hiv phd thesis

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Using molecular epidemiology to investigate HIV transmission and prevention efforts

The Human Immunodeficiency Virus (HIV) is a retrovirus that causes HIV infection and, if untreated, leads to Acquired Immunodeficiency Syndrome (AIDS) and death. An estimated 36.7 million people in the world are HIV-infected; around 10% of them live in Europe. In this thesis I use molecular epidemiology in combination with mathematical modelling and traditional epidemiological analysis to describe HIV transmission dynamics and to assess various HIV prevention strategies, which might help t...

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Modelling HIV/AIDS epidemic in Nigeria

Eze, Jude Ikechukwu (2009) Modelling HIV/AIDS epidemic in Nigeria. PhD thesis, University of Glasgow.

Nigeria is one of the countries most affected by the HIV/AIDS pandemic, third only to India and South Africa. With about 10% of the global HIV/AIDS cases estimated to be in the country, the public health and socio-economic implications are enormous.

This thesis has two broad aims: the first is to develop statistical models which adequately describe the spatial distribution of the Nigerian HIV/AIDS epidemic and its associated ecological risk factors; the second, to develop models that could reconstruct the HIV incidence curve, obtain an estimate of the hidden HIV/AIDS population and a short term projection for AIDS incidence and a measure of precision of the estimates.

To achieve these objectives, we first examined data from various sources and selected three sets of data based on national coverage and minimal reporting delay. The data sets are the outcome of the National HIV/AIDS Sentinel Surveillance Survey conducted in 1999, 2001, 2003 and 2005 by the Federal Ministry of Health; the outcome of the survey of 1057 health and laboratory facilities conducted by the Nigerian Institute of Medical Research in 2000; and case by case HIV screening data collected from an HIV/AIDS centre of excellence.

A thorough review of methods used by WHO/UNAIDS to produce estimates of the Nigerian HIV/AIDS scenario was carried out. The Estimation and Projection Package (EPP) currently being used for modelling the epidemic partitions the population into at-risk, not-at-risk and infected sub-populations. It also requires some parameter input representing the force of infection and behaviour or high risk adjustment parameter. It may be difficult to precisely ascertain the size of these population groups and parameters in countries as large and diverse as Nigeria. Also, the accuracy of vital rates used in the EPP and Spectrum program is doubtful. Literature on ordinary back-calculation, nonparametric back-calculation, and modified back-calculation methods was reviewed in detail. Also, an indepth review of disease mapping techniques including multilevel models and geostatistical methods was conducted.

The existence of spatial clusters was investigated using cluster analysis and some measure of spatial autocorrelation (Moran I and Geary c coefficients, semivariogram and kriging) applied to the National HIV/AIDS Surveillance data. Results revealed the existence of spatial clusters with significant positive spatial autocorrelation coefficients that tended to get stronger as the epidemic developed through time. GAM and local regression fit on the data revealed spatial trends on the north-south and east - west axis.

Analysis of hierarchical, spatial and ecological factor effects on the geographical variation of HIV prevalence using variance component and spatial multilevel models was performed using restricted maximum likelihood implemented in R and empirical and full Bayesian methods in WinBUGS. Results confirmed significant spatial effects and some ecological factors were significant in explaining the variation. Also, variation due to various levels of aggregation was prominent.

Estimates of cumulative HIV infection in Nigeria were obtained from both parametric and nonparametric back-calculation methods. Step and spline functions were assumed for the HIV infection curve in the parametric case. Parameter estimates obtained using 3-step and 4-step models were similar but the standard errors of these parameters were higher in the 4-step model. Estimates obtained using linear, quadratic, cubic and natural splines differed and also depended on the number and positions of the knots. Cumulative HIV infection estimates obtained using the step function models were comparable with those obtained using nonparametric back-calculation methods. Estimates from nonparametric back-calculation were obtained using the EMS algorithm. The modified nonparametric back-calculation method makes use of HIV data instead of the AIDS incidence data that are used in parametric and ordinary nonparametric back-calculation methods. In this approach, the hazard of undergoing HIV test is different for routine and symptom-related tests. The constant hazard of routine testing and the proportionality coefficient of symptom-related tests were estimated from the data and incorporated into the HIV induction distribution function. Estimates of HIV prevalence differ widely (about three times higher) from those obtained using parametric and ordinary nonparametric back-calculation methods. Nonparametric bootstrap procedure was used to obtain point-wise confidence interval and the uncertainty in estimating or predicting precisely the most recent incidence of AIDS or HIV infection was noticeable in the models but greater when AIDS data was used in the back-projection model.

Analysis of case by case HIV screening data indicate that of 33349 patients who attended the HIV laboratory of a centre of excellence for the treatment of HIV/AIDS between October 2000 and August 2006, 7646 (23%) were HIV positive with females constituting about 61% of the positive cases. The bulk of infection was found in patients aged 15-49 years, about 86 percent of infected females and 78 percent of males were in this age group. Attendance at the laboratory and the proportion of HIV positive tests witnessed a remarkable increase when screening became free of charge. Logistic regression analysis indicated a 3-way interaction between time period, age and sex. Removing the effect of time by stratifying by time period left 2-way interactions between age and sex. A Correction factor for underreporting was ascertained by studying attendance at the laboratory facility over two time periods defined by the cost of HIV screening. Estimates of HIV prevalence obtained from corrected data using the modified nonparametric back-calculation are comparable with UN estimates obtained by a different method.

The Nigerian HIV/AIDS pandemic is made up of multiple epidemics spatially located in different parts of the country with most of them having the potential of being sustained into the future given information on some risk factors. It is hoped that the findings of this research will be a ready tool in the hands of policy makers in the formulation of policy and design of programs to combat the epidemic in the country. Access to data on HIV/AIDS are highly restricted in the country and this hampers more in-depth modelling of the epidemic. Subject to data availability, we recommend that further work be done on the construction of stratification models based on sex, age and the geopolitical zones in order to estimate the infection intensity in each of the population groups. Uncertainties surrounding assumptions of infection intensity and incubation distribution can be minimized using Bayesian methods in back-projection.

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• v.103(2); Feb 2013

Interactions Between HIV/AIDS and the Environment: Toward a Syndemic Framework

A. Talman synthesized the findings and led the writing. A. Talman and S. Bolton conducted the study and completed the analyses. J. L. Walson conceptualized the study and supervised its implementation. All authors participated in developing the syndemic framework, interpreting the evidence, and reviewing and editing drafts of the article.

Although the social, economic, and political dimensions of the HIV/AIDS epidemic have been studied in considerable depth, the relationship between HIV/AIDS and its environmental causes and consequences remains largely unexplored. We reviewed the evidence of interactions between ecosystem health and the HIV/AIDS pandemic. We hypothesized a syndemic between environmental degradation and HIV/AIDS; they exhibit bidirectional, self-reinforcing interactions. We have presented a syndemic framework detailing multiple synergistic relationships. This framework hinges on the vulnerability of populations as the linchpin between the pandemic and environmental health. A coherent research and practice agenda for addressing the syndemic that focuses on the 2 issues as not only concurrent but also intertwined phenomena is urgently needed.

The devastating impact of HIV/AIDS is unprecedented, with more than 33 million individuals now infected globally. 1 In addition to 2 million deaths occurring annually as a result of HIV/AIDS, its regional economic, health, and social impacts have been well documented. The pandemic continues to affect the livelihoods of individuals, families, and communities, especially in sub-Saharan Africa.

In regions of the world most affected by HIV/AIDS, the pandemic is occurring in the context of massive environmental and societal changes. Global climate change, human industry, and shifting patterns of migration because of poverty, inequality, and conflict are dramatically altering the social and natural environment of those regions most affected and may play a key role in driving and sustaining the pandemic. However, the effects of HIV/AIDS on the environment and, conversely, those of climate and environmental changes on the spread of the virus have not been adequately explored.

Despite a number of studies and reviews that have addressed various facets of the relationships between the HIV/AIDS epidemic and the environment—including natural resource use, 2–8 workforce considerations, 7,9–11 effects of climate change, 12–16 food and livelihoods connections, 17–21 and gender issues related to both phenomena, 5,20,22–24 —to date, no authoritative review synthesizes the complex, bidirectional, self-reinforcing interactions between environment and HIV/AIDS. No comprehensive framework for conceptualizing the connections between the phenomena exists.

We hypothesized a syndemic between the HIV/AIDS epidemic and ecosystem degradation. A syndemic can be defined as “two or more afflictions interacting synergistically, contributing to excess burden of disease in a population.” 25 In epidemiological and public health contexts, a syndemic orientation has been applied to co-occurring health problems and pathogen–pathogen interactions but has also been used to more generally express the interactions between diseases and social conditions. 26 Singer characterizes this broader definition as follows:

A syndemic, in short, involves a set of enmeshed and mutually enhancing health problems that, working together in a context of deleterious social and physical conditions that increase vulnerability, significantly affect the overall disease status of a population. 26 (p15)

It is this more general conception of syndemic that we use to frame the discussion of the interactions between HIV/AIDS and the environment. We proposed that the “determinant importance of social conditions in the health of individuals and populations” 27 (p428) that Singer postulates in describing syndemics can and should be extended to broader environmental conditions.

The concurrent, intertwined, and mutually reinforcing relationships between impoverished ecosystem services and HIV/AIDS infections and their sequelae reflect the synergies inherent to syndemics. It is not just the colocation of environmental pressures and HIV/AIDS in regions most affected but rather the complex ways these factors interact that contributes to excess burden of disease, poverty, and depleted resources in vulnerable areas. We have presented evidence of the syndemic from the literature and from qualitative information provided by key informants. Furthermore, we have presented a conceptual framework to depict the complex, reinforcing relationships that form the syndemic.

Applying a syndemic lens to the intertwined relationships between HIV/AIDS and ecosystems degradation allows researchers, practitioners, and policymakers to address the 2 phenomena in an integrated fashion. Adopting a syndemic framework paves the way for developing a body of evidence regarding these relationships as well as for piloting integrated interventions that address the phenomena as intertwined and for identifying best practices for scaling up.

REVIEWING THE EVIDENCE

We reviewed the scientific literature on links between HIV/AIDS and the environment to determine whether sufficient data exist to conduct a formalized systematic review of the evidence. If adequate high-quality qualitative and quantitative data from the literature were not available, our objective was to develop a conceptual framework to serve as a theoretical basis for focusing additional research and to help public health practitioners interpret the relationships between the phenomena.

In the literature review, we focused on reports from East and Southern Africa, regions that are heavily afflicted by the HIV/AIDS epidemic and that have experienced major changes in the environment. We searched for articles in PubMed and ISI Web of Science, combining the medical subject headings or keywords HIV or AIDS and Africa or developing countries with any 1 of the following: agriculture, biodiversity, climate, conservation of natural resources, cost of illness, edible plants, emigration and immigration, environment, environmental and ecological phenomena, environmental health, environmental medicine, family characteristics, farming, fish, food, food supply, food habits, forest, health expenditures, nutrition, rural populations, sanitation, socioeconomic factors, vulnerable populations, water. In addition, we searched the Web sites of a number of government and nongovernmental agencies and reviewed the references of published articles for additional source material. We also contacted authors and program managers for additional documents, including program reports and workshop proceedings.

The database queries and other search methods identified approximately 6500 references for possible inclusion in the review. After reviewing titles, we excluded most of these references on the basis of title alone, as they did not address some aspect of both the HIV/AIDS epidemic and environmental issues. We reviewed the abstracts of 914 articles, after which we excluded 445 references. We reviewed the full text of 469 references, after which we excluded 227. We ultimately conducted a qualitative review of 242 documents.

Our review did not identify sufficient randomized trials and well-controlled studies to enable a traditional systematic review under our a priori conditions. We determined that a traditional systematic review—including thorough evaluation of the quantity and quality of rigorously controlled data on the multiple connections between HIV/AIDS and the environment—would not sufficiently address the complexity or the significance of the interrelationships we discovered in the literature. Because of significant gaps in research, the lack of a coherent conceptual or theoretical framework, and the multiple, overlapping, bidirectional relationships, we did not conduct a traditional systematic review.

Given the literature gaps and weaknesses, we determined that the best alternative was to synthesize the evidence in a subjective fashion with the goal of framing a conceptual model that could be tested under conditions of well-conducted trials. This might encourage further research and could provide a starting point for further discussion and hypothesis generation regarding the links between the epidemic and degradation of ecosystem services.

Our synthesis and conceptual framework rely on the scholarly articles, white and gray literature, and other reports we reviewed as well as on substantial subjective experiential and theoretical knowledge. In 2010, we conducted approximately 30 informal individual and small group discussions with academics, program managers, and implementers in Kenya and the United States and conducted site visits with multiple community groups and nongovernmental organizations working with HIV/AIDS or the environment in Kenya.

Because empirical data on the interactions between HIV/AIDS and the environment are scant, our review was exclusively qualitative, and emerging findings in the literature guided our analysis. We performed thematic content analysis, coding salient themes in the literature and in extensive notes from field visits. We then refined and narrowed these codes through discussion and comparison to ensure that they were not redundant and that they represented the source documents fairly. A number of themes emerged from this literature review and from qualitative discussions with partners. We have presented evidence of several of the primary connections between the HIV/AIDS epidemic and environmental health.

RELATIONSHIPS BETWEEN HIV/AIDS AND THE ENVIRONMENT

The conceptual framework addresses the complexity of the multiple relationships between HIV/AIDS and the environment. Because of the range of evidence we discovered regarding these topics and because of their centrality to the syndemic framework, 3 issues merit further introduction: vulnerabilities and coping, global climate change, and workforce effects.

Vulnerabilities and Coping

Because HIV/AIDS disproportionately affects individuals during their most productive wage-earning and reproductive period (between 18 and 45 years), its resultant illness and mortality often result in a labor shortage at the household and community levels. 28–31 Livelihoods dependent on physical labor, such as agriculture, pastoralism, and fisheries, may therefore be jeopardized when a family member becomes HIV infected.

In the agricultural sector, transitions to lower labor-intensity farming techniques, to increases in the leasing or sharecropping of land, and even to increased fallowing of productive land have been observed as a result of increasing HIV/AIDS prevalence in sub-Saharan Africa. 32,33 Untreated HIV-infected tea pickers in Kenya earned 17% less than did their uninfected coworkers in the 2 years before their termination, and they used significantly more leave time. 34 Increased adult mortality is negatively correlated with the amount of land cultivated at the community level and with total crop output. 31,35,36 Farmers may also be more focused on short-term rather than long-term concerns, as the household’s demand for “quick cash” or food today outweighs future considerations—including sustainable land management—in the face of what may seem to be imminent mortality. Changes in inheritance patterns and land tenure for widows of HIV-positive men have also been observed. Land fragmentation and land “grabbing,” especially from orphans and widows, have been noted in Kenya, South Africa, and elsewhere. 37,38 Women’s rights to land, although often officially codified in law, are not always protected in practice. 37

Studies have documented that families affected by HIV/AIDS sell off household goods such as livestock as a buffer against lost wages or lower productive value from farm products and livestock as a result of diminished labor capacity. 28,39 The subsequent erosion of household assets leaves families more vulnerable to further economic and health deterioration 30,32 and has been described as resulting in a “downward spiral” of livelihood degradation. 6,29 Even after starting antiretroviral therapy and physical recovery, many families are unable to recover socially and economically from the devastating effects of lost labor because of HIV morbidity. 40 Individuals may resort to other erosive coping mechanisms, such as commercial sex work and the frequently described but largely unquantified phenomenon of bartering “fish for sex.” 30,32 Erosive coping strategies further undermine the resilience of the household by diminishing its ability to absorb or recover from hazards. 41

Livelihood insecurity may also result in food insecurity. Food insecurity is a linchpin between HIV/AIDS and the environment. Malnourished individuals are more susceptible to HIV infection, 17,42 and to feed themselves or their families, they may be more likely to engage in risk behaviors that increase their exposure to the virus. 43,44 Among HIV-infected individuals, antiretroviral therapy may be less effective in persons with inadequate nutrition. 13,17 Low body mass index (defined as weight in kilograms divided by height in meters squared) is an independent predictor of death after antiretroviral therapy initiation, and food insecurity is a documented risk factor for noncompliance in antiretroviral therapy treatment. 45 At a national level, average daily calorie consumption has been negatively associated with HIV/AIDS prevalence in an ecological study of 33 African countries. 46

The relationship between food insecurity and HIV infection is circular; households affected by HIV/AIDS are subsequently less able—because of lost labor productivity—to ensure adequate supplies of food 47 and are more likely to consume fewer nutrient-rich foods, 48 increasing levels of malnutrition at the household level. Up to 5% of food insecurity in sub-Saharan Africa has been attributed to HIV/AIDS. 49

Poverty is an important correlate and confounder of the relationships among HIV/AIDS, food insecurity, and natural resource use. Although the poor are not necessarily at higher risk for being exposed to or infected with HIV, they are differentially affected in terms of its sequelae and the ability to deal with its economic and social consequences. 50 HIV-affected households are often likely to be impoverished and food insecure, 28,39 and thus they are more likely to depend on natural resources as a safety net. 30,32 Vulnerable households gather a number of natural products from the local environment, including wild foods (plants and animals), water, fuel wood, traditional medicinal products, timber, and raw materials for craft making. Natural resource collection is sometimes less labor intensive than is agriculture and requires little start-up capital. 28 In at least 2 studies, in South Africa and in multiple sites in Malawi and Mozambique, households affected by adult mortality were observed to be up to 3.3 times more likely to collect firewood than were unaffected households. 6,19

Anecdotal evidence suggests that increased dependence on natural resources of families affected by HIV/AIDS will lead to overharvesting of certain species and decreased biodiversity and ecosystem health. The quality, availability, predictability, and accessibility of natural resources have been observed to decline with increased use. 11,19,51 As with selling off household assets, relying on natural resources can be seen as an erosive coping strategy if those resources are quickly depleted. By contrast, increased use of natural resources may not necessarily be detrimental to ecosystems if the resources are available in sufficient supply. Increased reliance of households affected by HIV/AIDS may then be seen as a livelihood diversification strategy that improves household resilience to threats and distributes risk. 6 Few articles have addressed the environmental impacts of increased use of natural resources owing to HIV/AIDS, and quantification of the availability, use, and impact of natural resource use because of HIV/AIDS morbidity and mortality remains conspicuously absent.

Many groups, including women, orphans, and those affected by conflict and migration, appear to be particularly burdened by the syndemic between HIV/AIDS and ecosystem degradation. Because of their unique positions in both the epidemic and changing environments, these vulnerable populations represent a critical link between the 2 phenomena. The vulnerabilities of these populations lead both to increased HIV/AIDS risk and to more severe environmental consequences (e.g., erosive coping strategies, changes in livelihoods, and increased reliance on natural resources).

Gender inequality places girls and women at high risk for HIV infection by limiting the ability of women and girls to cope with economic, psychosocial, physical, or environmental difficulties. Girls and women worldwide have differential access to education, employment, credit, health services, and information 52 and have a heavier burden of health problems and safety and security issues. They are more susceptible to the direct health effects that stem from living in poverty; inadequate access to water, sanitation, and health care differentially affects women. 53 Female economic dependence on male partners is a major influence on the risk behaviors they undertake. 50 The power differential in sexual relationships, coercion, and expectations that they be passive and ignorant in sexual matters may further endanger girls and women, 54 as does their differential biological susceptibility to HIV infection. Meanwhile, women tend to carry the majority of the labor burden in household activities, childcare, and caring for the ill. 30 In sub-Saharan Africa, women make up 70% of the agricultural workforce, and so livelihoods may be disproportionately affected by female illness and death. 28 Discriminatory “traditional” practices such as widow inheritance, genital cutting, and early marriage also contribute to women’s vulnerability. 37 Women’s risky sexual behavior appears to be more strongly associated with poverty than does men’s; impoverished women were more likely to have earlier ages for sexual debut and report more concurrent partnerships than were impoverished men. 55 Food-insecure women have been documented to be more likely to engage in unprotected sex and to report less power in relationships than have men. 43,44 Female heads of households are more likely than are male heads to be HIV infected, 56 and households suffering female illness and mortality are more likely to suffer food insecurity. 57

The intergenerational effects of the HIV/AIDS epidemic on the environment are striking and are not limited to mother to child transmission of the virus. More than 11.6 million children in sub-Saharan Africa have been orphaned by HIV/AIDS since the beginning of the pandemic. 1 Orphans and vulnerable children are less likely to have been the beneficiaries of knowledge transfer. Gaps in traditional knowledge of farming techniques, natural resources management, and identification, collection, and use of natural products (including medicinal products) have been observed among orphans and vulnerable children. 5,58,59 For instance, children orphaned because of HIV/AIDS in Tanzania were 10 times more likely to collect natural products such as wild orchids for consumption than were nonorphaned children. 60 Additionally, like women, orphans and vulnerable children are more prone to land “grabbing” and are extremely vulnerable in terms of their livelihoods. 37,61

Conflict and migration also contribute to interactions between HIV/AIDS and the environment. Rural to urban and seasonal migrants are at increased risk of HIV infection because of enlarged sexual networks, partner concurrency, increased substance abuse, higher population-level virus prevalence, social disruption, and higher rates of casual and commercial sex. 33,51,62,63 At the same time, urban to rural reverse migration of the HIV infected puts additional demand on relatives—in terms of labor and care—and on the environment—in terms of natural resource utilization and increased pressure on ecosystems services. 32,33 In South Africa, people who moved to rural areas in the previous year were 28% more likely to die than were more permanent rural residents in 2009 and were 79% more likely to die from AIDS. 64

Two special cases of migration might further link the environment and HIV/AIDS risk. “Climate” refugees are forced out of their homes to migrate because of untenable land conditions, natural disasters, and climate change. 65,66 “Conservation” refugees are forced to migrate because they live in conservation or protected areas. 67 Both types of refugees might be at increased risk for HIV infection when their livelihoods and social networks are disrupted and they move to urban or periurban settings.

Conflict does not automatically translate to increased HIV/AIDS incidence or prevalence or to environmental degradation. Lack of privacy, decreased mobility, increased protection, and accessibility of health care and other services in refugee camps may actually shield some populations from HIV incidence in times of war. 28–31 Nonetheless, a number of factors associated with armed conflict, such as lack of income, breakdown of social structures, sexual violence, drug use, and destruction of health and educational infrastructure, can lead to increased transmission. 41,44,50,51 Conflict can lead to increased HIV/AIDS vulnerability both by increasing contact between uninfected and infected populations and by increasing the probability of HIV-transmitting events. 37,38 HIV prevalence in armed forces across Africa has been documented to be as high as 27%. 68

Likewise, the effects of conflict on ecosystem health are not unidirectional; conflict may preserve large tracts of land if people stay away because of fear of violence, but there is evidence of substantial environmental degradation because of armed conflict. 69,70

The Impact of Global Climate Change

Natural resource availability and agricultural land productivity are intimately linked to climate factors, including temperature and precipitation. Global climate change appears to be contributing to environmental variability via higher risk of extreme weather events (e.g., droughts, floods, heat waves, and cold spells). 14,71 This may lead to increased poverty, migration, and livelihood instability, which contribute to increased vulnerability and impaired coping ability, thus contributing to the syndemic. Degraded environments produce fewer crops, contributing to malnutrition and all its negative effects on health and the immune system. 13,72 Global climate change may also result in changes in markets, food prices, or supply chain infrastructure. 73

Environmental changes may foster conditions that are favorable for disease transmission, including many infections that affect people living with HIV/AIDS (e.g., malaria and diarrheal disease). Increased distances to reach water and decreased water quality threaten an increase in diarrheal pathogens. 15 In addition, each 2°C to 3°C increase in ambient environmental temperature increases malaria transmission by 3% to 5%. 74 Infection with malaria and other coinfections lead to significant increases in the amount of circulating virus in the blood of HIV-infected individuals, which may increase the rate of HIV disease progression and transmission. 75

Decreased plant diversity and species loss may limit access to valuable plants, including some identified as having medicinal or anti-HIV properties. 76 The Joint United Nations Programme on HIV/AIDS and the United Nations Environment Programme produced a joint working paper on HIV/AIDS and climate change in 2008 in which they present an “HIV/AIDS–climate change complex.” 77 Food security, patterns of infectious disease, effects of pollution and heat stress on the immune system, and issues of governance, policy, and conflict are major points of interaction between climate change and the epidemic. Mojola et al. identify the eutrophication, pollution, and deforestation of the areas surrounding Lake Victoria as disruptive processes, which disturbed not only the local ecosystem but also the primary industry—fishing—and thereby the economy and the structure of sexual, domestic, and social partnerships. 78 This ecological or “ecostructural” degradation is a potential root cause of increased HIV transmission. 78

A Note on Workforce and Human Capacity

An additional facet of the relationship between the HIV/AIDS pandemic and ecological health is related to the impact of the epidemic on the workforce of conservation and environmental organizations. Conservation workers might be at increased risk of HIV infection because of their jobs, as they are often placed at remote locations far from their families; large populations of mobile men, isolated from their families and with access to cash incomes, have been documented to access commercial sex more frequently and to be at increased risk for HIV acquisition. 11,61,77,79 Consequently, environmental institutions have observed the effects of HIV/AIDS morbidity and mortality, including increases in absenteeism, demand for employee assistance programs, medical or other support provided by the employer, and a decline in productivity and morale.

The loss of skilled professionals—many of whom are “investments” in terms of the education and on-the-job training they have received—has negative financial and programmatic effects on the functioning of the organization. In the environmental sector specifically, loss of workforce has led to decreased patrolling of protected areas and national parks, 79 which may contribute to higher levels of poaching and unregulated natural resource harvesting in or near parks. These effects are consequential, but they have been addressed elsewhere and are not the focus of this review. 11,51,58,63,66,80–83

TOWARD A SYNDEMIC FRAMEWORK

The conceptual framework is the consolidation of the literature review as well as a qualitative, subjective assessment of potential relationships between HIV/AIDS and the environment. It outlines the most important links between HIV/AIDS and the environment, reflecting the mutually reinforcing relationships and feedbacks between vulnerability, HIV/AIDS, and environmental degradation ( Figure 1 ). Because of the scarcity of empirical data, not every aspect of this framework is supported by well-controlled studies. It is based on our assessment and weighing of the evidence as well as on our experiential and theoretical understandings of the relationships discussed.

The syndemic framework for HIV/AIDS and the environment.

Note . The syndemic framework depicts the multiple, bidirectional, self-reinforcing relationships between the HIV/AIDS pandemic and ecosystem degradation. The syndemic framework is driven by global scale and upstream factors and is mediated by individual- and population-level vulnerabilities.

Several major global scale issues affect all aspects of the synergy between HIV/AIDS and environmental change. Global scale forces such as climate change, pollution, macroeconomic trade and aid policies, urbanization, conflict, and globalization set the stage for the challenging conditions in many of the nations of sub-Saharan Africa, yet they are forces over which Africans have little control at the household and community levels. Since the end of the colonial period, pervasive poverty, inequalities, conflict, and oppression have undermined community and household resilience. These interconnected factors have contributed to the emergence of structural violence and have placed communities in sub-Saharan Africa in a situation of both extensive ecosystem destruction and increased spread of HIV/AIDS.

Vulnerability has 2 aspects: stresses that people are subjected to (external) and their capacity to cope (internal) with those stresses. 41,84,85 Global scale forces and upstream determinants increase both internal and external vulnerability at the household and community level. The increased pressures wrought on people by global and upstream factors make them more vulnerable to threats of all kinds and less likely to be able to cope with these threats. That is, people affected by poverty, food insecurity, landlessness, lack of access to resources and services, oppression, pervasive inequalities, and the atrocities of war are in every way less able to deal with problems of every sort.

In the framework depicted in Figure 1 , vulnerability is the linchpin mediating between the upstream determinants and the downstream effects of HIV infection, changes in livelihoods, increased reliance on natural resources, and ecological degradation. Vulnerabilities limit the ability and opportunities of individuals or households to cope with short- and long-term challenges. Substantial evidence exists regarding vulnerabilities related to food security, livelihoods, HIV/AIDS, and natural resource use as well as the particular vulnerabilities of women, children, migrants, and those affected by conflict, which make them disproportionately burdened by the HIV/AIDS–ecosystem degradation syndemic.

The Syndemic

The syndemic interaction between HIV/AIDS and ecological health hinges on the feedback loop in Figure 1 . The upstream determinants of poverty, gender inequality, and social disruption influence this cycle, and it begins and ends with vulnerability.

Internal and external vulnerability and decreased coping ability increase the risk of HIV infection through changed behavioral and nonbehavioral risk factors such as malnutrition or infection with sexually transmitted diseases. HIV/AIDS in turn leads to income insecurity and increased dependence on natural resources, as households lose labor force, land tenure, and traditional knowledge and are less able to maintain their previous livelihoods. This increased reliance on natural resources in turn makes communities even more vulnerable, as they become increasingly more exposed to the vagaries of nature, weather, and availability of resources. Infection with HIV/AIDS itself also increases vulnerability, which may lead both to more behavior that increases HIV transmission and to changes in behavior, such as erosive coping, which also increase natural resource use. The cycle is self-reinforcing and reciprocal.

Figure 1 illustrates how the burden of HIV/AIDS feeds back into the upstream determinants, thereby reinforcing a continued cycle of vulnerability and risk. HIV infection feeds back by generating more social disruption as institutions continue to erode, contributing to increased poverty and reinforcing gender inequality. Women are overrepresented among the HIV infected and the HIV affected. Children orphaned by AIDS are often left with few resources, compounding the effect of intergenerational poverty in this feedback loop.

Most of the pathways in Figure 1 have multiple divergence points; there is no single path that all households, communities, or individuals follow. Figure 2 illustrates a possible pathway that starts with land degradation owing to global climate change. Land degradation initiated by global climate change (e.g., shifting rain patterns, extended droughts) decreases food production. Food insecurity decreases coping abilities through hunger or the need to find food for children at any cost, which leads to erosive behavioral changes. If these changes result in transactional or forced sexual contact, the risk of HIV infection increases. Illness associated with HIV/AIDS infection decreases the ability to successfully work or farm, which can lead to increased use of natural resources to fill the gap, which results in an additive, deleterious cycle or feedback loop by further degrading the land.

A synergistic relationship between land degradation, food insecurity, and HIV/AIDS.

Several factors differentiate HIV/AIDS effects from other threats to households or livelihoods. Health care costs for AIDS-related deaths have been shown to be more than are those for non–AIDS-related deaths in Zimbabwe, and AIDS-related deaths were more likely to be heads of household. 22 AIDS-related deaths were also more likely to result in dissolution of the household and out-migration. Gender bias, stigma, household clustering, and staging of HIV/AIDS infection differentiate HIV-related illness and mortality from other household shocks. 58,62,68,77 Kinship and community safety nets are already overstressed because of excess mortality. 86

It is also important to note, however, that this cycle can be completed without ever involving HIV infection. As illustrated in Figure 1 , a direct path from the global and upstream determinants, through vulnerabilities, can lead directly to livelihood insecurity and increased reliance on the natural environment, bypassing HIV infection, and can create a second self-reinforcing loop.

Applying the Syndemic Framework

Framing the HIV/AIDS epidemic in the context of a syndemic with ecosystem degradation has a number of advantages. At a practical level, the syndemic orientation facilitates interdisciplinary and cross-sector strategic partnerships, bidirectional mainstreaming of HIV/AIDS and ecological considerations across sectors, and the development of a multifaceted approach to addressing the multiple determinants of the syndemic. For researchers, applying a syndemic lens provides new avenues for addressing risk factors. The focus of most HIV/AIDS research and programs has been on prevention and treatment, with an emphasis on behavior modification. This narrow focus excludes the broader context of the disease and ignores some of the more ultimate, rather than proximate causes of the epidemic. A syndemic framework acknowledges the multifaceted nature of the HIV/AIDS epidemic, which can lead to more successful approaches for combating it. Singer synthesizes the benefits of syndemic research:

[It] focuses simultaneously on distal and proximal causes of disease, specific mechanisms and directionalities of interaction, broader patterns and contexts of vulnerability and risk, and consequences of disease synergies that increase the overall health burden of a population. 26 (p15)

However, challenges remain in moving forward with research and intervention agendas targeted at maximizing public health environment cobenefits. A disciplinary tension between public health and the environmental sector means that priorities in the public health sector may differ from, and even conflict with, those of environmental organizations. For instance, the public health literature glows about the benefits of wild foods as nutritional supplements for people living with HIV/AIDS, whereas the environmental literature worries about the biodiversity effects of wild food collection. What one field sees as an opportunity, another may perceive as a threat. This difference in perception is illustrated by an experience at Lake Victoria in Kenya. Upon arrival at the lakeshore, one author noted the entrepreneurial energy of various individuals vigorously washing cars, trucks, and buses, thus increasing their incomes and fostering resiliency. Another author noted that Lake Victoria is already an ecological disaster because of invasive species and bemoaned the addition of gasoline, oils, and other toxic materials to the lake from the activity. Neither immediately noticed yet another local health issue: the high rates of infection with schistosomiasis among the car washers.

Challenges for integrative HIV/AIDS environmental projects include limited evidence on their effectiveness, funding issues and sustainability of projects, and developing capacity for integrative responses at the local level. 87 Mainstreaming at the institutional and policy levels, using evidence-based research, and using monitored and evaluated interventions to document the added value of integration should be prioritized. The orientation of funding streams toward vertically applied, disease-specific programming should be reevaluated to accommodate integrated projects.

A coherent research and intervention agenda for addressing the HIV/AIDS and environment syndemic is urgently needed, as are more longitudinal, controlled, and comparative data. There has been a clear surge in enthusiasm, activity, and momentum for work on the links between HIV/AIDS and ecosystem integrity. Nonetheless, the vast majority of the evidence remains anecdotal or unreplicated, and specific evidence of the successfulness of integrated interventions is scant.

Specific research needs include further quantification of the impact of HIV/AIDS on natural resource use and livelihoods in a variety of settings and over time. Additionally, both poverty and food insecurity may confound the relationship between HIV infection and increased use of natural resources, and studies that tease out their differential effects will be important. Additional data on indicators of ecological health, such as status and trends of species and indicators of biodiversity, are warranted. Additional quantification and characterization of the impact of HIV/AIDS on conservation workforces are also needed. Furthermore, the relationship between global climate change and the HIV/AIDS pandemic needs further exploration; much of the speculation on how climate change might affect the epidemic is more conjectural than scientific. Continued documentation of actual and potential risks of climate change to health (including HIV/AIDS), livelihoods, and vulnerability is needed.

CONCLUSIONS

HIV/AIDS is inextricably linked to the global effects of environmental change, social disruption, and macroeconomics. HIV/AIDS issues should be incorporated into environmental analyses. Simultaneously, public health research and interventions must consider the many ways HIV/AIDS is tied to ecological health.

A syndemic approach is of use to both researchers and public health practitioners in investigating and crafting a response to the 2 intertwined phenomena. The global effort to address the HIV/AIDS pandemic must widen the lens through which HIV/AIDS is studied, evaluated, and mitigated to include its relationship to ecological health to maximize the benefits of decreased HIV/AIDS risk and improved ecosystem health. As Singer eloquently puts it,

This means advancing past narrowly conceived efforts toward an understanding of the broader socially and environmentally contextualized epidemiological patterns of a specific disease to prevent or control it. 26 (p15–16)

Adopting a syndemic framework when examining HIV/AIDS and ecosystem health will provide benefits to affected individuals and to the environment much beyond addressing the issues in isolation.

Acknowledgments

This work was made possible by financial support from the Eastern and Southern Africa Regional Office of the International Union for the Conservation of Nature and the International Planned Parenthood Federation Africa Regional Office. Additional support was provided by the University of Washington Department of Global Health and the School of Forest Resources.

Special thanks are due to Tom Hinckley, Ben Piper, Judy Wasserheit, Richard Fenske, Joachim Voss, Adam Akullian, Lawrence Oteba, Jonathan Davies, Claire Ogali, Ben Wandago, and Francis Mwaura for their involvement in every phase of this project, from proposal to article editing.

Human Participant Protection

These activities were conducted in the process of ongoing programmatic planning and evaluation, and because there was no human participants research, no protocol review was required.

• Open access
• Published: 20 April 2021

Prevalence and associated factors of HIV self-testing among men who have sex with men in Ningbo, China: a cross-sectional study

• Hang Hong 1 ,
• Hong-bo Shi 1 ,
• Hai-bo Jiang 1 ,
• Hong-jun Dong 1 &
• Yun-liang Shen 2  

AIDS Research and Therapy volume  18 , Article number:  14 ( 2021 ) Cite this article

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HIV testing and early linkage to care are critical for reducing the risk of HIV transmission. HIV self-testing (HIVST) is a useful tool for increasing HIV testing frequency.This study aimed to investigate HIVST rates among men who have sex with men (MSM), the characteristics of MSM who had HIVST, and factors associated with HIVST uptake among MSM in Ningbo, China.

A cross-sectional study was conducted from April to October 2019 in Ningbo,China. Participants were aged at least 18 years and having had sexual contact with men in the past year. Proportions were used for categorical variables. Adjusted Odds Ratio (AOR) and 95% Confidence Interval (CI) for characteristics associated with HIVST uptake was processed by multivariable logistic regression models.

Among a sample of 699 MSM recruited, 38.2% had reported previous use of an HIV self-test kit. A greater proportion of HIVST users had a higher frequency of HIV testing (≥ 2 times: 70.0% versus 41.2%, p < 0.001) in the past 1 year. The odds of older age (30–39 years: AOR = 0.49, CI 0.32–0.76; more than 40 years: AOR = 0.07, CI 0.04–0.14, compared to 18–29 years), bisexual (AOR = 0.49, CI 0.29–0.84) were lower among HIVST users,and were higher among MSM who were higher education level (high school: AOR = 2.82, CI 1.70–4.69, compared to middle school or less), gay apps use (AOR = 1.86, CI 1.13–3.05), multiple male sex partners (AOR = 1.90, CI 1.29–2.80), frequency of male–male sexual contact ≥ 1 times per week (AOR = 1.86, CI 1.30–2.66), syphilis infection (AOR = 5.48, CI 2.53–11.88).

Conclusions

Further HIVST education should be strengthened for school-aged children and teenagers, and free HIVST kits may be provided to high-risk MSM through gay apps and CBO to achieve the increased HIV testing frequency.

Introduction

Globally, there were an estimated 37.9 million people are living with HIV (PLWH), with about 1.7 million people newly infected with HIV at the end of 2018 [ 1 ]. Men who have sex with men (MSM) has become the high-risk group of HIV acquisition [ 2 , 3 ]. MSM accounted for an estimated 17% of new HIV infections globally, including more than half of new HIV infections in western and central Europe and North America [ 4 ]. MSM was about 28 times more likely to be living with HIV than it was among all adult men in 2018 [ 5 ].

To end the AIDS epidemic by 2030, the "90-90-90" goal by 2020 set up by UNAIDS in 2014 (90% of people with HIV infection diagnosed, 90% of people diagnosed on treatment, and 90% of people on treatment achieving virological suppression) [ 6 ]. However, it seems unlikely that many regions and countries would reach the target, especially the first 90% [ 7 ]. In China, an estimated less than 70% of PLWH were aware of their HIV-positive status by the end of 2018 [ 8 ]. HIV testing and early linkage to care were critical for reducing the risk of viral transmission from infected persons However, key population groups including MSM were unwilling to seek voluntary HIV counseling and testing (VCT) in the hospital or Centers for Disease Control and Prevention (CDC) due to stigma and discrimination [ 9 , 10 , 11 ].

HIV self-testing (HIVST) had recommended being offered as an additional HIV testing approach by WHO in 2016 [ 12 ]. Testers take their blood sample to perform HIV rapid tests and interpret the result at the time and location of their choosing. Several studies showed that HIVST had generally high sensitivity and specificity and was an acceptable and feasible testing approach due to the convenience, privacy, and ease of use [ 13 , 14 , 15 ]. These characteristics make it a potentially useful tool for increasing testing frequency and easy to reach first time and repeat testers for HIV [ 16 , 17 ]. In China, HIVST is highly acceptable and easily available through drugstore, e-commerce platform and community-based organisations (CBO) [ 18 ].

Given the need to improve HIV testing rates and target the first of the United Nation’s 90-90-90 HIV testing and treatment goals, the purpose of this study was to investigate HIVST uptake rates among MSM, the characteristics and factors associated with HIVST uptake among MSM in Ningbo, China.

Study design and participants

We conducted a cross-sectional survey from April 1 to October 30, 2019, in Ningbo. Ningbo is an eastern coastal city of China, nearby Shanghai, with an area of 9365 km 2 and a population of approximately 8.54 million people. HIV prevalence among MSM in Ningbo was 5.7% [ 19 ].Convenience sampling of participants was recruited through a combined online and offline method. Flyer advertisements were posted in MSM venues (Three parks, two bars, and eight community events) and VCT clinic,as well as on gay websites and gay apps. The criteria for recruiting were (1) being male, (2) aged at least18 years, (3) having resided in Ningbo for at least 6 months, (4) having had sexual contact with men in the past year.

Interested MSM contacted trained project workers for assessment of eligibility. After providing written informed consent, eligible participants were asked to complete self-administered questionnaires. Project workers were instructed to check questionnaires in place to ensure collection of quality data.

Questionnaire

All data were collected through self-administered paper questionnaires by trained project workers. The following variables were included: (1) demographic information including age, marital status, education level, duration of local residence, monthly income, and sexual orientation; (2) gay apps (Blued, Jack’d, and ZANK) use including duration and frequency of apps use; (3) Sexual behaviors including role and frequency in sexual intercourse, multiple male sex partners, unprotected sex with men and syphilis infection in the past 6 months; (4) HIV testing including reasons for test, frequency of test, time since latest test and site of the latest test; (5) HIVST including self-reported used HIVST in the lifetime (HIVST users), the type of HIVST kit,way to receive HIVST kit.

Statistical analysis

Characteristics of all participants were described by categorical variables presented as absolute values and percentages. The demographic information, gay apps use, sexual behaviors and HIV testing compared between HIVST users and Non-HIVST users were examined by chi-square tests. Univariate and multivariable forward stepwise logistic regression models were performed to examine risk factors associated with HIVST. The statistical significance was defined as P < 0.05. All statistical analyses were performed in SPSS (version 21.0, IBM, Armonk, NY, USA).

Ethical considerations

This study protocol was reviewed and approved by the Institutional Review Board of the Ningbo CDC. Informed consent was asked to sign for all eligible participants when the survey was starting. Participants could receive a gift for prizes of up to 50 Chinese Yuan (CNY) upon the completion of the survey.

Participant characteristics

Table 1 demonstrates the characteristics of the 699 MSM in Ningbo. The mean age was 31.9 (SD 8.8) years. Most participants (81.1%) were less than 30 years, 63.4% were single, 70.4% had a high school education or above, 77.7% had lived in Ningbo for at least 2 years, 62.9% had an income above 5000 CNY per month, and 74.8% self-identified as gay.

Most participants (83.4%) had used gay apps in the past 6 months. Of the 583 gay app users, 85.8% (500/583) had used gay apps for at least 1 year, 56.9% (332/583) used them at least 5 times a day. In terms of sexual practice, half of the participants were engaged in both insertive anal intercourse and receptive anal intercourse equally. 46.1% had sex with men for at least once per week in the prior 6 months.72.0% had multiple male sex partners and 27.2% had unprotected sex with men in the prior 6 months.

Comparisons of characteristics between HIVST users and Non-HIVST users

Among all participants, 604 (86.4%) reported having HIV testing at least once in their lifetimes, and 575 (82.3%) had been tested in the past year. Table 1 describes that a total of 267 participants of (699, 38.2%) reported having used an HIV self-test kit before, whereas 432 (61.8%) reported never having HIV self-test. Compared to non-HIVST users, a larger proportion of HIVST users were aged between 18 and 29 years (58.1% versus 40.5%, p < 0.001), had college or above education level (37.8% versus 29.4%, p = 0.022), had lived in Ningbo less than 2 years (28.5% versus 18.5%, p = 0.002), had an income above 5000 China Yuan (CNY) per month (72.3% versus 57.2%, p < 0.001) and self-identified as gay (82.4% versus 70.1%, p < 0.001).

A larger proportion of HIVST users reported having higher frequency of male-male sexual contact (≥ 1 time/week: 53.6% versus 41.4%, p = 0.002), having multiple male sex partners (32.6% versus 25.2%, p = 0.035), having had syphilis infection (10.9% versus 3.5%, p < 0.001) and having used gay apps (88.8% versus 80.1%, p = 0.003) in the prior 6 months. Among those who had used gay apps, a greater proportion of HIVST users also had a higher frequency of gay apps use (≥ 5 times/day: 63.3% versus 52.6%, p = 0.036) in the prior 6 months and used gay apps over 1 year (89.5% versus 83.2%, p = 0.035).

A greater proportion of HIVST users had a higher frequency of HIV testing (≥ 2 times: 70.0% versus 41.2%, p < 0.001) in the past 1 year. Among those who had HIV testing before, a greater proportion of HIVST users reported having HIV testing regularly (73.4% versus 70.0%, p = 0.011), their most recent HIV testing had been within the prior 3 months (30.3% versus 19.9%, p = 0.005), the site of latest HIV testing was CBO (63.3% versus 53.4%, p = 0.029).

Factor associated with HIVST uptake

As show in Table 2 , multivariable logistic regression analyses found that the odds of older age (30–39 years: AOR = 0.49, CI 0.32–0.76; more than 40 years: AOR = 0.07, CI 0.04–0.14, compared to 18–29 years), bisexual (AOR = 0.49, CI 0.29–0.84) were lower among HIVST users,and were higher among MSM who were higher education level (high school: AOR = 2.82, CI 1.70–4.69, compared to middle school or less), gay apps use (AOR = 1.86, CI 1.13–3.05), multiple male sex partners (AOR = 1.90, CI 1.29–2.80), frequency of male–male sexual contact ≥ 1 times per week (AOR = 1.86, CI 1.30–2.66), syphilis infection (AOR = 5.48, CI 2.53–11.88).

Globally, HIV testing had become an important strategy to end the HIV epidemic [ 20 , 21 ]. HIVST is reliable, safe, and accurate, which can help increase serostatus awareness and ultimately linkage-to-care or prevention services among HIV high-risk populations [ 22 , 23 ]. The proportion of HIV testing among MSM in the lifetimes and the past year in our analysis was higher than in other studies, but there is a certain distance to reach the first 90% targets by 2020 [ 7 , 21 ]. The study revealed that 38.2% of MSM had used HIVST before in Ningbo, which was lower than the rates reported in studies from other areas [ 24 , 25 ]. The reasons for the relatively low HIVST rate in our study could be related to the lack of inventions to promote HIVST by Ningbo CDC. Our study’s contribution to investigate factors associated with HIVST and help the government develop targeted strategies to improve HIV testing among MSM in China.

Our study showed that those MSM who were younger or high education levels were more likely to have had HIVST. It is possible that younger MSM had more worries about positive test results [ 11 ]. Worldwide, about 32% of new HIV infections among adults aged 15 years and older have occurred in youth ages 15–24 years in 2018 [ 4 ]. Therefore, HIVST education should be included as a part of comprehensive sexual and reproductive health education for school-age children and teenagers [ 23 ].

Gay apps were very popular among MSM in China [ 19 ]. HIV prevention through gay apps was widely applied toward reducing high-risk behaviors and promoting HIV testing [ 26 , 27 ]. Our results showed that HIVST users had a higher frequency of gay apps use than Non-HIVST users in the prior 6 months. As with previous findings, the utility of mobile health interventions can engage MSM in HIVST in Heifei and Shenzhen, China [ 28 , 29 ], and increase rates of confirmed HIV diagnoses and linkage to clinical care in the UK [ 30 ]. It indicated that HIVST kits usage and offer can be conducted as a part of HIV prevention through gay apps to access to more high-risk populations in China.

Furthermore, consistent with findings in other studies [ 24 ], those who had high-risk sex behavior, including multiple male sex partners, frequency of male-male sexual contact more than once per week and syphilis infection were more likely to have had HIVST. It is possible that commercial HIVST kits can be easily bought by online shopping platform in China. These high-risk MSM would be willingness to pay for HIVST kits instead of testing in the hospital [ 24 ]. But to avoid possible cost barriers, free HIVST kits might be provided to high-risk populations to achieve the increased testing frequency 17 .

This study demonstrated that HIVST users were more like to have a higher frequency of HIV testing and regular HIV testing compared to non-HIVST users. Regular HIV testing enables early identification and treatment of HIV among at-risk MSM [ 31 ]. As mentioned, the US CDC recommends MSM to take up HIV testing every 3–6 months if they have additional HIV risk factors [ 32 ]. But most of these MSM have no HIV testing routines [ 33 ]. So some HIV interventions should be improved to encourage MSM to use HIVST regular after VCT or HIV risk assessment. The results also showed that two-thirds of MSM received HIVST kits form CBO in the latest HIV testing. This indicated that CBO had become an important role in HIV intervention in China. So the government might strengthen support to CBO to promote HIVST uptake.

Limitations

The present study had several limitations. First, participants were relatively high-educated, had higher income, and our findings may not be generalizable in other contexts or settings. Second, some questions were asked in the prior 6 months. Despite implemented quality control measures, recall and social desirability bias might have existed.Third, this was not a representative sample of the MSM population in Ningbo, because only those who had a willingness and contacted trained project workers could be recruited into the study.Finally, as this was a cross-sectional study, we are unable to establish a causal relationship.

The coverage of HIVST had a significant gap in Ningbo, China. It is necessary to make continued efforts to expand HIVST coverage among MSM. Further HIVST education should strengthen for school-age children and teenagers, HIV prevention should include HIVST kits usage and offer through gay apps and CBO, and free HIVST kits might be provided to high-risk MSM to accelerate achieve the "90-90-90" goal.

Availability of data and materials

The datasets used and/or analyzed during this study is not publicly available, but may be available from the corresponding author upon reasonable request, and with permission from Ningbo Municipal Center for Disease Control and Prevention.

Abbreviations

• HIV self-testing

People are living with HIV

Voluntary HIV counseling and testing

Centers for disease control and prevention

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This study was supported by the Zhejiang Natural Science Fund (LQ20H260005), the Ningbo Natural Science Fund (2019A610380), Ningbo Health Branding Subject Fund (PPXK2018-10), and Zhejiang Medical Key Discipline (07-013). The funding organizations had no role in the design and conduct of this study.

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HH and HS designed the study, HH and HD coordinated the study, HS and HJ collected the data, HH did the primary data analysis, HH and HS contributed to part of the analysis. HH, HS, and YS drafted the paper. All authors contributed to results interpretation interpreted the data, revised the article, and approved the final version and manuscript revision. HD and YS had access to all the data and were responsible for the final decision to submit the manuscript for publication. All authors read and approved the final manuscript.

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Hong, H., Shi, Hb., Jiang, Hb. et al. Prevalence and associated factors of HIV self-testing among men who have sex with men in Ningbo, China: a cross-sectional study. AIDS Res Ther 18 , 14 (2021). https://doi.org/10.1186/s12981-021-00339-x

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Quantifying prognosis in the current era of antiretroviral therapy among persons with hiv in europe and north america across different hiv acquisition route groups, phd research project.

PhD Research Projects are advertised opportunities to examine a pre-defined topic or answer a stated research question. Some projects may also provide scope for you to propose your own ideas and approaches.

Self-Funded PhD Students Only

This project does not have funding attached. You will need to have your own means of paying fees and living costs and / or seek separate funding from student finance, charities or trusts.

Funded PhD- Physiology and therapeutic modulation of oxidative phosphorylation in HIV-1 infected cells.

Funded phd project (uk students only).

This research project has funding attached. It is only available to UK citizens or those who have been resident in the UK for a period of 3 years or more. Some projects, which are funded by charities or by the universities themselves may have more stringent restrictions.

Multipurpose gel formulations containing antiretroviral-loaded lactoferrin nanoparticles and antibiotics for combination HIV prevention and treatment of bacterial vaginosis

The development of new antiviral agents targeting hiv-1, self-funded phd- integrated multi-omics characterisation of human retroviral reservoirs, the use of machine learning models to identify new non-nucleoside reverse transcriptase inhibitors targeting hiv-1, exploring (inter-) generational experiences of living with a bleeding disorder (ref: sf23/hls/nmh/lariviere), discovering and characterising new protein antimicrobials, therapeutic resolution of coronavirus (covid-19) diseases by natural products, laser-based fabrication of medical diagnostic devices in paper, competition funded phd project (students worldwide).

This project is in competition for funding with other projects. Usually the project which receives the best applicant will be successful. Unsuccessful projects may still go ahead as self-funded opportunities. Applications for the project are welcome from all suitably qualified candidates, but potential funding may be restricted to a limited set of nationalities. You should check the project and department details for more information.

MSc by Research: Mapping the host response to fungal pathogens

Microneedle delivery systems for next-generation antibody therapeutics, developing biodegradable long acting drug delivery systems for the treatment of chronic conditions, enzyme-responsive peptide hydrogels as in situ forming long-acting drug delivery implants, platelets in health, ageing and disease: new diagnostics and treatments.

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Masters Degrees (African Centre for HIV/AIDS Management)

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• Pandemic Television: It’s a Sin and the Public History of HIV/AIDS in Britain

In the midst of the COVID-19 pandemic, it is perhaps no surprise that a TV programme covering the history of a recent public health crisis has found an enthusiastic audience. I have been eagerly awaiting the release of Russell T. Davies’ new series ‘It’s a Sin’ because, just as my PhD dissertation does, it explores the HIV/AIDS epidemic and responses to it in England.

Broadcast to much fanfare, the series follows the lives of a group of gay men as they live through the HIV/AIDS epidemic in London. Many previous films have focused on the history of radical HIV/AIDS activist groups in America and continental Europe, with most looking especially to the AIDS Coalition to Unleash Power (ACT UP). The recent HBO series ‘Pose’ explored the emergence and early campaigns of ACT UP New York, while the 2017 film ‘120 BPM’ thrust ACT UP Paris into the international spotlight.

‘It’s a Sin’ is one of the first cultural productions to highlight the place of radical HIV/AIDS activism in the UK. Film, TV and historical accounts of HIV/AIDS activism have been quick to point to American examples, whilst historical accounts of the epidemic in Britain have downplayed the significance of such activists. The title of the series is taken from the Pet Shop Boys’ 1987 number one song of the same name, whose music video was directed by Derek Jarman, an English AIDS activist and filmmaker. They could just have easily drawn from the discography of  Jimmy Somerville, lead singer of Bronski Beat and The Communards. Somerville was an early member of ACT UP London who was arrested several times on ACT UP demos and toured and performed to raise money for the group. As a solo artist in 1990 he released Read My Lips (Enough is Enough) in which he sang ‘Finding cures is not the only solution, and it's not a case of sinner absolution’. The song quickly became something of an ACT UP anthem, helped by the ‘ACT UP’ jumper worn by Somerville in the music video.

My PhD dissertation puts HIV/AIDS activists back into the history of the epidemic in England. England boasted several chapters of the international ACT UP Coalition. London was home to the first chapter, founded in 1989 off the back of the huge movement aimed at stopping Section 28 of the Local Government Act of 1988, which forbade the ‘promotion of homosexuality’ by local authorities. Soon after ACT UP chapters appeared in many British cities, including Edinburgh, Manchester, Leeds, Brighton and Norwich.

Capital Gay coverage of a Jimmy Somerville (pictured) performance to raise money for ACT UP in 1990.

Cambridge, which had a significant resistance movement to Section 28, also became home to an ACT UP chapter. It met on the last Sunday of every month in the City’s radical independent bookshop Grapevine, which operated out of the old Dales Brewery building on Gwydir Street, and which many readers may remember. ACT UP’s political reach extended to smaller provincial towns without active chapters of the group. An article in Solent Pride , a newsletter to mark Southampton’s 1992 gay pride celebrations, noted that ‘there are no ACT UP groups in Southampton, Portsmouth, Basingstoke, Reading, Aldershot, Bournemouth or Winchester’, but insisted that this did not ‘mean that we can’t be effective, in these, our hometowns’. ACT UP’s visible political presence in other British towns and cities was often the inspiration for people to become active in their local organisations or charities which formed part of the broader HIV/AIDS activist movement.

ACT UP was involved in several campaigns during its relatively short political life in Britain. Among the largest was directed against Texaco. The petroleum company had instituted a policy of mandatory HIV tests as part of their hiring process, refusing employment to those who tested positive. The policy caused outrage amongst AIDS activists across the country and largescale protests quickly followed. ACT UP Manchester began blockading Texaco petrol stations throughout the city, handing out literature to motorists explaining their actions and reporting largely sympathetic reactions in their newsletter. ACT UP ultimately failed to stop this policy, which ended up being reversed after HIV was listed as a named disability under the 1995 Disability Discrimination Act, but they succeeded in bringing the issue into much sharper relief than might otherwise have been the case.

ACT UP leaflet, n.d., Norfolk Heritage Centre LGBT+ Collection Health and Wellbeing Box.

As ‘It’s a Sin’ demonstrates, radical AIDS activism in England was about visibility and public displays of resistance to a system which didn’t seem to be taking HIV/AIDS seriously. When the oral historian Wendy Rickard asked John Campbell, who had been a leading member of the group, to ‘say what ACT UP [London] was about’ in 1996, he replied: ‘It was about direct action, about going onto the streets and shouting very loudly and chaining yourself to whatever you could chain yourself to, kicking and screaming and everything to try and get people to take notice of AIDS’. We’re likely to see such displays in abundance on Channel 4 across the five episodes of the series. And whilst there is much more to the HIV/AIDS activist movement in England, as my research shows, seeing representations of the English chapters of this movement is something of a first for television, and has the potential to be informative and highly entertaining.

George Severs is a PhD candidate in the Faculty of History where he is writing up his PhD thesis on HIV/AIDS activism in England c. 1982-1997.

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