant in Kumasi, they have been missed by HIV prevention and harm reduction programming. The findings from this study informed the design and implementation of a young female sex worker peer educator pilot program. Key elements of that program are presented, and recommendations for future program evaluation are made.

A new analytical framework of 'continuum of prevention and care' to maximize HIV case detection and retention in care in Vietnam

BackgroundThe global initiative ‘Treatment 2.0’ calls for expanding the evidence base of optimal HIV service delivery models to maximize HIV case detection and retention in care. However limited systematic assessment has been conducted in countries with concentrated HIV epidemic. We aimed to assess HIV service availability and service connectedness in Vietnam.MethodsWe developed a new analytical framework of the continuum of prevention and care (COPC). Using the framework, we examined HIV service delivery in Vietnam. Specifically, we analyzed HIV service availability including geographical distribution and decentralization and service connectedness across multiple services and dimensions. We then identified system-related strengths and constraints in improving HIV case detection and retention in care. This was accomplished by reviewing related published and unpublished documents including existing service delivery data.ResultsIdentified strengths included: decentralized HIV outpatient clinics that offer comprehensive care at the district level particularly in high HIV burden provinces; functional chronic care management for antiretroviral treatment (ART) with the involvement of people living with HIV and the links to community- and home-based care; HIV testing and counseling integrated into tuberculosis and antenatal care services in districts supported by donor-funded projects, and extensive peer outreach networks that reduce barriers for the most-at-risk populations to access services. Constraints included: fragmented local coordination mechanisms for HIV-related health services; lack of systems to monitor the expansion of HIV outpatient clinics that offer comprehensive care; underdevelopment of pre-ART care; insufficient linkage from HIV testing and counseling to pre-ART care; inadequate access to HIV-related services in districts not supported by donor-funded projects particularly in middle and low burden provinces and in mountainous remote areas; and no systematic monitoring of referral services.ConclusionsOur COPC analytical framework was instrumental in identifying system-related strengths and constraints that contribute to HIV case detection and retention in care. The national HIV program plans to strengthen provincial programming by re-defining various service linkages and accelerate the transition from project-based approach to integrated service delivery in line with the ‘Treatment 2.0’ initiative.

HIV service delivery models towards ‘Zero AIDS-related Deaths’: a collaborative case study of 6 Asia and Pacific countries

BackgroundIn the Asia-Pacific region, limited systematic assessment has been conducted on HIV service delivery models. Applying an analytical framework of the continuum of prevention and care, this study aimed to assess HIV service deliveries in six Asia and Pacific countries from the perspective of service availability, linking approaches and performance monitoring for maximizing HIV case detection and retention.MethodsEach country formed a review team that provided published and unpublished information from the national HIV program. Four types of continuum were examined: (i) service linkages between key population outreach and HIV diagnosis (vertical-community continuum); (ii) chronic care provision across HIV diagnosis and treatment (chronological continuum); (iii) linkages between HIV and other health services (horizontal continuum); and (iv) comprehensive care sites coordinating care provision (hub and heart of continuum).ResultsRegarding the vertical-community continuum, all districts had voluntary counselling and testing (VCT) in all countries except for Myanmar and Vietnam. In these two countries, limited VCT availability was a constraint for referring key populations reached. All countries monitored HIV testing coverage among key populations.Concerning the chronological continuum, the proportion of districts/townships having antiretroviral treatment (ART) was less than 70% except in Thailand, posing a barrier for accessing pre-ART/ART care. Mechanisms for providing chronic care and monitoring retention were less developed for VCT/pre-ART process compared to ART process in all countries.On the horizontal continuum, the availability of HIV testing for tuberculosis patients and pregnant women was limited and there were sub-optimal linkages between tuberculosis, antenatal care and HIV services except for Cambodia and Thailand. These two countries indicated higher HIV testing coverage than other countries.Regarding hub and heart of continuum, all countries had comprehensive care sites with different degrees of community involvement.ConclusionsThe analytical framework was useful to identify similarities and considerable variations in service availability and linking approaches across the countries. The study findings would help each country critically adapt and adopt global recommendations on HIV service decentralization, linkages and integration. Especially, the findings would inform cross-fertilization among the countries and national HIV program reviews to determine county-specific measures for maximizing HIV case detection and retention.

A short history of HIV prevention programs for female sex workers in Ghana: lessons learned over 3 decades.

Background:Female sex workers (FSWs) in Ghana have a 10-fold greater risk for acquiring HIV than the general adult population, and they contribute a substantial proportion of the new HIV infections in the country. Although researchers have conducted behavioral and biological surveys, there has been no review of the contextual, programmatic, and epidemiological changes over time. Methods:The authors conducted a historical review of HIV prevention programs in Ghana. We reviewed the use of different interventions for HIV prevention among FSWs and data from program monitoring and Integrated Biological and Behavioral Surveillance Surveys. In particular, we looked at changes in service access and coverage, the use of HIV testing and counseling services, and the changing prevalence of HIV and other sexually transmitted infections. Results:HIV prevention interventions among FSWs increased greatly between 1987 and 2013. Only 72 FSWs were reached in a pilot program in 1987, whereas 40,508 FSWs were reached during a national program in 2013. Annual condom sales and the proportion of FSWs who used HIV testing and counseling services increased significantly, whereas the prevalence of gonorrhea and chlamydia decreased. The representation of FSWs in national HIV strategic plans and guidelines also improved. Conclusions:Ghana offers an important historical example of an evolving HIV prevention program that—despite periods of inactivity—grew in breadth and coverage over time. The prevention of HIV infections among sex workers has gained momentum in recent years through the efforts of the national government and its partners—a trend that is critically important to Ghanas future.

Non-communicable diseases in southeast Asia

2004 www.thelancet.com Vol 377 June 11, 2011 According to Antonio Dans, lack of workforce and infra structure is one of the limitations to management of non-communicable diseases (NCDs) in southeast Asia. We agree that the health-care delivery system was designed mainly to manage acute infectious diseases in resourcelimited southeast Asian countries. However, many of these countries have also established a system to manage HIV as a chronic disease, and such systems can be applied for the management of NCDs too. In Burma, Cambodia, Thailand, and Vietnam, 312 566 HIV patients were on antiretroviral therapy (ART) in 2009: 68% of those in need. To promote a long-term continuum of care, these countries established pioneer chronic disease management systems. Services were integrated within public health-care facilities and linked to the communities. A key feature was the involvement of aff ected communities as co-service providers, whereby patients had a central role in promoting selfcare, treatment adherence, and peer support. Further, a longitudinal patient follow-up system has been developed with registers and individual patients’ cards and fi les, primary health care as the way to ensure care for millions aff ected with chronic conditions. This point echoes that of recent reviews on NCDs. But beyond establishment of a comprehensive service at primary level, putting people living with chronic conditions at the centre of managing themselves must be considered. Traditional service delivery platforms that put health teams at the heart of disease management might not be feasible given the nature of chronic conditions and current resources. Even with stronger prevention program mes, we can expect an ever-growing number of people to be aff ected with chronic disease in the next decades. Just between Indonesia and the Philippines, the most populous countries in the region, there will already be an estimated 29·2 million people with diabetes by 2030. Organisation of lifelong care for chronic conditions must move towards greater self-management, whereby patients gain a mastery of their disease. The role of expert patients, and peer and community support groups, must be harnessed further. In Cambodia, a communitybased diabetes support group provides not only information but also facilitates greater access to laboratory tests and essential medicines among its members. We must also seize the opportunities provided by the spread of mobile phones and smart devices to support patients in managing their own conditions and to reshape how they interact with health-care providers. We need to radically rethink our concept of health care to address the rise of non-communicable disease. This shift implies very simple diagnostic and treatment protocols, fewer barriers to essential medicines, greater access to simple monitoring devices, and a move towards true empowerment of patients.

Scaled-Up Mobile Phone Intervention for HIV Care and Treatment: Protocol for a Facility Randomized Controlled Trial.

Background Adherence to prevention, care, and treatment recommendations among people living with HIV (PLHIV) is a critical challenge. Yet good clinical outcomes depend on consistent, high adherence to antiretroviral therapy (ART) regimens. Mobile phones offer a promising means to improve patient adherence and health outcomes. However, limited information exists on the impact that mobile phones for health (mHealth) programs have on ART adherence or the behavior change processes through which such interventions may improve patient health, particularly among ongoing clients enrolled in large public sector HIV service delivery programs and key populations such as men who have sex with men (MSM) and female sex workers (FSW). Objective Our aim is to evaluate an mHealth intervention where text message reminders are used as supportive tools for health providers and as motivators and reminders for ART clients to adhere to treatment and remain linked to care in Ghana. Using an implementation science framework, we seek to: (1) evaluate mHealth intervention effects on patient adherence and health outcomes, (2) examine the delivery of the mHealth intervention for improving HIV care and treatment, and (3) assess the cost-effectiveness of the mHealth intervention. Methods The 36-month study will use a facility cluster randomized controlled design (intervention vs standard of care) for evaluating the impact of mHealth on HIV care and treatment. Specifically, we will look at ART adherence, HIV viral load, retention in care, and condom use at 6 and 12-month follow-up. In addition, participant adoption and satisfaction with the program will be measured. This robust methodology will be complemented by qualitative interviews to obtain feedback on the motivational qualities of the program and benefits and challenges of delivery, especially for key populations. Cost-effectiveness will be assessed using incremental cost-effectiveness ratios, with health effects expressed in terms of viral load suppression and costs of resources used for the intervention. Results This study and protocol was fully funded, but it was terminated prior to review from ethics boards and study implementation. Conclusions This cluster-RCT would have provided insights into the health effects, motivational qualities, and cost-effectiveness of mHealth interventions for PLHIV in public sector settings. We are seeking funding from alternate sources to implement the trial.

“Too Much Sex and Alcohol”: Beliefs, Attitudes, and Behaviors of Male Adolescents and Young Men Who have Sex with Men in Ghana

Background: Research suggests that men who have sex with men (MSM) often engage in high-risk sex and use illicit substances. Objective: To increase understanding of HIV knowledge and vulnerability among adolescent and young adult MSM, with a focus on alcohol and drug use and transactional sex. Methods: We conducted in-depth interviews and Focus Group Discussions (FGDs) with adolescent (aged 15-17 years) and young adult (aged 18-29 years) MSM in Kumasi, Ghana. MSM who reported recent alcohol and/or substance use or engagement in transactional sex were eligible. Questions covered HIV-related knowledge, experiences with substance-use and transactional sex, and attitudes regarding sexual risk-taking and HIV-related services. Data were analyzed thematically using NVivo 10.0 software. Results: Ninety-nine MSM participated in 44 interviews and 8 FGDs. Most were attending or had completed secondary school. HIV knowledge was high, but with major gaps. Most consumed alcohol; one-fourth used drugs. Alcohol and substances were consumed to enhance pleasure during sex with another man. Transactional sex was common and positively viewed. Half of the participants used condoms inconsistently or never, and self-perceived HIV risk was high. Nearly half faced stigma-related barriers to accessing HIV-related services. Conclusion: As Ghana strives to achieve the UNAIDS’s 90-90-90 global targets (90% of people living with HIV know their status, 90% who know their status are on sustained treatment, and 90% of those on treatment are virally suppressed), we recommend enhancing MSM-targeted prevention programs, improving care options, and increasing use of critical clinical HIV-services by ensuring that MSM receive unbiased, confidential care.

Love, power, resilience and vulnerability: relationship dynamics between female sex workers in Ghana and their intimate partners

Abstract Little is known about female sex workers’ daily lives or emotional relationships. Using relational-cultural theory, this study explored the relationship dynamics between sex workers and their intimate partners in Kumasi, Ghana. We collected qualitative data from 37 male intimate partners through 24 in-depth interviews and two focus group discussions (FGDs) with 13 male partners. We also conducted three FGDs with 20 women involved in sex work. Relationships between sex workers and their intimate partners were mutual, reciprocal and transactional. Male partners provided protection for financial support, a place to sleep and intimacy. Both men and women described their relationships in terms of friendship, love and a hopeful future. Women were reluctant to quit sex work because they depended on it for income. Most respondents did not use condoms in these romantic relationships, citing trust, love, faithfulness and commitment. Both men and women described high levels of violence in their relationships. The context of sex work heightens vulnerability but also appears to facilitate resilience and creative coping strategies. The relational dynamics between sex workers and their intimate partners in Ghana merit further exploration to examine the extent to which women involved in sex work hold and exert power within these relationships.

How can we better serve adolescent key populations? Strategies to encourage and inform future data collection, analysis, and use†

ABSTRACT Young key populations (ages 10–24) (YKPs) are uniquely vulnerable to HIV infection. Yet they are often underserved, due in part to a limited understanding of their needs. Many successful approaches to understanding YKPs exist but are not widely used. To identify the most useful approaches and encourage their uptake, we reviewed strategic information on YKPs and experiences collecting, analysing, and utilising it from countries in Africa, Asia, and Central and Eastern Europe. As a result, we recommend one central guiding principle – any effort to understand and serve YKPs should include a specific focus on adolescent key populations (AKPs) (ages 10–19) – and three strategies to inform data collection, analysis, and use: tailor recruitment practices to ensure young people’s representation, select indicators and research methods based on their ability to inform responsive programming for and give a voice to YKPs, and thoroughly disaggregate data. We demonstrate the utility of each strategy in YKP research and programmes, and in doing so note the particular importance for AKPs. We hope that this paper encourages additional research on YKPs and helps bridge the gap between research and effective programmes to serve the youngest and most vulnerable members of key populations.

P3.427 Exploring the Beliefs, Attitudes, and Behaviours of MSM Engaged in Substance Use and Transactional Sex in Ghana

Background This qualitative study was designed to examine vulnerability to HIV infection and health-related needs among young men who have sex with men (MSM) in Kumasi, Ghana. Study objectives were to explore substance use (SU) and transactional sex (TS), overlap between SU and TS, beliefs related to SU and TS, and HIV knowledge and risk behaviours in this population. Methods Adolescents (aged 15–17 years) and young adults (aged 18–29 years) who self-reported male-to-male sex in the previous 12 months and who either used alcohol or illicit substances or engaged in TS were recruited using snowball sampling. Data were collected through 44 in-depth interviews and eight focus group discussions, and analysed using QSR NVivo 10.0 software. Results A total of 99 MSM participated. Most reported engaging in alcohol use and TS; a minority used substances, mainly marijuana. The majority displayed knowledge of HIV transmission and prevention, though few understood the basics of HIV treatment. Most perceived they were at high risk of HIV infection due to inconsistent condom use. Their risky behaviours also encompassed group sex, multiple sexual partners, and SU. Most expressed specific health needs, including education, screening, and treatment for sexually transmitted infections. They reported having only one clinic that provides services specific to MSM, and requested shorter wait times at facilities. Barriers to health and HIV services access included stigmatisation, ill-treatment by providers, poor quality of services, fear of testing positive, and lack of privacy, health insurance, and not knowing where to access services. Participants suggested legalising male-to-male sex, educating the public about MSM, and providing MSM with jobs to alleviate their challenges. Conclusion Young MSM in Kumasi engage in high-risk behaviours and indicate a need for interventions to improve access to health and HIV-related services, increase HIV treatment knowledge, and reduce stigma among health providers and society.