The Potential Impact of a Gel-Based Point-of-Sex Intervention in Reducing Gonorrhea Incidence Among Gay and Bisexual Men: A Modeling Study.

BACKGROUND: Increases in sexually transmitted infections among gay and bisexual men (GBM) over the past decade have coincided with declines in condom use and rapid uptake of HIV preexposure prophylaxis (PrEP). We explored the impact of an antimicrobial gel-based point-of-sex intervention (gel-PSI) with a lower efficacy for reducing gonorrhea transmission risk than condoms on population-level gonorrhea incidence among GBM in Victoria, Australia. METHODS: A deterministic compartmental model of HIV and gonorrhea transmission was used to project annual gonorrhea incidence from 2020 to 2025. Individuals were classified as HIV-negative (PrEP or non-PrEP users) or HIV-positive, and further stratified by gonorrhoea risk (high/low). All possible scenarios where between 0% and 100% of GBM using condoms transitioned to gel-PSI (considered a downgrade in protection) and 0% and 100% of GBM not using condoms transitioned to gel-PSI (considered an upgrade in protection), with gel-PSI efficacy ranging from 20% to 50%, were run. RESULTS: The baseline scenario of no gel-PSI uptake (status quo) projected 94,367 gonorrhea infections between 2020 and 2025, with an exponentially increasing trend in annual infections. For a gel-PSI efficacy of 30%, a net reduction in cumulative gonorrhea incidence was projected, relative to the status quo, for any ratio of proportion of condom users "downgrading" to proportion of noncondom users "upgrading" to gel-PSI use of less than 2.6. Under the supposition of equal proportions of condom users and noncondom users switching to gel-PSI, a relative reduction was projected for any gel-PSI efficacy greater than 16%. CONCLUSIONS: Our model suggests that the introduction of a gel-PSI could have benefits for controlling gonorrhea transmission among GBM, even in scenarios where the gel-PSI is considerably less efficacious than condoms and when gel-PSI uptake leads to consequent reductions in consistent condom use.

Estimating the syphilis epidemic among gay, bisexual and other men who have sex with men in Australia following changes in HIV care and prevention.

Background Syphilis control remains a challenge in many high-income countries, including Australia, where diagnoses are concentrated among gay, bisexual men and other men who have sex with men (GBM). The aim of this study is to project the syphilis epidemic among GBM under a range of scenarios. METHODS: A dynamic coinfection model of HIV and syphilis transmission among GBM in Victoria, Australia, was parametrised to test data from clinics in Melbourne and syphilis case notifications in Victoria. Projected outcomes were new syphilis infections between 2018 and 2025 under seven testing and behaviour change scenarios. RESULTS: Among HIV-negative GBM, the model estimated that increasing syphilis testing coverage (69% - 75%) and frequency (~8-monthly - 6-monthly) could prevent 5% and 13% of syphilis cases respectively between 2018 and 2025 compared to the status quo. Among HIV-positive GBM, less syphilis testing due to changes in HIV care increased syphilis cases by 29% between 2018 and 2025 compared to the status quo. Under a scenario of 20% HIV pre-exposure prophylaxis (PrEP) coverage among HIV-negative GBM (and associated increased serodiscordant sex, reduced condom use and increased syphilis testing), syphilis cases were estimated to decrease by 6% among HIV-negative GBM and by 3% among HIV-positive GBM compared to the status quo, driven by increased testing among PrEP users. CONCLUSION: The present study findings support syphilis control policies focusing on increased testing among GBM. Current Australian PrEP guidelines of quarterly syphilis testing are likely to negate any increases in syphilis due to risk compensation occurring with PrEP scale-up.

Optimising HIV spending in 12 eastern European and central Asian countries: a modelling study.

BACKGROUND: The eastern European and central Asian (EECA) region has the fastest growing HIV epidemic globally. We aimed to identify how HIV resources could be allocated for maximum health impact. METHODS: Between Aug 1 and Dec 23, 2022, allocative efficiency analyses were undertaken for 12 countries in the EECA region (Albania, Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kosovo, Kyrgyzstan, Moldova, Serbia, Tajikistan, and Uzbekistan) using HIV epidemic models developed with Optima HIV. Country models were calibrated to demographic, epidemiological, and programmatic data and validated by national teams. Three scenarios were projected from 2023 to 2030: status quo (continued 2021 spending on HIV programmes); optimised allocation of different spending envelopes to minimise HIV infections and deaths; and achieving 95-95-95 UNAIDS targets by 2030. FINDINGS: Aggregated across the 12 models, HIV infections attributable to sexual transmission were estimated to surpass those attributable to transmission through injecting drugs in 2018, with male-to-male sexual transmission accounting for a continuously increasing share. In the status quo scenario, there were an estimated 111 520 (95% CI 28 960-208 270) new HIV infections and 34 530 (17 280-57 410) HIV-related deaths between 2023 and 2030. Aggregated optimisation results suggest that 35 860 (32%) of 111 520 new HIV infections and 9170 (27%) of 34 530 HIV-related deaths could be averted from 2023 to 2030 compared with the status quo, by prioritising antiretroviral therapy and targeted key population programmes. For ten countries, achieving 95% diagnosis was projected to not be possible with the current budget envelope, and for seven countries, this target could require more than three times the current spending. Compared with the status quo, achieving 95-95-95, or as close as possible, could avert 70 880 (64%) of 111 520 new HIV infections and 18 890 (55%) of 34 530 HIV-related deaths from 2023 to 2030. INTERPRETATION: Targeted key population programmes should remain high priorities in the EECA region. Achieving 95-95-95 will require more emphasis on implementing appropriate modes of service delivery that reduce the gap in diagnosis and treatment coverage for people living with HIV. FUNDING: The Global Fund to Fight AIDS, Tuberculosis and Malaria. TRANSLATION: For the Russian translation of the summary see Supplementary Materials section.

The cost and impact of distributing naloxone to people who are prescribed opioids to prevent opioid-related deaths: findings from a modelling study.

BACKGROUND AND AIMS: Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids. DESIGN: Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME). SETTING: Australia. PARTICIPANTS: People who are prescribed opioids. MEASUREMENTS: Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up. FINDINGS: Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400). CONCLUSION: In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

Hepatitis C elimination in Myanmar: Modelling the impact, cost, cost-effectiveness and economic benefits.

BACKGROUND: Myanmar has set national hepatitis C (HCV) targets to achieve 50% of people diagnosed and 50% treated by 2030. The WHO has additional targets of reducing incidence by 80% and mortality by 65% by 2030. We aimed to estimate the impact, cost, cost-effectiveness and net economic benefit of achieving these targets. METHODS: Mathematical models of HCV transmission, disease progression and the care cascade were calibrated to 15 administrative regions of Myanmar. Cost data were collected from a community testing and treatment program in Yangon. Three scenarios were projected for 2020-2030: (1) baseline (current levels of testing/treatment); and testing/treatment scaled up sufficiently to reach (2) the national strategy targets; and (3) the WHO targets. FINDINGS: Without treatment scale-up, 333,000 new HCV infections and 97,000 HCV-related deaths were estimated to occur in Myanmar 2020-2030, with HCV costing a total $100 million in direct costs (testing, treatment, disease management) and $10.4 billion in lost productivity. In the model, treating 55,000 people each year was sufficient to reach the national strategy targets and prevented a cumulative 40,000 new infections (12%) and 25,000 HCV-related deaths (25%) 2020-2030. This was estimated to cost a total $189 million in direct costs ($243 per DALY averted compared to no treatment scale-up), but only $9.8 billion in lost productivity, making it cost-saving from a societal perspective by 2024 with an estimated net economic benefit of $553 million by 2030. Reaching the WHO targets required further treatment scale-up and additional direct costs but resulted in greater longer-term benefits. INTERPRETATION: Current levels of HCV testing and treatment in Myanmar are insufficient to reach the national strategy targets. Scaling up HCV testing and treatment in Myanmar to reach the national strategy targets is estimated to generate significant health and economic benefits. FUNDING: Gilead Sciences.

Gender inequalities in health and wellbeing across the first two decades of life: an analysis of 40 low-income and middle-income countries in the Asia-Pacific region.

BACKGROUND: By adulthood, gender inequalities in health and wellbeing are apparent. Yet, the timing and nature of gender inequalities during childhood and adolescence are less clear. We describe the emergence of gender inequalities in health and wellbeing across the first two decades of life. METHODS: We focused on the 40 low-income and middle-income countries in Asia and the Pacific. A measurement framework was developed around four key domains of wellbeing across the first two decades: health, education and transition to employment, protection, and a safe environment. Specific measurement constructs were then defined by considering gender indicator frameworks, the Sustainable Development Goals, indicator frameworks for child and adolescent health and wellbeing, and key stakeholder input. Available data were then mapped to define 87 indicators, subsequently populated using databases (UN agencies and the Global Burden of Diseases, Injuries, and Risk Factors Study) and nationally representative surveys. Where possible, estimates in girls were compared with boys to report relative risks. FINDINGS: Although son preference is evident in some settings-as shown by higher than expected male-to-female sex ratios at birth in India, Vietnam, and China (all >1·10 compared with an expected ratio of 1·05) and excess mortality of girl children in some South Asian and Pacific nations-it is during early adolescence where marked gender inequalities consistently emerged. Adolescent girls face considerable disadvantage in relation to sexual and reproductive health (notably in South Asia and the Pacific), with high rates of child marriage (≥30% of women aged 20-24 years married before 18 years in Bangladesh, Nepal, and Afghanistan), fertility (≥65 livebirths per 1000 girls in Nauru, Laos, Afghanistan, Nepal, Marshall Islands, Bangladesh, Vanuatu, and Papua New Guinea), and intimate partner violence (>20% in Timor Leste, Afghanistan, Pakistan, and Myanmar). Despite educational parity in many countries, females aged 15-24 years were less likely than males to be in education, employment, or training in 17 of 19 countries for which data were available. Compared with girls, adolescent boys experienced excess all-cause mortality and substantially higher mortality due to unintentional injury, interpersonal violence, alcohol and other drugs, and suicide, and higher prevalence of harmful drinking and tobacco smoking. INTERPRETATION: These findings call for a focus on gender policy and programming in later childhood and early adolescence before gender inequalities become embedded. FUNDING: UNICEF.