HIV and other sexually transmitted infections among female sex workers in Moscow (Russia): prevalence and associated risk factors.

To estimate the prevalence and factors associated with HIV and five other STIs among outdoor female sex workers (OSFW) and indoor FSW (IFSW). METHODS: Cross-sectional survey using respondent-driven sampling methodology. Participants answered a bio-behavioural questionnaire and were tested for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), syphilis (lifetime contact) and Mycoplasma genitalium (MG). Weighted HIV and other STIs prevalence and 95% CIs were calculated. Weighted multivariate logistic regression was performed to identify factors associated with having at least one STI (including HIV). RESULTS: Between October 2017 and July 2018, 385 FSW participants were recruited, among whom 206 (53.5%) were IFSW and 179 (46.5%) were OFSW. The mean age was 31.4 years. Weighted HIV prevalence was 3.1% (95% CI 1.5 to 7.0). Weighted prevalence of other STIs was: 4.1% (95% CI 2.2 to 8.0) for NG, 8.8% (95% CI 5.9 to 13.0) for CT, 12.7% (95% CI 8.6 to 18.0) for TV, 13.9% (95% CI 9.9 to 19.0) for syphilis (lifetime contact) and 14.9% (95% CI 10.5 to 21.0) for MG. STI prevalence was significantly higher among OFSW for CT, TV and MG (p<0.001). In total, 43.2% of the participants had at least one HIV/STI. Factors associated with having HIV/STI were being an OFSW (OR 3.29; 95% CI 1.72 to 6.27); being registered in another Russian region (2.61 (95% CI 1.05 to 6.48)); having never been tested for HIV (2.51 (95% CI 0.98 to 6.41)) and having a low level of knowledge regarding HIV transmission (4.88 (95% CI 0.96 to 24.78)). CONCLUSION: Prevalence of HIV and STIs was high among FSW in Moscow. OFSW were more vulnerable to STIs. There is an urgent need to tailor programmes for sexual and reproductive health for FSW in Russia.

Hepatitis E virus outbreak associated with rainfall in the Central African Republic in 2008-2009.

BACKGROUND: Infection by hepatitis E virus (HEV) can cause a high burden of morbidity and mortality in countries with poor access to clean water and sanitation. Our study aimed to investigate the situation of HEV infections in the Central African Republic (CAR). METHODS: A retrospective analysis of the blood samples and notification forms collected through the national yellow fever (YF) surveillance program, but for which a diagnosis of YF was discarded, was carried out using an anti-HEV IgM ELISA and a HEV-specific RT-PCR. RESULTS: Of 2883 YF-negative samples collected between January 2008 and December 2012, 745 (~ 26%) tested positive by at least either of the 2 tests used to confirm HEV cases. The results revealed that the CAR was hit by a large HEV outbreak in 2008 and 2009. The results also showed a clear seasonal pattern with correlation between HEV incidence and rainfall in Bangui. A phylogenetic analysis showed that the circulating strains belonged to genotypes 1e and 2b. CONCLUSIONS: Overall, this study provides further evidences that HEV can be a significant cause of acute febrile jaundice, particularly among adults during rainy season or flood, in a country from Sub-Saharan Africa.

Staying hepatitis C negative: A systematic review and meta-analysis of cure and reinfection in people who inject drugs.

BACKGROUND AND AIMS: Direct-acting antivirals (DAAs) are highly effective in treating hepatitis C. However, there is concern that cure rates may be lower, and reinfection rates higher, among people who inject drugs. We conducted a systematic review of treatment outcomes achieved with DAAs in  people who inject drugs (PWID). METHODS: A search strategy was used to identify studies that reported sustained viral response (SVR), treatment discontinuation, adherence or reinfection in recent PWID and/or opioid substitution therapy (OST) recipients. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analysis of proportions was used to estimate pooled SVR and treatment discontinuation rates. The pooled relative risk of achieving SVR and pooled reinfection rate were calculated using generalized mixed effects linear models. RESULTS: The search identified 8075 references; 26 were eligible for inclusion. The pooled SVR for recent PWID was 88% (95% CI, 83%-92%) and 91% (95% CI 88%-95%) for OST recipients. The relative risk of achieving SVR for recent PWID compared to non-recent PWID was 0.99 (95% CI, 0.94-1.06). The pooled treatment discontinuation was 2% (95% CI, 1%-4%) for both recent PWID and OST recipients. Amongst recent PWID, the pooled incidence of reinfection was 1.94 per 100 person years (95% CI, 0.87-4.32). In OST recipients, the incidence of reinfection was 0.55 per 100 person years (95% CI, 0.17-1.76). CONCLUSIONS: Treatment outcomes were similar in recent PWID compared to non-PWID treated with DAAs. People who report recent injecting or OST recipients should not be excluded from hepatitis C treatment.

Survey of programmatic experiences and challenges in delivery of hepatitis B and C testing in low- and middle-income countries.

BACKGROUND: There have been few reports on programmatic experience of viral hepatitis testing and treatment in resource-limited settings. To inform the development of the 2017 World Health Organization (WHO) viral hepatitis testing guidance and in particular the feasibility of proposed recommendations, we undertook a survey across a range of organisations engaged with hepatitis testing in low- and middle-income countries (LMICs). Our objective was to describe current hepatitis B and C testing practices across a range of settings in different countries, as well as key barriers or challenges encountered and proposed solutions to promote testing scale-up. METHODS: Hepatitis testing programmes in predominantly LMICs were identified from the WHO Global Hepatitis Programme contacts database and through WHO regional offices, and invited to participate. The survey comprised a six-part structured questionnaire: general programme information, description of hepatitis testing, treatment and care services, budget and funding, data on programme outcomes, and perceptions on key barriers encountered and strategies to address these. RESULTS: We interviewed 22 viral hepatitis testing programmes from 19 different countries. Nine were from the African region; 6 from the Western Pacific; 4 from South-East Asia; and 3 from Eastern Europe. All but four of the programmes were based in LMICs, and 10 (45.5%) were supported by non-governmental or international organizations. All but two programmes undertook targeted testing of specific affected populations such as people living with HIV, people who inject drugs, sex workers, health care workers, and pregnant women. Only two programmes focussed on routine testing in the general population. The majority of programmes were testing in hospital-based or other health facilities, particularly HIV clinics, and community-based testing was limited. Nucleic acid testing (NAT) for confirmation of HCV and HBV viraemia was available in only 30% and 18% of programmes, respectively. Around a third of programmes required some patient co-payment for diagnosis. The most commonly identified challenges in scale-up of hepatitis testing were: limited community awareness about viral hepatitis; lack of facilities or services for hepatitis testing; no access to low cost treatment, particularly for HCV; absence of national guidance and policies; no dedicated budget for hepatitis; and lack of trained health care and laboratory workers. CONCLUSIONS: At this early stage in the global scale-up of testing for viral hepatitis, there is a wide variation in testing practices and approaches across different programmes. There remains limited access to NAT to confirm viraemia, and patient self-payment for testing and treatment is common. There was consensus from implementing organizations that scale-up of testing will require increased community awareness, health care worker training, development of national strategies and guidelines, and improved access to low cost NAT virological testing.

Timeliness of yellow fever surveillance, Central African Republic.

During January 2007-July 2012, a total of 3,220 suspected yellow fever cases were reported in the Central African Republic; 55 were confirmed and 11 case-patients died. Mean delay between onset of jaundice and case confirmation was 16.6 days. Delay between disease onset and blood collection could be reduced by increasing awareness of the population.

Association of the ANRS-12126 male circumcision project with HIV levels among men in a South African township: evaluation of effectiveness using cross-sectional surveys.

BACKGROUND: Randomized controlled trials have shown that voluntary medical male circumcision (VMMC) reduces HIV infection by 50% to 60% in sub-Saharan African populations; however, little is known about the population-level effect of adult male circumcision (MC) as an HIV prevention method. We assessed the effectiveness of VMMC roll-out on the levels of HIV in the South African township of Orange Farm where the first randomized controlled trial (RCT) to test the effect of VMMC on HIV acquisition was conducted in 2002-2005. METHODS AND FINDINGS: The Bophelo Pele project is a community-based campaign against HIV, which includes the roll-out of free VMMC. A baseline cross-sectional biomedical survey was conducted in 2007-2008 among a random sample of 1,998 men aged 15 to 49 (survey response rate 80.7%). In 2010-2011, we conducted a follow-up random survey among 3,338 men aged 15 to 49 (survey response rate 79.6%) to evaluate the project. Participants were interviewed, blood samples were collected and tested for HIV and recent HIV infection (using the BED HIV incidence assay), and MC status was assessed through a clinical examination. Data were analyzed using multivariate and propensity statistical methods. Owing to the VMMCs performed in the context of the RCT and the Bophelo Pele project, the prevalence rate of adult MC increased from 0.12 (95% CI 0.10-0.14) to 0.53 (95% CI 0.51-0.55). Without these VMMCs, the HIV prevalence rate in 2010-2011 would have been 19% (95% CI 12%-26%) higher (0.147 instead of 0.123). When comparing circumcised and uncircumcised men, no association of MC status with sexual behavior was detected. Among circumcised and uncircumcised men, the proportion consistently using condoms with non-spousal partners in the past 12 months was 44.0% (95% CI 41.7%-46.5%) versus 45.4% (95% CI 42.2%-48.6%) with weighted prevalence rate ratio (wPRR) = 0.94 (95% CI 0.85-1.03). The proportion having two or more non-spousal partners was 50.4% (95% CI 47.9%-52.9%) versus 44.2% (95% CI 41.3%-46.9%) with wPRR = 1.03 (95% CI 0.95-1.10). We found a reduction of BED-estimated HIV incidence rate ranging from 57% (95% CI 29%-76%) to 61% (95% CI 14%-83%) among circumcised men in comparison with uncircumcised men. CONCLUSIONS: Findings suggest that the roll-out of VMMC in Orange Farm is associated with a significant reduction of HIV levels in the community. The main limitation of the study is that it was not randomized and cannot prove a causal association. The roll-out of VMMC among adults in sub-Saharan Africa should be an international priority and needs to be accelerated to effectively combat the spread of HIV. Please see later in the article for the Editors' Summary.

Placental malaria is associated with increased risk of nonmalaria infection during the first 18 months of life in a Beninese population.

BACKGROUND: Several studies have shown that the risk of malaria infection increases for children born to a mother with placental malaria infection. An immune tolerance phenomenon has been hypothesized. We addressed whether Plasmodium falciparum placental infection could additionally be associated with the risk of nonmalaria fevers in infants. METHODS: From 2007 to 2009, 553 infants were followed up from birth to 18 months in Benin. The occurrence of fever was actively screened by trained community workers. Malaria fevers (temperature >37.5°C with positive results of rapid diagnostic test or thick blood smear) were excluded from analysis. The association between placental malaria infection and the number of total, gastrointestinal, and respiratory febrile episodes was explored using binomial negative regression, with adjustment for maternal age, parity, parents' schooling, socioeconomic level, sex, village of birth, season of birth, prematurity, Apgar score and nutritional status. RESULTS: The prevalence of placental malaria infection was 11.2%. During a median follow-up of 17.8 months, 624 nonmalaria fevers were registered. Placental malaria infection was associated with a higher risk of nonmalaria fever episodes (adjusted incidence rate ratio, 1.4; 95% confidence interval, 1.1-1.8) as well as gastrointestinal (1.6; 1.1-2.5) and respiratory (1.5; 1.1-2.1) febrile syndromes. The same pattern was obtained when considering consultations after the age of 6 months. CONCLUSIONS: These results suggest an association between placental malaria infection and nonmalaria infections in the first 18 months of life. Immune tolerance could lead to impaired immune development not specific to malaria infections in infants born to mothers with placental malaria infection, but further studies are needed.

Anaemia during pregnancy: impact on birth outcome and infant haemoglobin level during the first 18 months of life.

To determine the effect of maternal anaemia on pregnancy outcome and describe its impact on infant haemoglobin level in the first 18 months of life, we conducted a prospective study of 617 pregnant women and their children in Benin. Prevalence of maternal anaemia at delivery was 39.5%, and 61.1% of newborns were anaemic at birth. Maternal anaemia was not associated with low birth weight [OR = 1.2 (0.6-2.2)] or preterm birth [OR = 1.3 (0.7-2.4)], whereas the newborn's anaemia was related to maternal anaemia [OR = 1.8 (1.2-2.5)]. There was no association between an infant's haemoglobin level until 18 months and maternal anaemia. However, malaria attacks during follow-up, male gender and sickle cell trait were all associated with a lower infant haemoglobin level until 18 months, whereas good infant feeding practices and a polygamous family were positively associated with a higher haemoglobin level during the first 18 months of life.

Acute risk for hepatitis E virus infection among HIV-1-positive pregnant women in central Africa.

BACKGROUND: Hepatitis E virus (HEV), an enterically transmitted pathogen, is highly endemic in several African countries. Pregnant women are at particularly high risk for acute or severe hepatitis E. In Gabon, a central African country, the prevalence of antibodies to HEV among pregnant women is 14.1%. Recent studies have demonstrated unusual patterns of hepatitis E (chronic hepatitis, cirrhosis) among immunodeficient patients. FINDINGS: We investigated the prevalence of antibodies to HEV among pregnant women infected with HIV-1 or HTLV-1 in Gabon. Of 243 samples collected, 183 were positive for HIV-1 and 60 for HTLV-1; 16 women (6.6%) had IgG antibodies to HEV. The seroprevalence was higher among HIV-1-infected women (7.1%) than HTLV-1-infected women (5.0%). Moreover, the HIV-1 viral load was significantly increased (p ≤ 0.02) among women with past-HEV exposure (1.3E+05 vs 5.7E+04 copies per ml), whereas no difference was found in HTLV-1 proviral load (9.0E+01 vs 1.1E+03 copies per ml). CONCLUSIONS: These data provide evidence that HIV-1-infected women are at risk for acute or severe infection if they are exposed to HEV during pregnancy, with an increased viral load.

Permethrin and malathion resistance in head lice: results of ex vivo and molecular assays.

BACKGROUND: Treatment of head lice infestation relies on the application of topical insecticides. Overuse of these products has led to the emergence of resistance to pyrethroids and malathion worldwide. Permethrin resistance in head lice is mostly conferred by the knockdown resistance (kdr) trait. OBJECTIVE: To evaluate the occurrence of permethrin- and malathion-resistant head lice in Paris. METHODS: A prospective survey was conducted in 74 elementary schools. Live lice collected on schoolchildren were randomly selected and submitted to ex vivo bioassays or underwent individual DNA extraction. A fragment of kdr-like gene was amplified and compared with wild-type sequences. RESULTS: Live head lice were detected in 574 children. Ex vivo assays showed no surviving lice after a 1-hour contact with malathion while most lice died after a 1-hour exposure to permethrin and piperonyl butoxide (85.7%, 95% confidence interval [CI]: 83.9-87.5). Among the 670 lice with workable DNA sequences, 661 lice (98.7%, 95% CI 97.7-99.3) had homozygous kdr mutations. LIMITATIONS: The findings of this large-scale survey of the occurrence of insecticide-resistant head lice indicated a major insecticide pressure in the study population, but it was not sufficient to draw conclusions about other populations. The presence of T917I-L920F mutations in kdr gene may not correlate with treatment failure in prospective studies. CONCLUSION: The high occurrence of kdr mutant allele suggests that insecticide resistance was already strongly established in the studied population. This finding must be interpreted with caution as it may not be predictive of treatment failure.

Fatal Outcome in a Hepatitis E Virus/Human Immunodeficiency Virus Co-Infected Malnourished Child in the Central African Republic.

Hepatitis E virus (HEV) infection is responsible for major endemic outbreaks in developing countries. Human immunodeficiency virus (HIV) and HEV are widespread in the Central African Republic. We report the first documented case of an HEV infection in a 36-month-old child already suffering from HIV and severe acute malnutrition (SAM). The HIV patient was hospitalized for SAM with persistent diarrhea and prolonged fever. The presence of IgG anti-HEV antibodies was noted. Sequencing of the amplified HEV RNA revealed the presence of genotype 3c. The alanine aminotransferase level was slightly above average. The patient died despite being treated by antiretroviral therapy accompanied by probabilistic antibiotic therapy and nutritional rehabilitation. HEV/HIV co-infection in a malnourished patient can accelerate a fatal outcome. In the presence of biological abnormalities in a severe acutely malnourished HIV-infected patient, HEV RNA detection should be added to the standard medical assessment in sub-Saharan African countries.

Prevalence and management of tuberculosis among people who use drugs in Abidjan, Ivory Coast.

Background Although people who use drugs (PWUD) are a high-risk group for tuberculosis (TB), there is practically no data on TB prevalence in Ivory Coast. The aim of the study was to estimate pulmonary TB prevalence and assess the cascade of care with confirmed pulmonary TB (TB+) among PWUD in Abidjan. Methods The study targeted adult people who had used heroin and/or cocaine/crack in the previous six months. A first part consisted in a cross-sectional prevalence estimation survey using mobile facility testing in smoking spots. A multivariable logistic regression was performed to determine the factors associated with TB infection. In a second part, all participants who tested positive for pulmonary TB were offered follow-up for the duration of their treatment and invited to participate in a community-based support program (e.g. family mediation visits or self-support groups). Results Between October 2016 and May 2017, 545 PWUD were informed about the survey and 532 agreed to participate. Most of them were male (n = 484; 91.0%) single (n = 434; 81.6%), with an average age of 34.9 (SD 8.3) years. Drugs most commonly consumed were heroin and crack (n = 530; 99.6% and n = 353; 66.4% respectively) and were inhaled (i.e. smoked). Out of the 531 participants with an Xpert MTB/RIF® test result, 52 were diagnosed with pulmonary TB, i.e. a prevalence of 9.8%, 95% CI [7.5%-12.7%]. Among them, 17.3% had rifampicin-resistant TB. Factors significantly associated with TB infection in the multivariable analysis were: having been recruited in Treichville smoking spot (OR=2.0 [1.1 - 3.7]; p = 0.03), being unemployed (OR = 1.8 [1.0 - 3.4]; p = 0.05), and being co-infected with HIV (OR=3.3 [1.2 - 8.1]; p = 0.01); 60.0% of the patients were successfully treated. Conclusion TB prevalence among the PWUD is high. The community-based support model enables good treatment efficacy among this usually hard-to-reach population.

Direct acting antiviral-based treatment of hepatitis C virus infection among people who inject drugs in Georgia: A prospective cohort study.

BACKGROUND: People who inject drugs (PWID) are often excluded from HCV treatment programs due to concerns about their ability to adhere to care. Georgia has a high prevalence of HCV infection (5.4% of chronic cases in general population) with an epidemic concentrated among PWID. We evaluated adherence to care and sustained virologic response (SVR) among PWID in Georgia. METHODS: In this observational study, participants with recent injecting drug use (previous 6 months) and chronic HCV attending a needle- and syringe-program were included. Participants received sofosbuvir and ribavirin +/- pegylated interferon, with peer-based support during treatment. The primary endpoint was undetectable HCV RNA 12 weeks post-treatment (SVR12). Factors associated with SVR were assessed using logistic regression. RESULTS: Among 244 participants [HCV genotype (GT) 3, 52%; GT2, 25%; GT1, 19%; mixed GT, 4%]; 55% had cirrhosis. Overall, 24% were receiving OST and 50% injected drugs in the previous month. 98% (239 of 244) completed treatment, with 88% (210 of 239) having never delayed a medical appointment and 79% (189 of 239) never missing a dose of medication. Overall, SVR was 84.8% (207 of 244). SVR was 88.5% (207 of 234) among participants who attended 12-week follow up appointment for HCV RNA testing. In multivariate analyses, SVR was significantly associated with adherence (no missed doses) to treatment [vs. missed doses; adjusted OR (aOR) 2.77; 95% confidence interval (95%CI), 1.01-7.51), and genotype (vs. GT1; GT2, aOR 0.27; 95%CI 0.06-1.21; GT3, aOR 1.09; 95%CI 0.27-4.50; and mixed GT, aOR 0.14; 95%CI 0.02-0.97). CONCLUSION: In this real-life study in a middle-income country, PWID treated for HCV and receiving a simple peer-support intervention demonstrated an excellent treatment response and good adherence, not associated with injecting drug use during treatment and OST at treatment initiation.

Women's knowledge and perception of male circumcision before and after its roll-out in the South African township of Orange Farm from community-based cross-sectional surveys.

The roll-out of medical male circumcision (MC) is progressing in Southern and Eastern Africa. Little is known about the effect of this roll-out on women. The objective of this study was to assess the knowledge and perceptions of women regarding MC in a setting before and after the roll-out. This study was conducted in the South African township of Orange Farm where MC prevalence among men increased from 17% to 53% in the period 2008-2010. Data from three community-based cross sectional surveys conducted in 2007, 2010 and 2012 among 1258, 1197 and 2583 adult women, respectively were studied. In 2012, among 2583 women, 73.7% reported a preference for circumcised partners, and 87.9% knew that circumcised men could become infected with HIV. A total of 95.8% preferred to have their male children circumcised. These three proportions increased significantly during the roll-out. In 2007, the corresponding values were 64.4%, 82.9% and 80.4%, respectively. Among 2581 women having had sexual intercourse with circumcised and uncircumcised men, a majority (55.8%, 1440/2581) agreed that it was easier for a circumcised man to use a condom, 20.5% (530/2581) disagreed; and 23.07 (611/2581) did not know. However, some women incorrectly stated that they were fully (32/2579; 1.2%; 95%CI: 0.9% to 1.7%) or partially (233/2579; 9.0%; 95%CI: 8.0% to 10.2%) protected when having unprotected sex with a circumcised HIV-positive partner. This study shows that the favorable perception of women and relatively correct knowledge regarding VMMC had increased during the roll-out of VMMC. When possible, women should participate in the promotion of VMMC although further effort should be made to improve their knowledge.

Bone-borne distractor versus tooth-borne distractor for orthodontic distraction after surgical maxillary expansion: The patient's point of view.

INTRODUCTION: Orthodontic distraction after surgical maxillary expansion is a mode of treatment regularly used in the context of transverse maxillary constriction. There is, however, no consensus in the literature as to the type of distractor (bone-borne or tooth-borne) that should be used. PATIENTS AND METHOD: This retrospective study compared orthodontic distraction using a bone-borne or a tooth-borne distractor from the point of view of tolerance, ease of use and overall patient satisfaction, by means of a questionnaire completed by patients undergoing maxillary expansion surgery in the Stomatology and Maxillofacial Surgery Department of Lille University Hospital between January 2013 and March 2015. The efficacy of the two distractors was also assessed. RESULTS: Thirty-two patients were included: 10 in the bone-borne distractor group and 22 in the tooth-borne group. Sixty percent of patients questioned found the bone-borne distractor easy to use compared with 32% for the tooth-borne distractor (P=0.167). Tolerance was noted to be comparable and acceptable by the two groups. The overall satisfaction rate was high for both groups at over 90%, and was correlated with ease of use and clear information. The average space gain between the first molars was 11.1mm with the bone-borne device and 10.7mm for the tooth-borne appliance. CONCLUSION: The use of a bone-borne distractor for orthodontic distraction after maxillary expansion surgery appears to be an effective, simple and well-tolerated alternative to the use of a tooth-borne distractor. According to patients, this distractor also appears easier to use than the traditional Hyrax-type distractor. This ease of use is correlated with overall satisfaction.

Surveillance of Canine Rabies in the Central African Republic: Impact on Human Health and Molecular Epidemiology.

BACKGROUND: Although rabies represents an important public health threat, it is still a neglected disease in Asia and Africa where it causes tens of thousands of deaths annually despite available human and animal vaccines. In the Central African Republic (CAR), an endemic country for rabies, this disease remains poorly investigated. METHODS: To evaluate the extent of the threat that rabies poses in the CAR, we analyzed data for 2012 from the National Reference Laboratory for Rabies, where laboratory confirmation was performed by immunofluorescence and PCR for both animal and human suspected cases, and data from the only anti-rabies dispensary of the country and only place where post-exposure prophylaxis (PEP) is available. Both are located in Bangui, the capital of the CAR. For positive samples, a portion of the N gene was amplified and sequenced to determine the molecular epidemiology of circulating strains. RESULTS: In 2012, 966 exposed persons visited the anti-rabies dispensary and 632 received a post-exposure rabies vaccination. More than 90% of the exposed persons were from Bangui and its suburbs and almost 60% of them were under 15-years of age. No rabies-related human death was confirmed. Of the 82 samples from suspected rabid dogs tested, 69 were confirmed positive. Most of the rabid dogs were owned although unvaccinated. There was a strong spatiotemporal correlation within Bangui and within the country between reported human exposures and detection of rabid dogs (P<0.001). Phylogenetic analysis indicated that three variants belonging to Africa I and II lineages actively circulated in 2012. CONCLUSIONS: These data indicate that canine rabies was endemic in the CAR in 2012 and had a detrimental impact on human health as shown by the hundreds of exposed persons who received PEP. Implementation of effective public health interventions including mass dog vaccination and improvement of the surveillance and the access to PEP are urgently needed in this country.

Level of viral suppression and the cascade of HIV care in a South African semi-urban setting in 2012.

OBJECTIVE: In 2012, 7 years after the introduction of antiretroviral treatment (ART) in the South African township of Orange Farm, we measured the proportion of HIV-positive people who were virally suppressed, especially among high-risk groups (women 18-29 years and men 25-34 years). DESIGN: A community-based cross-sectional representative survey was conducted among 3293 men and 3473 women. METHODS: Study procedures included a face-to-face interview and collection of blood samples that were tested for HIV, 11 antiretroviral drugs and HIV-viral load. RESULTS: HIV prevalence was 17.0% [95% confidence interval: 15.7-18.3%] among men and 30.1% [28.5-31.6%] among women. Overall, 59.1% [57.4-60.8%] of men and 79.5% [78.2-80.9%] of women had previously been tested for HIV. When controlling for age, circumcised men were more likely to have been tested compared with uncircumcised men (66.1 vs 53.6%; P < 0.001). Among HIV+, 21.0% [17.7-24.6%] of men and 30.5% [27.7-33.3%] of women tested positive for one or more antiretroviral drugs. Using basic calculations, we estimated that, between 2005 and 2012, ART programs prevented between 46 and 63% of AIDS-related deaths in the community. Among antiretroviral-positive, 91.9% [88.7-94.3%] had viral suppression (viral load <400 copies/ml). The proportion of viral suppression among HIV+ was 27.0% [24.3-29.9%] among women and 17.5% [14.4-20.9%] among men. These proportions were lower among the high-risk groups: 15.6% [12.1-19.7%] among women and 8.4% [5.0-13.1%] among men. CONCLUSION: In Orange Farm, between 2005 and 2012, ART programs were suboptimal and, among those living with HIV, the proportion with viral suppression was still low, especially among the young age groups. However, our study showed that, in reality, antiretroviral drugs are highly effective in viral suppression at an individual level.

Prevalence and risk factors associated with HIV and tuberculosis in people who use drugs in Abidjan, Ivory Coast.

BACKGROUND: The number of people who use drugs (PWUD) has dramatically increased in West Africa over the last 15 years, but targeted interventions are falling behind, notably because of the lack of awareness of the health needs of PWUD. We aimed to assess prevalence and factors associated with HIV and other infections in PWUD in Abidjan, Ivory Coast, one of the countries most affected by HIV in Western Africa. METHODS: We used respondent-driven-sampling to obtain a representative sample of heroin or cocaine/crack users aged 18 years or more. Socio-behavioral data were obtained by face-to-face questionnaires. Blood samples were collected and tested for HIV. Two sputa were obtained in tuberculosis (TB) symptomatic participants for acid-fast-bacilli (AFB) smear testing. After a descriptive analysis, crude prevalence were calculated, then weighted to take account of the sampling method. Factors associated with HIV and TB were studied using adjusted log-binomial regression. Population size was estimated by capture-recapture. RESULTS: 450 PWUD were recruited in May 2014. The mean age was 33.5 years; 10.9% were women. Smoking was the main mode of consumption, ever injecting was reported by 12.7% of the participants (3.6% in the past month). Sex work was reported by 15.8% of the PWUD (13.7% of the men), and 10.2% of the men reported sexual relationships with other men (MSM). We found a weighted prevalence of 9.5% for HIV. Women were 3.4 times more likely to be infected than men. Among men, being a sex worker (SW) (adjusted OR 2.9 [95CI 1.06-7.98]) or MSM (adjusted OR 11.5 [95CI 4.22-31.42]) were the main factors associated with HIV infection in adjusted analysis. Injection was not associated with HIV. TB weighted prevalence was 1.8%, associated with poor living arrangements in adjusted analysis. We estimated that 3521; 95CI 3049-3993 PWUD live in Abidjan. CONCLUSION: PWUD in Abidjan are at high risk of HIV due to sexual transmission, especially in women, SW and MSM who also use drugs. Interventions should be developed to improve HIV prevention and linkage to care in these specific populations. More generally, improving the health of PWUD involves a broader reflection on the living environment and access to health care of slum residents in large African cities.

Access to hepatitis C treatment for people who inject drugs in low and middle income settings: Evidence from 5 countries in Eastern Europe and Asia.

BACKGROUND: People who inject drugs (PWID) are disproportionately affected by the hepatitis C (HCV) epidemic. Of the estimated 16 million PWID worldwide, approximately 8 million live with chronic HCV, and around 26% and 23% of the global HCV infections among PWID occur in East/Southeast Asia and Eastern Europe respectively. Globally, few PWID have access to treatment for HCV. METHODS: We conducted a systematic literature review and internet survey in 2014 to document the burden of disease, access to diagnosis and treatment and the existence of national policy and treatment guidelines for HCV. We included Georgia, Russia, Ukraine, Myanmar and Indonesia as countries with injection drug use epidemics. FINDINGS: HCV antibody prevalence among the general population ranged from 0.80% in Indonesia to 5% in Georgia, and among PWID from 48.1% in Myanmar to 92% in Georgia. PWID carried a significant burden of disease, ranging from 2.7% in Indonesia to 40.4% in Russia. Yearly treatment uptake was under 1% for the general population and PWID in all countries. Diagnostic tools and disease staging investigations as well as pegylated interferon/ribavirin treatment were available at a range of prices. Despite policy and treatment protocols for HCV in the majority of countries, strategies focusing on PWID were largely absent. CONCLUSION: PWID are a priority group for treatment, and access to treatment should be based on sound national policy, accessible public treatment programmes and functional surveillance systems.