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1.  RAPID HOME-BASED HIV TESTING TO REDUCE COSTS IN A LARGE TUBERCULOSIS COHORT STUDY 
Public health action  2013;3(2):172-174.
SUMMARY
To reduce costs in a large tuberculosis household contact cohort study in Lima, Peru, we replaced laboratory-based HIV testing with home-based rapid testing. We developed a protocol and training course to prepare staff for the new strategy; these included role playing for home-based deployment of the Determine® HIV 1/2 Ag/Ac Combo HIV test. Though the rapid HIV test produced more false-positives, the overall cost per participant tested, refusal rate and time to confirmatory HIV testing were lower with the home-based rapid testing strategy compared to the original approach. Rapid testing could be used in similar research or routine care settings.
doi:10.5588/pha.12.0092
PMCID: PMC4287227  PMID: 25580381
TB; HIV; Rapid testing
3.  A prospective cohort study characterising the role of anogenital warts in HIV acquisition among men who have sex with men: a study protocol 
BMJ Open  2014;4(9):e005687.
Introduction
The HIV epidemic in Latin America is concentrated among men who have sex with men (MSM) and transgender women (TGW) with transmission predominately occurring during unprotected anal intercourse. This mode of transmission is also responsible for other sexually transmitted infections (STIs) such as herpes simplex, chlamydia and gonorrhoea, human papillomavirus (HPV)/genital warts and syphilis. Studies assessing the prevalence of HIV and HPV among MSM have not addressed the role of genital warts and HPV-related diseases in the acquisition of HIV infection. Community-based testing programmes are a potentially important way to remove barriers including stigma for individuals to learn about their STI status.
Methods and analysis
The prospective cohort study will recruit 600 MSM/TGW at a community centre in Lima, Peru, named Epicentro. Half of the participants will have a history of or have current anogenital warts (AGW), and the other half will have no history of AGW. We will measure the prevalence and acquisition of STIs including syphilis, HPV, chlamydia and gonorrhoea and the HIV-incidence in the two groups. To the best of our knowledge, it will be the first study that specifically examines the impact of genital warts on incident HIV infection. This study will help to understand the relationship between AGW and HIV infection among MSM/TGW in Peru. Furthermore, it may facilitate the development of preventive intervention strategies to reduce the prevalence of AGW and prevent incident HIV infection. HPV-related manifestations may be a good proxy for HIV risk.
Ethics and dissemination
This study was approved by institutional review boards at the University of California, Los Angeles (UCLA) in the USA and Impacta in Peru. Study findings will be shared with the Peruvian Ministry of Health as well as other international and national public health organisations. Study results will be translated into Spanish for participants.
Trial registration number
The Clinicaltrials.gov registration number is NCT01387412
doi:10.1136/bmjopen-2014-005687
PMCID: PMC4166134  PMID: 25227629
Human papillomavirus; men who have sex with men; genital warts
4.  Rectal Douching and Implications for Rectal Microbicides among Populations Vulnerable to HIV in South America: A Qualitative Study 
Objective
While gel-formulated Rectal Microbicides (RM) are the first to enter clinical trials, rectal douching in preparation for anal intercourse is a common practise, thus RMs formulated as douches may be a convenient alternative to gels. Nonetheless, little is known about potential users’ thoughts regarding douche-formulated RMs or rectal douching practises, data needed to inform the advancement of douche-based RMs. This qualitative study examined thoughts regarding douches, their use as a RM and current douching practises among men who have sex with men and transgender women.
Methods
Ten focus groups and 36 in-depth interviews were conducted (N=140) to examine the overall acceptability of RM, of which one component focused on rectal douching. Focus groups and interviews were recorded, transcribed verbatim and coded; text relating to rectal douching was extracted and analysed. Sociodemographic information was collected using a self-administered questionnaire.
Results
Support for a douche-formulated RM centred on the possibility of combined pre-coital hygiene and HIV protection, and it was believed that a deeply-penetrating liquid douche would confer greater HIV protection than a gel. Drawbacks included rectal dryness; impracticality and portability issues; and, potential side effects. Non-commercial douching apparatus use was common and liquids used included detergents, vinegar, bleach, lemon juice and alcohol.
Conclusions
A douche-formulated RM while desirable and perceived as more effective than a gel-formulated RM also generated questions regarding practicality and side-effects. Of immediate concern were the non-commercial liquids already being used which likely damage rectal epithelia, potentially increasing HIV infection risk. Pre-coital rectal douching is common and a RM formulated as such is desirable, but education on rectal douching practices is needed now.
doi:10.1136/sextrans-2013-051154
PMCID: PMC4035233  PMID: 23966338
rectal douching; microbicides; HIV prevention; MSM; transgender women; South America
5.  Frequency, Patterns and Preferences of Lubricant Use During Anal Intercourse Within Male Sexual Partnerships in Lima, Peru: Implications for a Rectal Microbicide HIV Prevention Intervention 
AIDS care  2012;25(5):579-585.
Understanding current practices of lubricant use during anal intercourse can help to assess the contexts for the introduction of topical rectal microbicides as an HIV prevention tool for men who have sex with men (MSM). We used quantitative and qualitative methods to assess: current patterns of lubricant use; preferred characteristics of commercial lubricant formulations; and social and behavioral contexts of lubricant use within male sexual partnerships in Lima, Peru. Between 2007 and 2008, we conducted a quantitative behavioral survey with 547 MSM followed by qualitative individual and group interviews with 36 MSM from Lima, Peru. Approximately half of all participants in the quantitative survey (50.3%) reported using commercial lubricant during intercourse occasionally or consistently during the preceding two months, with lack of availability at the time of intercourse the most commonly reported reason for non-use. No clear preferences regarding the color, smell, taste, or viscosity of commercial lubricants were identified, and all participants who reported using a commercial lubricant used the same product (“Love-Lub”). In the qualitative analysis, participants characterized lubricant use as a sexual practice consistently controlled by the receptive partner, who typically obtained and applied lubricant independently, with or without the consent of the insertive partner. Quantitative findings supported this differential pattern of lubricant use, with men who reported sexual identities or roles consistent with receptive anal intercourse, including unprotected receptive intercourse, more likely to report lubricant use than MSM who claimed an exclusively insertive sexual role. Given the social, behavioral, and biological factors contributing to increased vulnerability for HIV and STI acquisition by the receptive partner in anal intercourse, delivery of a topical rectal microbicide as a lubricant formulation could provide an important HIV prevention resource for at-risk MSM in Lima, Peru.
doi:10.1080/09540121.2012.726335
PMCID: PMC3556347  PMID: 23082796
6.  Characterizing the syphilis epidemic among men who have sex with men in Lima, Peru to identify new treatment and control strategies 
BMC Infectious Diseases  2013;13:426.
Background
Syphilis is an important sexually transmitted infection (STI) with serious public health consequences. Among men who have sex with men (MSM) in Lima, the prevalence and incidence are extraordinarily high. Current syndromic approaches, however, fail to identify asymptomatic cases, and in settings where large proportions of individuals test positive again after treatment, it is frequently difficult to distinguish treatment failure from re-infection. Thus, new approaches are needed to improve treatment strategies and public health control efforts.
Methods/Design
Study participants will undergo baseline testing for syphilis infection along with a behavioral survey covering demographics, sexual behavior, drug and alcohol abuse and health-care seeking behavior. The cohort will be followed for 18 months at three-month intervals. Blood and earlobe scrapings will also be collected for T. pallidum DNA testing, to create molecular markers for subtyping. We will also perform cytokine testing on collected samples in order to create host immunologic profiles associated with recurrence, re-infection, treatment failure and success.
Discussion
Advances in social epidemiology, molecular typing and characterization of host immune responses will offer promise in developing new understandings of syphilis management. We will share our findings with the Peruvian Ministry of Health and other public health organizations, to identify new approaches of case detection and successful treatment.
doi:10.1186/1471-2334-13-426
PMCID: PMC3846360  PMID: 24016185
Syphilis; Peru; Men who have sex with men (MSM); HIV; T. pallidum; Molecular epidemiology; Cytokine; Macrolide resistance
7.  HPV and Genital Warts among Peruvian Men Who Have Sex with Men and Transgender People: Knowledge, Attitudes and Treatment Experiences 
PLoS ONE  2013;8(3):e58684.
Background
Several studies have assessed the epidemiology of HPV infection among MSM, but no qualitative studies have specifically assessed how HPV and genital warts (GW) affect South American men who have sex with men (MSM) and male-to-female transgendered women (TG). This study explored the knowledge, attitudes and experiences of Peruvian MSM and TG regarding HPV and GW.
Methods
We performed a qualitative study consisting of fifteen in-depth interviews and three focus groups carried out in Lima, Peru with diverse MSM and TG groups, including sex workers. Resulting data were analyzed by applying a systematic comparative and descriptive content analysis.
Results
While knowledge of HPV was limited, awareness of GW was common, particularly among TG persons and sex workers. Still, few participants recognized that GW are sexually transmitted, and many had problems differentiating between GW and other STI/anogenital conditions. Stigmatizing experiences were common during sexual encounters with people who had visible GW. Shame, emotional and physical troubles, and embarrassing sexual experiences were reported by individuals with GW. Search for treatment was mediated by peers, but stigma and apparent health services’ inability to deal with GW limited the access to effective medical care.
Conclusions
In Peru, public health interventions should strengthen services for HPV/GW management and increase accurate knowledge of the transmission, treatment, and sequelae of HPV/GW in MSM and TG populations.
doi:10.1371/journal.pone.0058684
PMCID: PMC3597710  PMID: 23516536
8.  The Role of Human Papillomavirus in Human Immunodeficiency Virus Acquisition in Men who have Sex with Men: A Review of the Literature 
Viruses  2012;4(12):3851-3858.
Human Papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) worldwide. Incidence rates of HPV infection among human immunodeficiency virus (HIV)-infected individuals are well documented and are several-fold higher than among HIV-uninfected individuals. Few studies have demonstrated an increased risk for acquiring HIV infection in those with HPV infection, and this risk seems to be higher when HPV strains are of high-risk oncogenic potential. The estimated prevalence of high-risk oncogenic HPV infection is highest in men who have sex with men (MSM), a particularly vulnerable group with high prevalence rates of HIV infection and other STIs. In this paper, we provide a comprehensive review of the available literature on the role of HPV infection in HIV acquisition. Our review includes data from cross-sectional and longitudinal studies.
doi:10.3390/v4123851
PMCID: PMC3528294  PMID: 23250451
human papillomavirus; human immunodeficiency virus; men who have sex with men; HIV incidence; review; HPV testing
9.  Acceptability of Pre-Exposure Prophylaxis (PrEP) as an HIV prevention strategy: Barriers and facilitators to PrEP uptake among at-risk Peruvian populations 
This study examined Pre-Exposure Prophylaxis (PrEP) acceptability among female sex workers, male-to-female transgendered persons, and men who have sex with men in Lima, Peru. Focus groups explored social issues associated with PrEP acceptability and conjoint analysis assessed preferences among eight hypothetical PrEP scenarios with varying attribute profiles and their relative impact on acceptability. Conjoint analysis revealed that PrEP acceptability ranged from 19.8 to 82.5 out of a possible score of 100 across the eight hypothetical PrEP scenarios. Out-of-pocket cost had the greatest impact on PrEP acceptability (25.2, p <0.001), followed by efficacy (21.4, p <0.001) and potential side effects (14.7, p <0.001). Focus group data supported these findings, and also revealed that potential sexual risk disinhibition, stigma and discrimination associated with PrEP use, and mistrust of health care professionals were also concerns. These issues will require careful attention when planning for PrEP roll-out if proven efficacious in ongoing clinical trials.
doi:10.1258/ijsa.2009.009255
PMCID: PMC3096991  PMID: 21571973
South America; HIV; MSM; FSW; PrEP Acceptability
10.  Sexual diversity, social inclusion and HIV/AIDS 
AIDS (London, England)  2008;22(Suppl 2):S45-S55.
Despite a number of programmes to prevent HIV among men who have sex with men (MSM) and, more generally, sexually diverse populations, gay and other homosexually active men continue to be at heightened risk of HIV and its consequences. This paper analyses some of the reasons for this situation and offers policy and programmatic recommendations to contribute to a solution. The social exclusion of MSM and transgender individuals is an overwhelming reality in the majority of countries worldwide. Although progress has been achieved in some countries, in most of the world the situation remains problematic. Present challenges to equality and to the realization of health, include the membership of groups or subcultures with high HIV prevalence, lower quality and coverage of services and programmes and the impact of higher-level influences such as laws, public policies, social norms and culture, which together configure an environment that is hostile to the integration and needs of certain groups. A social inclusion perspective on HIV prevention and AIDS-related care implies the adoption of strategies to understand and confront social vulnerability. Sexual exclusion intensifies the burden of HIV transmission and morbidity. As part of a comprehensive response there is an urgent need to: (i) improve our understanding of the characteristics and HIV burden among sexually diverse populations; (ii) creatively confront legal, social and cultural factors enhancing sexual exclusion; (iii) ensure the provision of broad-based and effective HIV prevention; (iv) offer adequate care and treatment; and (v) confront special challenges that characterize work with these populations in lower and middle-income countries.
doi:10.1097/01.aids.0000327436.36161.80
PMCID: PMC3329729  PMID: 18641469
care; HIV/AIDS; men who have sex with men; prevention; sexual minorities; social exclusion; transgender
11.  Innovative approaches to cohort retention in a community-based HIV/STI prevention trial for socially marginalized Peruvian young adults 
Background
The conduct of longitudinal clinical trials must involve effective strategies to retain study participants in order to ensure internal validity, adequate statistical power and generalizability of results.
Purpose
In a large trial in Peru, we implemented various retention strategies to maintain high participation rates over time.
Methods
Novel participant retention strategies were used to follow highly marginalized populations for two years because traditional locator information, such as telephone numbers and official identification (eg, passport, driver's license, the local equivalent of a social security number) were often unreliable or unavailable. These strategies included detailed preliminary ethnographic research to identify the behaviours of key target groups, approaches to develop strong informal bonds between project staff and participants outside of study settings, and methods to enhance positive participant attitudes towards the study.
Results
The overall study retention rate after two years was 84%, even though only 26% of the study populations supplied complete locator information (telephone, address and the names of two friends).
Limitations
The retention strategies used were labour intensive and iterative, which could prove difficult to replicate.
Conclusions
The two-year retention rate in this study was sufficient to maintain required sample sizes. The methods used to maintain contact with the populations were labour intensive, low tech and adequate for these populations and could be used to retain study participants in other marginalized, urban, low-income areas.
doi:10.1177/1740774506075869
PMCID: PMC2853960  PMID: 17327244

Results 1-11 (11)