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: Introduction: Population‐level data on durable HIV viral load suppression (VLS) following the implementation of Universal Test and Treat (UTT) in Africa are limited. We assessed trends in durable VLS and viraemia among persons living with HIV in 40 Ugandan communities during the UTT scale‐up. Methods: In 2015–2020, we measured VLS ( Results: Overall, 3080 participants contributed 4604 visit‐pairs over three survey rounds. Most visit‐pairs (72.4%) exhibited durable VLS, with few (2.5%) experiencing viral rebound. Among those with any viraemia at the initial visit (23.5%, n = 1083), 46.9% remained viraemic through follow‐up, 91.3% of which was high‐level viraemia. One‐fifth (20.8%) of visit‐pairs exhibiting persistent high‐level viraemia self‐reported antiretroviral therapy (ART) use for ≥12 months. Prevalence of persistent high‐level viraemia varied substantially across communities and was significantly elevated among young persons aged 15–29 years (vs. 40‐ to 49‐year‐olds; adjusted risk ratio [adjRR] = 2.96; 95% confidence interval [95% CI]: 2.21–3.96), males (vs. females; adjRR = 2.40, 95% CI: 1.87–3.07), persons reporting inconsistent condom use with non‐marital/casual partners (vs. persons with marital/permanent partners only; adjRR = 1.38, 95% CI: 1.10–1.74) and persons reporting hazardous alcohol use (adjRR = 1.09, 95% CI: 1.03–1.16). The prevalence of persistent high‐level viraemia was highest among males Conclusions: Following universal ART provision, most persons living with HIV in south‐central Uganda are durably suppressed. Among persons exhibiting any viraemia, nearly half exhibited high‐level viraemia for ≥12 months and reported higher‐risk behaviours associated with onward HIV transmission. Intensified efforts linking individuals to HIV treatment services could accelerate momentum towards HIV epidemic control., INTRODUCTION Universal Test and Treat (UTT) signalled a global paradigm shift in HIV control efforts through expanded antiretroviral therapy (ART) eligibility. Randomized trials in sub‐Saharan Africa demonstrated population‐level benefits of [...]

: Introduction: As they age, people living with HIV (PLWH) must face new challenges, such as accelerated ageing and higher rates of comorbidities. This study described the characteristics of HIV acquisition among treatment‐naïve PLWH aged ≥50 years and Methods: In this cross‐sectional study, differences in HIV‐related and non‐HIV‐related characteristics were compared using the t‐test, Mann−Whitney U test and chi‐square test. Temporal trend data were analysed via joinpoint regression. A multivariate logistic regression model was conducted to analyse the associated factors with PLWH having one or more comorbidities. Results: The proportion of PLWH aged ≥50 years has significantly increased since 2013, with a corresponding increase in homosexual transmission in this age group over the past decade. The proportion of individuals with CD4 counts Conclusions: Due to the persistent burden of HIV‐related characteristics or symptoms and the increasing prevalence of coexisting comorbidities among treatment‐naïve PLWH aged ≥50 years, physicians should provide the highest‐quality screening, prevention, treatment and management of coexisting comorbidities, adopting a multidisciplinary approach., INTRODUCTION Antiretroviral therapy (ART) has transformed human immunodeficiency virus (HIV) from a uniformly fatal to a chronic condition [1]. However, people living with HIV (PLWH) still have shorter life expectancies [...]

: Introduction: Eastern Europe is facing major HIV and hepatitis C (HCV) epidemics, with many people living with HIV (PLHIV) and HIV/HCV coinfection living in Ukraine. Despite the previous progress towards care quality improvement, the ongoing war in Ukraine is disrupting HIV and HCV care. Methods: We described an HIV cascade of care (CoC) in PLHIV from two clinical sites and an HCV CoC for anti‐HCV‐positive PLHIV from six sites in Ukraine, enrolled in the CARE cohort between 1 January 2019 and 1 June 2020. The cross‐sectional HIV CoC and HCV CoC are described at study enrolment. Results: Of 1028 PLHIV, 1014 (98.6%, 95% confidence interval [CI] 97.7–99.3) were on antiretroviral therapy (ART), and 876 (86.4% of those on ART, 95% CI 84.1–88.4) were virologically suppressed. Of 894 participants on ART >6 months, 90.8% (95% CI 88.7–92.6) were virologically suppressed (HIV‐RNA Conclusions: Over 98% of PLHIV in care in both CARE sites in Ukraine were receiving ART, and the target of 90% virally suppressed was achieved in persons >6 months on ART. Only one of six HIV/HCV study sites tested over 50% anti‐HCV‐positive PLHIV for HCV‐RNA and treated over 25% of eligible persons. While free HCV‐RNA testing and DAA treatment are paramount to achieving HCV elimination targets, they remained a challenge in Ukraine in 2019–2020. The extent of the HIV and HCV care disruption during the war will be further assessed in the CARE cohort and compared with the pre‐war findings., INTRODUCTION Ukraine, a country with the second‐largest HIV epidemic in Eastern Europe, was home to an estimated 260,000 people living with HIV (PLHIV) in 2021 [1], of whom, 150,005 were [...]

: Introduction: While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network. Methods: The “Home‐Based Intervention to Test and Start” (HITS) was a 2×2 factorial community‐randomized controlled trial in Umkhanyakude, KwaZulu‐Natal, South Africa, embedded in the Africa Health Research Institute's population‐based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro‐incentive and a male‐targeted HIV‐specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro‐incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co‐residents, a socio‐centric family network was constructed among HITS‐eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level. Results: Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3−7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9−22.3). The difference in efficacy was statistically significant (21.1–6.5 = 14.6%; 95% CI: 9.3−19.9). Conclusions: Micro‐incentives appear to have synergistic effects when distributed within family networks. These effects support family network‐based approaches for the design of health interventions., INTRODUCTION Though family relationships crucially determine health and wellbeing, their role in shaping the uptake of individual health interventions is not well‐understood. Using family network data from a large population‐based [...]

ORAL ABSTRACT Resident microbiota enhance HIV acquisition, replication and pathogenesis in vivo A. Wahl[sup.1] , W. Yao[sup.1] , B. Liao[sup.1] , M. Chateau[sup.1] , C. Richardson[sup.1] , L. Ling[sup.1] , [...]

The HIV field has been a champion in progressing global thought, action and capacity‐building towards models of healthcare that centre the lived experience, needs and preferences of affected individuals and [...]

: Introduction: Australia has set the goal for the virtual elimination of HIV transmission by the end of 2022, yet accurate information is lacking on the level of HIV transmission occurring among residents. We developed a method for estimating the timing of HIV acquisition among migrants, relative to their arrival in Australia. We then applied this method to surveillance data from the Australian National HIV Registry with the aim of ascertaining the level of HIV transmission among migrants to Australia occurring before and after migration, and to inform appropriate local public health interventions. Methods: We developed an algorithm incorporating CD4[sup.+] T‐cell decline back‐projection and enhanced variables (clinical presentation, past HIV testing history and clinician estimate of the place of HIV acquisition) and compared it to a standard algorithm which uses CD4[sup.+] T‐cell back‐projection only. We applied both algorithms to all new HIV diagnoses among migrants to estimate whether HIV infection occurred before or after arrival in Australia. Results: Between 1 January 2016 and 31 December 2020, 1909 migrants were newly diagnosed with HIV in Australia, 85% were men, and the median age was 33 years. Using the enhanced algorithm, 932 (49%) were estimated to have acquired HIV after arrival in Australia, 629 (33%) before arrival (from overseas), 250 (13%) close to arrival and 98 (5%) were unable to be classified. Using the standard algorithm, 622 (33%) were estimated to have acquired HIV in Australia, 472 (25%) before arrival, 321 (17%) close to arrival and 494 (26%) were unable to be classified. Conclusions: Using our algorithm, close to half of migrants diagnosed with HIV were estimated to have acquired HIV after arrival in Australia, highlighting the need for tailored culturally appropriate testing and prevention programmes to limit HIV transmission and achieve elimination targets. Our method reduced the proportion of HIV cases unable to be classified and can be adopted in other countries with similar HIV surveillance protocols, to inform epidemiology and elimination efforts., INTRODUCTION UNAIDS has set the ambitious target to eliminate the global transmission of HIV by 2030 [1] and Australia is aiming for “virtual elimination” by the end of 2022 [2]. [...]

: Introduction: While a large proportion of people with HIV (PWH) have experienced SARS‐CoV‐2 infections, there is uncertainty about the role of HIV disease severity on COVID‐19 outcomes, especially in lower‐income settings. We studied the association of mortality with characteristics of HIV severity and management, and vaccination, among adult PWH. Methods: We analysed observational cohort data on all PWH aged ≥15 years experiencing a diagnosed SARS‐CoV‐2 infection (until March 2022), who accessed public sector healthcare in the Western Cape province of South Africa. Logistic regression was used to study the association of mortality with evidence of antiretroviral therapy (ART) collection, time since first HIV evidence, CD4 cell count, viral load (among those with evidence of ART collection) and COVID‐19 vaccination, adjusting for demographic characteristics, comorbidities, admission pressure, location and time period. Results: Mortality occurred in 5.7% (95% CI: 5.3,6.0) of 17,831 first‐diagnosed infections. Higher mortality was associated with lower recent CD4, no evidence of ART collection, high or unknown recent viral load and recent first HIV evidence, differentially by age. Vaccination was protective. The burden of comorbidities was high, and tuberculosis (especially more recent episodes of tuberculosis), chronic kidney disease, diabetes and hypertension were associated with higher mortality, more strongly in younger adults. Conclusions: Mortality was strongly associated with suboptimal HIV control, and the prevalence of these risk factors increased in later COVID‐19 waves. It remains a public health priority to ensure PWH are on suppressive ART and vaccinated, and manage any disruptions in care that occurred during the pandemic. The diagnosis and management of comorbidities, including for tuberculosis, should be optimized., INTRODUCTION Three years have passed since the COVID‐19 pandemic began. A large proportion of people with HIV (PWH) have experienced SARS‐CoV‐2 infections, and this population appears to have a modestly [...]

PE11.01 Rates of undiagnosed HIV infection among racial/ethnic subgroups in a large nationwide cohort study of sexual minority men in the U.S.: Evidence for reframing from disparities to inequities H.J. [...]

: Introduction: Multiple studies have demonstrated elevated incidence and prevalence of HIV among transgender women; however, few studies have been conducted among transmasculine individuals. HIV prevalence among transgender men in the United States is estimated to be 0–4%; however, there have not been any US studies examining HIV prevalence that stratify by the gender of sexual partners. The aim of this research was to examine HIV prevalence and its association with socio‐demographic and other factors, including the gender of sexual partners and receipt of gender‐affirming care (hormones/surgery), among transmasculine individuals at the Callen‐Lorde Community Health Center in New York City. Methods: The Transgender Data Project was an Institutional Review Board‐approved retrospective chart review of all transgender and gender diverse clients at the clinic, ages 18+, between 1 January 2009 and 12 December 2010. Charts were reviewed manually. Data included birth sex, gender, race/ethnicity, education, employment, housing, insurance status, gender of sexual partners, HIV screening and status, and receipt of gender‐affirming care. Bivariate and multivariable logistic regression models were used to assess the association between HIV status and other variables. Results and discussion: Five hundred and seventy‐seven transmasculine individuals, mean age 32.1 years (18.3–70.5), were included in this analysis. A small majority were White (55% White, 13.9% Black and 11.7% Hispanic). The majority, 78.9%, had received hormones (testosterone) and 41.6% had received at least one gender‐affirming surgery. The HIV screening rate was 43.4%. HIV prevalence was 2.8%, (95% CI: 1.13%, 5.68%) among those screened, notably higher than the US population prevalence. HIV prevalence was highest among transmasculine individuals who had sex exclusively with cisgender men (11.1%). In the multivariable model (age, education and gender of sexual partners), the adjusted odds ratio of HIV for those who had sex exclusively with cisgender male partners compared to no cisgender male partners was 10.58 (95% CI: 1.33, 84.17). Conclusions: Although HIV prevalence has been estimated to be low among transgender men, the analysis found heterogeneous results when stratified by gender of sexual partners. The results underscore the need to understand sexual risk among transmasculine individuals and to disaggregate HIV data for those having sex with cisgender men, thus also allowing for better inclusion in HIV prevention efforts., INTRODUCTION There are an estimated 1 million transgender adults in the United States [1] who are heterogeneous in terms of age, race, ethnicity, socio‐economic status, gender and sexual orientation identities [...]

: Introduction: Differentiated service delivery (DSD) models for HIV are a person‐centred approach to providing services across the HIV care cascade; DSD has an increasing policy and implementation support in high‐burden HIV countries. The life‐course approach to DSD for HIV treatment has focused on earlier life phases, childhood and adolescence, families, and supporting sexual and reproductive health during childbearing years. Older adults, defined as those over the age of 50, represent a growing proportion of HIV treatment cohorts with approximately 20% of those supported by PEPFAR in this age band and have specific health needs that differ from younger populations. Despite this, DSD models have not been designed or implemented to address the health needs of older adults. Discussion: Older adults living with HIV are more likely to have significant co‐morbid medical conditions. In addition to the commonly discussed co‐morbidities of hypertension and diabetes, they are at increased risk of cognitive impairment, frailty and mental health conditions. Age and HIV‐related cognitive impairment may necessitate the development of adapted educational materials. Identifying the optimal package of differentiated services to this population, including the frequency of clinical visits, types and location of services is important as is capacitating the healthcare cadres to adapt to these challenges. Technological advances, which have made remote monitoring of adherence and other aspects of disease management easier for younger populations, may not be as readily available or as familiar to older adults. To date, adaptations to service delivery have not been scaled and are limited to nascent programmes working to integrate treatment of common co‐morbidities. Conclusions: Older individuals living with HIV may benefit from a DSD approach that adapts care to the specific challenges of ageing with HIV. Models could be developed and validated using outcome measures, such as viral suppression and treatment continuity. DSD models for older adults should consider their specific health needs, such as high rates of co‐morbidities. This may require educational materials, health worker capacity building and outreach designed specifically to treat this age group., INTRODUCTION The President's Emergency Program for AIDS Relief (PEPFAR) is a U.S. Government programme launched in 2003 to address the growing HIV pandemic in areas of the world most affected [...]

: Introduction: Contraceptive implants containing etonogestrel and levonorgestrel have emerged as popular contraceptive options among women in areas of high HIV burden in sub‐Saharan Africa. However, recent pharmacokinetic data have shown drug–drug interactions between implants and efavirenz‐containing antiretroviral therapy (ART), reducing the effectiveness of the implants. Here, we evaluated pregnancy incidence in 6‐month intervals following implant initiation among women using efavirenz and contraceptive implants to assess whether the risk of breakthrough pregnancy is higher after specific periods of implant use. Methods: We used data from a retrospective longitudinal analysis of women living with HIV ages 18–45 years in western Kenya who attended HIV‐care facilities between 2011 and 2015. We used Cox proportional hazard models to compute hazard ratios (HRs) for breakthrough pregnancy by implant type and ART regimen. Depending on the model, we adjusted for socio‐demographic and clinical factors, programme, site and interaction between calendar time and ART regimen. We utilized inverse probability weights (IPWs) to account for three sampling phases (electronic medical record [EMR], chart review and phone interview) and calculated overall parameter estimates. Results: Women contributed 14,768 woman‐years from the largest sampling phase (EMR). The median age was 31 years. Women used etonogestrel implants for 26–69% of the time and levonorgestrel implants for 7–31% of the time, depending on the sampling phase. Women used efavirenz, nevirapine or no ART for 27–33%, 40–46% and 15–26% of follow‐ups, respectively. When combining sampling phases, there was little evidence to suggest that the relative hazard of pregnancy among efavirenz‐containing ART users relative to nevirapine‐containing ART changed with length of time on implants: IPW‐adjusted HR of 3.1 (CI: [1.5; 6.4]) at 12 months, 3.4 (CI: [1.8; 6.3]) at 24 months, 3.8 (CI: [1.9; 7.7]) at 36 months and 4.2 (CI: [1.6; 11.1]) at 48 months (interaction p‐value = 0.88). Similarly, no significant change in HRs over time was found when comparing women not using ART to nevirapine‐containing ART users (interaction p‐value = 0.49). Conclusions: We did not find evidence to suggest implants being more fallible from drug–drug interactions with efavirenz at later time intervals of implant use. Thus, we would not recommend shortening the duration of implant use or replacing implants sooner when concomitantly used with efavirenz., INTRODUCTION In sub‐Saharan Africa, over half of pregnancies among women living with HIV (WLHIV) are unintended [1]. Unplanned pregnancy is associated with an increased risk of maternal morbidity and mortality [...]

: Introduction: Training in care for sexual and gender minority (SGM) populations is critical for ending the HIV epidemic. SGM people, particularly men who have sex with men (MSM) and transgender women, experience disproportionate HIV infection across the globe. The objective of this commentary was to synthesize facilitators of and barriers to SGM health training efforts for healthcare workers in Uganda, in order to help inform potential priorities, strategies and next steps to advance culturally responsive HIV‐related care for SGM communities across Uganda and sub‐Saharan Africa. Discussion: SGM health training often includes education on: foundational concepts and language; stigma, discrimination and SGM health disparities; understanding and addressing implicit bias; sensitive and effective communication and building SGM‐inclusive and welcoming healthcare environments. Clinicians’ education includes sexual and gender histories, sex‐positive HIV counselling, sexually transmitted infections, HIV pre‐exposure prophylaxis and gender‐affirming hormone therapy. SGM communities in sub‐Saharan Africa have often experienced discrimination, persecution, incarceration and physical violence, and they encounter unique barriers to engagement in sexual health services and HIV prevention and treatment. SGM health training efforts in Uganda reveal challenges to and opportunities for advancing equity for SGM communities in sexual health and HIV medical care across the region. In Uganda, SGM community advocacy, as well as policies and programmes of the Ministry of Health and US President’s Emergency Plan for AIDS Relief, have increased readiness and need for scaling up training and skills‐sharing in SGM‐focused HIV and sexual healthcare, including Ugandan‐led and international initiatives. Conclusions: Numerous challenges exist to widespread culturally responsive HIV and sexual healthcare for SGM communities in sub‐Saharan Africa. Lessons learned from healthcare worker training efforts in Uganda may inform future replication, adaptation and dissemination initiatives to meet the needs of more SGM communities in the region. Evaluation of SGM health training programmes to determine the impact on HIV virological suppression and sexual health outcomes will be critical for identifying best practices and strategies that may support advancing HIV epidemic control for SGM communities in Uganda and across sub‐Saharan Africa., INTRODUCTION Sexual and gender minority (SGM) people are often stigmatized and mistreated based on their sexual orientation, gender identity or gender expression. Training healthcare workers on serving SGM people is [...]

: Introduction: Despite the global scale‐up of HIV testing, prevention and treatment, these services remain inaccessible to groups most vulnerable to HIV. Globally, most new HIV infections are concentrated among members of key populations (KP), including female sex workers, men who have sex with men, transgender people, people who inject drugs and their sexual partners. These populations lag in access to HIV prevention and antiretroviral therapy (ART) and have less favourable HIV outcomes compared to the general population. Intersecting behavioural and structural factors contribute to these gaps in service access for at‐risk KP and those living with HIV; corresponding comprehensive approaches to improving service delivery for KP are urgently needed. Differentiated service delivery (DSD) models tailor HIV programmes to the needs and preferences of specific groups but are rarely implemented at scale for KP. We describe the FIKIA Project, which implemented innovative approaches to scaling up DSD models to reach and engage KP in Tanzania. Methods: The FIKIA Project worked with diverse KP communities in Tanzania to tailor HIV services to their needs and to pair healthcare workers with trained peer educators and expert client counsellors to expand uptake of community‐based HIV testing and ART services. We analysed routine aggregate project data from 2016 to 2020 to describe project implementation, outcomes and best practices. Results and discussion: The FIKIA Project conducted 1,831,441 HIV tests in community settings; of the 98,349 (5.4%) individuals with new HIV diagnoses, 89,640 (91.1%) initiated ART. The project reached substantial numbers of KP: 203,233 received HIV tests, 28,830 (14.2%) received a new HIV diagnosis and 25,170 KP (87.3%) initiated ART at the point of diagnosis. Over time, HIV testing increased by 1.6 times overall (2.3 times among KP), HIV diagnoses increased by 8.7 times (10.9 times among KP) and ART initiation at the point of diagnosis increased from 80.0% to 95.9% overall (from 69.6% to 94.9% among KP). Conclusions: Over four years, the FIKIA Project scaled up HIV testing, diagnosis and treatment by using DSD principles to design services that meet the needs of KP and their communities., INTRODUCTION Despite the scale‐up of effective, evidence‐based interventions for HIV testing, prevention and treatment, key populations (KP), including female sex workers (FSW), men who have sex with men (MSM), transgender [...]

: Introduction: HIV diagnosis is the necessary first step towards HIV care initiation, yet many persons living with HIV (PLWH) remain undiagnosed. Employing multiple HIV testing strategies in tandem could increase HIV detection and promote linkage to care. We aimed to assess an intervention to improve HIV detection within socio‐sexual networks of PLWH in two sexually transmitted infections (STI) clinics in Lilongwe, Malawi. Methods: We conducted a randomized controlled trial to evaluate an intervention combining acute HIV infection (AHI) screening, contract partner notification and social contact referral versus the Malawian standard of care: serial rapid serological HIV tests and passive partner referral. Enrolment occurred between 2015 and 2019. HIV‐seropositive persons (two positive rapid tests) were randomized to the trial arms and HIV‐seronegative (one negative rapid test) and ‐serodiscordant (one positive test followed by a negative confirmatory test) persons were screened for AHI with HIV RNA testing. Those found to have AHI were offered enrolment into the intervention arm. Our primary outcome of interest was the number of new HIV diagnoses made per index participant within participants’ sexual and social networks. We also calculated total persons, sexual partners and PLWH (including those previously diagnosed) referred per index participant. Results: A total of 1230 HIV‐seropositive persons were randomized to the control arm, and 561 to the intervention arm. Another 12,713 HIV‐seronegative or ‐serodiscordant persons underwent AHI screening, resulting in 136 AHI cases, of whom 94 enrolled into the intervention arm. The intervention increased the number of new HIV diagnoses made per index participant versus the control (ratio: 1.9; 95% confidence interval (CI): 1.2 to 3.1). The intervention also increased the numbers of persons (ratio: 2.5; 95% CI: 2.0 to 3.2), sexual partners (ratio: 1.7; 95% CI: 1.4 to 2.0) and PLWH (ratio: 2.3; 95% CI: 1.7 to 3.2) referred per index participant. Conclusions: Combining three distinct HIV testing and referral strategies increased the detection of previously undiagnosed HIV infections within the socio‐sexual networks of PLWH seeking STI care. Combination HIV detection strategies that leverage AHI screening and socio‐sexual contact networks offer a novel and efficacious approach to increasing HIV status awareness., INTRODUCTION HIV diagnosis is the essential first step for people living with HIV (PLWH) to access HIV care, which can improve health outcomes and reduce the potential for onward transmission [...]

: Introduction: HIV retesting during late pregnancy and breastfeeding can help detect new maternal infections and prevent mother‐to‐child HIV transmission (MTCT), but the optimal timing and cost‐effectiveness of maternal retesting remain uncertain. Methods: We constructed deterministic models to assess the health and economic impact of maternal HIV retesting on a hypothetical population of pregnant women, following initial testing in pregnancy, on MTCT in four countries: South Africa and Kenya (high/intermediate HIV prevalence), and Colombia and Ukraine (low HIV prevalence). We evaluated six scenarios with varying retesting frequencies from late in antenatal care (ANC) through nine months postpartum. We compared strategies using incremental cost‐effectiveness ratios (ICERs) over a 20‐year time horizon using country‐specific thresholds. Results: We found maternal retesting once in late ANC with catch‐up testing through six weeks postpartum was cost‐effective in Kenya (ICER = $166 per DALY averted) and South Africa (ICER=$289 per DALY averted). This strategy prevented 19% (Kenya) and 12% (South Africa) of infant HIV infections. Adding one or two additional retests postpartum provided smaller benefits (1 to 2 percentage point increase in infections averted versus one retest). Adding three retests during the postpartum period averted additional infections (1 to 3 percentage point increase in infections averted versus one retest) but ICERs ($7639 and in Kenya and $11 985 in South Africa) greatly exceeded the cost‐effectiveness thresholds. In Colombia and Ukraine, all retesting strategies exceeded the cost‐effectiveness threshold and prevented few infant infections (up to 31 and 5 infections, respectively). Conclusions: In high HIV burden settings with MTCT rates similar to those seen in Kenya and South Africa, HIV retesting once in late ANC, with subsequent intervention, is the most cost‐effective strategy for preventing infant HIV infections. In these settings, two HIV retests postpartum marginally reduced MTCT and were less costly than adding three retests. Retesting in low‐burden settings with MTCT rates similar to Colombia and Ukraine was not cost‐effective at any time point due to very low HIV prevalence and limited breastfeeding., INTRODUCTION Despite successful scale‐up of prevention of mother‐to‐child HIV transmission (PMTCT) programmes, an estimated 160 000 children worldwide became infected with HIV in 2018, with approximately 30% of these infections [...]

: Background: Efforts to increase HIV testing, diagnosis and care are critical to curbing HIV epidemics among cisgender men who have sex with men (MSM) and transgender women (TW) in low‐ and middle‐income countries (LMIC). We compared the effectiveness of respondent‐driven sampling (RDS) and venue‐based sampling (VBS) for identifying previously undiagnosed HIV infection among MSM and TW in Tijuana, Mexico. Methods: Between March 2015 and December 2018, we conducted RDS within the social networks of MSM and TW and VBS at venues frequented by MSM and TW to socialize and meet sexual partners. Those reached by RDS/VBS who reported at least 18 years of age, anal sex with MSM or TW, and no previous HIV diagnosis were eligible for HIV testing. Results: Of those screened following recruitment via RDS (N = 1232; 98.6% MSM; 1.3% TW), 60.8% (749/1232) were eligible for HIV testing and 97.5% (730/749) were tested for HIV infection, which led to the identification of 36 newly diagnosed HIV infections (4.9%). Of those screened following recruitment via VBS (N = 2560; 95.2% MSM; 4.6% TW), 56.5% (1446/2560) were eligible for HIV testing and 92.8% (1342/1446) were tested for HIV infection, which led to the identification of 82 newly diagnosed HIV infections (6.1%). The proportion of new HIV diagnoses did not differ by recruitment method (ratio = 0.81, 95% confidence interval: 0.55 to 1.18). Compared to those recruited via RDS, those tested following recruitment via VBS were younger, more likely to identify as gay, and more likely to identify as TW. Compared to those recruited via VBS, those newly diagnosed with HIV infection following recruitment via RDS reported higher levels of internalized stigma and were more likely to report injection drug use and a history of deportation from the United States. Conclusions: Despite RDS and VBS being equally effective for identifying undiagnosed HIV infection, each recruitment method reached different subgroups of MSM and TW in Tijuana. Our findings suggest that there may be benefits to using both RDS and VBS to increase the identification of previously undiagnosed HIV infection and ultimately support HIV care engagement among MSM and TW in Mexico and other similar LMIC., Introduction Key populations are often disproportionately affected by HIV in low‐ and middle‐income countries (LMIC) [1,2], including cisgender men who have sex with men (MSM) and transgender women (TW) in [...]

: Introduction: While there is a global consensus on monitoring Human Immunodeficiency Virus (HIV) treatment progress, there has been less attention to the degree of consistency of the measurement of HIV prevention programmes—and the global prevention response is not on‐track to achieve 2020 goals. In this paper, we assess the degree of variability in primary prevention indicators selected by national strategic plans (NSPs) and global stakeholder monitoring and evaluation (M&E) strategies. Methods: We obtained the most recent NSPs from low and middle income Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast‐Track countries, and M&E documents from The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), President’s Emergency Plan for AIDS Relief (PEPFAR), UNAIDS, the Global HIV Prevention Coalition and the World Health Organization (WHO). We extracted HIV primary prevention indicators from each document, standardized and aggregated them by age/ sex, categorized indicators by topic, and evaluated the frequency of matched indicators between countries and stakeholders. Data were collected between February and April of 2019. Results: Twenty‐one NSPs and five global stakeholder documents were assessed; 736 primary prevention indicators were identified; 284 remained following standardization and aggregation. NSPs contained from 3 to 48 primary prevention indicators, with an average of 23; categories included: HIV education and outreach (17.6%), testing (17.3%) and condom use (16.2%). Of unique national indicators, only 34% was shared between two or more countries. Sixty‐nine per cent was applied in a single country only. 56% of NSP indicators did not appear in any global stakeholder document. Conversely, 42% of global indicators did not appear in any surveyed NSPs. Within global indicators, 63% was only measured by one global body, and no single indicator was measured by all five. Conclusions: These analyses reveal a lack of consensus both between and within countries’ and global stakeholders' measurement of HIV prevention. Though some variability is expected, these findings point to a need to refocus attention on achieving greater consensus on a global measurement framework for HIV prevention., INTRODUCTION Substantial progress has been made in responding to the HIV epidemic over the past decade, with new HIV infections reduced by an estimated 40% since their peak in 1996, [...]

: Introduction: Young men who have sex with men (MSM) and transgender women (TGW) face stigmas that hinder access to healthcare. The aim of the study was to understand age‐related determinants of healthcare needs and engagement among MSM and TGW. Methods: The TRUST/RV368 cohort provides integrated prevention and treatment services for HIV and other sexually transmitted infections (STIs) tailored to the needs of sexual and gender minorities. MSM and TGW aged ≥16 years in Abuja and ≥18 years Lagos, Nigeria, completed standardized behavioural questionnaires and were tested for HIV, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) every three months for up to 18 months. Logistic regression was used to estimate adjusted odds ratios (aORs) for associations of age and other factors with outcomes of interest upon enrolment, including HIV care continuum steps – HIV testing, ART initiation and viral suppression Results: Between March 2013 and February 2019, 2123 participants were enrolled with median age 23 (interquartile range 21 to 27) years. Of 1745 tested, 865 (49.6%) were living with HIV. HIV incidence was 11.6/100 person‐years [PY], including 23.1/100PY (95% CI 15.5 to 33.1) among participants aged 16 to 19 years and 23.8/100 PY (95% CI 13.6 to 39.1) among TGW. Compared to participants aged ≥25 years, those aged 16 to 19 years had decreased odds of prior HIV testing (aOR 0.40 [95% CI 0.11 to 0.92]), disclosing same‐sex sexual practices to healthcare workers (aOR 0.53 [95% CI 0.36 to 0.77]) and receiving HIV prevention information (aOR 0.60 [95% CI 0.41 to 0.87]). They had increased odds of avoiding healthcare (aOR 1.94 [95% CI 1.3 to 2.83]) and engaging in transactional sex (aOR 2.76 [95% CI 1.92 to 3.71]). Age 16 to 19 years was independently associated with increased incidence of HIV (aHR 4.09 [95% CI 2.33 to 7.49]), NG (aHR 3.91 [95% CI 1.90 to 8.11]) and CT (aHR 2.74 [95% CI 1.48 to 5.81]). Conclusions: Young MSM and TGW demonstrated decreased healthcare engagement and higher incidence of HIV and other STIs as compared to older participants in this Nigerian cohort. Interventions to address unique obstacles to healthcare engagement by adolescents and young adults are needed to curb the spread of HIV and other STIs among MSM and TGW in Nigeria., INTRODUCTION Men who have sex with men (MSM) and transgender women (TGW) are disproportionately impacted by HIV and other sexually transmitted infections (STIs) [1,2]. Young adult MSM and TGW are [...]

: Introduction: HIV healthcare services for men who have sex with men (MSM) in Kenya have not been openly provided because of persistent stigma and lack of healthcare capacity within Kenya’s decentralized health sector. Building on an evaluation of a developed online MSM sensitivity training programme offered to East and South African healthcare providers, this study assessed views and responses to strengthen HIV healthcare services for MSM in Kenya. Methods: The study was conducted between January and July 2017 in Kilifi County, coastal Kenya. Seventeen policymakers participated in an in‐depth interview and 59 stakeholders, who were purposively selected from three key groups (i.e. healthcare providers, implementing partners and members of MSM‐led community‐based organizations) took part in eight focus group discussions. Discussions aimed to understand gaps in service provision to MSM from different perspectives, to identify potential misconceptions, and to explore opportunities to improve MSM HIV healthcare services. Interviews and focus group discussions were recorded, transcribed verbatim and analysed using Braun and Clarke’s thematic analysis. Results: Participants’ responses revealed that all key groups navigated diverse challenges related to MSM HIV health services. Specific challenges included priority‐setting by county government staff; preparedness of leadership and management on MSM HIV issues at the facility level; data reporting at the implementation level and advocacy for MSM health equity. Strong power inequities were observed between policy leadership, healthcare providers and MSM, with MSM feeling blamed for their sexual orientation. MSM agency, as expressed in their actions to access HIV services, was significantly constrained by county context, but can potentially be improved by political will, professional support and a human rights approach. Conclusions: To strengthen HIV healthcare for MSM within a decentralized Kenyan health system, a more responsive, multi‐pronged strategy adaptable and relevant to MSM’s healthcare needs is required. Continued engagement with policy leadership, collaboration with health facilities, and partnerships with different community stakeholders are critical to improve HIV healthcare services for MSM., INTRODUCTION Kenya has among the largest HIV epidemics in the world with an estimated 1.6 million people living with HIV, 46,000 new infections, and 25,000 AIDS‐related deaths in 2018 [1], [...]

: Introduction: Men who have sex with men (MSM), and transgender women (TGW), face specific obstacles to retention in care, particularly in settings with stigmatization such as sub‐Saharan Africa. We evaluated the impacts of HIV status and other factors on loss‐to‐follow‐up (LTFU) and visit adherence among MSM and TGW in Abuja and Lagos, Nigeria. Methods: TRUST/RV368 is an open cohort that provides comprehensive and integrated prevention and treatment services for HIV and sexually transmitted infections (STIs) at community venues supportive of sexual and gender minorities. Recruitment began in March 2013 and participants were followed every three months for up to 18 months. LTFU was defined as not presenting for an expected visit in the past 180 days. Visit adherence was calculated as a rate of completed visits adjusted by the number of three‐month intervals elapsed since enrolment. HIV and other factors predictive of LTFU and visit adherence were evaluated using Cox proportional hazards and Poisson regression models, respectively. Results: A total of 1447 participants who completed enrolment evaluations over two visits as of November 2018 were included in these analyses. Their median age was 24 years (interquartile range [IQR]: 21 to 28) and 53% (n = 766) were living with HIV. LTFU occurred in 56% (n = 808) and visit adherence was 0.62 (95% confidence interval: 0.61 to 0.64) visits per three‐month interval. Participants at risk and living with HIV had median follow‐up times of 12 months (IQR: 6 to 22), and 21 months (IQR: 12 to 30), respectively (p < 0.01). After controlling for other factors, LTFU was less common among participants living with HIV or other STIs and more common among those who did not own a cell phone, sold sex and had never undergone HIV testing prior to enrolment. These factors had parallel associations with visit adherence. Conclusions: Retention was suboptimal in Nigerian clinics designed to serve MSM and TGW. Particularly high LTFU and low visit adherence among participants at risk for HIV could complicate deployment of HIV prevention interventions. Marketing the benefits of testing, improving access to cell phones and nurturing more trust with clients may improve retention among marginalized communities in Nigeria., INTRODUCTION Retention of people at risk for and living with HIV (PLWH) in evidence‐based programmes has its challenges in countries across sub‐Saharan Africa where loss to follow‐up (LTFU) estimates range [...]

: Introduction: Screening for acute and early HIV infections (AEHI) among men who have sex with men (MSM) remains uncommon in sub‐Saharan Africa (SSA). Yet, undiagnosed AEHI among MSM and subsequent failure to link to care are important drivers of the HIV epidemic. We conducted a systematic review and meta‐analysis of AEHI yield among MSM mobilized for AEHI testing; and assessed which risk factors and/or symptoms could increase AEHI yield in MSM. Methods: We systematically searched four databases from their inception through May 2020 for studies reporting strategies of mobilizing MSM for testing and their AEHI yield, or risk and/or symptom scores targeting AEHI screening. AEHI yield was defined as the proportion of AEHI cases among the total number of visits. Study estimates for AEHI yield were pooled using random effects models. Predictive ability of risk and/or symptom scores was expressed as the area under the receiver operator curve (AUC). Results: Twenty‐two studies were identified and included a variety of mobilization strategies (eight studies) and risk and/or symptom scores (fourteen studies). The overall pooled AEHI yield was 6.3% (95% CI, 2.1 to 12.4; I[sup.2] = 94.9%; five studies); yield varied between studies using targeted strategies (11.1%; 95% CI, 5.9 to 17.6; I[sup.2] = 83.8%; three studies) versus universal testing (1.6%; 95% CI, 0.8 to 2.4; two studies). The AUC of risk and/or symptom scores ranged from 0.69 to 0.89 in development study samples, and from 0.51 to 0.88 in validation study samples. AUC was the highest for scores including symptoms, such as diarrhoea, fever and fatigue. Key risk score variables were age, number of sexual partners, condomless receptive anal intercourse, sexual intercourse with a person living with HIV, a sexually transmitted infection, and illicit drug use. No studies were identified that assessed AEHI yield among MSM in SSA and risk and/or symptom scores developed among MSM in SSA lacked validation. Conclusions: Strategies mobilizing MSM for targeted AEHI testing resulted in substantially higher AEHI yields than universal AEHI testing. Targeted AEHI testing may be optimized using risk and/or symptom scores, especially if scores include symptoms. Studies assessing AEHI yield and validation of risk and/or symptom scores among MSM in SSA are urgently needed., INTRODUCTION In 2018, sub‐Saharan Africa (SSA) faced approximately one million new HIV infections [1]. Although HIV disproportionally affects men who have sex with men (MSM) globally [2,3], HIV testing and [...]

: Introduction: The process indicators of ending the HIV epidemic include 90% of people living with HIV receiving antiretroviral therapy (ART). The population of youth, however, has less access to healthcare. We assessed ART initiation and attrition outcomes of the HIV continuum from HIV diagnosis to ART initiation in youth living with HIV (YLHIV) and factors associated with ART initiation. Methods: We studied YLHIV aged 15 to 24 years who were registered on the National AIDS Program (NAP) from January 2008 to May 2019. The study period was divided into 2008 to 2013 (initiated ART by CD4‐guided criteria) and 2014 to 2018 (initiate ART at any CD4). Date of registration was used as a surrogate for the diagnosis date and defined as the baseline. The database included ART prescription and laboratory results, and the vital status was linked daily with the National Death Registry. Competing risk methods were used to assess factors associated with accessing ART, with loss to follow‐up (LTFU) and death considered as competing events. Logistic regression was used to assess factors associated with rapid ART initiation, defined as initiation ≤1 month after registration. Results: Overall, 51,607 youth registered on the NAP (42% between 2008 and 2013). Median age was 21 (IQR 20 to 23) years; 64% were male. Overall ART initiation was 80% in the first period and 83% in the second. The ART initiation rate was higher among YLHIV aged 15 to 19 years (86%) than 20 to 24 years (82%) (p < 0.001) in the second period. The proportion of youth starting rapid ART increased significantly from 27% to 52% between the two periods (p < 0.001). Factors associated with ART initiation were age 15 to 19 years (aSHR 1.09, 95% CI 1.06 to 1.11), female (aSHR 1.26, 95% CI 1.23 to 1.29) and registration year 2014 to 2018 (aSHR 1.73, 95% CI 1.69 to 1.76). The cumulative incidence of LTFU/death prior to ART initiation at 12 months was 3.8% (95% CI 3.6% to 4.1%) in the first period and 1.9% (95% CI 1.8% to 2.1%) in the second period. Conclusions: In the era of universal treatment of all at any CD4 level, 83% of YLHIV registered on the Thai National AIDS Program initiated ART. The majority initiated within one month of registration., INTRODUCTION Treating 90% of people who know they are living with HIV by 2030, the second step in the HIV care cascade, is an important UNAIDS 90:90:90 target [1]. Studies [...]

: Introduction: Home‐based HIV testing fails to reach high coverage among adolescents and young adults (AYA), mainly because they are often absent during the day of home‐based testing. ADORE (ADolescent ORal tEsting) is a mixed‐method nested study among AYA in rural Lesotho, measuring the effect of home‐based secondary distribution of oral HIV self‐tests (HIVST) on coverage, as well as exploring how AYA perceive this HIV self‐testing model. Methods: ADORE study was nested in a cluster‐randomized trial. In intervention village‐clusters, oral HIVST were left for household members who were absent or declined testing during a testing campaign. One present household member was trained on HIVST use. Distributed HIVST were followed up by village health workers (VHW). In control clusters no self‐tests were distributed. The quantitative outcome was testing coverage among AYA (age 12 to 24) within 120 days, defined as a confirmed HIV test result or known status, using adjusted random‐effects logistic regression on the intention‐to‐treat population. Qualitatively, we conducted in‐depth interviews among both AYA who used and did not use the distributed HIVST. Results: From July 2018 to December 2018, 49 and 57 villages with 1471 and 1620 consenting households and 1236 and 1445 AYA in the control and intervention arm, respectively, were enrolled. On the day of the home‐visit, a testing coverage of 37% (461/1236) and 41% (596/1445) in the control and the intervention arm, respectively, were achieved. During the 120 days follow‐up period, an additional 23 and 490 AYA in control and intervention clusters, respectively, knew their status. This resulted in a testing coverage of 484/1236 (39%) in the control versus 1086/1445 (75%) in the intervention arm (aOR 8.80 [95% CI 5.81 to 13.32]; p < 0.001). 21 interviews were performed. Personal assistance after the secondary distribution emerged as a key theme and VHWs were generally seen as a trusted cadre. Conclusions: Secondary distribution of HIVST for AYA absent or refusing to test during home‐based testing in Lesotho resulted in an absolute 36% increase in coverage. Distribution should, however, go along with clear instructions on the use of the HIVST and a possibility to easily access more personal support., INTRODUCTION In Southern Africa, adolescents and young adults (AYA) experience high HIV transmission rates as access to HIV prevention, testing and care services remains low among AYA [1‐4]. In 2016, [...]

: Introduction: HIV continues to devastate the adolescent population in sub‐Saharan Africa (SSA). The complex array of interpersonal, social, structural and system‐level obstacles specific to adolescents have slowed progress in prevention and treatment of HIV in this population. The field of implementation science holds promise for addressing these challenges. Discussion: There is growing consensus that enhanced interactions between researchers and users of scientific evidence are important and necessary to tackle enduring barriers to implementation. In 2017, the Fogarty International Center launched the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) to promote communication and catalyse collaboration among implementation scientists and implementers to enhance the cross‐fertilization of insights as research advances and the implementation environment evolves. This network has identified key implementation science questions for adolescent HIV, assessed how members’ research is addressing them, and is currently conducting a concept mapping exercise to more systematically identify implementation research priorities. In addition, AHSA pinpointed common challenges to addressing these questions and discussed their collective capacity to conduct implementation science using the shared learning approach of the network. Specifically, AHISA addresses challenges related to capacity building, developing mentorship, engaging stakeholders, and involving adolescents through support for training efforts and funding region‐/country‐specific networks that respond to local issues and increase implementation science capacity across SSA. Conclusions: Innovative platforms, like AHISA, that foster collaborations between implementation science researchers, policymakers and community participants to prioritizes research needs and identify and address implementation challenges can speed the translation of effective HIV interventions to benefit adolescent health., INTRODUCTION While HIV continues to be one of the leading causes of death for adolescents in sub‐Saharan Africa (SSA) [1], interventions to address HIV prevention and treatment in this population [...]

: Introduction: As people with HIV age, prevention and management of other communicable and non‐communicable diseases (NCDs) will become increasingly important. Integration of screening and treatment for HIV and NCDs is a promising approach for addressing the dual burden of these diseases. The aim of this study was to assess the epidemiological impact and cost‐effectiveness of a community‐wide integrated programme for screening and treatment of HIV, hypertension and diabetes in Kenya. Methods: Coupling a microsimulation of cardiovascular diseases (CVDs) with a population‐based model of HIV dynamics (the Spectrum), we created a hybrid HIV/CVD model. Interventions were modelled from year 2019 (baseline) to 2023, and population was followed to 2033. Analyses were carried at a national level and for three selected regions (Nairobi, Coast and Central). Results: At a national level, the model projected 7.62 million individuals living with untreated hypertension, 692,000 with untreated diabetes and 592,000 individuals in need of ART in year 2018. Improving ART coverage from 68% at baseline to 88% in 2033 reduced HIV incidence by an estimated 64%. Providing NCD treatment to 50% of diagnosed cases from 2019 to 2023 and maintaining them on treatment afterwards could avert 116,000 CVD events and 43,600 CVD deaths in Kenya over the next 15 years. At a regional level, the estimated impact of expanded HIV services was highest in Nairobi region (averting 42,100 HIV infections compared to baseline) while Central region experienced the highest impact of expanded NCD treatment (with a reduction of 22,200 CVD events). The integrated HIV/NCD intervention could avert 7.76 million disability‐adjusted‐life‐years (DALYs) over 15 years at an estimated cost of $6.68 billion ($445.27 million per year), or $860.30 per DALY averted. At a cost‐effectiveness threshold of $2,010 per DALY averted, the probability of cost‐effectiveness was 0.92, ranging from 0.71 in Central to 0.92 in Nairobi region. Conclusions: Integrated screening and treatment of HIV and NCDs can be a cost‐effective and impactful approach to save lives of people with HIV in Kenya, although important variation exists at the regional level. Containing the substantial costs required for scale‐up will be critical for management of HIV and NCDs on a national scale., INTRODUCTION The HIV epidemic in Kenya is one of the largest globally, with an estimated 1.6 million people living with HIV (PLHIV) in 2018 [1]. According to the Joint United [...]

Remarkable advances in HIV prevention, care and treatment, made through the discovery of antiretroviral drugs, have enabled people living with HIV (PLHIV) to live longer lives [1]. Yet, as they [...]

: Introduction: Many HIV‐positive individuals in Africa have advanced disease when initiating antiretroviral therapy (ART) so have high risks of opportunistic infections and death. The REALITY trial found that an enhanced‐prophylaxis package including fluconazole reduced mortality by 27% in individuals starting ART with CD4 Methods: The REALITY trial enrolled from June 2013 to April 2015. A decision‐analytic model was developed to estimate the cost‐effectiveness of six management strategies in individuals initiating ART in the REALITY trial countries. Strategies included standard‐prophylaxis, enhanced‐prophylaxis, standard‐prophylaxis with fluconazole; and three CrAg testing strategies, the first stratifying individuals to enhanced‐prophylaxis (CrAg‐positive) or standard‐prophylaxis (CrAg‐negative), the second to enhanced‐prophylaxis (CrAg‐positive) or enhanced‐prophylaxis without fluconazole (CrAg‐negative) and the third to standard‐prophylaxis with fluconazole (CrAg‐positive) or without fluconazole (CrAg‐negative). The model estimated costs, life‐years and quality‐adjusted life‐years (QALY) over 48 weeks using three competing mortality risks: cryptococcal meningitis; tuberculosis, serious bacterial infection or other known cause; and unknown cause. Results: Enhanced‐prophylaxis was cost‐effective at cost‐effectiveness thresholds of US$300 and US$500 per QALY with an incremental cost‐effectiveness ratio (ICER) of US$157 per QALY in the CD4 Conclusions: The REALITY enhanced‐prophylaxis package in individuals with advanced HIV starting ART reduces morbidity and mortality, is practical to administer and is cost‐effective. Efforts should continue to ensure that components are accessed at lowest available prices., Introduction In low‐ and middle‐income settings, more than a third of HIV‐positive individuals starting antiretroviral therapy (ART) present with advanced disease (CD4 ≤ 200 cells/mm[sup.3]); over half of these have [...]

: Introduction: Heterogeneity of sociodemographics and risk behaviours across the HIV treatment cascade could influence the public health impact of universal ART in sub‐Saharan Africa if those not virologically suppressed are more likely to be part of a risk group contributing to onward infections. Sociodemographic and risk heterogeneity across the treatment cascade has not yet been comprehensively described or quantified and we seek to systematically review and synthesize research on this topic among adults in Africa. Methods: We conducted a systematic review of peer‐reviewed literature in Embase and MEDLINE databases as well as grey literature sources published in English between 2014 and 2018. We included studies that included people living with HIV (PLHIV) aged ≥15 years, and reported a 90‐90‐90 outcome: awareness of HIV‐positive status, ART use among those diagnosed or viral suppression among those on ART. We summarized measures of association between sociodemographics, within each outcome, and as a composite measure of population‐wide viral suppression. Results and discussion: From 3533 screened titles, we extracted data from 92 studies (50 peer‐reviewed, 42 grey sources). Of included studies, 32 reported on awareness, 53 on ART use, 32 on viral suppression and 23 on population‐wide viral suppression. The majority of studies were conducted in South Africa, Uganda, and Malawi and reported data for age and gender. When stratified, PLHIV ages 15 to 24 years had lower median achievement of the treatment cascade (60‐49‐81), as compared to PLHIV ≥25 years (70‐63‐91). Men also had lower median achievement of the treatment cascade (66‐72‐85), compared to women (79‐76‐89). For population‐wide viral suppression, women aged ≥45 years had achieved the 73% target, while the lowest medians were among 15‐ to 24‐year‐old men (37%) and women (49%). Conclusions: Considerable heterogeneity exists by age and gender for achieving the HIV 90‐90‐90 treatment goals. These results may inform delivery of HIV testing and treatment in sub‐Saharan Africa, as targeting youth and men could be a strategic way to maximize the population‐level impact of ART., Introduction In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) introduced the 90‐90‐90 goals as targets for achieving viral load suppression among people living with HIV (PLHIV) by 2020 [...]

: Introduction: The Treat‐All policy – antiretroviral therapy (ART) initiation irrespective of CD4 cell criteria – increases access to treatment. Many ART programmes, however, reported increasing attrition and viral failure during treatment expansion, questioning the programmatic feasibility of Treat‐All in resource‐limited settings. We aimed to describe and compare programmatic outcomes between Treat‐All and standard of care (SOC) in the public sectors of Eswatini. Methods: This is a prospective cohort study of ≥16‐year‐old HIV‐positive patients initiated on first‐line ART under Treat‐All and SOC in 18 health facilities of the Shiselweni region, from October 2014 to March 2016. SOC followed the CD4 350 and 500 cells/mm[sup.3] treatment eligibility thresholds. Kaplan‐Meier estimates were used to describe crude programmatic outcomes. Multivariate flexible parametric survival models were built to assess associations of time from ART initiation with the composite unfavourable outcome of all‐cause attrition and viral failure. Results: Of the 3170 patients, 1888 (59.6%) initiated ART under Treat‐All at a median CD4 cell count of 329 (IQR 168 to 488) cells/mm[sup.3] compared with 292 (IQR 161 to 430) (p < 0.001) under SOC. Although crude programme retention at 36 months tended to be lower under Treat‐All (71%) than SOC (75%) (p = 0.002), it was similar in covariate‐adjusted analysis (adjusted hazard ratio [aHR] 1.06, 95% CI 0.91 to 1.23). The hazard of viral suppression was higher for Treat‐All (aHR 1.12, 95% CI 1.01 to 1.23), while the hazard of viral failure was comparable (Treat‐All: aHR 0.89, 95% CI 0.53 to 1.49). Among patients with advanced HIV disease (n = 1080), those under Treat‐All (aHR 1.13, 95% CI 0.88 to 1.44) had a similar risk of an composite unfavourable outcome to SOC. Factors increasing the risk of the composite unfavourable outcome under both interventions were aged 16 to 24 years, being unmarried, anaemia, ART initiation on the same day as HIV care enrolment and CD4 ≤ 100 cells/mm[sup.3]. Under Treat‐All only, the risk of the unfavourable outcome was higher for pregnant women, WHO III/IV clinical stage and elevated creatinine. Conclusions: Compared to SOC, Treat‐All resulted in comparable retention, improved viral suppression and comparable composite outcomes of retention without viral failure., Introduction The World Health Organization (WHO) recommends antiretroviral therapy (ART) initiation at the time of HIV diagnosis irrespective of clinical and immunological criteria, aiming at improving patient‐level outcomes and reducing [...]

: Introduction: Online, supervised, HIV self‐testing has potential to reach men who have sex with men (MSM) and transgender women (TGW) who never tested before and who had high HIV‐positive yield. We studied linkages to HIV confirmatory test and antiretroviral therapy (ART) initiation among Thai MSM and TGW who chose online and/or offline platforms for HIV testing and factors associated with unsuccessful linkages. Methods: MSM and TGW were enrolled from Bangkok Metropolitan Region and Pattaya during December 2015 to June 2017 and followed for 12 months. Participants could choose between: 1) offline HIV counselling and testing (Offline group), 2) online pre‐test counselling and offline HIV testing (Mixed group) and 3) online counselling and online, supervised, HIV self‐testing (Online group). Sociodemographic data, risk behaviour and social network use characteristics were collected by self‐administered questionnaires. Linkages to HIV confirmatory testing and/or ART initiation were collected from participants who tested reactive/positive at baseline and during study follow‐up. Modified Poisson regression models identified covariates for poor retention and unsuccessful ART initiation. Results: Of 465 MSM and 99 TGW, 200 self‐selected the Offline group, 156 the Mixed group and 208 the Online group. The Online group demonstrated highest HIV prevalence (15.0% vs. 13.0% vs. 3.4%) and high HIV incidence (5.1 vs. 8.3 vs. 3.2 per 100 person‐years), compared to the Offline and Mixed groups. Among 60 baseline HIV positive and 18 seroconversion participants, successful ART initiation in the Online group (52.8%) was lower than the Offline (84.8%) and Mixed groups (77.8%). Factors associated with unsuccessful ART initiation included choosing to be in the Online group (aRR 3.94, 95% CI 1.07 to 14.52), Conclusions: Online, supervised, HIV self‐testing allowed more MSM and TGW to know their HIV status. However, linkages to confirmatory test and ART initiation once tested HIV‐reactive are key challenges. Alternative options to bring HIV test confirmation, prevention and ART services to these individuals after HIV self‐testing are needed., Introduction HIV testing uptake among key populations (KPs), in particularly men who have sex with men (MSM) and transgender women (TGW) in Thailand, has been low over the past decade. [...]

: Introduction: HIV testing is an essential prerequisite for accessing treatment with antiretroviral therapy or prevention using pre‐exposure prophylaxis. Internet distribution of HIV self‐tests is a novel approach, and data on the programmatic cost of this approach are limited. We analyse the costs and cost‐effectiveness of a self‐testing programme. Methods: Men who have sex with men (MSM) reporting unknown or negative HIV status were enrolled from March to August 2015 into a 12‐month trial of HIV self‐testing in the United States. Participants were randomly assigned either to the self‐testing arm or the control arm. All participants received information on HIV testing services and locations in their community. Self‐testing participants received up to four self‐tests each quarter, which they could use themselves or distribute to their social network associates. Quarterly follow‐up surveys collected testing outcomes, including number of tests used and new HIV diagnoses. Using trial expenditure data, we estimated the cost of implementing a self‐testing programme. Primary outcomes of this analysis included total programme implementation costs, cost per self‐test completed, cost per person tested, cost per new HIV diagnosis among those self‐tested and cost per quality adjusted life year (QALY) saved. Results: A total of 2665 men were assigned either to the self‐testing arm (n = 1325) or the control arm (n = 1340). HIV testing was reported by 971 self‐testing participants who completed a total of 5368 tests. In the control arm, 619 participants completed 1463 HIV tests. The self‐testing participants additionally distributed 2864 self‐tests to 2152 social network associates. Testing during the trial identified 59 participants and social network associates with newly diagnosed HIV infection in the self‐testing arm; 11 control participants were newly diagnosed with HIV. The implementation cost of the HIV self‐testing programme was $449,510. The cost per self‐test completed, cost per person tested at least once, and incremental cost per new HIV diagnosis was $61, $145 and $9365 respectively. We estimated that self‐testing programme potentially averted 3.34 transmissions, saved 14.86 QALYs and nearly $1.6 million lifetime HIV treatment costs. Conclusions: The HIV self‐testing programme identified persons with newly diagnosed HIV infection at low cost, and the programme is cost saving., Introduction An estimated 1.1 million people in the United States are living with HIV, and 14% are unaware of their HIV‐positive status. Gay, bisexual and other men who have sex [...]

: Introduction: New HIV diagnoses have fallen in the past decade due to increased HIV testing, earlier diagnosis, earlier antiretroviral treatment, improved linkage to care and engagement in care, and the recent increased uptake of pre‐exposure prophylaxis (PrEP). We propose a novel method to compute the rate of new HIV diagnoses at the Metropolitan Statistical Area (MSA) level in the US to support the evaluation of comprehensive treatment and prevention efforts over time. Methods: The number of new HIV diagnoses, number of individuals with a PrEP indication and aggregated person‐time exposed to PrEP during the years 2012 to 2017 were used to compute a new HIV diagnosis rate for people at risk of HIV excluding those already on PrEP for the 105 MSAs in the US with published HIV surveillance data. In our calculation of person‐time with a PrEP indication, time‐at‐risk excluded time on PrEP and time after an HIV diagnosis. We used a multivariate Poisson regression model to estimate HIV diagnosis rates by year and location. Results: From 2012 to 2017, the aggregate HIV diagnoses rate among high‐risk individuals with an indication for PrEP in the 105 MSAs decreased from 4.14 per 100 person‐years (PY) (95% CI 4.10 to 4.19) to 3.26 per 100 PY (95% CI 3.22 to 3.30). For the 25 US MSAs that overlapped with an ongoing large randomized clinical trial of PrEP in men who have sex with men (MSM), the HIV diagnosis rate from 2012 to 2017 decreased from 4.86 per 100 PY (95% CI 4.80 to 4.93) to 3.61 per 100 PY (95% CI 3.56 to 3.66), a decline that was more rapid than in non‐study MSAs (IRR for trial site 1.19, 95% CI 1.18 to 1.20). Conclusions: We propose a model to estimate the background HIV diagnosis rate in people at risk for HIV and with a PrEP indication in US MSAs (excluding those on PrEP) using publically available surveillance data which can evaluate trends over time. Data generated using this methodology could be used by policy makers and local HIV prevention specialists to evaluate and monitor their prevention efforts for the population at risk in their communities., Introduction New HIV diagnoses have fallen over the past decade due to the following: (1) increased HIV testing, (2) earlier diagnosis of HIV infection, (3) earlier antiretroviral treatment for people [...]

: Introduction: In response to suboptimal adherence and retention, South Africa’s National Department of Health developed and implemented National Adherence Guidelines for Chronic Diseases. We evaluated the effect of a package of adherence interventions beginning in January 2016 and report on the impact of Fast‐Track Treatment Initiation Counselling (FTIC) on ART initiation, adherence and retention. Methods: We conducted a cluster‐randomized mixed‐methods evaluation in 4 provinces at 12 intervention sites which implemented FTIC and 12 control facilities providing standard of care. Follow‐up was by passive surveillance using clinical records. We included data on subjects eligible for FTIC between 08 Jan 2016 and 07 December 2016. We adjusted for pre‐intervention differences using difference‐in‐differences (DiD) analyses controlling for site‐level clustering. Results: We enrolled 362 intervention and 368 control arm patients. Thirty‐day ART initiation was 83% in the intervention and 82% in the control arm (RD 0.5%; 95% CI: −5.0% to 6.0%). After adjusting for baseline ART initiation differences and covariates using DiD we found a 6% increase in ART initiation associated with FTIC (RD 6.3%; 95% CI: −0.6% to 13.3%). We found a small decrease in viral suppression within 18 months (RD −2.8%; 95% CI: −9.8% to 4.2%) with no difference after adjustment (RD: −1.9%; 95% CI: −9.1% to 5.4%) or when considering only those with a viral load recorded (84% intervention vs. 86% control). We found reduced crude 6‐month retention in intervention sites (RD −7.2%; 95% CI: −14.0% to −0.4%). However, differences attenuated by 12 months (RD: −3.6%; 95% CI: −11.1% to 3.9%). Qualitative data showed FTIC counselling was perceived as beneficial by patients and providers. Conclusions: We saw a short‐term ART‐initiation benefit to FTIC (particularly in districts where initiation prior to intervention was lower), with no reductions but also no improvement in longer‐term retention and viral suppression. This may be due to lack of fidelity to implementation and delivery of those components that support retention and adherence. FTIC must continue to be implemented alongside other interventions to achieve the 90‐90‐90 cascade and fidelity to post‐initiation counselling sessions must be monitored to determine impact on longer‐term outcomes. Understanding the cost‐benefit and role of FTIC may then be warranted., INTRODUCTION Extensive data from sub‐Saharan Africa since large‐scale antiretroviral therapy (ART) rollout began shows suboptimal retention in HIV care. A particular point of concern is the period between treatment eligibility [...]

: Introduction: Despite the higher risk of HIV among female sex workers (FSWs), men who have sex with men (MSM) and transgender women (TGW), these populations are under‐represented in the literature on HIV in Haiti. Here, we present the first nationally representative estimates of HIV prevalence and the first care and treatment cascade for FSWs, MSM and TGW in Haiti. We also examine the social determinants of HIV prevalence in these groups and estimate FSW and MSM population size in Haiti. Methods: Data were collected between April 2016 and February 2017 throughout the 10 geographical departments of Haiti. The Priorities for Local AIDS Control Efforts (PLACE) method was used to: (1) recruit participants for a behavioural survey; (2) provide rapid testing, counselling and linkage to care for syphilis and HIV; and (3) measure viral load using dried blood spots for participants testing HIV positive. Results: Study participants included 990 FSWs, 520 MSM and 109 TGW. HIV prevalence was estimated at 7.7% (95% CI 6.2%, 9.6%) among FSWs, 2.2% (0.9%, 5.3%) among MSM and 27.6% (5.0%, 73.5%) among TGW. Of participants who tested positive for syphilis, 17% of FSWs, 19% of MSM and 74% of TGW were co‐infected with HIV. Economic instability and intimate partner violence (IPV) were significantly associated with HIV among MSM; food insecurity, economic instability and history of rape were significantly associated with HIV among TGW. Fewer than one‐third of participants living with HIV knew their status, and more than a quarter of those who knew their status were not on treatment. While approximately four in five FSW and MSM participants on treatment for HIV were virally suppressed, viral suppression was less common among TGW participants at only 46%. Conclusions: This study demonstrates a need for targeted interventions to prevent and treat HIV among key populations in Haiti. Potential high‐impact interventions may include venue‐based, peer navigator‐led outreach and testing for HIV and syphilis and improving screening and case management for structural violence and IPV. TGW are in urgent need of such interventions due to our observations of alarmingly high HIV prevalence and low frequency of HIV viral suppression among TGW., Introduction Since 2000, HIV prevalence has remained relatively stable in Haiti, with the most recent data suggesting an HIV prevalence of 2.0% among adults ages 15 to 49. The country [...]

: Introduction: Several countries in southern Africa have made significant progress towards reaching the Joint United Nations Programme on HIV/AIDS goal of ensuring that 90% of people living with HIV are aware of their status. In Zimbabwe, progress towards this “first 90” was estimated at 73% in 2016. To reach the remaining people living with HIV who have undiagnosed infection, the Zimbabwe Ministry of Health and Child Care has been promoting index testing and partner notification services (PNS). We describe the implementation of index testing and PNS under the Zimbabwe HIV Care and Treatment (ZHCT) project and the resulting uptake, HIV positivity rate and links to HIV treatment. Methods: The ZHCT project has been implemented since March 2016, covering a total of 12 districts in three provinces. To assess the project's performance on index testing, we extracted data on HIV testing from the district health information system (DHIS 2) from March 2016 to May 2018, validated it using service registers and calculated monthly HIV positivity rates using Microsoft Excel. Data were disaggregated by district, province, sex and service delivery point. We used SPSS to assess for statistical differences in paired monthly HIV positivity rates by sex, testing site, and province. Results: The average HIV positivity rate rose from 10% during the first six months of implementation to more than 30% by August 2016 and was sustained above 30% through May 2018. The overall facility HIV positivity rate was 4.1% during the same period. The high HIV positivity rate was achieved for both males and females (mean monthly HIV positivity rate of 31.3% for males and 33.7% for females), with females showing significantly higher positivity compared to males (p < 0.001). The ZHCT mean monthly HIV positivity rate from index testing (32.6%) was significantly higher than that achieved through provider‐initiated testing and counselling and other facility HIV testing modalities (4.1%, p < 0.001). Conclusions: The ZHCT project has demonstrated successes in implementing index testing and PNS by attaining a high HIV positivity rate sustained over the study period. As the country moves towards HIV epidemic control, index testing and PNS are critical strategies for targeted HIV case identification., Introduction HIV testing and counselling is the first crucial step towards achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90‐90‐90 targets, where 90% of people living with HIV (PLHIV) [...]

: Introduction: Identifying HIV‐positive individuals is increasingly recognized as one of the most important and most challenging of the UNAIDS 90‐90‐90 goals. Assisted partner notification services (aPNS) involves tracing and offering HIV testing to partners of HIV‐positive individuals, and is effective and safe when provided to newly diagnosed HIV‐positive patients. Voluntary aPNS is now part of the World Health Organization's guidelines for HIV prevention and care. However, uptake of aPNS is significantly lower among adults with established HIV infection already engaged in care compared to newly diagnosed individuals. We sought to describe barriers encountered and potential opportunities to providing aPNS to established patients living with HIV. Methods: We conducted focus group discussions and in‐depth interviews at Nairobi's largest public HIV clinic in April to May 2016 to elucidate barriers to and opportunities for aPNS among established patients engaged in HIV care. Participants included HIV‐positive adults in care, their partners, and healthcare workers (HCWs). Qualitative data analysis took a grounded theory approach. Results: Barriers to aPNS fell under three main categories. Fear of disclosure to partners included concerns over relationship repercussions, loss of trust, blame and violence. Stigma and discrimination were described in the healthcare setting, at church and in general society. Participants described difficulties approaching communication, including cultural barriers and differences in education. For almost every barrier a potential solution was also identified, and a barrier‐opportunity relationship emerged. Opportunities included using couples testing centres to aid in disclosure, focusing on the ambiguous introduction of the infection, and sensitization of HCWs and community leaders. Conclusions: aPNS among established HIV patients is associated with different barriers and opportunities than aPNS among newly diagnosed patients, and HCWs should build their capacity to support aPNS in this population. There is a strong need for increased training and sensitization on the use of aPNS in different circumstances and for different clients, taking into consideration factors such as timing of partner notification, characteristics of the relationship and duration of knowledge discordance. The overall success of this intervention among populations living with HIV may rely on customization of services and key messages to meet the patients’ specific needs., Introduction As countries throughout Africa strive to achieve the UNAIDS 90‐90‐90 goals by 2020, diagnosing 90% of those living with HIV remains the most elusive target worldwide, and strategies to [...]

: Introduction: WHO recommends assisted partner notification (APN) for people living with HIV (PLHIV). These services have not been widely scaled in Central Asia. We describe the results from an APN intervention implemented within a programme focused on PLHIV and people who inject drugs in Kazakhstan, the Kyrgyz Republic and Tajikistan. Methods: Routine data from index cases and their partners were analysed from equal‐length periods before and after APN launch. Prior to APN index cases could recruit partners using passive referral, and under APN, had their choice of passive referral or APN (provider, contract or dual‐referral). We compared the demographic characteristics of index cases and their sexual/injecting partners from the pre‐APN and APN periods, described the number/proportion of HIV cases found (positivity rate) and evaluated predictors of HIV infection among partners using logistic regression. Results: Under APN 2676 PLHIV served as index cases and recruited 3735 partners for testing, compared to 4418 index cases and 2240 partners during the pre‐APN period. A total of 322 (8.6%) partners were rapid test positive during APN versus 161 (7.2%, p = 0.048) before APN. Women represented 38% of APN index cases (vs. 42% pre‐APN), 52% of partners tested (vs. 50% pre‐APN) and 56% of all PLHIV identified (vs. 63% pre‐APN). Compared to the pre‐APN period, the number of partners tested per index case recruited increased (0.5 to 1.4, p < 0.001) and the number of index cases needed to find one HIV‐positive partner decreased significantly (27.4 to 8.3, p < 0.001) under APN. Conclusions: APN was feasibly integrated within a people who inject drugs and PLHIV‐focused HIV programme, and was acceptable to high‐risk populations in Central Asia. Under APN, large numbers of sexual and injecting partners of PLHIV – including women and non‐marital partners – were tested while maintaining high positivity rates. Relative to the pre‐APN period, APN approximately tripled the number of partners recruited per index case and reduced the number of index cases needed to find a positive partner by >3 times., Introduction The HIV epidemics in Central Asia are highly concentrated, disproportionately impacting people who inject drugs (PWID) and their sexual partners. There are an estimated 168,600 PWID in Kazakhstan, the [...]

: Introduction: The HIV epidemic in Vietnam is concentrated in key populations and their partners – people who inject drugs, men who have sex with men, sex workers and partners of people living with HIV. These groups have poor access to and uptake of conventional HIV testing services (HTS). To address this gap, lay provider‐ and self‐testing and assisted partner notification (aPN) were introduced and delivered by the community. We explored the feasibility and effectiveness of implementing aPN as part of community testing services for key populations. Methods: Lay provider testing and self‐testing was started in January 2017, and targeted key populations and their partners. Since July 2017, aPN was introduced. HTS was offered at drop‐in houses or coffee shops in Thai Nguyen and Can Tho provinces. All self‐testing was assisted and observed by peer educators. Both in‐person and social network methods were used to mobilize key populations to test for HIV and offer HTS to partners of people living with HIV. Client‐level data, including demographic information and self‐reported risk behaviour, were collected on site by peer educators. Results: Between January 2017 and May 2018, 3978 persons from key populations were tested through community‐led HTS; 66.7% were first‐time testers. Of the 3978 clients, 3086 received HTS from a lay provider and 892 self‐tested in the presence of a lay provider. Overall, 245 (6.2% of tested clients) had reactive results, 231 (94.3%) were confirmed to be HIV positive; 215/231 (93.1%) initiated antiretroviral therapy (ART). Of 231 adult HIV‐positive clients, 186 (80.5%) were provided voluntary aPN, and 105 of their partners were contacted and received HTS. The ratio of partners who tested for HIV per index client was 0.56. Forty‐four (41.9%) partners of index clients receiving HTS were diagnosed with HIV, 97.7% initiated ART during the study period. No social harm was identified or reported. Conclusions: Including aPN as part of community‐led HTS for key populations and their partners is feasible and effective, particularly for reaching first‐time testers and undiagnosed HIV clients. Scale‐up of aPN within community‐led HTS for key populations is essential for achieving the United Nations 90‐90‐90 targets in Vietnam., Introduction In 2017, there were an estimated 250,000 people living with HIV (PLHIV) in Vietnam, a prevalence of 0.4% among adults aged 15 to 49 years. The majority of PLHIV [...]

: Introduction: Although knowledge of HIV positivity is a necessary step towards engagement in HIV care, more than one quarter of HIV‐positive Malawians remain unaware of their HIV status. Testing the sexual partners, guardians and children of HIV‐positive persons (index case finding or ICF) is a promising way of identifying HIV‐positive persons unaware of their HIV status. ICF can be passive where the HIV‐positive individual (index) invites a partner (or contact) for HIV testing or active where a health provider assists the index with partner notification and offers HIV testing to the partner. Strategies to improve passive ICF have not been thoroughly studied. We describe the impact of a behavioural skills‐building training to enhance healthcare workers’ (HCWs) implementation of Malawi's passive ICF programme. Methods: In June 2017, HCWs from 36 health facilities in Mangochi were oriented to Malawi's ICF programme and began implementation. In February and April 2018, a total of 573 HCWs from these facilities received further training from the Tingathe Programme. The training focused on eliciting more untested sexual contacts from indexes and better equipping indexes on issuing “family referral slips” to contacts. Monthly programmatic data were abstracted from clinical registers from October 2017 to July 2018. Monthly programmatic indicators were collected from the Index Case Testing Register and the HIV Counselling and Testing Register and were entered into a data set with one record per facility per month. T‐tests were used to compare the means of these indicators. Results: During the ten‐month study period, there were 200 facility‐months observed before and 124 facility‐months observed after training. The mean number of indexes identified per facility‐month remained stable after training (pre = 18.9, post = 21.2, p = 0.74), but the mean number of sexual partners listed per facility‐month (pre = 6.3, post = 10.6, p < 0.001) increased. The mean number of contacts who received HIV testing (pre = 11.1, post = 24.8, p < 0.001) and the mean number of HIV‐positive contacts identified per facility‐month (pre = 1.3, post = 2.3, p < 0.001) also increased. Conclusions: A brief behavioural skills‐building training impacted a range of meaningful outcomes, including identification of HIV‐positive individuals in a passive ICF programme. Such approaches could facilitate the identification of HIV‐positive persons unaware of their HIV status, a necessary step for engagement in HIV care., Introduction An estimated 36.9 million people were living with HIV in 2017, with substantial portions remaining unaware of their HIV status. In Malawi, in spite of a generalized HIV epidemic [...]

: Introduction: Changes to the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding have led to closures of non‐governmental HIV clinics with patient transfers to government‐funded clinics. We sought to determine the success of transfers in South Africa using a national data source. Methods: All adults (≥18 years) on antiretroviral therapy (ART) who visited a single PEPFAR‐funded hospital‐based HIV clinic in Durban, South Africa from March to June 2012 were transferred to community‐based clinics. Previously, we matched patient records from the hospital‐based HIV clinic with National Health Laboratory Services (NHLS) Corporate Data Warehouse (CDW) data to estimate the proportion of patients with a CD4 count or viral load (VL) in the CDW during the year before transfer. As a proxy for retention in care, in this study we evaluated whether patients had a CD4 count or VL at another facility within approximately three years of transfer. Patients referred to a private doctor at transfer were excluded from the analysis. We assessed predictors (age, sex, CD4 count, VL status, ART duration and location of future care) of not having post‐transfer laboratory data using Cox proportional hazards models. Results: Of the 3893 patients referred to a government facility at transfer, 41% were male and median age was 39 years (IQR 34 to 46). There was a post‐transfer CD4 count or VL from another facility for 23% of these individuals within six months, 44% within one year, 57% within two years and 61% within approximately three years. Male sex (aHR 1.20, 95% CI 1.10 to 1.31) and shorter duration on ART (1 year) were associated with not having a post‐transfer record. Conclusions: Using data from the NHLS CDW, 61% of patients had evidence of a post‐transfer laboratory record at another facility within approximately three years after closure of a large South African HIV clinic. Males and those with shorter time on ART prior to transfer were at highest risk for lacking follow‐up laboratory data. As patients transfer care, national data sources can be used to evaluate long‐term patient care trajectories., Introduction South Africa has the largest HIV treatment programme in the world, with more than 3.1 million people on antiretroviral therapy (ART). Because of a gradual, planned funding reduction from [...]

: Introduction: To achieve epidemic control of HIV by 2030, countries aim to meet 90‐90‐90 targets to increase knowledge of HIV‐positive status, initiation of antiretroviral therapy (ART) and viral suppression by 2020. We assessed the progress towards these targets from 2014 to 2016 in South Africa as expanded treatment policies were introduced using population‐representative surveys. Methods: Data were collected in January to March 2014 and August to November 2016 in Dr. Ruth Segomotsi Mompati District, North West Province. Each multi‐stage cluster sample included 46 enumeration areas (EA), a target of 36 dwelling units (DU) per EA, and a single resident aged 18 to 49 per DU. Data collection included behavioural surveys, rapid HIV antibody testing and dried blood spot collection. We used weighted general linear regression to evaluate differences in the HIV care continuum over time. Results: Overall, 1044 and 971 participants enrolled in 2014 and 2016 respectively with approximately 77% undergoing HIV testing. Despite increases in reported testing, known status among people living with HIV (PLHIV) remained similar at 68.7% (95% Confidence Interval (CI) = 60.9–75.6) in 2014 and 72.8% (95% CI = 63.6–80.4) in 2016. Men were consistently less likely than women to know their status. Among those with known status, PLHIV on ART increased significantly from 80.9% (95% CI = 71.9–87.4) to 91.5% (95% CI = 84.4–95.5). Viral suppression ( Conclusions: Over a period during which fixed‐dose combination was introduced, ART eligibility expanded, and efforts to streamline treatment were implemented, major improvements in the second and third 90‐90‐90 targets were achieved. Achieving the first 90 target will require targeted and improved testing models for men., Introduction The global HIV response has gained considerable momentum in increasing testing and treatment availability in the most heavily burdened regions. Spurred by findings that viral suppression would benefit not [...]

: Introduction: There are limited data on young people who inject drugs (PWID) from low? and middle?income countries where injection drug use remains a key driver of new HIV infections. India has a diverse injection drug use epidemic and estimates suggest that at least half of PWID are ?30 years of age. We compared injection and sexual risk behaviours and HIV incidence between younger and older PWID and characterized uptake of HIV testing and harm reduction services to inform targeted HIV prevention efforts. Methods: We analysed cross?sectional data from 14,381 PWID recruited from cities in the Northeast and North/Central regions of India in 2013 using respondent driven sampling (RDS). We compared ?emerging?adult? (18 to 24 years, 26% of sample) and ?young?adult? PWID (25 to 30 years, 30% of sample) to older PWID (>30 years, 44% of sample) using logistic regression to evaluate factors associated with three recent risk behaviours: needle?sharing, multiple sexual partners and unprotected sex. We estimated age?stratified cross?sectional HIV incidence using a validated multi?assay algorithm. Results: Compared to older adults, emerging?adults in the Northeastern states were significantly more likely to share needles (males adjusted odds ratio [aOR] 1.82; females aOR 2.29, p < 0.01), have multiple sexual partners (males aOR 1.56; females aOR 3.75, p < 0.01), and engage in unprotected sex (males aOR 2.29, p < 0.01). In the North/Central states, young?adult males were significantly more likely to needle?share (aOR 1.23, p < 0.05) while emerging?adult males were significantly more likely to have multiple sexual partners (aOR 1.74, p < 0.05). In both regions, emerging?adults had the lowest HIV testing. Participation in harm reduction services was low across all age groups. Annual HIV incidence was higher in emerging? and young?adult PWID in the North/Central region: emerging?adults: 4.3% (95% confidence interval [CI] 3.0, 5.6); young?adults: 4.9% (95% CI 3.7, 6.2); older adults: 2.1% (95% CI 1.4, 2.8). Conclusions: Higher HIV incidence and engagement in risky behaviours among younger PWID compared to older PWID, coupled with low utilization of harm reduction services highlight the importance of targeting this population in HIV programming. Age?specific interventions focused on addressing the needs of young PWID are urgently needed to curb the HIV epidemic in this vulnerable population., Introduction A recent United Nations AIDS report highlights that young people are a key driver of the HIV epidemic, accounting for more than a third of new HIV infections globally, [...]

: Achieving US state and municipal benchmarks to end the HIV epidemic and promote health equity requires access to comprehensive HIV care. However, this care may not be geographically accessible for all people living with HIV (PLHIV). We estimated county?level drive time and suboptimal geographic accessibility to HIV care across the contiguous US, assessing regional and urban?rural differences. We integrated publicly available data from four federal databases to identify and geocode sites providing comprehensive HIV care in 2015, defined as the co?located provision of core HIV medical care and support services. Leveraging street network, US Census and HIV surveillance data (2014), we used geographic analysis to estimate the fastest one?way drive time between the population?weighted county centroid and the nearest site providing HIV care for counties reporting at least five diagnosed HIV cases. We summarized HIV care sites, county?level drive time, population?weighted drive time and suboptimal geographic accessibility to HIV care, by US region and county rurality (2013). Geographic accessibility to HIV care was suboptimal if drive time was >30 min, a common threshold for primary care accessibility in the general US population. Tests of statistical significance were not performed, since the analysis is population?based. We identified 671 HIV care sites across the US, with 95% in urban counties. Nationwide, the median county?level drive time to HIV care is 69 min (interquartile range (IQR) 66 min). The median county?level drive time to HIV care for rural counties (90 min, IQR 61) is over twice that of urban counties (40 min, IQR 48), with the greatest urban?rural differences in the West. Nationally, population?weighted drive time, an approximation of individual?level drive time, is over five times longer in rural counties than in urban counties. Geographic access to HIV care is suboptimal for over 170,000 people diagnosed with HIV (19%), with over half of these individuals from the South and disproportionately the rural South. Nationally, approximately 80,000 (9%) drive over an hour to receive HIV care. Suboptimal geographic accessibility to HIV care is an important structural barrier in the US, particularly for rural residents living with HIV in the South and West. Targeted policies and interventions to address this challenge should become a priority., Introduction Many United States (US) municipalities and states are implementing strategic plans to end HIV as an epidemic. In addition to meeting benchmarks such as percent virally suppressed and number [...]

: Introduction: Although HIV testing services (HTS) have been successfully task‐shifted to lay counsellors, no model has tested the franchising of HTS to lay counsellors as independent small‐scale business owners. This paper evaluates the effectiveness of a social franchisee (SF) HTS‐managed pilot project compared to the Foundation for Professional Development (FPD) employee‐managed HTS programme in testing and linking clients to care. Methods: Unemployed, formally employed or own business individuals were engaged as franchisees, trained and supported to deliver HTS services under a common brand in high HIV‐prevalent communities in Tshwane district between 2016 and 2017. SFs were remunerated per‐HIV test and received larger payments per‐HIV‐positive client linked to care. In the standard HTS, FPD employed counsellors received similar training and observed similar standards as in the SF HTS, but were remunerated through the normal payroll. We assessed the proportion of clients tested, HIV positivity, linkage to care and per‐counsellor cost of HIV test and linkage to care in the two HTS groups. Results: The SF HTS had 19 HIV counsellors while FPD HTS employed 20. A combined total of 84,556 clients were tested by SFs (50.5%: 95% confidence interval (CI) 50.2 to 50.8)) and FPD (49.5%: 49.2 to 49.8). SFs tested more females than FPD (54.1%: 53.6 to 54.6 vs. 48%: 47.7 to 48.7). SFs identified more first‐time testers than FPD (21.5%: 21.1 to 21.9 vs. 8.9%: 8.6 to 9.1). Overall, 8%: 7.9 to 8.2 tested positive with more clients testing positive in the SF (10.2%: 9.9 to 10.5) than FPD (5.9%: 5.6 to 6.1) group. The SFs identified more female HIV‐positive clients (11.1%: 10.7 to 11.6) than FPD (6.5%: 6.2 to 6.9). The SFs linked fewer clients to HIV care and treatment (60.0%: 58.5 to 61.5) than FPD (80.3%: 78.7 to 81.9%). It cost four times less to conduct an HIV test using SFs ($3.90 per SF HIV test) than FPD ($13.98) and five times less to link a client to care with SFs ($62.74) than FPD ($303.13). Conclusions: SF HTS was effective in identifying more clients, first‐time HIV testers and more HIV‐positive people, but less effective in linking clients to care than FPD HTS. The SF HTS model was cheaper than the FPD‐employee model. We recommend strengthening SFs particularly their linkage to care activities., Introduction With an estimated 7.1 million people living with HIV (PLHIV) and almost 270,000 people newly infected with HIV in 2016 South Africa has a large HIV burden that requires [...]

KL1 HIV/AIDS, global health and the Sustainable Development Goals K De Cock CDC Country Office, US Centers for Disease Control and Prevention, Nairobi, Kenya Sustainable Goal (SDG) 3 calls for [...]

Background: Same-day antiretroviral therapy (SDART) initiation has been implemented since 2017 at the Thai Red Cross Anonymous Clinic (TRCAC), an HIV testing centre in Bangkok, Thailand. Clients who are willing [...]

: Introduction: HIV testing programmes have struggled to reach the most marginalized populations at risk for HIV. Social network methods such as respondent‐driven sampling (RDS) and peer‐based active case‐finding (ACF) may be effective in overcoming barriers to reaching these populations. We compared the client characteristics, proportion testing HIV positive (yield), and number of new cases found through two RDS strategies and an ACF approach to HIV case‐finding among people who inject drugs (PWID) in Tajikistan. Methods: Routine programme data from adult PWID recruited to testing under the HIV Flagship Project in Tajikistan were analysed to compare client demographic and clinical characteristics across the three approaches. We also compared the number of previously untested clients, the number of new HIV cases found, and the yield across the case‐finding strategies, and evaluated predictors of new HIV diagnosis using fixed‐effects logistic regression. Results: From 24 October 2016 to 30 June 2017, Flagship tested 10,300 PWID for HIV, including 2143 under RDS with unrestricted waves (RDS1, yield: 1.5%), 3517 under restricted RDS (RDS2, yield: 2.6%), and 4640 under ACF (yield: 1.5%). Clients recruited under ACF were similar in age (35.8 vs. 36.8) and gender (91% vs. 90% male) to those recruited through RDS, though ACF clients were more likely to report being a first‐time tester (85.1% vs. 68.3%, p < 0.001). After controlling for age, sex, previous testing history and accounting for clustering at the site level, we found that clients tested under both RDS1 (aOR: 1.74, 95% CI: 1.04 to 2.90) and RDS2 (aOR: 1.54, 95% CI: 1.11 to 2.15) had higher odds of testing newly positive for HIV relative to clients recruited through ACF. We did not find significant differences in the odds of new HIV infection between those recruited from RDS1 versus RDS2 (aOR: 1.12, 95% CI: 0.67 to 1.86). Conclusions: RDS‐based interventions resulted in higher yields and overall case‐finding, especially when recruitment was restricted. However, ACF identified a higher proportion of first‐time testers. To find at least 90% of PWID living with HIV in Tajikistan, it may be necessary to implement multiple case‐finding approaches concurrently to maximize testing coverage., Introduction While national HIV prevalence in Tajikistan is 0.3%, prevalence among the estimated 23,000 people who inject drugs (PWID) in the country is 13.5%. Though PWID represent To improve HIV [...]

: Introduction: In 2015, the World Health Organization recommended that all HIV‐infected individuals consider ART initiation as soon as possible after diagnosis. Sex differences in choice of initial ART regimen, indications for switching, time to switching and choice of second‐line regimens have not been well described. The aims of this study were to describe first‐line ART and CD4 count at ART initiation by sex, calendar year and region, and to analyse time to change or interruption in first‐line ART, according to sex in each region. Methods: Participating cohorts included: Southern, East and West Africa (IeDEA‐Africa), North America (NA‐ACCORD), Caribbean, Central/South America (CCASAnet) and Asia‐Pacific including Australia (IeDEA Asia‐Pacific). The primary outcomes analysed for each region and according to sex were choice of initial ART, time to switching and time to discontinuation of the first‐line regimen. Results and Discussion: The combined cohort data set comprised of 715,252 participants across seven regions from low‐ to high‐income settings. The median CD4 count at treatment initiation was lower in men compared with women in nearly all regions and time periods. Women from North America and Southern Africa were more likely to switch ART compared to men (p < 0.001) with approximately 90% of women reporting a major change after 10 years in North America. Overall, after 8 years on ART, >50% of HIV‐ positive men and women from Southern Africa, East Africa, South and Central America remained on their original regimen. Men were more likely to have a treatment interruption compared with women in low‐ and middle‐income countries from the Asia/Pacific region (p < 0.001) as were men from Southern Africa (p < 0.001). Greater than 75% of men and women did not report a treatment interruption after 10 years on ART from all regions except North America and Southern Africa. Conclusions: There are regional variations in the ART regimen commenced at baseline and rates of major change and treatment interruption according to sex. Some of this is likely to reflect changes in local and international antiretroviral guideline recommendations but other sex‐specific factors such as pregnancy may contribute to these differences., Introduction Over the past decade, HIV treatment guidelines have changed, with the CD4[sup.+] count threshold for initiating antiretroviral therapy (ART) gradually increasing from less than 350 cells/μL in 2010 to [...]