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36 www.thelancet.com/lancetgh Published Online April 8, 2016 Columbia University Medical Center, New York, NY, USA (A Gomes BA, C Nicholas BA, S Amesty MD, R Perez-Figueroa MD, S Nicholas MD, B Taylor MD); Instituto Dermatologico y Cirugia de Piel “Dr. Humberto Bogaert Diaz”, Santo Domingo, Dominican Republic (Y Donastorg MD, M Perez MS); University of Texas Health Science Center San Antonio, San Antonio, TX, USA (B Taylor MD) Correspondence to Angelina Gomes amg2272@cumc.columbia.edu Barriers and opportunities for sexual health services for key populations in the Dominican Republic: provider, government, and community-leader perspectives Angelina Gomes, Catherine Nicholas, Yeycy Donastorg, Martha Perez, Silvia Amesty, Rafael Perez-Figueroa, Stephen W Nicholas, Barbara S Taylor Abstract Background Sexually transmitted infections (STIs) are an important health issue in developing countries. Key populations, including people living with HIV, men who have sex with men, trans women, transactional sex workers, pregnant adolescents, and migrants, are at high risk of STIs and have barriers to sexual health services. In this study, we aim to understand capacities and barriers to access for key populations in the Dominican Republic, and to identify opportunities to improve services.Background Sexually transmitted infections (STIs) are an important health issue in developing countries. Key populations, including people living with HIV, men who have sex with men, trans women, transactional sex workers, pregnant adolescents, and migrants, are at high risk of STIs and have barriers to sexual health services. In this study, we aim to understand capacities and barriers to access for key populations in the Dominican Republic, and to identify opportunities to improve services. Methods We used purposive sampling to solicit views from stakeholders in Santo Domingo, Dominican Republic, including health-care agencies, community-based organisations, and government entities that guide STI screening policy. We conducted 19 semi-structured interviews between February, 2015, and May, 2015, with: nine health providers, seven community leaders, and three government authorities, asking questions about STI services for key populations, gaps in services, and barriers to access. Comprehensive notes and audio recordings were iteratively reviewed by two investigators to defi ne barriers and opportunities for STI screening. Findings Respondents identifi ed barriers to access at individual, community, organisational, and policy levels. Individual barriers include poor risk perception and health knowledge, drug use in transactional sex workers and trans women, inability to negotiate condom use in sex worker and adolescent groups, and poverty. Community barriers include: discrimination against sex workers, trans women, people living with HIV, men who have sex with men, and migrants; and a culture of self-medicating in all populations. Organisational barriers include a lack of centres off ering STI testing, unavailability of medications in centres accessed by key population, and poor knowledge of available resources in the community. Policy barriers include poor access to insurance in populations; low resource allocation to STIs, other than HIV; and inconsistent supply of materials and funds. Despite these barriers, local organisations that work with key populations expressed interest in increasing capacity to screen and treat STIs. Interpretation There are many barriers to STI services for key populations in the Dominican Republic. Communitybased organisations working with such populations could leverage their expertise to increase STI awareness, screening, and treatment. Our fi ndings can help generate sustainable interventions to reduce the burden of STIs in these key populations. Funding NIAID (K23AI081538 to B Taylor); Columbia University IFAP Global Health. Copyright © Gomes et al. Open Access article distributed under the terms of CC BY. Declaration of interests We declare no competing interests.

Background Cardiovascular disease (CVD) is a leading health threat for HIV+ patients on antiretroviral therapy (ART); cardiometabolic comorbidities are key predictors of risk. Data are limited on incidence of metabolic comorbidities in HIV+ individuals initiating ART in low and middle income countries (LMICs), particularly for Hispanics. We examined incidence of diabetes and obesity in a prospective cohort of those initiating ART in the Dominican Republic. Methods Participants ≥18 years, initiating ART