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Over 4 million adults are living with advanced HIV disease with approximately 650 000 fatalities from HIV reported in 2021. People with advanced HIV disease have low immunity and can present to health services in two ways: those who are well but at high risk of developing severe disease, and those who are severely ill. These two groups require specific management approaches that place different demands on the health system. The first group can generally be supported in primary care settings but require differentiated care to meet their needs. The second group are at high risk of death and need focused diagnostics and clinical care, and possibly hospitalisation. Investments in high-quality clinical management of patients with advanced HIV disease who are seriously ill at primary care or hospital level (often only for a brief period of time during their acute illness) improves the likelihood that their condition will stabilise and that they will recover. Providing high-quality and safe clinical care that is accessible to these groups of people living with HIV who are at risk of severe illness and death is a key priority for reaching the global target of zero AIDS deaths., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 World Health Organization. Published by Elsevier Ltd. All rights reserved.)

Task sharing has been one of the most important enabling policies supporting the global expansion of access to HIV testing and treatment. The WHO public health approach, which relies on delivery of antiretroviral therapy (ART) by nurses, has enabled a trebling of the number of people receiving ART during the past decade. WHO recognises that HIV pre-exposure prophylaxis (PrEP) can also be provided by nurses; however, many countries still do not have policies in place that support nurse provision of PrEP. In sub-Saharan Africa, most countries allow nurses to prescribe ART, but only a few countries have policies in place that allow nurses to prescribe PrEP. Nurse-led PrEP delivery is particularly low in the Asia-Pacific region, which has some of the world's fastest growing epidemics. Even in many high-income countries, PrEP scale-up has been limited because policies often require medical doctors or specialists to prescribe. Service providers in many countries are coming to realise that scaling up access to PrEP cannot be achieved by medical doctors alone, and nurse-led PrEP delivery can help to lay the groundwork for supporting uptake of other HIV prevention approaches that will become available in the future. Countries with policies that authorise nurses to prescribe ART could be early adopters and help to pave the way for wider adoption of nurse-led PrEP delivery., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. Published by Elsevier Ltd.. All rights reserved.)

Peter Ehrenkranz and co-authors present a cyclical cascade of care for people with HIV infection, aiming to facilitate assessment of outcomes., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: PE is an employee of the Bill & Melinda Gates Foundation. SR is a member of PLOS Medicine’s Editorial Board.

Objective: To describe the antiretroviral therapy status of people living with HIV (PLHIV) who died of AIDS-related causes between 2009 and 2013., Methods: We conducted a cross-sectional, population-based study. Data were obtained by linking the mortality information system and the national ART dispensing database. Trends were modelled using linear regression analysis., Results: A total of 61 425 AIDS-related deaths were registered in Brazil between 2009 and 2013. Median age at death was 41 years (IQR: 33-49), and 65.7% (40 337) of deaths were among men; 47.2% (29 004) of PLHIV who died during the study period had never started treatment, 7.0% (4274) had discontinued it, 15.9% (9775) were on ART for 6 months or less and 29.9% (18 372) were on ART for more than 6 months. Only 1.3% of PLHIV were on third-line ARV regimens when they died., Conclusions: AIDS-related mortality remains a challenge even in a context of sustained universal access to antiretroviral treatment due to failure of service provision, not to therapy failure. Robust health policies closing gaps in the HIV continuum of care are crucial to further reduce mortality., (© 2016 John Wiley & Sons Ltd.)

Choroidal tuberculosis is present in 5-20% of patients with disseminated tuberculosis, and point-of-care dilated binocular indirect ophthalmoscopy eye examination can provide immediate diagnosis. In geographical areas of high tuberculosis prevalence and in susceptible patients (CD4 counts less than 200 cells per μL) detection of choroidal granulomas should be accepted as evidence of disseminated tuberculosis. With training and proper support, eye screening can be done by HIV/AIDS clinicians, allowing early tuberculosis treatment. In regions with a high burden of tuberculosis, we recommend that eye screening be a standard part of the initial assessment of susceptible patients, including at a minimum all patients with HIV/AIDS with CD4 less than 100 cells per μL with or without eye symptoms, and with or without suspicion of disseminated tuberculosis., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: HIV/AIDS has historically had a sex and gender-focused approach to prevention and care. Some evidence suggests that HIV-positive men have worse treatment outcomes than their women counterparts in Africa., Methods: We conducted a systematic review and meta-analysis of the effect of sex on the risk of death among participants enrolled in antiretroviral therapy (ART) programs in Africa since the rapid scale-up of ART. We included all cohort studies evaluating the effect of sex (male, female) on the risk of death among participants enrolled in regional and national ART programs in Africa. We identified these studies by searching MedLine, EMBASE, and Cochrane CENTRAL. We used a DerSimonian-Laird random-effects method to pool the proportions of men receiving ART and the hazard ratios for death by sex., Results: Twenty-three cohort studies, including 216 008 participants (79 892 men) contributed to our analysis. The pooled proportion of men receiving ART was 35% [95% confidence interval (CI): 33-38%]. The pooled hazard ratio estimate indicated a significant increase in the risk of death for men when compared to women [hazard ratio: 1.37 (95% CI: 1.28-1.47)]. This was consistent across sensitivity analyses., Interpretation: The proportion of men enrolled in ART programs in Africa is lower than women. Additionally, there is an increased risk of death for men enrolled in ART programs. Solutions that aid in reducing these sex inequities are needed.

Context: Recent studies have highlighted the increased risk of adverse outcomes among older patients on antiretroviral therapy (ART). We report on the associations between older age and adverse outcomes in HIV/AIDS antiretroviral programmes across 17 programmes in sub-Saharan Africa., Methods: We included data from nine countries: Central African Republic, Côte d'Ivoire, Democratic Republic of Congo, Ethiopia, Nigeria, Republic of Congo, Uganda, Zambia and Zimbabwe. We describe survival probability for progression to death and loss to follow-up for patients initiating ART aged less than 50 years and at least 50 years. Multivariate Cox proportional hazards models were used to assess the association between age (15-39, 40-49, 50-59, 60-69 and 70-94 years) and adverse outcomes adjusting for confounders identified a priori., Results: Our analysis included 17,561 patients followed for a median of 12 months. The majority (65%) were female and 6672 (38%) were severely immunosuppressed at baseline. Median age at ART initiation was 36.0 years (interquartile range 30.1-42.8); 11.4% of patients were aged at least 50 years. Median gain in CD4 cell count at 6 and 12 months was significantly higher in patients less than 50 years old compared with those at least 50 years (134 vs. 112 cells/μl at 6 months; 170 vs. 139 cells/μl at 12 months; both P < 0.001). In multivariate analysis, there was a significant increased risk of mortality beyond 3 months after ART initiation in all age groups of at least 40 years of age compared with less than 40 years [40-49 years adjusted hazard ratios (aHRs) 1.59, P < 0.001; 50-59 years aHR 1.58, P = 0.002; 60-69 years aHR 2.63, P < 0.001; 70-94 years aHR 3.64, P = 0.004)., Conclusion: Older age groups represent an important proportion of the overall treatment cohort in these sub-Saharan Africa programmes, and risk of mortality increased as age increased. Future research should be directed at further understanding the reasons for higher mortality, and defining simple interventions that are feasible in highly under-resourced settings to allow for adapted follow-up and care approaches for older age groups.

Objective: The risk of death is highest in the first few months after initiation of antiretroviral therapy (ART). We examined whether initial CD4 cell count maintains a strong prognostic value among patients with at least 6 months follow-up after the initiation of ART., Design: Observational study of HIV patients in Uganda aged 14 years or older enrolled in 10 clinics across Uganda., Methods: Baseline CD4 cell count of patients with more than 6 months of follow-up were stratified into categories (<50, 50-99, 100-149, 150-249, >250 cells/μl). A Kaplan-Meier survival analysis and Cox proportional hazards regression was used to model the associations between baseline CD4 cell count and mortality., Results: Of 22 315 patients, 20 730 (92.8%) had more than 6 months of follow-up. Six hundred and eleven (2.9%) patients died during follow-up and 737 (3.6%) were lost to follow-up. Relative to a baseline CD4 cell counts of less than 50 cells/μl, the adjusted hazard ratios for death were 0.83 [95% confidence interval (CI) 0.67-1.02], 0.71 (95% CI 0.57-0.88), 0.52 (95% CI 0.42-0.64), and 0.55 (95% CI 0.42-0.70) favouring those with baseline CD4 cell counts of 50-99, 100-149, 150-249, and at least 250 cells/μl, respectively. Differing ages and male sex increased the likelihood of mortality., Conclusion: Among patients with more than 6 months of follow-up after initiation of ART, baseline CD4 cell count at initiation still has important prognostic value. This suggests that active engagement and earlier treatment initiation is important for long-term survival.

There has been an historic expectation that delivering combination antiretroviral therapy (cART) to populations affected by violent conflict is untenable due to population movement and separation of drug supplies. There is now emerging evidence that cART provision can be successful in these populations. Using examples from Médecins Sans Frontières experience in a variety of African settings and also local nongovernmental organizations' experiences in northern Uganda, we examine novel approaches that have ensured retention in programs and adequate adherence. Emerging guidelines from United Nations bodies now support the expansion of cART in settings of conflict.

Health worker shortages are a major bottleneck to scaling up antiretroviral therapy (ART), particularly in rural areas. In Lusikisiki, a rural area of South Africa with a population of 150,000 serviced by 1 hospital and 12 clinics, Médecins Sans Frontières has been supporting a program to deliver human immunodeficiency virus (HIV) services through decentralization to primary health care clinics, task shifting (including nurse-initiated as opposed to physician-initiated treatment), and community support. This approach has allowed for a rapid scale-up of treatment with satisfactory outcomes. Although the general approach in South Africa is to provide ART through hospitals-which seriously limits access for many people, if not the majority of people-1-year outcomes in Lusikisiki are comparable in the clinics and hospital. The greater proximity and acceptability of services at the clinic level has led to a faster enrollment of people into treatment and better retention of patients in treatment (2% vs. 19% lost to follow-up). In all, 2200 people were receiving ART in Lusikisiki in 2006, which represents 95% coverage. Maintaining quality and coverage will require increased resource input from the public sector and full acceptance of creative approaches to implementation, including task shifting and community involvement.

Objectives: The immediate objective was to up-date knowledge of the socio-sexual lifestyles and AIDS awareness of young people (16-24 years of age) in Somerset, and to compare these 1996 survey findings to the Somerset Survey findings from 1990. The ultimate objective was to provide information to assist the continuing development of HIV risk-reduction and sexual health promotion strategies for young people., Design: An identical schedule-structured survey strategy to that employed in 1990 was undertaken in May to July 1996 among 498 young people throughout Somerset. A quota sampling strategy was undertaken in 50 electoral wards, randomly selected in proportion to population size. The interviews, undertaken in respondents' homes, involved a combined personal interview and self-completion booklet., Results: Between 1990 and 1996 broad shifts in sexual lifestyles were identified, involving earlier ages of first intercourse, slight increases in numbers of sexual partners and more 'casual-recreational' sexual attitudes. These changes were accompanied by a substantial increase in condom use., Conclusions: The trend among youth in Somerset is towards more open sexual lifestyles, but with the positive public health implications of higher levels of 'safer sex' practice.

This paper discusses qualitative findings from a study of the sexual awareness, lifestyles and related health service needs of young, single factory workers in Thailand. The context of this study is Thailand's growing industrialization, the deepening intensity of the threats to sexual health (especially regarding HIV/AIDS transmission) and the vulnerability of young migrant women. Findings from 18 focus group discussions held with groups of young (15-24) male and female factory workers are outlined with principal reference to the gender construction of sexuality. Key themes explored include attitudes towards courtship, marriage, sexual feelings and arousal, expressions of involvement in pre-marital sexual activities and the consequences of such activity. In conclusion there is some discussion of the implication for young women's sexual health, of the interplay of a measure of pre-marital intercourse and the continuing emotional barriers to effective use of contraception.

A programme of surveys was undertaken in collaboration with District Health Authorities to assess the AIDS awareness and sexual behaviour of young people, in order to help the development and implementation of HIV/AIDS risk-reduction strategies. Given that the patterns of findings were strongly replicated in the different districts, the data is presented in terms of a combined data set comprising 2955 respondents aged 16-24. The surveys indicate fairly reasonable levels of knowledge about HIV/AIDS but very low personally perceived vulnerability to infection. The sexual culture is one of fairly early ages of first intercourse, moderate levels of partner change and low (one third) levels of condom use. The findings are discussed in terms of their implications for HIV/AIDS risk-reduction strategies.