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Paul De Lay and co-authors introduce a Collection on the design of targets for ending the AIDS epidemic.

Introduction Until COVID‐19, tuberculosis (TB) was the leading infectious disease killer globally, disproportionally affecting people with HIV. The COVID‐19 pandemic is threatening the gains made in the fight against both diseases. Discussion Although crucial guidance has been released on how to maintain TB and HIV services during the pandemic, it is acknowledged that what was considered normal service pre‐pandemic needs to improve to ensure that we rebuild person‐centred, inclusive and quality healthcare services. The threat that the pandemic may reverse gains in the response to TB and HIV may be turned into an opportunity by pivoting to using proven differentiated service delivery approaches and innovative technologies that can be used to maintain care during the pandemic and accelerate improved service delivery in the long term. Models of care should be convenient, supportive and sufficiently differentiated to avoid burdensome clinic visits for medication pick‐ups or directly observed treatments. Additionally, the pandemic has highlighted the chronic and short‐sighted lack of investment in health systems and the need to prioritize research and development to close the gaps in TB diagnosis, treatment and prevention, especially for children and people with HIV. Most importantly, TB‐affected communities and civil society must be supported to lead the planning, implementation and monitoring of TB and HIV services, especially in the time of COVID‐19 where services have been disrupted, and to report on legal, policy and gender‐related barriers to access experienced by affected people. This will help to ensure that TB services are held accountable by affected communities for delivering equitable access to quality, affordable and non‐discriminatory services during and beyond the pandemic. Conclusions Successfully reaching the related targets of ending TB and AIDS as public health threats by 2030 requires rebuilding of stronger, more inclusive health systems by advancing equitable access to quality TB services, including for people with HIV, both during and after the COVID‐19 pandemic. Moreover, services must be rights‐based, community‐led and community‐based, to ensure that no one is left behind.

Background/Aims HIV continues to be a major public health threat in the United States, and mathematical modeling has demonstrated that the universal effective use of antiretroviral therapy among all HIV-positive individuals (i.e. the “test and treat” approach) has the potential to control HIV. However, to accomplish this, all the steps that define the HIV care continuum must be achieved at high levels, including HIV testing and diagnosis, linkage to and retention in clinical care, antiretroviral medication initiation, and adherence to achieve and maintain viral suppression. The HPTN 065 (Test, Link-to-Care Plus Treat [TLC-Plus]) study was designed to determine the feasibility of the “test and treat” approach in the United States. Methods HPTN 065 was conducted in two intervention communities, Bronx, NY, and Washington, DC, along with four non-intervention communities, Chicago, IL; Houston, TX; Miami, FL; and Philadelphia, PA. The study consisted of five components: (1) exploring the feasibility of expanded HIV testing via social mobilization and the universal offer of testing in hospital settings, (2) evaluating the effectiveness of financial incentives to increase linkage to care, (3) evaluating the effectiveness of financial incentives to increase viral suppression, (4) evaluating the effectiveness of a computer-delivered intervention to decrease risk behavior in HIV-positive patients in healthcare settings, and (5) administering provider and patient surveys to assess knowledge and attitudes regarding the use of antiretroviral therapy for prevention and the use of financial incentives to improve health outcomes. The study used observational cohorts, cluster and individual randomization, and made novel use of the existing national HIV surveillance data infrastructure. All components were developed with input from a community advisory board, and pragmatic methods were used to implement and assess the outcomes for each study component. Results A total of 76 sites in Washington, DC, and the Bronx, NY, participated in the study: 37 HIV test sites, including 16 hospitals, and 39 HIV care sites. Between September 2010 and December 2014, all study components were successfully implemented at these sites and resulted in valid outcomes. Our pragmatic approach to the study design, implementation, and the assessment of study outcomes allowed the study to be conducted within established programmatic structures and processes. In addition, it was successfully layered on the ongoing standard of care and existing data infrastructure without disrupting health services. Conclusion The HPTN 065 study demonstrated the feasibility of implementing and evaluating a multi-component “test and treat” trial that included a large number of community sites and involved pragmatic approaches to study implementation and evaluation.

The World Health Organization (WHO) recommends viral load testing as the preferred method for monitoring the clinical response of patients with human immunodeficiency virus (HIV) infection to antiretroviral therapy (ART) (1). Viral load monitoring of patients on ART helps ensure early diagnosis and confirmation of ART failure and enables clinicians to take an appropriate course of action for patient management. When viral suppression is achieved and maintained, HIV transmission is substantially decreased, as is HIV-associated morbidity and mortality (2). CDC and other U.S. government agencies and international partners are supporting multiple countries in sub-Saharan Africa to provide viral load testing of persons with HIV who are on ART. This report examines current capacity for viral load testing based on equipment provided by manufacturers and progress with viral load monitoring of patients on ART in seven sub-Saharan countries (Côte d'Ivoire, Kenya, Malawi, Namibia, South Africa, Tanzania, and Uganda) during January 2015-June 2016. By June 2016, based on the target numbers for viral load testing set by each country, adequate equipment capacity existed in all but one country. During 2015, two countries tested85% of patients on ART (Namibia [91%] and South Africa [87%]); four countries tested25% of patients on ART. In 2015, viral suppression was80% among those patients who received a viral load test in all countries except Côte d'Ivoire. Sustained country commitment and a coordinated global effort is needed to reach the goal for viral load monitoring of all persons with HIV on ART.

The US President's Emergency Plan for AIDS Relief (PEPFAR) supports aggressive scale-up of antiretroviral therapy (ART) in high-burden countries and across all genders and populations at risk toward global human immunodeficiency virus (HIV) epidemic control. PEPFAR recognizes the risk of HIV drug resistance (HIVDR) as a consequence of aggressive ART scale-up and is actively promoting 3 key steps to mitigate the impact of HIVDR: (1) routine access to routine viral load monitoring in all settings; (2) optimization of ART regimens; and (3) routine collection and analysis of HIVDR data to monitor the success of mitigation strategies. The transition to dolutegravir-based regimens in PEPFAR-supported countries and the continuous evolution of HIVDR surveillance strategies are essential elements of PEPFAR implementation.

The US President's Emergency Plan for AIDS Relief (PEPFAR) supports aggressive scale-up of antiretroviral therapy (ART) in high-burden countries and across all genders and populations at risk toward global human immunodeficiency virus (HIV) epidemic control. PEPFAR recognizes the risk of HIV drug resistance (HIVDR) as a consequence of aggressive ART scale-up and is actively promoting 3 key steps to mitigate the impact of HIVDR: (1) routine access to routine viral load monitoring in all settings; (2) optimization of ART regimens; and (3) routine collection and analysis of HIVDR data to monitor the success of mitigation strategies. The transition to dolutegravir-based regimens in PEPFAR-supported countries and the continuous evolution of HIVDR surveillance strategies are essential elements of PEPFAR implementation.

The Maputo Declaration of 2008 advocated for commitment from global stakeholders and national governments to prioritise support and harmonisation of laboratory systems through development of comprehensive national laboratory strategies and policies in sub-Saharan Africa. As a result, HIV laboratory medicine in Africa has undergone a transformation, and substantial improvements have been made in diagnostic services, networks, and institutions, including the development of a competent workforce, introduction of point-of-care diagnostics, and innovative quality improvement programmes that saw more than 1100 laboratories enrolled and 44 accredited to international standards. These improved HIV laboratories can now be used to combat emerging continental and global health threats in the decades to come. For instance, the unprecedented Ebola virus disease outbreak in west Africa exposed the severe weaknesses in the overall national health systems in affected countries. It is now possible to build robust health-care systems in Africa and to combat emerging continental and global health threats in the future. In this Personal View, we aim to describe the remarkable transformation that has occurred in laboratory medicine to combat HIV/AIDS and improve global health in sub-Saharan Africa since 2008.

In 2006, the District of Columbia Department of Health (DC DOH) launched initiatives promoting routine HIV testing and improved linkage to care in support of revised the Centers for Disease Control and Prevention (CDC) HIV-testing guidelines. An ecological analysis was conducted using population-based surveillance data to determine whether these efforts were temporally associated with increased and earlier identification of HIV/AIDS cases and improved linkages to care. Publically funded HIV-testing data and HIV/AIDS surveillance data from 2005 to 2009 were used to measure the number of persons tested, new diagnoses, timing of entry into care, CD4 at diagnosis and rates of progression to AIDS. Tests for trend were used to determine whether statistically significant changes in these indicators were observed over the five-year period. Results indicated that from 2005 to 2009, publically funded testing increased 4.5-fold; the number of newly diagnosed HIV/AIDS cases remained relatively constant. Statistically significant increases in the proportion of cases entering care within three months of diagnosis were observed (p < 0.0001). Median CD4 counts at diagnosis increased over the five-year time period from 346 to 379 cells/µL. The proportion of cases progressing from HIV to AIDS and diagnosed with AIDS initially, decreased significantly (both p < 0.0001). Routine HIV testing and linkage to care efforts in the District of Columbia were temporally associated with earlier diagnoses of cases, more timely entry into HIV-specialized care, and a slowing of HIV disease progression. The continued use of surveillance data to measure the community-level impact of other programmatic initiatives including test and treat strategies will be critical in monitoring the response to the District's HIV epidemic.

Background In 2014, the Joint United Nations Program on HIV/AIDS (UNAIDS) issued treatment goals for human immunodeficiency virus (HIV). The 90-90-90 target specifies that by 2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. Consistent methods and routine reporting in the public domain will be necessary for tracking progress towards the 90-90-90 target. Methods and findings For the period 2010–2016, we searched PubMed, UNAIDS country progress reports, World Health Organization (WHO), UNAIDS reports, national surveillance and program reports, United States President’s Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans, and conference presentations and/or abstracts for the latest available national HIV care continuum in the public domain. Continua of care included the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed out of the estimated number of PLHIV. We ranked the described methods for indicators to derive high-, medium-, and low-quality continuum. For 2010–2016, we identified 53 national care continua with viral suppression estimates representing 19.7 million (54%) of the 2015 global estimate of PLHIV. Of the 53, 6 (with 2% of global burden) were high quality, using standard surveillance methods to derive an overall denominator and program data from national cohorts for estimating steps in the continuum. Only nine countries in sub-Saharan Africa had care continua with viral suppression estimates. Of the 53 countries, the average proportion of the aggregate of PLHIV from all countries on ART was 48%, and the proportion of PLHIV who were virally suppressed was 40%. Seven countries (Sweden, Cambodia, United Kingdom, Switzerland, Denmark, Rwanda, and Namibia) were within 12% and 10% of achieving the 90-90-90 target for “on ART” and for “viral suppression,” respectively. The limitations to consider when interpreting the results include significant variation in methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain. Conclusions Relatively few complete national continua of care are available in the public domain, and there is considerable variation in the methods for determining progress towards the 90-90-90 target. Despite bearing the highest HIV burden, national care continua from sub-Saharan Africa were less likely to be in the public domain. A standardized monitoring and evaluation approach could improve the use of scarce resources to achieve 90-90-90 through improved transparency, accountability, and efficiency., In a systematic review, Reuben Granich and colleagues assess the quality and comparability of publicly available data on national HIV care continua and progress towards the 90-90-90 targets., Author summary Why was this study done? Treatment prevents human immunodeficiency virus (HIV) illness, death, and transmission, prompting the Joint UN Program on HIV/AIDS (UNAIDS) to issue the 90-90-90 target. The 90-90-90 target specifies that by 2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. Our review aims to answer three critical questions: (1) What data for national continua of care are available in the public domain? (2) What is the quality and comparability of the information presented? and (3) How close are we to achieving the UNAIDS 90-90-90 targets? What did the researchers do and find? For the period 2010–2016, we searched the public domain for the latest available national HIV care continuum with the number and proportion of people living with HIV (PLHIV) who are diagnosed, on ART, and virally suppressed. We found 53 national care continua with viral suppression estimates (representing 54% of the 2015 global estimate of PLHIV), and the average proportion of PLHIV on ART and the average proportion of PLHIV who were virally suppressed were 48% and 40%, respectively. Although seven countries (Sweden, Cambodia, UK, Switzerland, Denmark, Rwanda, and Namibia) had reached or were within 12% and 10% of achieving the 90-90-90 target for “on ART” and for “viral suppression,” only 9 countries in sub-Saharan Africa had care continua with viral suppression estimates in the public domain. Limitations include significant variation in the methods used to determine national continua and the possibility that complete continua were not available through our comprehensive search of the public domain. What do these findings mean? Many countries are progressing toward and will likely achieve 90-90-90; however, it will be important to use consistent and accurate methods to report on progress. Relatively few complete national continua of care are available in the public domain, and there is wide variation in the methods for determining progress towards the 90-90-90 target. Despite bearing the highest HIV burden, complete national care continua from sub-Saharan Africa were less likely to be in the public domain. A standardized monitoring and evaluation approach could improve the use of scarce resources to achieve 90-90-90 through improved transparency, accountability, and efficiency.

Objectives. In June 2006, the District of Columbia (DC) Department of Health launched a citywide rapid HIV screening campaign. Goals included raising HIV awareness, routinizing rapid HIV screening, identifying previously unrecognized infections, and linking positives to care. We describe findings from this seminal campaign and identify lessons learned. Methods. We applied a mixed-methods approach using quantitative analysis of client data forms (CDFs) and qualitative evaluation of focus groups with DC residents. We measured characteristics and factors associated with client demographics, test results, and community perceptions regarding the campaign. Results. Data were available on 38,586 participants tested from July 2006 to September 2007. Of those, 68% had previously tested for HIV (44% within the last 12 months) and 23% would not have sought testing had it not been offered. Overall, 662 (1.7%) participants screened positive on the OraQuick® Advance™ rapid HIV test, with non-Hispanic black people, transgenders, and first-time testers being significantly more likely to screen positive for HIV than white people, males, and those tested within the last year, respectively. Of those screening positive for HIV, 47% had documented referrals for HIV care and treatment services. Focus groups reported continued stigma regarding HIV and minimal community saturation of the campaign. Conclusions. This widespread campaign tested thousands of people and identified hundreds of HIV-infected individuals; however, referrals to care were lower than anticipated, and awareness of the campaign was limited. Lessons learned through this scale-up of population-based HIV screening resulted in establishing citywide HIV testing processes that laid the foundation for the implementation of test-and-treat activities in DC.

Objectives To assess the prevalence and patterns of substance use, HIV prevalence, and sexual risk behaviors in a community-based sample of heterosexuals recruited from areas at high risk for HIV/AIDS and poverty in Washington, DC. Methods Community-recruited heterosexuals aged 18–50 from areas of high AIDS and poverty rates in DC were analyzed. Based on past 12 months use, participants were hierarchically classified into five groups: (1) ever injection drug use (IDU); (2) non-injection crack; (3) non-injection heroin and cocaine; (4) marijuana; and (5) no drug use. Sexual behaviors and HIV serology were also assessed. Results Of 862 participants, 40% were men, most were Black and unemployed, and more than half had ever been incarcerated. Prevalence of past year substance use was high: binge drinking (59%); marijuana (50%); non-injection crack (28%); heroin and/or cocaine injection (28%), non-injection cocaine (13%); and ecstasy (13%). In the hierarchical classification, 25% were ever IDU, 15% non-injection crack users, 2% non-injection heroin and/or cocaine users, 31% marijuana users, and 27% reported no drug use. Overall HIV seroprevalence was 5.7% and differed by drug use group—9.5%, 11.1%, 1.8%, 1.6%, and 3.2%, respectively. Nearly half reported having ≥3 sex partners in the past year; 20% reported exchange partners, and 69% had concurrent sex partners. Conclusion Estimated prevalence of substance use in this heterosexual population was high. HIV prevalence among IDUs and non-injection crack users was higher than the estimated population prevalence in Washington, DC. Sexual behaviors above and beyond drug use are likely to be driving HIV transmission.

The District of Columbia (DC) has among the highest HIV/AIDS rates in the United States, with 3.2% of the population and 7.1% of black men living with HIV/AIDS. The purpose of this study was to examine HIV risk behaviors in a community-based sample of men who have sex with men (MSM) in DC. Data were from the National HIV Behavioral Surveillance system. MSM who were 18 years were recruited via venue-based sampling between July 2008 and December 2008. Behavioral surveys and rapid oral HIV screening with OraQuick ADVANCE ½ (OraSure Technologies, Inc., Bethlehem, PA) with Western blot confirmation on positives were collected. Factors associated with HIV positivity and unprotected anal intercourse were identified. Of 500 MSM, 35.6% were black. Of all men, 14.1% were confirmed HIV positive; 41.8% of these were newly identified HIV positive. Black men (26.0%) were more likely to be HIV positive than white (7.9%) or Latino/Asian/other (6.5%) men (p

An adherence-focused case management intervention was evaluated in 84 public clinic patients in Los Angeles County, California, and included weekly contact with a paraprofessional case manager development of an individualized highly-active antiretroviral therapy (HAART) adherence support plan, and referrals to ancillary services. Participants were primarily Latino (65%) or African American (25%); male (74%); monolingual Spanish-speakers (57%) with annual incomes under $10,000 (65%). Participants were in the intervention for a median of 26 weeks; attended 67% of appointments; participated in an average of 9 hours of case management; and each visit averaged 23 minutes. Seventy-two percent of the goals established at baseline were achieved and 74% of referrals were completed. The most common goals were related to adherence (16%), housing (12%), or nutrition (12%). Self-reported adherence to HAART was no different for intervention participants compared to those in standard case management at 6 months. These d...

From a trial comparing interventions to improve adherence to antiretroviral therapy-directly administered antiretroviral therapy (DAART) or an intensive adherence case management (IACM)-to standard of care (SOC), for HIV-infected participants at public HIV clinics in Los Angeles County, California, we examined the cost of adherence programs and associated health care utilization. We assessed differences between DAART, IACM, and SOC in the rate of hospitalizations, hospital days, and outpatient and emergency department visits during an average of 1.7 years from study enrollment, beginning November 2001. We assigned costs to health care utilization and program delivery. We calculated incremental costs of DAART or IACM v SOC, and compared those costs with savings in health care utilization among participants in the adherence programs. IACM participants experienced fewer hospital days compared with SOC (2.3 versus 6.7 days/1000 person-days, incidence rate ratio [IRR]: 0.34, 97.5% confidence interval [CI]: 0.13-0.87). DAART participants had more outpatient visits than SOC (44.2 versus 31.5/1000 person-days, IRR: 1.4; 97.5% CI: 1.01-1.95). Average per-participant health care utilization costs were $13,127, $8,988, and $14,416 for DAART, IACM, and SOC, respectively. Incremental 6-month program costs were $2,120 and $1,653 for DAART and IACM participants, respectively. Subtracting savings in health care utilization from program costs resulted in an average net program cost of $831 per DAART participant; and savings of $3,775 per IACM participant. IACM was associated with a significant decrease in hospital days compared to SOC and was cost saving when program costs were compared to savings in health care utilization.

Background. A randomized, controlled trial was conducted to evaluate the impact of a directly administered antiretroviral therapy program (DAART) and intensive adherence case management (IACM) intervention on virologic and immunologic response to highly active antiretroviral therapy (HAART) among patients at 3 public human immunodeficiency virus clinics in Los Angeles County, California. Methods. Participants included 250 treatment-naive and treatment-experienced persons for whom no more than 1 prior HAART regimen had failed. Five days per week for 6 months, a community worker delivered 1 HAART dose to DAART participants and observed the participant take it. IACM participants met weekly with a case manager to overcome barriers to HAART adherence. A control group (the standard of care [SOC] group) received the usual care. Results. The majority of patients were Latino (64%) or African American (24%); 57% were monolingual Spanish speakers. Seventy-five percent of the patients were male, and 64% reported an annual income of !$10,000. In an intent-to-treat analysis, no statistical differences were observed in the percentage of patients with an undetectable viral load (i.e., !400 copies/mL) at 6 months between the DAART group (54%), IACM group (60%), and SOC group (54%; ). An on-treatment analysis determined that there were no statistical differences in P 1 .05 the percentage of patients with an undetectable viral load at 6 months between the DAART group (71%), IACM group (80%), and SOC group (74%; ). Additionally, there were no statistical differences in 6-month changes P 1 .05 in the CD4 + cell count or in self-reported adherence to therapy. Conclusions. Among patients with limited prior HAART experience and adherence barriers that had not been assessed before randomization, no differences were found in virologic or immunologic response for DAART or IACM, compared with SOC, at 6 months. DAART and IACM did not improve short-term outcomes when SOC included other means of adherence support that were not controlled for by the study design.

Background. Directly administered antiretroviral therapy (DAART) in methadone clinics has the potential to improve treatment outcomes for human immunodeficiency virus (HIV)—infected injection drug users (IDUs).Methods. DAART was provided at 3 urban methadone clinics. Eighty-two participants who were initiating or reinitiating highly active antiretroviral therapy (HAART) received supervised doses of therapy at the clinic on the mornings on which they received methadone. Treatment outcomes in the DAART group were compared with outcomes in 3 groups of concurrent comparison patients, who were drawn from the Johns Hopkins HIV Cohort. The concurrent comparison patients were taking HAART on a self-administered basis. The 3 groups of concurrent comparison patients were as follows: patients with a history of IDU who were receiving methadone at the time HAART was used (the IDU-methadone group; 75 patients), patients with a history of IDU who were not receiving methadone at the time that HAART was used (the IDU-nonmethadone group; 244 patients), and patients with no history of IDU (the non-IDU group; 490 patients).Results. At 12 months, 56% of DAART participants achieved an HIV type 1 RNA level

Improved treatment-adherence support programs are needed to help human immunodeficiency virus (HIV)-infected persons comply with complex highly active antiretroviral treatment (HAART) regimens. In an experimental directly administered antiretroviral therapy (DAART) program, treatment-naive and treatment-experienced persons who experienced failure of no more than 1 prior regimen were recruited from 3 public HIV/AIDS clinics in Los Angeles County. For 6 months, trained community workers observed ingestion of 1 of 2 daily HAART doses, 5 days per week, and questioned the patient about the second dose, which enabled intense adherence monitoring and real-time intervention. From November 2001 through November 2003, there were 67 DAART patients enrolled (69% Latino, 21% African American, and 9% white; 63% with annual income of

Methadone-maintenance treatment clinics are strategically appealing sites for provision of directly administered antiretroviral therapy (DAART) to human immunodeficiency virus type 1 (HIV-1)-infected injection drug users (IDUs). We initiated an ongoing DAART protocol at a university-associated methadone clinic in April 2001, which continues to enroll participants. Participants ingested antiretroviral medications under direct supervision on days they attended the clinic; evening doses and doses on "methadone take-home days" were self-administered. Comparison IDUs receiving either standard care or treatment-adherence support were randomly selected from the population of the HIV-1 clinic where DAART participants received their primary care for HIV-1 infection, with frequency matching by sex, prior antiretroviral exposure, and receipt of methadone therapy. In an intention-to-treat analysis, 79% of DAART participants achieved HIV-1 RNA levels of

Public-private partnerships (PPPs) align public and private needs around mutual goals to move vital projects forward. When PPPs work to strengthen the critical link in the healthcare system, such aslaboratorynetworks,as demonstrated inthissupplementbyauthors from the International Laboratory Branch at the Centers for Disease Control and Prevention (CDC), in-country officials from therespectiveCDCandMinistriesofHealth,implementingpartners, and Becton, Dickinson, and Company (BD), they significantly change the landscape of healthcare and patient outcomes. The laboratory networks in African countries supported by a PPP between BD and US President’s Emergency Plan for AIDS Relief are achieving a positive transformation. Over the years, thePPPhasdemonstratedsignificantcontributionsindeveloping a more competent laboratory workforce, reinforced laboratory systems, and improved treatment efficiencies by significantly reducing turnaround time to provide accurate laboratory results to patients afflicted by deadly diseases, such as multidrug resistant tuberculosis and human immunodeficiency virus (HIV). This PPP has not just improved efficiencies in the countries where they exist, it has also provided a successful model for other low-income countries to consider. The effort needed to meet the UNAIDS 90-90-90 treatment goals to help end the AIDS epidemic by 2020 is tremendous, and neither governments nor the private sector can do it alone. These goals, which state that, by 2020, all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy will have viral suppression, are being significantly advanced as a result of this collaboration. We encourage more entities—public, private, health ministries, and nongovernmental organizations— to consider PPPs as an opportunity to efficiently and synergistically meet the needs of people living with HIV/AIDS and of their caregivers.

Objectives: Recent data suggest that community viral load (CVL) can be used as a population-level biomarker for HIV transmission and its reduction may be associated with a decrease in HIV incidence. Given the magnitude of the HIV epidemic in Washington, District of Columbia, we sought to measure the District of Columbia’s CVL. Design: An ecological analysis was conducted. Methods: Mean and total CVL were calculated using the most recent viral load for prevalent HIV/AIDS cases reported to District of Columbia HIV/AIDS surveillance through 2008. Univariate and multivariable analyses were conducted to assess differences in CVL availability, mean CVL, proportion of undetectable viral loads, and 5-year trends in mean CVL and new HIV/AIDS diagnoses. Geospatial analysis was used to map mean CVL and selected indicators of socioeconomic status by geopolitical designation. Results: Among 15 467 HIV/AIDS cases alive from 2004 to 2008, 48.2% had at least one viral load reported. Viral load data completeness increased significantly over the 5 years (P < 0.001). Mean CVL significantly decreased over time (P < 0.0001). At the end of 2008, the mean CVL was 33 847 copies/ml; 57.4% of cases had undetectable viral loads. Overlaps in the geographic distribution of CVL by census tract were observed with the highest means observed in areas with high poverty rates and low high school diploma rates. Conclusion: Mean and total CVL provide markers of access to care and treatment, are indicators of the population’s viral burden, and are useful in assessing trends in local HIV/AIDS epidemics. Measurement of CVL is a novel tool for assessing the potential impact of population-level HIV prevention and treatment interventions. 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2012, 26:345–353

Washington, D.C., is the capital of the United States and is a major center for public health and health policy expertise. Yet the District of Columbia has an HIV prevalence rate among adults of 3 percent, on par with some sub-Saharan African countries. To date, the local public health response has not controlled the epidemic. The ways in which that response has been galvanized in recent years--through collaboration among the capital's public health agencies, community and faith organizations, and research institutions--may be instructive to other jurisdictions combating HIV/AIDS.

Objectives: Washington, District of Columbia has the highest HIV/AIDS rate in the United States, with heterosexual transmission a leading mode of acquisition and African–American women disproportionately affected. The purpose of this study was to examine risk factors driving the emergence of the local epidemic using National HIV Behavioral Surveillance data from the District of Columbia. Design: The design of the study is cross-sectional. Methods: Individuals at high risk for HIV based on connection to areas with elevated AIDS and poverty were collected from December 2006 to October 2007. Analyses characterized participants from a respondent-driven, nonclinic-based sample; factors associated with preliminary HIV positivity were assessed with logistic regression. Results: Of 750 participants, 61.4% were more than 30 years of age, 92.3% African–American, and 60.0% with an annual household income of less than $10 000; 5.2% (95% confidence interval, 2.9–7.2%) screened HIV positive; women were more likely to screen positive than men (6.3 versus 3.9%). Of those, 47.4% (95% confidence interval, 30.9–78.7%) did not know their status prior to the study. Last vaginal sex was unprotected for 71.2% of respondents; 44.9% reported concurrent sex partners, and 45.9% suspected concurrency in their partners. Correlates of screening HIV positive were identified. Conclusion: This study suggests that a generalized heterosexual HIV epidemic among African–Americans in communities at risk may be emerging in the nation's capital alongside concentrated epidemics among men who have sex with men and injecting drug users. Innovation of prevention strategies is necessary in order to slow the epidemic in District of Columbia.

The main objective of this paper was to identify HIV risk factors at the individual, partner, and partnership levels among married, lifetime monogamous women in a nationally representative sample of Zimbabweans aged 15–29 years. Cross-sectional data were collected through individual survey interviews among 1,286 women who provided blood for HIV testing. The HIV prevalence among these women was high (21.8%). HIV risk increased with female age, within-couple age difference of more than 5 years, the husband having children with other women, and the respondent being ‘extremely likely’ to discuss monogamy in the next 3 months with her husband. The latter suggests that women were attempting to communicate their concerns while unaware that they were already HIV positive. HIV risk largely appears related to the partner’s past and present sexual behavior, resulting in limited ability for married women to protect themselves from infection. Overall, lifetime monogamy offers insufficient protection for women.

Supervised dosing is a cornerstone of tuberculosis treatment. HIV treatment strategies that use directly administered antiretroviral therapy (DAART) are increasingly being assessed. In a prospective single-arm clinical trial, we enrolled methadone-maintained, HIV-infected participants to receive supervised doses of antiretroviral therapy (ART) on days when they received methadone. Other ART doses were self-administered. In this analysis we examined factors associated with retention to DAART, adherence to supervised doses, and virologic failure. Factors associated with retention to DAART were assessed with the Kaplan-Meier method and Cox proportional hazards models. Factors associated with nonadherence with supervised dosing and with virologic failure were assessed by logistic regression and techniques for longitudinal data analysis. A total of 16,453 supervised doses were administered to 88 participants over a median follow-up of 9.4 months. The median participant adherence with supervised dosing was 83%. Active drug use, determined by urine drug screens, was associated twofold increased risks of both intervention dropout and nonadherence with supervised doses. Adherence with supervised doses was strongly associated with virologic failure. Because DAART was administered only on methadone dosing days, fewer than half of the total ART doses were scheduled to be supervised in most participants. The percent of doses that was scheduled to be supervised was not associated with either adherence or with virologic failure. Given that a relatively small proportion of the total ART doses were supervised in many patients, future studies should assess how DAART affects adherence with nonsupervised doses and retention to ART.

Background: This paper brings together data from a variety of reports to provide a basis for assessing future steps for responding to and monitoring the HIV epidemic in Zimbabwe. Method: Data reported from four antenatal clinic (ANC) surveys conducted between 2000 and 2004, two small local studies in Zimbabwe conducted from 1997 through 2003, four general population surveys from 1999 through 2003, and service statistics covering 1990 through 2004 were used to describe recent trends in HIV prevalence and incidence, behaviour change, and programme provision. Results: HIV prevalence among pregnant women attending ANCs declined substantially from 32.1% in 2000 to 23.9% in 2004. The local studies confirmed the decline in prevalence. However, prevalence continued to be high. Sexual behaviour data from surveys suggests a reduction in sexual experience before age 15 years among both males and females age 15–19 years, and in the proportions of males and females aged 15–29 years reporting non-regular sexual partners in the past 12 months. Reported condom use with non-regular partners has been high since 1999. Condom distribution and HIV counseling and testing increased from 2000 to 2004. Discussion: On the basis of examination of data from a variety of sources, the recent decrease in HIV prevalence may be related to recent reductions in early-age sexual activity and non-regular sexual partnerships and increases in condom use. Comparison of data from sentinel surveillance systems, population based serosurveys, local studies, and service statistics provide increased confidence that a decline in HIV prevalence in Zimbabwe is actually happening in the population.

The Centers for Disease Control and Prevention (CDC) has participated in collaborative HIV prevention research activities in injection drug users (IDUs) with the Bangkok Metropolitan Administration (BMA) in Bangkok, Thailand, from 1995 to the present and with the Orel AIDS Center in Orel Oblast, Russia, from 2001 to 2003. Studies in Bangkok have included an HIV prevention trial preparatory cohort from 1995 to 1998, a seroconverter cohort from 1998 to the present, a phase III trial of the AIDSVAX B/E gp 120 HIV vaccine from 1999 to 2003, and a phase II/III HIV prophylaxis trial with tenofovir scheduled to begin in 2005. Activities in Orel included a review of HIV surveillance data in 2001, focus group discussions and a case-control study with HIV-infected and-uninfected IDUs in 2001, a cross-sectional study with the female sex partners of male IDUs in 2002, and a community outreach intervention in 2002–2003. In Bangkok, 1,209 IDUs were enrolled in the preparatory cohort which revealed an HIV incidence of 5.8% per 100 person-years; 133 HIV-infected IDUs have been followed in the seroconverter cohort with >85% follow-up and HIV and tuberculosis care provided; 2,546 IDUs were enrolled in the HIV vaccine efficacy trial which was successfully completed with a followup rate of >95%, although the vaccine was not shown to be effective at reducing HIV incidence; and 1,600 IDUs will be enrolled in the daily tenofovir HIV prophylaxis trial in 2005. In Orel, initial focus group discussions and epidemiologic studies revealed low HIV knowledge and high rates of unsafe injecting and sexual practices among IDUs and their female sex partners; and educational campaigns and the community outreach intervention were developed and implemented. A steady decline in new HIV infections in IDUs was then observed in Orel in 2002–2003. CDC has participated in the conduct of successful collaborative HIV prevention research activities in Thailand and Russia over the past decade. The establishment of long-term relationships with in-country public health and community partners has been instrumental in the success of these efforts.

ContextDuring the past decade, knowledge of human immunodeficiency virus (HIV) infection in women has expanded considerably but may not be easily accessible for use in understanding and prioritizing the clinical needs of HIV-infected women.ObjectivesTo perform a comprehensive review of epidemiologic, clinical, psychosocial, and behavioral information about HIV in women, and to recommend an agenda for future activities.Data SourcesA computerized search, using MEDLINE and AIDSline, of published literature was conducted; journal articles from January 1981 through July 2000 and scientific conference presentations from January 1999 through July 2000 were retrieved and reviewed for content; article reference lists were used to identify additional articles and presentations of interest.Study SelectionData from surveillance and prospective cohort studies with at least 20 HIV-infected women and appropriate comparison groups were preferentially included.Data ExtractionIncluded studies of historical importance and subsequent refined analyses of topics covered therein; these and studies with more current data were given preference. Four studies involving fewer than 20 women were included; 2 studies were of men only.Data SynthesisWomen account for an increasing percentage of all acquired immunodeficiency syndrome (AIDS) cases, from 6.7% (1819/27 140 cases) in 1986 to 18% (119 810/724 656 cases) in 1999. By the end of 1998, of all newly reported AIDS cases among women, proportionally more were in the South (41%), among black women (61%), and from heterosexual transmission (38%). Of note, increasingly more women have no identified or reported risk, about half or more of whom are estimated to be infected heterosexually. It is estimated that a total of at least 54% of women newly reported with AIDS in 1998 acquired HIV through heterosexual sex, including women in the no identified or reported risk category estimated to have been infected heterosexually, meeting the surveillance heterosexual risk definition. Natural history, progression, survival, and HIV-associated illnesses—except for those of the reproductive tract—thus far appear to be similar in HIV-infected women and men. Although antiretroviral therapy has proven to be highly effective in improving HIV-related morbidity and mortality rates, women may be less likely than men to use these therapies. Drug use, high-risk sex behaviors, depression, and unmet social needs interfere with women's use of available HIV prevention and treatment resources.ConclusionsContinued research on HIV pathogenesis and treatment is needed; however, emphasis should also be placed on using existing knowledge to improve the clinical care of women by enhancing use of available services and including greater use of antiretroviral therapy options, treating depression and drug use, facilitating educational efforts, and providing social support for HIV-infected women.

Background Increased funding for global human immunodeficiency virus prevention and control in developing countries has created both a challenge and an opportunity for achieving long-term global health goals. This paper describes a programme in Zimbabwe aimed at responding more effectively to the HIV/AIDS epidemic by reinforcing a critical competence-based training institution and producing public health leaders. Methods The programme used new HIV/AIDS programme-specific funds to build on the assets of a local education institution to strengthen and expand the general public health leadership capacity in Zimbabwe, simultaneously ensuring that they were trained in HIV interventions. Results The programme increased both numbers of graduates and retention of faculty. The expanded HIV/AIDS curriculum was associated with a substantial increase in trainee projects related to HIV. The increased number of public health professionals has led to a number of practically trained persons working in public health leadership positions in the ministry, including in HIV/AIDS programmes. Conclusion Investment of a modest proportion of new HIV/AIDS resources in targeted public health leadership training programmes can assist in building capacity to lead and manage national HIV and other public health programmes.

This publication addresses research questions related to an increase in the levels of access and utilization for four key interventions that have the potential to significantly reduce HIV infections among People Who Inject Drugs (PWID) and their sexual and injecting partners, and hence morbidity and mortality in low and middle-income countries (LMIC). These interventions are drawn from nine consensus interventions that comprise a 'comprehensive package' for PWID. The four interventions are: Needle and Syringe Programs (NSP), Medically Assisted Therapy (MAT), HIV Counseling and Testing (HCT), and Antiretroviral Therapy (ART). The book summarizes the results from several recent reviews of studies related to the effectiveness of the four key interventions in reducing risky behaviors in the context of transmitting or acquiring HIV infection. Overall, the four key interventions have strong effects on the risk of HIV infection among PWID via different pathways, and this determination is included in the documents proposing the comprehensive package of interventions. In order to attain the greatest effect from these interventions, structural issues must be addressed, especially the removal of punitive policies targeting PWID in many countries. The scientific evidence presented here, the public health rationale, and the human rights imperatives are all in accord: we can and must do better for PWID. The available tools are evidence-based, right affirming, and cost effective. What are required now are political will and a global consensus that this critical component of global HIV can no longer be ignored and under-resourced.