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The COVID-19 pandemic has profoundly disrupted the provision of health services across the globe. Travel to hospitals is restricted and many health facilities have limited services, deepening financial problems for some clinics and hospitals.1 Vulnerable groups who are already marginalised by their gender, race or nationality have been disproportionately affected by COVID-19.2 In response, social innovations have been developed to protect vulnerable groups and rapidly pivot health systems towards COVID-19. Social innovations in health are inclusive solutions that meet the needs of end users through a multistakeholder, community-engaged process to address the healthcare delivery gap.3 Social innovation is particularly well suited for the COVID-19 response because it focuses on local needs, develops low-cost solutions and builds on community strengths (figure 1). In partnership with partner academic institutions, the Special Programme for Research and Training in Tropical Diseases launched the Social Innovation in Health Initiative (SIHI) in 2014. SIHI focuses on research, training and advocacy related to social innovation in health. In collaboration with partners, the network organised an online open event to discuss social innovation responses to emergencies.4 This piece highlights how social innovation has contributed to the COVID-19 response and presents three examples of social innovation projects that have adapted to the pandemic. These examples demonstrate how social innovation during COVID-19 has mobilised local communities, swiftly adapted existing health services and built strong partnerships. Figure 1 Characteristics of social innovation that have facilitated its use during the COVID-19 pandemic. COVID-19 responses suggest the importance of local community mobilisation and the flexibility of projects that may already be operating in the field to improve other health outcomes. Mamas Del Rio is a community-based maternal and neonatal … more...

Peruvian women experience high mortality from reproductive cancers, partially due to suboptimal cancer care utilization and experiences. In this qualitative study, we examined factors contributing to positive cancer care experiences. Our sample included 11 cancer patients and 27 cancer providers who attended the First International Cancer Symposium survivorship conference in Lima, Peru in 2015. We conducted thematic analysis. Emergent themes revealed that, for patients, individualized empathic care by providers was an important facilitator to positive cancer care experiences. For providers, the ability to provide such care depended on provider norms and facility infrastructure to support such patient-centered practices. more...

Each year, more than 2 million women are diagnosed with breast or cervical cancer, yet where a woman lives largely determines whether she will develop one of these cancers, have access to timely and effective diagnostic and treatment services, and ultimately survive. Premature death and disability from cancer is a preventable tragedy for hundreds of thousands of women and their families every year. In regions with limited resources, and a fragile or fragmented health system, cancer contributes to the cycle of poverty. This is most striking for cervical cancer, as more than eight in ten women diagnosed and nine in ten women who die from cervical cancer live in a low- or middle-income country. There are proven and cost-effective approaches to reduce these disparities, yet for most women there are few opportunities to access life-saving interventions such as HPV vaccination, and cervical cancer screening with timely treatment of pre-cancerous lesions. These longstanding inequities highlight the urgent need for substantive and sustainable investments in cancer control more broadly, including prevention and early detection programs, capacity building for health service infrastructure and human resources for cancer management including all disciplines: pathology, surgery, radiotherapy, systemic therapy as well as palliative care. Equally vital is the development of high-quality population-based cancer registries, particularly in low- and middle-income countries. In this first Series paper we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality and survival; the social and economic impact on women and their families; and the disparities in cancer survival among socioeconomically disadvantaged women in different settings. more...

A growing number of low- and middle-income country (LMIC) institutions have developed and implemented formal programs to support mentorship. Although the individual-level benefits of mentorship are well established, such activities can also sustainably build institutional capacity, bridge inequities in health care, and catalyze scientific advancement. To date, however, evaluation of these programs remains limited, representing an important gap in our understanding about the impact of mentoring. Without rigorous and ongoing evaluation, there may be missed opportunities for identifying best practices, iteratively improving program activities, and demonstrating the returns on investment in mentorship. In this report, we propose a framework for evaluating mentorship programs in LMIC settings where resources may be constrained. We identify six domains: 1) mentor–mentee relationship, 2) career guidance, 3) academic productivity, 4) networking, 5) wellness, and 6) organizational capacity. Within each, we describe specific metrics and how they may be considered as part of evaluation plans. We emphasize the role of measurement and evaluation at the institutional level, so that programs may enhance their mentoring capacity and optimize the management of their resources. Although we advocate for a comprehensive approach to evaluation, we recognize that—depending on stage and relative maturity—some domains may be prioritized to address short- and medium-term program goals. Fil: Chi, Benjamin H.. University of North Carolina; Estados Unidos Fil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Blas, Magaly M.. Universidad Peruana Cayetano Heredia; Perú Fil: Chuang, Alice. University of North Carolina; Estados Unidos Fil: Wilson, Michael D.. University Of Ghana; Ghana Fil: Chibwesha, Carla J.. University of North Carolina; Estados Unidos Fil: Farquhar, Carey. University of Washington; Estados Unidos Fil: Cohen, Craig R.. University of California; Estados Unidos Fil: Raj, Tony. St. John’s Research Institut; India more...

Among Peruvian women, cervical cancer is the leading cause of death from cancer in women of reproductive age and has the second highest incidence of all cancers (behind breast cancer). The coastal capital, Lima, is home to the country's National Institute of Cancer (INEN) and has substantially lower rates of cervical cancer than elsewhere in the country, partially due to higher socioeconomic status and better access to screening and specialised care, such as chemotherapy and radiotherapy. This disparity has important implications in Peru, where uptake of early screening via the Papanicolaou (Pap) test is low, particularly for women who live in rural areas, have a low socioeconomic status, and speak indigenous languages... more...

Michelle C Chan,1 Angela M Bayer,1 Joseph R Zunt,2 Magaly M Blas,1 Patricia J Garcia1 1School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru; 2Departments of Neurology and Global Health, University of Washington, Seattle, WA, USA Abstract: To solve increasingly complex global health problems, health professionals must collaborate with professionals in non-health-related fields. The Universidad Peruana Cayetano Heredia and University of Washington created the NIH-funded Kuskaya training program in response to the need for transformative global health training for talented graduates from all disciplines. Kuskaya is a 1-year, interdisciplinary training program that teaches Peruvian and US graduates critical skills related to public health research through the design and implementation of a collaborative research project in Peru. Between 2014 and 2018, the program has trained 33 fellows, of which one third were from non-health disciplines. The program is unique because it targets junior trainees from disciplines outside of the health field, the program’s curriculum is adapted to fit the fellows’ backgrounds and professional aspirations, and the structure of the program allows for collaboration within the cohort and encourages fellows to apply for additional funding and pursue advanced degrees. Lessons learned in designing the Kuskaya program include: 1) involving mentors in the fellow selection process, 2) involving fellows in existing lines of research to increase mentor involvement, 3) institutionalizing mentoring through regular works-in-progress meetings and providing mentoring materials, and 4) defining a core curriculum for all fellows while providing additional supplementary materials to meet each cohort’s needs, and evaluating their progress. Kuskaya provides an innovative model for bi-national, global health training to engage and provide a public health career pathway for all professionals. Keywords: public health, international health, program design, education more...

The Loreto region of the Peruvian Amazon faces many obstacles to health care delivery. The majority of the population is river-bound and lives below the poverty line, with some of the worst health indicators in Peru. To overcome these barriers and fill a gap in health services, an NGO-based provider known as the Vine Trust has been providing care since 2001 via a mobile ship clinic called the Amazon Hope. This study presents an assessment of the Amazon Hope, first reporting health indicators of the program´s catchment area, services provided, and program utilization. It then describes perceptions of the program by community members and health workers, the program’s strengths and weaknesses in contributing to health service delivery, and provides recommendations addressing limitations. The qualitative analysis included 20 key informant interviews with community members and health service providers. In the quantitative analysis, 4,949 residents of the catchment area were surveyed about medical histories, experiences with the program, and suggestions for improvement. The survey showed poor indicators for reproductive health. The AH clinic was the main provider of health care among those surveyed. Community members reported satisfaction with the program’s quality of care, and health workers felt the program provided a unique and necessary service. However, community members requested prior notification and additional services, while health workers described misunderstandings in community-tailored care, and difficulties with continuity of care and coordination. Data show that the program has been successful in providing quality health care to a population but has room to improve in its health service delivery. Suggested improvements are provided based on participant suggestions and relevant literature. The study sheds light on the important role of mobile clinics in Peru, and the methodology can serve as a model for assessing the role of mobile clinics in other remote settings. more...

To examine the association between unintended pregnancy and inadequate rotavirus immunization in Peruvian children.Utilizing cross-sectional observational data from the 2012 Demographic and Health Survey (DHS), logistic regression analysis was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between unintended pregnancy and inadequate rotavirus immunization among children.Of 9 620 pregnancies in the five years preceding the survey, 5 396 of them (56.1%) were reported as unintended, of which 2 981 were mistimed (30.9%) and 2 415 (25.1%) were unwanted. A total of 5 187 children (54.9%; 95% CI = 53.8%-56.1%) were recorded to have inadequate rotavirus immunization. Maternal literacy status was found to be a significant effect modifier of the association between pregnancy intention and rotavirus immunization (P value = 0.006). Among children born to illiterate mothers, unintended pregnancy was significantly associated with increased odds of inadequate rotavirus immunization (aOR = 2.6; 95% CI = 1.2-4.4), as compared to children from intended pregnancies. Deficient rotavirus immunization was significantly predicted by inadequate polio, pneumococcal, and influenza vaccinations; having a television in the household; and less maternal education. In contrast, having received breast-feeding education was protective against inadequate rotavirus immunization. Among literate mothers, there was no association between pregnancy intention and rotavirus immunization.Our study provides evidence that improving literacy among mothers could increase rotavirus vaccination uptake among children from unintended pregnancies.Examinar la asociación entre el embarazo involuntario y la vacunación inadecuada contra rotavirus en niños peruanos.A partir de datos de observación transversales de la Encuesta de Demografía y Salud del 2012, se empleó el análisis de regresión logística para calcular las razones de posibilidades ajustadas (aOR) y los intervalos de confianza de 95% (IC) de la asociación entre el embarazo involuntario y la inmunización inadecuada contra rotavirus en los niños.De 9 620 embarazos en los cinco años anteriores a la encuesta, 5 396 (56,1%) se reconocieron como involuntarios, de los cuales 2 981 fueron inoportunos (30,9%) y 2 415 (25,1%) fueron no deseados. Se registraron 5 187 niños (54,9%; IC de 95% = 53,8%–56,1%) con inmunización contra rotavirus inadecuada. El alfabetismo materno resultó ser un importante modificador de efecto de la asociación entre la intencionalidad del embarazo y la vacunación antirrotavírica (valor deNuestro estudio aporta evidencia que muestra que mejorar el alfabetismo en las madres podría aumentar la captación de la vacunación antirrotavírica en los niños nacidos de embarazos involuntarios.Examinar a associação entre gravidez indesejada e falta de vacinação oportuna contra rotavírus em crianças peruanas.A partir de dados observacionais transversais obtidos na Pesquisa de Demografia e Saúde 2012, foi conduzida uma análise de regressão logística para estimar razões de chances ajustadas (OR aj) e intervalos de confiança de 95% (IC 95%) para a associação entre gravidez indesejada e falta de vacinação oportuna contra rotavírus em crianças.Dentre 9.620 gravidezes ocorridas nos cinco anos anteriores à pesquisa, 5.396 (56,1%) foram referidas como não intencionadas, das quais 2.981 foram não no momento certo (30,9%) e 2.415 (25,1%) indesejadas. Registrou-se falta de vacinação oportuna contra rotavírus em 5.187 crianças ao todo (54,9%; IC 95% = 53,8%–56.1%). Verificou-se que o nível de escolaridade materna é um importante modificador de efeito da associação entre intenção de engravidar e vacinação contra rotavírus (valor deO estudo evidencia que melhorar o nível de escolaridade materna poderia contribuir para aumentar a vacinação contra rotavírus em crianças nascidas de gravidez indesejada. more...

We aimed to gather information among gay men regarding their preferences for online sexual health information; 1,160 Peruvian MSM, 18 years or older, completed an online survey hosted on www.tunexo.org . The mean age was 26.8 years. Around 90% had post-high school education. The self-reported HIV prevalence was 12.3%. The acceptability of sexual health content was greater in the most highly educated group. The highest rated topics and services of interest were those related to improving sexual and mental health. The least educated group was significantly more interested in "getting prevention messages on mobiles" compared to men with the highest level of education (71% vs. 52%; p < 0.001). Men's sexual health was of more interest to the 30-39-year-old group compared to the 18-24-year-old one (97% vs. 87%; p = 0.005). Future Web-based interventions related to sexual health among targeted groups of MSM in Peru can be tailored to meet their preferences. more...

Introduction:Approximately 291 million women worldwide are HPV DNA carriers. Studies have indicated that having multiple sexual partners may lead to higher HPV transmission. Thus female sex workers (FSWs) may be at greater risk of infection compared to the general population. Herein we review publications with data on FSW cervical HPV test results. We also examine variations of HPV prevalence and risk behaviors by region. Knowledge of prevalent HPV types in FSWs may lead to improved prevention measures and assist in understanding vaccination in high-risk groups.Methods:We conducted a review of the literature by searching PUBMED using the terms “prostitution” or “female sex workers”, “human papillomavirus” or “HPV”, and “prevalence” or “PCR” to find articles. We excluded studies without HPV testing or HPV type specific results, or unconventional HPV testing.Results:A total of 35 peer-reviewed publications were included in our review. High risk HPV types 16 and 18 ranged from 1.1-38.9‰ in prevalence. In addition to high-risk HPV types, newer studies reported non-carcinogenic HPV types also of high prevalence. The most prevalent HPV types reported among FSWs included HPV 6 (11.5%), 16 (38.9%), 18 (23.1%), 31 (28.4%), 52 (32.7%), and 58 (26.0%).Conclusions:Female sex workers have an overall high prevalence of HPV infection of high-risk types as evident through various testing methods. FSWs are thought to be at increased risk of cervical cancer because of high HPV exposure. This highlights the need for HPV and cervical prevention campaigns tailored to FSWs. more...

Objective: The objective of this study is to identify features and content that short message service (SMS) should have in order to motivate HIV testing among men who have sex with men (MSM) in Lima, Peru. Methods: From October, 2010 to February, 2011, we conducted focus groups at two stages; six focus groups were conducted to explore and identify SMS content and features and two additional focus groups were conducted to tailor SMS content. The text messages were elaborated within the theoretical framework of the Information-Motivation-Behavioral Skills model and the Social Support Theory. Results: A total of 62 individuals participated in the focus groups. The mean age of participants was 28 years (range 18-39). We identified important features and content items needed for the successful delivery of text messages, including: a) the use of neutral and coded language; b) appropriate frequency and time of delivery; c) avoiding mass and repetitive messages; and d) use of short, concise and creative messages. Although in Peru receiving text messages is usually a free service, it is important to remind participants that receiving messages will be free of charge. Conclusion: Text messages can be used to promote HIV testing among Peruvian MSM. It is important to consider adequate frequency, message content and cost when delivering messages to promote HIV testing in this population. more...

Purpose Human papillomavirus (HPV) is the most common sexually transmitted infection globally and is responsible for a variety of cancers in men and women. An effective HPV vaccine licensed for use in girls and boys has been indicated for—but is not widely implemented in—men who have sex with men (MSM). Limited data are available for transgender women (TW). We explored the social and behavioral aspects related to HPV vaccine uptake and participation in HPV vaccine studies among Peruvian MSM and TW. Methods Focus groups and individual in-depth interviews were conducted to obtain the knowledge, thoughts, and opinions from Peruvian MSM and TW regarding HPV vaccination. Data were analyzed using systematic comparative and descriptive content analysis. Results Three focus groups and fifteen individual in-depth interviews were conducted among 36 MSM and TW. Participant mean age was 26 years (range 18–40). Though many participants were unfamiliar with HPV vaccination, most expressed positive attitudes. Participants expressed concerns about the potential for stigma when disclosing HPV vaccination. Conclusion Peruvian MSM and TW felt that HPV vaccination would be acceptable to themselves and their peers. Nonetheless, vaccine intake may be impeded by potential stigma. Findings from this study may guide HPV vaccine implementation in similar populations. more...

Vaccine acceptability and vaccine-related knowledge data were collected from female sex workers (FSWs) in Lima, Peru to determine their awareness of HPV and barriers to the potential acceptability of HPV vaccine. FSWs were found to have low knowledge of HPV, HPV vaccine, and cervical cancer. Due to high reported sexual exposure, FSWs are likely at increased risk of cervical cancer, and should have access to HPV vaccine. FSWs should be targeted for HPV education campaigns and barriers to vaccination should be addressed. Future studies should assess HPV prevalence in this population and examine retention issues for vaccine dose completion. more...

To improve global health and the welfare of a population, skilled human resources are required, not only in medicine and health, but also in the field of informatics. Unfortunately, training and research programs specific to biomedical informatics in developing countries are both scarce and poorly documented. The aim of this paper is to report the results from the first Informatics Expert Meeting for the Andean Region, including, nine Latin American based institutional case studies. This two-day event occurred in March 2010 and brought together twenty-three leaders in biomedical informatics from around the world. The blend of practical and experiential advice from these experts contributed to rich discussions addressing both challenges and applications of informatics within Latin American. In addition, to address the needs emphasized at the meeting, the QUIPU Network was established to expand the research consortium in the Andean Region, Latin America, and internationally. The use of these new technologies in existing public health training and research programs will be key to improving the health of populations in the Andean Region and around the globe. more...

BACKGROUND: Human Papilloma Virus (HPV) infection is the most common sexually transmitted viral infection worldwide. HPV is highly prevalent in sexually active men who have sex with men (MSM) and has been associated with anal cancer, penile cancer, and oropharyngeal cancer. METHODS: From March to September 2011, we conducted a cross-sectional study of HPV prevalence among MSM above age 18 years. Participants were recruited using respondent driven sampling at Clinica Cayetano Heredia. All participants provided anal, genital, and oral samples for HPV DNA testing, and blood for HIV and HPV antibody testing. RESULTS: A total of 200 MSM were recruited in the study. The mean age was 34 years (range 18-59 years, SD = 9.4) and101 participants were HIV negative (99 HIV positive). HPV 6/11/16/18 or quadrivalent HPV vaccine (HPV4) genotype seroprevalence among HIV negative and positive MSM was 64.3% (55%-75.9%) and 93.8% (87.6%-99.2%) respectively (p more...

While brothel-based sex work is regulated by the Peruvian government, there is little data on STI risk factors reported by female sex workers (FSW). This study compared high risk behaviors among 120 Peruvian FSW from government regulated brothels with both clients and non-commercial partners. Our study found that 12% of FSW reported unprotected vaginal sex with clients (compared to 75% with non-commercial partners), and 42% reported unprotected anal sex with clients (compared to 87% with non-commercial partners). Group differences were observed in the expectation to have oral sex (32% for partners vs 60% for clients; p more...

Isolates cases and groups of patients co-infected with human T cell lymphotropic virus type I (HTLV-I) and Norwegian scabies have been previously reported. Peru is considered to be endemic for HTLV-I. Between June 1999 and December 2000, 23 patients with Norwegian scabies were enrolled in this study after written informed consent was obtained. Antibodies against HTLV-I were detected by an enzyme-linked immunosorbent assay and confirmatory Western blot. Patients ranged in age from 3 months to 84 years; 15 (65.2%) were female. Infection with HTLV-I was found in 16 (69.6%) patients. Comorbid features included corticosteroid therapy (8.6%), malnutrition (8.6%), and Down's syndrome (4.3%). Among those who consented to be tested for human immunodeficiency virus (n = 13, 56.5%), no one had a positive result. The three patients that reported one or more prior episodes of Norwegian scabies were infected with HTLV-I and two of these HTLV-I-positive patients died. Infection with HTLV-I is an important co-factor related to Norwegian scabies in Peru. In our setting, the evaluation for HTLV-I in all Norwegian scabies cases is highly recommended, especially when no other risk factors are apparent. more...

Background Men who have sex with men (MSM) have the highest HIV prevalence in Peru, yet they are underserved by traditional preventive programs. In Peru, the Internet and mobile phones have emerged as an effective and convenient tool to reach this population. Methods and Findings From October 2010 to February 2011, we conducted eight focus groups with gay identified MSM (closeted and out-of-the-closet) and with self-identified heterosexual MSM in order to identify key features and preferences to be used to tailor culturally-appropriate messages that could be delivered through Internet and mobile phones to motivate MSM to get tested for HIV. Participants reported that in order to motivate HIV testing among MSM, interventions need to be based on motivational messages that encourage participants to overcome the fear of getting tested. Messages should increase the HIV risk perception (of participants who do not consider themselves at risk) by eliciting risky situations experienced by MSM. Messages should emphasize confidentiality, respect and the professionalism of the personnel conducting the counseling and testing. A thorough explanation of the process of HIV testing and the steps to follow after receiving the results should be provided. Messages should also contain information about the venue where the test will be conducted in terms of client characteristics, location, hours of operation and personnel. Finally, stigmatizing and stereotyping messages or images about “being gay” should not be included, as they act as deterrents for getting tested. Conclusions Interventions aimed at motivating HIV testing among MSM should include motivational messages that reduce the fear of getting tested and increase the risk perception of participants. They should also market the venue where the testing will be conducted, the professionals who will perform the tests, and the type of tests available. Stigmatizing messages or images should be avoided. more...

Objective: To share the lessons learned when recruiting and retaining Peruvian female sex workers (FSWs) in a clinical trial. Methods: Peruvian FSWs 18-26 years of age were asked to join a clinical study of HPV vaccine starting in August 2009. Condoms, lubricants, and health services were given as an incentive to join the study, as well as a gift valued at three US dollars at each study visit for retention purposes. Results: 120 participants completed the survey. Barriers to non-enrollment recruiting included the false association of our clinical trial with an ineffective HIV vaccine study, plans to become pregnant during the vaccine study, not identifying as sex workers, pushback from husbands with fear of vaccine related birth defects, questioning motives for a free vaccine, not wanting to use birth control, lack of high perceived value of incentives, and limited time availability. Barriers to retention included periodic travel out of Lima, high costs for commuting, the requirement of no clients one day before the visit, and misinformation by health care providers regarding associations between the vaccine and illnesses. Conclusions: Working with health promoters and brothel managers, making periodic phone call reminders of appointments, and identifying participants who were peer leaders helped facilitate study participation and retention. Despite hardships in recruiting and retaining female sex workers, this group will participate in a study they deem useful for their health. Before recruiting female sex workers in clinical trials, potential barriers need to be addressed by study investigators. more...

Background In an earlier study, we detected an association between human T-cell lymphotropic virus (HTLV) infection and cervical human papillomavirus (HPV) in indigenous Amazonian Peruvian women of the Shipibo-Konibo ethnic group. As both HTLV and HPV can be transmitted sexually, we now report a population-based study examining the prevalence and risk factors for HTLV-1 and HTLV-2 infection in this population. Methods Between July and December 2010, we conducted a comprehensive screening for HTLV among Shipibo-Konibo women 15 to 39 years of age living in two communities located in Lima and in 17 communities located within four hours by car or boat from the Amazonian city of Pucallpa in Peru. Results We screened 1,253 Shipibo-Konibo women for HTLV infection 74 (5.9%) tested positive for HTLV-1, 47 (3.8%) for HTLV-2 infection, and 4 (0.3%) had indeterminate results. In the multivariate analysis, factors associated with HTLV-1 infection included: older age (Prevalence Ratio (PR): 1.04, 95% CI 1.00–1.08), primary education or less (PR: 2.01, 95% CI: 1.25–3.24), younger or same age most recent sex partner (PR: 1.66, 95% CI: 1.00–2.74), and having a most recent sex partner who worked at a logging camp (PR: 1.73, 95% CI: 1.09–2.75). The only factor associated with HTLV-2 infection was older age (PR: 1.08, 95% CI: 1.03–1.12). Conclusion HTLV infection is endemic among Shipibo-Konibo women. Two characteristics of the sexual partner (younger age and labor history) were associated with infection in women. These results suggest the need for implementation of both HTLV screening during the antenatal healthcare visits of Shipibo-Konibo women, and counseling about the risk of HTLV transmission through prolonged breastfeeding in infected women. We also recommend the implementation of prevention programs to reduce sexual transmission of these viruses. more...

Summary Limited data exist on the effect of clinical trial participation on sexual behavioural change. Two hundred female sex workers working in Lima, Peru received human papillomavirus (HPV) vaccine in either the standard (0, 2, 6 months) or modified (0, 3, 6 months) schedule. Participants received comprehensive screening and treatment for sexually transmitted infections (STIs), counselling on safe sex practices, education about HPV and the HPV vaccine, contraceptives (oral and condoms) and family planning at each visit. We assessed vaccine completion rates, change in sexual practices, and changes in HPV knowledge before and after participation in the vaccine trial. There were high rates of vaccine completion, 91% overall. The estimated number of reported new and total clients over a 30-day period decreased significantly ( P < 0.001). Knowledge about HPV and HPV-related disease increased among all participants. In addition, all participants listed at least one preventive strategy during the month 7 follow-up survey. more...

HPV and Genital Warts among Peruvian Men Who Have Sex with Men and Transgender People: Knowledge, Attitudes and Treatment Experiences Ce´sar R. Nuren˜a 1 , Brandon Brown 2 *, Jerome T. Galea 3 , Hugo Sa´nchez 3 , Magaly M. Blas 4 1 Escuela de Antropologi´a, Universidad Nacional Mayor de San Marcos, Lima, Peru, 2 Department of Population Health and Disease Prevention, University of California Irvine, Irvine, California, United States of America, 3 Epicentro, Lima, Peru, 4 Epidemiology, STD and HIV Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru Abstract Background: Several studies have assessed the epidemiology of HPV infection among MSM, but no qualitative studies have specifically assessed how HPV and genital warts (GW) affect South American men who have sex with men (MSM) and male- to-female transgendered women (TG). This study explored the knowledge, attitudes and experiences of Peruvian MSM and TG regarding HPV and GW. Methods: We performed a qualitative study consisting of fifteen in-depth interviews and three focus groups carried out in Lima, Peru with diverse MSM and TG groups, including sex workers. Resulting data were analyzed by applying a systematic comparative and descriptive content analysis. Results: While knowledge of HPV was limited, awareness of GW was common, particularly among TG persons and sex workers. Still, few participants recognized that GW are sexually transmitted, and many had problems differentiating between GW and other STI/anogenital conditions. Stigmatizing experiences were common during sexual encounters with people who had visible GW. Shame, emotional and physical troubles, and embarrassing sexual experiences were reported by individuals with GW. Search for treatment was mediated by peers, but stigma and apparent health services’ inability to deal with GW limited the access to effective medical care. Conclusions: In Peru, public health interventions should strengthen services for HPV/GW management and increase accurate knowledge of the transmission, treatment, and sequelae of HPV/GW in MSM and TG populations. Citation: Nuren˜a CR, Brown B, Galea JT, Sa´nchez H, Blas MM (2013) HPV and Genital Warts among Peruvian Men Who Have Sex with Men and Transgender People: Knowledge, Attitudes and Treatment Experiences. PLoS ONE 8(3): e58684. doi:10.1371/journal.pone.0058684 Editor: Susan Marie Graham, University of Washington, United States of America Received September 4, 2012; Accepted February 6, 2013; Published March 14, 2013 Copyright: s 2013 Nuren˜a et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This research was funded, in part, by NIH grant T32 MH080634, FIC/NIH grant 1R01TW008398 to Magaly Blas, and the UCLA AIDS Institute International Travel grant. Supported in part by a research grant from the Merck Investigator-Initiated Studies Program of Merck & Co Inc. The opinions expressed in this paper are of the authors and do not necessarily represent those of Merck & Co Inc. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors declare that they have no competing interests. Magaly Blas and Brandon Brown received a research grant from the Investigator-Initiated Studies Program of Merck & Co., Inc. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials. * E-mail: brandojb@uci.edu infected with HPV of which nearly half – 47.3% -- were infected by a carcinogenic type [4]. Similarly, a study in Argentina which included a sample (N = 114) of transgendered (TG) sex workers reported an anal HPV prevalence of 97% and high-risk genotypes were detected in 87.5% of participant samples from which the infecting genotype was determined [5]. While it is well established that anogenital warts are caused by HPV and that HPV is linked to oral, anal and penile neoplasms [6], HPV infection has also been associated with acquisition of HIV in MSM [7–9], and there are ongoing studies looking at the association between GW and HIV [10]. Unfortunately, there is little public awareness about the HPV infection, and perhaps less-so in high risk groups [11]. Existing research has focused on women’s limited knowledge and susceptibility to HPV infection and its sequelae, most notably, cervical cancer [11]; however, there has been less empirical work Introduction Human papillomavirus (HPV) is one of the most common sexually transmitted infections (STI) worldwide and it causes morbidity and mortality in both men and women via cervical cancer, penile and anal cancer, oropharyngeal cancer and genital warts (GW) [1]. In many countries HPV prevalence is similar among men and women, with differences dependent on risk factors and methods used to detect infection [1–2]. While much of the emphasis in the literature has focused on women and the link between HPV and cervical cancer, evidence is mounting regarding the high prevalence of HPV infection in males, particularly in anogenital sites, and especially in men who have sex with men (MSM) [3]. Studies from developed countries have found a high prevalence of HPV and anal lesions among MSM [3] but data from developing countries are also emerging. For example, a recent study in Peru among 105 MSM found that 77.1% were PLOS ONE | www.plosone.org March 2013 | Volume 8 | Issue 3 | e58684 more...

Men who have sex with men (MSM) account for the greatest burden of the HIV epidemic in Peru. Given that MSM are frequent users of the Internet, understanding the risk behaviors and the reasons for not getting tested among MSM who surf the Internet may improve the tailoring of future online behavioral interventions. more...

Although men who have sex with men (MSM) have the highest HIV prevalence in Peru, they are underserved by traditional preventive programs. Interestingly, in Peru the Internet and cell-phones have emerged as a convenient tool to reach this population. more...

Two hundred female sex workers (FSWs) in Lima, Peru were randomized to receive HPV4 vaccine in the standard (0, 2, 6 months) or a modified schedule (0, 3, 6 months). One hundred and eighty four (92%) participants completed 3 doses of vaccine. Baseline seropositive rates were 58% for HPV6, 22.5% for HPV11, 41.5% for HPV16, and 13% for HPV18. The final geometric mean antibody titer (GMT) following vaccination was significantly greater for women who were seropositive at baseline compared to seronegative women: HPV6 (GMT ratio = 2.3, p< 0.01), HPV11 (GMT ratio = 2.7, p< 0.01), HPV16 (GMT ratio = 1.3, p= 0.04), and HPV18 (GMT ratio = 2.4, p< 0.01). Antibody titers in the modified schedule were not inferior to those in the standard schedule, suggesting the modified schedule may be paired with required STD visits. Although all women benefit from vaccination, administration at a younger age and before sexual debut is needed to achieve maximum protection from vaccine. more...

Female sex workers (FSWs) are at high risk of human papillomavirus (HPV) infection. Questionnaires were administered to 200 FSWs aged 18–26 years in Lima, Peru, to gather risk behaviours, and cervical swab samples were collected for Pap smears and HPV DNA testing as part of a longitudinal study. Participants reported a median of 120 clients in the past month, and 99.2% reported using condoms with clients. The prevalence of any HPV in cervical samples was 66.8%; 34 (17.1%) participants had prevalent HPV 16 or 18, and 92 (46.2%) had one or more oncogenic types. Fifteen women had abnormal Pap smears, 13 of which were HPV DNA positive. Fewer years since first sex was associated with oncogenic HPV prevalence in a model adjusted for previous sexually transmitted infection (STI) status and condom use with partners (prevalence ratio = 0.77, 95% confidence interval [CI] = 0.60–0.97). Our data confirm the high rates of HPV transmission among FSWs in Peru, highlighting the need for early and effective strategies to prevent cervical cancer. more...

Objective To report the results of a needs assessment of research and training in Medical Informatics (MI) and Bioinformatics (BI) in Latin America. Methods and results This assessment was conducted by QUIPU: The Andean Global Health Informatics Research and Training Center. After sending email invitations to MI–BI related professionals from Latin America, 142 surveys were received from 11 Latin American countries. The following were the top four ranked MI-related courses that a training programme should include: introduction to biomedical informatics; data representation and databases; mobile health; and courses that address issues of security, confidentiality and privacy. Several new courses and topics for research were suggested by survey participants. The information collected is guiding the development of curricula and a research agenda for the MI and BI QUIPU multidisciplinary programme for the Andean Region and Latin America., Article summary Article focus The objective of this paper is to report the results of the first needs assessment of research and training in Medical Informatics (MI) and Bioinformatics (BI) in Latin America. Key messages Top ranked courses in biomedical informatics included: mobile health, issues on security, confidentiality and privacy, public and clinical informatics and electronic health records. The information collected in this needs assessment is guiding the development of curricula and a research agenda for training and research in the Andean region through the Peruvian NIH funded centre QUIPU. ‘Quipu’ is a Quechua word that describes an ancient system used throughout the Andes by the Incas to record and distribute information. Strengths and limitations of this study The online survey included participants from 11 Latin American countries. It is the first needs assessment in Latin America addressing issues of training and research in biomedical informatics. The sample was, however, purposive. more...

Background: Men who have sex with men (MSM) account for the greatest burden of the HIV epidemic in Peru. Given that MSM are frequent users of the Internet, understanding the risk behaviors and the reasons for not getting tested among MSM who surf the Internet may improve the tailoring of future online behavioral interventions. Methods: From October 2007 to April 2008, we conducted an online survey among users of seven Peruvian gay websites. Results: We received 1,481 surveys, 1,301 of which were included in the analysis. The median age of the participants was 22.5 years (range 12 - 71), 67% were homosexual, and the remainder was bisexual. Of survey respondents, 49.4% had never been tested for HIV and only 11.3% were contacted in-person during the last year by peer health educators from the Peruvian Ministry of Health and NGOs. Additionally, 50.8% had unprotected anal or vaginal sex at last intercourse, and a significant percentage reported a condom broken (22.1%), slipped (16.4%) or sexual intercourse initiated without wearing a condom (39.1%). The most common reasons for not getting tested for HIV among high-risk MSM were "I fear the consequences of a positive test result" (n = 55, 34.4%), and "I don't know where I can get tested" (n = 50, 31.3%). Conclusions: A small percentage of Peruvian MSM who answered our online survey, were reached by traditional peer-based education programs. Given that among high-risk MSM, fear of a positive test result and lack of awareness of places where to get tested are the most important reasons for not taking an HIV test, Internet interventions aimed at motivating HIV testing should work to reduce fear of testing and increase awareness of places that offer free HIV testing services to MSM. more...

Background Although many men who have sex with men (MSM) in Peru are unaware of their HIV status, they are frequent users of the Internet, and can be approached by that medium for promotion of HIV testing. Methods We conducted an online randomized controlled trial to compare the effect of HIV-testing motivational videos versus standard public health text, both offered through a gay website. The videos were customized for two audiences based on self-identification: either gay or non-gay men. The outcomes evaluated were ‘intention to get tested’ and ‘HIV testing at the clinic.’ Findings In the non-gay identified group, 97 men were randomly assigned to the video-based intervention and 90 to the text-based intervention. Non-gay identified participants randomized to the video-based intervention were more likely to report their intention of getting tested for HIV within the next 30 days (62.5% vs. 15.4%, Relative Risk (RR): 2.77, 95% Confidence Interval (CI): 1.42–5.39). After a mean of 125.5 days of observation (range 42–209 days), 11 participants randomized to the video and none of the participants randomized to text attended our clinic requesting HIV testing (p = 0.001). In the gay-identified group, 142 men were randomized to the video-based intervention and 130 to the text-based intervention. Gay-identified participants randomized to the video were more likely to report intentions of getting an HIV test within 30 days, although not significantly (50% vs. 21.6%, RR: 1.54, 95% CI: 0.74–3.20). At the end of follow up, 8 participants who watched the video and 10 who read the text visited our clinic for HIV testing (Hazard Ratio: 1.07, 95% CI: 0.40–2.85). Conclusion This study provides some evidence of the efficacy of a video-based online intervention in improving HIV testing among non-gay-identified MSM in Peru. This intervention may be adopted by institutions with websites oriented to motivate HIV testing among similar MSM populations. Trial registration Clinicaltrials.gov NCT00751192 more...

Objectives: In Peru, current interventions in high-risk men who have sex with men (MSM) reach a limited number of this population because they rely solely on peer education. The objective of this study was to assess the use of the Internet as an alternative tool to access this population. Methods: Two nearly identical banner ads-both advertising an online survey but only one offering free HIV/syphilis tests and condoms- were displayed randomly at a Peruvian gay Web site. Results: The inclusion of the health incentive increased the frequency of both banner ad click-through (5.8% vs. 3.4% delivered impressions; P more...

Objectives: To measure the risk of preterm delivery, premature rupture of membranes, infant low birth weight and infant mortality, by a population-based retrospective cohort study using Washington State birth certificate data. Methods: All women diagnosed with Chlamydia trachomatis infection (n = 851), noted with a check box on the birth certificate from 2003, and a randomly selected sample of women not diagnosed with C trachomatis (n = 3404) were identified. To assess the RR between chlamydia infection and pregnancy outcomes, multivariable logistic regression analysis was used. Results: Women with chlamydia infection were younger, more likely to be non-white and had less years of education compared with women without chlamydia. Additionally, they were more likely to have inadequate prenatal care and coinfections with other sexually transmitted infections. After adjusting for age and education, chlamydia-infected women were at an increased risk of preterm delivery (RR 1.46, 95% CI 1.08 to 1.99) and premature rupture of membranes (RR 1.50, 95% CI 1.03 to 2.17) compared with non-infected women. However, no increased risk of infant death (RR 1.02, 95% CI 0.37 to 2.80) or low birth weight (RR 1.12, 95% CI 0.74 to 1.68) associated with chlamydia infection was observed. Conclusion: This study suggests that C trachomatis is associated with an increased risk of preterm delivery and premature rupture of membranes, but not with infant death and low birth weight. Routine screening and opportune treatment for C trachomatis should be considered a necessary part of prenatal care to reduce these adverse pregnancy outcomes. more...

OBJECTIVES: To analyze demographic and practice characteristics of private physicians in 10 cities of Peru, and to shed light on the role of private practice in the delivery of medical care to patients with sexually transmitted infections (STIs). METHODS: As part of an interventional trial designed to improve physician management of STIs in 10 cities in Peru, detailed information was compiled regarding numbers of physicians in each city. A door-to-door survey was then conducted within each city of all private and public medical offices and institutions. Each physician encountered who had a private practice was asked to answer a questionnaire regarding demographic information, medical education, specialty, type of private and public practices currently engaged in, number of STI cases seen per month, and average earnings per consultation. RESULTS: Of 2 060 physicians working in the 10 cities, 507 reported having a private practice, either exclusively or concurrently with other clinical positions. Almost all the private physicians (97.4%) reported managing cases of STIs. Regional differences among private physicians were found in physician density, gender, and place of medical training. In addition, significant variations by gender were seen in rates of specialization, earnings per consultation, and numbers of female patients with STIs seen per month. CONCLUSIONS: Studies of the physician workforce can provide meaningful insights for potential use in addressing public health problems. This study provides valuable information that can help understand the important role of private physicians in managing STIs in Peru. more...

El entrenamiento en Informática Biomédica es fundamental para enfrentar los desafíos de un mundo globalizado. Sin embargo, el desarrollo de programas de entrenamiento e investigación en posgrado en esta área son escasos en América Latina. A través del QUIPU: Centro Andino de Investigación y Entrenamiento en Informática para la Salud Global, se ha desarrollado el primer programa de Diplomado y Maestría en Informática Biomédica en la Región Andina. El objetivo de este artículo es describir la experiencia del programa. A la fecha han participado 51 alumnos de Perú, Chile, Ecuador, Colombia y Venezuela; procedentes de ministerios de salud, hospitales, universidades, centros de investigación, colegios profesionales y empresas privadas. Diecisiete cursos se impartieron con la participación presencial y virtual de profesores de Argentina, Chile, Colombia, Estados Unidos, México y Perú. Este programa está ya institucionalizado en la Facultad de Salud Pública y Administración de la Universidad Peruana Cayetano Heredia. more...