Pathways to prevention: insights on stemming HIV outbreaks in Larkana, Pakistan.

In the past two decades, Pakistan has faced multiple human immunodeficiency virus outbreaks, with Larkana appearing to be the hub of such outbreaks. While the previous Larkana outbreaks happened in high-risk populations, the alarming outbreak in 2019 occurred in a low-risk paediatric population, raising several concerning questions. Human immunodeficiency virus infections spilling into the general population is indicative of a steady increase in the number of cases, and the failure of control strategies to stem the concentrated epidemic from evolving. Although several causative factors have been identified from previous outbreaks, the one that occurred in 2019 may have been influenced by an additional, hitherto unexplored factor; child sexual abuse. The current narrative review was planned to summarise human immunodeficiency virus risk factors and causes identified in previous Larkana epidemics, to explore potential reasons for the outbreaks in children, and to discuss possible steps needed for stemming human immunodeficiency virus outbreaks in Pakistan.

Dynamic models augmented by hierarchical data: an application of estimating HIV epidemics at sub-national level.

Dynamic models have been successfully used in producing estimates of HIV epidemics at the national level due to their epidemiological nature and their ability to estimate prevalence, incidence, and mortality rates simultaneously. Recently, HIV interventions and policies have required more information at sub-national levels to support local planning, decision-making and resource allocation. Unfortunately, many areas lack sufficient data for deriving stable and reliable results, and this is a critical technical barrier to more stratified estimates. One solution is to borrow information from other areas within the same country. However, directly assuming hierarchical structures within the HIV dynamic models is complicated and computationally time-consuming. In this article, we propose a simple and innovative way to incorporate hierarchical information into the dynamical systems by using auxiliary data. The proposed method efficiently uses information from multiple areas within each country without increasing the computational burden. As a result, the new model improves predictive ability and uncertainty assessment.

HIV epidemiology and responses among men who have sex with men and transgender individuals in China: a scoping review.

BACKGROUND: Despite global efforts to control HIV among key populations, new infections among men who have sex with men (MSM) and transgender (TG) individuals are still increasing. The increasing HIV epidemic among MSM/TG in China indicates that more effective services are urgently needed. However, policymakers and program managers must have a clear understanding of MSM/TG sexual health in China to improve service delivery. To meet this need, we undertook a scoping review to summarize HIV epidemiology and responses among MSM and TG individuals in China. METHODS: We searched MEDLINE, EMBASE and the Cochrane Library for recent studies on MSM/TG HIV epidemiology and responses. We also included supplemental articles, grey literature, government reports, policy documents, and best practice guidelines. RESULTS: Overall, HIV prevalence among Chinese MSM was approximately 8 % in 2015 with a higher prevalence observed in Southwest China. TG are not captured in national HIV, STD, or other sexual health surveillance systems. There is limited data sharing between the public health authorities and community-based organizations (CBOs). Like other low and middle income countries, China is challenged by low rates of HIV testing, linkage, and retention. Several pilot interventions have been shown to be effective to increase HIV testing among MSM and TG individuals, but have not been widely scaled up. Data from two randomized controlled trials suggests that crowdsourcing contests can increase HIV testing, creating demand for services while engaging communities. CONCLUSION: Improving HIV surveillance and expanding HIV interventions for Chinese MSM and TG individuals are essential. Further implementation research is needed to ensure high-quality HIV services for MSM and TG individuals in China.

Data and methods to characterize the role of sex work and to inform sex work programs in generalized HIV epidemics: evidence to challenge assumptions.

In the context of generalized human immunodeficiency virus (HIV) epidemics, there has been limited recent investment in HIV surveillance and prevention programming for key populations including female sex workers. Often implicit in the decision to limit investment in these epidemic settings are assumptions including that commercial sex is not significant to the sustained transmission of HIV, and HIV interventions designed to reach "all segments of society" will reach female sex workers and clients. Emerging empiric and model-based evidence is challenging these assumptions. This article highlights the frameworks and estimates used to characterize the role of sex work in HIV epidemics as well as the relevant empiric data landscape on sex work in generalized HIV epidemics and their strengths and limitations. Traditional approaches to estimate the contribution of sex work to HIV epidemics do not capture the potential for upstream and downstream sexual and vertical HIV transmission. Emerging approaches such as the transmission population attributable fraction from dynamic mathematical models can address this gap. To move forward, the HIV scientific community must begin by replacing assumptions about the epidemiology of generalized HIV epidemics with data and more appropriate methods of estimating the contribution of unprotected sex in the context of sex work.

Seminal Shedding of CMV and HIV Transmission among Men Who Have Sex with Men.

As in many urban areas in the United States, the largest burden of the HIV epidemic in San Diego is borne by men who have sex with men (MSM). Using data from well-characterized HIV transmitting and non-transmitting partner pairs of MSM in San Diego, we calculated the population attributable risk (PAR) of HIV transmissions for different co-infections common among MSM in this area. We found that over a third of HIV transmissions could be potentially attributed to genital shedding of cytomegalovirus (CMV) (111 transmission events), compared to 21% potentially attributed to bacterial sexually transmitted infections (STI) (62 events) and 17% to herpes simplex virus type-2 (HSV-2) (51 events). Although our study cannot infer causality between the described associations and is limited in sample size, these results suggest that interventions aimed at reducing CMV shedding might be an attractive HIV prevention strategy in populations with high prevalence of CMV co-infection.

No association between gender inequality and peak HIV prevalence in developing countries - an ecological study.

The prevalence of both gender inequality and HIV prevalence vary considerably both within all developing countries and within those in sub-Saharan Africa. We test the hypothesis that the extent of gender inequality is associated with national peak HIV prevalence. Linear regression was used to test the association between national peak HIV prevalence and three markers of gender equality - the gender-related development index (GDI), the gender empowerment measure (GEM), and the gender inequality index (GII). No evidence was found of a positive relationship between gender inequality and HIV prevalence, either in the analyses of all developing countries or those limited to Africa. In the bivariate analyses limited to Africa, there was a positive association between the two measures of gender "equality" and peak HIV prevalence (GDI: coefficient 28, 95% confidence interval (CI) 9.1-46.8; GEM: coefficient 54.8, 95% CI 20.5-89.1). There was also a negative association between the marker of gender "inequality" and peak HIV prevalence (GII: coefficient -66.9, 95% CI -112.8 to -21.0). These associations all disappeared on multivariate analyses. We could not find any evidence to support the hypothesis that variations in the extent of gender inequality explain variations in HIV prevalence in developing countries.