1. Overview of HIV Epidemiology and Prevention Sciences for key populations
Stefan Baral, MD MPH FRCPC
Center for Public Health and Human Rights, Johns Hopkins School of Public Health

2. Outline Background HIV among Key Populations
Female Sex Workers
Men who have Sex with Men
People who Inject Drugs
Transgender People
Levels of HIV Risk
HIV among Key Populations
Epidemiology
Prevention Studies
Community Determinants
Conclusions and Moving Forward

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

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

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

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

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

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

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

10. PrEP
Many ongoing & planned Phase III/IV research & feasibility/demonstration projects
≥ 17 studies with GMT
Feasibility studies in FSW in Nigeria, Kenya, RSA, Benin, Senegal supported by BMGF
Trial & product
Population N
Country
Expected Completion
FTC/TDF
(Intervention to Enhance PrEP Uptake and Adherence in a Community-Based Setting)
GMT
445
Callen-Lorde Clinic, NYC, US
2015
TDF2 OLE
TDF/FTC
heterosexual men & women  
1,219
Botswana
Nov 2013
iPrEX OLE
1,770
Brazil, Ecuador, Peru, South Africa, Thailand & U.S.
Early 2014

11. PrEP Trial Product Population N Country Expected Completion HPTN073
FTC/TDF
Black MSM ≥18 years
225
U.S.
June 2015
PrEP at STD Clinics
GMT
600
Dec 2014
Project PrEPare
Young MSM years
300
March 2016
Partners Demonstration Project
Heterosexual serodiscordant couples
1000
Kenya & Uganda
2015
Sibanye
MSM
200
South Africa
Demo PrEP
400
Brazil
Jan 2016
PROUD
Immediate or deferred FTC/TDF
500
U.K.
Early 2015
PATH-PrEP
375
May 2017
VicPrEP Study
High risk men & women --
Australia
SAPPH-Ire
(C-RTC of combination prevention incl. PrEP)
Female sex workers
2800
Zimbabwe
Oct 2015

12. Oral PrEP – Dosing/Regimens Study
Trial
Intervention
Population N
Country
Expected Completion
ADAPT Study/ HPTN067
FTC/TDF: daily, time-based, or event-based
Inc. MSM & TGW
540
South Africa, Thailand & U.S.
July 2014
NEXT-PrEP/ HPTN069
Daily MVC, MVC+FTC, MVC+TDF, or FTC/TDF
MSM & women
600
U.S.
Dec 2014
IPERGAY/ CTN 268 ANRS
Intermittent FTC/TDF or placebo
MSM
1900
Canada & France
Dec 2016

13. Topical PrEP – Ongoing Research
Trial
Intervention
Population N
Country
Expected Completion
FACTS 001
1% TDF gel
Women 18-30
2900
South Africa
Dec 2014
CAPRISA 008
Women
700
Feb 2015
MTN-017
TDF rectal microbicide
GMT
186
Peru, South Africa, Thailand, U.S.
ASPIRE/ MTN-020
Dapivirine vaginal ring
Women 18-45
3476
Malawi, Uganda, South Africa & Zimbabwe
Dec 2014 / early 2015
The Ring Study/ IPM 027
1650
Rwanda & South Africa
Aug 2015

14. Acute Infection/Universal ART Study
Trial
Intervention
Population N
Country/
Region
Expected Completion
"Test & Treat" Indonesia
Immediate ART Y1, immediate ART & CB intervention package Y2
MSM, FSW, PWID --
Indonesia
TBD
Integrated Care Clinics (ICC) for IDUs in India
IDU-oriented ICCs for improving "seek, test, treat, and retain" continuum
PWID & MSM
1000
India
2016
Multi-component Intervention Packages
Package of Test & Link-to-Care interventions
MSM
China
2015

15. Universal Coverage of ART
Trial
Intervention
Population N
Country/
Region
Expected Completion
Thai MSM/TG Test & Treat Study
Universal HIV testing & ART regardless of CD4
GMT
2000
Thailand
Dec 2014
CDC Test & Treat Thailand
8000
TBD
Test and Treat - Peru
Immediate ART vs. ART after 24 weeks
150
Peru
Dec 2016
ART for prevention & treatment
Immediate ART
Serodiscordant couples
Viet Nam
Early ART among PWID
PWID
Dec 2015
Anza Mapema
Immediate ART; Comprehensive package of find, test, link & retain in care (FTLR) interventions
MSM
700
Kenya

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

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

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

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

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

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

22. Conclusions
Increasing amount of data characterizing the HIV epidemiology, prevention and HIV treatment needs of key populations
Predominant majority of epidemiologic and surveillance studies have focused on individual-level determinants of HIV risk among key populations
Burden of HIV
Often sustained or increasing HIV incidence
The future holds increased HIV prevention studies for key populations
Necessitates effective partnerships between community and academia
Contextualize HIV-related risk behaviors among key populations
Affect the coverage of HIV prevention, treatment, and care services by mitigating both the provision and uptake of services

23. Acknowledgements Key Populations Program
Ashley Grosso, Erin Papworth, Andrea Wirtz, Emily Crawford, Sheree Schwartz, Charles Cange, Sosthenes Ketende
Collaborators: Enda Santé (Daouda Diouf), UNAIDS Gambia (Nuha Ceesay), CEDEP (Gift Trapence), Desmond Tutu, HSRC, PAMAC, AEC, EVT, IRSS, AIDSETI, Emory University, Fenway Health, PNPEC, PLS-PHV (Dr. Marguerite Thiam), Rebecca Ezouatchi, Amara Bamba
CPHHR
Emily Clouse, Tara Lonergan, Michele Decker, Susan Sherman, Chris Beyrer
amfAR
Owen Ryan, Chris Collins, Sam Avrett, Kent Klindera
JHSPH Students
Claire Holland, Madeleine Schlefer, Faiza Yazin, Sarah Peitzmeier, Krystal Mason, Darrin Adams, Jennifer Wilburn, Ben Liestman, Ju Park, Antonio Lee, Katie Rischer, Michelle Silver, …