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BackgroundMinors who sell sex are likely to have complex mental health needs that may persist into adulthood. This topic is understudied in sub-Saharan Africa. This study hypothesized that adult female sex workers in Eswatini who started selling sex as minors have a higher prevalence of depression than those who started as adults. We also examined correlates of depression and underage initiation of selling sex, including stigma and condom-related behaviors.MethodsFrom October-December 2014, women aged 18 or older who sold sex in the past 12 months in Eswatini were recruited through venue-based sampling. Participants completed a survey including the 9-item Patient Health Questionnaire (PHQ-9) and a question about the age at which they first sold sex for money. T-tests, χ2 tests and multivariable logistic regression were used to assess associations.ResultsOverall, 43.1% of participants (332/770) had probable depression, and 16.6% (128/770) started selling sex as minors under the age of 18. Over half (55.5%, 71/128) of those who started selling sex as minors had depression. This was significantly higher than the 40.7% (261/642) prevalence of depression among participants who started selling sex as adults (p = 0.002). After adjusting for confounders, female sex workers who started selling sex as minors had higher odds of depression than those who started as adults (adjusted odds ratio [aOR] 1.70, 95% confidence interval 1.11-2.60).ConclusionResults highlight the need for trauma-informed and adolescent-friendly mental health services in settings free of stigma toward female sex workers in Eswatini.

BackgroundUse 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. ObjectiveThese 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. MethodsMSM 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. ResultsThe 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. ConclusionsOverall, 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.

Introduction: Sustainable Development Goals (SDGs) about gender equality; decent work; and peace, justice, and strong institutions include a focus on eradicating trafficking and sexual exploitation of and violence against women and children. In Lesotho, 86% of women have experienced gender-based violence. In addition, overall HIV prevalence is among the highest globally, and higher among adolescent girls than boys. Moreover, nearly three quarters of female sex workers (FSW) are estimated to be living with HIV in Lesotho. In this context, sexually exploited children may be particularly vulnerable to violence and HIV acquisition risks. This study's objective is to examine the prevalence and correlates of experiencing sexual exploitation as a child among FSW in Lesotho. Methods: FSW ([greater than or equal to] 18 years) recruited through respondent-driven sampling in Maseru and Maputsoe from February to September 2014 completed HIV and syphilis testing and an interviewer-administered survey, including a question about the age at which they started providing sex for money. This study examined correlates of experiencing sexual exploitation as a child ( Results: Across both cities, 20.0% (142/710) of participants were sexually exploited as children. Among them, 65.5% (93/142) tested positive for HIV and 31.0% (44/142) for syphilis, which was similar to those who started selling sex as adults, after adjusting for current age. Participants who experienced child sexual exploitation were more likely to have been forced to have sex before age 18 than those who started selling sex as adults (Maseru-adjusted odds ratio (aOR): 3.52, 95% Confidence Interval (CI): 1.61 to 7.66, p = 0.002; Maputsoe-aOR: 4.39, 95% CI: 1.22 to 15.75, p = 0.023). In Maseru, participants who were sexually exploited as children were more likely to avoid carrying condoms to prevent trouble with police (aOR: 3.18, 95% CI: 1.50 to 6.75, p = 0.003). Conclusions: Risk determinants for HIV and violence among sexually exploited children can be studied retrospectively through research with adult FSW. Further research working directly with sexually exploited children will improve understanding of their needs. Preventing commercial sexual exploitation of children and addressing the social and healthcare needs of those who are exploited are necessary to fully achieve SDGs 5, 8 and 16 and an AIDS-Free Generation. Keywords: AIDS; sex trafficking; human trafficking; sexual violence; physical violence; adolescents, 1 | INTRODUCTION Much of the research on the sexual exploitation of children has been conducted in Asia and the Americas, [1] but studies have increasingly explored this topic in [...]

Despite calls for an evidence-based focus on outcomes as a way to enhance accountability for public performance, findings from a prior study suggest that the public may be more impressed by high frequency (low cost) but ambiguous outputs (such as people served) rather than more meaningful but costly outcomes (causal effects). We attempt to replicate and extend the investigation of this output bias through a pair of survey experiments involving judgments about two evidence-based, highly effective social programs: one, an HIV/AIDS prevention program (adapted from the prior study), the other, a program for special needs high school students (Check and Connect). Our findings confirm that respondents viewed both programs more favorably when given information about mere outputs (people served) in comparison with more rigorous outcomes (causal effects). We then tested an extension of the Check and Connect experiment in which we modified the framing of cost and performance information in ways that reduced the tendency toward an output bias. We speculate on the possible mechanism that may lead to an output bias, and we discuss the implications of our findings for evidence-based public policy and management. [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., Introduction Swaziland is a small, land‐locked, lower‐middle‐income country that is surrounded by South Africa and Mozambique; it has a population of approximately 1.1 million people and a life expectancy at [...]

Introduction: Despite men who have sex with men (MSM) being a key population for HIV programming globally, HIV epidemiologic data on MSM in Central Africa are sparse. We measured HIV and syphilis prevalence and the factors associated with HIV infection among MSM in Cameroon. Methods: Two hundred and seventy‐two and 239 MSM aged ≥18 from Douala and Yaoundé, respectively, were recruited using respondent‐driven sampling (RDS) for this cross‐sectional surveillance study in 2011. Participants completed a structured questionnaire and HIV and syphilis testing. Statistical analyses, including RDS‐weighted proportions, bootstrapped confidence intervals and logistic regressions, were used. Results: Crude and RDS‐weighted HIV prevalence were 28.6% (73/255) and 25.5% (95% CI 19.1–31.9) in Douala, and 47.3% (98/207) and 44.4% (95% CI 35.7–53.2) in Yaoundé. Active syphilis prevalence in total was 0.4% (2/511). Overall, median age was 24 years, 62% (317/511) of MSM identified as bisexual and 28.6% (144/511) identified as gay. Inconsistent condom use with regular male partners (64.1%; 273/426) and casual male and female partners (48.5%; 195/402) was common, as was the inconsistent use of condom‐compatible lubricants (CCLs) (26.3%; 124/472). In Douala, preferring a receptive sexual role was associated with prevalent HIV infection [adjusted odds ratio (aOR) 2.33, 95% CI 1.02–5.32]. Compared to MSM without HIV infection, MSM living with HIV were more likely to have ever accessed a health service targeting MSM in Douala (aOR 4.88, 95% CI 1.63–14.63). In Yaoundé, MSM living with HIV were more likely to use CCLs (aOR 2.44, 95% CI 1.19–4.97). Conclusions: High HIV prevalence were observed and condoms and CCLs were used inconsistently indicating that MSM are a priority population for HIV prevention, treatment and care services in Douala and Yaoundé. Building the capacity of MSM community organizations and improving the delivery and scale‐up of multimodal interventions for MSM that are sensitive to concerns about confidentiality and the complex individual, social, community‐level and policy challenges are needed to successfully engage young MSM in the continuum of HIV care. In addition to scaling up condom and CCL access, evaluating the feasibility of novel biomedical interventions, including antiretroviral pre‐exposure prophylaxis and early antiretroviral therapy for MSM living with HIV in Cameroon, is also warranted., Introduction Globally, it has been observed that HIV prevalence among men who have sex with men (MSM) significantly exceeds HIV prevalence in the general population, even in the context of [...]

Introduction: The West and Central Africa (WCA) sub-region is the most populous region of sub-Saharan Africa (SSA), with an estimated population of 356 million living in 24 countries. The HIV epidemic in WCA appears to have distinct dynamics compared to the rest of SSA, being more concentrated among key populations such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID) and clients of FSWs. To explore the epidemiology of HIV in the region, a systematic review of HIV literature among key populations in WCA was conducted since the onset of the HIV epidemic. Methods: We searched the databases PubMed, CINAHL and others for peer-reviewed articles regarding FSWs, MSM and PWID in 24 countries with no date restriction. Inclusion criteria were sensitive and focused on inclusion of any HIV prevalence data among key populations. HIV prevalence was pooled, and in each country key themes were extracted from the literature. Results: The search generated 885 titles, 214 abstracts and 122 full articles, of which 76 met inclusion and exclusion criteria providing HIV prevalence data. There were 60 articles characterizing the burden of disease among FSWs, eight for their clients, one for both, six for MSM and one for PWID. The pooled HIV prevalence among FSWs was 34.9% (n = 14,388/41,270), among their clients was 7.3% (n = 435/5986), among MSM was 17.7% (n = 656/3714) and among PWID from one study in Nigeria was 3.8% (n = 56/1459). Conclusions: The disproportionate burden of HIV among FSWs appears to be consistent from the beginning of the HIV epidemic in WCA. While there are less data for other key populations such as clients of FSWs and MSM, the prevalence of HIV is higher among these men compared to other men in the region. There have been sporadic reports among PWID, but limited research on the burden of HIV among these men and women. These data affirm that the HIV epidemic in WCA appears to be far more concentrated among key populations than the epidemics in Southern and Eastern Africa. Evidence-based HIV prevention, treatment and care programmes in WCA should focus on engaging populations with the greatest burden of disease in the continuum of HIV care. Keywords: men who have sex with men; sex work; people who inject drugs; HIV epidemiology; West Africa; Central Africa; prevalence; risk factors. To access the supplementary material to this article please see Supplementary Files under Article Tools online., Introduction The sub-region of West and Central Africa (WCA) is the most populous of sub-Saharan Africa (SSA), with a combined population of roughly 356 million [1]. The region possesses a [...]

Objective: In this paper, we describe the implementation of a novel nutrition education intervention "¡Buen Provecho! - Eat Well" that aims to improve nutrition education, reduce food insecurity, increase healthy eating, and foster school engagement for families of pre-kindergarten through first grade students in 5 public schools in a low-income New York City neighborhood over 3 years. Methods: The intervention included free, weekly parent breakfasts with nutrition discussions, complemented by a common core-integrated classroom nutrition curriculum. A process evaluation assessed program uptake and feasibility of implementation, characterized participants, and identified lessons learned. Data sources included parent breakfast attendance records, parent surveys, and teacher interviews. Results: In the program's first year, 24% (169/717) of eligible children's parents attended at least one of the 130 breakfasts held. Parents redeemed 46% of the produce vouchers. We had 173 parents complete surveys. According to survey results, one-third of parents and children ate fruit daily, and 33% of children and 27% of parents ate vegetables daily. Nine of 36 teachers who had received the classroom curriculum were interviewed, and taught an average of 19% of the lessons from the curriculum. Conclusion: ¡Buen Provecho! - Eat Well has promising uptake and implementation. [ABSTRACT FROM AUTHOR]

Despite the Internet's global importance as a sex-seeking venue for men who have sex with men (MSM) and other sexual and gender minorities, little is known about this topic in sub-Saharan Africa. Furthermore, existing public health research offers limited insight into the sociocultural aspects of sexuality and how they articulate with patterns in online sex-seeking behavior. In 2015, we conducted survey and ethnographic research with 105 sexual and gender minorities in Abidjan, Côte d'Ivoire. Nearly half of survey respondents reported finding partners primarily online. Three quarters reported having found at least one partner online. Interviews with 24 of the survey participants revealed that a primary motivation for using online venues was that they allowed for the preservation and management of discretion and anonymity, permitting users to avoid discrimination and violence. While secondary to their strategies for managing such social risk, participants also reported using the profile features of online venues to filter out partners they perceived as presenting a risk to their sexual health. Though interview participants perceived online venues as providing a degree of protection against potential stigma and violence in offline contexts, survey data showed that over one quarter of participants had experienced extortion and/or blackmail by sexual partners they met online. By taking into account the sociocultural context of sexuality and sexual activity in Abidjan, these findings highlight the disjuncture between essentialist notions of MSM who use the Internet to find sex partners as a universal, at-risk group, and the complexity of sexual and gender minorities' experiences. [ABSTRACT FROM AUTHOR]

The correlation between current alcohol use and sexual risk behaviors among men who have sex with men (MSM) is well documented, but little is known about age of drinking onset and current risks among this population. Data from a 2008 Internet survey of 8,452 MSM in the United States were used to assess factors associated with age of onset of alcohol use. In a multivariable model, drinking onset before age 15 was significantly associated with a higher number of lifetime male anal sex partners and being behaviorally bisexual in the past 12 months. Men who reported depressive symptoms in the past two weeks or who screened positive for alcohol abuse in the past 60 days were more likely to have early age of drinking onset. Findings suggest the need for targeting younger adolescents for alcohol screening, particularly sexual minority youth, to prevent risk behaviors in adulthood. [ABSTRACT FROM AUTHOR]

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]