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Objectives: The 2018–2019 Rwanda Population–based HIV Impact Assessment (RPHIA) was conducted to measure national HIV incidence and prevalence. District-level estimates were modeled to inform resources allocation. Methods: RPHIA was a nationally representative cross-sectional household survey. Consenting adults were interviewed and tested for HIV using the national diagnostic algorithm followed by laboratory-based confirmation of HIV status and testing for viral load (VL), limiting antigen (LAg) avidity, and presence of antiretrovirals. Incidence was calculated using normalized optical density ≤ 1·5, VL ≥ 1,000 copies/mL, and undetectable antiretrovirals. Survey and programmatic data were used to model district-level HIV incidence and prevalence. Results: Of 31,028 eligible adults, 98·7% participated in RPHIA and 934 tested HIV positive. HIV prevalence among adults in Rwanda was 3·0% (95% CI:2·7–3·3). National HIV incidence was 0·08% (95% CI:0·02–0·14) and 0·11% (95% CI:0·00–0·26) in the City of Kigali (CoK). Based on district-level modeling, HIV incidence was greatest in the 3 CoK districts (0·11% to 0·15%) and varied across other districts (0·03% to 0·10%). Conclusions: HIV prevalence among adults in Rwanda is 3.0%; HIV incidence is low at 0.08%. District-level modeling has identified disproportionately affected urban hotspots: areas to focus resources.

Achieving optimal HIV outcomes, as measured by global 90-90-90 targets, that is awareness of HIV-positive status, receipt of antiretroviral (ARV) therapy among aware and viral load (VL) suppression among those on ARVs, respectively, is critical. However, few data from sub-Saharan Africa (SSA) are available on older people (50+) living with HIV (OPLWH). We examined 90-90-90 progress by age, 15-49 (as a comparison) and 50+ years, with further analyses among 50+ (55-59, 60-64, 65+ vs. 50-54), in 13 countries (Cameroon, Cote d'Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia and Zimbabwe).Using data from nationally representative Population-based HIV Impact Assessments, conducted between 2015and 2019, participants from randomly selected households provided demographic and clinical information and whole blood specimens for HIV serology, VL and ARV testing. Survey weighted outcomes were estimated for 90-90-90 targets. Country-specific Poisson regression models examined 90-90-90 variation among OPLWH age strata.Analyses included 24,826 HIV-positive individuals (15-49 years: 20,170; 50+ years: 4656). The first, second and third 90 outcomes were achieved in 1, 10 and 5 countries, respectively, by those aged 15-49, while OPLWH achieved outcomes in 3, 13 and 12 countries, respectively. Among those aged 15-49, women were more likely to achieve 90-90-90 targets than men; however, among OPLWH, men were more likely to achieve first and third 90 targets than women, with second 90 achievement being equivalent. Country-specific 90-90-90 regression models among OPLWH demonstrated minimal variation by age stratum across 13 countries. Among OLPWH, no first 90 target differences were noted by age strata; three countries varied in the second 90 by older age strata but not in a consistent direction; one country showed higher achievement of the third 90 in an older age stratum.While OPLWH in these 13 countries were slightly more likely than younger people to be aware of their HIV-positive status (first 90), this target was not achieved in most countries. However, OPLWH achieved treatment (second 90) and VL suppression (third 90) targets in more countries than PLWH50. Findings support expanded HIV testing, prevention and treatment services to meet ongoing OPLWH health needs in SSA.

We aimed to measure social protection coverage among the general population, women and men living with HIV (WLHIV, MLHV), female and male sex workers (FSW, MSW), men who have sex with men (MSM), adolescent girls young women (AGYW), and orphans vulnerable children (OVC) in Eswatini, Malawi, Tanzania, and Zambia. We used Population-Based HIV Impact Assessment data. We operationalised social protection benefits as external economic support from private and public sources to the household in the last three or 12 months. We estimated survey-weighted proportions and 95% confidence intervals (CI) for each population receiving social protection benefits. The sample size ranged from 10,233 adults ages 15–59 years in Eswatini to 29,638 in Tanzania. In the surveyed countries, social protection coverage among the general population was lower than the global average of 45%, ranging from 7.7% (95% CI 6.7%–8.8%) in Zambia to 39.6% (95% CI 36.8%–42.5%) in Eswatini. In Malawi and Zambia, social protection coverage among OVC, AGYW, SW, MSM, and people living with HIV (PLHIV) was similar to the general population. In Eswatini, more AGWY reported receiving social projection benefits than older women and more men not living with HIV reported receiving social protection benefits than MLHIV. In Tanzania, more WLHIV than women not living with HIV, MLHIV than men not living with HIV, and FSW than women who were not sex workers reported receiving social protection benefits. More data on access to social protection benefits by PLHIV or affected by HIV are needed to estimate better their social protection coverage.

To estimate the incidence of lipoatrophy and lipohypertrophy among HIV-infected and HIV-uninfected women from the Women's Interagency HIV Study. Eight hundred fifteen women with semiannual data on self-report of bidirectional change in body fat, anthropometric measurements, weight, and bioelectric impedance analysis were included in a 30-month incidence analysis. Lipoatrophy and lipohypertrophy in both peripheral (arms, legs, and buttocks) and central (waist, chest, and upper back) sites were defined by self-report of either a decrease or an increase in a body fat region over the previous 6 months that was confirmed by a corresponding change in anthropometric measurement. Weight and total body fat increased in HIV-uninfected women but remained stable in HIV-infected women over 30 months. Among HIV-infected women, the incidence of peripheral (relative hazard, 2.1; 95% confidence interval [CI], 1.4–3.3) and central (relative hazard, 1.9; 95% CI, 1.2–2.8) lipoatrophy was about double that among HIV-uninfected women, after adjustment for age and race. The incidence of peripheral lipohypertrophy appeared lower among HIV-infected women than among HIV-uninfected women (relative hazard, 0.8; 95% CI, 0.6–1.1), while the incidence of central lipohypertrophy did not differ by HIV status. Of HIV-infected women with 2 of 4 lipodystrophy outcomes, most (81%) had combined peripheral and central lipoatrophy or combined peripheral and central lipohypertrophy. Only 14% of these women had both peripheral lipoatrophy and central lipohypertrophy These prospective data suggest that lipoatrophy, affecting both peripheral and central sites, predominates in HIV-infected women. The simultaneous occurrence of peripheral lipoatrophy and central lipohypertrophy was uncommon.

As the result of the strengthening of TB-control programs nationwide, a decline in the overall number of reported TB cases in the United States has been observed within the last 10 years. Despite these declines in absolute numbers, the elderly continue to account for a disproportionate share of the cases. The high number of cases diagnosed at autopsy among the elderly suggests that this condition often remains unrecognized, possibly due to the subtle clinical manifestations in this age group. Evidence suggests that, compared with their community-dwelling counterparts, the institutionalized elderly are at a greater risk for re-activation of latent TB and for the acquisition of new TB infection. More studies are needed to make final conclusions. New guidelines for the treatment of LTBI emphasize targeted TST among persons at high risk for development of active TB and no longer use age as an exclusionary condition. All nursing home residents must therefore be regularly screened for LTBI and treated if necessary. Even though elderly persons are at greater risk for hepatic toxicity from TB treatment, the poor outcome of untreated TB in this age group warrants more aggressive treatment of this condition.

Rates of invasive disease caused by penicillin-resistant pneumococci are rising. Previous reports have found no association between resistant pneumococci and increased mortality. To evaluate the impact of penicillin resistance and other variables on mortality, we retrospectively studied all cases of pneumococcal bacteremia identified by our microbiology laboratory from 1 January 1992 through 31 December 1996. There were 462 cases of pneumococcal bacteremia in 432 patients. The mean age was 35 years; 55% of the cases occurred in male patients, 58% were in black patients, and 40% were in Hispanic patients. One-half of the cases occurred in patients with documented human immunodeficiency virus (HIV) infection. Penicillin resistance was first noted in 1994 and increased yearly, accounting for 17% of 1996 isolates. Of all resistant isolates, 65% were resistant to penicillin at a high level. The overall mortality was 17%. On multivariate analysis, high-level penicillin resistance, older age, severe disease, multilobar infiltrates and/or effusion(s) on chest roentgenogram, and Hispanic ethnicity were independent predictors of mortality in pneumococcal bacteremia. In HIV-infected patients, a CD4 cell count below the median just missed statistical significance. This is the first report demonstrating penicillin resistance as an independent predictor of mortality among patients with pneumococcal bacteremia.

For hospitalized patients with smear-positive pulmonary or laryngeal tuberculosis, the Centers for Disease Control and Prevention recommends that three consecutive sputum samples be negative for acid-fast bacilli (AFB) before respiratory isolation is discontinued. Limited data are available to predict the length of time to obtain three negative sputum smears and cultures and to determine factors associated with a prolonged interval before sputum smear and culture conversion, especially among patients infected with human immunodeficiency virus (HIV). For 100 consecutive patients with smear-positive pulmonary tuberculosis, the mean and median numbers of days from the initiation of appropriate therapy to the first of three consecutive negative smears were calculated, and associated risk factors were determined. The mean number of days before the first of three consecutive negative sputum smears was 33 days; the median was 23 days. On stepwise multiple regression analysis, cavitary disease, numerous AFB on the initial smear, and no prior history of tuberculosis were the factors independently associated with an increased number of days for both smear and culture conversion. HIV does not prolong the period of infectiousness.

The rapid scale-up of HIV care and treatment in resource-limited settings has overwhelmed many public health laboratory services already burdened with human resource shortages, an aging and inadequate infrastructure, and a lack of quality systems. There is, however, a growing appreciation of the opportunity to use HIV-related laboratory strengthening as means to strengthen health systems in general. We briefly describe ongoing efforts to integrate HIV laboratory support into HIV care and treatment systems, thereby strengthening laboratory systems in support of both HIV scale-up and overall health systems strengthening.

The use of antiretroviral therapy has reduced mortality and shifted the spectrum of malignancies affecting people living with HIV/AIDS (PLWH). We review guidelines and evidence for screening PLWH for non-AIDS-defining malignancies as compared with the general population. Cervical cancer screening clearly differs for HIV-seropositive women, with two Pap tests 6 months apart in the first year and then annually if normal. The role of cervical human papillomavirus screening has not yet been defined in HIV-seropositive women. Anal cancer screening consists of an annual digital rectal examination, and some (but not all) guidelines also recommend annual anal Pap tests. Screening for breast and colorectal cancer should follow standard, age-appropriate screening recommendations that apply to the general population. Screening HIV-infected men for prostate cancer, as with the general population, lacks a clear benefit. Despite increasing rates of hepatocellular carcinoma and lung cancers among PLWH, there is insufficient evidence to support routine screening.

Summary Worldwide, nearly half of all individuals living with HIV are now women, who acquire the virus largely by heterosexual exposure. With an HIV vaccine likely to be years away, topical microbicide formulations applied vaginally or rectally are being investigated as another strategy for HIV prevention. A review of preclinical and clinical research on the development of microbicides formulated to prevent vaginal HIV transmission yielded 118 studies: 73 preclinical and 45 clinical. Preclinical research included in-vitro assays and cervical explant models, as well as animal models. Clinical research included phase I and II/IIb safety studies, and phase III efficacy studies. Whereas most phase I and phase II clinical trials have found microbicide compounds to be safe and well tolerated, phase III trials completed to date have not demonstrated efficacy in preventing HIV transmission. Topical microbicides are grouped into five classes of agents, based on where they disrupt the pathway of sexual transmission of HIV. These classes include surfactants/membrane disruptors, vaginal milieu protectors, viral entry inhibitors, reverse transcriptase inhibitors, and a fifth group whose mechanism is unknown. The trajectory of microbicide development has been toward agents that block more specific virus–host cell interactions. Microbicide clinical trials face scientifically and ethically complex issues, such as the choice of placebo gel, the potential for viral resistance, and the inclusion of HIV-infected participants. Assessment of combination agents will most likely advance this field of research.

Objective: To assess the frequency of diabetes, prediabetes, and insulin resistance among a subset of participants in the Women's Interagency HIV Study (WIHS). Design: Cross-sectional substudy nested within a prospective multicenter cohort study. Women underwent 75 g oral glucose tolerance testing. Diagnoses of diabetes and prediabetes were made according to the American Diabetes Association criteria, and insulin resistance was determined by area under the curve insulin and homeostasis model assessment values. Setting: Six urban clinical sites in the United States (Brooklyn, NY; Bronx, NY; Washington, DC; Chicago, IL; San Francisco, CA; Los Angeles, CA) participate in the entire WIHS. The Bronx, NY, and San Franscisco, CA, WIHS sites participated in this substudy. Participants: A total of 258 women, 88 HIV negative, 74 HIV positive not on highly active antiretroviral therapy (HAART), and 96 HIV positive taking HAART were enrolled in the study. Main Outcomes: Prevalence of diabetes, prediabetes, and insulin resistance was compared among the HIV-uninfected and HIV-infected women. Results: The frequency of diabetes, prediabetes, or insulin resistance was unrelated to HIV status or antiretroviral treatment. Increasing body mass index was the only characteristic associated with the combined endpoints of diabetes and prediabetes (odds ratio = 1.104, P = 0.0002). Conclusions: Routine oral glucose tolerance testing of HIV-infected women is not supported by these findings. Elucidation of putative perturbations from HIV or antiretroviral medications requires direct studies of insulin resistance and β-cell function.

Since the advent of HAART, liver disease has become a leading cause of death in HIV-infected men and women [1, 2]. Death due to liver disease has been attributed to coinfection with hepatitis B virus (HBV), hepatitis C virus (HCV), or both HBV and HCV, as well as to other factors, including the use of alcohol and hepatotoxic medications. Even prior to the advent of HAART, coinfection with HIV and HBV (compared to infection with HIV alone) was associated with reduced survival [3]. In another study of men with chronic HBV infection [4], HIV coinfection was associated with a higher risk of HBV-related cirrhosis and decreased survival. As the clinical significance of coinfection with HIV and HBV becomes better understood, it is imperative to understand the prevalence and correlates of HBV infection in those with and at risk for HIV infection, especially because occult HBV infection (i.e., active HBV replication in the absence of HBV serological data suggestive of active disease) may be more common in this population. HBV infection is highly prevalent in certain populations in the United States; the prevalence approaches 60%–80% in immigrants from areas of endemicity [5], men who have sex with men [4], injection drug users [6], and persons with multiple sexual partners [7]. HIV infection is also highly prevalent in the latter 3 groups, because HBV and HIV infections have similar sexual and parenteral modes of transmission. Users of noninjection drugs have also been identified as a group potentially at high-risk for HBV infection. In a recent study conducted in New York City [8], nearly one-quarter of 483 noninjection heroin users were HBV infected; sexual risk factors appeared responsible for the increased risk. Epidemiologic studies of HBV infection have mainly involved men. The few studies involving women have been in predominantly HIV-uninfected women, and the prevalence of HBV infection has varied widely [7, 9, 10]. Women reporting injection drug use (IDU) and those reporting no history of IDU had prevalences of 74% and 38%, respectively, in a national multisite study conducted from 1986 through 1987 among 1368 female sex workers [7]. This study was conducted prior to the implementation of universal vaccination strategies to reduce HBV transmission and widespread strategies to reduce HIV transmission, which have likely impacted HBV transmission. Two subsequent studies [9, 10], both of which excluded women with a history of IDU, reported prevalences of HBV infection of 19% and 6%, respectively. The first study [9] was conducted from 1990 through 1991 and involved 599 inner city women in Brooklyn, New York; the other [10] was conducted from 1996 through 1998 and involved 1337 low-income young women in the San Francisco Bay area. Few if any studies have explored the prevalence and predictors of HBV infection in a cohort of predominantly HIV-infected women. We determined the prevalence of and risk factors for HBV infection among the participants of the Women’s Interagency HIV Study (WIHS). We performed a cross-sectional analysis of the predictors of HBV infection among women whom, at the time of their enrollment into the WIHS, reported either a history of IDU, a history of noninjection drug use (non-IDU) only, or no history of illicit drug use.

Objective To assess the association between protease inhibitor (PI) use and the incidence of diabetes mellitus (DM) among participants in the Women's Interagency HIV Study. Design Prospective multicenter cohort study. The diagnosis of DM was based on self-report at semiannual interviews conducted from 1994 to 1998. Setting Six inner-city clinical sites in the United States (Brooklyn, NY; Bronx, NY; Washington, DC; Chicago, IL; San Francisco, CA; and Los Angeles, CA). Participants A total of 1785 nonpregnant women who had no history of prior DM. The women made up four groups: 1) PI users (n = 609, person-years [PY] at risk = 707); 2) reverse transcriptase inhibitor (RTI)-only users (n = 932, PY = 1486); 3) HIV-infected women reporting no antiretroviral therapy (ART) ever (n = 816, PY = 1480); and 4) HIV-uninfected women (n = 350, PY = 905). Main outcomes Incidence of DM and median body mass index (BMI) from 1995 to 1998 were compared among the four groups. Results Sixty-nine incident cases of DM occurred among 1785 women (1.5 cases per 100 PY; 95% CI: 1.2-1.9). The incidence of DM among PI users was 2.8 cases per 100 PY (2.8%) versus 1.2% among both RTI users and women on no ART (95% CI: 1.6-4.1 [PI]; 0.7-1.8 [RTI and no ART]; P = 0.01 for comparison of the PI group with the RTI group) and 1.4% among HIV-uninfected women (95% CI: 0.7-2.2, P = 0.06 for comparison with PI group). Weight gain was not associated with either PI or RTI use. Multivariate models identified PI use (hazard ratio [HR] = 2.90 [95% CI: 1.50-5.60]; P = 0.002), age (HR = 1.75 per 10 years [95% CI: 1.31-2.34]; P = 0.0002) and BMI as independent risk factors for DM. Conclusions PI use was associated with a threefold increase in the risk of reporting incident DM. Routine screening for diabetes, particularly among older and heavier patients using PI therapy, is advisable.

Figure 1. A 30-year-old man with the acquired immunodeficiency syndrome (CD4 cell count, 14 per cubic millimeter) presented with a six-month history of enlarging facial lesions. The lesions had not responded to a six-week course of oral acyclovir (800 mg five times a day). The patient had no history of herpes or any other opportunistic infections. His only other medications were dapsone and fluconazole. On examination, he was afebrile and had extensive, friable, hemorrhagic crusts with impetiginization of the chin and around the nares (Panel A). He also had aphthous ulcers on the soft palate and the anterior portion of . . .