Has the quality of serosurveillance in low- and middle-income countries improved since the last HIV estimates round in 2007? Status and trends through 2009.

BACKGROUND: HIV surveillance systems aim to monitor trends of HIV infection, the geographical distribution and its magnitude, and the impact of HIV. The quality of HIV surveillance is a key element in determining the uncertainty ranges around HIV estimates. This paper aims to assess the quality of HIV surveillance systems in low- and middle-income countries in 2009 compared with 2007. METHODS: Four dimensions related to the quality of surveillance systems are assessed: frequency and timeliness of data; appropriateness of populations; consistency of locations and groups; and representativeness of the groups. An algorithm for scoring the quality of surveillance systems was used separately for low and concentrated epidemics and for generalised epidemics. RESULTS: The number of countries categorised as fully functioning in 2009 was 35, down from 40 in 2007. 47 countries were identified as partially functioning, while 56 were categorised as poorly functioning. When compared with 2007, the quality of HIV surveillance remains similar. The number of ANC sites in sub-Saharan Africa has increased over time. The number of countries with low and concentrated epidemics that do not have functioning HIV surveillance systems has increased from 53 to 56 between 2007 and 2009. CONCLUSION: Overall, the quality of surveillance in low- and middle-income countries has remained stable. Still too many countries have poorly functioning surveillance systems. Several countries with generalised epidemics have conducted more than one population-based survey which can be used to confirm trends. In countries with concentrated or low-level epidemics, the lack of data on high-risk populations remains a challenge.

Interventions among male clients of female sex workers in Benin, West Africa: an essential component of targeted HIV preventive interventions.

OBJECTIVES: To assess the impact of interventions targeted towards female sex workers (FSWs) and their male clients on client HIV/STI prevalence and sexual behaviour. METHODS: From 1993 to 2006, an HIV/STI preventive intervention focusing on condom promotion and STI care was implemented among FSWs in Cotonou, Benin, and then expanded to cover their male sexual partners in 2000. The interventions were scaled up to five other cities of Benin in 2001-2002. Serial cross-sectional surveys of HIV/STI prevalence and sexual behaviour were carried out among clients in Cotonou in 1998, 2002 and 2005; and in the five other cities (O/Cotonou) in 2002 and 2005. RESULTS: Significant declines in gonorrhoea prevalence among clients of FSWs: Cotonou, from 5.4% in 1998 to 1.6% in 2005; O/Cotonou: from 3.5% in 2002 to 0.59% in 2005. Chlamydia prevalence also declined O/Cotonou, from 4.8% to 1.8%, while HIV prevalence remained stable. Reported condom use by clients with both FSWs and casual non-FSW partners, but not regular partners, increased significantly. While condom use at last sex with an FSW was similar in Cotonou to O/Cotonou around the time of implementation of the interventions (56% in 1998 vs 49% in 2002, respectively), it had risen to similar levels by 2005 (95% and 96%, respectively). CONCLUSIONS: These results demonstrate that it is possible to implement preventive and clinical services for clients of FSWs, and suggest that such interventions, integrated with those targeted towards FSWs, can have a significant effect on sexual behaviour and STI prevalence (particularly gonorrhoea) among this population.

Management of sexually transmitted diseases and HIV prevention in men at high risk: targeting clients and non-paying sexual partners of female sex workers in Benin.

OBJECTIVES: Male clients of female sex workers have rarely been specific targets for HIV/sexually transmitted diseases (STD) interventions in sub-Saharan Africa. We assessed the effectiveness of outreach methodology for contacting sexual partners of female sex workers for purposes of HIV/STD prevention in Cotonou, Benin. DESIGN AND METHODS: In collaboration with owners/managers, outreach personnel and female sex workers, 404 clients were recruited on-site at prostitution venues, and provided urine samples for leukocyte esterase dipstick (LED), STD and HIV testing before having sex with female sex workers. After having sex they underwent an interview and physical examination. No payment was made for study participation. Prostitution site personnel (n = 41) and boyfriends of female sex workers (n = 56) were also recruited. RESULTS: In all 68% of the clients approached agreed to participate. On-site LED testing and free STD treatment were important factors in participation. HIV-1 prevalence was several-fold higher than in the general population in Cotonou, at 8.4, 12.2 and 16.1% in clients, personnel and boyfriends respectively, and was associated with increasing age and lack of condom use with female sex workers. Condom use rates by clients with female sex workers were non-negligible but sub-optimal, and low with regular partners. Approximately one-third of clients with regular partners also had other non-female sex worker sex partners. Boyfriends of female sex workers are of particular concern due to high numbers of partners, very low condom use rates and high HIV prevalence. CONCLUSIONS: Study findings indicate that male sex partners of female sex workers form a 'bridging population' for HIV/STD transmission both to female sex workers, as well as from female sex workers to the general population of women, particularly regular female partners.