Explore the vast range of titles available.

The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration. To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010–13) of incidence, drug resistance, and coverage of insecticide-treated bednets. Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990. Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. Incidence rates for HIV, tuberculosis, and malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action. Bill & Melinda Gates Foundation.

Background: Women employed by sex work (WESW) have a high risk of human immunodeficiency virus (HIV) infection and experience economic barriers in accessing care. However, few studies have described their financial lives and the relationship between expenditures and HIV-related behaviors. Methods: This exploratory study used financial diaries to collect expenditure and income data from WESW in Uganda over 6 months. Data were collected as part of a larger trial that tested the efficacy of an HIV prevention intervention method. Descriptive statistics were used to quantify women’s income, relative expenditures, and negative cash balances. Bivariate and multivariate logistic regressions were used to examine the odds of sexual risk behavior or use of HIV medications for several cash scenarios. Results: A total of 163 WESW were enrolled; the participants mean age was 32 years old. Sex work was the sole source of employment for most WESW (99%); their average monthly income was $62.32. Food accounted for the highest proportion of spending (44%) followed by sex work (20%) and housing expenditures (11%). WESW spent the least on health care (5%). Expenditures accounted for a large but variable proportion of these women’s income (56% to 101%). Most WESW (74%) experienced a negative cash balance. Some also reported high sex work (28%), health care (24%), and education (28%) costs. The prevalence of condomless sex (77%) and sex with drugs/alcohol (70%) was high compared to use of ART/PrEP (Antiretroviral therapy/Pre-exposure prophylaxis) medications (45%). Women’s cash expenditures were not statistically significantly associated with HIV-related behaviors. However, the exploratory study observed a consistent null trend of lower odds of condomless sex (adjusted odds ratio (AOR) = 0.70, 95% confidence interval (CI): 0.28–1.70), sex with drugs/alcohol (AOR = 0.93, 95% CI: 0.42–2.05), and use of ART/PrEP (AOR = 0.80, 95% CI: 0.39–1.67) among women who experienced a negative cash balance versus those who did not. Similar trends were observed for other cash scenarios. Conclusion: Financial diaries are a feasible tool to assess the economic lives of vulnerable women. Despite having paid work, most WESW encountered a myriad of financial challenges with limited spending on HIV prevention. Financial protections and additional income-generating activities may improve their status. More robust research is needed to understand the potentially complex relationship between income, expenditures, and HIV risk among vulnerable sex workers.

Background Some male heterosexual clients prefer to visit a cross-border Female Sex Worker (FSW) because of cheaper sex and unsafe sex practices, and may therefore be at risk for sexually transmitted infections (STI). The objective of this study was to assess whether having commercial cross-border sex is an independent risk factor for being diagnosed with a STI. Methods An observational retrospective study was performed using data of 8 Dutch STI clinics bordering Germany, between 2011 and 2013. All male heterosexual clients of FSWs were selected and data on country of FSW visit and occurrence of STI were used for multivariable regression analysis. Results The study population consisted of 2664 clients of FSW. Most clients visited the Netherlands (82.4%), followed by visits to another country (beyond cross-border) (9.9%) and cross-border visits (7.8%). Clients of FSW were less likely to be STI positive when they were younger than 25 years(OR = 0.6, 95%CI 0.4 to 0.8 25–44 years and OR = 0.5, 95%CI 0.4 to 0.7 older than 45 years), and more likely when they had 20 or more sex partners in the last 6 months (OR = 2.9, 95%CI 1.9 to 4.4), did not use a condom during last sexual contact (OR = 2.2, 95%CI 1.6 to 2.9) and made cross-border visits (OR = 1.7, 95%CI 1.1 to 2.6). Conclusions As cross-border visits appears to be a novel independent risk factor for STI in clients of FSW, this group should therefore be advised on STI prevention.

Despite their large numbers, and important role in the HIV epidemic in India, male clients of female sex workers (FSWs) are a difficult to reach population and little is known about their sexual behaviors. Using data from an integrated behavioral and biological assessment of 684 clients in Bangalore in 2012, we examined factors associated with their reports of having sex with three or more different female sex workers in the last month, and anal sex with sex workers. We included sociodemographic and sexual behavior factors and, for the first time in client studies in India, included data on the use of pornography and sexual enhancement products (SEPs) such as pills, oils, and sprays, in our multivariable analyses of client risk. Seventy-eight percent of clients had seen pornographic material and 8 % reported ever having used SEPs. The profiles of men practicing the two risk behaviors examined were quite different. Travel in the past year, drunkenness in the past month, young age at first commercial sex, non-use of condoms at last sex, and finding sex workers in public places (but not use of pornography and SEPs) were independently associated with multiple partnering. Sex with a man or transsexual, being a white collar worker, seeking out FSWs at home, pornography and SEP use, and condom use at last FSW sex, were all independently associated with anal sex with an FSW. More research is needed to better understand the links between pornography and SEPs, and HIV risk behaviors, and HIV prevention programs need to be cognizant of the importance of ensuring that condom use is adequately promoted and supported in the context of anal sex in female sex worker–client interactions.

Female sex workers (FSWs) are key groups in the transmission of sexual transmitted infections (STI), and vaginal microbiome variations play an important role in transmission. We aimed to explore the characteristics of vaginal microbiome among FSWs. A total of 24 cross-border FSWs were randomly selected from a cross-sectional survey for female sex workers in southwest China. Thirty-seven female non-sex workers (FNSWs) were randomly selected from the gynecology clinic and health examination center. Vaginal swabs were collected, bacterial DNA extracted and 16S rRNA genes were sequenced. Differences in the vaginal microbiome between both groups were compared using bioinformatics analysis. One DNA sample was excluded due to unqualified concentration, therefore 60 samples were sequenced. FSWs had significantly different vaginal microbiota β diversity, but undifferentiated α diversity when compared with non-sex workers. The average relative abundance of , , , , , and among FSWs was higher than FNSWs, and relative abundance of in FSWs was lower than FNSWs. The genus was the major genus in both groups. At the species level, , and , in female sex workers, were lower when compared to FNSWs. There were distinct differences in vaginal bacteria variety between FSWs and FNSWs. Some disease-related genus were also more abundant in FSWs. Based on these observations, further research is required to identify microbiome communities related to high STI risks and other diseases in these cohorts.

Clients of female sex workers (CFSW) are at high risk of HIV transmission. Circumcision reduces the risk of heterosexual transmission of HIV. A total of 353 CFSW were interviewed using a combined interviewer-computer-assisted method. Amongst the participants, 28.0% were circumcised, whilst 63.8% of the uncircumcised participants were willing to take up circumcision (conditioned on being briefed about a 50% potential risk reduction effect). In a stepwise logistic regression model, frequency of patronizing female sex workers and factors related to the Health Belief Model were significantly associated with conditional willingness. Amongst uncircumcised participants, 20.9% anticipated risk compensation (i.e. would use condoms less frequently after being circumcised). Adjusting for background variables, inconsistent condom use during commercial sex and self-reported STD history in the last 6 months were significantly associated with anticipated risk compensation. It is feasible to promote circumcision among CFSW but such programs also need to promote condom use.

This paper presents findings from an ethnographic, community-based research project with women in the sex trade in London, Ontario, the first of its kind in this Canadian city. Drawing upon 19 semi-structured life-history interviews with women between 24 and 60 years of age who have taken part in various aspects of the sex trade (i.e. street-based, indoor, transactional), this discussion focuses on how they entered the trade, the types of sex trade work done and the relationships with their male clients. Among the most important findings is the diversity that informs the women’s experiences across these fundamental aspects of the trade, which is best understood against the trajectory of these women’s lives and their oscillating, complicated involvement in sex work over time. Unlike most studies of sex work entry, which contend that this is a singular occurrence, our participants experienced entry and re-entry many times as they transition between different types of sex work. Their involvement in the trade follows a basic pattern of beginning in privately arranged situations (i.e. exotic dancing, sugar daddies) and moving to primarily street-based work, a significant change that is mediated by structural and inter-personal factors like the loss of their children, inability to access social and health services and deepening addictions to drugs. The women’s experiences with their male clients are also characterized by diversity and change according to the kind of sex work done and a constellation of mutable forces like socioeconomic need and drug dependency. Our findings, especially those regarding the factors affecting the women’s transition to the most dangerous and criminalized form of sex work, street-based, represent important and much-needed information with which to develop tailored, effective social policies and service provision to make London’s sex trade more supported and safer for the women who work here.

Background We update a previous systematic review to inform new World Health Organization HIV self-testing (HIVST) recommendations. We compared the effects of HIVST to standard HIV testing services to understand which service delivery models are effective for key populations. Methods We did a systematic review of randomised controlled trials (RCTs) which compared HIVST to standard HIV testing in key populations, published from 1 January 2006 to 4 June 2019 in PubMed, Embase, Global Index Medicus, Social Policy and Practice, PsycINFO, Health Management Information Consortium, EBSCO CINAHL Plus, Cochrane Library and Web of Science. We extracted study characteristic and outcome data and conducted risk of bias assessments using the Cochrane ROB tool version 1. Random effects meta-analyses were conducted, and pooled effect estimates were assessed along with other evidence characteristics to determine the overall strength of the evidence using GRADE methodology. Results After screening 5909 titles and abstracts, we identified 10 RCTs which reported on testing outcomes. These included 9679 participants, of whom 5486 were men who have sex with men (MSM), 72 were trans people and 4121 were female sex workers. Service delivery models included facility-based, online/mail and peer distribution. Support components were highly diverse and ranged from helplines to training and supervision. HIVST increased testing uptake by 1.45 times (RR=1.45 95% CI 1.20, 1.75). For MSM and small numbers of trans people, HIVST increased the mean number of HIV tests by 2.56 over follow-up (mean difference = 2.56; 95% CI 1.24, 3.88). There was no difference between HIVST and SoC in regard to positivity among tested overall (RR = 0.91; 95% CI 0.73, 1.15); in sensitivity analysis of positivity among randomised HIVST identified significantly more HIV infections among MSM and trans people (RR = 2.21; 95% CI 1.20, 4.08) and in online/mail distribution systems (RR = 2.21; 95% CI 1.14, 4.32). Yield of positive results in FSW was not significantly different between HIVST and SoC. HIVST reduced linkage to care by 17% compared to SoC overall (RR = 0.83; 95% CI 0.74, 0.92). Impacts on STI testing were mixed; two RCTs showed no decreases in STI testing while one showed significantly lower STI testing in the intervention arm. There were no negative impacts on condom use (RR = 0.95; 95% CI 0.83, 1.08), and social harm was very rare. Conclusions HIVST is safe and increases testing uptake and frequency as well as yield of positive results for MSM and trans people without negative effects on linkage to HIV care, STI testing, condom use or social harm. Testing uptake was increased for FSW, yield of positive results were not and linkage to HIV care was worse. Strategies to improve linkage to care outcomes for both groups are crucial for effective roll-out.

Background Female sex workers (FSWs) are amongst the most susceptible groups to acquire human papillomavirus (HPV) infection and consequently, to develop cervical intraepithelial neoplasia and cervical cancer. This is the first systematic review and meta-analysis to provide estimates of the pooled prevalence of HPV infection and the distribution of HPV types among FSWs across the world. Methods Five computerized databases were searched for relevant studies published since the inception date of databases to September 2019. The pooled HPV prevalence was calculated by the random effect model described by DerSimonian-Laird. Subgroup analysis was performed to identify the probable sources of heterogeneity. The meta-analysis was performed using the “Metaprop” function in the R package Meta. Results Sixty-two studies involving 21,402 FSWs from 33 countries were included in this meta-analysis, and the pooled HPV prevalence was 42.6% (95% confidence interval (CI): 38.5–46.7%). HPV-16 (10.1, 95% CI: 8.2–12.5%), HPV-52 (7.9, 95% CI: 5.9–10.7%), and HPV-53 (6.0, 95% CI: 4.4–8.1%) were the most common high-risk HPV types identified among FSWs. The pooled estimated prevalence of HPV infection among FSWs before and after 2010 were slightly different, 43.6% (95% CI: 36.1–51.4%) and 41.9% (95% CI: 37.2–46.8%), respectively. Conclusion Due to the high prevalence of HPV infection, particularly with high-risk types, FSWs have a great susceptibility to the development of cervical and vaginal cancers. Furthermore, they can transmit their infection to their clients, which may result in a high prevalence of HPV and the incidence of HPV-associated malignancies among the general population.

Background Men who have sex with men (MSM), female sex workers (FSW) have critical needs for effective HIV prevention tools. This study identified perspectives of MSM, FSW and policy makers on the needs for, barriers to, and challenges with pre-exposure HIV prophylaxis (PrEP); and the logistics required to support roll-out of PrEP for MSM and FSW in Nigeria. Methods Qualitative and quantitative data were collected through a cross-sectional study. The quantitative data were collected through an online survey administered to 519 MSM, FSW and transgender respondents. The qualitative data were collected through 22 focus group discussions with 140 MSM and 80 FSW, and a two-day consultative workshop with 65 participants. Two open-ended questions in the online survey were also a source of qualitative data. Results of the quantitative data were reported descriptively; the qualitative data were inductively examined with a content analytic approach to construct descriptive categories. The findings from the quantitative and qualitative responses were triangulated. Results Four hundred and ninety-four (95.2%) online respondents had heard about PrEP through community dialogue (71.3%), and 439 (84.6%) supported its use by MSM and FSW. Fewer than half of the respondents were aware of the clinical care required for PrEP, and misconceptions about PrEP were common. Stated barriers to PrEP uptake were stigma, cost, frequency of HIV counseling and treatment services required, and possible drug-drug interactions. Concerns included possible condom migration, increased risk for sexually transmitted infections and pregnancy for FSW, and poor adherence to medication and hospital schedules. Participants felt that trained peer educators and HIV-test counselors could provide information and refer clients to clinics that provide PrEP. PrEP can be provided through peer-led facilities for MSM and FSW, though its access should be expanded to all persons who are at substantial risk for HIV to prevent negative labeling of PrEP. Public awareness about the use of antiretrovirals for HIV prevention is needed to prevent labeling of PrEP users as being HIV positive. Conclusion Although MSM and FSW are interested in the use of PrEP, numerous individual and structural barriers need to be addressed to facilitate access to it in Nigeria.