Roadmap for Achieving Universal Antiretroviral Treatment.

Modern antiretroviral therapy safely, potently, and durably suppresses human immunodeficiency virus (HIV) that, if left untreated, predictably causes acquired immunodeficiency syndrome (AIDS), which has been responsible for tens of millions of deaths globally since it was described in 1981. In one of the most extraordinary medical success stories in modern times, a combination of pioneering basic science, innovative drug development, and ambitious public health programming resulted in access to lifesaving, safe drugs, taken as an oral tablet daily, for most of the world. However, substantial challenges remain in the fields of prevention, timely access to diagnosis, and treatment, especially in pediatric and adolescent patients. As HIV-positive adults age, treating their comorbidities will require understanding the course of different chronic diseases complicated by HIV-related and antiretroviral toxicities and finding potential treatments. Finally, new long-acting antiretrovirals on the horizon promise exciting new options in both the prevention and treatment fields.

Trends of HIV indicators in Egypt from 1990 to 2021: time-series analysis and forecast toward UNAIDS 90-90-90 targets.

BACKGROUND: Infection with Human immunodeficiency virus (HIV) and the development of acquired immunodeficiency syndrome (AIDS) pose severe threats to public health across the world. This study aimed to describe and forecast the trend of HIV indicators, including progress towards the 90-90-90 targets in Egypt since 1990. METHODS: The HIV indicators were graphically described, where the X axis is the time in a year and the Y axis is the value of the selected indicator for each year using data retrieved from UNAIDS. We used the Autoregressive Integrated Moving Average (ARIMA) model to forecast different HIV indicators from 2022 to 2024. RESULTS: Since 1990, HIV prevalence has been < 0.01, the number of people living with HIV (PLHIV) has increased from < 500 to 30,000 with a higher male predominance since 2010, and the number of children living with HIV has increased from < 100 to 1100. The number of pregnant women who needed antiretroviral treatment (ART) to prevent maternofetal HIV transmission increased from < 500 during 2010-2014 to 780 in 2021, the percentage of women who received ART increased from 3% in 2010 to 18% in 2021, the number of children exposed to HIV who did not get infection increased from < 100 in 1990-1991 to 4900 in 2021. The number of AIDS-related deaths increased from < 100 in 1990 to < 1000 in 2021. Based on forecasting, we expect that by 2024 the number of PLHIV will be 39,325(95%CI, 33,236-37,334), 22% (95%CI, 13.0%-32.0%) of pregnant females will have access to ART, 6100(95%CI, 5714-6485) HIV exposed children will not be infected, 77.0%(95% CI 66.0%-86.0%) of the population who knew their HIV status, and 71.0% (95%CI, 61.0%-81.0%) among those who know their HIV status will be on ART. CONCLUSION: HIV is moving forward fast, however, the Egyptian health authority implements different control measures to control its spread.

Differences between persons with and without disability in HIV prevalence, testing, treatment, and care cascade in Tanzania: a cross-sectional study using population-based data.

BACKGROUND: Persons with disability may have a higher HIV prevalence and be less likely than persons without disability to know their HIV-positive status, access antiretroviral therapy (ART), and suppress their HIV viral load (HIV care cascade). However, studies examining differences between persons with and without disability in HIV prevalence and the HIV care cascade are lacking. Using the Tanzania HIV Impact Survey (THIS) data collected between October 2016 and August 2017, we assessed differences in HIV prevalence and progress towards achieving the 2020 HIV care cascade target between persons with and without disability. METHODS: Using the Washington Group Short Set (WG-SS) Questions on Disability, we defined disability as having a functional difficulty in any of the six life domains (seeing, hearing, walking/climbing, remembering/ concentrating, self-care, and communicating). We classified respondents as disabled if they responded having either "Some Difficulty", "A lot of difficulties" or "Unable to" in any of the WG-SS Questions. We presented the sample characteristics by disability status and analyzed the achievement of the cascade target by disability status, and sex. We used multivariable logistic regressions, and adjusted for age, sex, rural-urban residence, education, and wealth quintile. RESULTS: A total of 31,579 respondents aged 15 years and older had HIV test results. Of these 1,831 tested HIV-positive, corresponding to an estimated HIV prevalence of 4.9% (CI: 4.5 - 5.2%) among the adult population in Tanzania. The median age of respondents who tested HIV-positive was 32 years (with IQR of 21-45 years). HIV prevalence was higher (5.7%, 95% CI: 5.3-7.4%) among persons with disability than persons without disability (4.3%, 95% CI: 4.0 - 4.6%). Before adjustment, compared to women without disability, more women with disability were aware of their HIV-positive status (n = 101, 79.0%, 95% CI: 68.0-87.0% versus n = 703, 63.0%, 95% CI: 59.1-66.7%) and accessed ART more frequently (n = 98, 98.7%, 95% CI: 95.3-99.7% versus n = 661, 94.7%, 95% CI: 92.6-96.3%). After adjusting for socio-demographic characteristics, the odds of having HIV and of accessing ART did not differ between persons with and without disability. However, PLHIV with disability had higher odds of being aware of their HIV-positive status (aOR 1.69, 95% 1.05-2.71) than PLHIV without disability. Men living with HIV and with disability had lower odds (aOR = 0.23, 95% CI: 0.06-0.86) to suppress HIV viral loads than their counterparts without disability. CONCLUSION: We found no significant differences in the odds of having HIV and of accessing ART between persons with and without disability in Tanzania. While PLHIV and disability, were often aware of their HIV-positive status than their non-disabled counterparts, men living with HIV and with disability may have been disadvantaged in having suppressed HIV viral loads. These differences are correctable with disability-inclusive HIV programming. HIV surveys around the world should include questions on disability to measure potential differences in HIV prevalence and in attaining the 2025 HIV care cascade target between persons with and without disability.

Factors associated with patients defaulting on HIV treatment at Helen Joseph Hospital, Gauteng province, South Africa.

Background: South Africa's government has made significant improvements in expanding access to antiretroviral (ARV) treatment. A rate of adherence of 95% to 100% is necessary to achieve the intended outcomes of antiretroviral treatment. However, antiretroviral treatment adherence remains a significant challenge at Helen Joseph Hospital, where an adherence rate of 51% to 59% has been reported.Objective: The goal of this study was to examine the factors associated with ARV therapy non-adherence among HIV patients at Helen Joseph Hospital.Method: The study used a case-control design. There were 32 570 eligible patients for this study and 322 were selected from the overall population. Epi Info™ 7.2 was used to calculate the sample size. A total of 322 questionnaires were administered to participants during their clinic visits. The Aids Clinical Trial Group (ACTG) Questionnaire was used to measure and describe factors associated with ART treatment defaulting. Epi Info™ 7.2 was used to calculate crude odds ratios and SPSS version 26 was used to conduct multivariate logistic regression to compute adjusted odds ratios at 95% confidence intervals and p-values.Results: In total, there were 322 (100%) study participants, of which 51% (n = 165) were non-adherent to ARV therapy and 49% (n = 157) were adherent. Participants' ranged between 19 and 58 years old, with a mean age of 34 years old and a standard deviation of 8.03 years. Treatment non-adherence was associated with long waiting times at Helen Joseph's Themba Lethu Clinic after adjusting for gender, age, educational level and employment status. The adjusted odds ratio was 4.78, 95% CI 1.12-20.42, and p = 0.04.Conclusion: The study explored factors associated with ARV treatment defaults at Helen Joseph hospital. The long waiting times at the hospital were strongly associated with non-adherence to ARV treatment. A reduction in clinic waiting times will result in improved adherence to ARV treatment. To reduce long waiting times, the study recommends a multi-month medication dispensing programme and differentiation of HIV care. We recommend that future research include patients and clinic managers (as well as other key players) in the development of solutions to reduce waiting times.Contribution: Helen Joseph Hospital did not view long waiting times as a factor that would cause a patient to default on their ARV treatment in the past. Helen Joseph Hospital's management team was influenced by the study results. To achieve an adherence rate of 95% to 100%, the hospital is reducing waiting times.

Global Health Facility-Based Interventions to Achieve UNAIDS 90-90-90: A Systematic Review and Narrative Analysis.

To evaluate whether health facility-based HIV interventions align with UNAIDS 90-90-90 targets, we performed a systematic review through the lens of UNAIDS targets. We searched 11 databases, retrieving 5201 citations with 26 eligible studies classified by country income and UNAIDS target. We analyzed whether reporting of study outcome metrics was in line with UNAIDS targets using a standardized extraction form and results were summarized in a narrative synthesis given data heterogeneity. We also assessed the quality of randomized trials with the Cochrane Risk of Bias Tool and observational studies with the Newcastle-Ottawa Scale. Stratification of interventions by country income level revealed themes in successful interventions that provide insight for scale-up in similar resource contexts. Few studies reported outcomes using metrics according to UNAIDS targets. Standardization of reporting according to the UNAIDS framework could facilitate comparability of interventions and inform country-level progress on an international scale.

Understating the barriers to achievement of the UNAIDS 90-90-90 goal in Tanzania using a population-based HIV impact assessment survey 2016-2017.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched the 90-90-90 targets. We used Tanzania HIV Impact Survey (THIS) data in 2017 to study the barriers to achieve 90-90-90 targets. THIS was a population-based survey with a stratified multistage stage sampling design. We used weighted logistic regression to associate three targets with socio-demographics, HIV-related discrimination, fear and shame. We defined HIV awareness by a combination of self-reported of HIV status positive and detected antiretroviral (ARV) in blood among PLWH. On ARV was defined as those who self-reported among awareness. Viral load suppression was defined as 400 copies/ml or less in the blood sample. The three targets were estimated at 61-90-85 in Tanzania from the weighted analysis. The first target was far from being achieved. The weighted regression showed that being female, having attained higher education, married, having insurance, and living in urban areas were associated with a high likelihood of having ever tested for HIV. The results indicated that intervention programmes in Tanzania should focus on the first target. Intervention programmes should be designed for each target separately. Integrated strategies in the context of low and middle-income countries are needed to achieve these targets.

Achieving the UNAIDS 90-90-90 targets: a comparative analysis of four large community randomised trials delivering universal testing and treatment to reduce HIV transmission in sub-Saharan Africa.

BACKGROUND: Four large community-randomized trials examining universal testing and treatment (UTT) to reduce HIV transmission were conducted between 2012-2018 in Botswana, Kenya, Uganda, Zambia and South Africa. In 2014, the UNAIDS 90-90-90 targets were adopted as a useful metric to monitor coverage. We systematically review the approaches used by the trials to measure intervention delivery, and estimate coverage against the 90-90-90 targets. We aim to provide in-depth understanding of the background contexts and complexities that affect estimation of population-level coverage related to the 90-90-90 targets. METHODS: Estimates were based predominantly on "process" data obtained during delivery of the interventions which included a combination of home-based and community-based services. Cascade coverage data included routine electronic health records, self-reported data, survey data, and active ascertainment of HIV viral load measurements in the field. RESULTS: The estimated total adult populations of trial intervention communities included in this study ranged from 4,290 (TasP) to 142,250 (Zambian PopART Arm-B). The estimated total numbers of PLHIV ranged from 1,283 (TasP) to 20,541 (Zambian PopART Arm-B). By the end of intervention delivery, the first-90 target (knowledge of HIV status among all PLHIV) was met by all the trials (89.2%-94.0%). Three of the four trials also achieved the second- and third-90 targets, and viral suppression in BCPP and SEARCH exceeded the UNAIDS target of 73%, while viral suppression in the Zambian PopART Arm-A and B communities was within a small margin (~ 3%) of the target. CONCLUSIONS: All four UTT trials aimed to implement wide-scale testing and treatment for HIV prevention at population level and showed substantial increases in testing and treatment for HIV in the intervention communities. This study has not uncovered any one estimation approach which is superior, rather that several approaches are available and researchers or policy makers seeking to measure coverage should reflect on background contexts and complexities that affect estimation of population-level coverage in their specific settings. All four trials surpassed UNAIDS targets for universal testing in their intervention communities ahead of the 2020 milestone. All but one of the trials also achieved the 90-90 targets for treatment and viral suppression. UTT is a realistic option to achieve 95-95-95 by 2030 and fast-track the end of the HIV epidemic.

Progress toward the UNAIDS 90-90-90 targets among female sex workers and sexually exploited female adolescents in Juba and Nimule, South Sudan.

BACKGROUND: Little is known about HIV in South Sudan and even less about HIV among female sex workers (FSW). We characterized progress towards UNAIDS 90-90-90 targets among female sex workers (FSW) and sexually exploited female adolescents in Juba and Nimule, South Sudan. METHODS: We conducted a biobehavioral survey of FSW and sexually exploited female adolescents using respondent-driven sampling (RDS) in Juba (November 2015-March 2016) and in Nimule (January-March 2017) to estimate achievements toward the UNAIDS 90-90-90 targets (90% of HIV-positive individuals know their status; of these, 90% are receiving antiretroviral therapy [ART]; and of these, 90% are virally suppressed). Eligibility criteria were girls and women who were aged ≥15 years; spoke English, Juba Arabic, or Kiswahili; received money, goods, or services in exchange for sex in the past 6 months; and resided, worked, or socialized in the survey city for ≥1 month. Data were weighted for RDS methods. RESULTS: We sampled 838 FSW and sexually exploited female adolescents in Juba (HIV-positive, 333) and 409 in Nimule (HIV-positive, 108). Among HIV-positive FSW and sexually exploited female adolescents living in Juba, 74.8% self-reported being aware of their HIV status; of these, 73.3% self-reported being on ART; and of these, 62.2% were virally suppressed. In Nimule, 79.5% of FSW and sexually exploited female adolescents living with HIV self-reported being aware of their HIV status; of these, 62.9% self-reported being on ART; and of these, 75.7% were virally suppressed. CONCLUSIONS: Although awareness of HIV status is the lowest of the 90-90-90 indicators in many countries, treatment uptake and viral suppression were lowest among FSW and sexually exploited female adolescents in South Sudan. Differentiated service delivery facilitate linkage to and retention on treatment in support of attainment of viral suppression.

Long-term Experience and Outcomes of Programmatic Antiretroviral Therapy for Human Immunodeficiency Virus Type 2 Infection in Senegal, West Africa.

BACKGROUND: Programmatic treatment outcome data for people living with human immunodeficiency virus type 2 (HIV-2) in West Africa, where the virus is most prevalent, are scarce. METHODS: Adults with HIV-2 initiating or receiving antiretroviral therapy (ART) through the Senegalese national AIDS program were invited to participate in this prospective, longitudinal observational cohort study. We analyzed HIV-2 viral loads, CD4 cell counts, antiretroviral drug resistance, loss to follow-up, and mortality. We also examined changes in treatment guidelines over time and assessed progress toward the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 targets for HIV-2. RESULTS: We enrolled 291 participants at 2 sites for 926.0 person-years of follow-up over 13 years. Median follow-up time was 2.2 years per participant. There were 21 deaths reported (7.2%), and 117 individuals (40.2%) were lost to follow-up, including 43 (14.7%) who had an initial visit but never returned for follow-up. CD4 counts and HIV-2 viral suppression (< 50 copies/mL) at enrollment increased over calendar time. Over the study period, 76.7% of plasma viral loads for participants receiving ART were suppressed, and median CD4 gain was 84 cells/µL in participants' first 2 years on study. Since the UNAIDS 90-90-90 strategy was published, 88.1% of viral loads were suppressed. Fifteen percent of patients experienced virologic failure with no known resistance mutations, while 56% had evidence of multiclass drug resistance. CONCLUSIONS: Participants in the Senegalese national AIDS program are initiating ART earlier in the course of disease, and more modern therapeutic regimens have improved outcomes among those receiving therapy. Despite these achievements, HIV-2 treatment remains suboptimal, and significant challenges to improving care remain.

Gaps in HIV Testing and Treatment Among Female Sex Workers in Lae and Mt. Hagen, Papua New Guinea.

We conducted biobehavioral surveys among female sex workers (FSW) in Lae and Mt. Hagen, Papua New Guinea (January-December 2017). Respondent-driven sampling was used to recruit FSW aged ≥ 12 years, who were assigned female sex at birth, who spoke English or Tok Pisin, and who sold or exchanged sex for money, goods, or services in the last 6 months. When adjusted for viral suppression, 48.9% of FSW Lae and 61.9% in Mt. Hagen were aware of their HIV positive status. Of these women, 95.3% in Lae and 98.9% in Mt. Hagen were on antiretroviral therapy, and of these, 83.5% in Lae and 87.0% in Mt. Hagen had suppressed viral load. Renewed efforts are needed to increase HIV testing among FSW and provide support to FSW on treatment in both cities to attain viral suppression.

Effect of perceived HIV risk on initiation of antiretroviral therapy during the universal test and treat era in South Africa.

BACKGROUND: South Africa has not achieved the 90-90-90 goals, in part due to low rates of antiretroviral therapy (ART) initiation among those aware of their HIV status. Perceived risk of HIV at the time of testing may affect likelihood of rapid ART initiation. The purpose of this study was to evaluate factors associated with perceived risk of HIV and the relationship between perceived HIV risk and rapid ART initiation during the universal test and treat era which was adapted in October 2016. METHODS: We conducted a prospective study of adults undergoing HIV testing from October 2016-February 2019 at Ithembalabantu Clinic in Durban. Eligible participants reported not previously being diagnosed with HIV. Before HIV testing, participants were asked to assess their perceived HIV risk on a four-level scale. We categorized "definitely not" and "probably not going to acquire HIV" as a low perceived risk, and "probably will" and "definitely will become HIV-infected" as a high perceived risk of HIV infection. Participants were followed for up to 14 months following HIV testing to assess ART initiation. RESULTS: Among 1519 people newly diagnosed with HIV, 55% were female and mean age was 33 years. Among those, 1382 (90.9%) had a high HIV risk perception and 137 (9.1%) reported low HIV risk perception. In the low risk group individuals were more likely to be female (58% vs 55%), unemployed (62% vs 59%), have a partner with unknown HIV status (61% vs 55%) compared to the high risk group. 83.2% of those with low HIV risk perception reported previously HIV testing compared 91.5% of those with high HIV risk perception. In the multivariate model, males were associated with a higher chances of initiating ART compared to females (adjusted hazard ratio (aHR): 1.187, CI 1.187 (1.060-1.329) and being unemployed (aHR 0.767 CI (0.650-0.905). Those with a low HIV risk perception were less likely to initiate ART 125 (91%) vs 1310 (95%) p = 0.022), and took longer to initiate on ART after HIV diagnosis (11 days' vs 4 days, p = 0.042). CONCLUSION: Factors associated with high HIV risk perception included being unemployed, single, and having a partner of unknown HIV status. People living with HIV (PLHIV) in South Africa who had a low self-perceived risk to HIV infection were less likely to initiate ART. Assessing self-perceived risk of HIV infection may help direct counselling and improve ART initiation to achieve universal 90-90-90 goal.

Determinants of gender disparities in scaling up the first 90 towards the UNAIDS 90-90-90 targets in South Africa: findings from the 2017 household-based national cross-sectional survey.

BACKGROUND: The first 90 of UNAIDS 90-90-90 targets to have 90% of the people living with HIV know their status is an important entry point to the HIV treatment cascade and care continuum, but evidence shows that there is a large gap between males and females in this regard. It is therefore important to understand barriers and facilitators of achieving the first 90 target. This study examined determinants of the first 90 target among females and males in order to inform strategies aimed at improving the HIV cascade in South Africa. METHODS: The data used in the analysis were obtained from a 2017 household-based cross-sectional nationally representative survey conducted using a multi-stage stratified cluster random sampling design. A series of hierarchical multiple logistic regression models were fitted to identify the determinants of the first 90 target by gender. RESULTS: Overall, 84.8% of HIV-positive individuals aged 15 years and older were aware of their HIV status. Females were significantly more aware of their HIV status compared to males (88.7% vs 78.2%, p < 0.001). Both females aged 25 to 49 years [aOR = 3.20 (95% CI 1.35-7.57), p = 0.008], and 50 years and older [aOR = 3.19 (95% CI 1.04-9.76), p = 0.042] and males aged 25 to 49 years [aOR = 3.00 (95% CI 1.13-7.97), p = 0.028], and 50 years and older [aOR = 7.25 (95% CI 2.07-25.36), p = 0.002] were significantly more likely to know their HIV status compared to those aged 15 to 19 years. Males with tertiary education level were significantly more likely to be aware of their HIV positive status [aOR = 75.24 (95% CI 9.07-624.26), p < 0.001] compared to those with no education or with primary level education. Females with secondary [aOR = 3.28 (95% CI 1.20-8.99), p = 0.021] and matric [aOR = 4.35 (95% CI 1.54-12.37), p = 0.006] educational levels were significantly more likely to be aware of their HIV positive status, compared to those with no education or with primary level education. CONCLUSION: Significant progress has been made with regards to reaching the UNAIDS first 90 target. In this context achieving the first 90 target is feasible but there is a need for additional interventions to reach the males especially youth including those with no education or low levels of education.

Socio-economic differences in the uptake of HIV testing and associated factors in South Africa.

BACKGROUND: Improved understanding of barriers to HIV testing is important for reaching the first of the UNAIDS 90-90-90 targets, which states that 90% of HIV positive individuals ought to know their HIV status. This study examined socio-economic status (SES) differences in HIV testing uptake and associated factors among youth and adults 15 years and older in South Africa. METHODS: This study used data from a national cross-sectional, population-based household survey conducted in 2017 using a multi-stage sampling design. A composite SES score was created using multiple correspondence analyses of household assets; households were classified into wealth quintiles and dichotomised into low SES/poorest (lowest 3 quintiles) and high SES/less-poor (highest 2 quintiles). Bivariate and multivariate logistic regression models were used to examine factors associated with the uptake of HIV testing in low and high SES households. RESULTS: HIV testing uptake was 73.8 and 76.7% among low and high SES households, respectively, both of which were below the first 90 targets. Among both low and high SES households, increased HIV testing uptake was significantly associated with females than males. The decreased likelihood was significantly associated with residing in rural formal areas than urban areas, those with no education or low levels of educational attainment and alcohol drinkers among low SES households. Whites and Indians/Asians had a decreased likelihood than Black Africans in high SES households. CONCLUSIONS: HIV testing interventions should target males, residents in rural formal areas, those with no or low education and those that consume alcohol in low SES households, including Whites and Indians/Asians from high SES households in order to bridge socio-economic disparities in the uptake of HIV testing. This should entail expanding HIV testing beyond traditional centres for voluntary counselling and testing through outreach efforts, including mobile testing and home-based testing.

Changes over time in HIV testing and counselling uptake and associated factors among youth in Zambia: a cross-sectional analysis of demographic and health surveys from 2007 to 2018.

INTRODUCTION: Zambia is among the countries with the highest HIV burden and where youth remain disproportionally affected. Access to HIV testing and counselling (HTC) is a crucial step to ensure the reduction of HIV transmission. This study examines the changes that occurred between 2007 and 2018 in access to HTC, inequities in testing uptake, and determinants of HTC uptake among youth. METHODS: We carried out repeated cross-sectional analyses using three Zambian Demographic and Health Surveys (2007, 2013-14, and 2018). We calculated the percentage of women and men ages 15-24 years old who were tested for HIV in the last 12 months. We analysed inequity in HTC coverage using indicators of absolute inequality. We performed bivariate and multivariate logistic regression analyses to identify predictors of HTC uptake in the last 12 months. RESULTS: HIV testing uptake increased between 2007 and 2018, from 45 to 92% among pregnant women, 10 to 58% among non-pregnant women, and from 10 to 49% among men. By 2018 roughly 60% of youth tested in the past 12 months used a government health centre. Mobile clinics were the second most common source reaching up to 32% among adolescent boys by 2018. Multivariate analysis conducted among men and non-pregnant women showed higher odds of testing among 20-24 year-olds than adolescents (aOR = 1.55 [95%CI:1.30-1.84], among men; and aOR = 1.74 [1.40-2.15] among women). Among men, being circumcised (aOR = 1.57 [1.32-1.88]) and in a union (aOR = 2.44 [1.83-3.25]) were associated with increased odds of testing. For women greater odds of testing were associated with higher levels of education (aOR = 6.97 [2.82-17.19]). Education-based inequity was considerably widened among women than men by 2018. CONCLUSION: HTC uptake among Zambian youth improved considerably by 2018 and reached 65 and 49% tested in the last 12 months for women and men, respectively. However, achieving the goal of 95% envisioned by 2020 will require sustaining the success gained through government health centres, and scaling up the community-led approaches that have proven acceptable and effective in reaching young men and adolescent girls who are less easy to reach through the government facilities.

Dramatic decline in new HIV diagnoses in persons born in France in a large nationwide HIV cohort.

OBJECTIVES: As trends in new HIV diagnoses represent a measure of the HIV epidemic, we conducted a 6-year longitudinal study to evaluate the change in rates of new HIV diagnosis, stratified by birthplace, HIV risk groups and CD4 cell count at diagnosis in a large French multicentre cohort. STUDY DESIGN: We performed a retrospective cohort study using data from the mainland French Dat'AIDS cohort. METHODS: Data were obtained for subjects with a new HIV diagnosis date between 2013 and 2018. HIV diagnosis date was defined as the date of the first known positive HIV serology. RESULTS: Between 2013 and 2018, a total of 68,376 people living with HIV (PLHIV) were followed in the Dat'AIDS cohort; 9543 persons were newly diagnosed with HIV. The annual number of new HIV diagnoses decreased from 1856 in 2013, to 1149 in 2018 (-38.1%), P = 0.01; it was more pronounced among subjects born in France, from 858 to 484 (-43.6%), P < 0.01, than in those born abroad (-23.8%, from 821 to 626, P = 0.13). Among subjects born in France, the decrease over the period was -46.7% among men who have sex with men (MSM), -43.5% for heterosexual women and -33.3% for heterosexual men. CONCLUSION: Our findings show changes in HIV epidemiology in PLHIV born in France, with a decline around 40% in new HIV diagnoses, and a more pronounced decrease among MSM and heterosexual women. Our results support the long-term effectiveness of the antiretroviral therapy as a prevention strategy among the various tools for HIV prevention.

Effectiveness of the Sista2Sista programme in improving HIV and other sexual and reproductive health outcomes among vulnerable adolescent girls and young women in Zimbabwe.

Background: In Zimbabwe, adolescent girls and young women (AGYW) experience high rates of HIV and other sexual and reproductive health challenges. In 2013, the Zimbabwe Ministry of Health and Child Care partnered with the United Nations Population Fund to implement the Sista2Sista programme, a structured peer group intervention aimed at improving health outcomes among vulnerable in- and out-of-school AGYW.Methods: Programme data was analysed for 91 612 AGYW aged 10-24 years old who participated in Sista2Sista from 2013 to 2019. Logistic regression was used to determine odds ratios (OR) and evaluate programme exposure as a factor in a set of defined variables.Results: 58 471 AGYW (63.82%) graduated from the Sista2Sista programme by completing at least 30 of 40 exercises. Graduates were more likely to take an HIV test (2.78 OR 95% CI 2.52-3.10), less likely to get married (0.63 OR 95% CI 0.55-0.73) and less likely to drop out of school (0.60 OR 95% CI 0.53-0.69). At higher thresholds of programme completion, additional positive outcomes were observed. Participants who completed all 40 exercises were more likely to return to school (1.41 OR 95% CI 1.18-1.69), more likely to use contraception (1.38 OR 95% CI 1.21-1.56), more likely to report sexual abuse (1.76 OR 95% CI 1.17-2.66), and less likely to become pregnant as adolescents (0.41 OR 95% CI 0.24-0.72). Individual counselling improved the likelihood of programme graduation.Conclusions: The Sista2Sista programme had a positive effect on HIV and other sexual health outcomes among vulnerable AGYW in Zimbabwe. Strategies to improve graduation rates should be explored.

Reaching the Second and Third Joint United Nations Programme on HIV/AIDS 90-90-90 Targets Is Accompanied by a Dramatic Reduction in Primary Human Immunodeficiency Virus (HIV) Infection and in Recent HIV Infections in a Large French Nationwide HIV Cohort.

BACKGROUND: In late 2013, France was one of the first countries to recommend initiation of combination antiretroviral therapy (cART) irrespective of CD4 cell count. METHODS: To assess the impact of achieving the second and third Joint United Nations Programme on HIV/AIDS 90-90-90 targets (ie, 90% of diagnosed people on sustained cART, and, of those, 90% virologically controlled) on human immunodeficiency virus (HIV) incidence, we conducted a longitudinal study to describe the epidemiology of primary HIV infection (PHI) and/or recent HIV infection (patients with CD4 cell count ≥500/mm3 at HIV diagnosis; (PRHI) between 2007 and 2017 in a large French multicenter cohort. To identify changes in trends in PHI and PRHI, we used single breakpoint linear segmented regression analysis. RESULTS: During the study period, 61 822 patients were followed in the Dat'AIDS cohort; 2027 (10.0%) had PHI and 7314 (36.1%) had PRHI. The second and third targets were reached in 2014 and 2013, respectively. The median delay between HIV diagnosis and cART initiation decreased from 9.07 (interquartile range [IQR], 1.39-33.47) months in 2007 to 0.77 (IQR, 0.37-1.60) months in 2017. A decrease in PHI (-35.1%) and PRHI (-25.4%) was observed starting in 2013. The breakpoints for PHI and PRHI were 2012.6 (95% confidence interval [CI], 2010.8-2014.4) and 2013.1 (95% CI, 2011.3-2014.8), respectively. CONCLUSIONS: Our findings show that the achievements of 2 public health targets in France and the early initiation of cART were accompanied by a reduction of about one-third in PHI and PRHI between 2013 and 2017. CLINICAL TRIALS REGISTRATION: NCT02898987.

Integrating and Interpreting Findings from the Latest Treatment as Prevention Trials.

PURPOSE OF REVIEW: In 2018-2019, studies were published assessing the effectiveness of reducing HIV incidence by expanding HIV testing, linkage to HIV treatment, and assistance to persons living with HIV to adhere to their medications (the "90-90-90" strategy). These tests of "treatment as prevention" (TasP) had complex results. RECENT FINDINGS: The TasP/ANRS 12249 study in South Africa, the SEARCH study in Kenya and Uganda, and one comparison (arms A to C) of the HPTN 071 (PopART) study in South Africa and Zambia did not demonstrate a community impact on HIV incidence. In contrast, the Botswana Ya Tsie study and the second comparison (arms B to C) of PopART indicated significant ≈ 30% reductions in HIV incidence in the intervention communities where TasP was expanded. We discuss the results of these trials and outline future research and challenges. These include the efficient expansion of widespread HIV testing, better linkage to care, and viral suppression among all persons living with HIV. A top implementation science priority for the next decade is to determine what strategies to use in specific local contexts.

Community-based antiretroviral therapy (ART) delivery for female sex workers in Tanzania: intervention model and baseline findings.

To increase linkage to and retention in antiretroviral therapy (ART) care, we piloted a community-based, ART service delivery intervention for female sex workers (FSWs). At baseline, we recruited and collected data from 617 FSWs (intervention: 309; comparison: 308) who were HIV positive and not on ART. This paper presents (1) the description of the intervention model, and (2) key descriptive and bivariate-level findings of the baseline FSW cohort. The data showed more than half of FSWs had a non-paying sex partner, and less than one-third used a condom at last sex with paying and non-paying clients, which suggest potentially high levels of HIV transmission. In addition, there is a gap in HIV testing and treatment because one-third learned about their HIV-positive status only at study enrollment, and among FSWs who had known their status for more than a month, half had not registered in care. This substantiates the importance of timely HIV diagnosis and treatment. A community-based ART program may serve as an important strategy in closing the HIV care and treatment gap for FSWs.

Towards achieving the 90-90-90 HIV targets: results from the south African 2017 national HIV survey.

BACKGROUND: Measuring progress towards the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90-90-90 treatment targets is key to assessing progress towards turning the HIV epidemic tide. In 2017, the UNAIDS model estimated that 75% of people living with HIV (PLHIV) globally knew their HIV positive status, 79% of those who knew their status were on antiretroviral therapy (ART), and 81% of those who knew their HIV status and were on ART had a suppressed viral load. The fifth South African national HIV sero-behavioural survey collected nationally representative data that enabled the empirical estimation of these 90-90-90 targets for the country stratified by a variety of key factors. METHODS: To evaluate progress towards achievement of the 90-90-90 targets for South Africa, data obtained from a national, representative, cross-sectional population-based multi-stage stratified cluster random survey conducted in 2017 were analysed. The Fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM V), collected behavioural and biomarker data from individuals residing in households from 1000 randomly selected Small Area Layers (SALs), across all nine provinces of the country. Structured questionnaires were used to collect socio-demographic data, knowledge and perceptions about HIV, and related risk behaviours. Blood samples were collected to test for HIV infection, antiretroviral use, and viral suppression (defined as < 1000 copies/ml). Weighted proportions of study participants aged 15 years and older who tested HIV positive were computed for those who reported awareness of their status (1st 90), and among these, those who were currently on ART (2nd 90) and of these, those who were virally suppressed (3rd 90). RESULTS: Among persons 15 years and older who were HIV positive, 84.8% were aware of their HIV positive status, of whom 70.7% were currently on ART, with 87.4% of these estimated to have suppressed viral load at the time of the survey. These estimates varied by sex, age, and geo-location type. Relatively higher percentages across all three indicators for women compared to men were observed: 88.7% versus 78.2% for those aware of their status, 72.3% versus 67.7% for on ART, and 89.8% versus 82.3% for viral suppression. Knowing one's positive HIV status increased with age: 74.0, 85.8, and 88.1% for age groups 15-24 years old, 25-49 years old and 50-64 years old, although for those 65 years and older, 78.7% knew their HIV positive status. A similar pattern was observed for the 2nd 90, among those who knew their HIV positive status, 51.7% of 15 to 24 year olds, 70.5% of those aged 25-49 years old, 82.9% of those aged 50-64 years old and 82.4% of those aged 65 years or older were currently on ART. Viral suppression for the above mentioned aged groups, among those who were on ART was 85.2, 87.2, 89.5, and 84.6% respectively. The 90-90-90 indicators for urban areas were 87.7, 66.5, and 87.2%, for rural settings was 85.8, 79.8, and 88.4%, while in commercial farming communities it was 56.2, 67.6 and 81.4%. CONCLUSIONS: South Africa appears to be on track to achieve the first 90 indicator by 2020. However, it is behind on the second 90 indicator with ART coverage that was ~ 20-percentage points below the target among people who knew their HIV status, this indicates deficiencies around linkage to and retention on ART. Overall viral suppression among those on ART is approaching the target at 87.4%, but this must be interpreted in the context of low reported ART coverage as well as with variation by age and sex. Targeted diagnosis, awareness, and treatment programs for men, young people aged 15-24 years old, people who reside in farming communities, and in specific provinces are needed. More nuanced 90-90-90 estimates within provinces, specifically looking at more granular sub-national level (e.g. districts), are needed to identify gaps in specific regions and to inform provincial interventions.