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Journal of the International AIDS Society

Published by Wiley and International AIDS Society

Online ISSN: 1758-2652

Disciplines: Infectious disease

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Study selection process.
estimates of advanced HIV disease prevalence in health care settings. AHD, advanced HIV disease. Studies that reported data from both inpatient and outpatient settings not included.
Subgroup analyses. AHD, advanced HIV disease; ART, antiretroviral therapy. All analyses other than setting restricted to outpatient and mixed settings (inpatient studies dropped from analysis).
Global prevalence of advanced HIV disease in healthcare settings: a rapid review

February 2025

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29 Reads

Nathan Ford

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Reshma Kassanjee

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Dominik Stelzle

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Ajay Rangaraj
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Aims and scope


The Journal of the International AIDS Society (JIAS) is a peer-reviewed and open access journal for the generation and dissemination of evidence from a wide range of disciplines: basic and biomedical sciences; behavioural sciences; epidemiology; clinical sciences; health economics and health policy; operations research and implementation sciences; and social sciences and humanities. Submission of HIV research carried out in low- and middle-income countries is strongly encouraged.

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CONSORT diagram: screening, randomization, and analysis populations.
Early initiation of fast‐track care for persons living with HIV initiating dolutegravir‐based regimens during a period of severe civil unrest in Port‐au‐Prince, Haiti: a pilot randomized trial
  • Article
  • Full-text available

February 2025

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8 Reads

Introduction Differentiated service delivery (DSD) models have been widely implemented for patients in stable HIV care. However, DSD has rarely been offered to newly diagnosed patients. We assessed the effectiveness of early fast‐track care during a period of severe civil unrest in Port‐au‐Prince, Haiti. Methods We conducted a pilot randomized trial among adults presenting with early HIV disease to determine whether early fast‐track care (8−12 weeks after same‐day HIV testing and antiretroviral therapy [ART] initiation) was associated with superior outcomes compared with standard (deferred eligibility for fast‐track care). All participants received tenofovir/lamivudine/dolutegravir (TLD), and HIV‐1 RNA <200 copies/ml was required prior to initiating fast‐track care. The primary outcome was 48‐week HIV‐1 RNA <200 copies/ml, with intention‐to‐treat analysis. Results From December 2020 to August 2022, 245 participants were randomized to standard (n = 116) and early fast‐track (n = 129) groups. All initiated TLD on the day of HIV diagnosis. In the early fast‐track group, one (0.8%) died, 12 (9.3%) were internally displaced/emigrated, five (3.9%) were lost‐to‐follow‐up (LTFU), two (1.6%) had a gap in care/later return, one (0.8%) was transferred and 108 (83.7%) were retained; 88 (68.2%) received 48‐week viral load testing and 80 (90.9% of tested; 62.0% of randomized) had HIV‐1 RNA <200 copies/ml. In the standard group, two (1.7%) died, six (5.2%) were internally displaced/emigrated, three (2.6%) were LTFU, one (0.9%) had a gap in care/later return, one (0.9%) was transferred and 103 (88.8%) were retained; 78 (67.2%) received 48‐week viral load testing and 66 (84.6% of tested; 56.9% of randomized) had HIV‐1 RNA <200 copies/ml. By design, the sample size of this pilot study was too small to provide definitive evidence of treatment effect, but the primary outcome was numerically higher in the early fast‐track group (62.0% vs. 56.9%; RD: 0.051: 95% CI: −0.072, 0.174). Conclusions Early fast‐track care was associated with high levels of viral suppression among adults initiating same‐day TLD, despite severe civil unrest in Haiti. Completion of 48‐week viral load testing was suboptimal, due to the need for participants to leave Port‐au‐Prince during peak periods of gang‐related violence, and the lack of availability of viral load testing for those receiving non‐facility‐based ART.


Study selection process.
estimates of advanced HIV disease prevalence in health care settings. AHD, advanced HIV disease. Studies that reported data from both inpatient and outpatient settings not included.
Subgroup analyses. AHD, advanced HIV disease; ART, antiretroviral therapy. All analyses other than setting restricted to outpatient and mixed settings (inpatient studies dropped from analysis).
Global prevalence of advanced HIV disease in healthcare settings: a rapid review

Introduction Recent studies have indicated a high enduring burden of advanced HIV disease, but estimates across regions and settings are lacking. The aim of this study was to estimate the prevalence of advanced HIV disease since 2015 among those people with CD4 measured in healthcare settings, disaggregated by age group, level of healthcare and region. Methods We searched MedLine via Pubmed and Hinari for studies that reported the proportion of individuals with advanced HIV disease (defined as CD4 cell count <200 cells/mm³) in healthcare settings since 2015; this search was complemented by conference abstracts and data from the International epidemiology Databases to Evaluate AIDS Consortium (IeDEA). We estimated pooled prevalence of advanced HIV disease using random‐effects models and performed subgroup and sensitivity analyses to explore heterogeneity. Results We obtained data from 117 cohorts, representing 1,814,362 individuals from 52 countries across all six World Health Organization regions. The majority of studies (n = 83) were conducted among adults and recorded CD4 cell count among treatment naïve individuals at antiretroviral therapy start (n = 86). Studies included data reported up to 2023. The proportion of individuals with advanced HIV disease was higher in inpatient settings (44.3%, 95% CI 39.1−49.6%) compared to outpatient settings (33.5%, 95% CI 31.5−35.4%). Prevalence was similar across age groups, time since HIV diagnosis and treatment status, and highest in West and Central Africa, South‐East Asia and the Eastern Mediterranean region. Discussion This review finds that at least a third of people presenting to healthcare settings have advanced HIV disease, with no evidence that this has changed in recent years. Screening for advanced HIV remains important to be able to direct appropriate preventive, diagnostic and therapeutic interventions to prevent progression to severe illness and death. Conclusions This review summarizes recent evidence of the continued high proportion of individuals who (re)present to care with advanced HIV disease. These findings underscore the urgent need to reinforce programme capacity to diagnose, prevent and treat advanced HIV disease as an essential pillar of the global AIDS response.


Proportion of children with varying categories of immunodeficiency at antiretroviral therapy (ART) start, by age at ART start.
Proportion of mothers and children with varying categories of immunodeficiency at child antiretroviral therapy (ART) start, and child immunodeficiency categories at 12, 24, 36 and 48 months after ART start.
Note: For child CD4% at ART start, an interval of 1 month (30 days) before or after ART start was used. For maternal CD4 count at child ART start, an interval of 1 year (365 days) before or after child ART start was used. For child measurements at 12, 24, 36 and 48 months after ART start, an interval of 9−18 months (274−547 days), 18−30 months (548−912 days), 30−42 months (913−1277 days) and 42−54 months (1278−1644 days) after child ART start was used. For all measurements, the one closest to the relevant timepoint was used if multiple results were available during an interval.
Proportion of mothers and children with varying categories of viral load (VL) at child antiretroviral therapy (ART) start and at 4, 12, 24, 36 and 48 months after child ART start.
Note: For child measurements at 4, 12, 24, 36 and 48 months after ART start, an interval of 3−9 months (91−273 days), 9−18 months (274−547 days), 18−30 months (548−912 days), 30−42 months (913−1277 days) and 42−54 months (1278−1644 days) after child ART start was used. The same intervals were used for maternal measurements, except that for maternal VL at 12 months after child ART start, an interval of 6−18 months (182−547 days) was used. For maternal VL at child ART start, an interval of 12 months (365 days) before to 6 months (181 days) after child ART start was used. For all measurements, the one closest to the relevant timepoint was used if multiple results were available during an interval.
Mother‐child dyads living with HIV in the Western Cape, South Africa: Undetectable = Undetectable?

January 2025

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5 Reads

Introduction Globally, children living with HIV continue to lag behind UNAIDS targets for viral suppression (VS). Because studies with linked mother‐child data are limited, we describe VS and associated factors among young children in a setting with early infant HIV testing (at birth, age 10 weeks and 6 months) and early protease inhibitor‐based first‐line antiretroviral therapy (ART). Methods We analysed routinely collected mother‐child data for children living with HIV born 2018–2022 in Western Cape province, South Africa (followed through mid‐2023). We assessed associations between child and maternal viral load (VL) results at 12 and 24 months after child ART start using logistic regression, adjusted for child sex, birthyear, severity of child immunodeficiency at ART start, maternal age and timing of maternal HIV diagnosis. Results Among 2219 children living with HIV; 30% were diagnosed at birth (≤7 days), 41% before age 1 year (8−365 days) and 29% at age >1 year. Overall, 5% (n = 112/2219) of children died, a third of whom had not started ART; 90% of children (n = 1990) started ART, at median age 5 months (IQR 1–16). Median follow‐up from ART start was 26 months (IQR 14–40). Among children with available VL at 12 months (n = 853/1582), 24 months (n = 614/1129) and 36 months (n = 350/658) after ART start, 36%, 43% and 48% were virally suppressed, respectively (VL<100 copies/ml). VS among children at 12 and 24 months was more likely if maternal VL was <100 versus ≥100 copies/ml at 12 months (adjusted odds ratio [aOR] = 3.5; 95% CI 1.9−6.5) and 24 months (aOR = 6.1; 95% CI 2.8−13.1) after child ART start. Children with no/mild versus advanced/severe immunodeficiency at ART start were more likely to achieve VS at 12 months (aOR = 2.3; 95% CI 1.3−4.2) but not at 24 months. Eligible children with missing VL at 24 months (39%) were more likely to have gaps in care of >6 months than those with VL≥100 or VL<100 copies/ml (84% vs. 28% vs. 14%, respectively; p<0.001). Conclusions Less than half of children on ART achieved VS, and children were more likely to achieve VS if their mothers were also virally suppressed. Significant efforts are needed to support mother‐child dyads to achieve optimal VS.


Pharmacokinetics, safety and efficacy of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide in children with HIV aged from 2 years and weighing at least 14 kg

January 2025

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2 Reads

Introduction Elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) was efficacious and well tolerated in children/adolescents with HIV (aged ≥6 years, weighing ≥25 kg) in a Phase 2/3 study. Here, we report data from children aged ≥2 years and weighing ≥14–<25 kg. Methods This is an analysis of data from the youngest cohort in an open‐label, multicentre, multi‐cohort, single‐group, international study of children/adolescents with HIV. Participants in this cohort were children aged ≥2 years, weighing ≥14–<25 kg at screening and able to swallow tablets, on stable antiretroviral therapy with virologic suppression (HIV‐1 RNA <50 copies/ml for ≥6 consecutive months) and a CD4 count ≥400 cells/µl. Eligible participants received low‐dose E/C/F/TAF (90/90/120/6 mg) once daily through Week 48. The study included pharmacokinetic evaluation of the low‐dose E/C/F/TAF tablet at Week 2. Safety, efficacy, palatability and acceptability were also evaluated. Results Between 16 January and 25 November 2019, 27 participants were enrolled with a median (quartile [Q]1, Q3) age of 6 (4, 8) years, body weight of 19.3 (17.0, 20.5) kg, CD4 count of 1061 (895, 1315) cells/µl and CD4 cell percentage of 37.4 (30.6, 40.3). Most (92.6%) participants acquired HIV through vertical transmission. On 6 October 2020 (data‐cut), median (Q1, Q3) exposure to E/C/F/TAF was 48.3 (48.0, 60.1) weeks. Pharmacokinetic parameters were within the safe and efficacious range of previous data in adult and paediatric populations. Drug‐related treatment‐emergent adverse events occurred in 4/27 (15%) participants. There were no Grade 3/4 adverse events, or adverse events leading to E/C/F/TAF discontinuation. One participant experienced a serious treatment‐emergent adverse event (Grade 2 pneumonia not considered E/C/F/TAF related). Virologic suppression (US FDA Snapshot algorithm) was maintained by 26/27 (96%) participants at Weeks 24 and 48. At Week 48, most children reported positive palatability (84.6%) and acceptability (96.2%). Conclusions These data support the use of single‐tablet E/C/F/TAF (90/90/120/6 mg) regimen for the treatment of HIV in children aged ≥2 years and weighing ≥14–<25 kg. Clinical Trial Number NCT01854775


Phylogenetic trees obtained with the sequences of protease plus reverse transcriptase regions of the HIV‐1 compendium 2018 and the strains collected during the study, France, 2013–2022 (n = 98).
The clusters CRF94 and CRF132 included 63 and 32 patients, respectively. Three were outside (*).
The shortest distance between the two clusters is between infections diagnosed in 2013 (blue circle).
Analysis of the recombination pattern of the new cluster. The bootscan analysis of the CRF94 (Genbank reference: MH141491) and CRF132 (ON901787) against their two main ancestral lineages, that is sub‐type B (K03455—line dark blue) and CRF02 (AB485636—line yellow) are depicted in panels A and B, respectively. The red regions illustrate the region presenting significant differences between CRF94 and CRF132 as identified in the Simplot analysis of CRF132 with its potential ancestral lineages (sub‐type B, CRF02, F2 and CRF94), provided in panel C. The region IV corresponding to the accessory genes. The phylogenetic reconstruction of five areas identified with the Simplot analysis is provided in panel D, breakpoints were confirmed using RDP5. Ancestral nodes of interest with a branch support >90% are indicated by an asterisk. Panel E provides the map of recombination breakpoints identified for CRF94 and CRF132 using subtype B and CRF02 as parental lineage to highlight differences with CRF94 and for CRF132 using its direct parental lineages, CRF94 and subtype B. The alignment positions are provided using HXB2 as reference.
Geographic distribution of residence for the patients who were involved in two different HIV transmission cluster, France, 2013–2022 (n = 95). The pink and green zones show the main spreading areas for CRF94 and CRF132, respectively. The blue zone, centred south of Paris, shows the common area where the first CRF94 and CRF132 infections were detected.
Kaplan−Meier survival curve comparing the time to achieve two consecutive viral loads <50 copies/ml after treatment initiation depending on the cluster.
Benefits of HIV‐1 transmission cluster surveillance: a French retrospective observational study of the molecular and epidemiological co‐evolution of recent circulating recombinant forms 94 and 132

January 2025

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7 Reads

Introduction Molecular surveillance is an important tool for detecting chains of transmission and controlling the HIV epidemic. This can also improve our knowledge of molecular and epidemiological factors for the optimization of prevention. Our objective was to illustrate this by studying the molecular and epidemiological evolution of the cluster including the new circulating recombinant form (CRF) 94_cpx of HIV‐1, detected in 2017 and targeted by preventive actions in 2018. Methods In June 2022, 32 HIV‐1 sequence databases from French laboratories were screened to identify all individuals who had acquired CRF94_cpx or a similar strain, whatever the date of diagnosis. Phylogenetic analyses were performed with the sequences identified, and biological parameters were collected at the time of diagnosis and after the start of treatment to analyse the evolution of the cluster. Full genomes were sequenced to characterize the new strains. Results We analysed 98 HIV‐1 isolates: 63 were CRF94, three were unclassifiable, and the other 32 formed a new cluster containing a new recombinant, CRF132_94B, derived from CRF94 and a subtype B strain. At least 95% of the individuals in both the CRF94 and CRF132 clusters were men who have sex with men (MSM), most of whom had acquired HIV less than 12 months before diagnosis. The number of CRF94 diagnoses declined drastically after 2018, but CRF132 strains spread widely between 2020 and 2022, into a different area of Ile‐de‐France region and within a younger population nevertheless aware of pre‐exposure prophylaxis. Higher viraemia, lower CD4 cell counts and delayed treatment efficacy suggested that CRF94 was more virulent than CRF132, possibly due to the F subtype fragment of the vif gene. Conclusions These findings highlight the role of the MSM transmission cluster in spreading HIV and new variants. They show also the benefits of cluster surveillance for improving the targeting of preventive interventions, detecting the emergence of new strains and enriching our knowledge on virulence mechanisms. However, these investigations require support with sufficient resources dedicated to a regional or national programme to be responsive and effective.


Impact of POC screening of curable STIs in antenatal care on vertical transmission of HIV. Bars represent the percent reduction for each outcome with lower and upper error bars representing confidence intervals.
Abbreviations: ANC, antenatal clinic; POC, point‐of‐care; STIs, sexually transmitted infections.
Sensitivity analysis of the impact of POC STI screening in ANC on vertical transmission of HIV. The horizontal bold line represents a reduction in total vertical HIV transmission (8.6%).
Abbreviations: ANC, antenatal clinic; POC, point‐of‐care; STIs, sexually transmitted infections; WLHIV, women living with HIV.
Sensitivity analysis of the impact of POC STI screening in ANC on adverse birth outcomes. Lower and upper error bars are calculated using the 95% confidence interval limits for the odds ratio for the STI‐adverse pregnancy outcome association.
Abbreviations: LBW, low birthweight; POC, point‐of‐care; PTD, preterm delivery; SGA, small for gestational age; STIs, sexually transmitted infections.
Effect of POC screening and treatment of curable STIs during pregnancy. The dotted lines show the risk ratio of 1. Lower and upper error bars represent the 95% confidence intervals for each outcome.
Abbreviations: POC, point‐of‐care; STIs, sexually transmitted infections.
The effect of STI screening during pregnancy on vertical transmission of HIV and adverse pregnancy outcomes in South Africa: a modelling study

January 2025

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13 Reads

Introduction Sexually transmitted infections (STIs) in pregnancy are associated with an increased risk of vertical HIV transmission and adverse pregnancy and birth outcomes. In South Africa, syndromic management is the standard of care for STI management. We assessed the potential impact of point‐of‐care (POC) screening for curable STIs (Chlamydia trachomatis [CT], Trichomonas vaginalis [TV] and Neisseria gonorrhoeae [NG]) during pregnancy on vertical HIV transmission and adverse pregnancy and birth outcomes. Method We developed a static mathematical model to estimate the impact of syndromic management compared to POC screening of STIs in pregnant women attending antenatal clinics in South Africa over one calendar year (2022). Our model assumptions regarding the effect of CT, NG and TV on adverse pregnancy/birth outcomes and vertical HIV transmission were informed by two separate meta‐analyses that we conducted. Local studies informed estimates of STI prevalence, POC screening uptake and treatment, and sensitivity of syndromic management. Results In the absence of POC screening for curable STIs, 25.5% of pregnant women without HIV and 34.6% of pregnant women living with HIV were estimated to have undiagnosed and untreated STIs. In the POC scenario, 92% (95% CI: 85−100%) of STIs were diagnosed and treated during pregnancy, reducing antenatal maternal HIV incidence by 10.0% (95% CI: 1.0−20.1%). Overall, vertical HIV transmission was anticipated to reduce by 8.6% (5.2−13.8%), with reductions of 20.9% (15.2−27.0%) at birth and 2.5% (−0.9% to 9.0%) postnatally, in the POC screening scenario compared to current syndromic management. POC screening of curable STIs is further estimated to reduce the incidence of stillbirth by 10.1% (1.3–18.7%), preterm delivery by 6.3% (3.4–9.7%), infants born small for gestational age by 2.7% (0.7–4.9%) and low birth weight by 9.1% (0.9–18%). Conclusions POC STI screening and treatment may modestly reduce maternal HIV incidence, vertical HIV transmission, and the risk of adverse pregnancy and birth outcomes, and would substantially reduce the burden of curable STIs in pregnancy. The study provides evidence to move beyond the syndromic management of STIs in South Africa, particularly in antenatal care.


Included countries according to country income level (N = 36).
Location of PEP access, stratified by (a) regions of the world and (b) country income level (N = 46). Unclear = location of access to antiretrovirals was described in the document but not specifically related to PEP access (Brazil, Nigeria, Thailand and Zimbabwe).
A global review of national guidelines of post‐exposure prophylaxis for the prevention of HIV

Introduction The World Health Organization (WHO) recommends the use of antiretroviral drugs as post‐exposure prophylaxis (PEP) for preventing HIV acquisition for occupational and non‐occupational exposures. To inform the development of global WHO recommendations on PEP, we reviewed national guidelines of PEP for their recommendations. Methods Policies addressing PEP from 38 WHO HIV priority countries were obtained by searching governmental and non‐governmental websites and consulting country and regional experts; these countries were selected based on HIV burden, new HIV acquisitions and the number of HIV‐associated deaths. We reviewed national guidelines to collate data on where PEP can be offered, who can prescribe PEP, PEP eligibility, recommended drug regime, linkage to other interventions, recommended investigations prescribed with PEP, HIV self‐test recommendation related to PEP and stopping rules for PEP. Results In total, 46 guidelines from January 2010 to May 2023 across 36 countries were included, with 70% of documents published during or after 2020. There was significant variation across national guidelines regarding where PEP can be accessed and who can provide or prescribe PEP. Six countries (17%) described being able to access PEP from a primary care facility, four countries (11%) from hospitals and two (6%) from community‐based services. Only three countries (8%) specifically considered dispensing PEP by professionals other than doctors (e.g. nurses). None mentioned pharmacists as prescribers. We found a lack of consistency across countries regarding who is eligible for PEP, regimens used, interventions integrated into PEP provision and recommended investigations for PEP users. No country guidance provided considerations on using HIV self‐tests for starting or stopping PEP. Discussion Despite PEP being recommended for more than three decades, many national policies were lacking in terms of PEP guidance. There are opportunities for countries to update and optimize guidance to consider ways to improve the accessibility of PEP. Greater efforts are needed to support the development of global consensus on how best to implement and integrate PEP, as well as how to include decentralization and task‐sharing to achieve sufficient scale for impact. Conclusions Improving timely access to PEP and promoting PEP adherence could help contribute to reducing the incidence of HIV globally.


Literature inclusion and exclusion process.
Geographic distribution of prevalence of syphilis among PLHIV in China.
Forest plots of prevalence of syphilis among PLHIV in China.
CI, confidence interval.
Prevalence of syphilis among PLHIV by transmission route.
Forest plot of prevalence of syphilis among men living with HIV compared with women living with HIV in China.
CI, confidence interval; OR, odds ratio.
The impact of the National Syphilis Prevention Program on the prevalence of syphilis among people living with HIV in China: a systematic review and meta‐analysis

Introduction In 2010, China launched the 10‐year National Syphilis Prevention and Control Program to curb the spread of syphilis by integrating syphilis screening and treatment with HIV services. Herein, we aimed to evaluate changes in the prevalence of syphilis among people living with HIV (PLHIV) in China. Methods We conducted this systematic review and meta‐analysis by searching the PubMed, Embase, Web of Science, China Biomedical Literature, China National Knowledge Infrastructure, Wanfang and CQVIP databases from inception to 1 June 2024 to obtain relevant articles. A total of 75 studies were ultimately included. We used a DerSimonian‒Laird random effects model to estimate the prevalence and 95% confidence interval of syphilis among PLHIV. Results The overall prevalence of syphilis among PLHIV in China was 18.6% (95% CI 16.5–21.0). Regional differences (R² = 15.29%) were observed in the prevalence rates: 22.2% (18.9–25.8) in the eastern region, 19.0% (15.1–23.8) in the central region and 14.0% (11.1–17.5) in the western region. The prevalence decreased from 22.8% (18.4–27.9) before 2010 to 17.0% (14.6–19.6) in 2010 and thereafter (R² = 5.82%). Among PLHIV via homosexual transmission, the prevalence of syphilis was 24.9% (21.3–28.9), which significantly declined from 33.8% (27.5–40.8) to 21.4% (18.3–24.9) in 2010 and thereafter (R² = 22.35%). The prevalence of syphilis was significantly higher in men living with HIV than in women living with HIV (pooled odds ratio 1.67, 95% CI 1.29–2.15), with the highest prevalence in the eastern region (2.55, 95% CI 1.80–3.59). Discussion The prevalence of syphilis among PLHIV, particularly in cases of homosexual transmission, has declined. There was a correlation between the prevalence of syphilis and regional economic conditions, with a greater burden in developed eastern coastal areas. Additionally, the risk of syphilis differed across sexes, with men living with HIV having a higher risk. Conclusions There has been preliminary success in the control of syphilis among PLHIV, but there is still a long way to go to meet the WHO's 2030 syphilis prevention and control goal. Syphilis prevention measures should be integrated into broader health policies and development plans, particularly in high‐burden regions and populations.


Characterizing populations prioritized for PrEP in 19 African countries: a review of national guidance

January 2025

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13 Reads

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1 Citation

Introduction While African countries have expanded access to HIV pre‐exposure prophylaxis (PrEP) since 2015, regional targets for PrEP uptake remain unmet. Understanding which populations are prioritized for PrEP at the policy level is an important step in determining the scope of PrEP distribution across Africa and identifying gaps in programme implementation. We reviewed national guidance to characterize populations prioritized for PrEP in Africa. Methods Between January and June 2023, we searched for current National HIV Treatment and Prevention Guidelines, National HIV Strategic Plans, and the United States President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans (COPs) for all African countries implementing PrEP programmes supported by PEPFAR in 2022. From each document, we summarize the populations prioritized for PrEP within a country and describe PrEP eligibility. Results In 2022, 19 African countries implemented PrEP programmes supported by PEPFAR. Eighteen of these countries contributed National Guidelines (2016−2022), 18 contributed National Strategic Plans (2017−2023) and 19 contributed COPs (2022) to this review. Twenty‐nine population groups were prioritized for PrEP in these documents. All countries prioritized HIV‐serodifferent couples, female sex workers (FSWs), adolescent girls and young women (AGYW), pregnant and breastfeeding women (PBFW) and people who inject drugs (PWID), and most prioritized men who have sex with men (MSM; n = 18), transgender people (n = 18) and people in prisons (n = 17). The remaining 21 populations were prioritized in fewer than two‐thirds of countries. Discussion FSWs, MSM, PWID, transgender people and people in prisons were typically prioritized for PrEP with no eligibility restrictions. In contrast, most countries had at least one document indicating that HIV‐serodifferent couples, AGYW and PBFW were only eligible for PrEP if classified as high risk. Few documents specified how risk was determined, and no document included validated HIV risk assessment tools to guide implementation. We observed similarities in priority populations across countries with different HIV epidemics and inconsistencies in who was prioritized for PrEP within a country's own set of policy documents. Conclusions Understanding how PrEP prioritization policies impact HIV incidence in different epidemiologic settings is critical for strengthening PrEP implementation across the continent.


Cumulative incidence of virological failure by ART initiation group.
Proportion of virological suppression after ART initiation.
Note: The denominator was the number of PLHIV having VL tests.
The impact of same‐day and rapid ART initiation under the Universal Health Coverage programme on HIV outcomes in Thailand: a retrospective real‐life cohort study

January 2025

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8 Reads

Introduction Antiretroviral therapy (ART) initiation, regardless of CD4 count, has been recommended in Thailand since 2014, with same‐day initiation recommended since 2021. We assessed HIV treatment outcomes among Thai people living with HIV (PLHIV) by the time from HIV diagnosis to ART initiation under the Universal Health Coverage (UHC) programme and identified factors associated with virological failure (VF). Methods PLHIV aged ≥15 years initiating ART between 2014 and 2022 were included from the UHC database. We categorized participants into four groups using the duration from HIV diagnosis to ART initiation: (1) ≤ 7 days (same‐day ART); (2) 8 days to <1 month; (3) 1–3 months; and (4) >3 months. Viral load (VL) was measured 6 months after starting ART, and annually thereafter. VF was defined as VL ≥1000 copies/ml. Factors associated with VF were analysed using competing risk models considering death and loss to follow‐up (LTFU) as competing events. Results Among 252,239 PLHIV who started ART, the median age at initiation was 34 years (interquartile range [IQR]: 26–43 years). The median (IQR) pre‐ART CD4 count was 233 (76–420) cells/mm³. ART initiation occurred within 7 days for 25% (17% on the same day, 8% in 2–7 days), 24% in 8 days to <1 month, 23% in 1–3 months and 28% in >3 months. ART initiation within 7 days increased from 20% (2014–2016) to 32% (2021–2022). VF occurred with a rate of 3.11 (95% CI 3.07–3.159) per 100 person‐years (PYs). PLHIV initiating ART 8 days to 1 month were at lower risk of VF (aSHR 0.52, 95% CI 0.50–0.54) when compared to ART initiation >3 months. ART initiation within 7 days resulted in the lowest mortality (6%: 1.28 [95% CI 1.24–1.32] per 100 PYs), but the highest rate of LTFU (12%: 2.69 [95% CI 2.63–2.75] per 100 PYs) when compared to other ART initiation groups. Conclusions Although ART initiation within 7 days has increased in Thailand, the overall rate of early initiation remains low. ART initiation within 1 month significantly lowered the risk of VF. ART initiation within 7 days significantly reduced mortality. To further optimize health outcomes, innovative strategies are urgently needed to promote earlier ART initiation in Thailand.


Box plots of standardized infant growth measures at birth, by study arm.
Geometric mean CAB‐LA concentrations following first positive pregnancy date in study participants who received at least one injection of CAB‐LA (n = 27). The in vitro protein‐adjusted 90% CAB‐LA inhibitory concentration (PA‐IC90) is 166 ng/ml [28]. The assay LLOQ is 25.0 ng/ml.
Individual participant log‐linear regression curves of plasma CAB‐LA concentrations from the visit after last injection to the last available quantifiable sample in (a) pregnant women from HPTN 084 (n = 17) and (b) non‐pregnant women from HPTN 077 (n = 35). Curves were fitted for each individual extrapolated to the intersection with LLOQ and all extended beyond the observed concentrations.
Evaluation of long‐acting cabotegravir safety and pharmacokinetics in pregnant women in eastern and southern Africa: a secondary analysis of HPTN 084

January 2025

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57 Reads

Introduction Long‐acting injectable cabotegravir (CAB‐LA) for pre‐exposure prophylaxis significantly reduced HIV acquisition in HPTN 084. We report on the safety and CAB‐LA pharmacokinetics in pregnant women during the blinded period of HPTN 084. Methods Participants were randomized 1:1 to either active cabotegravir (CAB) plus tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) placebo or active TDF/FTC plus CAB placebo. Pregnancy testing was performed at each visit; participants with a positive test had study product withheld and were offered open‐label TDF/FTC. Pregnancies were confirmed on two tests at least 4 weeks apart. All participants with a positive pregnancy test prior to November 5, 2020 are included in this analysis. Pregnancy incidence, maternal adverse event (AE) incidence, pregnancy outcomes (including composite outcome of spontaneous abortion <20 weeks, intrauterine foetal death or stillbirth ≥20 weeks, premature birth <37 weeks, or small for gestational age) were assessed. The apparent terminal phase half‐life (t1/2app) of CAB‐LA in pregnant women in HPTN 084 was compared to non‐pregnant women from the phase 2a HPTN 077 trial. Multivariable models assessed associations with t1/2app. Results Fifty‐seven pregnancies (30 CAB‐LA, 27 TDF/FTC) were confirmed over 3845 person‐years [py] (incidence 1.5/100 py, 95% CI 1.1−1.9). CAB‐LA group participants had a median 342 days (IQR 192, 497) of CAB‐LA exposure prior to pregnancy detection. Grade 2 or higher maternal AE incidence did not differ by study arm (CAB 157, 95% CI 91−271 per 100 py vs. TDF/FTC 217, 95% CI 124–380 per 100 py; p = 0.256). Most pregnancies (81%) resulted in live births (25 CAB‐LA, 22 TDF/FTC). Composite poor pregnancy outcomes did not differ significantly by group (CAB 6/30 vs. TDF/FTC 4/27; p = 0.476). No congenital anomalies were observed. The CAB t1/2app geometric mean was 52.8 days (95% CI 40.7−68.4) in pregnant women compared to 60.3 days (95% CI 47.7−76.3; p = 0.66) in non‐pregnant women; neither pregnancy nor body mass index were significantly associated with t1/2app. Conclusions CAB‐LA concentrations post‐cessation of injections were generally well tolerated in pregnant women. The t1/2app was comparable between pregnant and non‐pregnant women. Ongoing studies will examine the safety and pharmacology of CAB‐LA in women who choose to continue CAB‐LA through pregnancy and lactation.


Frequency of deficits in intrinsic capacity domains in PWH and controls, and its association with markers of immune activation in PWH. (a) Bar graph demonstrating difference in frequencies of PWH (n = 200) and controls (n = 101) experiencing deficits in intrinsic capacity (IC) domains and (b) comparison of immune activation markers across the number of IC deficits in PWH. Comparisons were performed using Kruskal−Wallis (KW) test for group comparisons. A p‐value of <0.05 was considered significant and error bars correspond to median and interquartile range.
Performance of aggregate intrinsic capacity (IC) scores and VACS index 1.0 in identifying PWH with frailty and deficits in instrumental activities of daily living (IADL deficits) in two independent cohorts from Malaysia and Hong Kong. Area under the ROC curve for intrinsic capacity (IC) scores and VACS 1.0 with the outcomes of (a) frailty and (b) instrumental activities of daily living (IADL) in the Malaysian (left panel) and Hong Kong (right panel) cohorts.
Assessing intrinsic capacity for person‐centred HIV care: a cross‐sectional study in ageing populations in Malaysia and Hong Kong

December 2024

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10 Reads

Introduction WHO's Integrated Care for Older People (ICOPE) proposes we measure the functional construct of intrinsic capacity (IC) to monitor and identify individuals with age‐associated vulnerabilities. Assessments of IC may be useful to address the evolving, non‐HV care needs of ageing people with HIV (PWH). However, to date, its utility within the context of HIV has not been assessed. Methods Participants included 200 PWH attending out‐patient care (2021−2023) in Universiti Malaya Medical Centre, Malaysia and 101 community controls aged 35 years and above. The ICOPE framework was adapted to derive aggregate IC scores (ranging 0–6) encompassing the five domains of cognition, sensory (hearing and vision), mobility, mood and vitality. Multivariable analyses were used to explore the association of IC scores in PWH with multiple health outcomes including frailty, difficulties performing instrumental activities of daily living (IADL) and inflammatory markers. Area under the receiver operator characteristic (AUC‐ROC) was calculated to predict frailty and IADL deficits in the current cohort and an independent cohort of 275 PWH from Hong Kong (HK). Results Median (interquartile range, IQR) age among PWH and controls were 50 (42−56) and 50 (39−59) years, respectively. There were more males among PWH (83% vs. 56%, p<0.001). All PWH received antiretroviral therapy (ART) for a median duration of 11 (8−14) years. Aggregate IC scores were lower in PWH but not significantly different compared to controls, (5.4 vs. 5.6, p = 0.093) and PWH performed significantly worse than controls only in the cognitive domain. Aggregate IC scores in PWH was independently associated with frailty (OR 0.17 95% CI 0.07−0.42, p<0.001), IADL deficits (OR 0.25 95% CI 0.14−0.46, p<0.001) and all other patient‐reported outcomes assessed. Aggregate IC scores correlated with IL‐6 but not sCD14 and sCD163 levels. IC scores performed well in identifying PWH with frailty (AUC‐ROC ≥ 0.80) in the HK and Malaysian cohorts but more modestly (AUC‐ROC ≥ 0.64) for IADL deficits. Conclusions IC is a good composite measure to monitor non‐HIV, age‐associated physical and social vulnerabilities in PWH on ART and should complement disease‐based monitoring in routine HIV care. Assessments of IC should be validated in larger, longitudinal cohorts of PWH from diverse settings.



PRISMA Flow chart.
(a) That is, the title and abstract indicate no information about MSM, or focuses on settings other than SSA. (b) Reasons to exclude full‐text articles: 364 concerned gay men or MSM in SSA but had no data on MSMW; 180 concerned HIV/sexually transmitted infections epidemics in SSA but did not examine HIV‐bridging from infected MSM to women; 136 did not have enough data (e.g. conference abstract without related published article); 133 concerned a setting other than SSA); 76 investigated men in SSA but had no data on MSMW and male bisexuality; 74 were duplicates; 17 studied women in SSA but had no data on MSMW partners; 3 had publication issues; 2 articles were not in the languages set out in the protocol (i.e. English or French). (c) The first two thematic syntheses, covering different topics, derived from the systematic review have been published separately [1, 2].
Synthesis of studies with quantitative data about HIV knowledge, HIV acquisition risk perception and HIV information received in men who have sex with men (MSM) in SSA in terms of sex with men and with women.
Men who have sex with men perceiving that sex with women carries the greatest risk of HIV acquisition: results from a mixed‐methods systematic review in sub‐Saharan Africa

Introduction In sub‐Saharan Africa (SSA), men who have sex with men (MSM) often have female sexual partners. Their overall risk of acquiring HIV is higher with male partners. Risk perception is associated with HIV knowledge, sexual risk and preventive behaviours. This synthesis aimed to summarize existing data about HIV knowledge and perceived HIV acquisition risk regarding sex with men and with women in MSM in SSA. Methods We conducted a systematic literature review of MSM's relationships with women in SSA (PROSPERO‐CRD42021237836). Quantitative and qualitative data related to MSM's perceived risk from sex with men and with women and HIV knowledge (published up to 2021) were selected and synthesized. Results Twenty studies were selected. More MSM perceived that the greatest risk of HIV acquisition came from heterosexual/vaginal sex than from homosexual/anal sex (53% vs. 15%; 51% vs. 39%; 42% vs. 8%; 27% vs. 25%; 43% vs. 11%; 23% vs. 13%; 35% vs. 16%, cumulative sample n = 4396, six countries). A higher proportion of MSM received preventive information on heterosexual HIV transmission than on homosexual transmission (79% vs. 22%; 94% vs. 67%; 54% vs. 19%; cumulative sample n = 1199, four countries). The qualitative synthesis (eight studies) highlighted biology‐ and behaviour‐based misconceptions leading MSM to perceive lower or negligible HIV risk from sex with men, compared to sex with women. These misconceptions were partly fuelled by the predominant focus on heterosexual and vaginal HIV transmission in HIV prevention information. Discussion Common misconceptions regarding sexual risk between men remain unaddressed by the heteronormative messaging of HIV prevention. Underestimation by MSM of their HIV acquisition risk with male partners can pose significant barriers to effective HIV preventive behaviours and strengthen the transmission risk from MSM to their female partners. Conclusions Improving access of MSM to tailored HIV prevention information and tools that address their practices with male and female partners is crucial. Integrating messages about anal sex into broader public health initiatives, including sexual health programmes targeting the general population, is essential. Further research in diverse settings in SSA is necessary to gain a greater understanding of the drivers and implications of HIV risk perception in MSM.


Prisma flow diagram.
Forest plot for the proportion who were linked to confirmatory testing in social network‐based approach.
Linkage to care and prevention after HIV self‐testing: a systematic review and meta‐analysis

December 2024

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31 Reads

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1 Citation

Introduction Effective linkage to prevention and care is a crucial step following HIV testing services. This systematic review aimed to determine the proportion of individuals linked to prevention and care after HIV self‐testing (HIVST) and describe factors associated with linkage. Methods Following PRISMA guidelines, a comprehensive search across eight databases (2010–October 2023) identified studies on linkage to care after HIVST, defined as receiving a confirmatory test or initiating antiretroviral therapy (ART) if the self‐test was reactive, and/or pre‐exposure prophylaxis (PrEP) if the self‐test was non‐reactive. A random‐effects meta‐analysis summarized the findings and meta‐regression explored study‐level covariates, such as world region, population type and service delivery model, that might explain the between‐study heterogeneity. Results From 10,071 screened studies, 173 were included in the meta‐analysis. The majority of studies focused on key populations in Africa using unassisted, oral fluid‐based HIVST kits. Among those with reactive HIVST results, 92% (95% confidence interval [CI]: 88–95) were linked to confirmatory testing (n = 124 studies), and 89% (95% CI: 84–93) of newly diagnosed individuals initiated ART (n = 88 studies). Overall, 84% (95% CI: 74–93) of self‐testers were linked to care (n = 69 studies). However, only 9% (95% CI: 2–19) of individuals with non‐reactive HIVST results were linked to PrEP services (n = 9 studies). Assisted HIVST was associated with higher linkage rates to confirmatory testing and ART initiation compared to unassisted testing. Meta‐regression revealed that the type of delivery model for the HIVST kits influenced linkage and that individuals who obtained their HIVST kits through a social network‐based approach (SNA) were more likely to be linked to confirmatory testing (adjusted odds ratio = 1.28 [95% CI: 1.10–1.50], p = 0.001) compared to non‐SNA service delivery model. Discussion In the context of expanding HIVST services globally, we found that linkage to confirmatory testing and ART initiation after HIVST is generally high, particularly when assisted HIVST or SNA‐based distribution is used. Conclusions Strengthening timely linkage is vital for improving health outcomes, reducing HIV transmission and achieving the UNAIDS 95‐95‐95 goal. Ongoing research and collaboration with community‐based organizations are needed to overcoming barriers and ensuring positive outcomes for those using HIVST. PROSPERO Number CRD42022357570.


Study flow for INSIGHT cohort, depicts the number of participants who screened for the INSIGHT, reasons for ineligibility, enrolment, PrEP uptake at enrolment and follow‐up visits, refill dispensation, point‐of‐care urine tenofovir tests, HIV seroconversions and PrEP discontinuation at follow‐up visits.
High recent PrEP adherence with point‐of‐care urine tenofovir testing and adherence counselling among young African women: results from the INSIGHT cohort

December 2024

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8 Reads

Introduction Adolescent girls and young women (AGYW) account for two‐thirds of new HIV infections in Africa. African AGYW have had high uptake of oral HIV pre‐exposure prophylaxis (PrEP) but low adherence, which might be improved by point‐of‐care adherence monitoring with tailored counselling. Methods From August 2022 to July 2023, we conducted a PrEP demonstration project with sexually active AGYW ages 16−30 years from 20 sites in South Africa, Eswatini, Kenya, Malawi, Uganda and Zambia. Participants were offered oral tenofovir‐based PrEP at enrolment and followed up at 1, 3 and 6 months. PrEP adherence was assessed by a point‐of‐care qualitative lateral flow urine tenofovir (TFV) assay indicating PrEP use in the prior 4 days, which accompanied real‐time adherence counselling that incorporated urine TFV results when testing was available (70.8% of month 1, 35.3% of month 3 and 83.9% of month 6 visits). We estimated overall adherence, correcting for missing test results, and analysed the association of having received urine TFV results at month 1 or 3 with subsequent urine TFV test positivity, using modified Poisson regression. Results Of the 3087 AGYW enrolled, the median age was 24 years (interquartile range 21−27), 75.7% were from South Africa, 2878 (93.2%) initiated PrEP at enrolment and 107 (3.5%) after enrolment. Visit retention was 92.0−96.2% for months 1, 3 and 6, and 2518 (90.1%) exited the study with a PrEP refill. Adherence, based on the point‐of‐care urine tenofovir test positivity rate, was estimated as 72%, 71% and 65% at months 1, 3 and 6, respectively. Women who received one prior urine TFV test had a 42% higher likelihood of a subsequent positive urine TFV test (adjusted odds ratio, OR = 1.42, 95% confidence interval, CI 1.27−1.60), and those having received two prior tests had a 67% higher likelihood (adjusted OR = 1.67; 95% CI 1.41−1.98). Observed HIV incidence was 1.38/100 person‐years (95% CI 0.97−2.08). Conclusions Oral PrEP uptake, recent adherence and persistence were high in a multisite cohort of young African women over 6 months of follow‐up. The use of a novel point‐of‐care tenofovir assay with tailored real‐time adherence counselling was associated with increased adherence to PrEP at subsequent visits, warranting further study. Clinical trials registration clinicaltrials.gov NCT05746065


Facilities at which the project was implemented.
Flow chart for final analytic sample.
The heterogeneity among people re‐engaging in antiretroviral therapy highlights the need for a differentiated approach: results from a cross‐sectional study in Johannesburg, South Africa

December 2024

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22 Reads

Introduction Disengagement and re‐engagement with antiretroviral therapy (ART) are common in South Africa, but routine monitoring is insufficient to inform policy development. To address this gap, Anova implemented the 2020 National Adherence Guidelines’ re‐engagement standard operating procedure (re‐engagement SOP) and collected additional data to describe the characteristics of re‐engagement visits to inform HIV programmes. Methods Between July and December 2022, we conducted a study at nine primary healthcare facilities in Johannesburg. Staff were trained on the re‐engagement SOP and provided with job aides to support implementation. Administration clerks categorized visits based on the time elapsed since the missed appointment: ≤14days and >14 days, with the latter identified as re‐engaging. For these clients, clinicians filled out “re‐engagement clinical assessment forms” that included visit dates, both clinician‐assessed and self‐reported treatment interruptions, and clinical details. Data on missed appointments and previous viral loads were extracted from medical records. The information was entered into REDCap. We present data from three out of the nine facilities, selected for their comprehensive data collection and high coverage of all re‐engaging clients. Results A total of 2342 clients returned following a missed scheduled appointment. The majority, 1523 (65%), missed their appointments by ≤ 14 days, while 819 (35%) were >14 days late (re‐engaging). Among those re‐engaging, 635 (78%) re‐engagement clinical assessment forms were completed. A missed appointment date was available for 623 with 25% (n = 161) returning 2–4 weeks late, 47% (n = 298) 4–12 weeks and 26% (n = 164) >12 weeks late. Self‐reported ART interruption, available for 89% (567/635), indicated the majority (54%, n = 304) experienced no interruption. Clinical concerns were identified in 65 (10%) cases. A majority (79%, 504/635) had prior viral load results, with 73% (370/504) below 50 copies/ml. Conclusions Clients frequently return to care shortly after missed appointments. Despite missing scheduled ART refill dates, many report not interrupting treatment, either having treatment on hand or sourcing ART elsewhere. Most re‐engaging clients were adherent prior to disengagement, and clinical concerns are rare. A differentiated service delivery approach, prioritizing flexibility and reduced healthcare burden, is required to support client's needs and preferences at re‐engagement.


Health regions (here “HR”) of the CAR, number of PLHIV enrolled in care in 2021 and % included in the study sample.¹
* Health region 7, centred around the capital city Bangui, includes 18 sampling sites.
1 In brackets, we indicate the number of ARV refill centres in each health region.
(a−g) Kaplan‐Meier estimates (black lines) of the cumulative probability of patient retention in antiretroviral treatment (ART) by health region (here, “HR”) and smoothed rate estimates of lost to follow‐up stratified by health region (red lines). Rates are expressed in 1000 persons‐month.
Geospatial localization of persons living with HIV (PLVIH) living in Bangui under antiretroviral treatment (ART) respective to the refill centres; drafted lines link patients or cluster of patients with the respective refill centre.¹
1. Each start line indicates the centroid of the neighbourhood where patients are living. Lines represent the Euclidean distance between the ARV refill centre where these patients are followed up and the neighbourhood of residence. Lines width correlates by the number of patients included in each node (see the legend).
Retention on antiretroviral therapy and drivers of lost‐to‐follow up in the Central African Republic: a longitudinal analysis

December 2024

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10 Reads

Introduction The retention in care of patients undergoing antiretroviral therapy (ART) is a cornerstone for preventing AIDS‐associated morbidity and mortality, as well as further transmission of HIV. Adherence to ART poses particular challenges in conflict‐affected settings like the Central African Republic (CAR). The study objective was to estimate the rate of lost‐to‐follow‐up (LTFU) and determine factors associated with LTFU among patients living with HIV under ART in CAR. Methods A retrospective cohort analysis was conducted using data from patients being managed at 42 representative ART dispensing sites (i.e. management of ≥200 patients) in the seven health regions of CAR which started ART between January 2019 to September 2021 and followed up to December 2021. The outcome of LTFU was defined as a failure of a patient to attend a scheduled ART refill appointment for at least 90 days from the last appointment. Patients were censored at the first LTFU event. Results A total of 6844 patients enrolled in ART care were included in the analysis, of whom 67.5% were females. The mean age (standard deviation) was 35.3 years (10.5). Forty‐two per cent (n = 2874/6844) had an LTFU event during the follow‐up period. However, 23.2% (n = 666/2874) returned to care after LTFU. Overall retention in antiretroviral care at 12 months was 64.2% (CI 63.0−65.5), which ranged from 76.1% in the capital to 48.2% in the inner country region. Risk factors related to LTFU were being male (adjusted hazard ratio [aHR] 1.33; CI 1.1−1.5), age < 25 (aHR 1.46; CI 1.1−1.9), living in regions outside the capital (aHR 1.83; CI 1.6−2.3) and undernutrition (aHR 1.13; CI 1.0−1.3). Conclusions Retention to care in CAR is suboptimal, especially in the inner country. Our results underline the difficulties involved in retaining patients in ART in complex settings, the interplay between poor retention, social unrest, stigma, food insecurity and HIV epidemic control, and the need for tailored programming and interventions like differentiated treatment strategies and complementary food provision.


Incidence prevalence ratio among people living with HIV in Australia, 2015−2022.
Abbreviation: IPR, incidence prevalence ratio.
Incidence prevalence ratio among men living with HIV attributed to male‐to‐male sex in Australia, 2015−2022.
Abbreviation: IPR, incidence prevalence ratio.
Incidence prevalence ratio among women living with HIV in Australia, 2015−2022.
Abbreviation: IPR, incidence prevalence ratio.
Incidence prevalence ratio among people living with HIV attributed to injection drug use in Australia, 2015−2022.
Abbreviation: IPR, incidence prevalence ratio.
Applying population‐specific incidence prevalence ratio benchmarks to monitor the Australian HIV epidemic: an epidemiological analysis

December 2024

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11 Reads

Introduction Due to a lack of robust population denominators, Australia is unable to accurately monitor changes in the HIV epidemic for some populations. The ratio of HIV transmission relative to the number of people with HIV (an incidence prevalence ratio, or IPR) can measure such changes. The IPR is measured against an IPR benchmark derived from post‐HIV acquisition life expectancy, to indicate whether an HIV epidemic is shrinking or growing. Using IPRs and Australia‐specific IPR benchmarks, this study aims to describe the Australian HIV epidemic among three groups: men with HIV attributed to male‐to‐male sex, women with HIV and people with HIV attributed to injection drug use. Methods Using mathematical modelling derived from HIV notifications, cohort and administrative data, IPRs were generated for each of the three groups. These IPRs were compared with IPR benchmarks derived from post‐HIV acquisition mortality estimates using abridged life tables for men, women and people who inject drugs. The IPR benchmark for men was applied to people with HIV attributed to male‐to‐male sex. Trends in the IPR over time were described for each reported population from 2015 to 2022. Results Overall, the IPR fell by 80%, from 0.040 (range: 0.034−0.045) in 2015 to 0.008 (range: 0.003−0.013) in 2022 and fell below the benchmark (0.022) in 2020. Among people with HIV attributed to male‐to‐male sex, the IPR fell by 85%, from 0.041 (range: 0.034−0.047) in 2015 to 0.006 (range: 0.003−0.024) in 2022 and fell below the benchmark (0.022) in 2020. Among women with HIV, the IPR fell by 56%, from 0.032 (range: 0.026−0.039) in 2015 to 0.014 (range: 0.003−0.029) in 2022 and fell below the benchmark (0.022) in 2019. Among people with HIV attributed to injection drug use, the IPR fell by 61%, from 0.036 (range: 0.022−0.047) in 2015 to 0.014 (range: 0.002−0.057) in 2022 and fell below the benchmark (0.028) in 2019. Conclusions Australian IPRs in all populations examined have dropped below the level required to sustain the HIV epidemic at current levels. By applying this method in other contexts, the changing scale of HIV epidemics may be better described for populations lacking robust population denominators.


(a) Flow diagram of the selection of the studied populations (Analysis 1). (b) Selection of individuals for the emulation of a target trial, 2019–2020. ART, antiretroviral therapy; DTG, dolutegravir.
*Non‐initiators of DTG could be included as initiators in subsequent trials if they initiated DTG and still met the eligibility criteria or several times as non‐initiators if they did not initiate DTG but still met the eligibility criteria.
(a) Flow diagram of the selection of the studied populations (Analysis 1). (b) Selection of individuals for the emulation of a target trial, 2019–2020. ART, antiretroviral therapy; DTG, dolutegravir.
*Non‐initiators of DTG could be included as initiators in subsequent trials if they initiated DTG and still met the eligibility criteria or several times as non‐initiators if they did not initiate DTG but still met the eligibility criteria.
Weight evolution from month‐24 pre‐switch to month‐12 post‐switch to DTG according to sex, age and ART regimen pre‐switch.
AAWG, annual average weight gain (in kg/year); EFV, efavirenz; NRTIs, nucleoside reverse transcriptase inhibitors;
NVP, nevirapine; PI, protease inhibitor.
Impact of switching to a dolutegravir‐based regimen on body weight changes: insights from West African adult HIV cohorts

November 2024

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12 Reads

Introduction Adverse metabolic effects related to dolutegravir (DTG) are increasingly reported as countries are adopting DTG‐based regimens as first‐line antiretroviral therapy (ART), but there is limited data from sub‐Saharan Africa. We explored changes in body weight pre‐ and post‐switch to a DTG‐based regimen and assessed the association between DTG switch and significant weight gain (SWG) defined as a ≥10% increase over a 12‐month period in people living with HIV (PLHIV) on ART in West Africa. Methods We first included all PLHIV followed in the IeDEA West Africa cohorts between January 2017 and June 2021, with a documented switch to DTG during 2019–2021 and in care ≥36 months at the day of switch. Weight change was estimated using a two slope piecewise linear mixed model with change point at the switch date. Secondly, we emulated a sequence of target trials (ETT) based on the observational data, performing pooled logistic regression analysis to compare SWG occurrence between PLHIV who switched to DTG and those who did not. Results We first included 6705 PLHIV from Burkina Faso, Côte d'Ivoire and Nigeria. Their median age at the time of switch was 48 years (IQR: 42–54) with a median follow‐up of 9 years (IQR: 6–12), 63% were female. Most patients switched from efavirenz (EFV)‐based ART (56.6%) and nevirapine (NVP)‐based ART (30.9%). The overall post‐switch annual average weight gain (AAWG) was significantly elevated at 3.07 kg/year [95% CI: 2.33–3.80] compared to the pre‐switch AWG which stood at 0.62 kg/year [95% CI: 0.36–0.88]. The post‐switch AWG was greater in patients previously on EFV and protease inhibitor (PI)‐based ART compared to those on NVP‐based ART. The pooled logistic regression analyses of a sequence of 24 ETT, including 9598 person‐trials, switching to DTG was significantly associated with an SWG (aOR = 2.54; 95% CI = 2.18–2.97). Conclusions In West Africa, a 12‐month DTG exposure was associated with substantial weight gain, especially in PLHIV previously on EFV and PI‐based ARTs. Continuous weight monitoring and metabolic profiling is imperative in HIV cohorts to delineate the long‐term cardiometabolic impact of DTG as patients with, or at elevated risk for cardiovascular diseases might benefit from alternative ART regimens.



Attributes and levels in the discrete choice experiment describing different tuberculosis preventive treatment (TPT) regimens. This figure shows the final selection of attributes (column 1) and how levels were depicted to participants (columns 2–4). The need to adjust antiretroviral therapy (ART) dosage was described as requiring an increased dose, that is taking the ART twice daily during TPT, with an extra pill of the same ART drugs. Mild side effects were described as short‐lasting, such as nausea, dizziness, fatigue or skin rashes for a week or so, not requiring a stop of TPT or a clinic visit. Moderate or severe side effects were described as tingling of the feet, allergy or liver damage, requiring additional visits to the clinic and stopping TPT or being admitted to the hospital.
ART, antiretroviral therapy; HIV, human immunodeficiency virus.
Participants’ study flow with 392 participants included in the final analysis.
TB, tuberculosis; TPT, tuberculosis preventive treatment.
Mean preference weights of attribute levels and relative importance of attributes among all participants. Bars indicate the mean preference weights for each level among 392 participants using hierarchical Bayesian estimation. Blue bars indicate levels with the strongest positive preference (most preferred) per attribute, orange bars indicate levels with negative preference (least preferred). The percentage on the right side indicates the mean relative importance for each attribute. No treatment had a mean preference weight of −135.2 [95% CI −147.2, −123.2] (not shown).
ART, antiretroviral therapy.
Mosaic plot showing the mean relative importance modelled using hierarchical Bayesian analysis among three groups identified by latent class analysis. The width of each column corresponds the proportion each group comprises of the overall population.
ART, antiretroviral therapy.
Willingness to trade (A) additional treatment duration months or (B) additional pills per dose for other improved regimen features. Results are truncated below zero months and above 5 months, and below zero pills and above 9 pills per dose (extrapolated values). The arrow in (A) indicates the upper confidence limit for 1 versus 10 pills was out of range. Antiretroviral therapy (ART) dosage adjustment was presented as requiring a second daily dose of ART. Moderate or severe side effects were described as side effects requiring medical care.
ART, antiretroviral therapy.
Preferences of people living with HIV for features of tuberculosis preventive treatment regimens in Uganda: a discrete choice experiment

November 2024

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11 Reads

Introduction Tuberculosis (TB) preventive treatment (TPT) is recommended for people living with HIV (PLHIV) in high TB burden settings. While 6 months of daily isoniazid remains widely used, shorter regimens are now available. However, little is known about preferences of PLHIV for key features of TPT regimens. Methods From July to November 2022, we conducted a discrete choice experiment among adult PLHIV engaged in care at an urban HIV clinic in Kampala, Uganda. Participants chose between two hypothetical TPT regimens with five different features (pills per dose, frequency, duration, need for adjusted antiretroviral therapy [ART] dosage and side effects), organized across nine random choice tasks. We analysed preferences using hierarchical Bayesian estimation, latent class analysis and willingness‐to‐trade simulations. Results Of 400 PLHIV, 392 (median age 44, 72% female, 91% TPT‐experienced) had high‐quality choice task responses. Pills per dose was the most important attribute (relative importance 32.4%, 95% confidence interval [CI] 31.6–33.2), followed by frequency (20.5% [95% CI 19.7–21.3]), duration (19.5% [95% CI 18.6–20.5]) and need for ART dosage adjustment (18.2% [95% CI 17.2–19.2]). Latent class analysis identified three preference groups: one prioritized less frequent, weekly dosing (N = 222; 57%); another was averse to ART dosage adjustment (N = 107; 27%); and the last prioritized short regimens with fewer side effects (N = 63; 16%). All groups highly valued fewer pills per dose. Overall, participants were willing to accept a regimen of 2.8 months’ additional duration [95% CI: 2.4–3.2] to reduce pills per dose from five to one, 3.6 [95% CI 2.4–4.8] months for weekly rather than daily dosing and 2.2 [95% CI 1.3–3.0] months to avoid ART dosage adjustment. Conclusions To align with preferences of PLHIV in Uganda, decision‐makers should prioritize the development and implementation of TPT regimens with fewer pills, less frequent dosing and no need for ART dosage adjustment, rather than focus primarily on duration of treatment.


Recent infection testing algorithm flow diagram.
Recent infection testing to inform HIV prevention responses and surveillance in a programme context: lessons from implementation within a nationally scaled female sex worker programme in Zimbabwe

November 2024

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11 Reads

Introduction In the context of key population HIV testing programmes, identifying new HIV acquisitions, tracking incidence, and responding with prevention and treatment interventions will be critical for achieving HIV epidemic control. Laboratory tests for recently acquired HIV used as part of a “recent infection testing algorithm” (RITA), offer a potential tool to support this work. We implemented a RITA for female sex workers (FSWs) in Zimbabwe to explore opportunities and programmatic benefits. Methods Between October 2021 and January 2023, recency testing was offered to FSWs attending the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) Zimbabwe's key populations programme. Dried blood spot (DBS) samples were taken at 86 clinic sites across 10 provinces and Laboratory LAg Avidity and viral load testing conducted. RITA results were analysed and linked to programme data to explore geographical differences and calculate HIV incidence. We describe concurrent efforts in HIV testing for social (social network testing [SNT]) and sexual (index case testing [ICT]) contacts of those testing HIV positive. Results Among 24,976 FSWs tested at programme sites, 9.5% (2363/24,976) were confirmed HIV positive. We enrolled 55.5% (1311/2363) of eligible HIV‐positive FSWs to our study, of whom 11.7% (153/1311) were identified as having recently acquired HIV. It took a median of 37 days (IQR 20–67) for samples to be processed. Enrolment rates varied between provinces but the proportion of recently acquired HIV was similar (range: 18.4% to 4.0%). Overall HIV incidence was 3.4 (95% CI 2.7−4.0) per 100py. Where results could be linked to routinely collected data, we found no evidence of a difference in test‐positivity between the ICT and SNT contacts of those with recently acquired compared to those with long‐term HIV. Conclusions Implementation of a RITA was possible within a nationally scaled sex worker programme, and while challenging to implement, can provide an understanding of transmission dynamics and HIV incidence in this context. Sub‐optimal recruitment and data linkage limited the interpretation of our findings and opportunities for strategic gains though focusing on HIV prevention efforts.


Pre‐exposure prophylaxis (PrEP) use regimen among PrEP users, 2019–2023 (n = 12,922).
*“Other” option introduced in 2021.
Increasing event‐driven HIV pre‐exposure prophylaxis use among gay, bisexual and other men who have sex with men in Australia: results from behavioural surveillance 2019–2023

November 2024

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Introduction HIV pre‐exposure prophylaxis (PrEP) has been publicly available since 2018 in Australia as a daily regimen. In 2019, clinical guidelines were updated to support guidance on event‐driven PrEP (ED‐PrEP) use. We assessed trends in the PrEP dosing regimen by comparing daily PrEP use to ED‐PrEP among cisgender gay, bisexual and other men who have sex with men (GBMSM). Methods Data from repeated, cross‐sectional, national behavioural surveillance surveys were analysed from 2019 to 2023 among participants not living with HIV. Logistic regression models were conducted to assess trends and compared ED‐PrEP users to non‐PrEP users and daily PrEP. Results Among 38,880 participants, overall PrEP use with any regimen increased from 27.6% in 2019 to 42.7% in 2023 (OR = 1.16, 95% CI = 1.15−1.18, p < 0.001). Among 12,922 participants who reported PrEP use in the last 6 months, the proportion reporting ED‐PrEP use increased from 7.6% in 2019 to 27.8% in 2023 (OR = 1.41, 95% CI = 1.37−1.46, p < 0.001) with those who reported daily PrEP decreasing from 92.4% to 63.3% (OR = 0.64, 95% CI = 0.62−0.66, p < 0.001). In a cross‐sectional sub‐sample in 2022–2023 (n = 8840), compared to ED‐PrEP users, non‐PrEP users were less likely to have received three or more HIV tests in the last 12 months (aRRR = 0.26, 95% CI = 0.22−0.31, p < 0.001), have 2−10 male sexual partners in the last 6 months (aRRR = 0.24, 95% CI = 0.14−0.41, p < 0.001) or 11 or more (aRRR = 0.26, 95% CI = 0.15−0.45, p < 0.001) compared to none, or to report condomless anal intercourse with casual partners (aRRR = 0.38, 95% CI = 0.32−0.46, p < 0.001). Compared to ED‐PrEP users, daily PrEP users were more likely to have received three of more HIV tests in the last year (aRRR = 3.73, 95% CI = 3.15−4.40, p < 0.001) and less likely to be born overseas and lived in Australia for less than 5 years compared to being born in Australia (aRRR = 0.64, 95% CI = 0.49−0.83, p = 0.001). Conclusions While daily PrEP remains the most common PrEP dosing regimen among GBMSM in Australia, there has been a steep increase in the proportion of PrEP users who are taking ED‐PrEP. Monitoring of PrEP use should continue to adapt to new dosing methods and future PrEP options. As ED‐PrEP use increases, further work is needed to ensure those taking ED‐PrEP are taking it effectively to prevent HIV.



Journal metrics


4.6 (2023)

Journal Impact Factor™


19%

Acceptance rate


8.6 (2023)

CiteScore™


25 days

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$2,600 / £2,000 / €2,400

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