1. ENHANCING BENEFITS OR INCREASING HARMS COMMUNITY RESPONSES FOR HIV AMONG KEY POPULATIONS Stefan Baral, MD MPH FRCPC Center for Public Health and Human Rights, Johns Hopkins School of Public Health

2. Acknowledgements  Coauthors  Claire Holland, Kate Shannon, Carmen Logie, Paul Semugoma, Bhekie Sithole, Erin Papworth, Fatou Drame, Chris Beyrer  Acknowledgements  Beth Mallalieu  Lynn Van Lith

3. Outline  Background  Key Populations Female Sex Workers Men who have Sex with Men People who Inject Drugs Transgender People  Community Level Determinants of HIV  Search Protocol Methods  Results  Conclusions and Moving Forward

4. Most At Risk or Key Populations  Populations that have specific acquisition and transmission risk factors for HIV  Three Universal Key Populations Sex workers (SW) and their clients Gay Men and other Men who have sex with Men (MSM) People who Use Drugs (PUD)  Country Specific Key Populations Migrant populations Fisherfolk, Truckers Often clients of sex workers

5. Levels of HIV Acquisition and Transmission Risks Source: Baral, Logie, et al. Modified Social Ecological Model of HIV Risk. BMC Public Health. 2013

6. Map of HIV prevalence among female sex workers in low-income and middle-income countries, 2007-2011  Pooled OR for HIV infection among FSW compared to other reproductive age women  13.49 (95% CI 10.04-18.12)

7. Source: Beyrer, Baral, van Griensven, Goodreau, Chariyalertsak, Wirtz, Brookmeyer, The Lancet, 2012 Global HIV prevalence among MSM, 2007-2011

8. Legend 2002 2003 2004 2005 2006 2007 2008 Senegal 21.5% (463) 21.8% (501) Ghana 25.0% (N/A) Nigeria 13.4% (1,125) Sudan 9.3% (713) 7.3% (406) Kenya 24.6% (285) Tanzania 12.3% (509) Malawi 21.4% (201) Soweto 28.9% (249) Botswana 19.7% (117) 25.0% (200) Cape Town (Township) Cape Town 10.6% (538) Namibia 12.4% (218) Egypt 6.2% (267) HIV Prevalence among MSM in Africa Modified From : van Griensven, Baral, et al. The Global Epidemic of HIV Infection among Men who have Sex with Men. Curr Opinion on HIV/AIDS, 2009 2009 2010 2011 17.2% (1,291) The Gambia 13.3% (215) 4.9% (1,778) Tunisia 4.4% (90) Morocco 5.7% (259) 13.2% (306) Uganda 5.9% (262) 40.7% (285) 19.0% (563)

9. Map of HIV prevalence among transgender women, 2000-2011  Pooled OR for HIV infection among TGW compared to other reproductive people.  48.8 (95% CI 31.2-76.3)

10. Source: Mathers, et, al, Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet, 2008 HIV prevalence among PWID in 2011

11. PrEP Trial & productPopulationNCountryExpected Completion FTC/TDF (Intervention to Enhance PrEP Uptake and Adherence in a Community-Based Setting) GMT445 Callen-Lorde Clinic, NYC, US 2015 TDF2 OLE TDF/FTC heterosexual men & women 1,219BotswanaNov 2013 iPrEX OLE TDF/FTC GMT1,770 Brazil, Ecuador, Peru, South Africa, Thailand & U.S. Early 2014 Many ongoing & planned Phase III/IV research & feasibility/demonstration projects ≥ 17 studies with GMT Feasibility studies in FSW in Nigeria, Kenya, RSA, Benin, Senegal supported by BMGF

12. PrEP TrialProductPopulationNCountry Expected Completion HPTN073FTC/TDFBlack MSM ≥18 years225U.S.June 2015 PrEP at STD Clinics FTC/TDF GMT600U.S.Dec 2014 Project PrEPareFTC/TDFYoung MSM 15-22 years300U.S.March 2016 Partners Demonstration Project FTC/TDFHeterosexual serodiscordant couples 1000 Kenya & Uganda 2015 SibanyeFTC/TDFMSM200South Africa2015 Demo PrEP FTC/TDF GMT400BrazilJan 2016 PROUD Immediate or deferred FTC/TDF MSM500U.K.Early 2015 PATH-PrEP FTC/TDF GMT375U.S.May 2017 VicPrEP StudyFTC/TDFHigh risk men & women--Australia2015 SAPPH-Ire FTC/TDF (C-RTC of combination prevention incl. PrEP) Female sex workers 2800ZimbabweOct 2015

13. Oral PrEP – Dosing/Regimens Study TrialInterventionPopulationNCountry Expected Completion ADAPT Study/ HPTN067 FTC/TDF: daily, time- based, or event- based Inc. MSM & TGW 540 South Africa, Thailand & U.S. July 2014 NEXT-PrEP/ HPTN069 Daily MVC, MVC+FTC, MVC+TDF, or FTC/TDF MSM & women 600U.S.Dec 2014 IPERGAY/ CTN 268 ANRS Intermittent FTC/TDF or placebo MSM1900 Canada & France Dec 2016

14. Topical PrEP – Ongoing Research TrialInterventionPopulationNCountry Expected Completion FACTS 0011% TDF gel Women 18- 30 2900South AfricaDec 2014 CAPRISA 008 1% TDF gelWomen700South AfricaFeb 2015 MTN-017 TDF rectal microbicide GMT186 Peru, South Africa, Thailand, U.S. Dec 2014 ASPIRE/ MTN-020 Dapivirine vaginal ring Women 18- 45 3476 Malawi, Uganda, South Africa & Zimbabwe Dec 2014 / early 2015 The Ring Study/ IPM 027 Dapivirine vaginal ring Women 18- 45 1650 Rwanda & South Africa Aug 2015

15. Acute Infection/Universal ART Study TrialInterventionPopulationN Countr y/ Region Expected Completion "Test & Treat" Indonesia Immediate ART Y1, immediate ART & CB intervention package Y2 MSM, FSW, PWID -- Indonesi a TBD Integrated Care Clinics (ICC) for IDUs in India IDU-oriented ICCs for improving "seek, test, treat, and retain" continuum PWID & MSM1000India2016 Multi-component Intervention Packages Package of Test & Link-to-Care interventions MSM--China2015

16. Universal Coverage of ART TrialInterventionPopulationN Country/ Region Expected Completion Thai MSM/TG Test & Treat Study Universal HIV testing & ART regardless of CD4 GMT2000ThailandDec 2014 CDC Test & Treat Thailand Universal HIV testing & ART regardless of CD4 GMT8000ThailandTBD Test and Treat - Peru Immediate ART vs. ART after 24 weeks GMT150PeruDec 2016 ART for prevention & treatment Immediate ART Serodiscordant couples 150Viet NamDec 2014 Early ART among PWID Immediate ARTPWIDViet NamDec 2015 Anza Mapema Immediate ART; Comprehensive package of find, test, link & retain in care (FTLR) interventions MSM700KenyaTBD

17. Studies for Transgender Women  NIH Funded Studies  Feasibility study of an anti-stigma intervention among health care providers in Mumbai, India to improve access to HIV services for hijra  Feasibility study of a telemedicine approach to improving engagement in care among TGW of color in Washington, DC  RCT of the LifeSkills program (a six session, peer-led, group intervention for sexually active TGW ages 16-24 years) in Boston and Chicago.  RCT of T-Talk, a peer-led harm reduction and social support intervention for TGW in New York City  Pilot RCT of Sheroes, a 5-session group intervention based on gender affirmation in the USA.

18. Community Level Determinants  Reinforce stigma and discrimination  Stigmas Sexual stigma, transphobia, HIV-related stigma Intersecting/layered stigmas  Pejorative public discourse limits the effectiveness of health communication programs for these populations  Promote health and well-being  Social Capital Inclusion, Participation, and Cohesion

19. Objective  Synthesize the evidence characterizing the community-level determinants that potentiate or mitigate HIV-related outcomes for key populations

20. Search protocol  Search Strategy  Medical subject headings (MeSH)/key terms HIV Sex workers, gay men/MSM, transgender women, and people who inject drugs Community- or social-level determinants  Inclusion Criteria  Peer-reviewed literature review from 2000 to 2014  Low and middle income countries (LMIC)  Contained community- or social-level associations with HIV and HIV related risk (ie sexual behaviours)

21. Search Results  1191 unique articles were obtained from the search  132 articles were included in the full text review 22 articles contained community- or social-level associations with HIV or HIV-related outcomes

22. Map of low-income and middle-income countries reporting community level measurements for HIV risk among key populations, 2000-2014

23. Results Men who have Sex with Men  Mitigating HIV Risks  Participating in HIV Prevention Programs in Beijing OR 2.3 (95% CI 1.3-4.0) knowing 10 or more MSM  Potentiating HIV Risks  Prevalent HIV infections in Kampala, Uganda OR 4.3 (95% CI 1.3-14.0) exposure to homophobic abuse Sources: Ma W, Raymond HF, Wilson EC, et al. Participation of HIV prevention programs among men who have sex with men in two cities of China—a mixed method study. BMC Public Health. 2012; Hladik W, Barker J, Ssenkusu JM, et al. HIV infection among men who have sex with men in Kampala, Uganda—a respondent driven sampling survey. PLoS One. 2012.

24. Results Female sex workers  Studies regularly focused on measuring social participation and cohesion among FSW  Consistent condom use with all partners  Swaziland OR 2.3 (95% CI 1.3-3.9) social cohesion  China OR 1.2 (p<.01) peer support for condom use Sources: Fonner VA, Kerrigan D, Mnisi Z, et al. Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland. PloS One. 2014; Correlates of consistent condom use among female entertainment workers in Shanghai, China: a repeated measures analysis. Int J STD AIDS. 2013.

25. Results Transgender people  Limited studies in LMIC focused on this population  Consistent condom use with a paying partner in India OR 1.9 (95% CI 1.5-2.3) collective efficacy among high-risk MSM and transgender women Source: Saggurti N, Mishra RM, Proddutoor L, et al. Community collectivization and its association with consistent condom use and STI treatment seeking behaviors among female sex workers and high-risk men who have sex with men/transgenders in Andhra Pradesh, India. Aids Care. 2013.

26. Results People who inject drugs  Limited data measuring community- and social-level determinants among PWID  Highly criminalized population  Avoiding HIV testing in Bangkok, Thailand OR 6.7 (95% CI 3.1-14.7) ever been refused health care services Source: Ti L, Hayashi K, Kaplan K, et al. HIV test avoidance among people who inject drugs in Thailand. AIDS Behavior. 2013.

27. Conclusions  Predominant majority of epidemiologic and surveillance studies have focused on individual-level determinants of HIV risk among key populations  Community determinants  Contextualize HIV-related risk behaviors among key populations  Affect the coverage of HIV prevention, treatment, and care services by mitigating both the provision and uptake of services

28. Ways Forward  Epidemiology and Prevention Programs  Increased measurement and characterizations of community-level determinants of HIV risk is needed to Characterize barriers to service provision and uptake for key populations Translate efficacious HIV prevention interventions to effective and scalable HIV prevention, treatment, and care programs  Policy  Failure to address each level of HIV risk will cost lives, harm communities, and undermine the gains of the HIV response