JAIDS Journal of Acquired Immune Deficiency Syndromes

ObjectivesTo estimate the increase in HIV infections in 11 US states if Ryan White services are interrupted or ended. MethodsWe applied a population-level model of HIV transmission to 11 states. We represented the proportion of people with HIV receiving Ryan White AIDS Drug Assistance, Outpatient Health services, or Support services, and simulated a loss of suppression in each category if services permanently end or return after delays of 1.5 or 3.5 years. ResultsCessation of Ryan White services in 2025 was projected to result in 69,695 additional infections from 2025-2030 (95% credible interval 18,943 to 123,628) - 68% (18% to 118%) more than if Ryan White were continued. Temporary interruptions of 1.5 and 3.5 years resulted in 26,951 (7,341 to 47,534) and 53,594 (14,645 to 94,860) additional infections, respectively. Excess infections varied across states, from a 45% increase in Texas to 126% in Missouri. ConclusionsProjected increases in HIV infections due to disruptions of Ryan White services threaten the progress made in curtailing the US HIV epidemic, illustrating the critical role Ryan White plays in preventing HIV transmission.

BackgroundDespite progress in HIV prevention and treatment, resulting in overall incidence reductions in the United States, large racial/ethnic (r/e) disparities in HIV incidence remain due to stigma, discrimination, racism, poverty, and other social and structural factors. SettingWe used the HIV Optimization and Prevention Economics (HOPE) model to analyze which intervention strategies provide the most effective path towards eliminating r/e disparities in HIV incidence. MethodsWe considered four intervention scenarios for 2023-2035, which focused on eliminating r/e disparities by 2027 in the HIV care continuum only, HIV prevention services only, both continuum and prevention services, and a final scenario where prevention and care levels for Black and Hispanic/Latino were set to maximum feasible levels. The primary outcome is the incidence-rate-ratio (IRR) for Black and Hispanic/Latino populations compared to Other populations (of whom 89% are White) with the goal of IRRs [≤] 1 by 2035. ResultsAll scenarios reduced IRRs but only Maximum Feasible eliminated HIV incidence disparities by 2035, with respective IRRs of 0.9 and 1.1 among the Black and Hispanic/Latino populations, compared to 6.5 and 4.1 in the baseline scenario. Continuum-only was more effective at reducing disparities (2035 IRRs of 4.7 for Black and 3.1 for Hispanic/Latino populations) than Prevention-only (6.1 and 3.7 respectively). ConclusionsWith no prioritized changes, our simulation showed that r/e disparities in HIV incidence persist through 2035. Elimination of r/e incidence disparities by 2035 is only possible if maximum HIV prevention and care levels for Black and Hispanic/Latino populations can be realized by 2027.

BackgroundMen who have sex with men (MSM) who experience sexual violence are at increased risk for HIV. Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection. Associations between sexual violence and PrEP discussion or PrEP use among MSM are not well-understood. MethodsNational HIV Behavioral Surveillance used venue-based sampling methods to recruit and interview MSM in 23 U.S. urban areas in 2017. We estimated the prevalence of sexual violence and examined associations between sexual violence and PrEP discussion with a health care provider (HCP) or PrEP use among HIV-negative MSM in the past 12 months. We reported weighted percentages and 95% confidence intervals (CI). Adjusted prevalence ratios (aPR) with 95% CIs were calculated using logistic regression with predicted margins to compare groups. ResultsAmong 7,121 HIV-negative MSM, 4.2% (95% CI: 3.6%-4.8%) experienced sexual violence in the past 12 months. Sexual violence was not independently associated with PrEP discussion with HCP (47.6% vs. 40.0%; aPR = 1.16, 95% CI: 0.98-1.37). MSM who experienced sexual violence were more likely to use PrEP than those who did not experience sexual violence, even after adjusting for demographic differences (34.9% vs. 25.7%; aPR = 1.34, 95% CI: 1.07-1.67). ConclusionsOverall PrEP discussion and PrEP use were low among HIV-negative MSM. PrEP use was higher among MSM who experienced sexual violence. Supportive patient-provider relationships that foster PrEP discussion and sexual violence screening in healthcare settings may be important to identifying HIV risk and PrEP needs while assessing MSMs safety.

Potential cuts to Ryan White Parts C and D, and funding for the Minority AIDS and EHE threaten to undermine the progress made in controlling the US HIV epidemic. Using an HIV simulation model in 30 states and Washington, DC, we project that ending these programs would lead to 23,883 additional HIV infections over five years - a 17.6% increase compared to continuing all Ryan White programs. The projected increases varied by state but were disproportionately large in the seven EHE priority states with a high rural burden of HIV. These findings highlight the importance of Ryan White services in preventing HIV transmission in the US.

BackgroundState AIDS Drug Assistance Programs (ADAPs) provide HIV medication access for people with HIV (PWH) with low incomes in the United States (US). We quantified the proportion of viral suppression (VS) that is from ADAP clients for 2015-2022. MethodsFor 2015-2022, we obtained viral load (VL) test results and VS data from publicly available, jurisdiction-level data on ADAP clients and PWH. We report descriptive statistics including the proportion of PWH with a VL who had VS and were supported by ADAPs. ResultsAfter excluding jurisdictions with missing data, PWH who were included in the analysis for each year was 63.7-96.4%. VS for PWH each year was 60-66.3%. VS for ADAP clients was 81.2%-91.4%. In all years, compared to all PWH, a lower proportion of ADAP clients had a reported VL and a higher proportion had VS. Over 2015-2022, the average proportion of PWH who were ADAP clients was 23.1%, the proportion of PWH with VLs who were ADAP clients was 22.2%, and the proportion of PWH with VS who were ADAP clients was 30.8%. ConclusionsAlmost a third of the entire VS rate was from ADAP clients, despite ADAP serving less than 25% of PWH. A much higher proportion of ADAP clients achieved VS, compared to PWH. ADAPs impact is not due to ADAP clients being over represented among PWH with reported VLs. ADAP does not directly receive any federal Ending the HIV Epidemic (EHE) Initiative funding. Policymakers should examine how ADAPs can support the EHE Initiative. SummaryDespite state AIDS Drug Assistance Programs (ADAPs) serving less than a quarter of people with HIV, almost a third of the viral suppression in the United States can be attributed to ADAPs. ADAPs are essential for ending the HIV epidemic.

Structured AbstractO_ST_ABSImportanceC_ST_ABSPre-exposure prophylaxis (PrEP) is a proven effective intervention to reduce risk for HIV infection, but changes in policies that lead to increased out of pocket PrEP costs or that decrease access to convenient PrEP locations could reduce PrEP coverage, resulting in excess HIV infections and costs. ObjectiveTo estimate the impacts of federal policy changes on PrEP coverage, new HIV infections and costs associated with new HIV infections DesignEstimation of excess HIV infections under different policy impacts were conducted using parameters from a previously published ecological model of the relationship between PrEP coverage and new HIV infections. Costs were estimated for the treatment of infections not averted under different scenarios. SettingUnited States ParticipantsThere was no individual participation in research activities; population-based data sources were used to describe the population-level PrEP use and new diagnoses under different hypothetical changes in PrEP coverage. ExposuresPercent of people with indications for PrEP who are taking PrEP Main Outcome and MeasuresEstimated change in new HIV infections under different assumptions of change in PrEP coverage; costs of treatment for avoidable HIV infections and net costs of avoidable infections after accounting for costs of PrEP medications. ResultsEven modest reductions in PrEP coverage would result in thousands of avoidable HIV infections. An absolute 3.3% annual reduction in PrEP coverage over the next decade would result in 8,618 avoidable HIV infections, with lifetime medical costs of over $3.6 billion (discounted) for treatment of the unaverted HIV infections. Conclusions and RelevanceChanges in policy that reduce PrEP uptake would result in avoidable HIV infections and increased costs for HIV treatment. Maintaining policies and programs that support PrEP uptake offers benefits for health and is estimated to result in net cost savings. Key pointsO_ST_ABSQuestionC_ST_ABSWhat are the likely impacts on HIV transmissions and healthcare costs if policy changes result in decreased PrEP utilization in the United States? FindingsUnder assumptions of even modest reductions in PrEP use, we estimated thousands of HIV infections would fail to be averted over the next decade, and billions of dollars of additional treatment costs would accrue to the healthcare system. Results of the studyWe used historical descriptive data on the US HIV epidemic to quantify the relationship between PrEP coverage and trends in HIV diagnoses and to estimate future trends in HIV infections if PrEP coverage were to be rolled back. If PrEP use declines modestly - about 3% annually - we estimate that 8,618 new infections would fail to be averted in a decade because of lowered PrEP uptake, and the estimated lifetime medical costs of these unaverted infections would be $3.6 billion (discounted) and $9.3 billion (undiscounted). MeaningChanges in healthcare priorities and policies, especially those that increase out of pocket costs of PrEP or reduce the convenience of engaging in PrEP care, risk rolling back our progress in ending the HIV epidemic, accruing avertable HIV infections, and incurring increased costs for medical care of people whose HIV infections were avoidable.

BackgroundHIV testing and counseling is a key component of HIV prevention and the entry point into the treatment cascade, which improves for individual clinical outcomes and reduces onward HIV transmission. Current guidelines recommend at least annual testing for key populations. More frequent testing could provide health benefits, but these additional services increase the program the cost-effectiveness is not well-evaluated. MethodsWe used a compartmental mathematical model to simulate the health and economic impact of HIV testing one to four times per year for men who have sex with men, people who inject drugs, and female sex workers in Viet Nam. Model outcomes included costs, HIV infections, HIV-related deaths, and disability-adjusted life years (DALYs) associated with each scenario. We used an opportunity cost-based cost-effectiveness threshold of US $2,255 per DALY averted, discounted costs and health benefits at 3% annually, and used a time horizon from 2021 to 2030 to calculate incremental cost-effectiveness ratios (ICERs). ResultsCompared to the baseline scenario, more frequent HIV testing was estimated to incrementally avert 10.2%, 5.2%, 3.0%, and 1.6% discounted infections for one-, two-, three-, and four-tests per year, respectively. ICERs associated with each scenario ranged from $464, $1,190, $1,762, and $2,727 per DALY averted for one-, two-, three-, and four-tests per year, respectively. ConclusionsIncreased HIV testing frequency for key populations was projected to avert HIV incidence, mortality, and disability in Viet Nam and was cost-effective. Settings with a similar context should consider strategies on how to optimize retesting among key populations.

Background: HIV prevalence among female sex workers in Benin has declined steeply over the last thirty years, driven by successful HIV prevention and treatment programming among sex workers and their clients. To maintain progress in an era of constrained funding, HIV prevention programming should be targeted towards those most at risk of HIV seroconversion. We present a model-based approach that produces finely stratified HIV incidence estimates from widely available HIV prevalence data from serial cross-sectional surveys among female sex workers. Methods: We analysed participant-level data from twelve cross-sectional surveys among FSW in Cotonou, Benin from 1993-2022. We created a compartmental model representing women transitioning into and out of sex work and acquiring HIV. The model was stratified by single year of age, duration at-risk, calendar year, and time since HIV seroconversion and calibrated to HIV prevalence by single-year age and duration at-risk, and age and duration distribution data. Results: HIV prevalence among sex workers aged 15-49 in Cotonou declined from 44.9% (95%CI 41.2-48.9) in 1995 to 8.6% (95%CI 6.4-11.8%) in 2022 (Figure 1). HIV incidence declined by 86% (95%CI 82-90%) between 1994 and 2013 from 19.7/100py (95%CI 9.5-26.9) to 2.5/100py (95%CI 1.2-3.5), and remained stable thereafter through 2022 (Figure 2A). Throughout the study period, new infections were concentrated among women who recently started selling sex: in 2022, 72% of infections occurred in the first year of sex work (95%CI 64-81%; Figure 2B). Incidence patterns by age varied less than by duration and was similar at around 1.5/100py for all sex workers under age 30, rising to 4/100py among those over age 40. Modelled incidence exceeded empirical cohort estimates, highlighting sensitivity to assumptions about HIV prevalence at sex work initiation, episodic sex work, duration misclassification, and population size. Conclusion: We estimated large declines in HIV incidence among sex workers in Benin from 1994-2013, but slower progress from 2013-2022. New sex workers across all age groups, who may be weakly linked to programmes, should be the highest priority for HIV prevention interventions and community outreach efforts. This modelling approach to empirically monitor incidence among sex workers should be applied across high burden epidemic settings with serial survey data to guide prevention efforts, including the allocation of limited provision of long-acting pre-exposure prophylaxis.

PurposeWe developed metrics to estimate the number of people who could benefit from PrEP using clinical, behavioral, and economic considerations. MethodsWe estimated the distribution of annual HIV acquisition risk in the U.S. population and the number who would benefit from PrEP based on HIV acquisition risk thresholds. Estimates were generated for men who have sex with men (MSM), men who have sex with women (MSW), women who have sex with men (WSM), and people who inject drugs (PWID). Populations were stratified by state, age, and race and ethnicity. Adult PWID were stratified by state and sex. We also derived a measure anchored on a willingness-to-pay threshold to gain one quality-adjusted life year (QALY). ResultsWe estimated 31-57% of MSM could benefit from PrEP by HIV acquisition risk thresholds, and 30% when using the cost-per-QALY threshold. For PWID, estimates ranged from 7% (cost-per-QALY) to 60% (highest risk threshold). MSW and WSM had the lowest proportions estimated to benefit (0-11%), but the absolute number of individuals remained large due to the size of these populations. DiscussionThese estimates provide a broader framework in which to examine need for PrEP at the population and program level in the United States.

BackgroundYoung women engaged in sex work (YSW) experience a disproportionately high burden of HIV, yet most HIV programs for sex workers are not designed to reach adolescent girls and young women. MethodsLongitudinal data from the start of sex work are infeasible, but cross-sectional surveys may help identify "contact gaps". We used data from the 2015 Transitions Study, a cross-sectional survey of sexually active women aged 14-24 who self-identified as a sex worker in Mombasa, Kenya. We created a virtual cohort using self-reported event timing described relative to the survey date. We quantified the time from self-identification as sex worker to the initial program contact ("contact gap") and employed time-to-event analyses to estimate and characterize factors associated with the rate of program contact. ResultsOf 392 YSW, 47 (12%) reported program contact, with a median time of 12 months (interquartile range: 2, 24). The rate of program contact per 100 person-months was 0.52 [95% confidence interval (CI): 0.38, 0.68], and when applied to the estimated population size of YSW in Mombasa, the minimum access gap was 11,532 person-years. A shorter contact gap was associated with: older age when first negotiated for sex (adjusted hazard ratio:1.2 [95%CI: 1.0, 1.5]); and self-perceived ease of earning money through sex work (11.5 [2.8, 47.7]). ConclusionA large contact gap highlights the need to reshape HIV prevention services for YSW across their life course. Despite limitations, cross-sectional data could help estimate the contact gap and support program monitoring and evaluation.

ImportanceBlood donor selection policies should be evidence-based. Individual risk assessment allows potential donors to be evaluated based on their own behaviors. ObjectiveThe Assessing Donor Variability and New Concepts in Eligibility (ADVANCE) study examined behavioral and biomarkers of HIV risk in sexually active men who have sex with men (MSM) to estimate the proportion of the study population who would not be deferred for higher risk HIV sexual behaviors and might be eligible to donate. DesignA cross-sectional assessment of sexually active MSM interested in blood donation. Setting: An 8-city study of MSM aged 18 - 39 years assigned male sex at birth. Interventions or ExposuresParticipants completed surveys during 2 study visits to define eligibility, self-reported sexual and HIV prevention behaviors. Blood was drawn at study visit 1 and tested for HIV and the presence of tenofovir, 1 of the drugs in oral HIV pre-exposure prophylaxis (PrEP). Main Outcomes and MeasuresAssociations between HIV infection status or HIV PrEP use and self-reported HIV risk behaviors, including number of male sex partners, new partners, and anal sex. ResultsAmong 1788 screened MSM, 1593 were eligible and 1566 completed the visit 1 HIV risk questionnaire and blood draw. A median of 22 days later, 1197 completed the visit 2 follow-up questionnaire. Four individuals tested HIV positive (0.25%). Among HIV-negative participants, 789 (50.4%) reported no PrEP use in the past 3 months. The number of sex partners in the past 3 months was significantly higher among PrEP users versus non-users, as was the number reporting a new male sex partner in the same period. Among HIV-negative, non-PrEP using participants, 66.2% reported only 1 sexual partner or no anal sex and 69% reported no new sexual partners or no anal sex with a new partner in the past 3 months. Conclusion and RelevanceAmong sexually active MSM, there are subgroups who self-report no new sexual partners and only 1 sexual partner within the past 3 months. These individuals are likely at lower risk of HIV infection than other MSM and would meet proposed individual risk assessment criteria for blood donation in the U.S. Key PointsO_ST_ABSQuestionC_ST_ABSCan a set of blood donor screening questions based on individual behaviors identify a population of lower HIV risk men who have sex with men (MSM) who wish to donate blood? FindingsIn this cross-sectional study of 1566 enrolled MSM, among 1562 persons without HIV, 789 (50.4%) were not taking pre-exposure prophylaxis (PrEP). Of those not taking PrEP, 66.2% reported only 1 sexual partner or no anal sex and 69% reported no new sexual partners or no anal sex with a new partner in the past 3 months. MeaningPotential blood donor history questions were able to identify sexually active MSM with lower-risk sexual behaviors who may be eligible to donate blood.

BackgroundThe evidence for an increased incidence of sexually transmitted infections (STIs) among patients utilizing HIV pre-exposure prophylaxis (PrEP) has been inconsistent. We assessed the risk of incident STI while on PrEP compared to periods off PrEP among military service members starting PrEP. MethodsIncidence rates of chlamydia, gonorrhea, syphilis, hepatitis C virus, and HIV were determined among military service members without HIV prescribed daily oral tenofovir disoproxil fumarate and emtricitabine for HIV PrEP from February 1, 2014 through June 10, 2016. Hazard ratios for incident STIs were calculated using an Anderson-Gill recurrent event proportional hazard regression model. ResultsAmong 755 male service members, 477 (63%) were diagnosed with incident STIs (overall incidence 21.4 per 100 person-years). In multivariate analysis, male service members had a significantly lower risk of any STIs (adjusted hazard ratio (aHR) 0.24, 95% CI 0.12-0.47) compared to periods off PrEP after adjustment for socio-demographic characteristics and reasons for initiating PrEP. However, when stratifying for site and type of infection, the risk of extragenital gonorrhea infection (pharyngeal: aHR 2.08, 95% CI 0.85-5.11; rectal: aHR 1.36, 95% CI 0.54-3.46) and extragenital chlamydial infection (pharyngeal: aHR 3.33, 95% CL 0.54-20.36; rectal: aHR 1.73, 95% CI 0.93-3.24) was greater on PrEP compared to off PrEP although these values did not reach statistical significance. ConclusionsThe data suggest entry into PrEP care reduced the overall risk of STIs. Service members engaged in PrEP services also receive more STI prevention counseling, which might contribute to decreases in STI risk while on PrEP.

BackgroundSocial network-based HIV self-testing (HIVST) is useful to promote HIV testing. Secondary distribution is one social network-based method whereby individuals (indexes) access multiple HIVST kits and distribute them to their social networks (alters). This quasi-experimental study compared the effectiveness and cost of two social network-based HIV testing strategies (HIVST secondary distribution and HIV testing card referral) in promoting HIV testing among Chinese men who have sex with men (MSM). MethodsMSM aged 18 years or older were recruited in Guangzhou, Guangdong Province. From May to September 2019, indexes recruited during that period could distribute HIVST kits to people within their social network. Indexes recruited from October 2019 to January 2020 could refer HIV testing cards to people within their social network for free facility-based tests. Participants could access 1-5 HIVST kits or testing referral cards for distribution. Alters were encouraged to upload a picture of their test results and complete an online survey. Indexes and alters received an incentive to report test results. ResultsTwo hundred thirty-nine potential participants were assessed for eligibility and 208/245 (84.9%) were eligible. Among those who completed baseline assessment, 154/208 (74.0%) completed one month of follow-up. Overall,106 indexes were recruited in the HIVST arm and 102 in the testing card arm. The two arms had similar socio-demographic characteristics. At the one-month follow-up, 92 indexes in the HIVST arm self-reported having distributed self-test kits to 179 unique alters, and 62 in the testing card arm self-reported having distributed testing referral cards to 26 unique alters. Additionally, 69/92 (75%) in the HIVST arm distributed any test to friends or sexual partners compared to 18/62 (29%) in the testing card arm, with a risk difference of 46% (95% CI 31%, 61%). Indexes in the HIVST arm distributed an average of 1.95 (SD=1.90) tests, compared to 0.42 (SD=0.78) in the testing card arm, with a risk difference of 1.53 (95% CI 1.09, 1.96). Subgroup analysis suggested that indexes in the HIVST arm who self-identified as gay (p = 0.007) or were previously tested for HIV (p = 0.02) were more likely to distribute. The HIVST arm had a higher total cost and higher testing coverage compared to the testing card referral arm. The ICER per alter tested was $52.78. ConclusionsSecondary distribution of HIVST engaged more MSM to distribute tests to their social network and reached more MSM for test. MSM who self-identify as gay or who have previously tested for HIV were more effective in distributing tests. Future testing approaches should include HIVST kits in voluntary counselling and testing settings and incorporate digital strategies for secondary distribution.

BackgroundMajor geopolitical events and structural shocks are thought to play a significant role in shaping HIV epidemics by influencing individual behaviours, reshaping social networks, and impacting HIV prevention and treatment programs. Here, we describe individual-level measures of estimated time since HIV infection (ETI) from viral next generation sequencing data among female sex workers and their clients in relation to significant geopolitical events in Ukraine. MethodsThe Dynamics study, is a cross-sectional integrated biological and behavioural survey conducted among female sex workers and their clients in Dnipro, Ukraine (December 2017 to March 2018). We were able to successfully sequence a portion of the HIV pol gene on dried blood spot specimens among n = 5/9 clients and n = 5/16 female sex workers who tested positive for HIV (total n = 10/25) using an in-house drug resistance genotyping assay. The "HIV EVO" Intrapatient HIV Evolution web-based tool (https://biozentrum.unibas.ch/) was used to infer ETI from viral diversity. ResultsThe median ETI for female sex workers and their clients was 5.4 years (IQR = 2.9, 6.6) and 6.5 years (IQR = 5.4, 10.8) respectively. Nearly all HIV acquisition events (n=7/10; 70%) were estimated to have occurred between the Great Recession (2008 - 2009) and the War in Donbas (May 2014 - February 2022). In general, ETI suggests that HIV acquisition occurred earlier among clients (2012 [IQR = 2007, 2013]) compared to sex workers (2013 [IQR = 2012, 2016]). ConclusionOur findings suggest that most HIV acquisition in this small subset of female sex workers and clients living with HIV, occurred during periods of economic decline. Molecular studies on timing of HIV acquisition against timing of major geopolitical events offer a novel way to contextualize how such events may shape transmission patterns.

BackgroundThe impact of migration on HIV risk among non-migrating household members is poorly understood. We measured HIV incidence among non-migrants living in households with and without migrants in Uganda. MethodsWe used four survey rounds of data collected from July 2011-May 2018 from non-migrant participants aged 15-49 years in the Rakai Community Cohort Study, an open, population-based cohort. Non-migrants were individuals with no evidence of migration between surveys or at the prior survey. The primary exposure, household migration, was assessed using census data and defined as [≥]1 household member migrating in or out of the house from another community between surveys ([~]18 months). Incident HIV cases tested positive following a negative result at the preceding visit. Incidence rate ratios (IRR) with 95% confidence intervals were estimated using Poisson regression with generalized estimating equations and robust standard errors. Analyses were stratified by gender, migration into or out of the household, and the relationship between non-migrants and migrants (i.e., any household migration, spouse, child). FindingsOverall, 11,318 non-migrants (5,674 women) were followed for 37,320 person-years. 28% (6,059/21,370) of non-migrant person-visits had recent migration into or out of the household, and 240 HIV incident cases were identified in non-migrating household members. Overall, non-migrants in migrant households were not at greater risk of acquiring HIV. However, HIV incidence among men was significantly higher when the spouse had recently migrated in (adjIRR:2{middle dot}12;95%CI:1{middle dot}05-4{middle dot}27) or out (adjIRR:4{middle dot}01;95%CI:2{middle dot}16-7{middle dot}44) compared to men with no spousal migration. Women with in- and out-migrant spouses also had higher HIV incidence, but results were not statistically significant. InterpretationHIV incidence is higher among non-migrating persons with migrant spouses, especially men. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for those with migrant spouses. FundingNational Institutes of Health, US Centers for Disease Control and Prevention Research in contextWe searched PubMed for studies focused on HIV acquisition, prevalence or sexual behaviors among non-migrants who lived with migrants in sub-Saharan Africa (SSA) using search terms such as "HIV", "Emigration and Immigration", "family", "spouses", "household", "parents", and "children". Despite high levels of migration and an established association with HIV risk in SSA, there is limited data on the broader societal impacts of migration on HIV acquisition risk among non-migrant populations directly impacted by it. There has been only one published study that has previously evaluated impact of migration on HIV incidence among non-migrating persons in sub-Saharan Africa. This study, which exclusively assessed spousal migration, was conducted in Tanzania more than two decades earlier prior to HIV treatment availability and found that non-migrant men with long-term mobile partners were more than four times as likely to acquire HIV compared to men who had partners that were residents. To the best of our knowledge, this is the first study to examine the effect of non-spousal migration, including any household migration and child migration, on HIV incidence among non-migrants Added value of this studyIn this study, we used data from the Rakai Community Cohort Study (RCCS), a population-based HIV surveillance cohort to measure the impact of migration on HIV incidence for non-migrant household members. The RCCS captures HIV incident events through regular, repeat HIV testing of participants and migration events through household censuses. Our study adds to the current literature by examining the general effect of migration in the household on HIV incidence in addition to child, and spousal migration. Using data from over 11,000 non-migrant individuals, we found that spousal, but not other types of household migration, substantially increased HIV risk among non-migrants, especially among men. Taken together, our results suggest that spousal migration may be associated with an increased risk of HIV acquisition in the period surrounding and immediately after spousal migration. Implications of all the available evidenceOur findings suggest that spousal migration in or out of the household is associated with greater HIV incidence. Targeted HIV testing and prevention interventions such as pre-exposure prophylaxis could be considered for men with migrant spouses.

BackgroundFemale bar or sex workers (FBSWs) in Eastern Africa experience a high burden of HIV. However, there is limited population-level data on HIV seroprevalence, incidence, and viral suppression among their male partners. MethodsMen who had sex with FBSWs in the past year were identified through longitudinal population-based HIV surveillance in southern Uganda between 2013 and 2020. Surveillance was conducted over four surveys in four Lake Victoria fishing communities (HIV seroprevalence[~]40%) and 37 inland agricultural and trading communities ([~]12%). Primary outcomes included laboratory-confirmed HIV seropositivity, incident infection, and viral suppression (<200 copies/mL). Prevalence and incidence rate ratios (PR, IRR) were estimated using univariable and multivariable Poisson regressions with 95% confidence intervals (95%CIs). Findings17,438 male participants contributed 35,273 visits, with 2,420 (13.9%) reporting FBSW partners at [&ge;]1 study visit. Men with FBSW partners tended to be older, have less education and lower incomes, and be previously married compared to those without. HIV seroprevalence was significantly higher among men with FBSW partners (vs. without FBSW partners) in both inland (21.0%vs.7.5%; PR=2.79,95%CI=2.41-3.23) and fishing communities (38.6%vs.23.0%; PR=1.67,95%CI=1.53-1.84). Overall, 154 HIV incident events occurred over 27,396 years of participant follow-up. HIV incidence was also higher among men with FBSW partners than those without (1.93vs.0.44/100 person-years; IRR=4.37,95%CI=3.04-6.16). Among men with HIV, viral suppression was similar among those with and without FBSW partners. However, the population prevalence of HIV viremia was 1.6 times higher (95%CI=1.41-1.84) among men with FBSW partners due to a higher background seroprevalence of HIV. InterpretationMen in Uganda frequently report sex with FBSWs, which is associated with a significantly higher risk of HIV acquisition. Tailored HIV prevention strategies, including the promotion and uptake of PrEP, are essential to reduce the HIV burden in this population. FundingNational Institute of Allergy and Infectious Diseases, National Institutes of Health

BackgroundTo reduce the high HIV incidence among key populations in Indonesia, we implemented a clinical pathway for screening, diagnosis and treatment of acute HIV infection (AHI) in sexual health clinics in Jakarta and Bali. This paper presents a cohort profile and analysis of baseline data on the study uptake, diagnostic yield, and estimated AHI prevalence and screening cascade outcomes. MethodsWe performed a baseline analysis of 1879 individuals who underwent AHI screening at three sexual health clinics in Jakarta and Bali between May and December 2023, comprising a risk-score assessment, fourth-generation antibody/p24 antigen-based rapid diagnostic test (RDT; Abbott Determine HIV Early Detect) and HIV-PCR (Xpert) testing. ResultsMedian age was 27 years (IQR24-31), and 75.4% were male. Men who have sex with men (MSM) accounted for 50.4%, clients of sex workers 20.1%, and sex workers 5.2%. Of 1866 participants tested at study enrolment, 113 (6.1% [113/1866]) had chronic HIV (antibody-positive) and 6 (0.34% [6/1748]) had AEHI. HIV-PCR testing led to a 5.3% (95%CI1.9-11.2) increase in confirmed HIV diagnoses. The number needed to test to detect one AEHI case was 291 (1748/6) overall and 169 (842/5) among MSM. Overall HIV and AHI prevalence was 6.4% (95%CI 5.3-7.6; 119/1866) and 0.34% (95%CI0.12-0.74; 6/1748) overall; and 10.8% (95%CI8.9-13.0; 102/940) and 0.53% (95%CI 0.17-1.2; 5/940) among MSM. The Abbott Determine HIV Early Detect RDT only detected 2 (18.2%) of 11 AEHI cases. 113 (95.0%) newly diagnosed individuals were linked to care and started ART, of whom 75 (66.4%) on the same day and 104 (92.0%) within a week (median 0 days, range 0-93). ConclusionAHI screening, diagnosis and prompt treatment is feasible among high-risk urban MSM in Indonesia. Further evaluations are needed to estimate clinical impact and cost-effectiveness of AHI screening in this setting. The study continues accrual and follow-up, and provides a platform for future immuno-virological, social science, and intervention studies in Indonesia.

BackgroundStage at time of diagnosis and survival after diagnosis are critical parameters regarding control of any cancer in any geographical setting. In earlier research focusing on the initial years of the "Treat All" era (2016-2019), we found that HIV-associated Kaposi sarcoma (KS) in East Africa continued to be diagnosed at advanced stage of disease and conferred high mortality. Given the potential for broader implementation of "Treat All" as well as the announcement of National Comprehensive Cancer Network guidelines for cancer treatment in Africa since 2020 -- but also the countervailing influence of the COVID-19 pandemic -- we sought to provide an update on KS stage at diagnosis and survival after KS diagnosis among people living with HIV (PLWH) in East Africa. MethodsWe evaluated adult PLWH in Kenya, Tanzania and Uganda with a new diagnosis of KS identified at ambulatory and inpatient settings in four regions between September 2021 and April 2024. At time of biopsy, participants were examined to document the extent of KS. In a prospective cohort study, we followed participants to monitor vital status. ResultsAmong 493 PLWH with a new diagnosis of KS, the median (IQR) number of anatomic sites with KS lesions was 9 (4-12), and 91% had ACTG stage T1 (advanced KS). Over a median follow-up of 11 (IQR: 2.2-20) months, a total of 209 participants died, and three were lost to follow-up. Cumulative incidence of death (95% confidence interval) at months, 3, 6, 12 and 18 following KS diagnosis was 26% (22% to 30%), 32% (28%-36%), 39% (34%-43%) and 45% (40%-51%), respectively. Cumulative incidence of death was similar between countries and year of KS diagnosis. ConclusionsAmong PLWH with newly diagnosed KS in East Africa during the post-initial phase of the "Treat All" era (2021-2024), the majority had advanced disease at KS diagnosis and survival was very poor. These parameters are unchanged from the five prior years. Our findings emphasize the need for better KS control strategies in the region, including primary prevention, novel approaches for earlier detection, more timely linkage to care, and more accessible and potent anti-KS therapy.

Background Adolescents and young adults (AYAs) from key and priority populations face persistent challenges with sustained engagement in HIV pre-exposure prophylaxis (PrEP) care. While PrEP initiation has expanded across sub-Saharan Africa, evidence on long-term retention and determinants of disengagement among AYAs remains limited. We examined time to PrEP disengagement and associated factors among AYAs initiating PrEP in eastern Uganda. Methods We conducted a retrospective longitudinal analysis of routinely collected program data for AYAs aged 15-29 years from key and priority populations who initiated PrEP between 2019 and 2025 at Mbale Regional Referral Hospital. Time to PrEP disengagement was assessed using Kaplan-Meier survival analysis and Cox proportional hazards regression. Multivariable models adjusted for sociodemographic, relational, behavioral, and service delivery factors. Sensitivity analyses redefined the time origin to day 91 following PrEP initiation to reflect the programmatic 90-day grace period. Results Among 3,553 AYAs initiating PrEP, the median time to disengagement was 284 days (95% CI: 273-295). The median age was 24 years (interquartile range [IQR]: 20-26). The probability of remaining engaged in PrEP care declined from 60.1% at 90 days to 20.2% at 365 days. Survival patterns differed significantly by population category and sex at birth but not by age group. In adjusted analyses (N = 3,391), knowledge of a partners HIV status (aHR = 2.04; 95% CI: 1.82-2.29) and initiation through community-based services (aHR = 1.42; 95% CI: 1.17-1.72) were associated with faster disengagement. Married participants had lower hazards of disengagement compared with single participants (aHR = 0.69; 95% CI: 0.64-0.76). Reporting an STI syndrome (aHR = 0.42; 95% CI: 0.32-0.55) or recent gender-based violence (aHR = 0.76; 95% CI: 0.60-0.96) was associated with reduced disengagement. Findings were highly consistent in sensitivity analyses using an alternative risk-period definition. Conclusions PrEP disengagement among AYAs occurs rapidly following initiation, with substantial attrition within the first year. Relational factors, service delivery modality, and population-specific vulnerabilities strongly shape retention trajectories. These findings underscore the need for risk-responsive, differentiated PrEP delivery strategies that strengthen partner-based services, integrate STI and GBV screening, and adapt retention support for AYAs in community and facility settings.

IntroductionHIV remains a global public health challenge, with social determinants such as stigma influencing transmission dynamics, access to testing, and treatment. HIV stigma shapes both individual behaviour and community responses to HIV. However, modelling approaches have rarely represented the complex role of stigma in HIV epidemics. Our study introduces an innovative modelling framework designed to capture the interplay between stigma and HIV transmission dynamics. MethodsWe modelled effects of anticipated, internalised, and experienced HIV stigma on HIV testing, antiretroviral treatment initiation, and treatment adherence. We built an individual-based model representing the HIV epidemic (HIV-IBM) in a USA-like population of 3 million individuals that accounts for community demography, behaviour, and healthcare access. Stigma parameters were based on a scoping review focused on the prevalence and effects of stigma in people living with and without HIV. HIV-IBM was used to assess effects of interventions targeting different types of stigma. We tested reductions of stigma by 50% and 100% across the simulated population and performed a sensitivity analysis to identify effects of each type of stigma on the simulated HIV epidemic. ResultsWithout reduced stigma, the HIV-IBM had an annual incidence rate of 12.6 (95% credible interval [CI]: 11.4-13.5) new cases per 100,000 people. Reducing the overall level of stigma in the population by 50% resulted in an annual incidence rate of 9.6 (95% CI: 8.6-10.3) per 100,000, and a 100% reduction in stigma resulted in an annual incidence rate of just 6.8 (95% CI: 6.1-7.3) per 100,000. In addition to reducing HIV incidence, reducing stigma resulted in a substantial increase of viral suppression among people living with HIV (50% stigma reduction: +10.5%; 100% stigma reduction: +16.4%). Sensitivity analysis showed that outcomes resulting from interventions targeting each type of stigma were highly heterogeneous. ConclusionSimulation results suggest that reducing HIV stigma could have a large effect on HIV incidence and viral suppression. Our model framework provides a dynamic approach to understanding the role of stigma in HIV outcomes that facilitates exploration of stigma reduction strategies and offers insights to inform evidence-based policies and interventions for reducing stigma and curtailing HIV.