The Effect of HIV Programs in South Africa on National HIV Incidence Trends, 2000-2019.

BACKGROUND: Recent studies have shown HIV incidence declines at a population level in several African countries. However, these studies have not directly quantified the extent to which incidence declines are attributable to different HIV programs. METHODS: We calibrated a mathematical model of the South African HIV epidemic to age- and sex-specific data from antenatal surveys, household surveys, and death registration, using a Bayesian approach. The model was also parameterized using data on self-reported condom use, voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral treatment (ART). Model estimates of HIV incidence were compared against the incidence rates that would have been expected had each program not been implemented. RESULTS: The model estimated incidence in 15-49 year olds of 0.84% (95% CI: 0.75% to 0.96%) at the start of 2019. This represents a 62% reduction (95% CI: 55% to 66%) relative to 2000, a 47% reduction (95% CI: 42% to 51%) relative to 2010, and a 73% reduction (95% CI: 68% to 77%) relative to the incidence that would have been expected in 2019 in the absence of any interventions. The reduction in incidence in 2019 because of interventions was greatest for ART and condom promotion, with VMMC and behavior change after HIV testing having relatively modest impacts. HIV program impacts differed significantly by age and sex, with condoms and VMMC having greatest impact in youth, and overall incidence reductions being greater in men than in women. CONCLUSIONS: HIV incidence in South Africa has declined substantially since 2000, with ART and condom promotion contributing most significantly to this decline.

Progress towards 2020 global HIV impact and treatment targets.

INTRODUCTION: Over the past 20 years, the response to the HIV epidemic has achieved remarkable results. These results have often been motivated by targets adopted by countries through United Nations (UN) Political Declarations on HIV. The 2016 political declaration included two impact targets, to achieve a 75% decline in new HIV infections and AIDS-related deaths between 2010 and 2020, and to reach the 90-90-90 testing and treatment targets by 2020. Our objective is to summarize progress towards these targets using robust and comparable HIV estimates released by UNAIDS in July 2021. In addition, we comment on the importance of targets and the modelled estimates required to quantify those targets. DISCUSSION: The UNAIDS estimates indicate that at the global and regional levels, the 2020 targets were missed: new infections declined by 31% and AIDS-related deaths declined by 47% between 2010 and 2020, compared to a target of 75% decline for both indicators. Similarly, no region achieved the 90-90-90 testing and treatment targets. Some countries, in diverse settings, achieved these targets showing that the targets were not overly ambitious if the right funding, policies and evidence-informed interventions at the right scale were in place. The 2021 UN Political Declaration on HIV, adopted on 8 June 2021, has set out a new set of ambitious but achievable targets for 2025. The 2025 targets and the required actions to reach those targets are described in the Global AIDS Strategy 2021-2026, which provides a framework to reprioritize HIV responses by reducing inequalities and building on the achievements of multiple Sustainable Development Goals. The Strategy encourages countries to monitor progress against targets for different geographic areas and populations to maximize equitable services and ensure accountability and also to understand why targets are being missed. CONCLUSIONS: The UNAIDS epidemiological estimates provide information that promote accountability and estimate progress towards global targets at the national level. Additional strategic information and analyses are required to identify the populations that are furthest from the targets and the programmes and policies that are keeping countries from meeting their targets.

Modelling of HIV prevention and treatment progress in five South African metropolitan districts.

Globally, large proportions of HIV-positive populations live in cities. The Fast-Track cities project aims to advance progress toward elimination of HIV as a public health threat by accelerating the response in cities across the world. This study applies a well-established HIV transmission model to provide key HIV estimates for the five largest metropolitan districts in South Africa (SA): Cape Town, Ekurhuleni, eThekwini, Johannesburg and Tshwane. We calibrate the model to metro-specific data sources and estimate progress toward the 90-90-90 targets set by UNAIDS (90% of people living with HIV (PLHIV) diagnosed, 90% of those diagnosed on antiretroviral therapy (ART) and viral suppression in 90% of those on ART). We use the model to predict progress towards similarly defined 95-95-95 targets in 2030. In SA, 90.5% of PLHIV were diagnosed in 2018, with metro estimates ranging from 86% in Johannesburg to 92% in eThekwini. However, only 68.4% of HIV-diagnosed individuals nationally were on ART in 2018, with the proportion ranging from 56% in Tshwane to 73% in eThekwini. Fractions of ART users who were virally suppressed ranged from 77% in Ekurhuleni to 91% in eThekwini, compared to 86% in the whole country. All five metros are making good progress to reach diagnosis targets and all (with the exception of Ekurhuleni) are expected to reach viral suppression targets in 2020. However, the metros and South Africa face severe challenges in reaching the 90% ART treatment target.

HIV incidence among people who inject drugs in the Middle East and North Africa: mathematical modelling analysis.

INTRODUCTION: Emerging HIV epidemics have been documented among people who inject drugs (PWID) in the Middle East and North Africa (MENA). This study estimates the HIV incidence among PWID due to sharing needles/syringes in MENA. It also delineates injecting drug use role as a driver of the epidemic in the population, and estimates impact of interventions. METHODS: A mathematical model of HIV transmission among PWID was applied in seven MENA countries with sufficient and recent epidemiological data and HIV prevalence ≥1% among PWID. Estimations of incident and/or prevalent infections among PWID, ex-PWID and sexual partners of infected current and ex-PWID were conducted. RESULTS: The estimated HIV incidence rate for 2017 among PWID ranged between 0.7% per person-year (ppy) in Tunisia and 7.8% ppy in Pakistan, with Libya being an outlier (24.8% ppy). The estimated number of annual new infections was lowest in Tunisia (n = 79) and Morocco (n = 99), and highest in Iran and Pakistan (approximately n = 6700 each). In addition, 20 to 2208 and 5 to 837 new annual infections were estimated across the different countries among sexual partners of PWID and ex-PWID respectively. Since epidemic emergence, the number of total ever acquired incident infections across countries was 706 to 90,015 among PWID, 99 to 18,244 among sexual partners of PWID, and 16 to 4360 among sexual partners of ex-PWID. The estimated number of prevalent infections across countries was 341 to 23,279 among PWID, 119 to 16,540 among ex-PWID, 67 to 10,752 among sexual partners of PWID, and 12 to 2863 among sexual partners of ex-PWID. Increasing antiretroviral therapy (ART) coverage to the global target of 81% - factoring in ART adherence and current coverage - would avert about half of new infections among PWID and their sexual partners. Combining ART with harm reduction could avert over 90% and 70% of new infections among PWID and their sexual partners respectively. CONCLUSIONS: There is considerable HIV incidence among PWID in MENA. Of all new infections ultimately due to injecting drug use, about 75% are among PWID and the rest among sexual partners. Of all prevalent infections ultimately attributed to injecting drug use as epidemic driver, about half are among PWID, 30% among ex-PWID and 20% among sexual partners of PWID and ex-PWID. These findings call for scale-up of services for PWID, including harm reduction as well as testing and treatment services.

Exposure to domestic violence between parents: a perspective from Tehran, Iran.

Women may bear the brunt of domestic violence, but children are also inflicted by the consequences of violence between their parents. We sought to evaluate the lifetime prevalence of exposure to physical violence between parents among some senior secondary school students in Tehran. The study was conducted on senior secondary school students in all 19 educational districts of the Iranian capital, Tehran, in the academic year of 2005-06 using a multi-stage sampling. Data were collected via a self-administered questionnaire. A total of 1,495 students participated in this survey, with the prevalence estimated at 22.8%. More than half of the subjects had witnessed domestic violence between their parents; the prevalence of exposure among the girls was twice that among the boys. The most frequent act of violence was beating the partner with bare hands and the perpetrators of the violent acts were predominantly the fathers. Exposure was long-lasting; and in those with more than one exposure, the mean duration of exposure was 5.1 years. The most prevalent rates of exposure to domestic violence came from Educational Districts 15 and 10. The fact that a considerable portion of the teenagers in the present study had witnessed physical violence between their parents bears testimony to the high frequency of this form of violence in Tehran households. It is noteworthy that the socio-economic status of the families and parental divorce and estrangement increased the likelihood of exposure to domestic violence in our series.

The prevalence of lens opacities in Tehran: the Tehran Eye Study.

PURPOSE: To determine the prevalence of lens opacities and cataract surgical coverage among Tehran citizens 40 years of age and older. METHODS: The Tehran Eye Study was a population-based survey, with random sampling from Tehran household clusters. Those 40 years of age and older from that survey were included in this analysis. All participants underwent full optometric, slit lamp, and fundoscopic examinations. Lens opacity was assessed after pupil dilation using the modified Lens Opacities Classification System III (LOCS III). The main indices for prevalence of cataract were any lens changes, defined as the presence of a gradable cataract in one or both eyes, and all lens changes, defined as any lens changes plus a history of cataract surgery. RESULTS: A total of 1434 participants were included in this analysis; 305 of which met the criteria for all lens changes resulting in an adjusted prevalence of 22.7% (CI95%: 20.2%-25.3%). The prevalence was 21.2% among men and 24.5% among women. The prevalence of any lens changes was 19.1% (CI95%: 16.6%-21.6%) and the prevalence was higher in women. The prevalence for both indices increased with age. Considering their better eyes, 39 people (2.7%) were shown to have low vision because of cataract and another 12 (0.8%) were classified as blind. CONCLUSIONS: Cataract has affected approximately one-fifth of the Tehran population aged 40 years and over, women more than men, and has severely affected the vision of approximately 3.5% of this population. We found that access to cataract surgery facilities was not an issue.

Reliability and validity of opiate use self-report in a population at high risk for esophageal cancer in Golestan, Iran.

OBJECTIVE: To assess the reliability and validity of self-reported opium use in a rural Iranian population at high risk for esophageal cancer in preparation for a large cohort study. METHOD: 1,057 subjects ages 33 to 84 years were recruited from Gonbad city and three surrounding villages in Golestan province of Iran and completed a questionnaire and provided biological samples. The history and duration of using opium, smoking tobacco, chewing nass, and drinking alcohol were measured by questionnaire in the entire cohort. A subgroup of 130 people was reinterviewed after 2 months to assess reliability. Validity of the opium question was assessed by comparing the questionnaire responses with the presence of codeine and morphine in the urine of 150 selected subjects. RESULTS: Self-reported opiate use is reliable and valid in this population. The reliability of ever opium use and duration of opium use had kappa's of 0.96 and 0.74, respectively. The validity of self-reported opium use was also high. Using urine codeine or morphine as the gold standard for use of opium, self-report had a sensitivity of 0.93 and a specificity of 0.89. CONCLUSIONS: The self-reported use of opium can provide a reliable and valid measurement in this population and will be useful for studying associations between opium use and occurrence of esophageal cancer and other diseases.