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Objective To describe the scale-up of cervical cancer screening and treatment for women living with human immunodeficiency virus (HIV), aged 25-49 years in Uganda, and to analyse the programme data. Methods The health ministry targeted existing HIV clinics in a 2-year scale-up of cervical cancer screening services from October 2020. In preparation, we trained health workers to assess women attending HIV clinics for screening eligibility, provided either by human papillomavirus (HPV) testing and/or visual inspection with acetic acid. Clinic staff treated women with precancerous cervical lesions with thermocoagulation or referred women with suspected cancer to external services. We analysed data reported every 6 months for the number of clinics offering screening, screening uptake, the number of positive diagnoses and the number of women who received treatment. Findings The number of HIV clinics offering cervical cancer screening services increased from 11, before the programme launch, to 1571. During the programme, screening uptake increased from 5.0% (6506/130 293) to 107.3% (151872/141 527) of targets. The cumulative proportion of positive diagnoses was 5.9% (23 970/407 323) overall, but was much lower for screening offering visual inspection only compared with clinics offering HPV testing. Although the proportion of women receiving treatment if positive increased from 12.8% (53/413) to 84.3% (8087/9592), the World Health Organization target of 90% was not reached. Conclusion We demonstrated marked increases, potentially replicable by other countries, in screening and treatment. These increases could be improved further by expanding HPV testing and same-day treatment of precancerous lesions. Objectif Decrire Intensification du depistage et du traitement du cancer du col de l'uterus chez les femmes vivant avec le virus de l'immunodeficience humaine (VIH) et agees de 25 a 49 ans en Ouganda, puis analyser les donnees du programme. Methodes Le Ministere de la Sante a cible les cliniques de prise en charge du VIH existantes dans le cadre d'un renforcement des services lies au cancer du col de l'uterus sur une periode de deux ans, a partir d'octobre 2020. En amont, nous avons forme des professionnels de la sante a examiner les femmes frequentant les cliniques du VIH afin de determiner leur admissibility au depistage, par un test de detection du papillomavirus humain (HPV) et/ou une inspection visuelle apres application d'acide acetique. Le personnel des cliniques a traite les femmes presentant des lesions precancereuses du col de l'uterus par thermocoagulation, ou les ont renvoyees vers des services externes lorsqu'elles etaient susceptibles d'etre atteintes d'un cancer. Nous avons analyse les donnees transmises tous les six mois concernant le nombre de cliniques proposant un depistage, la participation au depistage, le nombre de diagnostics positifs et le nombre de femmes ayant repu un traitement. Resultats Le nombre de cliniques du VIH disposant de services de depistage du cancer du col de l'uterus a augmente: 11 avant le lancement du programme, 1571 apres. Au cours de ce programme, la participation au depistage est passee de 5,0% (6506/130 293) a 107,3% (151 872/141 527) des cibles. Le pourcentage cumule de diagnostics positifs s'elevait a 5,9% (23 970/407 323) au total; cependant, il etait nettement moins important dans des cliniques effectuant uniquement des inspections visuelles que dans celles proposant un test de detection du HPV. Bien que le pourcentage de femmes ayant regu un traitement en cas de diagnostic positif ait progresse de 12,8% (53/413) a 84,3% (8087/9592), l'objectif de l'Organisation mondiale de la Sante, fixe a 90%, n'a pas ete atteint. Conclusion Nous avons observe des hausses considerables, susceptibles de se reproduire dans d'autres pays, en matiere de depistage et de prise en charge. Ces hausses pourraient etre accentuees par le developpement des tests de detection du HPV et de traitement des lesions precancereuses le jour meme. Objetivo Describir la ampliacion del cribado y tratamiento del cancer de cuello uterino para mujeres con el virus de la inmunodeficiencia humana (VIH) de entre 25 y 49 anos en Uganda, y analizar los datos del programa. Metodos El Ministerio de Salud se centro en las clinicas de VIH existentes en una ampliacion de dos anos de los servicios de cribado del cancer de cuello uterino a partir de octubre de 2020. Como preparacion, formamos a profesionales sanitarios para que evaluaran a las mujeres que acudian a las clinicas de VIH para determinar si cumplian los requisitos para someterse al cribado, mediante pruebas del virus del papiloma humano (VPH) o inspeccion visual con acido acetico. El personal clinico trato a las mujeres que presentaban lesiones cervicales precancerosas con termocoagulacion o derivo a las mujeres con sospecha de cancer a servicios externos. Se analizaron los datos comunicados cada seis meses sobre el numero de clinicas que ofrecian el cribado, la aceptacion del cribado, el numero de diagnosticos positivos y el numero de mujeres que recibieron tratamiento. Resultados El numero de clinicas de VIH que ofrecen servicios de cribado del cancer de cuello uterino aumento de 11, antes del lanzamiento del programa, a 1571. Durante el programa, la aceptacion del cribado aumento del 5,0% (6506/130 293) al 107,3% (151 872/141 527) de los objetivos. El porcentaje acumulado de diagnosticos positivos fue del 5,9% (23 970/407 323) en general, pero fue mucho menor en el caso de los diagnosticos en clinicas que solo ofrecian inspeccion visual en comparacion con las clinicas que ofrecian pruebas del VPH. Aunque el porcentaje de mujeres que recibieron tratamiento en caso positivo aumento del 12,8% (53/413) al 84,3% (8087/9592), no se alcanzo el objetivo del 90% que habia fijado la Organizacion Mundial de la Salud. Conclusion Se registraron aumentos notables, potencialmente reproducibles en otros paises, en el cribado y el tratamiento. Estos aumentos podrian mejorarse aun mas ampliando las pruebas del VPH y el tratamiento en el mismo dia de las lesiones precancerosas. [phrase omitted], Introduction Cervical cancer is a disease of the female reproductive tract caused primarily by oncogenic types of human papillomavirus (HPV). In 2020, it was the fourth most common cancer among [...]

Objective To estimate the feasibility, positivity rate and cost of offering child testing for human immunodeficiency virus (HIV) to mothers living with HIV attending outpatient clinics in Burkina Faso. Methods We conducted this implementation study in nine outpatient clinics between October 2021 and June 2022. We identified all women [less than or equal to] 45 years who were attending these clinics for their routine HIV care and who had at least one living child aged between 18 months and 5 years whose HIV status was not known. We offered these mothers an HIV test for their child at their next outpatient visit. We calculated intervention uptake, HIV positivity rate and costs. Findings Of 799 eligible children, we tested 663 (83.0%) and identified 16 new HIV infections: 2.5% (95% confidence interval, CI: 1.5-4.1). Compared with HIV-negative children, significantly more HIV-infected children were breastfed beyond 12 months (8-value: 0.003) and they had not been tested before (8-value: 0.003). A significantly greater proportion of mothers of HIV-infected children were unaware of the availability of child testing at 18 months (8-value: < 0.001) and had more recently learnt their HIV status (8-value: 0.01) than mothers of HIVnegative children. The intervention cost 98.1 United States dollars for one child testing HIV-positive. Barriers to implementing this strategy included shortages of HIV tests, increased workload for health-care workers and difficulty accessing children not living with their mothers. Conclusion Testing HIV-exposed children through their mothers in outpatient clinics is feasible and effective in a low HIV-prevalence setting such as Burkina Faso. Implementation of this strategy to detect undiagnosed HIV- infected children is recommended. Objectif Evaluer la faisabilite, le taux de positivite et le cout que representerait un depistage du virus de l'immunodeficience humaine (VIH) chez les enfants s'il est propose aux meres vivant avec le VIH qui se rendent dans des cliniques externes au Burkina Faso. Methodes Nous avons deploye cette etude de mise en oeuvre dans neuf cliniques externes entre octobre 2021 et juin 2022. Nous avons identifie toutes les femmes agees de [less than or equal to] 45 ans qui frequentaient ces cliniques pour leurs soins de routine dans le cadre d'une prise en charge du VIH et avaient au moins un enfant vivant de minimum 18 mois et maximum 5 ans, dont le statut VIH n'etait pas connu. Nous avons propose a ces meres de proceder au depistage de leur enfant lors de leur prochaine visite a la clinique. Enfin, nous avons calcule le nombre de recours a cette intervention, le taux de positivite du VIH et les couts. Resultats Sur 799 enfants eligibles, nous en avons teste 663 (83,0%) et avons detecte 16 nouvelles infections au VIH: 2,5% (intervalle de confiance de 95%: 1,5-4,1). Par rapport aux enfants seronegatifs, un nombre nettement superieur d'enfants seropositifs avaient ete allaites au-dela de 12 mois (valeur-p: 0,003) et n'avaient pas ete testes auparavant (valeur-p: 0,003). Un pourcentage sensiblement plus eleve de meres d'enfants seropositifs ignoraient l'existence d'un depistage chez les enfants ages de 18 mois (valeur-p: < 0,001) et avaient appris leur statut VIH plus recemment (valeur-p: 0,01) que les meres d'enfants seronegatifs. Cette intervention a coute 98,1 dollars americains par enfant seropositif. Parmi les obstacles a cette strategie figurent la penurie de tests de depistage du VIH, l'augmentation de la charge de travail pour les professionnels de la sante et les difficultes d'acces aux enfants qui ne vivent pas avec leur mere. Conclusion Tester les enfants exposes au VIH par l'intermediaire de leur mere dans les cliniques externes est faisable et efficace dans les lieux oU la prevalence du VIH est faible, comme au Burkina Faso. Nous recommandons l'application de cette strategie pour identifier les enfants seropositifs non diagnostiques. Objetivo Estimar la viabilidad, la tasa de positividad y el coste de ofrecer pruebas de deteccion del virus de la inmunodeficiencia humana (VIH) en ninos a las madres seropositivas que acuden a las clinicas de atencion ambulatoria de Burkina Faso. Metodos Se realizo este estudio de implementacion en nueve clinicas de atencion ambulatoria entre octubre de 2021 y junio de 2022. Se identifico a todas las mujeres [less than or equal to] 45 anos que acudian a estas clinicas para su atencion de rutina del VIH y que tenian al menos un hijo vivo de entre 18 meses y 5 anos, cuyo estado serologico respecto al VIH se desconocia. Se ofrecio a estas madres una prueba del VIH para su hijo en su siguiente consulta externa. Se calcularon la aceptacion de la intervencion, la tasa de positividad del VIH y los costes. Resultados De 799 ninos que cumplian los requisitos, se realizaron pruebas a 663 (83,0%) y se identificaron 16 nuevas infecciones por VIH: 2,5% (intervalo de confianza del 95%: 1,5-4,1). En comparacion con los ninos seronegativos, un numero significativamente mayor de ninos infectados por el VIH fueron amamantados mas de 12 meses (valor de p: 0,003) y no se habian sometido a pruebas anteriormente (valor de p: 0,003). Un porcentaje significativamente mayor de madres de ninos infectados por el VIH desconocia la disponibilidad de pruebas infantiles a los 18 meses (valor de p: Conclusion La realizacion de pruebas a ninos expuestos al VIH a traves de sus madres en clinicas de atencion ambulatoria es viable y eficaz en un entorno de baja prevalencia del VIH como Burkina Faso. Se recomienda la aplicacion de esta estrategia para detectar a los ninos infectados por el VIH no diagnosticados., Introduction Despite great improvements in the response to human immunodeficiency virus (HIV), the 90-90-90 targets of the Joint United Nations Programme on HIV and AIDS (acquired immunodeficiency syndrome) for 2020 [...]

The articles in this supplement are designated by Washington University School of Medicine in St. Louis for AMA PRA Category 1 Credit™ for physicians. After reading the articles, access the [...]

: Introduction: Community‐based cohort studies of HIV seroconversion can identify important avenues for enhancing HIV prevention efforts in the era of pre‐exposure prophylaxis (PrEP). Within individuals, one can assess exposure and outcome variables repeatedly and with increased certainty regarding temporal ordering. This cohort study examined the association of several risk factors with subsequent HIV seroconversion. Methods: We report data from a 4‐year study (2017−2022) of 6059 HIV seronegative sexual and gender minority individuals who have sex with men who had indications for‐, but were not using‐, PrEP at enrolment. Participants completed repeat exposure assessments and self‐collection of biospecimens for HIV testing. We examined the roles of race and ethnicity, socio‐economic status, methamphetamine use and PrEP uptake over the course of follow‐up in relation to HIV seroconversion. Results: Over 4 years, 303 of the participants seroconverted across 18,421 person‐years (incidence rate = 1.64 [95% CI: 1.59−1.70] per 100 person‐years). In multivariable discrete‐time survival analysis, factors independently associated with elevated HIV seroconversion risk included being Black/African American (adjusted risk ratio [aRR]: 2.44, 1.79−3.28), Hispanic/Latinx (1.53, 1.19−1.96), housing instability (1.58, 1.22−2.05) and past year methamphetamine use (3.82, 2.74−5.33). Conversely, time since study enrolment (24 vs. 12 months, 0.67, 0.51−0.87; 36 months, 0.60, 0.45−0.80; 48 months, 0.48, 0.35−0.66) and higher education (master's degree or higher vs. less than or equal to high school, 0.36, 0.17−0.66) were associated with reduced seroconversion risk. Compared to non‐PrEP users in the past 2 years without a current clinical indication, those who started PrEP but then discontinued had higher seroconversion risk, irrespective of clinical indication (3.23, 1.74−6.46) or lack thereof (4.30, 1.85−9.88). However, those who initiated PrEP in the past year (0.14, 0.04−0.39) or persistently used PrEP in the past 2 years (0.33, 0.14−0.74) had a lower risk of seroconversion. Of all HIV seroconversions observed during follow‐up assessments (12, 24, 36 and 48 months), methamphetamine was reported in the 12 months prior 128 (42.2%) times (overall). Conclusions: Interventions that acknowledge race and ethnicity, economic variables such as education and housing instability, and methamphetamine use are critically needed. Not only are interventions to engage individuals in PrEP care needed, but those that retain them, and re‐engage those who may fall out of care are essential, given the exceptionally high risk of seroconversion in these groups., INTRODUCTION Sexual minority individuals represent 2−5% of the United States, yet account for more than two‐thirds of new HIV acquisitions [1−4]. Meanwhile, gender minority individuals (transgender [trans] men and trans [...]

Objective To evaluate resource allocation and costs associated with delivery of human Immunodeficiency virus (HIV) services In Uganda and the United Republic of Tanzania. Methods We used time-driven activity-based costing to determine the resources consumed and costs of providing five HIV services in Uganda and the United Republic of Tanzania: antiretroviral therapy (ART); HIV testing and counselling; prevention of mother-to-child transmission; voluntary male medical circumcision; and pre-exposure prophylaxis. Findings Country-based teams undertook time-driven activity-based costing with 1119 adults in Uganda and 886 adults in the United Republic of Tanzania. In Uganda, service delivery costs ranged from 8.18 United States dollars (US$) per visit for HIV testing and counselling to US$ 43.43 for ART (for clients in whom HIV was suppressed). In the United Republic of Tanzania, these costs ranged from US$ 3.67 per visit for HIV testing and counselling to US$ 28.00 for voluntary male medical circumcision. In both countries, consumables were the main cost driver, accounting for more than 60% of expenditure. Process maps showed that in both countries, registration, measurement of vital signs, consultation and medication dispensing were the steps that occurred most frequently for ART clients. Conclusion Establishing a rigorous, longitudinal system for tracking investments in HIV services that includes thousands of clients and numerous facilities is achievable in different settings with a high HIV burden. Consistent engagement of implementation partners and standardized training and data collection instruments proved essential for the success of these exercises. Objectif Analyser l'allocation des ressources et les couts lies a la fourniture de services de prise en charge du virus de l'immunodeficience humaine (VIH) en Ouganda et en Republique-Unie de Tanzanie. Methodes Nous avons utilise un systeme de calcul des couts par activite pilote par le temps (TDABC), pour identifier les ressources consommees et les couts engendres par cinq services de prise en charge du VIH en Ouganda et en Republique-Unie de Tanzanie: le traitement antiretroviral (TAR); le depistage du VIH et les conseils en la matiere; la prevention de la transmission de la mere a l'enfant; la pratique volontaire de la circoncision masculine medicalisee; et enfin, la prophylaxie preexposition. Resultats Des equipes deployees dans chaque pays ont mene un calcul des couts par activite pilote par le temps aupres de 1119 adultes en Ouganda et 886 adultes en Republique-Unie de Tanzanie. En Ouganda, les couts de prestation des services etaient compris entre 8,18 dollars americains (USD) par visite de depistage du VIH et de conseils en la matiere, et 43,43 USD pour un TAR (sur les patients chez qui la charge virale a ete supprimee). En Republique-Unie de Tanzanie, ces couts variaient entre 3,67 USD par visite de depistage du VIH et de conseils en la matiere a 28,00 USD pour la pratique volontaire de la circoncision masculine medicalisee. Dans les deux pays, les consommables representaient le principal facteur de cout, avec plus de 60% des depenses. Les schemas de procedure ont montre que, dans les deux pays, l'enregistrement, la mesure des signes vitaux, la consultation et l'administration du traitement constituaient les etapes les plus frequentes chez les patients faisant l'objet d'un TAR. Conclusion Il est possible d'etablir un dispositif longitudinal rigoureux pour suivre les investissements realises dans les services de prise en charge du VIH, qui inclut des milliers de patients et de nombreux etablissements dans differents endroits fortement touches par le VIH. Limplication constante des partenaires de mise en oeuvre et la standardisation des formations et instruments de collecte des donnees se sont revelees essentielles a la reussite de ces demarches. Objetivo Analizar la asignacion de recursos y los costes asociados a la prestacion de servicios por el virus de la inmunodeficiencia humana (VIH) en Uganda y en la Republica Unida de Tanzania. Metodos Utilizamos los costes basados en el tiempo invertido por actividad, con el fin de determinar los recursos consumidos y los costes de la prestacion de cinco servicios por VIH en Uganda y en la Republica Unida de Tanzania: terapia antirretroviral (TAR); pruebas y asesoramiento sobre el VIH; prevencion de la transmision de madre a hijo; circuncision medica masculina de caracter voluntario y profilaxis previa a la exposicion. Resultados Los equipos fundados en el pais se encargaron de analizar los costes basados en el tiempo invertido por actividad con 1119 adultos en Uganda y 886 adultos en la Republica Unida de Tanzania. En Uganda, los costes por la prestacion de servicios oscilaron entre 8,18 dolares estadounidenses (USD) por visita destinada a pruebas y asesoramiento sobre VIH, y 43,43 USD por TAR (para clientes en los que se habia erradicado el VIH). En la Republica Unida de Tanzania, estos costes estuvieron comprendidos entre 3,67 USD por visita destinada a pruebas y asesoramiento sobre VIH, y 28,00 USD por circuncision medica masculina de caracter voluntario. En ambos paises, los consumibles fueron los principales generadores de costes, representando mas del 60% del gasto. Los mapas de procesos mostraron que en ambos paises el registro, la medicion de las constantes vitales, asi como las consultas y la dispensacion de medicacion fueron los pasos que mas se repitieron entre los clientes con TAR. Conclusion Implantar un sistema riguroso y longitudinal para realizar un seguimiento de las inversiones en servicios por VIH, lo que engloba a miles de clientes y numerosas instalaciones, es algo que se puede lograr en aquellos centros con una elevada incidencia de VIH. Quedo demostrado que el compromiso constante de los socios encargados de la implementacion, asi como la existencia de instrumentos estandarizados de formacion y de recopilacion de datos resultaban esenciales para el exito de estos ejercicios., Introduction Despite evolving epidemiological trends, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) are still responsible for one of the largest disease burdens in sub-Saharan Africa. (1) In low-income [...]

Self-care is not a new concept, but the public health sector has only recently started actively promoting tools that provide greater autonomy and agency to people without formal health training [...]

Background World Health Organization (WHO) guidelines recommend cotrimoxazole prophylaxis for children who are HIV-exposed until infection is excluded and vertical transmission risk has ended. While cotrimoxazole has benefits for children with HIV, there is no mortality benefit for children who are HIV-exposed but uninfected, prompting a review of global guidelines. Here, we model the potential impact of alternative cotrimoxazole strategies on mortality in children who are HIV-exposed. Methods and findings Using a deterministic compartmental model, we estimated mortality in children who are HIV-exposed from 6 weeks to 2 years of age in 4 high-burden countries: Côte d'Ivoire, Mozambique, Uganda, and Zimbabwe. Vertical transmission rates, testing rates, and antiretroviral therapy (ART) uptake were derived from UNAIDS data, trial evidence, and meta-analyses. We explored 6 programmatic strategies: maintaining current recommendations; shorter cotrimoxazole provision for 3, 6, 9, or 12 months; and starting cotrimoxazole only for children diagnosed with HIV. Modelled alternatives to the current strategy increased mortality to varying degrees; countries with high vertical transmission had the greatest mortality. Compared to current recommendations, starting cotrimoxazole only after a positive HIV test had the greatest predicted increase in mortality: Mozambique (961 excess annual deaths; excess mortality 339 per 100,000 HIV-exposed children; risk ratio (RR) 1.06), Uganda (491; 221; RR 1.04), Zimbabwe (352; 260; RR 1.05), and Côte d'Ivoire (125; 322; RR 1.06). Similar effects were observed for 3-, 6-, 9-, and 12-month strategies. Increased mortality persisted but was attenuated when modelling lower cotrimoxazole uptake, smaller mortality benefits, higher testing coverage, and lower vertical transmission rates. The study is limited by uncertain estimates of cotrimoxazole coverage in programmatic settings; an inability to model increases in mortality arising from antimicrobial resistance due to limited surveillance data in sub-Saharan Africa; and lack of a formal health economic analysis. Conclusions Changing current guidelines from universal cotrimoxazole provision for children who are HIV-exposed increased predicted mortality across the 4 modelled high-burden countries, depending on test-to-treat cascade coverage and vertical transmission rates. These findings can help inform policymaker deliberations on cotrimoxazole strategies, recognising that the risks and benefits differ across settings., Author(s): Shrey Mathur 1,*, Melanie Smuk 1, Ceri Evans 1,2,3, Catherine J. Wedderburn 4,5, Diana M. Gibb 4, Martina Penazzato 6, Andrew J. Prendergast 1,2 Introduction Vertical transmission of HIV [...]