Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approachJournal articleErik Lamontagne, Vincent Leroy, Anna Yakusik, Warren Parker, Sean Howell et Bruno Ventelou, BMC public health, Volume 24, Issue 1, pp. 215, 2024

BACKGROUND: Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people.
METHODS: This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms.
RESULTS: Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities.
CONCLUSIONS: The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

Evidence-based policymaking when evidence is incomplete: The case of HIV programme integrationJournal articleJan A. C. Hontelez, Caroline A. Bulstra, Anna Yakusik, Erik Lamontagne, Till W. Bärnighausen et Rifat Atun, PLOS Medicine, Volume 18, Issue 11, pp. e1003835, 2021

Jan Hontelez and co-authors discuss the use of different types of evidence to inform HIV program integration.

Integrating HIV services and other health services: A systematic review and meta-analysisJournal articleCaroline A. Bulstra, Jan A. C. Hontelez, Moritz Otto, Anna Stepanova, Erik Lamontagne, Anna Yakusik, Wafaa M. El-Sadr, Tsitsi Apollo, Miriam Rabkin, UNAIDS Expert Gro Integration, et al., PLOS Medicine, Volume 18, Issue 11, pp. e1003836, 2021

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

Methods and findings
We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41–1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16–1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20–1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05–2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03–1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of ‘ending AIDS by 2030’, while simultaneously supporting progress towards universal health coverage.

Economic, Mental Health, HIV Prevention and HIV Treatment Impacts of COVID-19 and the COVID-19 Response on a Global Sample of Cisgender Gay Men and Other Men Who Have Sex with MenJournal articleGlenn-Milo Santos, Benjamin Ackerman, Amrita Rao, Sara Wallach, George Ayala, Erik Lamontagne, Alex Garner, Ian W. Holloway, Sonya Arreola, Vince Silenzio, et al., AIDS and Behavior, Volume 25, Issue 2, pp. 311-321, 2021

There is an urgent need to measure the impacts of COVID-19 among gay men and other men who have sex with men (MSM). We conducted a cross-sectional survey with a global sample of gay men and other MSM (n = 2732) from April 16, 2020 to May 4, 2020, through a social networking app. We characterized the economic, mental health, HIV prevention and HIV treatment impacts of COVID-19 and the COVID-19 response, and examined whether sub-groups of our study population are disproportionately impacted by COVID-19. Many gay men and other MSM not only reported economic and mental health consequences, but also interruptions to HIV prevention and testing, and HIV care and treatment services. These consequences were significantly greater among people living with HIV, racial/ethnic minorities, immigrants, sex workers, and socio-economically disadvantaged groups. These findings highlight the urgent need to mitigate the negative impacts of COVID-19 among gay men and other MSM.

The economic returns of ending the AIDS epidemic as a public health threatJournal articleErik Lamontagne, Mead Over et John Stover, Health Policy, Volume 123, Issue 1, pp. 104-108, 2019

In 2016, countries agreed on a Fast-Track strategy to "end the AIDS epidemic by 2030". The treatment and prevention components of the Fast-Track strategy aim to markedly reduce new HIV infections, AIDS-related deaths and HIV-related discrimination. This study assesses the economic returns of this ambitious strategy.

We estimated the incremental costs, benefits and economic returns of the Fast-Track scenario in low- and middle-income countries, compared to a counterfactual defined as maintaining coverage of HIV-related services at 2015 levels. The benefits are calculated using the full-income approach, which values both the changes in income and in mortality, and the productivity approach.

The incremental costs of the Fast-Track scenario over the constant scenario for 2017-2030 represent US$86 billion or US$13.69 per capita. The full-income valuation of the incremental benefits of the decrease in mortality amounts to US$88.14 per capita, representing 6.44 times the resources invested for all countries. These returns on investment vary by region, with the largest return in the Asia-Pacific region, followed by Eastern and Southern Africa. Returns using the productivity approach are smaller but ranked similarly across regions.

In all regions, the economic and social value of the additional life-years saved by the Fast-Track approach exceeds its incremental costs, implying that this strategy for ending the AIDS epidemic is a sound economic investment.

A socioecological measurement of homophobia for all countries and its public health impactJournal articleErik Lamontagne, Marc d'Elbée, Michael W. Ross, Aengus Carroll, André du Plessis et Luiz Loures, European Journal of Public Health, Volume 28, Issue 5, pp. 967-972, 2018

Measuring homophobia at country level is important to guide public health policy as reductions in stigma are associated with improved health outcomes among gay men and other men who have sex with men. Methods: We developed a Homophobic Climate Index incorporating institutional and social components of homophobia. Institutional homophobia was based on the level of enforcement of laws that criminalise, protect or recognise same-sex relations. Social homophobia was based on the level of acceptance and justifiability of homosexuality. We estimated the Index for 158 countries and assessed its robustness and validity.

Western Europe is the most inclusive region, followed by Latin America. Africa and the Middle East are home to the most homophobic countries with two exceptions: South Africa and Cabo Verde. We found that a 1% decrease in the level of homophobia is associated with a 10% increase in the gross domestic product per capita. Countries whose citizens face gender inequality, human rights abuses, low health expenditures and low life satisfaction are the ones with a higher homophobic climate. Moreover, a 10% increase in the level of homophobia at country level is associated with a 1.7-year loss in life expectancy for males. A higher level of homophobia is associated with increased AIDS-related death among HIV-positive men.

The socioecological approach of this index demonstrates the negative social, economic and health consequences of homophobia in low- and middle-income countries. It provides sound evidence for public health policy in favour of the inclusion of sexual minorities.

The macroeconomic consequences of renouncing to universal access to antiretroviral treatment for HIV in Africa: a micro-simulation model.Journal articleBruno Ventelou, Yves Arrighi, Robert Greener, Erik Lamontagne, Patrizia Carrieri et Jean-Paul Moatti, PLoS ONE, Volume 7, Issue 4, pp. e34101, 2012

AIM: Previous economic literature on the cost-effectiveness of antiretroviral treatment (ART) programs has been mainly focused on the microeconomic consequences of alternative use of resources devoted to the fight against the HIV pandemic. We rather aim at forecasting the consequences of alternative scenarios for the macroeconomic performance of countries. METHODS: We used a micro-simulation model based on individuals aged 15-49 selected from nationally representative surveys (DHS for Cameroon, Tanzania and Swaziland) to compare alternative scenarios : 1-freezing of ART programs to current levels of access,