Andrew Mitchell

Anal cancer poses a significant risk for sexual minority males (SMM) living with HIV, with a 100-fold higher incidence compared to the general population. Despite success in high-income settings, training on anal cancer prevention in Africa faces challenges due to limited resources and lack of trained practitioners. We evaluated adapting training using an implementation science framework in a Nigerian SMM-friendly clinic. The Consolidated Framework for Implementation Research (CFIR) Card Game assessed barriers to training on anal cancer prevention. Stakeholders ranked the importance of different CFIR constructs. Sessions were conducted separately for internal stakeholders, external stakeholders, and patients. Facilitators identified barriers using culturally adapted text and a hybrid format for consensus discussion. Potential strategies to overcome the barriers were identified with the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. The CFIR card game was conducted in August 2023 with 20 participants (Internal: 4, External: 8, Patients: 8). Internal stakeholders identified adaptability, cost, and the absence of external change agents. External stakeholders highlighted adaptability, design quality, and financial burden, proposing advocacy and local discussions. Patients expressed concerns about adaptability and external policies affecting trust and acceptance, emphasizing strategic adaptations and local involvement. The CFIR-ERIC Matching Tool recommended identifying champions and altering incentives as strategies. Incorporating champion roles, local adaptations, policy enforcement, and financial support can enhance training on anal cancer prevention in Nigeria. The findings stress the importance of cultural sensitivity and engagement with local stakeholders to support training practitioners in anal cancer prevention.

Background: Nigeria has the fourth largest burden of HIV globally. Key populations, including female sex workers, men who have sex with men, and people who inject drugs, are more vulnerable to HIV than the general population due to stigmatized and criminalized behaviors. Reliable key population size estimates are needed to guide HIV epidemic response efforts. Objective: The objective of our study was to use empirical methods for sampling and analysis to improve the quality of population size estimates of female sex workers, men who have sex with men, and people who inject drugs in 7 states (Akwa Ibom, Benue, Cross River, Lagos, Nasarawa, Rivers, and the Federal Capital Territory) of Nigeria for program planning and to demonstrate improved statistical estimation methods. Methods: From October to December 2018, we used 3-source capture-recapture to produce population size estimates in 7 states in Nigeria. Hotspots were mapped before 3-source capture-recapture started. We sampled female sex workers, men who have sex with men, and people who inject drugs during 3 independent captures about one week apart. During hotspot encounters, key population members were offered inexpensive, memorable objects unique to each capture round. In subsequent rounds, key population members were offered an object and asked to identify objects received during previous rounds (if any). Correct responses were tallied and recorded on tablets. Data were aggregated by key population and state for analysis. Median population size estimates were derived using Bayesian nonparametric latent-class models with 80% highest density intervals. Results: Overall, we sampled approximately 310,000 persons at 9015 hotspots during 3 independent captures. Population size estimates for female sex workers ranged from 14,500 to 64,300; population size estimates for men who have sex with men ranged from 3200 to 41,400; and population size estimates for people who inject drugs ranged from 3400 to 30,400. Conclusions: This was the first implementation of these 3-source capture-recapture methods in Nigeria. Our population size estimates were larger than previously documented for each key population in all states. The Bayesian models account for factors, such as social visibility, that influence heterogeneous capture probabilities, resulting in more reliable population size estimates. The larger population size estimates suggest a need for programmatic scale-up to reach these populations, which are at highest risk for HIV.

The observed epidemiology of SARS-CoV-2 in sub-Saharan Africa has varied greatly from that in Europe and the United States, with much lower reported incidence. Population-based studies are needed to estimate true cumulative incidence of SARS-CoV-2 to inform public health interventions. This study estimated SARS-CoV-2 seroprevalence in four selected states in Nigeria in October 2020. We implemented a two-stage cluster sample household survey in four Nigerian states (Enugu, Gombe, Lagos, and Nasarawa) to estimate age-stratified prevalence of SARS-CoV-2 antibodies. All individuals in sampled households were eligible for interview, blood draw, and nasal/oropharyngeal swab collection. We additionally tested participants for current/recent malaria infection. Seroprevalence estimates were calculated accounting for the complex survey design. Across all four states, 10,629 (96·5%) of 11,015 interviewed individuals provided blood samples. The seroprevalence of SARS-CoV-2 antibodies was 25·2% (95% CI 21·8–28·6) in Enugu State, 9·3% (95% CI 7·0–11·5) in Gombe State, 23·3% (95% CI 20·5–26·4) in Lagos State, and 18·0% (95% CI 14·4–21·6) in Nasarawa State. Prevalence of current/recent malaria infection ranged from 2·8% in Lagos to 45·8% in Gombe and was not significantly related to SARS-CoV-2 seroprevalence. The prevalence of active SARS-CoV-2 infection in the four states during the survey period was 0·2% (95% CI 0·1–0·4). Approximately eight months after the first reported COVID-19 case in Nigeria, seroprevalence indicated infection levels 194 times higher than the 24,198 officially reported COVID-19 cases across the four states; however, most of the population remained susceptible to COVID-19 in October 2020.

BACKGROUND Nigeria has the fourth largest burden of HIV globally. Key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who inject drugs (PWID) often have poor social visibility and are more vulnerable to HIV than the general population due to stigma, discrimination, and criminalization of KP-defining behaviors. Reliable, empirical population size estimates (PSE) are needed to guide focused and appropriately scaled HIV epidemic response efforts for KP. We used novel approaches to sampling and analysis to calculate PSE in Nigeria. OBJECTIVE We sampled the population using three-source capture-recapture (3S-CRC) and analyzed results using Bayesian nonparametric latent-class models to generate median PSE with 80% highest density intervals. METHODS During October–December 2018, we used three-source capture-recapture (3S-CRC) to estimate the size of KP in seven United States President’s Emergency Plan for AIDS Relief (PEPFAR) priority states in Nigeria. Hotspots were mapped before 3S-CRC started. We sampled FSW, MSM, and PWID during three independent captures approximately one week apart. During encounters in KP hotspots, distributors offered inexpensive and memorable objects to KP, unique to each capture round and KP type. In subsequent rounds, participants were offered an object and asked to produce or identify objects received during previous rounds (if any); affirmative responses were tallied upon producing or identifying the correct object. Distributors recorded responses on tablets and uploaded to a secure server after each encounter. Data were aggregated by KP and state for analysis. Median PSE were derived using Bayesian nonparametric latent-class models with 80% highest density intervals for precision. RESULTS We sampled approximately 310,000 persons at 9,015 hotspots during three independent captures in all seven states. Overall, FSW PSE ranged from 14,500-64,300; MSM PSE, 3,200-41,400; and PWID PSE, 3,400-30,400. CONCLUSIONS This study represents the first implementation of these 3S-CRC sampling and novel analysis methods for large-scale population size estimation in Nigeria. Overall, our estimates were larger than previously documented for each KP in all states. The current Bayesian models account for factors (i.e., social visibility and stigma) that influence heterogeneous capture probabilities resulting in more reliable PSE. The larger estimates suggest a need for programmatic scale-up to reach these populations at highest risk for HIV.

Background: With the fourth highest HIV burden globally, Nigeria is characterized as having a mixed HIV epidemic with high HIV prevalence among key populations, including female sex workers, men who have sex with men, and people who inject drugs. Reliable and accurate mapping of key population hotspots is necessary for strategic placement of services and allocation of limited resources for targeted interventions. Objective: We aimed to map and develop a profile for the hotspots of female sex workers, men who have sex with men, and people who inject drugs in 7 states of Nigeria to inform HIV prevention and service programs and in preparation for a multiple-source capture-recapture population size estimation effort. Methods: In August 2018, 261 trained data collectors from 36 key population–led community-based organizations mapped, validated, and profiled hotspots identified during the formative assessment in 7 priority states in Nigeria designated by the United States President’s Emergency Plan for AIDS Relief. Hotspots were defined as physical venues wherein key population members frequent to socialize, seek clients, or engage in key population–defining behaviors. Hotspots were visited by data collectors, and each hotspot’s name, local government area, address, type, geographic coordinates, peak times of activity, and estimated number of key population members was recorded. The number of key population hotspots per local government area was tabulated from the final list of hotspots. Results: A total of 13,899 key population hotspots were identified and mapped in the 7 states, that is, 1297 in Akwa Ibom, 1714 in Benue, 2666 in Cross River, 2974 in Lagos, 1550 in Nasarawa, 2494 in Rivers, and 1204 in Federal Capital Territory. The most common hotspots were those frequented by female sex workers (9593/13,899, 69.0%), followed by people who inject drugs (2729/13,899, 19.6%) and men who have sex with men (1577/13,899, 11.3%). Although hotspots were identified in all local government areas visited, more hotspots were found in metropolitan local government areas and state capitals. Conclusions: The number of key population hotspots identified in this study is more than that previously reported in similar studies in Nigeria. Close collaboration with key population–led community-based organizations facilitated identification of many new and previously undocumented key population hotspots in the 7 states. The smaller number of hotspots of men who have sex with men than that of female sex workers and that of people who inject drugs may reflect the social pressure and stigma faced by this population since the enforcement of the 2014 Same Sex Marriage (Prohibition) Act, which prohibits engaging in intimate same-sex relationships, organizing meetings of gays, or patronizing gay businesses.

BACKGROUND With the fourth highest HIV burden globally, Nigeria is characterized as having a mixed HIV epidemic with high HIV prevalence among key populations, including female sex workers, men who have sex with men, and people who inject drugs. Reliable and accurate mapping of key population hotspots is necessary for strategic placement of services and allocation of limited resources for targeted interventions. OBJECTIVE We aimed to map and develop a profile for the hotspots of female sex workers, men who have sex with men, and people who inject drugs in 7 states of Nigeria to inform HIV prevention and service programs and in preparation for a multiple-source capture-recapture population size estimation effort. METHODS In August 2018, 261 trained data collectors from 36 key population–led community-based organizations mapped, validated, and profiled hotspots identified during the formative assessment in 7 priority states in Nigeria designated by the United States President’s Emergency Plan for AIDS Relief. Hotspots were defined as physical venues wherein key population members frequent to socialize, seek clients, or engage in key population–defining behaviors. Hotspots were visited by data collectors, and each hotspot’s name, local government area, address, type, geographic coordinates, peak times of activity, and estimated number of key population members was recorded. The number of key population hotspots per local government area was tabulated from the final list of hotspots. RESULTS A total of 13,899 key population hotspots were identified and mapped in the 7 states, that is, 1297 in Akwa Ibom, 1714 in Benue, 2666 in Cross River, 2974 in Lagos, 1550 in Nasarawa, 2494 in Rivers, and 1204 in Federal Capital Territory. The most common hotspots were those frequented by female sex workers (9593/13,899, 69.0%), followed by people who inject drugs (2729/13,899, 19.6%) and men who have sex with men (1577/13,899, 11.3%). Although hotspots were identified in all local government areas visited, more hotspots were found in metropolitan local government areas and state capitals. CONCLUSIONS The number of key population hotspots identified in this study is more than that previously reported in similar studies in Nigeria. Close collaboration with key population–led community-based organizations facilitated identification of many new and previously undocumented key population hotspots in the 7 states. The smaller number of hotspots of men who have sex with men than that of female sex workers and that of people who inject drugs may reflect the social pressure and stigma faced by this population since the enforcement of the 2014 Same Sex Marriage (Prohibition) Act, which prohibits engaging in intimate same-sex relationships, organizing meetings of gays, or patronizing gay businesses.

Despite large welfare caseload declines in Ontario in recent years, little is known about the longer-term circumstances of people who leave welfare or remain on a much-changed system. This paper reports on a second round of qualitative interviews with current and former workfare participants in Toronto. The findings demonstrate how the lives of most remain marked by poverty, hunger and uncertainty, and reveal contradictions between the realities of their daily lives and the government's “work-first” strategy. Rather than “one size fits all,” the respondent experiences suggest the need for different pathways to sustainable employment, as well as recognition that for some the labour market is an unlikely destination.