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Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety. [ABSTRACT FROM AUTHOR]

Social cohesion and social participation are social factors that may help reduce HIV risks and optimize health-seeking behaviors. We examined the association between these factors and HIV testing in the last 12 months among men who have sex with men (MSM) in Swaziland using a cross-sectional survey conducted with 326 men, 18 years of age or older reporting having sex with another man in the last 12 months. Social capital analyses included measures of social cohesion and social participation. The social cohesion measurement scale was created through exploratory factor analysis using polychoric correlations to determine unidimensionality and Cronbach's Alpha to assess internal consistency. The measurement scale was divided at the 25th and 75th percentiles using “high,” “medium” and “low” levels of social cohesion for between-group comparisons. The social participation index included four questions regarding participation, resulting in a participation index ranging from 0 to 4. In the final multivariate logistic regression model, an increase in the level of social participation was found to be significantly associated with HIV testing in the last 12 months, adjusting for age, income, reporting a casual partner, family exclusion and rejection by other MSM due to sexual orientation (adjusted odds ratio [aOR]: 1.3, 95% confidence interval [CI] 1.1–1.7,p < .01). MSM with high social cohesion had almost twice the odds of HIV testing in the last 12 months (aOR: 1.8, 95% CI 1.1–3.3,p < .05) as MSM with medium social cohesion, though the overall social cohesion variable was not found to be significant using a Wald test in either the adjusted or unadjusted logistic regression models. These data suggest that building solidarity and trust within and between groups may be a strategy to improve uptake of HIV testing. [ABSTRACT FROM PUBLISHER]

Background: HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland. Methods: A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines. Results: Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21(median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW(53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project(n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314)reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture(53.2%, n = 173/314) was prevalent. Conclusions: While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions. [ABSTRACT FROM AUTHOR]

Introduction Similar to other Southern African countries, Swaziland has been severely affected by HIV, with over a quarter of its reproductive-age adults estimated to be living with the virus, equating to an estimate of 170,000 people living with HIV. The last several years have witnessed an increase in the understanding of the potential vulnerabilities among men who have sex with men (MSM) in neighbouring countries with similarly widespread HIV epidemics. To date, there are no data characterizing the burden of HIV and the HIV prevention, treatment and care needs of MSM in Swaziland. Methods In 2011, 324 men who reported sex with another man in the last 12 months were accrued using respondent-driven sampling (RDS). Participants completed HIV testing using Swazi national guidelines as well as structured survey instruments administered by trained staff, including modules on demographics, individual-level behavioural and biological risk factors, social and structural characteristics and uptake of HIV services. Population and individual weights were computed separately for each variable with a data-smoothing algorithm. The weights were used to estimate RDS-adjusted univariate estimates with 95% bootstrapped confidence intervals (BCIs). Crude and RDS-adjusted bivariate and multivariate analyses were completed with HIV as the dependent variable. Results Overall, HIV prevalence was 17.6% ( n=50/284), although it was strongly correlated with age in bivariate- [odds ratio (OR) 1.2, 95% BCI 1.15-1.21] and multivariate-adjusted analyses (adjusted OR 1.24, 95% BCI 1.14-1.35) for each additional year of age. Nearly, 70.8% ( n=34/48) were unaware of their status of living with HIV. Condom use with all sexual partners and condom-compatible-lubricant use with men were reported by 1.3% (95% CI 0.0-9.7). Conclusions Although the epidemic in Swaziland is driven by high-risk heterosexual transmission, the burden of HIV and the HIV prevention, treatment and care needs of MSM have been understudied. The data presented here suggest that these men have specific HIV acquisition and transmission risks that differ from those of other reproductive-age adults. The scale-up in HIV services over the past decade has likely had limited benefit for MSM, potentially resulting in a scenario where epidemics of HIV among MSM expand in the context of slowing epidemics in the general population, a reality observed in most of the world. [ABSTRACT FROM AUTHOR]

Within the broadly generalized HIV epidemic in Swaziland, men who have sex with men (MSM) have specific HIV acquisition and transmission risks. In the current era of expanding antiretroviral therapy-based prevention and treatment approaches, condom use remains a core component of mitigating these risks. A cross-sectional study characterizing the vulnerabilities for HIV among MSM in Swaziland was analyzed to describe factors associated with condom use at last sex with a male partner. Bivariate and multivariate logistic regression analyses were conducted to assess correlates of condom use at last sex with both casual and regular male partners. Disclosure of sexual practices to a healthcare provider and being able to count on other MSM to support condom use were significantly associated with condom use at last sex with a causal and a regular partner, respectively. Reporting difficulty insisting on condom use was inversely associated with condom use at last sex with both regular and casual partners. In addition, having faced legal discrimination was similarly inversely associated with condom use at last sex with a regular partner. Condom use among MSM in Swaziland may increase with improved partner communication, provider sensitization to encourage sexual disclosure, and the promotion of safer sex norms within MSM communities. These approaches, in combination with existing and emerging evidence of informed and human rights affirming prevention and HIV treatment approaches may reduce the incidence of HIV among MSM in Swaziland and all those in their sexual networks.

Background: Use of the Internet for finding sexual partners is increasing, particularly among men who have sex with men (MSM). In particular, MSM who seek sex online are an important group to target for human immunodeficiency virus (HIV)/sexually transmitted infection (STI) interventions because they tend to have elevated levels of sexual risk behavior and because the Internet itself may serve as a promising intervention delivery mechanism. However, few studies have examined the correlates of online sexual partner seeking among MSM in sub-Saharan Africa., Objective: These analyses aim to describe the prevalence of using the Internet to find new male sexual partners among MSM in two southern African countries. In addition, these analyses examine the sociodemographic characteristics, experiences of discrimination and stigma, mental health and substance use characteristics, and HIV-related knowledge, attitudes, and behaviors among MSM associated with meeting sex partners online., Methods: MSM were enrolled into a cross-sectional study across two sites in Lesotho (N=530), and one in Swaziland (N=322) using respondent-driven sampling. Participants completed a survey and HIV testing. Data were analyzed using bivariate and multivariable logistic regression models to determine which factors were associated with using the Internet to meet sex partners among MSM., Results: The prevalence of online sex-seeking was high, with 39.4% (209/530) of MSM in Lesotho and 43.8% (141/322) of MSM in Swaziland reporting meeting a new male sexual partner online. In the multivariable analysis, younger age (adjusted odds ratio [aOR] 0.37, 95% confidence interval [CI] 0.27-0.50 per 5 years in Lesotho; aOR 0.68, 95% CI 0.49-0.93 in Swaziland), having more than a high school education (aOR 18.2, 95% CI 7.09-46.62 in Lesotho; aOR 4.23, 95% CI 2.07-8.63 in Swaziland), feeling scared to walk around in public places (aOR 1.89, 95% CI 1.00-3.56 in Lesotho; aOR 2.06, 95% CI 1.23-3.46 in Swaziland), and higher numbers of male anal sex partners within the past 12 months (aOR 1.27, 95% CI 1.01-1.59 per 5 partners in Lesotho; aOR 2.98, 95% CI 1.51-5.89 in Swaziland) were significantly associated with meeting sex partners online in both countries. Additional country-specific associations included increasing knowledge about HIV transmission, feeling afraid to seek health care services, thinking that family members gossiped, and having a prevalent HIV infection among MSM in Lesotho., Conclusions: Overall, a high proportion of MSM in Lesotho and Swaziland reported meeting male sex partners online, as in other parts of the world. The information in this study can be used to tailor interventions or to suggest modes of delivery of HIV prevention messaging to these MSM, who represent a young and highly stigmatized group. These data suggest that further research assessing the feasibility and acceptability of online interventions will be increasingly critical to addressing the HIV epidemic among MSM across sub-Saharan Africa.