HIV Prevention in Care and Treatment Settings: Baseline Risk Behaviors among HIV Patients in Kenya, Namibia, and Tanzania.

HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP). TRIAL REGISTRATION: ClinicalTrials.gov NCT01256463

Characterizing the transitioning epidemiology of herpes simplex virus type 1 in the USA: Model-based predictions

Background: Herpes simplex virus type 1 (HSV-1) is a prevalent lifelong infection that appears to be undergoing an epidemiologic transition in the United States (US). Using an analytical approach, this study aimed to characterize HSV-1 transitioning epidemiology and estimate its epidemiologic indicators, past, present, and future. Methods: An age-structured mathematical model was developed to describe HSV-1 transmission through oral and sexual modes of transmission. The model was fitted to the National Health and Nutrition Examination Surveys, 1976-2016 data series. Results: HSV-1 seroprevalence was projected to decline from 61.5% in 1970 to 54.8% in 2018, 48.5% in 2050, and 42.0% in 2100. In 30% for those aged 0-19 years, but 60. Meanwhile, the number of new infections per year (oral and genital) was persistent at 2,762,000 in 1970, 2,941,000 in 2018, 2,933,000 in 2050, and 2,960,000 in 2100. Of this total, genital acquisitions contributed 252,000 infections in 1970, 410,000 in 2018, 478,000 in 2050, and 440,000 in 2100 - a quarter of which are symptomatic with clinical manifestations. For those aged 15-49 years, nearly 25% of incident infections are genital. Most genital acquisitions (> 85%) were due to oral-to-genital transmission through oral sex, as opposed to genital-to-genital transmission through sexual intercourse. Conclusion: HSV-1 epidemiology is undergoing a remarkable transition in the US, with less exposure in childhood and more in adulthood, and less oral but more genital acquisition. HSV-1 will persist as a widely prevalent infection, with ever-increasing genital disease burden.This publication was made possible by NPRP grant number 9-040-3-008 from the Qatar National Research Fund (a member of Qatar Foundation). The findings achieved herein are solely the responsibility of the authors. The authors are also grateful for pilot funding provided by the Biomedical Research Program and infrastructure support provided by the Biostatistics, Epidemiology, and Biomathematics Research Core, both at Weill Cornell Medicine in Qatar

Characterizing HIV epidemiology among female sex workers and their clients in the Middle East and North Africa.

OBJECTIVES: This thesis aims to address the evidence gap in understanding HIV epidemiology among female sex workers (FSWs) in the Middle East and North Africa (MENA) region by 1) conducting the first comprehensive assessment of HIV epidemic status among FSWs and their clients, and of other key sexually transmitted infections (STIs) among FSWs, 2) investigating the utility of herpes simplex virus type 2 (HSV-2) prevalence in predicting HIV epidemic potential in FSWs, and 3) estimating HIV incidence in heterosexual sex work networks (HSWNs) and assessing the impact of interventions on epidemiological measures of relevance to HIV response. METHODS: Methodologies include systematic reviews, meta-analyses and meta-regressions of HIV/STI prevalence data, ecological analysis of global HSV-2/HIV prevalence data among FSWs, and an individual-based mathematical model simulating HIV transmission dynamics in HSWNs. RESULTS: The median proportion of reproductive-age women reporting current/recent sex work was 0.6% (range: 0.2-2.4%), and of men reporting currently/recently buying sex was 5.7% (range: 0.3-13.8%). Risk behaviors varied widely within and across countries. The HIV epidemic was concentrated in Djibouti and South Sudan (prevalence ~20%), of intermediate intensity in North Africa and Somalia (1-5%), and limited in other countries (<1%). There was steady growth in odds of HIV prevalence since 2003 at ~15% per year (95% CI: 9-21%). STI prevalence among FSWs was substantial (relative to general population women), supporting a key role for HSWNs in STI transmission dynamics. Pooled prevalence of current infection was 12.7% (95% CI: 8.5-17.7%) for T. pallidum (syphilis), 14.4% (95% CI: 8.2-22.0%) for C. trachomatis, 5.7% (95% CI: 3.5-8.4%) for N. gonorrhoeae, and 7.1% (95% CI: 4.3-10.5%) for T. vaginalis, while that of lifetime infection was 23.7% (95% CI: 10.2-40.4%) for HSV-2. Syphilis prevalence varied by MENA subregion and has been declining by 7% per year for three decades. Analysis of 231 global paired HSV-2/HIV measures identified a strong positive association among FSWs after adjusting for confounders such as region, temporal trend, and condom use. HIV prevalence was negligible where HSV-2 prevalence was ≤20%, but HIV infection odds doubled with each 25% increase in HSV-2 prevalence indicating a threshold effect and utility of HSV-2 in predicting HIV epidemic potential. The individual-based model was developed, calibrated, tested, and applied to 12 MENA countries with sufficient input data. The estimated number of new infections in 2020 in these countries was 3,471 (range: 1,295-10,308) among FSWs, 6,416 (range: 3,144-14,223) among clients, and 4,717 (range: 3,490-7,288) among client spouses. These infections accounted for 25.1% of total HIV incidence in MENA. Incidence was distributed equally among FSWs, clients, and client spouses. The contribution of incidence in HSWNs to total incidence ranged from 3.3% in Pakistan where injecting drug use is prevalent to 71.8% in South Sudan and 72.7% in Djibouti where sex is the dominant mode of transmission. Scale-up of interventions such as antiretroviral therapy, condom use, and pre-exposure prophylaxis substantially reduced incidence among FSWs, clients, and client spouses either directly or indirectly by reducing onward transmission. CONCLUSIONS: HIV epidemics among FSWs in MENA are emerging, and some are already established. The epidemic has been growing steadily in recent years, but with strong regionalization and heterogeneity. Integrating testing for HSV-2 in HIV surveillance can be useful in predicting HIV epidemic potential particularly in countries where HIV among FSWs is still limited but has potential to grow. Substantial HIV incidence occurs in HSWNs, suggesting the need for rapidly scaling up comprehensive treatment and prevention services at least for FSWs

Characterizing HIV epidemiology in stable couples in Cambodia, the Dominican Republic, Haiti, and India.

Using a set of statistical methods and HIV mathematical models applied on nationally representative Demographic and Health Survey data, we characterized HIV serodiscordancy patterns and HIV transmission dynamics in stable couples (SCs) in four countries: Cambodia, the Dominican Republic, Haiti, and India. The majority of SCs affected by HIV were serodiscordant, and about a third of HIV-infected persons had uninfected partners. Overall, nearly two-thirds of HIV infections occurred in individuals in SCs, but only about half of these infections were due to transmissions within serodiscordant couples. The majority of HIV incidence in the population occurred through extra-partner encounters in SCs. There is similarity in HIV epidemiology in SCs between these countries and countries in sub-Saharan Africa, despite the difference in scale of epidemics. It appears that HIV epidemiology in SCs may share similar patterns globally, possibly because it is a natural 'spillover' effect of HIV dynamics in high-risk populations

Distinct HIV discordancy patterns by epidemic size in stable sexual partnerships in sub-Saharan Africa

OBJECTIVE: To describe patterns of HIV infection among stable sexual partnerships across sub-Saharan Africa (SSA). METHODS: The authors defined measures of HIV discordancy and conducted a comprehensive quantitative assessment of discordancy among stable partnerships in 20 countries in SSA through an analysis of the Demographic and Health Survey data. RESULTS: HIV prevalence explained at least 50% of the variation in HIV discordancy, with two distinct patterns of discordancy emerging based on HIV prevalence being roughly smaller or larger than 10%. In low-prevalence countries, approximately 75% of partnerships affected by HIV are discordant, while only about half of these are discordant in high-prevalence countries. Out of each 10 HIV infected persons, two to five are engaged in discordant partnerships in low-prevalence countries compared with one to three in high-prevalence countries. Among every 100 partnerships in the population, one to nine are affected by HIV and zero to six are discordant in low-prevalence countries compared with 16-45 and 9-17, respectively, in high-prevalence countries. Finally, zero to four of every 100 sexually active adults are engaged in a discordant partnership in low-prevalence countries compared with six to eight in high-prevalence countries. CONCLUSIONS: In high-prevalence countries, a large fraction of stable partnerships were affected by HIV and half were discordant, whereas in low-prevalence countries, fewer stable partnerships were affected by HIV but a higher proportion of them were discordant. The findings provide a global view of HIV infection among stable partnerships in SSA but imply complex considerations for rolling out prevention interventions targeting discordant partnerships

"Men are always scared to test with their partners … it is like taking them to the Police": Motivations for and barriers to couples' HIV counselling and testing in Rakai, Uganda: a qualitative study.

INTRODUCTION: Uptake of couples' HIV counselling and testing (couples' HCT) can positively influence sexual risk behaviours and improve linkage to HIV care among HIV-positive couples. However, less than 30% of married couples have ever tested for HIV together with their partners. We explored the motivations for and barriers to couples' HCT among married couples in Rakai, Uganda. METHODS: This was a qualitative study conducted among married individuals and selected key informants between August and October 2013. Married individuals were categorized by prior HCT status as: 1) both partners never tested; 2) only one or both partners ever tested separately; and 3) both partners ever tested together. Data were collected on the motivations for and barriers to couples' HCT, decision-making processes from tested couples and suggestions for improving couples' HCT uptake. Eighteen focus group discussions with married individuals, nine key informant interviews with selected key informants and six in-depth interviews with married individuals that had ever tested together were conducted. All interviews were audio-recorded, translated and transcribed verbatim and analyzed using Nvivo (version 9), following a thematic framework approach. RESULTS: Motivations for couples' HCT included the need to know each other's HIV status, to get a treatment companion or seek HIV treatment together - if one or both partners were HIV-positive - and to reduce mistrust between partners. Barriers to couples' HCT included fears of the negative consequences associated with couples' HCT (e.g. fear of marital dissolution), mistrust between partners and conflicting work schedules. Couples' HCT was negotiated through a process that started off with one of the partners testing alone initially and then convincing the other partner to test together. Suggestions for improving couples' HCT uptake included the need for couple- and male-partner-specific sensitization, and the use of testimonies from tested couples. CONCLUSIONS: Couples' HCT is largely driven by individual and relationship-based factors while fear of the negative consequences associated with couples' HCT appears to be the main barrier to couples' HCT uptake in this setting. Interventions to increase the uptake of couples' HCT should build on the motivations for couples' HCT while dealing with the negative consequences associated with couples' HCT

Hepatitis C Virus Infection in Populations With Liver-Related Diseases in the Middle East and North Africa.

We investigated hepatitis C virus (HCV) epidemiology in populations with liver-related diseases (LRDs) in the Middle East and North Africa. The data source was standardized databases of HCV measures populated through systematic reviews. Random-effects meta-analyses and meta-regressions were performed, and genotype diversity was assessed. Analyses were based on 252 HCV antibody prevalence measures, eight viremic rate measures, and 30 genotype measures on 132,358 subjects. Pooled mean prevalence in LRD populations was 58.8% (95% confidence interval [CI], 51.5%-66.0%) in Egypt and 55.8% (95% CI, 49.1%-62.4%) in Pakistan; these values were higher than in other countries, which had a pooled prevalence of only 15.6% (95% CI, 12.4%-19.0%). Mean prevalence was highest in patients with hepatocellular carcinoma at 56.9% (95% CI, 50.2%-63.5%) and those with cirrhosis at 50.4% (95% CI, 40.8%-60.0%). Type of LRD population and country were the strongest predictors of prevalence, explaining 48.6% of the variation. No evidence for prevalence decline was found, but there was strong evidence for prevalence increase in Pakistan. A strong, positive association was identified between prevalence in the general population and that in LRD populations; the Pearson correlation coefficient ranged between 0.605 and 0.862. The pooled mean viremic rate was 75.5% (95% CI, 61.0%-87.6%). Genotype 4 was most common (44.2%), followed by genotype 3 (34.5%), genotype 1 (17.0%), genotype 2 (3.5%), genotype 6 (0.5%), and genotype 5 (0.3%). Conclusion: HCV appears to play a dominant role in liver diseases in Egypt and Pakistan and has a growing role in Pakistan. Testing and treatment of LRD populations are essential to reduce disease burden and transmission and to reach HCV elimination by 2030

Understanding dynamics and overlapping epidemiologies of HIV, HSV-2, chlamydia, gonorrhea, and syphilis in sexual networks of men who have sex with men

Introduction: We aimed to investigate the overlapping epidemiologies of human immunodeficiency virus (HIV), herpes simplex virus type 2 (HSV-2), chlamydia, gonorrhea, and syphilis in sexual networks of men who have sex with men (MSM), and to explore to what extent the epidemiology of one sexually transmitted infection (STI) relates to or differs from that of another STI. Methods: An individual-based Monte Carlo simulation model was employed to simulate the concurrent transmission of STIs within diverse sexual networks of MSM. The model simulated sexual partnering, birth, death, and STI transmission within each specific sexual network. The model parameters were chosen based on the current knowledge and understanding of the natural history, transmission, and epidemiology of each considered STI. Associations were measured using the Spearman's rank correlation coefficient (SRCC) and maximal information coefficient (MIC). Results: A total of 500 sexual networks were simulated by varying the mean and variance of the number of partners for both short-term and all partnerships, degree correlation, and clustering coefficient. HSV-2 had the highest current infection prevalence across the simulations, followed by HIV, chlamydia, syphilis, and gonorrhea. Threshold and saturation effects emerged in the relationship between STIs across the simulated networks, and all STIs demonstrated moderate to strong associations. The strongest current infection prevalence association was between HIV and gonorrhea, with an SRCC of 0.84 (95% CI: 0.80-0.87) and an MIC of 0.81 (95% CI: 0.74-0.88). The weakest association was between HSV-2 and syphilis, with an SRCC of 0.54 (95% CI: 0.48-0.59) and an MIC of 0.57 (95% CI, 0.49-0.65). Gonorrhea exhibited the strongest associations with the other STIs while syphilis had the weakest associations. Across the simulated networks, proportions of the population with zero, one, two, three, four, and five concurrent STI infections were 48.6, 37.7, 11.1, 2.4, 0.3, and < 0.1%, respectively. For lifetime exposure to these infections, these proportions were 13.6, 21.0, 22.9, 24.3, 13.4, and 4.8%, respectively. Conclusion: STI epidemiologies demonstrate substantial overlap and associations, alongside nuanced differences that shape a unique pattern for each STI. Gonorrhea exhibits an "intermediate STI epidemiology," reflected by the highest average correlation coefficient with other STIs.The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. RO acknowledges the support of Precursory Research for Embryonic Science and Technology (PRESTO) grant number JPMJPR15E1 from Japan Science and Technology Agency (JST), Japan Society for the Promotion of Science (JSPS), Grant-in-Aid for Young Scientists (B) 19\u2009K20393, and Japan Agency for Medical Research and Development (AMED) under Grant Number JP23fk0108676. This publication was made possible by ARG01-0522-230273 from the Qatar Research, Development and Innovation Council. The findings achieved herein are solely the responsibility of the authors. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors are also grateful for infrastructure support provided by the Biostatistics, Epidemiology, and Biomathematics Research Core at Weill Cornell Medicine-Qatar.Scopu

Understanding dynamics and overlapping epidemiologies of HIV, HSV-2, chlamydia, gonorrhea, and syphilis in sexual networks of men who have sex with men

IntroductionWe aimed to investigate the overlapping epidemiologies of human immunodeficiency virus (HIV), herpes simplex virus type 2 (HSV-2), chlamydia, gonorrhea, and syphilis in sexual networks of men who have sex with men (MSM), and to explore to what extent the epidemiology of one sexually transmitted infection (STI) relates to or differs from that of another STI.MethodsAn individual-based Monte Carlo simulation model was employed to simulate the concurrent transmission of STIs within diverse sexual networks of MSM. The model simulated sexual partnering, birth, death, and STI transmission within each specific sexual network. The model parameters were chosen based on the current knowledge and understanding of the natural history, transmission, and epidemiology of each considered STI. Associations were measured using the Spearman’s rank correlation coefficient (SRCC) and maximal information coefficient (MIC).ResultsA total of 500 sexual networks were simulated by varying the mean and variance of the number of partners for both short-term and all partnerships, degree correlation, and clustering coefficient. HSV-2 had the highest current infection prevalence across the simulations, followed by HIV, chlamydia, syphilis, and gonorrhea. Threshold and saturation effects emerged in the relationship between STIs across the simulated networks, and all STIs demonstrated moderate to strong associations. The strongest current infection prevalence association was between HIV and gonorrhea, with an SRCC of 0.84 (95% CI: 0.80–0.87) and an MIC of 0.81 (95% CI: 0.74–0.88). The weakest association was between HSV-2 and syphilis, with an SRCC of 0.54 (95% CI: 0.48–0.59) and an MIC of 0.57 (95% CI, 0.49–0.65). Gonorrhea exhibited the strongest associations with the other STIs while syphilis had the weakest associations. Across the simulated networks, proportions of the population with zero, one, two, three, four, and five concurrent STI infections were 48.6, 37.7, 11.1, 2.4, 0.3, and &lt; 0.1%, respectively. For lifetime exposure to these infections, these proportions were 13.6, 21.0, 22.9, 24.3, 13.4, and 4.8%, respectively.ConclusionSTI epidemiologies demonstrate substantial overlap and associations, alongside nuanced differences that shape a unique pattern for each STI. Gonorrhea exhibits an “intermediate STI epidemiology,” reflected by the highest average correlation coefficient with other STIs

External infections contribute minimally to HIV incidence among HIV sero-discordant couples in sub-Saharan Africa.

OBJECTIVE: Recent randomised clinical trials among stable HIV sero-discordant couples (SDCs) in sub-Saharan Africa (SSA) have reported that about 20-30% of new HIV infections are acquired from external sexual partners, rather than transmitted from the infected to the uninfected partner within the couple. The aim of this study is to examine whether, and to what extent, these findings are generalisable to SDCs in the wider population in SSA. METHODS: A mathematical model was constructed to calculate the fraction of new HIV-1 infections among SDCs that are due to sources external to the couple. The model was parameterised using empirical and population-based data for 20 countries in SSA. Uncertainty and sensitivity analyses were also conducted. RESULTS: The contribution of external infections among SDCs was generally modest, but it varied widely across SSA. In low HIV prevalence countries (≤ 3.0%), it ranged from 0.6-2.9%. In intermediate prevalence countries (3.0-18.0%), it ranged from 4.9-11.7%. In Swaziland and Lesotho, the world's most-intense epidemics, sizable levels of 27.9% and 27.3% were found, respectively. CONCLUSIONS: In most countries in SSA, nearly all HIV acquisitions by the uninfected partners in SDCs appear to be due to transmissions from the HIV infected partners in the SDCs. The contribution of externally acquired infections varies with HIV population prevalence, but rarely exceeds 10% in the majority of countries. Only in hyperendemic HIV epidemics the contribution of external infections is substantial and may reach the levels reported in recent randomised clinical trials involving SDCs