Measuring progress towards reaching zero new HIV acquisitions among key populations in Québec (Canada) using routine surveillance data: a mathematical modelling study.

INTRODUCTION: Men who have sex with men (MSM) and people who inject drugs (PWID) are disproportionately impacted by the HIV epidemic in Canada. Having the second-highest provincial diagnosis rate, an improved understanding of the epidemic among these populations in Québec could aid ongoing elimination efforts. We estimated HIV incidence and other epidemic indicators among MSM and PWID in Montréal and across Québec using a back-calculation model synthesizing surveillance data. METHODS: We developed a deterministic, compartmental mathematical model stratified by age, HIV status and disease progression, and clinical care stages. Using AIDS and HIV diagnoses data, including self-reported time since the last negative test and laboratory results of CD4 cell count at diagnosis, we estimated HIV incidence in each population over 1975-2020 by modelling a cubic M-spline. The prevalence, undiagnosed fraction, fraction diagnosed that started antiretroviral treatment (ART) and median time to diagnosis were also estimated. Since the COVID-19 pandemic disrupted testing, we excluded 2020 data and explored this in sensitivity analyses. RESULTS: HIV incidence in all populations peaked early in the epidemic. In 2020, an estimated 97 (95% CrI: 33-227) and 266 (95% CrI: 103-508) HIV acquisitions occurred among MSM in Montréal and Québec, respectively. Among PWID, we estimated 2 (95% CrI: 0-14) and 6 (95% CrI: 1-26) HIV acquisitions in those same regions. With 2020 data, unless testing rates were reduced by 50%, these estimates decreased, except among Québec PWID, whose increased. Among all, the median time to diagnosis shortened to <2 years before 2020 and the undiagnosed fraction decreased to <10%. This fraction was higher in younger MSM, with 22% of 15-24 year-olds living with HIV in Montréal (95% CrI: 9-39%) and 31% in Québec (95% CrI: 17-48%) undiagnosed by 2020 year-end. Finally, ART access neared 100% in all diagnosed populations. CONCLUSIONS: HIV incidence has drastically decreased in MSM and PWID across Québec, alongside significant improvements in diagnosis and treatment coverage-and the 2013 introduction of pre-exposure prophylaxis. Despite this, HIV transmission continued. Effective efforts to halt this transmission and rapidly diagnose people who acquired HIV, especially among younger MSM, are needed to achieve elimination. Further, as the impacts of the COVID-19 pandemic on HIV transmission are understood, increased efforts may be needed to overcome these.

Sexual risk factors associated with intimate partner violence against women in Rwanda: a couples-based analysis.

The goal of this study was to measure the prevalence of intimate partner violence (IPV) against women and to examine the independent association of sexual risk factors of women and their husbands/partners with IPV. We used data from 2,169 couples from the 2005 Rwanda Demographic and Health Survey. Face-to-face interviews were conducted, and multiple logistic regression was used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI). A total of 560 (29.2%), 415 (22.2%), and 233 (12.4%) women reported any physical, psychological, or sexual IPV, respectively. History of genital ulcer in women was significantly associated with psychological IPV (AOR: 2.77; 95% CI: 1.67-4.59), whereas history of genital ulcer reported by husbands/partners was significantly associated with sexual IPV (AOR 2.80, 95% CI: 1.08-7.29). The number of lifetime sexual partners of husbands was positively associated with increasing odds of their wives being exposed to psychological IPV (p = 0.025) and physical IPV (p = .017). In a representative sample of couples, husbands/partners' sexual risk factors were associated with IPV reported by their wives. Genital ulcer appeared to be a risk marker for the presence of IPV victimization/perpetration.

Violence toward women, men's sexual risk factors, and HIV infection among women: findings from a national household survey in Rwanda.

OBJECTIVES: We used the third Rwanda demographic and health survey data to examine the relationship between violence toward women, men sexual risk factors, and HIV prevalence among women. METHODS: The Rwanda demographic and health survey was conducted in 10,272 households in 2005. Analyses were restricted to 2715 women and 2461 men who were legally married or cohabiting. We used logistic regression to analyze associations between HIV and violence toward women. Couple-specific analyses were carried out for assessing the relationship between men sexual risk factors and intimate partner violence (IPV) reported by their wives. RESULTS: Respectively, 29.2%, 22.2%, and 12.4% of women reported having experienced physical, psychological, and sexual IPV, whereas 52.1% reported control practices by their partners. There was a positive link between IPV reported by women and attitudes justifying wife beating endorsed by their husband. After controlling for sociodemographic variables and women sexual risk factors, the odds of HIV prevalence was 3.23 (confidence interval: 1.30 to 8.03) among women with a score from 3 to 4 on the psychological IPV scale compared with those with a score from 0 to 2. Women who reported having experienced interparental violence (father who beat mother) were more likely to test HIV positive as follows: adjusted odds ratio: 1.95; 95% confidence interval: 1.11 to 3.43. There was also a statistically significant relationship between men risky sexual factors and experience of IPV and HIV prevalence among women. CONCLUSIONS: Violence toward women is associated with HIV in Rwanda. Intervention to reduce gender-based violence should be integrated into HIV/AIDS policy.

Use of routine data collected by the prevention of mother-to-child transmission program for HIV surveillance among pregnant women in Rwanda: opportunities and limitations.

To compare HIV prevalence measured by antenatal clinics (ANC) sentinel surveillance and by the prevention of mother-to-child transmission (PMTCT) program in Rwanda. We compared HIV prevalence from anonymous testing performed under ANC surveillance, and that measured from voluntary counselling and testing performed under the PMTCT program, in a random sample of the same population of pregnant women attending for their first antenatal visit at 29 ANC surveillance sites with a PMTCT program in 2007 in Rwanda. All of the 13,318 pregnant women recruited in the ANC surveillance accepted to participate in the PMTCT program. HIV prevalence measured by sentinel surveillance was 4.35% whereas that measured for 1873 pregnant women (out of the total sentinel population) by the PMTCT program was 3.49% (p=0.07). For 3% of the PMTCT population, HIV test results were missing from the counselling logbook versus 0.3% in the ANC laboratory logbooks. For 10 pregnant women, HIV test results were divergent between the PMTCT and the ANC laboratory logbooks. After missing data and errors were corrected, HIV prevalence results from PMTCT was 3.27% (significantly different from ANC surveillance: p =0.03). High uptake of PMTCT program among pregnant women was observed in Rwanda in 2007. HIV prevalence measured by the ANC surveillance and PMTCT program were significantly different. Poor performance in HIV testing practices and PMTCT/laboratories data management could explain this difference. Improvement in HIV testing practices and in PMTCT/laboratory data management are needed in order to use PMTCT data for HIV surveillance and to ensure good performance of all the package of care provided by the PMTCT program.

HIV Prevalence Comparison Between Antenatal Sentinel Surveillance and Demographic and Health Survey in Rwanda.

OBJECTIVE: To compare HIV prevalence from antenatal surveillance to that of the demographic and health survey (DHS), and to identify factors determining the difference of HIV prevalence between women recruited in these two surveys in Rwanda in 2005. METHODS: Comparative cross-sectional study of HIV prevalence and socio-demographic factors collected by the antenatal survey in 13,745 pregnant women, seen in 30 health centres located throughout the country and those collected by the DHS among 5641 women, aged 15-49 years living in households located throughout the country. Log-binomial regression and direct standardization were used to estimate and compare HIV prevalence between the two surveys. RESULTS: HIV prevalence in the antenatal survey was slightly higher than that in DHS women (4.1% versus 3.6% p=0.103). Socio-demographic characteristics were differently distributed between the two populations. Whereas, 59%, 93%, 53% of pregnant women were aged 20-29 years, married or cohabiting and living in rural areas respectively, the corresponding proportions among DHS women were 35%, 48% and 83% (p<0.001). Simultaneous standardization of antenatal prevalence according to the distribution of socio-demographic characteristics in the DHS gave an overall HIV prevalence estimate of 3.6%, similar to the prevalence measured among DHS women. CONCLUSIONS: HIV prevalence in the antenatal survey overestimated that among women of the general population in Rwanda in 2005. This overestimation could be corrected by standardization of antenatal prevalence according to the distribution of age, geographical area, marital status, parity, and education, in the general population.

[Female sex workers in Benin, 2002. Behavioural survey and HIV and other STI screening]. / Enquête de surveillance intégrée du VIH et des autres infections sexuellement transmissibles chez les travailleuses du sexe au Bénin en 2002.

BACKGROUND: As part of an HIV prevention program aimed at female sex workers (FSWs) and their male clients in Benin, we conducted a survey combining laboratory testing and a behavioural questionnaire in 2002 to estimate the prevalence of HIV, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and to determine the social, demographic and behavioral factors associated with these infections. The study provided a follow-up of the epidemiological situation in Cotonou, Benin's largest city, where the intervention began in 1993 with the collection of baseline data; it also collected such data for three other cities in Benin, to which the intervention was being extended in 2002. DESIGN AND METHODS: A cross-sectional study was conducted among 723 self-identified FSWs aged at least 15 years: 474 recruited in Cotonou, 128 in Porto-Novo, 42 in Abomey-Bohicon and 79 in Parakou. The univariate analysis compared the categorical variables with the chi-square test and measured associations with crude prevalence odds ratios (POR). Multivariate logistic regression was used to assess the independent adjusted associations between HIV, NG and CT infections, and the social, demographic and behavioural variables. RESULTS: Globally, the prevalence of HIV was 46%, NG 20.4% and CT 6.0%. All were lower in Cotonou (38.5%, 14%, and 4.8%, respectively) than in the other cities. In multivariate logistic regression analysis, HIV prevalence was significantly associated with gonorrhea (aPOR = 2.77; 95% confidence interval (95% CI): 1.30-5.87), older age (P = 0.0126; trend test), Nigerian origin (aPOR = 0.47; 95% CI: 0.24-0.89) and number of paying clients in the previous 7 days (> 10) (aPOR = 2.41; 95% CI: 1.23-4.71). Infection with NG, CT or both (NG/CT) was significantly associated with HIV (aPOR = 2.22; 95% CI: 1.24-3.95) and 100% condom use was protective against these infections (aPOR = 0.48; 95% CI: 0.25-0.91). CONCLUSION: In developing countries, particularly in sub-Saharan Africa, interventions targeting FSWs are an essential priority for HIV prevention.

[Quality of disease management of sexually transmitted diseases: investigation of care in six countries in West Africa]. / Qualité de la prise en charge des maladies sexuellement transmises: enquête auprés des soignants de six pays de l'Afrique de l'Quest.

OBJECTIVES: the objectives of this study were, in healthcare facilities in six countries in West Africa, to: (1) estimate the proportion of patients consulting for sexually transmitted diseases (STDs) for whom an adequate case history was taken and who received an appropriate physical examination and effective treatement (prevention indicator PI6); (2) to determine the percentage of patients who were given advice on condom use and notification of sexual partners for STD treatment (prevention indicator PI7); (3) to determine the level of knowledge of healthcare workers concerning STD case management; and (4) to compare reported and observed behaviour regarding STD case management by healthcare workers. MATERIAL AND METHOD: this descriptive study was carried out in 240 health care facilities in six countries: Benin, Burkina Faso, Côte d'Ivoire, Guinea, Mali, and Senegal, using the WHO protocol for PI6 and PI7 indicators to evaluate the quality of management of urethral discharge and genital ulcers, as well as an extension of this protocol to evaluate STD syndromes specific to women, namely vaginal discharge and pelvic inflammatory disease. Healthcare workers were observed during STD consultations, and thereafter interviewed. Up to five observations per healthcare worker were carried out over a period of three days spent at each health care facility. Criteria for an adequate case history were inclusion of questions on the nature, time of initiation and duration of symptoms, and for physical examination, visualisation and examination of genital organs for discharge and lesions. Treatments prescribed were judged as effective when in conformity with national algorithms for syndromic STD management. The PI6 indicator was estimated as the proportion of cases where an adequate case history was taken, an appropriate physical examination carried out and effective treatment prescribed. The PI7 score corresponded to the percentage of patients who received advice on condom use and partner notification for treatment. In order to control for intra-healthcare-worker correlation, the SUUDAN software was used for the computation of 95% confidence intervals of the proportions, obtained from univariate analysis in EPI-INFO, and for the comparison of the PI6 and PI7 scores by country, sex, marital status and symptoms of the patient, as well as by level of qualification of the healthcare workers, using the khi2 test. RESULTS: overall, 613 observations and 504 interviews of 263 healthcare workers were carried out. The majority of STD patients were female (57.1%) and unmarried (53.0%). Healthcare workers were most frequently doctors (33.6%) and the most common complaint was vaginal discharge (42.2%). Intercountry variation was observed for all these variables. An adequate case history was taken in 84.6% of cases and an adequate physical examination carried out in 60.8% of cases. Healthcare workers gave a diagnosis in conformity with national syndromic STD management algorithms in 35.3% of cases, while effective treatment was given to 14.1% of patients. Patients were encouraged to use condoms in 19.5% of cases and to advise their partners to seek treatment in 50.8% of cases; this advice was given more frequently to men than to women. PI6 and PI7 scores were respectively 9.9% (95% CI: 6.9%; 12.9%) and 15.4% (95% CI: 11.4%; 19.2%). Healthcare workers' knowledge of effective STD treatment regimes was low. Practices reported during interviews with regard to STD patients were comparable to observed behaviour with regard to case history-taking and physical examination, but not for diagnosis and treatment nor for condom promotion or partner notification advice. CONCLUSION: the results of this study demonstrate the low quality of STD management in the six countries evaluated, which may be explained by the lack of availability of examination material, the inadequate knowledge of healthcare workers, as well as the infrequent promotion of STD prevention methods, particularly in women.