Frequent chlamydia and gonorrhoea but very infrequent syphilis among men who have sex with men using HIV pre-exposure prophylaxis in West Africa.

OBJECTIVES: Although oral pre-exposure prophylaxis (PrEP) for HIV is being rolled out in West Africa, data on sexually transmitted infections (STIs) in PrEP users are scarce. We assessed the prevalence, incidence and determinants of bacterial STIs in men who have sex with men (MSM) taking PrEP in Burkina Faso, Côte d'Ivoire, Mali and Togo. METHODS: A prospective cohort study among MSM initiating PrEP as part of a comprehensive HIV prevention package was conducted between 2017 and 2021 in community-based clinics in the four study countries. Molecular screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) was performed at months 0, 6 and 12. Serological testing for syphilis was performed every 3 months over the first year of follow-up. Determinants of CT and/or NG incidence were identified using Poisson generalised linear mixed models. RESULTS: A total of 598 participants with a median age of 24.7 years were included. Prevalence of CT and/or NG was 24.4% (95% CI 21.0 to 28.1), 22.4% (95% CI 18.4 to 26.8) and 29.0% (95% CI 24.2 to 34.1) at months 0, 6 and 12, respectively. The prevalence of syphilis ranged from 0.2% (95% CI 0.0 to 0.9) at month 0 to 0.8% (95% CI 0.2 to 2.4) at month 12. Ninety incident CT and/or NG infections occurred during a total follow-up time of 280.6 person-years (incidence rate 32.1 per 100 person-years, 95% CI 25.8 to 39.4). Three incident syphilis infections were detected during a total follow-up time of 459.7 person-years (incidence rate 0.7 per 100 person-years, 95% CI 0.1 to 1.9). CT and/or NG incidence was associated with condomless insertive anal sex (adjusted incidence rate ratio 1.96, 95% CI 1.04 to 3.71, p=0.038). CONCLUSIONS: CT and NG were frequent but syphilis was very infrequent in MSM using HIV PrEP in West Africa. HIV programme managers should integrate STI services into PrEP programmes.

Men Who Have Sex with Both Men and Women in West Africa: Factors Associated with a High Behavioral Risk of Acquiring HIV from Male Partners and Transmission to Women (CohMSM ANRS 12324-Expertise France).

HIV is highly prevalent in men who have sex with men (MSM) in West Africa. Many MSM in the region also have sex with women (MSMW). Accordingly, they are a potential bridge subpopulation for HIV transmission to women. We aimed to evaluate the proportions and characteristics of West African MSMW at high behavioral risk of acquiring HIV from male partners and transmitting it to female partners (HBRMF). The cohort ANRS-12324 CohMSM Study included 630 HIV-negative MSM in Burkina Faso, Cote d'Ivoire, Mali, and Togo. Among MSMW (i.e., with ≥ 1 female partner) in the cohort, HBRMF was identified using trajectory models based on seven at-risk sexual practices with male and female partners, including inconsistent condom use, multiple partnerships, and receptive same-sex anal intercourse. To assess the relevance of using trajectory models, we compared the proportions of participants who seroconverted during the cohort follow-up among those at HBRMF and those not at HBRMF. Factors associated with HBRMF were identified using a generalized estimation equation logistic regression model accounting for longitudinal data. Approximately half (47%) of the 304 MSMW (22% of all CohMSM study participants) were at HBRMF. This group accounted for 75% of the 28 HIV seroconversions observed during follow-up (p = 0.001). HBRMF was positively associated with being aged < 25 years (aOR 95% CI 1.67 [1.23-2.27]), being sexually attracted only to men (1.97 [1.38-2.78]), feelings of loneliness (1.92 [1.38-2.65]), and homonegative violence score (1.22 [1.05-1.41]). HBRMF was negatively associated with having had both stable and casual female partners in the previous 6 months (0.34 [0.20-0.60] vs. only a stable female partner). HBRMF tended to be negatively associated with having ≥ 4 sexual intercourses with female partners in the previous four weeks (0.54 [0.27-1.06] vs. no intercourse). Establishing official relationships with women might be a strategy for young and/or stigmatized MSMW to comply with social pressure to display a heterosexual lifestyle. However, this seems to increase the risk of HIV transmission to female partners. In the present study, almost half of MSMW were at HBRMF. This result stresses the need to adapt HIV research and prevention to MSMW and their female partners.

Human Immunodeficiency Virus Seroconversion Among Men Who Have Sex With Men Who Use Event-Driven or Daily Oral Pre-Exposure Prophylaxis (CohMSM-PrEP): A Multi-Country Demonstration Study From West Africa.

BACKGROUND: Data on human immunodeficiency virus (HIV) seroconversion among men who have sex with men (MSM) using pre-exposure prophylaxis (PrEP) in West Africa are needed. This study aimed to document HIV seroconversion and associated determinants, PrEP adherence, plasma drug concentrations, and HIV drug resistance in MSM using event-driven or daily PrEP in Burkina Faso, Côte d'Ivoire, Mali, and Togo. METHODS: A prospective cohort study was conducted in 2017-2021 among HIV-seronegative MSM aged 18 or over who were at high risk of HIV infection. Participants could choose between event-driven and daily PrEP, switch regimens, and discontinue or restart PrEP. The determinants of HIV incidence were investigated using a multivariate mixed-effects Poisson regression analysis. RESULTS: A total of 647 participants were followed for a total time of 1229.3 person-years. Of 5371 visits, event-driven PrEP was chosen in 3873 (72.1%), and daily PrEP in 1400 (26.1%). HIV incidence was 2.4 per 100 person-years (95% confidence interval [CI] 1.5-3.6) for event-driven PrEP, and 0.6 per 100 person-years (95% CI .1-2.3) for daily PrEP (adjusted incidence rate ratio 4.40, 95% CI 1.00-19.36, P = .050). Adequate adherence was lower with event-driven than daily PrEP (44.3% vs 74.9%, P < .001). Plasma drug concentrations were undetectable in 92 (97.9%) of the 94 measures taken for 23 participants who seroconverted. Only 1 participant had resistance to PrEP drugs. CONCLUSIONS: HIV seroconversions mainly occurred in participants who chose event-driven PrEP. The study's data highlighted major difficulties with adherence to this regimen. Improving adherence to event-driven PrEP constitutes a major research and public health priority in this context.

Decrease in incidence of sexually transmitted infections symptoms in men who have sex with men enrolled in a quarterly HIV prevention and care programme in West Africa (CohMSM ANRS 12324-Expertise France).

OBJECTIVE: Although men who have sex with men (MSM) are at high risk of STI, their access to tailored healthcare services remains limited in West Africa. We assessed the change in STI symptoms incidence over time among MSM enrolled in a quarterly HIV prevention and care programme in four cities in Burkina Faso, Côte d'Ivoire, Mali and Togo. METHODS: We performed a prospective cohort study in MSM followed up between 2015 and 2019. Men aged over 18 who reported anal sex with another man within the previous 3 months were offered quarterly syndromic diagnosis and treatment for STI, as well as HIV testing, peer-led counselling and support. Condoms and lubricants were also provided. The change in STI symptoms incidence during follow-up was investigated using a non-parametric trend test and mixed-effect Poisson regression models. RESULTS: 816 participants were followed for a total duration of 1479 person-years. 198 participants (24.3%) had at least one STI symptom during follow-up. Overall, STI symptoms incidence was 20.4 per 100 person-years (95% CI 18.4 to 22.6), ranging from 15.3 in Abidjan to 33.1 in Ouagadougou (adjusted incidence rate ratio (aIRR) 2.39, 95% CI 1.55 to 3.69, p<0.001). STI symptoms incidence was 16.8 and 23.0 per 100 person-years in HIV-positive and HIV-negative participants, respectively (aIRR 0.77, 95% CI 0.57 to 1.04, p=0.087). STI symptoms incidence decreased significantly from 29.9 per 100 person-years in the first 6 months to 8.6 at 30-35 months of follow-up (aIRR per 6-month increase 0.84, 95% CI 0.77 to 0.92, p<0.001). CONCLUSION: STI symptoms incidence decreased over time but the overall burden of STI appeared to be very high in MSM followed up in West Africa. STI services including counselling, diagnosis and treatment should be reinforced. Laboratory tests that allow accurate diagnosis of STI are required. Strengthening STI services will be critical for controlling the HIV and STI epidemics in this vulnerable population and in the general population. TRIAL REGISTRATION NUMBER: NCT02626286.

Rate and Predictors of Ineffective HIV Protection in African Men Who Have Sex with Men Taking Pre-Exposure Prophylaxis.

We investigated the rate and predictors of ineffective HIV protection in men who have sex with men (MSM) taking pre-exposure prophylaxis (PrEP) in a prospective cohort study from November 2017 to November 2020 in Mali, Côte d'Ivoire, Burkina Faso, and Togo. MSM had to be 18 years or older and at high risk of HIV infection to participate. They also received a comprehensive sexual health prevention package, including PrEP, in community-based clinics as part of the cohort study. Using socio-behavioral/clinical data, HIV protection during their most recent anal intercourse with a male partner was categorized as effective or ineffective (i.e., incorrect PrEP adherence and no condom use). Seventeen percent (500/2839) of intercourses were ineffectively protected for the 520 study participants. Predictors of ineffective HIV protection included being an event-driven user with financial difficulties, having a high alcohol misuse score, and not being a member of a community association. PrEP programs in West Africa must be tailored to socially vulnerable MSM who struggle to adopt PrEP.

RESUMEN: En este artículo hemos investigado la proporción y los factores predictivos de la protección ineficaz de VIH en un grupo de hombres, que tienen sexo con hombres (HSH) y que usan la profilaxis pre-exposición (PrEP). Se usaron los datos de un estudio de cohorte prospectivo realizado entre noviembre del 2017 y noviembre del 2020 en Mali, Costa de Marfil, Burkina Faso y Togo. Los participantes son HSH, de 18 años o más, y con alto riesgo de contaminación por el VIH. Estos han recibido un paquete completo de prevención en salud sexual incluyendo la PrEP en clínicas comunitarias como parte del estudio de cohorte. La protección contra el VIH durante la última relación sexual anal con un hombre fue categorizada como eficaz o ineficaz a partir de datos socio-comportamentales/clínicos (i.e. adhesión incorrecta à la PrEP y no utilización del condón). Concerniente a 520 participantes, 17% (500/2839) de las relaciones sexuales fueron protegidas de manera ineficaz. Entre los factores predictivos de la protección ineficaz contra el VIH se encuentran, el uso intermitente de la PrEP asociado a una situación financiera difícil, el consumo de alcohol y no ser miembro de una asociación comunitaria. Los programas de PrEP en África del Oeste, deben adaptarse a los HSH más vulnerables quienes podrían tener más dificultad para adoptar la PrEP.

Examining educational attainment and allostatic load in non-Hispanic Black women.

BACKGROUND: Research suggests that non-Hispanic Black (henceforth, Black) women and people with lower educational attainment have higher levels of allostatic load (AL). This study sought to determine the association between educational attainment and AL among a large sample of Black women. METHODS: We analyzed data among 4177 Black women from the National Health and Nutrition Examination Survey years 1999-2018. AL score was defined as the total for abnormal measures of eight biomarkers. We further categorized participants with AL score greater than or equal to 4 as having high AL. We calculated mean estimates of total allostatic load scores using generalized linear models. We performed modified Poisson Regression models with robust variance estimation to estimate prevalence ratios (PRs) of high allostatic load and their associated 95% confidence intervals (CIs) by educational attainment. RESULTS: Black women with a college degree or higher had the lowest prevalence of high allostatic load (31.8% vs. 42.7%, 36.3%, 36.6%), and age adjusted mean allostatic load scores (mean = 1.90 vs. mean = 2.34, mean = 1.99, mean = 2.05) when compared to Black women with less than a high school diploma, high school diploma or GED, and some college or associates degree respectively. Even after accounting for age, poverty-to-income ratio, smoking, congestive heart failure, and heart attack, Black college graduates had an 14.3% lower prevalence of high allostatic load (PR = 0.857, 95% CI 0.839-0.876) when compared to Black women with lower educational attainment. CONCLUSIONS: Black women with a baccalaureate degree or higher educational attainment had lower allostatic load compared to Black women with less than a high school education. This finding further confirms higher education is a social determinant of health. Future research should explore differences in AL by more granular degree types.

Socio-behavioral correlates of pre-exposure prophylaxis use and correct adherence in men who have sex with men in West Africa.

BACKGROUND: Multiple barriers compromise pre-exposure prophylaxis (PrEP) engagement (i.e., use and adherence) in men who have sex with men (MSM). In low/middle-income countries, little is known about PrEP engagement in this population. In West Africa, the CohMSM-PrEP study was one of the rare interventions providing PrEP to MSM. We estimated PrEP use and correct adherence rates in CohMSM-PrEP, together with associated factors over time.  METHODS: CohMSM-PrEP recruited MSM in four community-based clinics in Mali, Côte d'Ivoire, Burkina Faso, and Togo. Quarterly follow-up included collecting socio-behavioral data, and providing a comprehensive HIV prevention package, PrEP (daily or event-driven), and peer educator (PE)-led counselling. Using repeated measures, multivariate generalized estimating equations models were used to identify factors associated with self-reported i) PrEP use and ii) correct PrEP adherence during participants' most recent anal intercourse (defined as four pills/week for daily users and 2 + 1 + 1 for event-driven users). RESULTS: Five hundred twenty participants were included with a median follow-up time of 12 months (IQR 6-21). Of the 2839 intercourses declared over the follow-up period, PrEP use was self-reported for 1996 (70%), and correct PrEP adherence for 1461 (73%) of the latter. PrEP use was higher in participants who also attended participating clinics outside of scheduled visits (adjusted odds ratio (aOR) [95% Confidence Interval, CI], p-value; 1.32[1.01-1.71], 0.040), and in those who practiced condomless anal sex (1.86[1.54-2.24], < 0.001). Correct adherence was higher in those who often contacted PE outside of scheduled visits (2.16[1.01-4.64], 0.047) and in participants who adopted receptive/versatile sexual positions with stable partners (1.36[1.03-1.81], 0.030). Instead, after an interaction effect between financial situation and regimen was tested, it was lower in event-driven users with a difficult/very difficult financial situation (comfortable/just making ends meet & daily, 4.19[2.56-6.86], < 0.001; difficult/very difficult & daily, 6.47[4.05-10.30], < 0.001; comfortable/just making ends meet & event-driven, 1.63[1.22-2.17], 0.001), and in participants who felt alone (0.76[0.58-0.99], 0.042). CONCLUSIONS: Community-based clinic attendance and PE contact outside of scheduled visits were both associated with higher PrEP engagement, but some socially and economically marginalized participants struggled with adherence. As scale-up continues in West Africa, we recommend implementing community-based interventions and providing extra support for vulnerable users to ensure adequate PrEP engagement.

Heterogeneity in the Prevalence of High-Risk Human Papillomavirus Infection in Human Immunodeficiency Virus-Negative and Human Immunodeficiency Virus-Positive Men Who Have Sex With Men in West Africa.

BACKGROUND: Men who have sex with men (MSM) are at high risk of human papillomavirus (HPV) infection. We assessed (i) the prevalence of high-risk HPV (HR-HPV) infection and associated factors, and (ii) the prevalence of vaccine-preventable HPV infections in MSM in Burkina Faso, Côte d'Ivoire, Mali, and Togo. METHODS: A cross-sectional study was conducted in 2017-2018 among MSM ≥18 years old followed in community-based clinics. HPV infection was investigated in oral and anal samples using the e-BRID system. Factors associated with HR-HPV infection were identified using multivariate logistic regressions. RESULTS: Among 631 participants, 425 were HIV-negative and 206 HIV-positive. HR-HPV prevalence ranged from 9.2% to 34.8% in the former, and 33.3% to 71.0% in the latter, according to the study country. In multivariate analysis, HIV infection (adjusted odds ratio (aOR) 3.61, 95% confidence interval (CI) 2.48-5.27) and study country (4.73, 2.66-8.43 for Mali; 3.12, 1.68-5.80 for Burkina Faso; 3.51, 1.92-6.42 for Togo) were associated with HR-HPV infection. Other associated factors were low educational level, self-defined homosexual identity, and condomless anal sex. The prevalence of infections which can be prevented with bivalent, quadrivalent, and nonavalent vaccines was 5.9, 27.1, and 34.6% in HIV-negative participants, and 18.9, 43.7, and 54.9% in HIV-positive participants, respectively. CONCLUSIONS: HR-HPV prevalence was very heterogeneous between the study countries in both HIV-negative and HIV-positive MSM. Vaccine-preventable HPV infections predominated. Vaccination should be proposed to young MSM to reduce the burden of HPV infection in this vulnerable population and their female partners in West Africa.

Adherence to quarterly HIV prevention services and its impact on HIV incidence in men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France).

BACKGROUND: Access to tailored HIV prevention services remains limited for West African MSM. We assessed adherence to quarterly HIV prevention services and its impact on HIV incidence in MSM followed up in four cities in Burkina Faso, Côte d'Ivoire, Mali, and Togo. METHODS: We performed a prospective cohort study between 2015 and 2018. HIV-negative MSM aged over 18 benefited from quarterly medical visits which included a clinical examination, HIV testing, screening and treatment for other sexually transmitted infections, peer-led counselling and support, and the provision of condoms and lubricants. Determinants of adherence to quarterly follow-up visits and incident HIV infections were identified using generalized estimating equation models and Cox proportional hazard models, respectively. RESULTS: 618 MSM were followed up for a median time of 20.0 months (interquartile range 15.2-26.3). Overall adherence to quarterly follow-up visits was 76.5% (95% confidence interval [CI] 75.1-77.8), ranging from 66.8% in Abidjan to 87.3% in Lomé (p < 0.001). 78 incident HIV infections occurred during a total follow-up time of 780.8 person-years, giving an overall incidence of 10.0 per 100 person-years (95% CI 8.0-12.5). Adherence to quarterly follow-up visits was not associated with the risk of incident HIV infection (adjusted hazard ratio 0.80, 95% CI 0.44-1.44, p = 0.545). CONCLUSIONS: Strengthening HIV prevention services among MSM in West Africa, including the use of PrEP, will be critical for controlling the epidemic, not only in this key population but also in the general population. Quarterly follow-up of MSM, which is essential for PrEP delivery, appears feasible. TRIAL REGISTRATION: ClinicalTrials.gov, number NCT02626286 (December 10, 2015).

Spectroscopy on the wing: Investigating possible differences in protein secondary structures in feather shafts of birds using Raman spectroscopy.

The central shaft of a bird's flight feather bears most of the aerodynamic load during flight and exhibits some remarkable mechanical properties. The shaft comprises two parts, the calamus and the rachis. The calamus is at the base of the shaft, while the rachis is the longer upper part which supports the vanes. The shaft is composed of a fibrous outer cortex, and an inner foam-like core. Recent nanoindentation experiments have indicated that reduced modulus values, Er, for the inner and outer regions of the cortex can vary, with the Er values of the inner region slightly greater than those of the outer region. In this work, Raman spectroscopy is used to investigate the protein secondary structures in the inner and outer regions of the feather cortex. Analysis of the Amide I region of Raman spectra taken from four birds (Swan, Gull, Mallard and Kestrel) shows that the ß-sheet structural component decreases between the inner and outer region, relative to the protein side-chain components. This finding is consistent with the proposal that Er values are greater in the inner region than the outer region. This work has shown that Raman spectroscopy can be used effectively to study the change in protein secondary structure between the inner and outer regions of a feather shaft.

Changes in risky sexual behaviours among West African MSM enrolled in a quarterly HIV testing and counselling prevention programme (CohMSM ANRS 12324 - Expertise France).

OBJECTIVES: Whether regular HIV testing and counselling reduce risky sexual behaviours in African men who have sex with men (MSM) is still a matter for debate. We aimed to identify behavioural trajectories based on HIV risk exposure (HRE) and factors affecting their evolution. METHODS: Data were collected from 621 HIV-negative West African MSM (Mali, Cote d'Ivoire, Burkina Faso and Togo) included in a community-based cohort providing quarterly HIV testing and counselling. Sociobehavioural data were collected every 6 months. HRE was defined as reporting inconsistent condom use during receptive anal sex with male partners of unknown HIV status in the previous 6 months. Using 18-month follow-up data, group-based trajectory modelling helped identify behavioural trajectories and determine the factors associated with their evolution. HIV seroconversions (n=67) were specified in each group trajectory. RESULTS: Two distinct group trajectories were identified: medium-risk exposure MSM (ME-MSM) (61%, 6.4% of whom having seroconverted) and high-risk exposure MSM (HE-MSM) (39%, 17.5% of whom having seroconverted). A significant declining trend in the probability of reporting HRE over time ((95% CI)) was observed for HE-MSM (from 0.59 (0.48 to 0.70) at M0 to 0.31 (0.22 to 0.41) at M18), while it remained constant for ME-MSM (0.034 (0.0 to 0.079)). This can be explained by a progressive use of risk reduction strategies (less receptive anal sex, better knowledge of their partners' status and increasing condom use). Being younger, living in Burkina Faso, self-considering both a man and a woman and reporting a higher level of depression were all associated with HE membership. Among HE-MSM, HRE was higher in those practising transactional or group sex and those experiencing psychological harassment. CONCLUSIONS: Quarterly HIV testing and counselling seem to reduce risky sexual behaviours in HIV-negative MSM at greatest risk of infection. Specific support for young MSM, focusing on identity and mental health, is needed to strengthen HIV prevention in West African MSM.

To Pool or Not to Pool Samples for Sexually Transmitted Infections Detection in Men Who Have Sex With Men? An Evaluation of a New Pooling Method Using the GeneXpert Instrument in West Africa.

BACKGROUND: Men who have sex with men (MSM) using preexposure prophylaxis (PrEP) are at risk for sexually transmitted infections (STIs). Therefore, PrEP services should include regular screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) at urethra, anorectum, and pharynx. However, financial and logistic challenges arise in low-resource settings. We assessed a new STI sample pooling method using the GeneXpert instrument among MSM initiating PrEP in West Africa. METHODS: Urine, anorectal, and pharyngeal samples were pooled per individual for analysis. In case of an invalid result only (strategy 1) or a positive result of the pool (strategy 2), samples were analyzed individually to identify the infection's biological location. The results of 2 different pooling strategies were compared against the individual results obtained by a criterion standard. RESULTS: We found a prevalence of 14.5% for chlamydia and 11.5% for gonorrhea, with a predominance of infections being extragenital (77.6%). The majority of infections were asymptomatic (88.2%). The pooling strategy 1, had a sensitivity, specificity and agreement for CT of 95.4%, 98.7%, and 0.93, respectively; and 92.3%, 99.2%, and 0.93 for pooling strategy 2. For NG, these figures were 88.9%, 97.7%, and 0.85 for strategy 1, and 88.9%, 96.7%, and 0.81 for strategy 2. CONCLUSIONS: West African MSM have a high prevalence of extragenital and asymptomatic STIs. The GeneXpert method provides an opportunity to move from syndromic toward etiological STI diagnosis in low-income countries, as the platform is available in African countries for tuberculosis testing. Pooling will reduce costs of triple site testing.

Imaging techniques for observing laminar geometry in the feather shaft cortex.

Bird feather shafts are light, stiff and strong, but the fine details of how their structure, mechanics and function relate to one another remains poorly understood. The missing piece in our understanding may be the various fibrous layers that make up the shaft's cortex. Detailed imaging techniques are needed to enable us to capture, analyse and quantify these layers before we can begin to unravel the relationship between their structure, mechanics and function. We show that Serial-Block-Face scanning electron microscopy, scanning confocal polarised microscopy and synchrotron-based computed tomography are three suitable techniques to investigate layer thickness and fibre orientation in the feather cortex. These techniques and other are discussed in terms of their ability to resolve the fibrous laminar structure of the feather cortex, on sample preparation, and on throughput. Annotated images are presented for each and less suitable techniques are presented in the Supplementary Material. LAY DESCRIPTION: Bird feathers have a light, stiff and strong central shaft. However, the fine details of how their structure, mechanics and function relate to one another remains poorly understood. The missing piece in our understanding may have to do with how fibrous layers within the shaft vary in thickness and alignment. Detailed imaging techniques are needed so that we can quantify some of this variation before we can revisit some long-unanswered questions about the feather shaft's structure, mechanics and function. We investigate a number of microscopy techniques and show that three techniques are suitable for the sort of investigation that is required. These techniques and others are discussed in terms of their ability to resolve the layers' thickness and alignment, on sample preparation, and on the sample sizes they are able to process. Annotated images are presented and discussed for each of the three techniques and unsuitable techniques receive the same examination in the Supplementary Material.

Hepatitis B testing, treatment, and virologic suppression in HIV-infected patients in Cameroon (ANRS 12288 EVOLCAM).

BACKGROUND: Hepatitis B is a major concern in Africa, especially in HIV-infected patients. Unfortunately, access to hepatitis B virus (HBV) testing and adequate treatment remains a challenge in the continent. We investigated HBV testing, treatment, and virologic suppression in HIV-infected patients followed up as part of Cameroon's national antiretroviral programme. METHODS: A cross-sectional survey was performed in adult patients receiving antiretroviral therapy (ART) in 19 hospitals in the Centre and Littoral regions in Cameroon. The proportions of patients tested for hepatitis B surface antigen (HBsAg) prior to the study were compared among all study hospitals using the Chi-square test. The association of individual and hospital-related characteristics with HBV testing and virologic suppression was assessed using multilevel logistic regression models. RESULTS: Of 1706 patients (women 74%, median age 42 years, median time on ART 3.9 years), 302 (17.7%) had been tested for HBsAg prior to the study. The proportion of HBV-tested patients ranged from 0.8 to 72.5% according to the individual hospital (p < 0.001). HBV testing was lower in women (adjusted odds ratio [aOR] 0.64, 95% confidence interval [CI] 0.46-0.89, p = 0.010) and higher in patients who initiated ART in 2010 or later (aOR 1.66, 95% CI 1.23-2.27, p < 0.001). Of 159 HBsAg-positive patients at the time of the study (9.3%), only 97 (61.0%) received Tenofovir + Lamivudine (or Emtricitabine). Of 157 coinfected patients, 114 (72.6%) had a HBV viral load < 10 IU/mL. HBV suppression was higher in patients with a HIV viral load < 300 copies/mL (aOR 3.46, 95% CI 1.48-8.09, p = 0.004) and lower in patients with increased ALT level (aOR 0.86 per 10 IU/mL increase, 95% CI 0.75-0.97, p = 0.019). CONCLUSIONS: A substantial proportion of HIV/HBV coinfected patients were at higher risk of liver disease progression. Improving the management of HBV infection in the routine healthcare setting in Africa is urgently required in order to achieve the 2030 elimination targets. Micro-elimination of HBV infection in people living with HIV could be an easier and cost-effective component than more widely scaling up HBV policies.

Combined Sexual Behavioral Profiles in HIV-Seronegative Men Who have Sex with Men in West Africa (CohMSM ANRS 12324-Expertise France).

Understanding the dynamics of HIV infection in men who have sex with men (MSM) can help improve efficiency in existing prevention strategies. We aimed to identify and describe the sexual behaviors of MSM most at risk of HIV infection in West Africa. HIV-negative MSM were provided a quarterly preventive follow-up package in the community-based cohort CohMSM. They completed face-to-face sociobehavioral questionnaires every 6 months. This sub-study on 520 participants used a baseline, 6-, 12- and 18-month data cluster analysis to categorize two profiles (high risk [HRE] and moderate risk [MRE] of exposure to HIV) based on three risky sexual practices over the previous 6 months. HRE-MSM (61%) were more engaged in receptive practices, had a higher proportion of inconsistent condom use during anal sex, and reported more sexual partners than MRE-MSM (39%). The proportion of HIV seroconversions observed during the first 18 months of follow-up using sexual behavioral profiles (92% are HRE-MSM) was higher than using the three risky sexual practices separately. Factors associated with the HRE-MSM profile were being younger (18-21 years), reporting stigma, and having had no female partner while being attracted only to men. Our findings suggest that in order to identify MSM most at risk of HIV infection, several risky sexual practices need to be evaluated in a combined approach. Prevention programs should pay particular attention to younger MSM, and implement activities addressing questions of MSM identity and stigma in order to reduce the dynamic of HIV infection in Western African MSM.

Taking empowerment into account: the response of community-based organisations to the HIV care needs of men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France).

Empowerment is an ongoing process through which individuals and communities appropriate power and acquire the capability to function autonomously. Research on empowerment in men who have sex with men (MSM) is lacking in community-based contexts. We investigated the relationship between willingness to be empowered and HIV care needs in West African MSM accessing community-based organisations' (CBO) services. Fifty-three interviews were administered to HIV-negative MSM participating in the CohMSM study (Mali, Burkina Faso, Côte d'Ivoire, Togo). Five indicators of empowerment were identified from a discourse analysis: (i) motivation to access HIV services, (ii) willingness to improve HIV services, (iii) desire to be involved in new activities, (iv) desire to participate in such services, (v) willingness to collaborate in decision making. Based on these indicators, participants were classified into two profiles: high (19/53, 36%) and low (34/53, 64%) level of willingness to be empowered (HWE, LWE). Using a thematic analysis, HWE participants were focused on collective benefit (preventive follow-up, questions about MSM identity), while LWE participants were centred on individual benefit (medical care). CBOs should consider empowerment as a tool to advance collective health benefits for MSM. To improve empowerment in MSM, specific training on issues regarding sexual identity and stigma is needed for CBO providers.

Outcomes of Patients Lost to Follow-up in African Antiretroviral Therapy Programs: Individual Patient Data Meta-analysis.

Background: Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs. Methods: This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART. Results: Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/µL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but had stopped cART, 14.8% (95% CI, 14.0%-15.6%) had transferred to another clinic, 9.2% (95% CI, 8.5%-9.8%) were retained on cART, and 31.6% (95% CI, 30.6%-32.7%) could not been found. Mortality was associated with male sex, more advanced disease, and shorter cART duration; stopping cART with less advanced disease andlonger cART duration; and silent transfer with female sex and less advanced disease. Conclusions: Mortality in patients LTFU must be considered for unbiased assessments of program outcomes and UNAIDS targets in sub-Saharan Africa. Immediate start of cART and early tracing of patients LTFU should be priorities.

Treatment interruption in HIV-positive patients followed up in Cameroon's antiretroviral treatment programme: individual and health care supply-related factors (ANRS-12288 EVOLCam survey).

INTRODUCTION: Decreasing international financial resources for HIV and increasing numbers of antiretroviral treatment (ART)-treated patients may jeopardise treatment continuity in low-income settings. Using data from the EVOLCam ANRS-12288 survey, this study aimed to document the prevalence of unplanned treatment interruption for more than 2 consecutive days (TI>2d) and investigate the associated individual and health care supply-related factors within the Cameroonian ART programme. METHODS: A cross-sectional mixed methods survey was carried out between April and December 2014 in 19 HIV services of the Centre and Littoral regions. A multilevel logistic model was estimated on 1885 ART-treated patients in these services to investigate factors of TI>2d in the past 4 weeks. RESULTS: Among the study population, 403 (21%) patients reported TI>2d. Patients followed up in hospitals reporting ART stock-outs were more likely to report TI>2d while those followed up in the Littoral region, in medium- or small-sized hospitals and in HIV services proposing financial support were at lower risk of TI>2d. The following individual factors were also associated with a lower risk of TI>2d: living in a couple, having children, satisfaction with attention provided by doctor, tuberculosis co-infection and not having consulted a traditional healer. CONCLUSIONS: Besides identifying individual factors of TI>2d, our study highlighted the role of health care supply-related factors in shaping TI in Cameroon's ART programme, especially the deleterious effect of ART stock-outs. Our results also suggest that the high proportion of patients reporting TI could jeopardise progress in the fight against HIV in the country, unless effective measures are quickly implemented like ensuring the continuity of ART supply.

Interest in HIV pre-exposure prophylaxis in men who have sex with men in West Africa (CohMSM ANRS 12324 - Expertise France).

OBJECTIVE: To explore the interest in taking PrEP among Western African men who have sex with men (MSM). METHODS: A cross-sectional survey was implemented at enrolment of HIV-negative MSM in a multiple centre community-based cohort study in four West African countries (Mali, Côte d'Ivoire, Burkina Faso, Togo). A standardised face-to-face questionnaire collected data on socio-demographic and behavioural characteristics over the previous 6 months. Descriptive analysis and multivariate logistic regression helped identify factors associated with the interest in taking PrEP. RESULTS: Of 564 participants, 87% were interested in taking PrEP. Interest in PrEP was associated with inconsistent condom use for anal sex (adjusted odds ratio (aOR): 2.11; 95% confidence interval (CI) 1.21-3.67), transactional sex (aOR: 2.02; 95% CI 1.11-3.71), searching for male sexual partners on the Internet in the previous month (aOR: 1.86; 95% CI 1.01-3.43), having a high level of self-esteem (aOR: 1.20; 95% CI 1.06-1.36), having at least one sexually transmitted infections at enrolment (aOR: 5.08; 95% CI 1.40-18.4) and not being aware of PrEP (aOR: 2.03; 95% CI 1.04-3.96). Participants having sex with HIV-positive male partners (aOR: 0.28; 95% CI 0.11-0.74), those being more sexually attracted to women than to men (aOR: 0.20; 95% CI 0.07-0.89) and those reporting psychological and material support from close friends (aOR: 0.33; 95% CI 0.15-0.73) were less interested in taking PreP. CONCLUSIONS: Western African HIV-negative MSM appear very interested in taking PrEP, especially those most at risk of HIV infection. PrEP implementation in a comprehensive prevention package should be considered urgently.

Secret intake of antiretroviral treatment and HIV-1 viremia in a public routine clinic in Burkina Faso: a surprising relationship.

In sub-Saharan Africa, where people living with HIV are frequently stigmatized, the intake of antiretroviral treatment (ART) remains a critical issue for many patients. Although the secret intake of ART may hinder the adherence to treatment, data on its specific impact on therapeutic effectiveness are lacking. We therefore assessed the association between secret intake of ART (i.e., hidden from family) and HIV-1 viremia among patients treated in a public routine clinic in Burkina Faso. We performed a cross-sectional study from December 2012 to September 2013 among patients on ART at the Day Care Unit in Bobo Dioulasso. Patients were eligible for the study if they were 15 years old or over, infected with HIV-1 or HIV-1 + 2, and on ART for at least six months. HIV-1 viral load was measured using Biocentric or Abbott Real Time assay. Study-specific data were collected by social workers using face-to-face interviews, and medical data using the routine electronic database. The association between secret intake of ART and viral load >300 copies/mL was assessed using a multivariate logistic regression. Of 771 patients (women 81.4%; median age 41 years; median time on ART 51 months), 408 reported secret intake of ART and 363 declared open intake. Compared to the latter, patients who hid their intake were younger, more likely to be women and to be involved in a polygamist or in a non-cohabiting union. Viremia was observed in 4.4% of patients hiding ART intake and 9.4% of those taking it openly. By multivariate analysis, secret intake of ART was significantly associated with a lower risk of viremia (adjusted odds ratio 0.41, 95% confidence interval 0.22-0.76). The unexpected relation between secret intake of ART and viremia found in this study requires further investigations. Quantitative and qualitative studies need to be performed.