Sexually Transmitted Infections

Background. The objective was through an analysis of longitudinal data from the DepIST-H cohort to estimate the incidence, describe the dynamics and factors associated with CT/NG infection in MSM in Togo. Methods. A total of 200 MSM in Lome, Togo, were included in the ANRS I MIE 12400/DepIST-H cohort, half living with HIV. After inclusion in the study, participants received follow-up clinical visits at 6 and 18 months, and laboratory tests were performed at baseline (M0) and at 12 and 24 months (M12 and M24). PCR tests for CT and NG were performed from pharyngeal, anal and urine samples collected using the Xpert(R) CT/GC kit (Sunnyvale, CA, USA). To identify the factors associated with anal bacterial STIs, offset term Poisson regression models were performed. Results. Among 200 MSM (median age 24 years), CT and NG incidence rates were high ({approx}22 cases per 100 person-years), particularly at the anal site. Multiple partners significantly increased anal NG incidence (aIRR 2.35). Anal NG incidence was significantly lower among participants with income-generating activity (aIRR 0.57). Trends suggested higher anal CT and NG incidence in the presence of pharyngeal infection, but associations were not statistically significant Conclusion. This study confirms that MSM remain highly exposed to STIs in Togo and highlights the need to strengthen prevention efforts within this population. Postexposure doxycycline prophylaxis and multisite pooled-sample screening represent promising avenues to strengthen prevention efforts within these populations.

Background: Doxycycline post-exposure prophylaxis (doxy-PEP) reduces the incidence of bacterial sexually transmitted infections (STIs) among men who have sex with men and transgender women (MSMTW), but it may select for antimicrobial resistance (AMR). AMR development will depend in part how doxy-PEP changes rates of antibiotic use. Methods: We conducted a retrospective electronic medical record review of antibiotic prescriptions received by patients at the Massachusetts General Hospital Sexual Health Clinic from January 1, 2023, to December 27, 2025. Using a Bayesian negative binomial regression, we assessed the direct, indirect, and combined effects of doxy-PEP implementation on antibiotic prescription rates among doxy-PEP-eligible MSMTW who were receiving HIV pre-exposure prophylaxis. Results: Controlling for direct effects, the cohort's total antibiotic prescription rate decreased by 10% (0.90, 95% CI 0.87 - 0.94) for every 100 doxy-PEP starts. Doxy-PEP users were prescribed antibiotics at double the rate predicted in the absence of doxy-PEP implementation, and, controlling for indirect effects, received 3.40 (95% CI 2.95 - 3.91) times the antibiotic prescriptions of patients not using doxy-PEP. Doxy-PEP non-users were prescribed antibiotics at less than half the rate predicted in the absence of doxy-PEP. The full cohort's overall antibiotic prescription rate increased by 1.4 times after doxy-PEP implementation. Conclusions: Individuals who are taking doxy-PEP have higher antibiotic prescription rates, increasing selection for antibiotic-resistant bacteria in these individuals. However, doxy-PEP-driven decreases in the overall incidence of bacterial STIs have the potential to decrease selective pressure for resistant organisms in those not using doxy-PEP.

Background Preventing sexually transmitted re-infections brings health benefits and can be significantly less costly than treating their sequelae. Safetxt is a potential novel digital intervention developed to promote safer sexual behaviours. However, a recent randomised controlled trial of safetxt found no effect on reinfection at 1 year (OR 1.13, 95%CI: 0.98-1.31). We investigated if safetxt's effect was mediated through sexually risky behaviours. Methods We used data from 6248 young people with STIs from 92 UK sexual health clinics. The direct and indirect effects of safetxt on reinfection were estimated using the counterfactual approach. Condom use at last sexual encounter, number of sexual partners and STI testing were assessed as mediators. These were analysed singly and together, using regression models and a formal weighting approach. The assumptions of each approach were considered and tested. Analyses were repeated in the subgroup showing the most promising effect of safetxt: men who have sex with men or with men and women (MSM/MSMW). Results No evidence was found for the total, indirect or direct effects differing from the null. Despite not being significant, for MSM/MSMW, some of safetxt's effect on reducing reinfection was identified as being offset through its effect on number of sexual partners. Conclusions There was no evidence that safetxt's effect on reinfection was mediated through changes in sexually risky behaviours. Adaptations to specifically target these behaviours are unlikely to improve safetxt's overall effect. However, improving safetxt's effect on the number of sexual partners a participant has may improve its effect for MSM/MSMW.

Background: Urethritis in women of childbearing age constitutes a significant but underreported burden of reproductive morbidity in Sub-Saharan Africa, where diagnostic constraints often necessitate suboptimal syndromic management. Methods: To identify the localized etiological profile, mid-stream urine and urethral swab specimens were prospectively collected from symptomatic women attending local clinics, subjected to standard microbiological culture, and characterized using rigorous phenotypic and biochemical diagnostic protocols. Results: Microbiological analysis successfully isolated a high prevalence of both Gram-negative and Gram-positive uropathogens, predominantly Escherichia coli, Staphylococcus aureus, and Klebsiella pneumoniae, demonstrating distinct phenotypic traits characteristic of the regional microbial ecology. Conclusion: The pronounced isolation of these specific bacterial agents highlights the critical inadequacy of generalized empirical treatments and underscores the urgent need for tailored diagnostic criteria in resource-limited African healthcare settings.

Background In November 2023, the Joint Committee on Vaccination and Immunisation advised the UK government that a targeted, opportunistic vaccination programme using 4CMenB to prevent gonorrhoea primarily in gay, bisexual and other men who have sex with men (GBMSM) at higher risk of infection should be introduced in sexual health services (SHSs). Data on the acceptability of 4CMenB vaccination and factors influencing uptake were needed. Methods Three focus group discussions (FGDs) were conducted with 17 GBMSM aged [≥]18 years, resident in England, who self-reported bacterial sexually transmitted infection or [≥]5 sexual partners in the previous 12 months. One FGD with five sexual healthcare professionals (HCPs) was conducted. Data were analysed using reflexive thematic analysis. Themes were organised using the Vaccine Uptake Continuum and interpreted using the Social Ecological Model. Results Acceptability of 4CMenB vaccination was high among GBMSM and HCP participants. GBMSM described vaccination as supporting sexual wellbeing and reducing anxiety about gonorrhoea, particularly when positioned alongside existing prevention strategies like HIV pre-exposure prophylaxis and Doxycycline post-exposure prophylaxis. While the estimated effectiveness of ~30-35% was perceived as modest, it did not deter acceptability, but reduced willingness to actively seek vaccination. Structural constraints, including limited SHS capacity, appointment availability, and restrictive eligibility criteria, were identified as barriers to equitable uptake. Community-based and outreach delivery models were widely supported as strategies to improve access. HCPs drew on experience from mpox vaccination to anticipate implementation challenges, emphasising the need for clear guidance, staff training, and sustainable resourcing. Mixed views were expressed regarding additional protection against meningitis, which was generally considered a secondary influence on decision-making. Conclusions 4CMenB vaccination for gonorrhoea was acceptable for both GBMSM and HCPs; however, uptake is likely to depend on ease of access, clear communication, and system-level support. Addressing structural constraints and supporting community-based delivery may help achieve equitable delivery of 4CMenB.

BACKGROUND: Sexual pleasure is integral to sexual health, offering important physical and mental benefits. Yet, sex education programs often neglect pleasure, focusing instead on preventing sexual risk behaviors (SRBs), which young adults are particularly vulnerable to. AIM: This study investigates the association between SRBs and sexual pleasure in young adults and whether sex assigned at birth moderates this relationship. METHODS: Embedded within the Generation R cohort, 1010 young adults completed an online questionnaire assessing sexual pleasure using the six subscales of the Amsterdam Sexual Pleasure Inventory (ASPI 1.0), Arousal Enjoyment, Enjoyment-Related Self-Efficacy, Enjoyment-Related Self-Worth, Interaction Enjoyment, Bonding Enjoyment, and Sexual Experience Enjoyment, and various SRBs including sexual debut <15 years, six or more lifetime partners, frequent unprotected sex, and substance use during sex. Multiple linear regression analyses were performed for each SRB and sexual pleasure subscale, adjusting for demographics, self-esteem, relationship status, socioeconomic status, and psychopathology, with additional stratification by sex assigned at birth. OUTCOMES: The primary outcome measure is sexual pleasure, measured across six domains, examined in relation to SRBs. RESULTS: Fully adjusted regression analyses showed that engaging in SRB was positively associated with several dimensions of sexual pleasure. All SRBs were associated with higher Enjoyment-Related Self-Efficacy (ERSE) scores (p<0.002). Early sexual debut was additionally linked to higher Interaction Enjoyment scores, while having six or more lifetime partners was associated with increased Enjoyment-Related Self-Worth and Sexual Experience Enjoyment scores (p<0.002). Some associations, particularly involving ERSE, were only significant among males. Individuals without partnered sexual experience reported lower sexual pleasure scores. CLINICAL IMPLICATIONS: Incorporating sexual pleasure into sex education could promote a more balanced, realistic understanding of sexuality among young adults, emphasizing both enjoyment and responsible sexual decision-making. STRENGHTS & LIMITATIONS: Key strengths of this study are the use of the multidimensional Amsterdam Sexual Pleasure Inventory (ASPI 1.0) and the large population-based cohort study design, enabling a nuanced and generalizable analysis. This study is limited by potential selection and reporting bias, the cross-sectional design, residual confounding, and the absence of universally agreed-upon thresholds for defining SRBs. CONCLUSION: These findings suggest there is a positive association between engagement in SRB and sexual pleasure, possibly reflecting greater overall sexual experience. The stronger associations observed among males might reflect gendered differences in the role of self-esteem and societal expectations.

HIV/AIDS remains a major global public health challenge, and disparities in HIV testing persist. In 2024, an estimated 87% of people living with HIV were aware of their status, with lower testing coverage among children aged 0-14 years (63%), and among men (84%) compared with women (92%). Romania initiated its national AIDS program in 1995 and quickly progressed in addressing the epidemic; however, HIV testing remains largely concentrated in specialized services, with late diagnosis, missed testing opportunities, and stigma continuing to limit timely identification and linkage to care. This study aimed to understand better HIV testing/screening practices among clinicians in eastern Romania and to identify gaps that could be addressed through medical education. We conducted an analytical cross-sectional study among healthcare providers in the eastern region of Romania to assess whether HIV testing is routinely offered to patients, explore gaps in clinical judgment and perceived responsibility, and identify factors that facilitate HIV testing. A 17-question anonymous survey was distributed via WhatsApp to clinician groups between August 1 and September 30, 2023. Respondents included physicians (71.9%), nurses (28.1%), and other healthcare professionals, working in infectious diseases (36.0%), internal medicine (22.3%), primary care (13.7%), and other specialties, such as obstetrics-gynecology and pediatrics (18.0%). Only 38.1% of respondents reported routinely screening all patients aged 18 years and older for HIV, while 61.9% did not offer regular HIV testing. The most cited reasons for not screening were the perception that HIV testing was not their responsibility and that their department did not require testing (18.1% each). Clinicians working in settings with established policies on HIV confidentiality, non-discrimination, testing, and post-exposure prophylaxis were more likely to offer routine testing. Universal HIV screening remains uncommon among clinicians in eastern Romania. Supportive institutional policies appear to facilitate routine testing and may reduce missed opportunities for early diagnosis. Normalizing HIV testing as part of routine clinical care, in line with the Romanian National Health Strategy 2022-2030, is crucial for enhancing early detection and strengthening prevention efforts through coordinated action among clinicians, public institutions, and civil society.

Background Clinical trials demonstrated high efficacy of daily and event-driven oral pre-exposure prophylaxis (PrEP) in HIV prevention. Event-driven PrEP involves taking two tablets before and two times one tablet after sexual contact (2-1-1/on-demand). While both are implemented in Dutch clinical practice, evaluating real-world effectiveness requires large-scale data from routine clinical care. This study compared HIV incidence between daily and event-driven PrEP in the Netherlands. Methods We used surveillance data from the Dutch national PrEP program (August 1, 2019-December 31, 2025). Individuals [&ge;]16 years with [&ge;]1 follow-up consultation after PrEP initiation were included; PrEP regimen since last visit was recorded at each visit. Person-time was modeled as time-varying based on the regimen reported at each consultation. HIV incidence rates were calculated per 100 person-years and Cox proportional hazards models estimated hazard ratios between regimens for HIV acquisition, adjusted for sociodemographics, sexual behavior, and history of sexually transmissible infections. Findings 16,469 individuals (15,843 men who have sex with men, 579 transgender and gender diverse persons, 45 women and two men who have sex with women) initiated PrEP and had [&ge;]1 follow-up visit (median follow-up 2.0 years (IQR=0.8-4.0)). Median age was 33 years (IQR=27-44). 49 PrEP users were diagnosed with HIV over 41,092 person-years (IR=0.12/100 py;95%CI=0.09-0.16), of whom 42 event-driven users (IR=0.20/100 py;95%CI=0.15-0.27) and seven daily PrEP users (IR=0.04/100 py;95%CI=0.02-0.07). In multivariable Cox regression, event-driven PrEP use was associated with a higher hazard of HIV acquisition (aHR=7.0;95%CI=3.0-16.4). Interpretation Despite overall low HIV incidence, the incidence rate in the Dutch national PrEP program was seven-fold higher during event-driven PrEP use compared to daily, which may be due to lower adherence. These findings denotes that, in real-world settings, improved person-centered counseling is needed for individuals interested in, or using event-driven PrEP. Research should identify domains and preferred methods of support. Funding None for this study.

Background Women living with Human Immunodeficiency Virus (WLHIV) are at high risk of cervical cancer. While Human Papilloma Virus Deoxyribonucleic acid (HPV DNA) testing is the standard of care, its cost limits widespread use in resource-limited settings, therefore visual inspection with acetic acid (VIA) remains the primary screening method. This study therefore evaluated the diagnostic accuracy of VIA compared to HPV DNA testing for cervical cancer screening among WLHIV in Nigeria. Methods This cross-sectional analytical study was conducted between November 2022 and November 2024 in Osogbo, Nigeria among 300 WLHIV on antiretroviral therapy aged 25-49 years underwent cervical cancer screening using VIA and HPV DNA testing (Ampfire HPV test kits, ATILA Biosystems(R) USA). All 309 participants underwent colposcopy and biopsy regardless of their screening results, with histological examination serving as the gold standard. Data were analyzed using Stata, with diagnostic performance measures calculated using histology as the gold standard. Results The mean age of participants was 42.6 {+/-} 6.4 years. Thirty-six of 309 women (11.7%) were VIA-positive, while 91 (29.4%) were HPV-positive. Histology confirmed CIN2+ in 22 participants (7.1%). HPV testing demonstrated significantly higher sensitivity than VIA for detecting CIN2+ (91.2%, 95% CI: 76.3-98.1 vs. 44.1%, 95% CI: 26.7-62.6; p<0.001) and higher negative predictive value (98.9%, 95% CI: 96.3-99.8 vs. 92.0%, 95% CI: 88.0-95.0; p<0.001). However, VIA showed higher specificity (91.7%, 95% CI: 87.8-94.7 vs. 83.3%, 95% CI: 78.4-87.6; p=0.003). The agreement between the two tests was fair (kappa = 0.20, p<0.001). Both HPV positivity (adjusted OR: 42.1, 95% CI: 9.5-186.2; p<0.001) and VIA positivity (adjusted OR: 6.9, 95% CI: 2.6-18.4; p<0.001) were independently associated with CIN2+. Conclusion HPV DNA testing demonstrated superior sensitivity and negative predictive value compared to VIA for detecting CIN2+ among WLHIV, while VIA showed higher specificity. Keywords: Cervical cancer screening, visual inspection with acetic acid, Human Papilloma Virus Women living with HIV, Nigeria

Colombia has been internationally recognised as a paradigmatic case of vaccine confidence crisis since the 2014 Carmen de Bolivar event, and national HPV vaccination coverage remains far below the World Health Organization 2030 target. Most published evidence focuses on female adolescents and on cervical cancer; the perception of the HPV vaccine in university-age populations of both sexes--and across the broader spectrum of HPV-attributable disease--remains comparatively understudied. We aimed to describe the influence of biopsychosocial determinants on HPV vaccine perception among university students of both sexes in Cucuta, Norte de Santander, Colombia. We conducted a cross-sectional study with a mixed quantitative-qualitative approach in 2024 among four universities (Universidad de Santander, Universidad Francisco de Paula Santander, Universidad de Pamplona and Universidad Libre; combined enrolment 21,033 students). Using convenience sampling stratified by institution, 750 actively enrolled undergraduate students of both sexes (18-60 years) completed a structured online questionnaire adapted from previously validated instruments. The instrument captured sociodemographic information, HPV knowledge and HPV vaccine perception. Data were analysed using Students t-test, one-way analysis of variance, Tukey post-hoc tests, effect sizes and 95% confidence intervals, with a 0.05 significance threshold. Of 750 respondents, 54.2% were women, 61.3% were under 20 years of age, and 75.1% attended public universities. HPV knowledge was high in 39.2%, intermediate in 42.4% and low in 18.4%; women and students aged 26 years or older displayed higher knowledge. Although 91.2% had heard of HPV and 82.5% knew that both sexes could acquire it, recognition of clinical manifestations and complications was uneven: cervical cancer 51.7%, penile cancer 30.5%, vaginal warts 45.9% and warts in the penis, larynx, anus or rectum 34.0%. Vaccine-specific knowledge was low in 77.1%, with men disproportionately represented (85.9% versus 69.5% in women). Overall positive perception of HPV vaccination was 66.6%, slightly higher in women (68.8%) than men (63.9%), in students aged 26 years or older (70.1%) and in students from private universities (68.1% versus 65.9%). Inferential analysis identified sex (Cohens d = -0.357), type of university (d = 0.189) and HPV knowledge (partial eta-squared = 0.096) as the only significant determinants. Age, socioeconomic stratum, age at sexual debut and vaccine-specific knowledge did not reach meaningful significance. HPV vaccine perception was predominantly positive but conditioned by three biopsychosocial determinants, with HPV knowledge as the primary driver. The persistent gender gap reflects historical anchoring of HPV messaging in cervical disease and female-targeted campaigns. Public-health strategies should adopt comprehensive, gender-inclusive educational interventions that explicitly visibilise non-cervical HPV-related cancers and address both sexes from a common evidence base.

Background A national human papillomavirus (HPV) vaccination programme for gay, bisexual, and other men who have sex with men (GBMSM) in England began in 2016. We evaluated the impact of this programme by monitoring the prevalence of type-specific HPV infections over time. Methods Residual rectal swab specimens were collected from GBMSM aged [&le;]45 years undergoing chlamydia and/or gonorrhoea screening at 10 SHS between 2017-19 (Phase 1) and 2021-24 (Phase 2). Specimens were linked to data on sociodemographic characteristics, previous STI diagnoses, and HPV vaccination reported to UKHSA's national STI surveillance system. Anonymised specimens were tested for type-specific HPV DNA using an in-house multiplex PCR and Luminex-based genotyping test. We compared the prevalence of vaccine-type HPV in each phase, and in those with and without any reported HPV vaccinations. Results Data from 5,787 rectal swab specimens with HPV testing results were analysed: 3,291 in Phase 1 and 2,496 in Phase 2. There was a 36% decline in the prevalence of anal HPV16/18 infection between Phase 1 and Phase 2. Overall, the prevalence of HPV16/18 was similar in GBMSM with (16.6%; 95% CI 15.2-18.1) and without reported HPV vaccination (15.8%; 95% CI 14.5-17.1). Conclusion Eight years after HPV vaccination of GBMSM began, the prevalence of vaccine-type HPV in GBMSM has declined. Vaccine effectiveness estimates were uncertain, likely due to the combined effects of underreporting of vaccinations, herd protection, and bias in vaccination uptake. These findings, albeit ecological, bode well for this targeted programme meeting its aim of reducing HPV-related diseases amongst GBMSM and reducing health inequalities.

Introduction: HIV testing and pre-exposure prophylaxis (PrEP) are efficacious HIV prevention strategies, but uptake remains low among Sub-Saharan African men. Peer-delivered approaches may improve engagement. We developed an intervention combining peer-delivered oral HIV self-testing (HIVST) with incentivized peer referral to HIV services and an SMS-based HIV risk assessment among men in eastern Zimbabwe (IMPERATIVE Trial: NCT06370923). We co-adapted the intervention through iterative prototyping (IP) to enhance its acceptability, feasibility, and potential effectiveness. Methods: From November 2023 to June 2024, we implemented a novel IP framework to refine and test the intervention. Four primary distributors (PDs) were trained to deliver HIVSTs to three peers and refer them to clinic services. Peers could become secondary distributors (SDs), obtain HIVSTs from community hubs and distribute them further. Qualitative data were collected alongside intervention testing to adapt the intervention over two iterations. Activities included three forum theatre workshops, one community advisory board meeting, 25 in-depth interviews, four focus group discussions, and eight observational reports involving men, implementers, stakeholders, and advisory board members. Additionally, 20 men completed baseline and one-week follow-up surveys. Quantitative data were analysed descriptively; qualitative data were analysed using thematic analysis. Results: During testing, HIVST uptake was 100% among PDs, 90% among PD-recruited peers, and 63% among SD-recruited peers. Among self-testers, 50% sought confirmatory testing and about one-quarter initiated PrEP (PDs 25%, PD-recruited peers 30%, SD-recruited peers 25%). Participants viewed the intervention positively and anticipated increased HIV testing and PrEP initiation. Four areas for refinement were identified: recruitment, information dissemination, incentives, and socio-cultural factors. Participant recommendations were adopted before randomised controlled trial testing. Conclusion: Peer-delivered HIVST with referral to HIV services shows promise for engaging Zimbabwean men. The IP framework incorporating participant recommendations enhanced intervention design and delivery within the IMPERATIVE trial. This methodology may inform future intervention development in similar settings.

Background: Sexually transmitted infections (STIs) and vaginal dysbiosis during pregnancy are associated with adverse pregnancy outcomes. Mycoplasma genitalium is the most recent STI implicated but evidence remains limited. The objectives of this study were to investigate 1) the association between M. genitalium infection during pregnancy and gestational age at delivery, preterm birth, miscarriage or stillbirth, and low birth weight and 2) the interaction with vaginal dysbiosis. Methods: We conducted a prospective cohort study in East London, South Africa. We enrolled pregnant women at gestational age <27 weeks, confirmed by ultrasound. We tested vaginal samples using nucleic acid amplification tests for M. genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, other genital mycoplasmas and Candida spp. We defined vaginal dysbiosis using Gram-stain criteria as a Nugent score 4-10. We used quantile regression to compare the outcome in women with and without M. genitalium across the gestational age distribution, adjusting for prespecified sociodemographic and clinical characteristics and co-occurring organisms. Results: From April 1, 2021 to August 29, 2023, we enrolled 603 women, followed up 584 and obtained pregnancy outcomes for 560 (93%). Median age was 28 years (interquartile range, IQR 24, 33) and 27% of women were living with HIV. M. genitalium was detected in 44/584 (8%, 95% CI 6, 10%) and vaginal dysbiosis in 375/584 (64%) of women. Median gestational age at delivery was 39 weeks +0 days (IQR 37+4, 40+1) in women with and 39 weeks +0 days (37+4, 40+0) in those without M. genitalium. In multivariable models, associations were not observed for any adverse birth outcomes. There was no interaction between M. genitalium and vaginal dysbiosis. Discussion: M. genitalium in pregnancy was not associated with earlier gestational age at delivery or with other adverse birth outcomes. These findings do not support routine testing and treatment for M. genitalium in pregnancy.

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.

Precision targeting is essential for maximising impact and cost-effectiveness of interventions at this stage of the HIV response in Malawi. We aimed to measure gaps in access to and use of condoms, HIV testing, pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision among HIV-negative individuals at public health facilities and social venues (bars, rest houses and liquor stores) in Blantyre, Malawi. We analysed cross-sectional data from 2,227 HIV-negative patients at government clinics and 1,634 patrons at social venues recruited in the Clinic vs Venue (CLOVE) study between January and March 2022. We estimated gaps in access to and use of condoms, HIV testing, PrEP and circumcision. Estimates were stratified by risk group, defined as reporting transactional sex, having multiple sex partners in the past 4 weeks, being female aged 15 to 24, or being male aged 30 and above. Access and use were based on self-reports. Overall, 30% of clinic and 60% of venue participants reported higher risk. Among men, we found a gap between access to condoms and condom use at last sex (76.7% vs 29.8% among clinic men; 75.4% vs 36.7% among venue men). Among women, the gap between access and use of condoms was 65.9% vs 18.0% at clinics and 79.9% vs 46.0% in the venues. Approximately 80-85% of participants reported knowing where to get an HIV test in Blantyre but less than half reported testing in the past 6 months. Use of PrEP was low (~2%). Comparable proportions of men who paid for sex and those with multiple partners (~77%) reported being circumcised, but this was lower among those aged 30 years or older (~57%). Despite expanded HIV prevention services in Blantyre, gaps remain in the uptake of prevention services among people reachable at public health facilities and social venues. Use of PrEP was particularly low across all groups. Condom and testing use remained suboptimal despite high reported access. Targeted efforts are needed to address barriers to uptake, particularly for PrEP among high-risk venue-based populations.

HIV prevention and testing programmes primarily reach people who self-refer or attend routine health services. Higher-risk individuals are missed if they are healthy, under-estimate their risk of infection or under-report sexual risk-behaviours. We assess a new approach to address limitations in existing programmes by targeting HIV services on ''Circumstantial Determinants'' (CDs) of HIV risk - the social circumstances, settings, and norms associated with behaviours that increase risk of HIV acquisition. Data on potential CDs and sexual behaviour were collected in a population survey in Zimbabwe in 2018/19 (N=9141). HIV-negative individuals reporting [&ge;] 1 sexual risk-behaviours were defined as the 'priority population' for HIV prevention. For each sex, six circumstantial determinants were associated with being in the priority population (aOR [&ge;] 1.30; p [&le;] 0.01). Reach and efficiency of CDs (and combinations) were calculated; ROC curve algorithms evaluated their ability to identify priority population membership; and HIV prevention condom cascades were compared between CD-defined priority population subgroups. Example findings include that targeting men at bars and beerhalls could reach 48.5% of the priority population and 25.1% of lower-risk men. These percentages increase to 77.1% and 53.7% if men with poor mental health, no religious affiliation, negative social capital, or living on agricultural estates are also targeted. Targeting women with poor mental health could reach 32.0% of the priority population and 21.3% of lower-risk women. Targeting additional circumstantial determinants increases these percentages to 54.1% and 37.5%, respectively. Cascade barriers to condom use differed between CD-defined subgroups. The Circumstantial Determinants approach demonstrates proof-of-concept potential to strengthen HIV prevention services.

Introduction Viet Nam has achieved one of the fastest declines in new HIV infections in the WHO Western Pacific Region. In 2020, the Government launched the National Strategy to End the AIDS Epidemic by 2030. At its midpoint in 2025, a national epidemiological and programmatic review was undertaken to assess the countrys progress and remaining challenges. Methods We conducted a review of the national HIV surveillance and programme data and the Joint United Nations Programme on HIV/AIDS database, focusing on four components: disease burden, prevention, testing, and treatment programmes. Results Estimated annual new HIV infections among adults declined from 14,000 (2010) to 6,117 (2024), a 57% reduction, while the number of PLHIV stabilised at 267,455 in 2024. The epidemic has shifted from being mainly among people who inject drugs (PWID) in the 1990s and early 2000s to being increasingly concentrated among men who have sex with men (MSM) and transgender people (TG), who accounted for 58% of new infections in 2024. In 2024, 88% of people living with HIV (PLHIV) knew their status, 79% of those diagnosed received antiretroviral therapy (ART), and 96% of people on ART achieved viral suppression. Harm reduction outcomes were strong, with opioid substitution therapy (OST) coverage around 40% since 2020 and safe injecting practices among PWID above 90% over the last ten years. The pre-exposure prophylaxis programme expanded rapidly in recent years, reaching 17.4% of the MSM. HIV testing volume was 3.4 million in 2024, with an increasing number of confirmatory testing laboratories. HIV status awareness in 2024 was below the 80% national target for sex workers (59.0%), PWID (62.5%), and MSM (79.2%), but exceeded the target for TG (94.1%). The high rate of viral load suppression indicates strong adherence and reflects the overall quality of treatment services. Conclusions Viet Nams progress reflects two decades of sustained harm reduction among people who inject drugs, early adoption of community-led and decentralised HIV testing innovations, rapid scale-up of PrEP, and consistently high viral suppression among people on ART. These combined system and community-based approaches offer transferable lessons for other low- and middle-income countries.

Access to accurate cost-effective technologies for typing high-risk human papillomaviruses (hrHPV) is critical to expand cervical cancer screening and inform vaccination strategies. Compared with clinical-standard quantitative polymerase chain reaction (qPCR) assays, HPV genotyping by next-generation sequencing (NGS) provides greater flexibility, scalability, and genotype specificity. We have developed a method for HPV genotyping, HPV Phased Amplicon Multiplex Sequencing (PhAM-Seq), that uses combinatorial barcoding of amplicons with short, variable-length inline sequences to enable higher throughput and lower per-sample costs than conventional amplicon sequencing approaches. We evaluated HPV PhAM-Seq using degenerate and type-specific primers targeting the L1 and E6-E7 gene loci in a blinded cohort of 170 cervical samples previously typed by the Seegene Anyplex II HPV28 Detection qPCR assay. Across eight common hrHPV types (HPV16, 18, 31, 33, 35, 45, 52, and 58), HPV PhAM-Seq demonstrated >80% overall agreement with qPCR using degenerate L1-targeting primers, with the highest sensitivity for HPV16, 31, 33, and 58. Sensitivity for HPV35, 45, and 52 improved to 85% or greater with type-specific primers targeting genes E6/E7. Parallel processing and sequencing enables a single technician to assay hundreds of samples per week at a reagent cost of around $10 USD per sample, with laboratory automation and sequencing on higher-output platforms enabling further scaling and cost reduction to a scale amenable to population-level surveillance. We include a detailed SOP; tools for primer design, sequencing library construction, and sample tracking; and all scripts needed for data analysis to ensure HPV PhAM-Seq can be readily implemented for scalable, cost-effective hrHPV genotyping or extended to other similar applications.

Introduction After U.S. foreign assistance was frozen in January 2025, empirical data on the status of the HIV response has been limited. To better understand the ongoing impacts of changes in U.S. foreign assistance, we launched an open survey to assess disruptions in HIV-related care among clinics and programs in low- and middle-income countries (LMICs). Methods Conducted from August to December 2025, the survey explored U.S. foreign assistance-related disruptions in HIV service delivery, medication availability, laboratory services and clinic operations; whether disruptions were fully resolved at the survey timepoint; and the introduction of clinic mitigation strategies. Data on other impacts of U.S. funding changes were explored through an open-ended question. A convergent mixed-methods design, involving parallel quantitative and qualitative analyses and merging of findings from each, was used to examine the impacts of U.S. funding freezes on HIV-related care. Results We received 158 responses from 38 LMICs, including 30 countries supported by the U.S. President's Emergency Fund for AIDS Relief (PEPFAR) at the beginning of 2025 (n=123 responses) and eight non-PEPFAR countries (n=35 responses). Respondents represented health centers (25%), hospitals (31%), dedicated HIV clinics and drop-in centers (39%), and multi-site programs (4%), with a majority (59%) in the non-governmental/private sector. Overall, 81% reported disruptions in at least one HIV-related service since January 2025 because of changes in U.S. foreign assistance, with most also reporting disruptions in medication availability, laboratory services, and clinic operations. The largest reported disruptions were in the areas of pre-exposure prophylaxis (67%) and HIV testing (63%), along with patient tracing (67%), adherence support (63%) and services to key populations (64%). Disruptions were more prevalent in PEPFAR-supported countries and were more likely to be "not fully resolved" by time of survey completion. Qualitative data highlighted the impact of U.S. foreign assistance disruptions on the erosion of client trust in the health system and strains on staff morale. Conclusions Substantial and sustained disruptions in HIV prevention and care reported by diverse clinics in LMICs reinforce concerns that recent funding shifts could reverse progress in ending the HIV epidemic, particularly for vulnerable and key populations.

Women engaged in informal cross-border trade in Southern Africa experience frequent mobility, economic pressure, and exposure to new social environments that may increase vulnerability to risky sexual behaviour and HIV. Limited evidence exists on how pre-migratory, migratory, and post-migratory factors interact to shape sexual risk among this population. This study examined the prevalence and determinants of risky sexual behaviour among women informal cross-border traders at COMESA Market in Lusaka, Zambia. A cross-sectional survey was conducted with 499 women informal cross-border traders. A composite risk score was used to classify respondents as "low risk" or "high risk" for sexual behaviour. Descriptive statistics, chi-square tests, and multivariate binary logistic regression were used to investigate associations between selected covariates and risky sexual behaviour, guided by migration and vulnerability theory. The majority (67.7%) of respondents were classified as high-risk. In multivariate analysis, women who used personal savings for start-up capital were 73% less likely to be high-risk compared to those relying on nuclear family capital (aOR = 0.27, 95% CI: 0.10-0.73). Women with 5-9 years of trading experience also had lower odds (aOR = 0.21, 95% CI: 0.29-0.96). Conversely, using Katima Mulilo border increased the odds 15-fold (aOR = 14.59, 95% CI: 1.26-169.50). Not feeling disconnected while away (aOR = 3.39, 95% CI: 1.03-11.11) and sharing accommodation with one roommate (aOR = 4.42, 95% CI: 1.10-17.84) were also significant predictors of high-risk behaviour. This study demonstrates that risk among women informal cross-border traders is produced across the migration continuum by economic dependence, specific transit routes, and destination living conditions. Interventions should therefore prioritise financial independence, targeted health and protection services at high-risk borders, and safe accommodation with peer-led HIV prevention to reduce vulnerability among mobile women traders.