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International audience; Background: Global HIV-1 genetic diversity and evolution form a major challenge to treatment and prevention efforts. An increasing number of distinct HIV-1 recombinants have been identified worldwide, but their contribution to the global epidemic is unknown. We aimed to estimate the global and regional distribution of HIV-1 recombinant forms during 1990-2015.Methods: We assembled a global HIV-1 molecular epidemiology database through a systematic literature review and a global survey. We searched the PubMed, Embase (Ovid), CINAHL (Ebscohost), and Global Health (Ovid) databases for HIV-1 subtyping studies published from Jan 1, 1990, to Dec 31, 2015. Unpublished original HIV-1 subtyping data were collected through a survey among experts in the field who were members of the WHO-UNAIDS Network for HIV Isolation and Characterisation. We included prevalence studies with HIV-1 subtyping data collected during 1990-2015. Countries were grouped into 14 regions and analyses were done for four time periods (1990-99, 2000-04, 2005-09, and 2010-15). The distribution of circulating recombinant forms (CRFs) and unique recombinant forms (URFs) in individual countries was weighted according to the UNAIDS estimates of the number of people living with HIV in each country to generate regional and global estimates of numbers and proportions of HIV-1 recombinants in each time period. The systematic review is registered with PROSPERO, CRD42017067164.Findings: Our global data collection yielded an HIV-1 molecular epidemiology database of 383 519 samples from 116 countries in 1990-2015. We found that the proportion of recombinants increased over time, both globally and in most regions, reaching 22·8% (7 978 517 of 34 921 639) of global HIV-1 infections in 2010-15. Both the proportion and the number of distinct CRFs detected increased over time to 16·7% and 57 CRFs in 2010-15. The global and regional distribution of HIV-1 recombinants was diverse and evolved over time, and we found large regional variation in the numbers (0-44 CRFs), types (58 distinct CRFs), and proportions (0-80·5%) of HIV-1 recombinants. Globally, CRF02_AG was the most prevalent recombinant, accounting for 33·9% (2 701 364 of 7 978 517) of all recombinant infections in 2010-15. URFs accounted for 26·7% (2 131 450 of 7 978 517), CRF01_AE for 23·0% (1 838 433), and other CRFs for 16·4% (1 307 270) of all recombinant infections in 2010-15. Although other CRFs accounted for small proportions of infections globally (

TOC Summary: The spread of genotype E in Africa occurred after the end of the transatlantic slave trade., In Haiti, >90% of the population descended from African slaves. Of 7,147 Haitian pregnant women sampled, 44% of hepatitis B virus (HBV) infections were caused by genotype A1, which today is found mainly in eastern Africa. Twenty percent belong to a rare subgenotype, A5, which has been found only in the former Bight of Benin, a former primary slave trading post. Haitian A subgenotypes appear to have separated early from the African subgenotypes; the most prevalent genotype and subgenotype in West Africa today (E and A3, respectively) are rare in Haiti. This difference indicates that the dominant subgenotypes in Africa emerged in the general population only after the slave trade and explains the low genetic diversity of genotype E. The high prevalence of HBV genotype E in much of Africa further suggests that HBV hyperendemicity is a recent phenomenon, probably resulting from extensive use of unsafe needles.

Background Since 1999 GHESKIO, a large voluntary counseling and HIV testing center in Port-au-Prince, Haiti, has had an ongoing collaboration with the Haitian Ministry of Health to reduce the rate of mother to child HIV transmission. There are limited data on the ability to administer complex regimens for reducing mother to child transmission and on risk factors for continued transmission and infant mortality within programmatic settings in developing countries. Methods and Findings We analyzed data from 551 infants born to HIV-infected mothers seen at GHESKIO, between 1999 and 2005. HIV-infected mothers and their infants were given “short-course” monotherapy with antiretrovirals for prophylaxis; and, since 2003, highly active antiretroviral therapy (HAART) when clinical or laboratory indications were met. Infected women seen in the pre-treatment era had 27% transmission rates, falling to 10% in this cohort of 551 infants, and to only 1.9% in infants of women on HAART. Mortality rate after HAART introduction (0.12 per year of follow-up [0.08–0.16]) was significantly lower than the period before the availability of such therapy (0.23 [0.16–0.30], P

Background New rapid syphilis tests permit simple and immediate diagnosis and treatment at a single clinic visit. We compared the cost-effectiveness, projected health outcomes, and annual cost of screening pregnant women using a rapid syphilis test as part of scaled-up prenatal testing to prevent mother-to-child HIV transmission in Haiti. Methods and Findings A decision analytic model simulated health outcomes and costs separately for pregnant women in rural and urban areas. We compared syphilis syndromic surveillance (rural standard of care), rapid plasma reagin test with results and treatment at 1-wk follow-up (urban standard of care), and a new rapid test with immediate results and treatment. Test performance data were from a World Health Organization–Special Programme for Research and Training in Tropical Diseases field trial conducted at the GHESKIO Center Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes in Port-au-Prince. Health outcomes were projected using historical data on prenatal syphilis treatment efficacy and included disability-adjusted life years (DALYs) of newborns, congenital syphilis cases, neonatal deaths, and stillbirths. Cost-effectiveness ratios are in US dollars/DALY from a societal perspective; annual costs are in US dollars from a payer perspective. Rapid testing with immediate treatment has a cost-effectiveness ratio of $6.83/DALY in rural settings and $9.95/DALY in urban settings. Results are sensitive to regional syphilis prevalence, rapid test sensitivity, and the return rate for follow-up visits. Integrating rapid syphilis testing into a scaled-up national HIV testing and prenatal care program would prevent 1,125 congenital syphilis cases and 1,223 stillbirths or neonatal deaths annually at a cost of $525,000. Conclusions In Haiti, integrating a new rapid syphilis test into prenatal care and HIV testing would prevent congenital syphilis cases and stillbirths, and is cost-effective. A similar approach may be beneficial in other resource-poor countries that are scaling up prenatal HIV testing., Analyzing data from Haiti, Bruce Schackman and colleagues report that scale-up of prenatal HIV testing programs provides a cost-effective opportunity to prevent congenital syphilis through rapid testing., Editors' Summary Background. Congenital syphilis (syphilis that is passed on from a woman infected with the disease to her unborn baby) is a major preventable public health problem. Around half of all pregnancies among women infected with syphilis result in stillbirth or death of the baby shortly after birth. However, it should be possible to reduce the health burden of congenital syphilis if infections among pregnant women could be quickly and accurately diagnosed. In resource-poor countries, many syphilis infections go undiagnosed, because the tests that are normally used involve sending samples away to a laboratory for processing. This means that the diagnosis can only be confirmed, and treatment started, at the next available visit. As a result, there is a delay in starting antibiotic treatment, and some women may never receive their intended treatment at all if they cannot return for their follow-up visit. However, new tests are available that don't involve cold storage of reagents or electrical equipment, and these can be used to give an immediate result about syphilis infection even in rural or resource-poor settings. Currently, global initiatives are underway to ensure many more pregnant women are tested for HIV and to reduce the risk of HIV being passed on from a woman to her baby. These initiatives could provide an important opportunity for carrying out widespread immediate screening for syphilis during pregnancy as well. Such screening might then help reduce infant deaths substantially. Why Was This Study Done? Field trials evaluating rapid syphilis tests have already been carried out by the World Health Organization's Special Programme for Research and Training in Tropical Diseases. One such trial, carried out in Port-au-Prince, Haiti, evaluated the success of three different rapid syphilis tests as compared to two “gold standard” tests (older tests that are generally considered reliable, but which don't give an immediate result). These researchers wanted to use data from these trials to compare costs and predicted health outcomes of including different types of syphilis screening as part of scaled-up prenatal care. Specifically, the researchers wanted to find out whether including rapid syphilis testing as part of universal prenatal care would be cost-effective and whether it would reduce the rate of stillbirths and congenital syphilis. What Did the Researchers Do and Find? This research was based on data from the field trials previously carried out in Haiti. The data from these trials were used to create a model comparing three different strategies for screening pregnant women for syphilis infections. The three strategies were as follows: checking for the symptoms of syphilis (assumed to be the standard of care in rural areas); standard testing for antibody response to the syphilis bacterium, after which treatment can be provided at follow-up a week later (assumed to be the standard of care in urban areas); and, finally, rapid testing that gives an immediate result. For each strategy, the researchers predicted what the health outcomes would be. These outcomes are summarized in “disability-adjusted life years” (DALYs) that reflect the number of years of healthy life lost due to congenital syphilis among newborn babies, the number of stillbirths, and the number of neonatal deaths. Cost-effectiveness of each strategy was also worked out by dividing the additional costs of testing and treatment for each strategy by the number of DALYs avoided using that screening method compared to the next most expensive alternative. Under the model, urban and rural settings were looked at separately. Immediate testing was more expensive than either standard testing or checking for symptoms, but emerged as more cost-effective than standard testing in rural settings; the immediate test would cost an additional $7–$10 per disability-adjusted life year compared to the current rural or urban standard of care. The researchers predicted that if immediate syphilis testing were provided to all pregnant women in Haiti who currently have access to prenatal care, over 1,000 congenital syphilis cases would be avoided, along with over 1,000 stillbirths and neonatal deaths, at a yearly cost of $525,000. What Do These Findings Mean? This model suggests that including rapid syphilis testing as part of current global initiatives for preventing mother-to-child transmission of HIV could substantially reduce infant deaths. The strategy is also likely to be cost-effective. Additional Information. Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040183. MedlinePlus encyclopedia entry on congenital syphilis Information from the World Health Organization about congenital syphilis, including information about screening programs and new screening tests A report is also available from the Special Programme for Research and Training in Tropical Diseases regarding rapid syphilis tests AVERT, an international AIDS charity, provides information about preventing mother-to-child transmission of HIV