Pronounced difference in Covid-19 antibody prevalence indicates cluster transmission in Stockholm, Sweden.

The prevalence of COVID-19 antibodies on June 17-18, 2020 was investigated in two residential areas of Stockholm, Sweden. Among the residents in Norra Djurgårdsstaden, a newly built upper- and middle-class area of Stockholm, 4.1% of study participants had SARS-CoV-2-specific antibodies, while in Tensta, a highly segregated low-income area, 30% of the participants tested antibody positive.

Vital need to engage the community in HIV control in South Africa.

According to the latest 2014 UNAIDS report, which was based on the 2012 South African National HIV Prevalence, Incidence & Behavior Survey, there were between 6.3 and 6.4 million HIV infected people in South Africa. Although the number of new infections appears to have declined in the past 5 years, 370,000 new infections were still estimated to occur in 2013. Young, black women were most at risk with a very high incidence of 4.5%. Of the infected, only 2.2 million were on antiretroviral therapy (ART), meaning that the majority living with HIV was not virally suppressed and thus at risk of infecting somebody else. Eight out of 10 South Africans still believed they were at low risk of HIV infection. Condom use was declining and multiple sexual partnerships were increasing. These findings raise questions about whether current control efforts are properly addressing the drivers of the epidemic. Recent behavior change campaigns target intergenerational sex and blame the high transmission rates among girls on 'sugar daddies' thus diverting attention away from common risk behaviors in the general population. Reduction of new infections is crucial. Much of the current global HIV debate focuses on treatment as prevention (TasP) - an approach hampered by resource problems and the fact that most people are infected by someone who is unaware of his/her HIV status. This raises doubts TasP alone is a sufficient and sustainable solution to prevention. It is not enough to mainly treat those already infected; there is also a need to allocate more resources to address the root causes - ART plus norm and behavior change. We thus propose increased attention to common sexual and social norms and behaviors. New and harmful community norms are one of the major drivers of the ongoing spread of HIV among young women and men in black communities. Addressing sexual risk behaviors and the gender and sexual norms that influence them to scale requires ensuring communities are provided with skills to reflect on the individual and social mechanisms by which these risk behaviors are generated and normalized. To achieve this, partnerships must be formed between political leaders, researchers, technocrats and affected communities. Considering the severity of the epidemic and the continued high incidence of HIV, it is high time to review the current strategy to HIV control in South Africa and allocate more resources to approaches that emphasize community driven norm and behavior change.

Estimating the capacity for ART provision in Tanzania with the use of data on staff productivity and patient losses.

BACKGROUND: International targets for access to antiretroviral therapy (ART) have over-estimated the capacity of health systems in low-income countries in Sub-Saharan Africa. The WHO target for number on treatment by end 2005 for Tanzania was 10 times higher than actually achieved. The target of the national Care and Treatment Plan (CTP) was also not reached. We aimed at estimating the capacity for ART provision and created five scenarios for ART production given existing resource limitations. METHODS: A situation analysis including scrutiny of staff factors, such as available data on staff and patient factors including access to ART and patient losses, made us conclude that the lack of clinical staff is the main limiting factor for ART scale-up, assuming that sufficient drugs and supplies are provided by donors. We created a simple formula to estimate the number of patients on ART based on availability and productivity of clinical staff, time needed to initiate vs maintain a patient on ART and patient losses using five different scenarios with varying levels of these parameters. FINDINGS: Our scenario assuming medium productivity (40% higher than that observed in 2002) and medium loss of patients (20% in addition to 15% first-year mortality) coincides with the actual reported number of patients initiated on ART up to 2008, but is considerably below the national CTP target of 90% coverage for 2009, corresponding to 420,000 on ART and 710,000 life-years saved (LY's). Our analysis suggests that a coverage of 40% or 175,000 on treatment and 350,000 LY's saved is more achievable. CONCLUSION: A comparison of our scenario estimations and actual output 2006-2008 indicates that a simple user-friendly dynamic model can estimate the capacity for ART scale-up in resource-poor settings based on identification of a limiting staff factor and information on availability of this staff and patient losses. Thus, it is possible to set more achievable targets.

HIV control in low-income countries in sub-Saharan Africa: are the right things done?

HIV control efforts in sub-Saharan Africa meet with difficulties. Incidence and prevalence remains high, and little behaviour change seems to have taken place. The focus on HIV control has shifted to anti-retroviral therapy (ART), although this is unlikely either to be cost-effective or the reduce the incidence of HIV. There is reason to change the current approach. Three questions arise: Is there a need to adjust the view on the determinants of the HIV epidemic in sub-Saharan Africa? Are the right things being done to control HIV? Are the things that are being done, done in the right way? We try to answer these questions. The determinants of the epidemic are reviewed and summarized in Figure 2. The need to adjust the view on the determinants and get rid of myths is stressed. A possible, locally adaptable intervention mix is outlined. Male circumcision is a key intervention where socially acceptable. Operationalisation and organisational changes are briefly discussed. Conclusively, the need for a "social revolution" through the opening up of a discussion on sexuality in the community, as well as a focus on cost-effective interventions and a slimmed down, more effective organisation is underlined. Such steps might make it possible to considerably reduce HIV-incidence, even in low-income countries.