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Overall increases in the uptake of HIV testing in the past two decades might hide discrepancies across socioeconomic groups. We used data from population-based surveys done in sub-Saharan Africa to quantify socioeconomic inequalities in uptake of HIV testing, and to establish trends in testing uptake in the past two decades.We analysed data from 16 countries in sub-Saharan Africa where at least one Demographic and Health Survey was done before and after 2008. We assessed the country-specific and sex-specific proportions of participants who had undergone HIV testing in the previous 12 months across wealth and education groups, and quantified socioeconomic inequalities with both the relative and slope indices of inequalities. We assessed time trends in inequalities, and calculated mean results across countries with random-effects meta-analyses.We analysed data for 537 784 participants aged 15-59 years (most aged 15-49 years) from 32 surveys done between 2003 and 2016 (16 before 2008, and 16 after 2008) in Cameroon, Côte d'Ivoire, DR Congo, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Malawi, Mali, Niger, Rwanda, Sierra Leone, Tanzania, Zambia, and Zimbabwe. A higher proportion of female participants than male participants reported uptake of HIV testing in the previous 12 months in five of 16 countries in the pre-2008 surveys, and in 14 of 16 countries in the post-2008 surveys. After 2008, in the overall sample, the wealthiest female participants were 2·77 (95% CI 1·42-5·40) times more likely to report HIV testing in the previous 12 months than were the poorest female participants, whereas the richest male participants were 3·55 (1·85-6·81) times more likely to report HIV testing than in the poorest male participants. The mean absolute difference in uptake of HIV testing between the richest and poorest participants was 11·1 (95% CI 4·6-17·5) percentage points in female participants and 15·1 (9·6-20·6) in male participants. Over time (ie, when pre-2008 and post-2008 data were compared), socioeconomic inequalities in the uptake of HIV testing in the previous 12 months decreased in male and female participants, whereas absolute inequalities remained similar in female participants and increased in male participants.Although relative socioeconomic inequalities in uptake of HIV testing in sub-Saharan Africa has decreased, absolute inequalities have persisted or increased. Greater priority should be given to socioeconomic equity in assessments of HIV-testing programmes.INSERM-ANRS (France Recherche Nord and Sud Sida-HIV Hépatites).

SummaryBackgroundOverall increase in the uptake of HIV testing in the past decades may hide discrepancies across socio-economic groups. We used population-based surveys conducted in sub-Saharan Africa to quantify socio-economic inequalities in recent HIV testing uptake, together with their trends over the two past decades.MethodsWe analyzed the data from Demographic and Health Surveys in sub-Saharan African countries where at least one survey was conducted before and after 2008. Country- and gender-specific proportions of recent (FindingsWe analyzed data from 32 surveys conducted between 2003 and 2016 in 16 countries among 537,784 participants. In pre-2008 surveys, women reported higher HIV testing uptake than men in 8 out of 16 countries, and in 15 out of 16 countries in post-2008 surveys. After 2008, the wealthiest women were on average 2.77 (95% CI 1.42-5.40) times more likely to report recent testing than the poorest; and 3.55 (1.85-6.81) times in men. The averaged absolute difference in recent testing between the richest and poorest was 11.1 (4.6-17.5) percentage points in women and 15.1 (9.6-20.6) in men. Over time, relative inequalities in recent HIV testing decreased in both genders, while absolute inequalities plateaued in women and increased in men.InterpretationsThe overall increase in HIV testing uptake that was stimulated by the impetus to scale up HIV treatment in sub-Saharan Africa led to a decrease in relative inequalities, while absolute inequalities persisted. Within most countries, large inequalities still remained, both in absolute and relative scales, especially in West and Central Africa. A greater focus should be put on equity in monitoring HIV testing programs.A French version of this article is available in the Appendices [Une version française de cet article est disponible en appendice].FundingINSERM-ANRS (France Recherche Nord & Sud Sida-HIV Hépatites), grant number ANRS-12377.

Summary Background The past two decades have seen expansion of childhood vaccination programmes in low-income and middle-income countries (LMICs). We quantify the health impact of these programmes by estimating the deaths and disability-adjusted life-years (DALYs) averted by vaccination against ten pathogens in 98 LMICs between 2000 and 2030. Methods 16 independent research groups provided model-based disease burden estimates under a range of vaccination coverage scenarios for ten pathogens: hepatitis B virus, Haemophilus influenzae type B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, Streptococcus pneumoniae, rotavirus, rubella, and yellow fever. Using standardised demographic data and vaccine coverage, the impact of vaccination programmes was determined by comparing model estimates from a no-vaccination counterfactual scenario with those from a reported and projected vaccination scenario. We present deaths and DALYs averted between 2000 and 2030 by calendar year and by annual birth cohort. Findings We estimate that vaccination of the ten selected pathogens will have averted 69 million (95% credible interval 52–88) deaths between 2000 and 2030, of which 37 million (30–48) were averted between 2000 and 2019. From 2000 to 2019, this represents a 45% (36–58) reduction in deaths compared with the counterfactual scenario of no vaccination. Most of this impact is concentrated in a reduction in mortality among children younger than 5 years (57% reduction [52–66]), most notably from measles. Over the lifetime of birth cohorts born between 2000 and 2030, we predict that 120 million (93–150) deaths will be averted by vaccination, of which 58 million (39–76) are due to measles vaccination and 38 million (25–52) are due to hepatitis B vaccination. We estimate that increases in vaccine coverage and introductions of additional vaccines will result in a 72% (59–81) reduction in lifetime mortality in the 2019 birth cohort. Interpretation Increases in vaccine coverage and the introduction of new vaccines into LMICs have had a major impact in reducing mortality. These public health gains are predicted to increase in coming decades if progress in increasing coverage is sustained. Funding Gavi, the Vaccine Alliance and the Bill & Melinda Gates Foundation.

International audience

Background: The last two decades have seen substantial expansion of childhood vaccination programmes in low and middle income countries (LMICs). Here we quantify the health impact of these programmes by estimating the deaths and disability-adjusted life years (DALYs) averted by vaccination against ten pathogens in 98 LMICs between 2000 and 2030. Methods: Independent research groups provided model-based disease burden estimates under a range of vaccination coverage scenarios for ten pathogens: hepatitis B (HepB), Haemophilus influenzae type b (Hib), human papillomavirus (HPV), Japanese encephalitis (JE), measles, Neisseria meningitidis serogroup A (MenA), Streptococcus pneumoniae, rotavirus, rubella, yellow fever. Using standardized demographic data and vaccine coverage estimates for routine and supplementary immunization activities, the impact of vaccination programmes on deaths and DALYs was determined by comparing model estimates from the no vaccination counterfactual scenario with those from a default coverage scenario. We present results in two forms: deaths/DALYs averted in a particular calendar year, and in a particular annual birth cohort. Findings: We estimate that vaccination will have averted 69 (2⋅5-97⋅5% quantile range 52-88) million deaths between 2000 and 2030 across the 98 countries and ten pathogens considered, 35 (29-45) million of these between 2000-2018. From 2000-2018, this represents a 44% (36-57%) reduction in deaths due to the ten pathogens relative to the no vaccination counterfactual. Most (96% (93-97%)) of this impact is in under-five age mortality, notably from measles. Over the lifetime of birth cohorts born between 2000 and 2030, we predict that 122 (96-147) million deaths will be averted by vaccination, of which 58 (39-75) and 38 (26-52) million are due to measles and Hepatitis B vaccination, respectively. We estimate that recent increases in vaccine coverage and introductions of additional vaccines will result in a 72% (61-79%) reduction in lifetime mortality caused by these 10 pathogens in the 2018 birth cohort. Interpretation: Increases in vaccine coverage and the introduction of new vaccines into LMICs over the last two decades have had a major impact in reducing mortality. These public health gains are predicted to increase in coming decades if progress in increasing coverage is sustained. Funding Statement: VIMC is jointly funded by Gavi, the Vaccine Alliance, and the Bill & Melinda Gates Foundation (BMGF). Funding from Gavi is channelled via VIMC to the Consortium's modelling groups (VIMCfunded institutions represented in this paper: Imperial College London, London School of Hygiene & Tropical Medicine, Oxford University Clinical Research Unit, Public Health England, Johns Hopkins University, The Pennsylvania State University, Center for Disease Analysis Foundation, Kaiser Permanente Washington, University of Cambridge, University of Notre Dame, Harvard University, Conservatoire National des Arts et Metiers). Funding from BMGF was used for salaries of the Consortium secretariat (authors represented here: Professor Hallett, Professor Grassly, Dr Cucunuba, Professor Jit, Dr Xiang Li, Dr Mukandavire, Ms Woodruff, Professor Ferguson, Dr Garske); and channelled via VIMC for travel and subsistence costs of all Consortium members (all authors). In addition, the following funding declarations are noted: Dr Eilertson and Dr Ferrari report grants from BMGF, outside the submitted work. Mr Gamkrelidze, Dr Razavi and Mr Razavi-Shearer report grants from John C Martin Foundation during the conduct of the study; and grants from AbbVie, Gilead, Intercept, Pan American Health Organization, and Association of State and Territorial Health Officials outside the submitted work; all three authors are employees of the Center for Disease Analysis Foundation which had no role in study design, data collection and analysis, interpretation of data, or preparation of the manuscript. Dr Gaythorpe reports personal fees from Wellcome Genome Campus advanced courses and scientific conferences, and grants from MRC during the conduct of the study. Dr Hallett reports grants and personal fees from WHO, Pharos, Avenhir Health, outside the submitted work. Dr Nayagam reports Consultancy work for WHO and Pharos Global Health Advisors, and acknowledges support from NIHR Imperial Biomedical Research Centre (BRC). Dr Trotter reports personal fees from GSK, outside the submitted work. Professor Hallett, Dr Nayagam, Dr Garske, Dr Gaythorpe, Dr Hinsley, Dr Jean, and Professor Ferguson acknowledge joint Centre funding from the UK Medical Research Council and Department for International Development (MR/R015600/1). Development of LSHTM's models for HPV, measles, PCV, Hib and rotavirus was funded by WHO, Gavi and BMGF under several grants, past and current. BMGF supported the development and maintenance of the Lives Saved Tool. Dr Resch and Mr Sy acknowledge other funding from BMGF not related to this work and with no influence on the manuscript or the decision to submit it for publication. Declaration of Interests: This publication is authored by members of the Vaccine Impact Modelling Consortium (VIMC, www.vaccineimpact.org). VIMC is jointly funded by Gavi, the Vaccine Alliance, and by the Bill & Melinda Gates Foundation. The views expressed are those of the authors and not necessarily those of the Consortium or its funders. The funders were given the opportunity to review this paper prior to publication, but the final decision on the content of the publication was taken by the authors. Consortium members received funding from Gavi and BMGF via VIMC during the course of the study (see funding statement above). In addition, the following potential conflicts of interest were disclosed: Dr Eilertson and Dr Ferrari report grants from Bill and Melinda Gates Foundation, outside the submitted work. Dr Gamkrelidze, Dr Razavi and Dr Razavi-Shearer report grants from John C Martin Foundation during the conduct of the study; and grants from AbbVie, Gilead, Intercept, Pan American Health Organization, and Association of State and Territorial Health Officials outside the submitted work. Dr Gaythorpe reports personal fees from Wellcome Genome Campus advanced courses and scientific conferences, and grants from MRC during the conduct of the study. Dr Hallett reports grants and personal fees from WHO, Pharos, Avenhir Health, outside the submitted work. Dr Nayagam reports Consultancy work for WHO and Pharos Global Health Advisors. Dr Trotter reports personal fees from GSK, outside the submitted work. Professor Ferguson reports grants from UK Medical Research Council during the conduct of the study, and grants from NIH NIGMS, UK National Institute of Health Research, Janssen Pharmaceuticals, outside the submitted work. Dr Garske reports grants from Janssen Pharmaceuticals, outside the submitted work. Ethical Approval Statement: Not required.

Recent yellow fever (YF) outbreaks have highlighted the increasing global risk of urban spread of the disease. In context of recurrent vaccine shortages, preventive vaccination activities require accurate estimates of existing population-level immunity. We present POLICI (POpulation-Level Immunization Coverage - Imperial), an interactive online tool for visualising and extracting YF vaccination coverage estimates in Africa. We calculated single year age-disaggregated sub-national population-level vaccination coverage for 1950-2050 across the African endemic zone by collating vaccination information and inputting it into a demographic model. This was then implemented on an open interactive web platform. POLICI interactively displays age-disaggregated, population-level vaccination coverages at the first subnational administrative level, through numerous downloadable and customisable visualisations. POLICI is available at https://polici.shinyapps.io/yellow_fever_africa/. POLICI offers an accessible platform for relevant stakeholders in global health to access and explore vaccination coverages. These estimates have already been used to inform the WHO strategy to Eliminate Yellow fever Epidemics (EYE).

Background Yellow fever virus (YFV) is a vector-borne flavivirus endemic to Africa and Latin America. Ninety per cent of the global burden occurs in Africa where it is primarily transmitted by Aedes spp, with Aedes aegypti the main vector for urban yellow fever (YF). Mosquito life cycle and viral replication in the mosquito are heavily dependent on climate, particularly temperature and rainfall. We aimed to assess whether seasonal variations in climatic factors are associated with the seasonality of YF reports. Methodology/Principal findings We constructed a temperature suitability index for YFV transmission, capturing the temperature dependence of mosquito behaviour and viral replication within the mosquito. We then fitted a series of multilevel logistic regression models to a dataset of YF reports across Africa, considering location and seasonality of occurrence for seasonal models, against the temperature suitability index, rainfall and the Enhanced Vegetation Index (EVI) as covariates alongside further demographic indicators. Model fit was assessed by the Area Under the Curve (AUC), and models were ranked by Akaike’s Information Criterion which was used to weight model outputs to create combined model predictions. The seasonal model accurately captured both the geographic and temporal heterogeneities in YF transmission (AUC = 0.81), and did not perform significantly worse than the annual model which only captured the geographic distribution. The interaction between temperature suitability and rainfall accounted for much of the occurrence of YF, which offers a statistical explanation for the spatio-temporal variability in transmission. Conclusions/Significance The description of seasonality offers an explanation for heterogeneities in the West-East YF burden across Africa. Annual climatic variables may indicate a transmission suitability not always reflected in seasonal interactions. This finding, in conjunction with forecasted data, could highlight areas of increased transmission and provide insights into the occurrence of large outbreaks, such as those seen in Angola, the Democratic Republic of the Congo and Brazil., Author summary In this article, we describe the development of a model to quantify the seasonal dynamics of yellow fever virus (YFV) transmission across Africa. YFV is a flavivirus transmitted, within Africa, primarily by Aedes spp where it causes an estimated 78,000 deaths a year despite the presence of a safe and effective vaccine. The importance of sufficient vaccination, made difficult by a global shortage, has been highlighted by recent large scale, devastating, outbreaks in Angola, the Democratic Republic of the Congo and Brazil. Here we describe a novel way of parameterising the effect of temperature on YFV transmission and implement statistical models to predict both the geographic and temporal heterogeneities in transmissions, while demonstrating their robustness in comparison to models simply predicting geographic distribution. We believe this quantification of seasonality could lead to more precise applications of vaccination campaigns and vector-control programmes. In turn this would help maximise their impact, especially vital with limited resources, and could contribute to lessening the risk of large scale outbreaks. Not only this, but the methods described here could be applied to other Aedes-borne diseases and as such provide a useful tool in understanding, and combatting, several other important diseases such as dengue and zika.

With social policies increasingly directed toward enhancing equity through health programs, it is important that methods for estimating the health and economic benefits of these programs by subpopulation be developed, to assess both equity concerns and the programs' total impact. We estimated the differential health impact (measured as the number of deaths averted) and household economic impact (measured as the number of cases of medical impoverishment averted) of ten antigens and their corresponding vaccines across income quintiles for forty-one low- and middle-income countries. Our analysis indicated that benefits across these vaccines would accrue predominantly in the lowest income quintiles. Policy makers should be informed about the large health and economic distributional impact that vaccines could have, and they should view vaccination policies as potentially important channels for improving health equity. Our results provide insight into the distribution of vaccine-preventable diseases and the health benefits associated with their prevention.

Aim Our understanding of the ecology and biogeography of microbes, including those that cause human disease, lags behind that for larger species. Despite recent focus on the geographical distribution of viruses and bacteria, the overall environmental distribution of human pathogens and parasites on Earth remains incompletely understood. As islands have long inspired basic ecological insights, we aimed to assess whether the microorganisms that cause human disease in modern times follow patterns common to insular plants and animals. Location Global and regional. Methods Relying on the publically accessible GIDEON database, we use the spatial distribution of nearly 300 human parasites and pathogens across 66 island countries and territories to assess the current predictive value of the 'equilibrium theory' of island biogeography. The relationships between species richness and (1) island surface area and (2) distance to the nearest mainland were investigated with linear regression, and ANCOVAs were used to test for differences in these relationships with respect to pathogen ecology and taxonomy. Results Pathogen species richness increases with island surface area and decreases with distance to the nearest mainland. The effect of area is more than 10 times lower than that usually reported for macroorganisms, but is greater than the effect of distance. The strongest relationships are for pathogens that are vector-borne, zoonotic (with humans as dead-end hosts) or protozoan. Main conclusion Our results support the basic predictions of the theory: disease diversity is a positive function of island area and a negative function of island isolation. However, differences in the effects of area, distance and pathogen ecology suggest that globalization, probably through human travel and the animal trade, has softened these relationships. Parasites that primarily target non-human species, whose distributions are more constrained by island life than are those restricted to human hosts, drive the island biogeography of human disease.

International audience; Whether risk compensation could offset the preventive effect of early initiation of antiretroviral therapy (ART) on human immunodeficiency virus (HIV) transmission remains unknown. Using virological and behavioral data collected 12 months after inclusion in the TEMPRANO randomized trial of early ART (Abidjan, Côte d'Ivoire, 2009–2012), we estimated the risk of HIV transmission and compared it between the intervention (early ART; n = 490) and control (deferred ART; n = 467) groups. We then simulated increases in various sexual risk behaviors in the intervention group and estimated the resulting preventive effect. On the basis of reported values of sexual behaviors, we estimated that early ART had an 89% (95% confidence interval: 81, 95) preventive effect on the cumulative risk of HIV transmission over a 1-month period. This preventive effect remained significant for a wide range of parameter combinations and was offset (i.e., nonsignificant) only for dramatic increases in different sexual behaviors simulated simultaneously. For example, when considering a 2-fold increase in serodiscordance and the frequency of sexual intercourse together with a 33% decrease in condom use, the resulting preventive effect was 47% (95% confidence interval: −3, 74). An important reduction of HIV transmission may thus be expected from the scale-up of early ART, even in the context of behavioral change.

In 2012, 7 years after the introduction of antiretroviral treatment (ART) in the South African township of Orange Farm, we measured the proportion of HIV-positive people who were virally suppressed, especially among high-risk groups (women 18-29 years and men 25-34 years).A community-based cross-sectional representative survey was conducted among 3293 men and 3473 women.Study procedures included a face-to-face interview and collection of blood samples that were tested for HIV, 11 antiretroviral drugs and HIV-viral load.HIV prevalence was 17.0% [95% confidence interval: 15.7-18.3%] among men and 30.1% [28.5-31.6%] among women. Overall, 59.1% [57.4-60.8%] of men and 79.5% [78.2-80.9%] of women had previously been tested for HIV. When controlling for age, circumcised men were more likely to have been tested compared with uncircumcised men (66.1 vs 53.6%; P 0.001). Among HIV+, 21.0% [17.7-24.6%] of men and 30.5% [27.7-33.3%] of women tested positive for one or more antiretroviral drugs. Using basic calculations, we estimated that, between 2005 and 2012, ART programs prevented between 46 and 63% of AIDS-related deaths in the community. Among antiretroviral-positive, 91.9% [88.7-94.3%] had viral suppression (viral load400 copies/ml). The proportion of viral suppression among HIV+ was 27.0% [24.3-29.9%] among women and 17.5% [14.4-20.9%] among men. These proportions were lower among the high-risk groups: 15.6% [12.1-19.7%] among women and 8.4% [5.0-13.1%] among men.In Orange Farm, between 2005 and 2012, ART programs were suboptimal and, among those living with HIV, the proportion with viral suppression was still low, especially among the young age groups. However, our study showed that, in reality, antiretroviral drugs are highly effective in viral suppression at an individual level.

Based on social indicators collected within the TEMPRANO-ANRS12136 trial, we assessed the social consequences of early antiretroviral therapy (ART) initiation in west Africa. We did not observe any significant differences in the levels or the time trends of various social indicators, including union status, HIV disclosure and HIV-related discrimination, between early and deferred ART initiation. Early ART does not carry detectable adverse social consequences that could impair its clinical and preventive benefits.

To evaluate the implication of WHO guidelines for serodiscordant couples, we interviewed HIV-infected adults on their partner's serostatus. We found that 12% with more than 500 CD4(+) R cells/mu l should be recommended antiretroviral treatment (ART) because their partner was seronegative; 24% could be recommended not to start ART because their partner was seropositive; and 64% could not be given any recommendation regarding ART early initiation because they had either no stable partnership (30%) or were in a stable partnership with a partner whose status they were not aware of (34%).

Introduction Viral hepatitis B and C display high morbidity and mortality among migrants born in Southeast Asia and living in France whereas prevalence in French general population is low (0.3–0.8%). Moreover, access to screening tests for HIV and viral hepatitis B and C remain unknown in this population. Methods This prospective, multicenter and observational study was conducted at a free clinic (“Association DHEVA-KH”, Lyon, France) among Southeast Asian community associations. The study period has started in April 2016 and inclusions remain ongoing in February 2018. Participants were screened during each community event where people were able to be tested for HIV, HBV, and HCV by point-of-care rapid testing. The main study endpoints were the proportion of participants who were infected by HIV, HBV, and HCV status and who were linked to care when testing positive. This study was approved by local Committee on Ethics as usual practices. Results A total of 199 individuals, representing Southeast Asian immigrants, were included and all participants performed a blood draw for viral hepatitis B and C and 186 for HIV (93.4%). Mean age was 55.6 ± 14 years-old. One hundred twenty-four were women (62.3%). All patients retrieved their tests results; 170 of 199 (85.4%) patients tested prefered point-of-care rapid testing rather than classical serology tests. Only 20 people among 199 were previously tested for HIV or viral hepatitis B or C. Nine of the 199 (4.5%) participants testing positive [HIV, n = 0; HBV, n = 6 (3.0%); HCV, n = 3 (1.5%)]. Mean age was 60.8 ± 12.6 years-old. Seven infected people were women. Six were pensioners. Only one infected patient was covered by usual social security system. All infected patients were born in Southeast Asia. Seven of 9 testing positive participants have been able to consult medical staff later at hospital to be followed for their viral hepatitis. Conclusion In a Southeast Asian highly at-risk population for chronic viral infections, the simultaneous use of HIV, HBV, and HCV point-of-care tests clearly improves the screening and the access to care for HBV and HCV positive patients. Migrants from Southeast Asia display a higher prevalence for viral hepatitis rather than French general population. Nonetheless, the prevalence of people living with HIV remains low even null in our sample population among Southeast Asian community living in Lyon city.

Introduction Recent yellow fever (YF) outbreaks in Africa, such as 2016 in Angola, or 2017 in Nigeria, have demonstrated the ongoing threat of large-scale urban YF outbreaks. Moreover, outbreaks of other mosquito-borne diseases (Zika, chikungunya) have increased awareness of the potential for rapid, international spread of arboviruses. Swift outbreak response, for YF primarily in the form of vaccination, is therefore essential to prevent local and international spread. However, limited global stockpiles means that the prioritization of geographic areas for pre-emptive vaccination campaigns is required (i.e. vaccination campaigns targeting areas that are at risk of disease introduction and spread but as yet unaffected). Conducting a rapid prioritization assessment based on the risk of disease spread is thus highly valuable to inform decisions on vaccination activities in a context of emergency. Objective To develop a method for rapid risk assessment of YF spread to prioritize sub-national administrative units (hereafter called province) for pre-emptive campaigns. Specific requirements for this method are: –speed of implementation in the context of emergency response; –transparent methodology to allow discussions with and feedback from decision-makers. Method We developed a heuristic method to quantify the risk of YF spread by integrating multiple data streams: population sizes, estimates of existing vaccine-induced population-level immunity, recent incidence of yellow fever cases in the province and travel flows between provinces. The resulting risk score primarily reflects the expected absolute number of yellow cases in the respective province, accounting for local cases and the risk of case importation. Based on their risk score, provinces are ranked according to priority for vaccination and target population sizes are estimated. This baseline, quick-to-compute, risk assessment can be refined by integrating additional elements. For example, the presence and population size of large urban centres at the province level may be relevant to characterize the risk of urban outbreaks, and of international spread in the case of highly connected urban centres. Similarly, independent estimates of the local transmission potential of the disease produced by a mathematical model can be combined into this risk metric. Results This heuristic method has been used in collaboration with the World Health Organization in the context of urgent response to yellow fever outbreaks that affected Angola and the Democratic Republic of Congo (DRC) in 2016 and Nigeria in 2017. Results were provided in a form that allowed decision-makers to easily and interactively adjust the relative weights of different factors and visualize the effect on the results. Moreover, the transparency of the method allowed decision-makers to provide feedback and to request the integration of additional elements considered as relevant for outbreak control (for instance: trans-border movements in Angola-DRC). This risk assessment contributed to inform decision for mass vaccination campaigns conducted in the DRC in 2017 and for campaigns (still under consideration) in Nigeria in 2018. Conclusion By integrating different, mostly publicly available, data streams, we developed a risk assessment method that can be quickly implemented in the context of yellow fever outbreak response. The transparency and flexibility of the method enhanced interactions with decision-makers to refine estimates.

BACKGROUND: The effect of early initiation of antiretroviral therapy (ART; ie, at CD4(+) T-cell counts >350 cells/mm(3)) on sexual behaviors and human immunodeficiency virus type 1 (HIV) transmission risk has not been documented in populations other than HIV-serodiscordant couples in stable relationships. METHODS: On the basis of data from a behavioral study nested in a randomized, controlled trial (Temprano-ANRS12136) of early ART, we compared proportions of risky sex (ie, unprotected sex with a partner of negative/unknown HIV status) reported 12 months after inclusion between participants randomly assigned to initiate ART immediately (hereafter, "early ART") or according to ongoing World Health Organization criteria. Group-specific HIV transmission rates were estimated on the basis of sexual behaviors and viral load-specific per-act HIV transmission probabilities. The ratio of transmission rates was computed to estimate the protective effect of early ART. RESULTS: Among 957 participants (baseline median CD4(+) T-cell count, 478 cells/mm(3)), 46.0% reported sexual activity in the past month; of these 46.0%, sexual activity for 41.5% involved noncohabiting partners. The proportion of subjects who engaged in risky sex was 10.0% in the early ART group, compared with 12.8% in the standard ART group (P = .17). After accounting for sexual behaviors and viral load, we estimated that the protective effect of early ART was 90% (95% confidence interval, 81%-95%). CONCLUSION: Twelve months after inclusion, patients in the early and standard ART groups reported similar sexual behaviors. Early ART decreased the estimated risk of HIV transmission by 90%, suggesting a major prevention benefit among seronegative sex partners in stable or casual relationships with seropositive individuals.

Introduction : Whether early antiretroviral therapy (ART) initiation could impact sexual risk behaviours remains to be documented. We aimed to investigate changes in sexual behaviours within the 24 months following an early versus standard ART initiation in HIV-positive adults with high CD4 counts. Methods : We used data from a prospective behavioural study nested in a randomized controlled trial of early ART (Temprano-ANRS12136). Time trends in sexual behaviours from enrolment in the trial (M0) to 12-month (M12) and 24-month (M24) visits were measured and compared, using Generalized Estimating Equations models, between participants randomly assigned either to initiate ART immediately (early ART) or to defer ART initiation until on-going WHO starting criteria are met (standard ART). Indicators of sexual behaviours included 1) sexual activity in the past year, 2) multiple partnership in the past year, 3) unprotected sex at last intercourse and 4) risky sex (i.e. unprotected sex with a partner of HIV negative/unknown status) at last intercourse. Results : Analyses included 1952 participants (975 with early ART and 977 with standard ART; overall median baseline CD4 count: 469/mm 3 ). Among participants with early ART, significant decreases were found between M0 and M24 in sexual activity (Odds Ratio [OR] 0.72, 95% Confidence Interval [95% CI] 0.57–0.92), multiple partnership (OR 0.57, 95% CI 0.41–0.79), unprotected sex (OR 0.59, 95% CI 0.47–0.75) and risky sex (OR 0.58, 95% CI 0.45–0.76). Among participants with standard ART, sexual behaviours showed similar trends over time. These decreases mostly occurred within the 12 months following enrolment in the trial in both groups and prior to ART initiation in participants with standard ART. For unprotected sex and risky sex, decreases were or tended to be more pronounced among patients reporting that their last sexual partner was non-cohabiting. Conclusions : In these sub-Saharan adults with high CD4 counts, entry into HIV care, rather than ART initiation, resulted in decreased sexual activity and risky sexual behaviours. We did not observe any evidence of a risk compensation phenomenon associated with early ART initiation. These results illustrate the potential behavioural preventive effect of early entry into care, which goes hand in hand with early ART initiation. Keywords: HIV; AIDS; antiretroviral treatment; sexual behaviours; early ART initiation; HIV prevention; sub-Saharan Africa. To access the supplementary material to this article please see Supplementary Files in the column to the right (under Article Tools) (Published: 30 June 2014) Citation: Jean K et al. Journal of the International AIDS Society 2014, 17 :18977 http://www.jiasociety.org/index.php/jias/article/view/18977 | http://dx.doi.org/10.7448/IAS.17.1.18977

In response to the COVID-19 epidemic, Egypt established a unique care model based on quarantine hospitals where only externally-referred confirmed COVID-19 patients were admitted, and healthcare workers resided continuously over 1-to 2-week working shifts. While the COVID-19 risk for HCWs has been widely reported in standard healthcare settings, it has not been evaluated yet in quarantine hospitals.Here, we relied on longitudinal data, including results of routine RT-PCR tests, collected within three quarantine hospitals located in Cairo and Fayoum, Egypt. Using a model-based approach that accounts for the time-since-exposure variation in false-negative rates of RT-PCR tests, we computed the incidence of SARS-CoV-2 infection among HCWs. Over a total follow-up of 6,064 person-days (PD), we estimated an incidence rate (per 100 PD) of 1.05 (95% CrI: 0.58–1.65) at Hospital 1, 1.92 (95% CrI: 0.93–3.28) at Hospital 2 and 7.62 (95% CrI: 3.47–13.70) at Hospital 3. The probability for an HCW to be infected at the end of a shift was 13.7% (95% CrI: 7.8%–20.8%) and 23.8% (95% CrI: 12.2%–37.3%) for a 2-week shift at Hospital 1 and Hospital 2, respectively, which lies within the range of risk levels previously documented in standard healthcare settings, whereas it was >3-fold higher for a 7-day shift at Hospital 2 (42.6%, 95%CrI: 21.9%–64.4%). Our model-based estimates unveil a proportion of undiagnosed infections among HCWs of 46.4% (95% CrI: 18.8%–66.7%), 45.0% (95% CrI: 5.6%–70.8%) and 59.2% (95% CrI: 34.8%–78.8%), for Hospitals 1 to 3, respectively.The large variation in SARS-CoV-2 incidence we document here suggests that HCWs from quarantine hospitals may face a high occupational risk of infection, but that, with sufficient anticipation and infection control measures, this risk can be brought down to levels similar to those observed in standard healthcare settings.WHAT THIS PAPER ADDSWhat is already known on this topicPrevious studies conducted in standard care settings have documented that frontline healthcare workers (HCWs) face high risk of COVID-19. Whether risk levels differ in alternative care models, such as COVID-19 quarantine hospitals in Egypt where HCWs resided in the hospital days and nights for various durations, is unknown.What this study addsCOVID-19 risk for HCWs in quarantine hospitals varies substantially between facilities, from risk levels that are in the range of those documented in standard healthcare settings to levels that were approximatively 3 times higher.How this study might affect research, practice or policyWith sufficient anticipation and infection control measures, occupational COVID-19 risk for HCWs working in quarantine hospitals can be brought down to levels similar to those observed in standard healthcare settings.