Factors Related to Pregnancy among Female Sex Workers Living with HIV in the Dominican Republic

Female sex workers (FSWs) living with HIV are a vulnerable population for multiple health concerns and have been vastly understudied in public health literature. This study analyzes factors related to pregnancy among 268 FSWs living with HIV in the Dominican Republic. 

Results indicate that 

• 34% of participants had been pregnant since HIV diagnosis. 

Multivariate analysis revealed significant associations between 

• pregnancy after HIV diagnosis and ART interruption, 
• knowledge of mother-to-child transmission, 
• serostatus disclosure to a sex partner, 
• older age 
• and a more negative perception of their health provider. 

Results indicate noteworthy associations between having been pregnant and the health provider experience and ART interruption, indicating a significant need for further research on this population to ensure both maternal and child health.

Purchase full article at:   http://goo.gl/c9TS6h

By:  Cernigliaro D¹, Barrington C², Perez M³, Donastorg Y³, Kerrigan D⁴.

¹Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, HH287, 624 N. Broadway St., Baltimore, MD, 21205, USA. danacern@gmail.com.

²The Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

³HIV Vaccine Research Unit, Instituto Dermatalógico y Cirugia de Piel Dr. Humberto Bogart Diaz, Santo Domingo, Dominican Republic.

⁴Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, HH287, 624 N. Broadway St., Baltimore, MD, 21205, USA.

AIDS Behav. 2016 May 4. [Epub ahead of print]

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'HIV and work don't go together': Employment as a social determinant of HIV outcomes among men who have sex with men and transgender women in the Dominican Republic

Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV in the Dominican Republic. Little is known about their experiences living with HIV as a chronic condition. 

We explored employment as a social determinant of well-being with HIV. We conducted 42 qualitative in-depth interviews with MSM (n = 16) and transgender women (n = 5) living with HIV; each participant completed 2 interviews to facilitate depth and iterative analysis. We used narrative analysis and systematic coding to identify salient themes related to employment and the HIV experience and developed a conceptual model of the pathways between HIV stigma, unemployment, and HIV outcomes. Early life experiences, including rejection from families and school, resulted in limited work opportunities, especially among transgender women. Following HIV diagnosis, participants across all socio-economic levels lost jobs and/or were unable to get jobs due to illegal HIV testing and HIV stigma and discrimination. Not being able to work impacted mental health, engagement in HIV care, and overall well-being. 

We conclude that lack of employment is a salient concern among MSM and transgender women living with HIV. Holistic, multi-level programmes that address illegal HIV testing and discriminatory hiring practices are urgently needed to facilitate engagement in care and long-term well-being.

Purchase full article at:   http://goo.gl/xEjW71

By:  Barrington C1, Acevedo R2, Donastorg Y3, Perez M3, Kerrigan D4.

• 1 Department of Health Behavior, Gillings School of Global Public Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA.
• 2 Consejo Nacional para el VIH y el SIDA , Santo Domingo , Dominican Republic.
• 3 HIV Vaccine Research Unit, Instituto Dermatalógico y Cirugía de Piel Dr. Huberto Bogaert Díaz , Santo Domingo , Dominican Republic.
• 4 Department of Health, Behavior, and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA. 
• Glob Public Health. 2016 Mar 21:1-16. 

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HIV Testing, Care & Treatment Experiences among the Steady Male Partners of Female Sex Workers Living with HIV in The Dominican Republic

Male steady partners of female sex workers (FSW) living with human immunodeficiency virus (HIV) represent a key population for treatment as prevention and/or pre-exposure prophylaxis interventions. 

This study uses data collected from male steady partners who were referred by FSW living with HIV participating in a multi-level HIV prevention and care intervention in Santo Domingo, Dominican Republic. We conducted a socio-behavioral survey and HIV testing with all men (n = 64) and 16 in-depth interviews with a sub-sample to obtain more depth. Thirty-five of the 64 participants were living with HIV; 27 were previously diagnosed and 8 were diagnosed during our study. As a result, 45% of men were members of sero-discordant sexual partnerships. 

Of men with no previous HIV diagnosis (n = 37), 15 had never been tested for HIV and nine had not been tested in the past two years. Ninety-three percent of men previously diagnosed with HIV reported receiving HIV care in the past 6 months and 78% were taking anti-retrovirals. Low HIV testing was partly due to men not feeling at risk for HIV, despite having an HIV-infected partner. 

Additionally, a lack of tailored care inhibited engagement in anti-retroviral treatment for those infected. HIV testing was low, highlighting a need for test-and-treat strategies. Men not living with HIV would benefit from regular testing and would be good candidates for pre-exposure prophylaxis. 

While almost all men who had been diagnosed with HIV were engaged in care and adherent to anti-retroviral therapy, future research should assess whether they are achieving optimal HIV outcomes for their health and prevention of ongoing transmission.

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By:  Fleming PJ1, Barrington C2, Perez M3, Donastorg Y3, Kerrigan D4.

• 1 Division of Global Public Health , University of California , San Diego , CA , USA.
• 2 Department of Health Behavior , University of North Carolina , Chapel Hill , NC , USA.
• 3 HIV Vaccine Trials Unit , Instituto Dermatológico y Cirugía de Piel 'Dr. Huberto Bogaert Díaz' , Santo Domingo , Dominican Republic.
• 4 Department of Health, Behavior and Society , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA.
• AIDS Care. 2016 Mar 24:1-6 

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"I Feel Like More of a Man": A Mixed Methods Study of Masculinity, Sexual Performance, and Circumcision for HIV Prevention

Ethnographic studies from numerous societies have documented the central role of male circumcision in conferring masculinity and preparing boys for adult male sexuality. Despite this link between masculinity, sexuality, and circumcision, there has been little research on these dynamics among men who have been circumcised for HIV prevention. 

We employed a mixed methods approach with data collected from recently circumcised men in the Dominican Republic (DR) to explore this link. We analyzed survey data collected six to 12 months post-circumcision (N = 293) as well as in-depth interviews conducted with a subsample of those men (n = 30).

We found that 42% of men felt more masculine post-circumcision. In multivariate analysis, feeling more masculine was associated with greater concern about being perceived as masculine, feeling more potent erections post-circumcision, and reporting increased ability to satisfy their partners post-circumcision. 

In qualitative interviews, these factors were all related to masculine norms of sexually satisfying one's partner, and men's experiences of circumcision were shaped by social norms of masculinity. 

This study highlights that circumcision is not simply a biomedical intervention and that circumcision programs need to incorporate considerations of masculine norms and male sexuality into their programming.

Purchase full article at:   http://goo.gl/taOEyG

By:  Fleming PJ1,2, Barrington C2,3, Pearce LD4, Lerebours L5, Donastorg Y6, Brito MO7.

• 1 Division of Global Public Health , University of California , San Diego.
• 2 Department of Health Behavior , Gillings School of Global Public Health, University of North Carolina at , Chapel Hill.
• 3 Carolina Population Center , University of North Carolina at , Chapel Hill.
• 4 Carolina Population Center and the Department of Sociology , University of North Carolina at , Chapel Hill.
• 5 Clinica de Familia , La Romana , Dominican Republic.
• 6 HIV Vaccine Trials Unit , Instituto Dermatológico y Cirugía de Piel , Santo Domingo , Dominican Republic.
• 7 Division of Infectious Diseases , University of Illinois at Chicago. 

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Characterizing HIV Epidemiology in Stable Couples in Cambodia, the Dominican Republic, Haiti, and India

Using a set of statistical methods and HIV mathematical models applied on nationally representative Demographic and Health Survey data, we characterized HIV serodiscordancy patterns and HIV transmission dynamics in stable couples (SCs) in four countries: Cambodia, the Dominican Republic, Haiti, and India. The majority of SCs affected by HIV were serodiscordant, and about a third of HIV-infected persons had uninfected partners. 

Overall, nearly two-thirds of HIV infections occurred in individuals in SCs, but only about half of these infections were due to transmissions within serodiscordant couples. The majority of HIV incidence in the population occurred through extra-partner encounters in SCs. 

There is similarity in HIV epidemiology in SCs between these countries and countries in sub-Saharan Africa, despite the difference in scale of epidemics. It appears that HIV epidemiology in SCs may share similar patterns globally, possibly because it is a natural 'spillover' effect of HIV dynamics in high-risk populations.

Below:  Patterns of HIV serodiscordancy in India, Cambodia, the Dominican Republic, and Haiti compared to those in low and high HIV prevalence countries in sub-Saharan Africa. Countries are shown in order of increasing HIV prevalence

Below:  HIV incidence and its sources in stable couples. (a) Fraction of new HIV infections in stable HIV serodiscordant couples that are due to sources external vs. internal to the couple. Estimates are shown for HIV incidence arising in stable HIV serodiscordant couples due to sources external to the couple. (b–h) The mean country-specific contributions to HIV incidence in the population stratified by couples' serostatus and source of HIV infection. Results are displayed for India, Cambodia, the Dominican Republic, and Haiti, compared to those in low and high HIV prevalence countries in sub-Saharan African. Countries are shown in order of increasing HIV prevalence.

Full article at:   http://goo.gl/YmTqBv

By:  Chemaitelly H1, Abu-Raddad LJ1.

• 1Infectious Disease Epidemiology Group,Weill Cornell Medical College - Qatar,Cornell University,Qatar Foundation - Education City,Doha,Qatar. 

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Feasibility of Identifying a Female Sex Worker Cohort at High Risk of HIV Infection in the Caribbean for HIV Vaccine Efficacy Trials

Background: Identifying cohorts of Caribbean women with HIV infection rates sufficient for inclusion in HIV vaccine efficacy trials has been challenging. HVTN 907 determined the feasibility of identifying and retaining a cohort of women at high risk for HIV acquisition by focusing recruitment on female sex workers (FSWs).

Methods: HIV uninfected FSWs, residing in Haiti, Dominican Republic, and Puerto Rico, who reported unprotected sex and met previously described more stringent site-specific eligibility criteria, were eligible. Behavioral risk assessment, HIV counseling and testing, and pregnancy testing were performed at baseline, 6, 12, and 18 months.

Results: Among 799 FSWs (264 from Dominican Republic, 334 from Haiti, and 201 from Puerto Rico), the median age was 26 years, with 54% having less than a high school education and 45% having a monthly household income of less than $US 100. Median number of male partners 6 months before screening was 200. Retention at 18 months was 93%. Twelve women became HIV infected, 9 from Haiti. The annualized HIV incidence was 1.07% (95% confidence interval: 0.55% to 1.87%). Pregnancy incidence was 22.5% (95% confidence interval: 21.9% to 29.5%). Statistically significant declines in risk behaviors occurred between screening and the 18-month visit assessment.

Discussion: The HVTN 907 study identified a high-risk cohort of women with excellent retention for all 3 sites, despite major challenges especially in Haiti. These results show that a bridging study of a vaccine shown to be efficacious in other clade settings would be possible among FSWs in the region, particularly in Haiti.

Purchase full article at:   http://goo.gl/pOQ0xX

By:   Deschamps, Marie M. MD^*; Metch, Barbara MA, MS^†; Morgan, Cecilia A. PhD^†; Zorilla, Carmen D. MD^‡; Donastorg, Yeycy MD^§; Swann, Edith PhD, MN^‖; Taina, Dadaille MD^*; Patrice, Joseph MD^*; Pape, William J. MD^*; on behalf of the HVTN 907 Study Team

doi: 10.1097/QAI.0000000000000796 

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Heterosexual Transmission of HIV in The Dominican Republic: Gendered Indicators Are Associated with Disparities in Condom Use

Background

Gendered dynamics in heterosexual relationships compromise women’s self-efficacy and increase their vulnerability to acquiring HIV. This study examines the impact of socioeconomic determinants, media exposure, and sexual expectations on sexual behaviors of men and women in the Dominican Republic (DR).

Methods

We analyzed cross-sectional data from 51,018 adults in the Dominican Republic age 15 to 45 years collected by the Demographics and Health Survey (DHS) in 2007. Measures included demographic and socioeconomic indicators, social exposures, sexual expectations and sexual behaviors. Logistic regression models explored gender differences in condom use.

Results

Study findings indicated that women were less likely to use a condom at last intercourse than men. Among men, secondary and higher education, being in the richest quintile, and living in a female-headed household increased the likelihood of condom use. Compared to never married men, currently and formerly married men were less likely to use condoms. The odds of condom use increased for young women 15–19 years old in comparison with women age 30–34 years, but decreased as they grew older. For women, being in the richer quintile, living in a female-headed household, and having good access to media increased the likelihood of condom use. Being currently married or formerly married and living in rural areas decreased such likelihood among women.

Conclusions

Study findings provide evidence that, in the DHS, socioeconomic and cultural differences between men and women affects condom use. Efforts to reduce HIV transmission within heterosexual relationships in the DR call for tailored, gender-specific interventions that take into account gender differences of power and sexual behaviors.

Full article at:  http://goo.gl/715BRI

By: Michelle M. Jimenez^1*, Flavia C. D. Andrade², Marcela Raffaelli³ and Juliet Iwelunmor²

¹Department of Medicine, Pontificia Universidad Catolica Madre y Maestra, Santiago, Dominican Republic

²Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Illinois, USA

³Department of Human and Community Development, University of Illinois at Urbana-Champaign, Illinois, USA

 

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Understanding Internalized HIV/AIDS-Related Stigmas in the Dominican Republic: A Short Report

HIV/AIDS-related stigmas can become internalized, resulting in declines in physical and mental health. Pathways to internalized HIV-related stigma (IS), characterized by persistently negative, self-abasing thoughts, are not well established among women living with HIV/AIDS (WLWHA) in the Dominican Republic (DR). 

Identifying factors involved in self-directed shaming and blaming is important, given the high HIV prevalence in the DR's most vulnerable populations. The present study sheds light on factors involved in negative and self-abasing thoughts in WLWHA in the DR by examining the relationship between depression, perceived HIV-related stigma from the community (PSC), perceived HIV-related stigma from family (PSF), and IS. 

The Internalized AIDS-Related Stigma Scale (IA-RSS), the Center for Epidemiologic Studies Short Depression Scale (CES-D 10), and an instrument designed to measure perceived HIV-related stigma from the community and family was administered to 233 WLWHA in Puerto Plata, DR. Data were analyzed using descriptive statistics and ordered multiple logistic regression. Results showed that depression, perceived HIV-related stigma from the community, and perceived HIV-related stigma from family were positively associated with internalized HIV-related stigma. 

These findings indicate that IS-reducing interventions should address HIV-related depression. Additionally, HIV-related treatment and care services should work with WLWHA to adopt healthier attitudes about how community members view people living with HIV/AIDS in the DR.

Purchase full article at: http://goo.gl/625Mec

By: Rael CT1, Hampanda K2.

• 1a HIV Center for Clinical and Behavioral Studies at Columbia University and New York State Psychiatric Institute , New York , NY , USA.
• 2b Department of Health and Behavioral Sciences , University of Colorado-Denver , Denver , CO , USA.  

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A Clinical Trial to Introduce Voluntary Medical Male Circumcision for HIV Prevention in Areas of High Prevalence in the Dominican Republic

Voluntary Medical Male Circumcision (VMMC) is an effective strategy to reduce the risk of HIV infection. Studies conducted in the Dominican Republic (DR) suggest that acceptability of VMMC among men may be as high as 67%. The goal of this clinical trial was to assess the acceptability, uptake and safety for VMMC services in two areas of high HIV prevalence in the country.

539 men consented for the study. Fifty seven were excluded from participation for medical or anatomical reasons and 28 decided not to have the procedure after providing consent. 

• A total of 454 men were circumcised using the Forceps Guided Method Under Local Anesthesia. 
• The rate of adverse events (AE) was 4.4% (20% moderate, 80% mild). 
• There were no serious AEs and all complications resolved promptly with treatment. 
• 80% of clients reported being "very satisfied" and 12% were "somewhat satisfied" with the outcome at the one-week postoperative visit.

Recruitment and uptake were satisfactory. Client satisfaction with VMMC was high and the rate of AEs was low. Roll out of VMMC in targeted areas of the DR is feasible and should be considered.

Read more at:  http://goo.gl/mEQpKX

By: Brito MO1, Lerebours L2, Volquez C3, Basora E2, Khosla S1, Lantigua F3, Flete R3, Rosario R2, Rodriguez LA3, Fernandez M3, Donastorg Y3, Bailey RC1.

• 1University of Illinois at Chicago, Chicago, Illinois, United States of America.
• 2Clinica de Familia, La Romana, Dominican Republic.
• 3HIV Vaccine Trials Unit, Instituto Dermatologico y Cirugia De Piel, Santo Domingo, Dominican Republic. 
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Family Planning for Strangers: An Experiment on the Validity of Reported Contraceptive Use

Below:  Scatterplot for Reported Sterilization and TFR in Urban Latin American DHS data, 42 surveys from 15 countries, including OLS Regression Prediction Line (R2 = 0.14; p = 0.015).

Sterilization levels reported in the Dominican Republic appear well above what we would normally expect given prevailing patterns in the region. We suspect that the use of strangers as interviewers—the normative approach in data collection in both developed and developing country settings—may be partly responsible for this result, and may underlie a long history of bias in family planning data. We present findings from a field experiment conducted in a Dominican town in 2010, where interviewer assignment was randomized by level of preexisting level of familiarity between interviewer and respondent. In our data, sterilization use is higher when the interviewer is an outsider, as opposed to someone known to the respondent or from the same community. In addition, high sterilization use is correlated with a propensity of respondents to present themselves in a positive light to interviewers. These results call into question the routine use of strangers and outsiders as interviewers in demographic and health surveys.

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