Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy ... more Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011-March 2012 using respondent driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% (95%CI:20.3- 31.4) of MSM (106/329) reported primarily usingWBL during anal sex. In multivariable analysis, higher income (aOR:5.9; 95%CI:2.48-14.19), family being aware of their sexual practices (aOR:2.52; 95%CI:1.29-4.92), and reporting consistent condom use in the last six months (aOR:1.27; 95%CI:1.06-1.52) were positively associated with WBL use. Increasing age (per one year increase in age) (aOR:0.89; 95%CI:0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggest the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.
BackgroundHIV risks are heterogeneous in nature even in generalized epidemics. However, data are ... more BackgroundHIV risks are heterogeneous in nature even in generalized epidemics. However, data are often missing for those at highest risk of HIV, including female sex workers. Statistical models may be used to address data gaps where direct, empiric estimates do not exist.MethodsWe proposed a new size estimation method that combines multiple data sources (the Malawi Biological and Behavioral Surveillance Survey, the Priorities for Local AIDS Control Efforts study, and Malawi Demographic Household Survey). We employed factor analysis to extract information from auxiliary variables, and constructed a linear mixed effects model for predicting population size for all districts of Malawi.ResultsOn average, the predicted proportion of FSW among women of reproductive age across all districts was about 0.58%. The estimated proportions seemed reasonable in comparing with a recent study PLACE II. Compared to using a single data source, we observed increased precision and better geographic coverage.ConclusionsWe illustrate how size estimates from different data sources may be combined for prediction. Applying this approach to other sub-populations in Malawi and to countries where size estimate data are lacking can ultimately inform national modeling processes and estimate the distribution of risks and priorities for HIV prevention and treatment programs.
Malawi has a population of around 20 million people and is one of the world's most economically d... more Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and
BMC International Health and Human Rights, Jun 3, 2014
Background: In the context of a generalized epidemic and criminalization of homosexuality, men wh... more Background: In the context of a generalized epidemic and criminalization of homosexuality, men who have sex with men (MSM) in Malawi have a disproportionate burden of HIV compared to other adults. Past research has documented low uptake of HIV prevention and health services among MSM, self-reported fear of seeking health services, and concerns of disclosure of sexual orientation and discrimination in health settings. Qualitative research was conducted among MSM and health service providers in Blantyre, Malawi to understand underlying factors related to disclosure and health seeking behaviors and inform the development of a community-based comprehensive HIV prevention intervention. Methods: Using peer recruitment, eight MSM participants representing a range of ages, orientations, and social and behavioral characteristics were enrolled for in-depth interviews. Five service providers were recruited from the district hospital, local health and STI clinics, and a HIV prevention service organization. We use the Health Belief Model as a framework to interpret the influential factors on 1) health seeking and uptake among MSM, and 2) influences on provision of services by healthcare providers for MSM. Results: Results highlight disclosure fears among MSM and, among providers, a lack of awareness and self-efficacy to provide care in the face of limited information and political support. Service providers reported concerns of adverse repercussions related to the provision of services to men in same sex sexual relationships. Some MSM demonstrated awareness of HIV risk but believed that within the wider MSM community, there was a general lack of HIV information for MSM, low awareness of appropriate prevention, and low perception of risks related to HIV infection. Conclusions: Qualitative research highlights the need for appropriate information on both HIV risks and acceptable, effective HIV prevention options for MSM. Information and educational opportunities should be available to the wider MSM community and the health sector. Health sector interventions may serve to increase cultural and clinical competency to address health problems experienced by MSM. To ensure availability and use of services in light of the criminalization and stigmatization of same sex practices, there is need to increase the safety of uptake and provision of these services for MSM.
Background The participant recruitment process is a key ethical pivot point when conducting robus... more Background The participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to fulfill study requirements is an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants’ motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi. Methods We conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group di...
Background: Dual infection with HIV-1 and HIV-2, which is not uncommon in West Africa, has import... more Background: Dual infection with HIV-1 and HIV-2, which is not uncommon in West Africa, has important implications for transmission, progression, and antiretroviral therapy. Few studies have examined HIV viral dynamics in this setting. Methods: We compared HIV-1 and HIV-2 viral loads from 65 dually infected, antiretroviral therapy-naïve Senegalese subjects. Participants provided demographic information and blood, oral fluid, and cervicovaginal lavage (CVL) or semen samples for virologic and immunologic testing. Associations between HIV-1 and HIV-2 levels in plasma, PBMC, oral and genital samples were assessed using linear regression models with generalized estimating equations to account for subjects with multiple samples over time. Results: In analyses adjusting for CD4 count, age, sex, and commercial sex work, HIV-1 RNA levels were significantly higher than HIV-2 levels in semen (b02.05 log 10 copies/ml, 95% CI 0.44 to 3.66), CVL (b 01.37, 95% CI 0.83 to 1.91), and oral fluids (b 01.93, 95% CI 1.56 to 2.30). HIV-1 and HIV-2 PBMC viral DNA loads were similar in those with normal immune function (CD4 counts above 500 cells/ml) (b 00.17 log 10 copies/mg of PBMC DNA, 95% CIÁ0.58 to 0.24), but compared to those with high CD4 counts, subjects with CD4 counts below 500 cells/ml had higher HIV-1 and lower HIV-2 levels. In plasma, subjects with CD4 counts above 500 cells/ml had mean HIV-1 plasma RNA viral loads 0.87 log 10 copies/ml higher (95% CI 0.35 to 1.38) than HIV-2, while among subjects with CD4 counts between 200 and 500 cells/ml or below 200 cells/ml, this difference increased to 4.28 and 4.35 log 10 copies/ml (95% CIs 2.51 to 6.04 and 2.67 to 6.04), respectively. Conclusion: Our data are consistent with the hypothesis that with decreasing CD4 counts and HIV disease progression, HIV-1 may outcompete HIV-2 in dually-infected individuals. This finding may help explain the differences in epidemiology between HIV-1 and HIV-2.
Background: We evaluated brief combination interventions to simultaneously reduce sexual and inje... more Background: We evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad Juarez (CJ) Mexico during 2008-2010, when harm reduction was expanding in TJ, but not CJ. Methods: FSW-IDUs ]18 years reporting recently sharing injection equipment and unprotected sex with clients participated in a randomized factorial trial comparing four brief, single-session combinations of active motivational-interviewing and didactic interventions focused on negotiating safer-sex in the context of drug use and safer-injection skills. The injection intervention included a video made by FSW-IDUs. Women underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and
This letter explores the societal aspects and healthcare implications that underlie thinking abou... more This letter explores the societal aspects and healthcare implications that underlie thinking about monkeypox, in the 2022 outbreak, as a sexually transmitted infection (STI). The authors examine what underlies this question, exploring what is an STI, what is sex, and what is the role of stigma in sexual health promotion. The authors argue that, in this specific outbreak, monkeypox is an STI among men who have sex with men (MSM). The authors highlight the need of critically thinking about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences.
Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy ... more Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011-March 2012 using respondent driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% (95%CI:20.3- 31.4) of MSM (106/329) reported primarily usingWBL during anal sex. In multivariable analysis, higher income (aOR:5.9; 95%CI:2.48-14.19), family being aware of their sexual practices (aOR:2.52; 95%CI:1.29-4.92), and reporting consistent condom use in the last six months (aOR:1.27; 95%CI:1.06-1.52) were positively associated with WBL use. Increasing age (per one year increase in age) (aOR:0.89; 95%CI:0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggest the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.
A qualitative assessment of health seeking practices among and provision practices for men who ha... more A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi
Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy ... more Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011-March 2012 using respondent driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% (95%CI:20.3- 31.4) of MSM (106/329) reported primarily usingWBL during anal sex. In multivariable analysis, higher income (aOR:5.9; 95%CI:2.48-14.19), family being aware of their sexual practices (aOR:2.52; 95%CI:1.29-4.92), and reporting consistent condom use in the last six months (aOR:1.27; 95%CI:1.06-1.52) were positively associated with WBL use. Increasing age (per one year increase in age) (aOR:0.89; 95%CI:0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggest the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.
BackgroundHIV risks are heterogeneous in nature even in generalized epidemics. However, data are ... more BackgroundHIV risks are heterogeneous in nature even in generalized epidemics. However, data are often missing for those at highest risk of HIV, including female sex workers. Statistical models may be used to address data gaps where direct, empiric estimates do not exist.MethodsWe proposed a new size estimation method that combines multiple data sources (the Malawi Biological and Behavioral Surveillance Survey, the Priorities for Local AIDS Control Efforts study, and Malawi Demographic Household Survey). We employed factor analysis to extract information from auxiliary variables, and constructed a linear mixed effects model for predicting population size for all districts of Malawi.ResultsOn average, the predicted proportion of FSW among women of reproductive age across all districts was about 0.58%. The estimated proportions seemed reasonable in comparing with a recent study PLACE II. Compared to using a single data source, we observed increased precision and better geographic coverage.ConclusionsWe illustrate how size estimates from different data sources may be combined for prediction. Applying this approach to other sub-populations in Malawi and to countries where size estimate data are lacking can ultimately inform national modeling processes and estimate the distribution of risks and priorities for HIV prevention and treatment programs.
Malawi has a population of around 20 million people and is one of the world's most economically d... more Malawi has a population of around 20 million people and is one of the world's most economically deprived nations. Severe mental illness (largely comprising psychoses and severe mood disorders) is managed by a very small number of staff in four tertiary facilities, aided by clinical officers and nurses in general hospitals and clinics. Given these constraints, psychosis is largely undetected and untreated, with a median duration of untreated psychosis (DUP) of around six years. Our aim is to work with people with lived experience (PWLE), caregivers, local communities and health leaders to develop acceptable and sustainable psychosis detection and management systems to increase psychosis awareness, reduce DUP, and to improve the health and lives of people with psychosis in Malawi. We will use the UK Medical Research Council guidance for developing and evaluating complex interventions, including qualitative work to explore diverse perspectives around psychosis detection, management, and outcomes, augmented by co-design with PWLE, and underpinned by a Theory of Change. Planned deliverables include a readily usable management blueprint encompassing education and community supports, with an integrated care pathway that includes Primary Health Centre clinics and District Mental Health Teams. PWLE and
BMC International Health and Human Rights, Jun 3, 2014
Background: In the context of a generalized epidemic and criminalization of homosexuality, men wh... more Background: In the context of a generalized epidemic and criminalization of homosexuality, men who have sex with men (MSM) in Malawi have a disproportionate burden of HIV compared to other adults. Past research has documented low uptake of HIV prevention and health services among MSM, self-reported fear of seeking health services, and concerns of disclosure of sexual orientation and discrimination in health settings. Qualitative research was conducted among MSM and health service providers in Blantyre, Malawi to understand underlying factors related to disclosure and health seeking behaviors and inform the development of a community-based comprehensive HIV prevention intervention. Methods: Using peer recruitment, eight MSM participants representing a range of ages, orientations, and social and behavioral characteristics were enrolled for in-depth interviews. Five service providers were recruited from the district hospital, local health and STI clinics, and a HIV prevention service organization. We use the Health Belief Model as a framework to interpret the influential factors on 1) health seeking and uptake among MSM, and 2) influences on provision of services by healthcare providers for MSM. Results: Results highlight disclosure fears among MSM and, among providers, a lack of awareness and self-efficacy to provide care in the face of limited information and political support. Service providers reported concerns of adverse repercussions related to the provision of services to men in same sex sexual relationships. Some MSM demonstrated awareness of HIV risk but believed that within the wider MSM community, there was a general lack of HIV information for MSM, low awareness of appropriate prevention, and low perception of risks related to HIV infection. Conclusions: Qualitative research highlights the need for appropriate information on both HIV risks and acceptable, effective HIV prevention options for MSM. Information and educational opportunities should be available to the wider MSM community and the health sector. Health sector interventions may serve to increase cultural and clinical competency to address health problems experienced by MSM. To ensure availability and use of services in light of the criminalization and stigmatization of same sex practices, there is need to increase the safety of uptake and provision of these services for MSM.
Background The participant recruitment process is a key ethical pivot point when conducting robus... more Background The participant recruitment process is a key ethical pivot point when conducting robust research. There is a need to continuously review and improve recruitment processes in research trials and to build fair and effective partnerships between researchers and participants as an important core element in ensuring the ethical delivery of high-quality research. When participants make a fair, informed, and voluntary decision to enroll in a study, they agree to fulfill their roles. However, supporting study participants to fulfill study requirements is an important ethical obligation for researchers, yet evidenced as challenging to achieve. This paper reports on participants’ motivations to volunteer and remain part of a dietary study conducted in Kasungu District, Malawi. Methods We conducted twenty in-depth interviews (with chiefs, religious leaders, trial participants, and health surveillance assistants), five systematic ethnographic observations, and fourteen focus group di...
Background: Dual infection with HIV-1 and HIV-2, which is not uncommon in West Africa, has import... more Background: Dual infection with HIV-1 and HIV-2, which is not uncommon in West Africa, has important implications for transmission, progression, and antiretroviral therapy. Few studies have examined HIV viral dynamics in this setting. Methods: We compared HIV-1 and HIV-2 viral loads from 65 dually infected, antiretroviral therapy-naïve Senegalese subjects. Participants provided demographic information and blood, oral fluid, and cervicovaginal lavage (CVL) or semen samples for virologic and immunologic testing. Associations between HIV-1 and HIV-2 levels in plasma, PBMC, oral and genital samples were assessed using linear regression models with generalized estimating equations to account for subjects with multiple samples over time. Results: In analyses adjusting for CD4 count, age, sex, and commercial sex work, HIV-1 RNA levels were significantly higher than HIV-2 levels in semen (b02.05 log 10 copies/ml, 95% CI 0.44 to 3.66), CVL (b 01.37, 95% CI 0.83 to 1.91), and oral fluids (b 01.93, 95% CI 1.56 to 2.30). HIV-1 and HIV-2 PBMC viral DNA loads were similar in those with normal immune function (CD4 counts above 500 cells/ml) (b 00.17 log 10 copies/mg of PBMC DNA, 95% CIÁ0.58 to 0.24), but compared to those with high CD4 counts, subjects with CD4 counts below 500 cells/ml had higher HIV-1 and lower HIV-2 levels. In plasma, subjects with CD4 counts above 500 cells/ml had mean HIV-1 plasma RNA viral loads 0.87 log 10 copies/ml higher (95% CI 0.35 to 1.38) than HIV-2, while among subjects with CD4 counts between 200 and 500 cells/ml or below 200 cells/ml, this difference increased to 4.28 and 4.35 log 10 copies/ml (95% CIs 2.51 to 6.04 and 2.67 to 6.04), respectively. Conclusion: Our data are consistent with the hypothesis that with decreasing CD4 counts and HIV disease progression, HIV-1 may outcompete HIV-2 in dually-infected individuals. This finding may help explain the differences in epidemiology between HIV-1 and HIV-2.
Background: We evaluated brief combination interventions to simultaneously reduce sexual and inje... more Background: We evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad Juarez (CJ) Mexico during 2008-2010, when harm reduction was expanding in TJ, but not CJ. Methods: FSW-IDUs ]18 years reporting recently sharing injection equipment and unprotected sex with clients participated in a randomized factorial trial comparing four brief, single-session combinations of active motivational-interviewing and didactic interventions focused on negotiating safer-sex in the context of drug use and safer-injection skills. The injection intervention included a video made by FSW-IDUs. Women underwent quarterly interviews and testing for HIV, syphilis, gonorrhea, Chlamydia and
This letter explores the societal aspects and healthcare implications that underlie thinking abou... more This letter explores the societal aspects and healthcare implications that underlie thinking about monkeypox, in the 2022 outbreak, as a sexually transmitted infection (STI). The authors examine what underlies this question, exploring what is an STI, what is sex, and what is the role of stigma in sexual health promotion. The authors argue that, in this specific outbreak, monkeypox is an STI among men who have sex with men (MSM). The authors highlight the need of critically thinking about how to communicate effectively, the role of homophobia and other inequalities, and the importance of the social sciences.
Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy ... more Condom compatible lubricants (CCL) including water-based lubricants (WBL) represent one strategy to prevent the breakage of latex condoms and thus decrease the risk of HIV transmission during anal intercourse. The analyses presented here characterize the correlates of WBL use during anal sex among men who have sex with men (MSM) in Blantyre, Malawi enrolled from April 2011-March 2012 using respondent driven sampling (RDS). Bivariate and multivariable logistic regression analyses with RDS-weighting were conducted on a total sample of 338 MSM. With RDS-weighting, 25.4% (95%CI:20.3- 31.4) of MSM (106/329) reported primarily usingWBL during anal sex. In multivariable analysis, higher income (aOR:5.9; 95%CI:2.48-14.19), family being aware of their sexual practices (aOR:2.52; 95%CI:1.29-4.92), and reporting consistent condom use in the last six months (aOR:1.27; 95%CI:1.06-1.52) were positively associated with WBL use. Increasing age (per one year increase in age) (aOR:0.89; 95%CI:0.83-0.95) was negatively associated with WBL. Taken together, these data highlight the limited uptake of WBL among MSM in Blantyre, Malawi especially among older men and those belonging with lower income. Older MSM in Malawi are known to have a higher prevalence of HIV and lower reported use of WBL suggesting significant risks of onward HIV transmission. Separately, the limited use among those with lower incomes suggest the need for free or subsidized distribution of CCL together with condoms and counseling about their use specifically for MSM in Malawi.
A qualitative assessment of health seeking practices among and provision practices for men who ha... more A qualitative assessment of health seeking practices among and provision practices for men who have sex with men in Malawi
Uploads
Papers by Eric Umar