Describing the effect of COVID-19 on sexual and healthcare-seeking behaviours of men who have sex with men in three counties in Kenya: a cross-sectional study.

BACKGROUND: While the COVID-19 pandemic disrupted HIV preventative services in sub-Saharan Africa, little is known about the specific impacts the pandemic has had on men who have sex with men (MSM) in Kenya. METHODS: Data were from an HIV self-testing intervention implemented in Kisumu, Mombasa and Kiambu counties in Kenya. Baseline data collection took place from May to July 2019, and endline in August-October 2020, coinciding with the lifting of some COVID-19 mitigation measures. Using endline data, this study characterised the impact the pandemic had on participants' risk behaviours, experience of violence and behaviours related to HIV. Logistic regression was used to understand factors related to changes in risk behaviours and experiences of violence; adjusted AORs (AORs) and 95% CIs are reported. RESULTS: Median age was 24 years (IQR: 21-27). Most respondents (93.9%) reported no change or a decrease in the number of sexual partners (median number of male sexual partners: 2, IQR: 2-4). Some participants reported an increase in alcohol (10%) and drug (16%) consumption, while 40% and 28% reported decreases in alcohol and drug consumption, respectively. Approximately 3% and 10% reported an increase in violence from intimate partners and police/authorities, respectively. Compared with those with primary education, those with post-secondary education were 60% less likely to report an increase in the number of male sexual partners per week (AOR: 0.4, 95% CI: 0.2 to 0.9), while those who were HIV positive were at twofold the odds of reporting an increase or sustained levels of violence from intimate partners (AOR: 2.0, 95% CI: 1.1 to 4.0). CONCLUSION: The results of this study demonstrate heterogeneity in participants' access to preventative HIV and clinical care services in Kenya after the onset of the COVID-19 epidemic. These results indicate the importance of responding to specific needs of MSM and adapting programmes during times of crisis.

Regional and country-level trends in cervical cancer screening coverage in sub-Saharan Africa: A systematic analysis of population-based surveys (2000-2020).

BACKGROUND: Sub-Saharan Africa (SSA) has the highest cervical cancer (CC) burden globally-worsened by its HIV epidemics. In 2020, the World Health Organization (WHO) introduced a CC elimination strategy with goals for vaccination, screening, and treatment. To benchmark progress, we examined temporal trends in screening coverage, percent screened at least twice by the age of 45, screening coverage among women living with HIV (WLHIV), and pre-cancer treatment coverage in SSA. METHODS AND FINDINGS: We conducted a systematic analysis of cross-sectional population-based surveys. It included 52 surveys from 28 countries (2000 to 2020) with information on CC screening among women aged 25 to 49 years (N = 151,338 women). We estimated lifetime and past 3-year screening coverage by age, year, country, and HIV serostatus using a Bayesian multilevel model. Post-stratification and imputations were done to obtain aggregate national, regional, and SSA-level estimates. To measure re-screening by age 45, a life table model was developed. Finally, self-reported pre-cancer treatment coverage was pooled across surveys using a Bayesian meta-analysis. Overall, an estimated 14% (95% credible intervals [95% CrI]: 11% to 21%) of women aged 30 to 49 years had ever been screened for CC in 2020, with important regional and country-level differences. In Eastern and Western/Central Africa, regional screening coverages remained constant from 2000 to 2020 and WLHIV had greater odds of being screened compared to women without HIV. In Southern Africa, however, screening coverages increased and WLHIV had equal odds of screening. Notably this region was found to have higher screening coverage in comparison to other African regions. Rescreening rates were high among women who have already been screened; however, it was estimated that only 12% (95% CrI: 10% to 18%) of women had been screened twice or more by age 45 in 2020. Finally, treatment coverage among 4 countries with data was 84% (95% CrI: 70% to 95%). Limitations of our analyses include the paucity of data on screening modality and the few countries that had multiple surveys. CONCLUSION: Overall, CC screening coverage remains sub-optimal and did not improve much over the last 2 decades, outside of Southern Africa. Action is needed to increase screening coverage if CC elimination is to be achieved.

A cross-sectional survey exploring HIV and HCV prevalence among men who purchase sex in Dnipro, Ukraine.

BACKGROUND: HIV programming in Ukraine largely targets "key population" groups. Men who purchase sex are not directly reached. The aim of our study was to explore the prevalence of sexually transmitted and blood-borne infections (STBBIs) among men who purchase sex from female sex workers. METHODS: Following geographic mapping and population size estimation at each "hotspot", we conducted a cross-sectional bio-behavioural survey with men who purchase sex between September 2017 and March 2018 in Dnipro, Ukraine. Eligibility criteria included purchasing sex services at a "hotspot" and being ≥ 18 years. Participants completed a structured questionnaire, followed by HIV/HCV rapid testing and a dried blood spot (DBS) sample collection for confirmatory serology. RESULTS: The study enrolled 370 participants. The median age was 32 (interquartile range [IQR] = 27-38) and the median age of first purchase of sexual services was 22 (IQR = 19-27). Over half (56%) of participants reported ever testing for HIV; four participants (2%, N = 206) reported having tested positive for HIV, with three out of the four reporting being on ART. Forty percent of participants had ever tested for HCV, with three (2%, N = 142) having ever tested positive for HCV. In DBS testing, nine participants (2.4%) tested positive for HIV and 24 (6.5%) tested positive for ever having an HCV infection. CONCLUSION: Prevalence of HIV and HCV in this population was high. Given high rates of study enrolment and testing, efforts should be made to reach men who purchase sex with expanded STBBI programming.

PopART-IBM, a highly efficient stochastic individual-based simulation model of generalised HIV epidemics developed in the context of the HPTN 071 (PopART) trial.

Mathematical models are powerful tools in HIV epidemiology, producing quantitative projections of key indicators such as HIV incidence and prevalence. In order to improve the accuracy of predictions, such models need to incorporate a number of behavioural and biological heterogeneities, especially those related to the sexual network within which HIV transmission occurs. An individual-based model, which explicitly models sexual partnerships, is thus often the most natural type of model to choose. In this paper we present PopART-IBM, a computationally efficient individual-based model capable of simulating 50 years of an HIV epidemic in a large, high-prevalence community in under a minute. We show how the model calibrates within a Bayesian inference framework to detailed age- and sex-stratified data from multiple sources on HIV prevalence, awareness of HIV status, ART status, and viral suppression for an HPTN 071 (PopART) study community in Zambia, and present future projections of HIV prevalence and incidence for this community in the absence of trial intervention.

Spatial modeling of individual-level infectious disease transmission: Tuberculosis data in Manitoba, Canada.

Geographically dependent individual level models (GD-ILMs) are a class of statistical models that can be used to study the spread of infectious disease through a population in discrete-time in which covariates can be measured both at individual and area levels. The typical ILMs to illustrate spatial data are based on the distance between susceptible and infectious individuals. A key feature of GD-ILMs is that they take into account the spatial location of the individuals in addition to the distance between susceptible and infectious individuals. As a motivation of this article, we consider tuberculosis (TB) data which is an infectious disease which can be transmitted through individuals. It is also known that certain areas/demographics/communities have higher prevalent of TB (see Section 4 for more details). It is also of interest of policy makers to identify those areas with higher infectivity rate of TB for possible preventions. Therefore, we need to analyze this data properly to address those concerns. In this article, the expectation conditional maximization algorithm is proposed for estimating the parameters of GD-ILMs to be able to predict the areas with the highest average infectivity rates of TB. We also evaluate the performance of our proposed approach through some simulations. Our simulation results indicate that the proposed method provides reliable estimates of parameters which confirms accuracy of the infectivity rates.

Prevalence and patterns of gender-based violence across adolescent girls and young women in Mombasa, Kenya.

BACKGROUND: We sought to estimate the prevalence and describe heterogeneity in experiences of gender-based violence (GBV) across subgroups of adolescent girls and young women (AGYW). METHODS: We used data from a cross-sectional bio-behavioural survey among 1299 AGYW aged 14-24 in Mombasa, Kenya in 2015. Respondents were recruited from hotspots associated with sex work, and self-selected into one of three subgroups: young women engaged in casual sex (YCS), young women engaged in transactional sex (YTS), and young women engaged in sex work (YSW). We compared overall and across subgroups: prevalence of lifetime and recent (within previous year) self-reported experience of physical, sexual, and police violence; patterns and perpetrators of first and most recent episode of physical and sexual violence; and factors associated with physical and sexual violence. RESULTS: The prevalences of lifetime and recent physical violence were 18.0 and 10.7% respectively. Lifetime and recent sexual violence respectively were reported by 20.5 and 9.8% of respondents. Prevalence of lifetime and recent experience of police violence were 34.7 and 25.8% respectively. All forms of violence were most frequently reported by YSW, followed by YTS and then YCS. 62%/81% of respondents reported having sex during the first episode of physical/sexual violence, and 48%/62% of those sex acts at first episode of physical/sexual violence were condomless. In the most recent episode of violence when sex took place levels of condom use remained low at 53-61%. The main perpetrators of violence were intimate partners for YCS, and both intimate partners and regular non-client partners for YTS. For YSW, first-time and regular paying clients were the main perpetrators of physical and sexual violence. Alcohol use, ever being pregnant and regular source of income were associated with physical and sexual violence though it differed by subgroup and type of violence. CONCLUSIONS: AGYW in these settings experience high vulnerability to physical, sexual and police violence. However, AGYW are not a homogeneous group, and there are heterogeneities in prevalence and predictors of violence between subgroups of AGYW that need to be understood to design effective programmes to address violence.

Evaluation of community-based HIV self-testing delivery strategies on reducing undiagnosed HIV infection, and improving linkage to prevention and treatment services, among men who have sex with men in Kenya: a programme science study protocol.

BACKGROUND: HIV prevalence among men having sex with men (MSM) in Kenya is 18.2%. Despite scale-up of HIV testing services, many MSM remain unaware of their HIV status and thus do not benefit from accessing HIV treatment or prevention services. HIV self-testing (HIVST) may help address this gap. However, evidence is limited on how, when, and in what contexts the delivery of HIVST to MSM could increase awareness of HIV status and lead to early linkage to HIV treatment and prevention. METHODS: The study will be embedded within existing MSM-focused community-based HIV prevention and treatment programmes in 3 counties in Kenya (Kisumu, Mombasa, Kiambu). The study is designed to assess three HIV testing outcomes among MSM, namely a) coverage b) frequency of testing and c) early uptake of testing. The study will adopt a mixed methods programme science approach to the implementation and evaluation of HIVST strategies via: (i) a baseline and endline bio-behavioural survey with 1400 MSM; (ii) a socio-sexual network study with 351 MSM; (iii) a longitudinal qualitative cohort study with 72 MSM; (iv) routine programme monitoring in three sites; (v) a programme-specific costing exercise; and (vi) mathematical modelling. This protocol evaluates the impact of community-based implementation of HIV self-testing delivery strategies among MSM in Kenya on reducing the undiagnosed MSM population, and time for linkage to prevention, treatment and care following HIV self-testing. Baseline data collection started in April 2019 and the endline data collection will start in July 2020. DISCUSSION: This study is one of the first programme science studies in Sub-Saharan Africa exploring the effectiveness of integrating HIVST interventions within already existing HIV prevention and treatment programmes for MSM in Kenya at scale. Findings from this study will inform national best approaches to scale up HIVST among MSM in Kenya.

Assessing the influence of conflict on the dynamics of sex work and the HIV and HCV epidemics in Ukraine: protocol for an observational, ethnographic, and mathematical modeling study.

BACKGROUND: Armed conflict erupted in eastern Ukraine in 2014 and still continues. This conflict has resulted in an intensification of poverty, displacement and migration, and has weakened the local health system. Ukraine has some of the highest rates of HIV and Hepatitis C (HCV) in Europe. Whether and how the current conflict, and its consequences, will lead to changes in the HIV and HCV epidemic in Ukraine is unclear. Our study aims to characterize how the armed conflict in eastern Ukraine and its consequences influence the pattern, practice, and experience of sex work and how this affects HIV and HCV rates among female sex workers (FSWs) and their clients. METHODS: We are implementing a 5-year mixed methods study in Dnipro, eastern Ukraine. Serial mapping and size estimation of FSWs and clients will be conducted followed by bio-behavioral cross-sectional surveys among FSWs and their clients. The qualitative component of the study will include in-depth interviews with FSWs and other key stakeholders and participant diaries will be implemented with FSWs. We will also conduct an archival review over the course of the project. Finally, we will use these data to develop and structure a mathematical model with which to estimate the potential influence of changes due to conflict on the trajectory of HIV and HCV epidemics among FSW and clients. DISCUSSION: The limited data that exists on the effect of conflict on disease transmission provides mixed results. Our study will provide rigorous, timely and context-specific data on HIV and HCV transmission in the setting of conflict. This information can be used to inform the design and delivery of HIV and HCV prevention and care services.

Phylogenetic Tools for Generalized HIV-1 Epidemics: Findings from the PANGEA-HIV Methods Comparison.

Viral phylogenetic methods contribute to understanding how HIV spreads in populations, and thereby help guide the design of prevention interventions. So far, most analyses have been applied to well-sampled concentrated HIV-1 epidemics in wealthy countries. To direct the use of phylogenetic tools to where the impact of HIV-1 is greatest, the Phylogenetics And Networks for Generalized HIV Epidemics in Africa (PANGEA-HIV) consortium generates full-genome viral sequences from across sub-Saharan Africa. Analyzing these data presents new challenges, since epidemics are principally driven by heterosexual transmission and a smaller fraction of cases is sampled. Here, we show that viral phylogenetic tools can be adapted and used to estimate epidemiological quantities of central importance to HIV-1 prevention in sub-Saharan Africa. We used a community-wide methods comparison exercise on simulated data, where participants were blinded to the true dynamics they were inferring. Two distinct simulations captured generalized HIV-1 epidemics, before and after a large community-level intervention that reduced infection levels. Five research groups participated. Structured coalescent modeling approaches were most successful: phylogenetic estimates of HIV-1 incidence, incidence reductions, and the proportion of transmissions from individuals in their first 3 months of infection correlated with the true values (Pearson correlation > 90%), with small bias. However, on some simulations, true values were markedly outside reported confidence or credibility intervals. The blinded comparison revealed current limits and strengths in using HIV phylogenetics in challenging settings, provided benchmarks for future methods' development, and supports using the latest generation of phylogenetic tools to advance HIV surveillance and prevention.

Global epidemiology of HIV among female sex workers: influence of structural determinants.

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per µL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

How do HIV-negative individuals in sub-Saharan Africa change their sexual risk behaviour upon learning their serostatus? A systematic review.

OBJECTIVE: To determine whether, and how, sexual behaviour of HIV-negative individuals in sub-Saharan Africa (SSA) changes upon learning their serostatus. METHODS: We systematically reviewed the published literature using EMBASE and Medline to search for publications between 2004 and 2014. We included studies that quantified behaviour change (condom use, number of sexual partners or sex acts) following an HIV test in HIV-negative adults in SSA, and extracted relevant data including study characteristics and measurement type. RESULTS: From 2185 unique citations, n=14 studies representing 22 390 participants met our inclusion criteria. We did not pool data due to marked heterogeneity in study outcome measures. The proportion of participants reporting consistent condom use (n=6) post-testing ranged from 7.6% greater, to 10.6% fewer, while 'no condom use' (n=5) ranged from 40.0% less, to 0.7% more. Condom use in serodiscordant couples increased (n=3). Five studies measured the proportion reporting abstinence, finding an increase of 10.9% to a decrease of 5.3% post-testing. The post-testing change in the mean number of sex acts (n=3) ranged from a relative decrease of 15.7% to a relative increase of 9.4%. Two studies reported relative decreases in the mean number of sexual partners of 35.2% and 14.0%. Three studies examining serodiscordant primary relationships specifically all showed increases in extrarelational sex. CONCLUSIONS: With the exception of serodiscordant couples, there is variable evidence that awareness of one's serostatus leads to substantial changes in risk behaviour among HIV-negative individuals. Further research is needed to estimate the behavioural impact of learning one's serostatus in SSA.

Prevalence and Frequency of Heterosexual Anal Intercourse Among Young People: A Systematic Review and Meta-analysis.

We aim to assess if heterosexual anal intercourse (AI) is commonly practiced and how frequently it is practiced by young people. We searched PubMed for articles published 1975 to July 2014 reporting data on the proportion of young people (mean age <25) practicing heterosexual AI (AI prevalence) and on number of AI acts (AI frequency). Stratified random-effects meta-analysis and meta-regression were used to produce summary estimates and assess the influence of participant and study characteristics on AI prevalence. Eighty-three and thirteen of the 136 included articles reported data on lifetime AI prevalence and monthly AI frequency, respectively. Estimates were heterogenous. Overall summary estimates of lifetime AI prevalence were 22 % (95 % confidence interval 20-24) among sexually active young people, with no statistically significant differences by gender, continent or age. Prevalence increased significantly with confidentiality of interview method and, among males and in Europe, by survey year. Prevalence did not significantly differ by recall period. An estimated 3-24 % of all reported sex acts were AI. Reported heterosexual AI is common but variable among young people worldwide. To fully understand its impact on STI spread, more and better quality data on frequency of unprotected AI, and trends over time are required.

Distinguishing sources of HIV transmission from the distribution of newly acquired HIV infections: why is it important for HIV prevention planning?

OBJECTIVE: The term 'source of HIV infections' has been referred to as the source of HIV transmission. It has also been interpreted as the distribution of newly acquired HIV infections across subgroups. We illustrate the importance of distinguishing the two interpretations for HIV prevention planning. METHODS: We used a dynamical model of heterosexual HIV transmission to simulate three HIV epidemics, and estimated the sources of HIV transmission (cumulative population attributable fraction) and the single-year distribution of new HIV infections. We focused an intervention guided by the largest transmission source versus the largest single-year distribution of new HIV infections, and compared the fraction of discounted HIV infections averted over 30 years. RESULTS: The single-year distribution of newly acquired HIV infections underestimated the source of HIV transmission in the long term, when the source was unprotected sex in high-risk groups. Under equivalent and finite resources, an intervention strategy directed by the long-term transmission source was shown to achieve a greater impact than a distribution-directed strategy, particularly in the long term. CONCLUSIONS: Impact of HIV prevention strategies may vary depending on whether they are directed by the long-term transmission source or by the distribution of new HIV infections. Caution is required when interpreting the 'source of HIV infections' to avoid misusing the distribution of new HIV infections in HIV prevention planning.

Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya.

BACKGROUND: The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk. SETTING: This study took place in Mombasa, Kenya. METHODS: We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors. RESULTS: Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW. CONCLUSION: AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Associations between HIV stigma and health-related quality-of-life among people living with HIV: cross-sectional analysis of data from HPTN 071 (PopART).

People living with HIV (PLHIV) report lower health-related quality-of-life (HRQoL) than HIV-negative people. HIV stigma may contribute to this. We explored the association between HIV stigma and HRQoL among PLHIV. We used cross-sectional data from 3991 randomly selected PLHIV who were surveyed in 2017-2018 for HPTN 071 (PopART), a cluster randomised trial in Zambia and South Africa. Participants were 18-44 years, had laboratory-confirmed HIV infection, and knew their status. HRQoL was measured using the EuroQol-5-dimensions-5-levels (EQ-5D-5L) questionnaire. Stigma outcomes included: internalised stigma, stigma experienced in the community, and stigma experienced in healthcare settings. Associations were examined using logistic regression. Participants who had experienced community stigma (n = 693/3991) had higher odds of reporting problems in at least one HRQoL domain, compared to those who had not (adjusted odds ratio, aOR: 1.51, 95% confidence interval, 95% Cl: 1.16-1.98, p = 0.002). Having experienced internalised stigma was also associated with reporting problems in at least one HRQoL domain (n = 552/3991, aOR: 1.98, 95% CI: 1.54-2.54, p < 0.001). However, having experienced stigma in a healthcare setting was less common (n = 158/3991) and not associated with HRQoL (aOR: 1.04, 95% CI: 0.68-1.58, p = 0.850). A stronger focus on interventions for internalised stigma and stigma experienced in the community is required.

Exploring the impact of military conflict on sex work in Ukraine: Women's experiences of economic burden.

Little is known about the impact of military conflict on sex work from the perspective of sex workers. We attempt to explore the meaning of conflict on sex work by asking women about the changes that they have experienced in their lives and work since the beginning of the 2014 military conflict in eastern Ukraine. The findings in this article are based on qualitative interviews with 43 cisgender women living and practicing sex work in Dnipro, eastern Ukraine. Our analysis highlights the meanings that sex workers have linked to the conflict, with financial concerns emerging as a dominant theme. The conflict therefore functions as a way of understanding changing economic circumstances with both individual and broader impacts. By better understanding the meaning of conflict as expressed by sex workers, we can begin to adapt our response to address emerging, and unmet, needs of the community.

Uptake of medical male circumcision with household-based testing, and the association of traditional male circumcision and HIV infection.

OBJECTIVES: Voluntary medical male circumcision (VMMC) is an important component of combination HIV prevention. Inclusion of traditionally circumcised HIV negative men in VMMC uptake campaigns may be important if traditional male circumcision is less protective against HIV acquisition than VMMC. METHODS: We used data from the HIV Prevention Trials Network (HPTN) 071 (PopART) study. This cluster-randomized trial assessed the impact of a combination prevention package on population-level HIV incidence in 21 study communities in Zambia and South Africa. We evaluated uptake of VMMC, using a two-stage analysis approach and used discrete-time survival analysis to evaluate the association between the types of male circumcision and HIV incidence. RESULTS: A total of 10 803 HIV-negative men with self-reported circumcision status were included in this study. At baseline, 56% reported being uncircumcised, 26% traditionally circumcised and 18% were medically circumcised. During the PopART intervention, 11% of uncircumcised men reported uptake of medical male circumcision. We found no significant difference in the uptake of VMMC in communities receiving the PopART intervention package and standard of care {adj. rate ratio=1·10 [95% confidence interval (CI) 0.82, 1.50, P  = 0.48]}. The rate of HIV acquisition for medically circumcised men was 70% lower than for those who were uncircumcised adjusted hazard ratio (adjHR) = 0.30 (95% CI 0.16-0.55; P  < 0.0001). There was no difference in rate of HIV acquisition for traditionally circumcised men compared to those uncircumcised adjHR = 0.84 (95% CI 0.54, 1.31; P  = 0.45). CONCLUSIONS: Household-based delivery of HIV testing followed by referral for medical male circumcision did not result in substantial VMMC uptake. Traditional circumcision is not associated with lower risk of HIV acquisition.

HIV acquisition prior to entry into formal sex work: inference from next-generation viral sequencing.

OBJECTIVE: To infer the timing of HIV acquisition in relation to self-reported events in the sexual life course of adolescent girls and young women (AGYW) who self-identify as female sex workers (FSW) in Mombasa, Kenya. DESIGN: Next-generation viral sequencing of samples of AGYW living with HIV in the Transitions study, a cross-sectional bio-behavioural survey of AGYW aged 14-24 years in Mombasa, Kenya. METHOD: Dried blood spot specimens were collected from study participants ( n  = 37, all FSW). A portion of the HIV pol gene was sequenced using an in-house next-generation sequencing assay for HIV drug resistance mutation genotyping. Estimated time since infection (ETI) was inferred using the HIV EVO web-based tool ( https://hiv.biozentrum.unibas.ch/ETI/ ), and data on self-reported events were obtained from the survey. RESULTS: The median ETI among FSW was 3.4 (interquartile range = 1.7, 6.3) years, with a median ETI of 1.5 years prior to entry into formal sex work. We estimated that 74.1% (95% confidence interval = 53.7-88.9%) of participants living with HIV and who self-identified as FSW likely acquired HIV prior to self-identification as a sex worker. CONCLUSIONS: Findings suggest a large fraction of prevalent HIV infection among AGYW engaged in sex work stems from acquisition prior to entry into formal sex work. Current HIV prevention programs tailored for sex workers may miss key opportunities for HIV prevention as they are designed to reach women after entry into formal sex work, signaling a need for tailored programs to reach high-risk AGYW earlier on in their sexual life course.

Strengthening the HIV prevention cascade to maximise epidemiological impact in eastern Zimbabwe: a modelling study.

BACKGROUND: HIV prevention cascades provide a systematic understanding of barriers to prevention. In this study we used mathematical modelling to understand the consequences of these barriers and how the cascade could be strengthened to maximise epidemiological impact, providing potentially important insights for programmes. METHODS: We used an individual-based model of HIV transmission (PopART-IBM), calibrated to data from the Manicaland cohort from eastern Zimbabwe. HIV prevention cascade estimates from this cohort were used as probabilities for indicators in the model representing an individual's motivation, access, and capacity to effectively use pre-exposure prophylaxis, voluntary male medical circumcision, and condoms. We examined how current barriers affect the number and distribution of HIV infections compared with a no-barrier scenario. Using assumptions about how interventions could strengthen the HIV prevention cascade, we estimated the reduction in HIV infections over a 10-year period through addressing different elements of the cascade. FINDINGS: 21 200 new potentially avertable HIV infections will occur over the next 10 years due to existing HIV prevention cascade barriers, 74·2% of the 28 500 new infections that would occur with existing barriers in a population of approximately 1·2 million adults. Removing these barriers would reduce HIV incidence below the benchmarks for epidemic elimination. Addressing all cascade steps in one priority population is substantially more effective than addressing one step across all populations. INTERPRETATION: Interventions exist in eastern Zimbabwe to reduce HIV towards elimination, but barriers of motivation, access, and effective use prevent their full effect being realised. Interventions need to be multilayered and address all steps along the HIV prevention cascade. Models incorporating the HIV prevention cascade can help to identify the main barriers to greater effectiveness. FUNDING: National Institutes of Mental Health, Bill & Melinda Gates Foundation, and Medical Research Council Centre for Global Infectious Disease Analysis funding from the UK Medical Research Council and UK Foreign, Commonwealth & Development Office (FCDO).

Assessing awareness and use of HIV self-testing kits after the introduction of a community-based HIV self-testing programme among men who have sex with men in Kenya.

Men who have sex with men (MSM) bear a disproportionate burden of new HIV infections in Kenya, while experiencing discrimination, leading to suboptimal levels of HIV care. HIV self-testing (HIVST) is a tool to increase HIV screening and earlier diagnosis; however, questions remain regarding how best to scale-up HIVST to MSM in Kenya. The main objective of this study was to examine changes in knowledge and use of HIVST after implementation of a community-led HIVST project. Participants were MSM recruited from Kisumu, Mombasa, and Kiambu counties. Data were collected from two rounds (Round 1: 2019; Round 2: 2020) of serial cross-sectional integrated biological and behavioural assessments (IBBA), pre-, and post-project implementation. Two main outcomes were measured: 1) whether the respondent had ever heard of HIVST; and 2) whether they had ever used HIVST kits. Changes in outcomes between IBBA rounds were examined using modified multivariable Poisson regression models; adjusted prevalence ratios (aPR) and 95% confidence intervals (95% CI) are reported. A total of 2,328 respondents were included in main analyses. The proportion of respondents who had heard of HIVST increased from 75% in Round 1 to 94% in Round 2 (aPR: 1.2, 95% CI: 1.2-1.3), while those reporting using an HIVST kit increased from 20% to 53% (aPR: 2.3, 95% CI: 2.0-2.6). Higher levels of education and HIV programme awareness were associated with both outcomes. Awareness and use of HIVST kits increased after implementation of a community-led HIVST implementation project, demonstrating the importance of integration with existing community groups.