Stefan Baral

Stefan Baral
Johns Hopkins Bloomberg School of Public Health | JHSPH · Department of Epidemiology

MD, MPH, MBA, MSc, FRCPC, CCFP

About

593
Publications
94,441
Reads
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19,338
Citations
Introduction
Through his role as the Director of the Key Populations Program at the JHSPH, Stefan has led HIV epidemiology and implementation research focused on characterizing the epidemiology of HIV and effective HIV prevention, treatment, and care approaches for gay men and other men who have sex with men, transgender women, and female sex workers across Western and Central, and Southern Africa with support from USAID, CDC, NIH, amfAR, and the Global Fund.
Additional affiliations
June 2010 - May 2015
Karolinska Institutet
Position
  • Professor (Associate)
July 2006 - present
Johns Hopkins University
Position
  • Professor (Associate)

Publications

Publications (593)
Article
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Background Men who have sex with men (MSM) are consistently burdened by HIV at higher levels than other adults. While HIV prevention programs for MSM are growing in coverage and quality, HIV incidence remains high. In response, pre-exposure prophylaxis (PrEP) was introduced in 2019 to support HIV risk reduction among MSM in Cameroon. Understanding...
Article
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Background In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored pref...
Preprint
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Introduction: Over half of female sex workers (FSW) in South Africa are living with HIV and clinical depression has been frequently documented among FSW. Data characterizing structural determinants of depression and the role of syndemic theory, an aggregation of multiple risk factors, on viral suppression among FSW in South Africa are limited. Meth...
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Background COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interve...
Preprint
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Background Minors who sell sex likely have complex mental health needs that may persist into adulthood. This topic is understudied in Sub-Saharan Africa. This study hypothesized that adult female sex workers in Eswatini who started selling sex as minors have a higher prevalence of depression than those who started as adults. We also examined correl...
Article
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HIV remains a threat to global public health, disproportionately affecting countries across Sub-Saharan Africa. Although treatment and access to care have improved, prevention remains critical to ending new HIV infections by 2030. A variety of prevention strategies exist, yet their effectiveness is difficult to measure and variable due to the natur...
Article
Background Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID). We examined the prevalence of public injecting and associations with non–fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran. Methods Using respondent-driven sampling, we recruit...
Article
Long-term adherence to antiretroviral medication continues to present as a challenge along the continuum of the HIV care cascade. HIV interventions and support programs are significantly threatened in resource-limited settings by challenges in maintaining long-term follow-up for ART adherence. We sought to complete a systematic review to comprehens...
Preprint
Background HIV programmes in sub-Saharan Africa (SSA) require information about HIV among key populations to ensure equitable and equal access to HIV prevention and treatment. Surveillance has been conducted among female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender populations, but is not syste...
Article
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In South Africa, 62% of female sex workers (FSW) are estimated to be living with HIV. Qualitative research indicates that FSW share antiretroviral therapy (ART) with peers to surmount treatment barriers. We quantitatively described ART sharing, its correlates, and its relationship with viral suppression (VS) among FSW living with HIV in eThekwini,...
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Linkage to care (LTC) and initiation of antiretroviral therapy (ART) are key components in the longitudinal care cascade for people living with HIV. Many strategies to optimize these stages of HIV care have been implemented, though there is a paucity of analyses comparing the outcomes of these efforts in low- and middle-income countries. We conduct...
Article
Background: Given available effective biomedical and behavioral prevention and treatment interventions, HIV-related implementation research (IR) is expanding. The rapid generation and dissemination of IR to inform guidelines and practice has the potential to optimize the impact of the Ending the Epidemic Initiative and the HIV pandemic response mo...
Article
HIV-related implementation research holds great promise in achieving the potential of efficacious prevention and treatment tools in reducing the incidence of HIV and improving HIV treatment outcomes among people living with HIV. From the perspectives of HIV-related implementation research training and academia and through consultations with funders...
Article
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There remains a limited understanding of the HIV prevention and treatment needs among female sex workers in many parts of the world. Systematic reviews of existing literature can help fill this gap; however, well-done systematic reviews are time-demanding and labor-intensive. Here, we propose an automatic document classification approach to a syste...
Preprint
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Background: Mobility is an important risk determinant for HIV given the potential for intermittent access to HIV services. Mobility may be particularly relevant among female sex workers, (FSW) who have been shown to be at high risk for HIV in settings around the world. Data regarding the role mobility plays in exacerbating HIV risks among FSW acros...
Preprint
Objective To assess the prevalence and predictors of underage initiation of selling sex among female sex workers (FSW) in Guinea-Bissau. Methods 505 adult FSW recruited using respondent-driven sampling were surveyed in 2017. Multivariable logistic regression was used to identify demographic, behavioral, and psychosocial characteristics associated...
Article
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Introduction: Pre-exposure prophylaxis (PrEP) is proven to be a highly effective HIV prevention method for key populations. However, its scale-up in resource-limited settings remains sub-optimal. This paper seeks to describe PrEP initiation and continuation among key populations in Cameroon. Methodology: From June 2019 through October 2020, we c...
Article
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HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or po...
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Background: Shared and divergent predictors of clinical severity across respiratory viruses may support clinical and community responses in the context of a novel respiratory pathogen. Methods: We conducted a retrospective cohort study to identify predictors of 30-day all-cause mortality following hospitalization with influenza (N = 45,749; 2010...
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Vaccination policies have shifted dramatically during COVID-19 with the rapid emergence of population-wide vaccine mandates, domestic vaccine passports and differential restrictions based on vaccination status. While these policies have prompted ethical, scientific, practical, legal and political debate, there has been limited evaluation of their p...
Preprint
Background Identification of shared and divergent predictors of clinical severity across respiratory viruses may support clinical decision-making and resource planning in the context of a novel or re-emergent respiratory pathogen. Methods We conducted a retrospective cohort study to identify predictors of 30-day all-cause mortality following hospi...
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Background Despite progress in improving antiretroviral therapy (ART) for people with HIV in Malawi, the burden of HIV infections and HIV treatment outcomes among key populations is suboptimal. Client-centered differentiated service delivery approaches may facilitate addressing HIV prevention and treatment needs of key populations in Malawi. Metho...
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Introduction Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight. Methods In response, a cross-sectional survey was administe...
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Background Global HIV treatment programs have sought to lengthen the interval between clinical encounters for people living with HIV (PLWH) who are established on antiretroviral treatment (ART) to reduce the burden of seeking care and to decongest health facilities. The overall effect of reduced visit frequency on HIV treatment outcomes is however...
Preprint
Importance Social determinants of health (SDOH) play an important role in COVID-19 outcomes. More research is needed to quantify this relationship and understand the underlying mechanisms. Objectives To examine differential patterns in COVID-19-related mortality by area-level SDOH accounting for confounders; and to compare these patterns to those...
Article
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Background Despite the established efficacy of PrEP to prevent HIV and the advantages of a user-controlled method, PrEP uptake and persistence by women in both trials and demonstration projects has been suboptimal. We utilized real-world data from an HIV service provider to describe persistence on oral PrEP among female sex workers (FSW) in eThekwi...
Article
Objectives People experiencing homelessness (PEH) are at increased risk of respiratory infections and associated morbidity and mortality. To characterize optimal intervention strategies, we completed a systematic review of mitigation strategies for PEH to minimize the spread and impact of respiratory infectious disease outbreaks, including COVID-19...
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Background Stigma is an established barrier to the provision and uptake of HIV prevention, diagnostic, and treatment services. Despite consensus on the importance of addressing stigma, there are currently no country-level summary measures to characterize stigma and track progress in reducing stigma around the globe. This data mapping exercise aimed...
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Background: Many studies have examined the effectiveness of non-pharmaceutical interventions (NPIs) on SARS-CoV-2 transmission worldwide. However, less attention has been devoted to understanding the limits of NPIs across the course of the pandemic and along a continuum of their stringency. In this study, we explore the relationship between the gr...
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Background: Understanding inequalities CoV-2 in each city, and calculated Gini in SARS-CoV-2 transmission associated covariance coefficients to determine with the social determinants of health each city’s heterogeneity by each social could help the development of effective determinant (income, education, housmitigation strategies that are responsiv...
Article
Gender-based violence (GBV) is that perpetrated based on sex, gender identity, or perceived adherence to socially defined gender norms. This human rights violation is disproportionately experienced by HIV key populations including female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM). Consequently, addressing...
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Introduction: Health-related quality of life (HRQoL) is an important HIV outcome beyond viral suppression. However, there are limited data characterizing HRQoL of key populations, including female sex workers (FSW) living with HIV. Methods: We used baseline data (22 June 2018-23 March 2020) of FSW who were diagnosed with HIV and enrolled into a...
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Objective : To report clinical characteristics and outcomes of people with multiple sclerosis (PwMS) who developed COVID-19 infection in Toronto, Canada. Methods : Descriptive, retrospective, single-center study that included all known PwMS at the St. Michael's Hospital MS Clinic who had PCR-confirmed COVID-19 infection between March 2020 and May...
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Background: In Rwanda, epidemiological data characterizing people who inject drugs (PWID) and their burden of HIV are limited. We examined injection drug use (IDU) history and practices, and HIV infection in a sample of PWID in Kigali. Methods: From October 2019 to February 2020, 307 PWID aged ≥ 18 were enrolled in a cross-sectional study using...
Article
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Background For men who have sex with men (MSM) across sub-Saharan Africa (SSA), disclosure of same-sex practices to family and healthcare workers (HCWs) can facilitate access to HIV prevention services and support, but can also lead to experiences of stigma. Methods We performed mixed-effects regressions on pooled data from MSM in Cameroon, Senega...
Article
Background: Multiple anal human papillomavirus (HPVs) may increase the risk of anal cancer among men who have sex with men (MSM) living with HIV. The Jaccard Similarity Index (JSI) was explored as a measure of multiple HPV persistence. Methods: The TRUST/RV368 cohort enrolled MSM living with and without HIV in Abuja and Lagos, Nigeria. Participa...
Preprint
BACKGROUND Disproportionate risks of COVID-19 in congregate settings including long-term care homes, retirement homes, and shelters both affect and are affected by SARS-CoV-2 infections among facility-staff. In cities across Canada, there has been a consistent trend of geographic clustering of COVID-19 cases. However, there remain limited data on h...
Article
HIV self-testing (HIVST) shows promise to improve HIV diagnosis among those seeking privacy and anonymity in HIV testing. This may include sexual and gender diverse populations, who experience disproportionately high burdens of stigma and HIV globally. To inform potential scale-up of HIVST in Myanmar, we implemented a community-led, mixed-methods r...
Preprint
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Background Black cisgender women in the U.S. South bear a disproportionate burden of HIV compared to cisgender women in other racial and ethnic groups and in any other part of the US. Critical to decreasing new HIV infections is the improved delivery of pre-exposure prophylaxis (PrEP) for Black cisgender women as it remains underutilized in 2021. I...
Preprint
Background: Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response to the pandemic mo...
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Background Strategies to control coronavirus 2019 disease (COVID-19) have often been based on preliminary and limited data and have tended to be slow to evolve as new evidence emerges. Yet knowledge about COVID-19 has grown exponentially, and the expanding rollout of vaccines presents further opportunity to reassess the response to the pandemic mor...
Article
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To evaluate the role of sexual behavior stigma as a determinant of depressive symptoms among men who have sex with men (MSM) and transgender women (TGW) in Kigali, Rwanda. MSM/TGW aged ≥ 18 years were recruited using respondent-driven sampling (RDS) between March–August, 2018. Mental health was assessed using the Patient Health Questionnaire (PHQ-9...
Article
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BACKGROUND: There are limited in-depth analyses of COVID-19 differential impacts, especially in resource-limited settings such as South Africa (SAOBJECTIVES: To explore context-specific sociodemographic heterogeneities in order to understand the differential impacts of COVID-19METHODS: Descriptive epidemiological COVID-19 hospitalisation and mortal...
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Introduction With over 82.4 million forcibly displaced persons worldwide, there remains an urgent need to better describe culturally, contextually and age-tailored strategies for preventing COVID-19 in humanitarian contexts. Knowledge gaps are particularly pronounced for urban refugees who experience poverty, overcrowded living conditions and poor...
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Background Men who have sex with men (MSM) are disproportionately affected by HIV in China. Globally, younger MSM are at higher risk for incident HIV infections, but there has been substantial variation in the estimates of age-stratified HIV incidence among MSM in mainland China, potentially due to regional differences in the nature of the epidemic...
Article
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Background Pre-exposure prophylaxis (PrEP) has the potential to reduce transmission of HIV among Black cisgender women in the Southern United States (U.S.); however, national data suggests that PrEP initiation is lowest in the South and among Black women compared to other U.S. regions and white women. This study applied intersectionality and PrEP m...
Article
Men who have sex with men (MSM) in the United States are stigmatized for their same-sex practices, which can lead to risky sexual behavior, potentiating risk for human immunodeficiency virus (HIV) infection. Improved measurement is necessary for accurately reporting and mitigating sexual behavior stigma. We added 13 sexual behavior stigma items to...
Article
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We characterized the prevalence of, and estimated associations between, (1) HIV-related healthcare stigma/discrimination and (2) unmet social, mental, and chronic condition healthcare needs among persons living with HIV (PLHIV) in England and Wales. We used data from Positive Voices 2017, a national, cross-sectional probability survey of persons li...
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Background: Experiences of HIV stigma remain prevalent across Canada, causing significant stress and negatively affecting the health and wellbeing of people living with HIV. While studies have consistently demonstrated that stigma negatively impacts health, there has been limited research on the mechanisms behind these effects. This study aims to...
Article
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Introduction: There is an urgent need to identify men who have sex with men (MSM) living with HIV with unsuppressed viral loads to prevent transmission. Though respondent-driven sampling (RDS) is traditionally used for hard-to-reach populations, we compare how RDS and direct recruitment (DR) perform in identifying MSM living with HIV with unsuppre...
Article
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Background Testing for COVID-19 and linkage to services is fundamental to successful containment and control of transmission. Yet, knowledge on COVID-19 testing among transgender and non-binary communities remains limited. Methods Between October 2020 and November 2020, we examined the prevalence and associations of COVID-19 testing in an online s...
Article
Optimiser la réponse de la santé publique pour diminuer le fardeau de la COVID-19 nécessite la caractérisation de l’hétérogénéité du risque posé par la maladie à l’échelle de la population. Cependant, l’hétérogénéité du dépistage du SRAS-CoV-2 peut fausser les estimations selon le modèle d’étude analytique utilisé. Notre objectif était d’explorer l...
Preprint
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Background In Rwanda, epidemiological data characterizing people who inject drugs (PWID) and their burden of HIV are limited. We examined injecting drug use (IDU) history, practices, and HIV infection in a sample of PWID in Kigali. Methods From October 2019–February 2020, 322 PWID aged >18 were enrolled in a cross–sectional study using convenience...
Preprint
Full-text available
Background: There is a growing recognition that strategies to reduce SARS-CoV-2 transmission should be responsive to local transmission dynamics. Studies have revealed inequalities along social determinants of health, but little investigation was conducted surrounding geographic concentration within cities. We quantified social determinants of geog...
Article
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Background: Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability...
Article
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Individual and network heterogeneity should inform respiratory pandemic responses