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BackgroundThe use of mobile technologies to prevent STIs is recognised as a promising approach worldwide; however, evidence has been inconclusive, and the field has developed rapidly. With about 1 million new STIs a day globally, up-to-date evidence is urgently needed.ObjectiveTo assess the effectiveness of mobile health interventions delivered to participants for preventing STIs and promoting preventive behaviour.MethodsWe searched seven databases and reference lists of 49 related reviews (January 1990–February 2020) and contacted experts in the field. We included randomised controlled trials of mobile interventions delivered to adolescents and adults to prevent sexual transmission of STIs. We conducted meta-analyses and assessed risk of bias and certainty of evidence following Cochrane guidance.ResultsAfter double screening 6683 records, we included 22 trials into the systematic review and 20 into meta-analyses; 18 trials used text messages, 3 used smartphone applications and 1 used Facebook messages as delivery modes. The certainty of evidence regarding intervention effects on STI/HIV occurrence and adverse events was low or very low. There was moderate certainty of evidence that in the short/medium-term text messaging interventions had little or no effect on condom use (standardised mean differences (SMD) 0.02, 95% CI −0.09 to 0.14, nine trials), but increased STI/HIV testing (OR 1.83, 95% CI 1.41 to 2.36, seven trials), although not if the standard-of-care control already contained an active text messaging component (OR 1.00, 95% CI 0.68 to 1.47, two trials). Smartphone application messages also increased STI/HIV testing (risk ratio 1.40, 95% CI 1.22 to 1.60, subgroup analysis, two trials). The effects on other outcomes or of social media or blended interventions is uncertain due to low or very low certainty evidence.ConclusionsText messaging interventions probably increase STI/HIV testing but not condom use in the short/medium term. Ongoing trials will report the effects on biological and other outcomes.

HIV-infected adults have increased risk of several individual micronutrient deficiencies. However, the prevalence and risk factors of concurrent and multiple micronutrient deficiencies and whether micronutrient concentrations change after antiretroviral therapy (ART) initiation have not been well described. The objective of this study was to determine the prevalence and risk factors of individual, concurrent and multiple micronutrient deficiencies among ART-naïve HIV-infected adults from nine countries and assess change in micronutrient status 48 weeks post-ART initiation.A random sub-cohort (n = 270) stratified by country was selected from the multinational PEARLS clinical trial (n = 1571 ART-naïve, HIV-infected adults). We measured serum concentrations of vitamins A, D (25-hydroxyvitamin), E, carotenoids and selenium pre-ART and 48 weeks post-ART initiation, and measured vitamins B6, B12, ferritin and soluble transferrin receptor at baseline only. Prevalence of single micronutrient deficiencies, concurrent (2 coexisting) or conditional (a deficiency in one micronutrient given a deficiency in another) and multiple (≥3) were determined using defined serum concentration cutoffs. We assessed mean changes in micronutrient concentrations from pre-ART to week 48 post-ART initiation using multivariable random effects models.Of 270 participants, 13.9%, 29.2%, 24.5% and 32.4% had 0, 1, 2 and multiple deficiencies, respectively. Pre-ART prevalence was the highest for single deficiencies of selenium (53.2%), vitamin D (42.4%), and B6 (37.3%) with 12.1% having concurrent deficiencies of all three micronutrients. Deficiency prevalence varied widely by country. 48 weeks post-ART initiation, mean vitamin A concentration increased (p 0.001) corresponding to a 9% decrease in deficiency. Mean concentrations also increased for other micronutrients assessed 48 weeks post-ART (p 0.001) but with minimal change in deficiency status.Single and multiple micronutrient deficiencies are common among HIV-infected adults pre-ART initiation but vary between countries. Importantly, despite increases in micronutrient concentrations, prevalence of individual deficiencies remains largely unchanged after 48 weeks on ART. Our results suggest that ART alone is not sufficient to improve micronutrient deficiency.

A case-cohort analysis of human immunodeficiency virus (HIV)–infected individuals receiving antiretroviral therapy (ART) was performed within a multicountry randomized trial (PEARLS) to assess the prevalence of persistently elevated C-reactive protein (CRP) levels, based on serial measurements of CRP levels, and their association with HIV clinical failure. A persistently elevated CRP level in plasma (defined as ≥ 5 mg/L at both baseline and 24 weeks after ART initiation) was observed in 50 of 205 individuals (24%). A persistently elevated CRP level but not an elevated CRP level only at a single time point was independently associated with increased clinical failure, compared with a persistently low CRP level, despite achievement of virologic suppression. Serial monitoring of CRP levels could identify individuals who are at highest risk of HIV progression and may benefit from future adjunct antiinflammatory therapies.

Mark W. Tenforde, MD, MPH,* Ashish Yadav, MBBS, MD, MPH,† David W. Dowdy, MD, PhD, Nikhil Gupte, PhD,§ Rupak Shivakoti, PhD, MSPH,§ Wei-Teng Yang, MD, MPH,k Noluthando Mwelase, MBChB, Cecilia Kanyama, MD,# Sandy Pillay, MBChB,** Wadzanai Samaneka, MBChB, MSc,†† Breno Santos, MD,‡‡ Selvamuthu Poongulali, MBBS,§§ Srikanth Tripathy, MBBS,kk Cynthia Riviere, MD, Sima Berendes, MD, MPH,##*** Javier R. Lama, MD, MPH,††† Sandra W. Cardoso, MD,‡‡‡ Patcharaphan Sugandhavesa, MD,§§§ Rarul Christian, DrPH, MSc,† Richard D. Semba, MD, MPH,kkk Thomas B. Campbell, MD, and Amita Gupta, MD, MHS,†§ the NWCS319 and ACTG 5175 study team From the *Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, WA; Departments of †International Health; ‡Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; §Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; kDepartment of Medicine, Bridgeport Hospital, Yale New Haven Health, Bridgeport, CT; Department of Medicine, University of Witwatersrand, Johannesburg, South Africa; #UNC Lilongwe, Lilongwe, Malawi; **Durban International Clinical Research Site, Durban University of Technology, Durban, South Africa; ††University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe; ‡‡Hospital Nossa Senhora de Conceicao, Porto Alegre, Brazil; §§YR Gaitonde Centre for AIDS Research and Education, Chennai, India; kkNational AIDS Research Institute, Pune, India; Les Centres GHESKIO, Port-Au-Prince, Haiti; ##Malawi College of Medicine, Johns Hopkins University Research Project, Blantyre, Malawi; ***Liverpool School of Tropical Medicine, Liverpool, United Kingdom; †††Asociacion Civil Impacta Salud y Educacion, Lima, Peru; ‡‡‡STD/AIDS Clinical Research Laboratory, Instituto de Pesquisa Clinica Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil; §§§Research Institute for Health Sciences, Chiang Mai, Thailand; kkkDepartment of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD; and Division of Infectious Diseases, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.

Background. Combination antiretroviral therapy (cART) reduces genital tract human immunodeficiency virus type 1 (HIV-1) load and reduces the risk of sexual transmission, but little is known about the efficacy of cART for decreasing genital tract viral load (GTVL) and differences in sex or HIV-1 subtype. Methods. HIV-1 RNA from blood plasma, seminal plasma, or cervical wicks was quantified at baseline and at weeks 48 and 96 after entry in a randomized clinical trial of 3 cART regimens. Results. One hundred fifty-eight men and 170 women from 7 countries were studied (men: 55% subtype B and 45% subtype C; women: 24% subtype B and 76% subtype C). Despite similar baseline CD4+ cell counts and blood plasma viral loads, women with subtype C had the highest GTVL (median, 5.1 log10 copies/mL) compared to women with subtype B and men with subtype C or B (4.0, 4.0, and 3.8 log10 copies/mL, respectively; P < .001). The proportion of participants with a GTVL below the lower limit of quantification (LLQ) at week 48 (90%) and week 96 (90%) was increased compared to baseline (16%; P < .001 at both times). Women were significantly less likely to have GTVL below the LLQ compared to men (84% vs 94% at week 48, P = .006; 84% vs 97% at week 96, P = .002), despite a more sensitive assay for seminal plasma than for cervical wicks. No difference in GTVL response across the 3 cART regimens was detected. Conclusions. The female genital tract may serve as a reservoir of persistent HIV-1 replication during cART and affect the use of cART to prevent sexual and perinatal transmission of HIV-1.

© 2016 The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. Background. Both wasting and obesity are associated with inflammation, but the extent to which body weight changes influence inflammation during human immunodeficiency virus infection is unknown. Methods. Among a random virologically suppressed participants of the Prospective Evaluation of Antiretrovirals in Resource-Limited Settings trial, inflammatory markers were measured at weeks 0, 24, and 48 after antiretroviral therapy (ART) initiation. Associations between both baseline and change in body mass index (BMI; calculated as the weight in kilograms divided by the height in meters squared) and changes in inflammation markers were assessed using random effects models. Results. Of 246 participants, 27% were overweight/obese (BMI, ≥ 25), and 8% were underweight (BMI < 18.5) at baseline. After 48 weeks, 37% were overweight/obese, and 3% were underweight. While level of many inflammatory markers decreased 48 weeks after ART initiation in the overall group, the decrease in C-reactive protein (CRP) level was smaller in overweight/obese participants (P =. 01), and the decreases in both CRP (P =. 01) and interleukin 18 (P =. 02) levels were smaller in underweight participants. Each 1-unit gain in BMI among overweight/obese participants was associated with a 0.02-log10increase in soluble CD14 level (P =. 05), while each 1-unit BMI gain among underweight participants was associated with a 9.32-mg/L decrease in CRP level (P =. 001). Conclusions. Being either overweight or underweight at ART initiation was associated with heightened systemic inflammation. While weight gain among overweight/obese persons predicted increased inflammation, weight gain among underweight persons predicted reduced inflammation.

Objectives We adapted a rapid monitoring method to South Sudan, a new nation with one of the world's highest maternal and child mortality rates, aiming to assess coverage of maternal, neonatal and child health (MNCH) services at the time of independence, and introducing a monitoring and evaluation system (M&E) for equity-sensitive tracking of progress related to Millennium Development Goals (MDG) 4 and 5 at national, state and county levels to detect local variability. Methods We conducted a national cross-sectional household survey among women from six client populations in all, but six of South Sudan's 79 counties. We used lot quality assurance sampling (LQAS) to measure coverage with diverse MNCH indicators to obtain information for national-, state- and county-level health system management decision-making. Results National coverage of MNCH services was low for all maternal and neonatal care, child immunisation, and child care indicators. However, results varied across states and counties. Central Equatoria State (CES), where the capital is located, showed the highest coverage for most indicators (e.g. ≥4 antenatal care visits range: 4.5% in Jonglei to 40.1% in CES). Urban counties often outperformed rural ones. Conclusions This adaptation of LQAS to South Sudan demonstrates how it can be used in the future as an M&E system to track progress of MDGs at national, state and county levels to detect local disparities. Overall, our data reveal a desperate need for improving MNCH service coverage in all states.

BACKGROUND Anemia is a known risk factor for clinical failure following antiretroviral therapy (ART). Notably, anemia and inflammation are interrelated, and recent studies have associated elevated C-reactive protein (CRP), an inflammation marker, with adverse human immunodeficiency virus (HIV) treatment outcomes, yet their joint effect is not known. The objective of this study was to assess prevalence and risk factors of anemia in HIV infection and to determine whether anemia and elevated CRP jointly predict clinical failure post-ART. METHODS A case-cohort study (N = 470 [236 cases, 234 controls]) was nested within a multinational randomized trial of ART efficacy (Prospective Evaluation of Antiretrovirals in Resource Limited Settings [PEARLS]). Cases were incident World Health Organization stage 3, 4, or death by 96 weeks of ART treatment (clinical failure). Multivariable logistic regression was used to determine risk factors for pre-ART (baseline) anemia (females: hemoglobin

A case-cohort study, within a multi-country trial of antiretroviral therapy (ART) efficacy (Prospective Evaluation of Antiretrovirals in Resource Limited Settings (PEARLS)), was conducted to determine if pre-ART serum selenium deficiency is independently associated with human immunodeficiency virus (HIV) disease progression after ART initiation. Cases were HIV-1 infected adults with either clinical failure (incident World Health Organization (WHO) stage 3, 4 or death by 96 weeks) or virologic failure by 24 months. Risk factors for serum selenium deficiency (&lt, 85 μg/L) pre-ART and its association with outcomes were examined. Median serum selenium concentration was 82.04 μg/L (Interquartile range (IQR): 57.28–99.89) and serum selenium deficiency was 53%, varying widely by country from 0% to 100%. In multivariable models, risk factors for serum selenium deficiency were country, previous tuberculosis, anemia, and elevated C-reactive protein. Serum selenium deficiency was not associated with either clinical failure or virologic failure in multivariable models. However, relative to people in the third quartile (74.86–95.10 μg/L) of serum selenium, we observed increased hazards (adjusted hazards ratio (HR): 3.50, 95% confidence intervals (CI): 1.30–9.42) of clinical failure but not virologic failure for people in the highest quartile. If future studies confirm this relationship of high serum selenium with increased clinical failure, a cautious approach to selenium supplementation might be needed, especially in HIV-infected populations with sufficient or unknown levels of selenium.

STUDY BACKGROUND\ud Vitamin D has wide-ranging effects on the immune system, and studies suggest that low serum vitamin D levels are associated with worse clinical outcomes in HIV. Recent studies have identified an interaction between antiretrovirals used to treat HIV and reduced serum vitamin D levels, but these studies have been done in North American and European populations.\ud \ud METHODS\ud Using a prospective cohort study design nested in a multinational clinical trial, we examined the effect of three combination antiretroviral (cART) regimens on serum vitamin D levels in 270 cART-naïve, HIV-infected adults in nine diverse countries, (Brazil, Haiti, Peru, Thailand, India, Malawi, South Africa, Zimbabwe and the United States). We evaluated the change between baseline serum vitamin D levels and vitamin D levels 24 and 48 weeks after cART initiation.\ud \ud RESULTS\ud Serum vitamin D levels decreased significantly from baseline to 24 weeks among those randomized to efavirenz/lamivudine/zidovudine (mean change: -7.94 [95% Confidence Interval (CI) -10.42, -5.54] ng/ml) and efavirenz/emtricitabine/tenofovir-DF (mean change: -6.66 [95% CI -9.40, -3.92] ng/ml) when compared to those randomized to atazanavir/emtricitabine/didanosine-EC (mean change: -2.29 [95% CI -4.83, 0.25] ng/ml). Vitamin D levels did not change significantly between week 24 and 48. Other factors that significantly affected serum vitamin D change included country (p

BACKGROUND: Libya had one of the world's largest nosocomial HIV outbreaks in the late 1990s leading to the detention of six foreign medical workers. They were released in 2007 after the Libyan Government and the European Union agreed to humanitarian cooperation that included the development of Libya's first National HIV-Strategy and the research reported in this paper. Despite the absence of sound evidence on the status and dynamics of Libya's HIV-epidemic, some officials posited that injecting drug use (IDU) was a main mode of transmission. We therefore sought to assess HIV-prevalence and related risk factors among people who inject drugs (PWID) in Tripoli. METHODS: We conducted a cross-sectional survey among 328 PWID in Tripoli using respondent-driven sampling. We collected behavioural data and blood samples for HIV, hepatitis C virus (HCV) and hepatitis B virus (HBC) testing. RESULTS: We estimate an HIV-prevalence of 87%, HCV-prevalence of 94% and HBV-prevalence of 5%. We detected IDU-related, and sexual risk factors in the context of poor access to comprehensive services for HIV-prevention and mitigation. For example, most respondents (85%) reported having shared needles. CONCLUSION: In this first bio-behavioural survey among PWID in Libya we detected one of the highest (or even the highest) levels of HIV infection worldwide in the absence of a comprehensive harm-reduction programme. There is urgent need to implement an effective National HIV-Strategy informed by the results of this research, especially because recent military events, and related socio-political disruption and migration might lead to a further expansion of the epidemic.

This study was carried out to test the hypothesis that HIV-related stigma would function as a barrier to uptake of HIV testing and that knowledge and self-efficacy would serve as facilitators. We also hypothesized that exposure to a behavior-change campaign would be associated with lower levels of stigma and higher levels of knowledge and self-efficacy. We conducted two separate cross-sectional surveys as part of the Malawi BRIDGE Project, including one at baseline in eight districts (n = 891), and another at mid-term in four districts in Malawi (n = 881). HIV-related knowledge, self-efficacy, and lack of stigma were positively associated with HIV testing. A positive association was also found between program exposure, on one hand, and knowledge, self-efficacy, and lack of stigma, on the other. These findings suggest that important psychosocial variables are linked with people’s likelihood of HIV testing, and that these variables may be influenced by behavior-change programs.\ud \ud Key words

Background\ud \ud Publications on Libya’s HIV epidemic mostly examined the victims of the tragic nosocomial HIV outbreak in the 1990s and the related dispute about the detention of foreign medical workers. The dispute resolution in 2003 included an agreement with the European Union on humanitarian cooperation and the development of Libya’s first National HIV Strategy. As part of this we conducted Libya’s first bio-behavioural survey among men having sex with men (MSM) and female sex workers (FSW).\ud \ud Methods\ud \ud Using respondent-driven sampling, we conducted a cross-sectional study to estimate the prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and related risk factors among 227 MSM and 69 FSW in Tripoli (FSW recruitment ended prematurely due to the political events in 2011).\ud \ud Results\ud \ud For MSM we estimated an HIV prevalence of 3.1%, HBV prevalence of 2.9%, and HCV prevalence of 7.3%, and for FSW an HIV prevalence of 15.7%, HBV prevalence of 0%, and HCV prevalence of 5.2%. We detected high levels of risk behaviours, poor HIV-related knowledge, high stigma and lack of prevention programmes. These results must be interpreted in the context of the political situation which prohibited reaching an ideal sample size for FSW.\ud \ud Conclusion\ud \ud There is urgent need to implement an effective National HIV Strategy informed by the results of this research. The risk of transmission within different risk groups and to the general population may be high given the recent military events that led to increased violence, migration, and the disruption of essential HIV-related services.