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We aimed to elucidate the role of partnerships with older men in the HIV epidemic among adolescent girls and young women (AGYW) aged 15-24 years in sub-Saharan Africa.Analysis of Population-based HIV Impact Assessments in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe.We examined associations between reported partner age and recent HIV infection among AGYW, incorporating male population-level HIV characteristics by age-band. Recent HIV infection was defined using the LAg avidity assay algorithm. Viremia was defined as a viral load of more than 1000 copies/ml, regardless of serostatus. Logistic regression compared recent infection in AGYW with older male partners to those reporting younger partners. Dyadic analysis examined cohabitating male partner age, HIV status, and viremia to assess associations with AGYW infection.Among 17 813 AGYW, increasing partner age was associated with higher odds of recent infection, peaking for partners aged 35-44 (adjusted odds ratio = 8.94, 95% confidence interval: 2.63-30.37) compared with partners aged 15-24. Population-level viremia was highest in this male age-band. Dyadic analyses of 5432 partnerships confirmed the association between partner age-band and prevalent HIV infection (male spousal age 35-44-adjusted odds ratio = 3.82, 95% confidence interval: 2.17-6.75). Most new infections were in AGYW with partners aged 25-34, as most AGYW had partners in this age-band.These results provide evidence that men aged 25-34 drive most AGYW infections, but partners over 9 years older than AGYW in the 35-44 age-band confer greater risk. Population-level infectiousness and male age group should be incorporated into identifying high-risk typologies in AGYW.

Mobile women are at risk of HIV infection in sub-Saharan Africa, although we lack evidence for HIV risk among women in mobile partnerships, especially in the context of household food insecurity, a growing concern in the region.Women aged 15-59 years with a cohabitating male partner who participated in population-based HIV impact assessment surveys in Eswatini, Lesotho, Namibia, Tanzania, Uganda, and Zambia.We evaluated the association between women's and their partner's mobility (being away from home for more than 1 month or staying elsewhere) and transactional sex (selling sex or receiving money or goods in exchange for sex). We examined associations for effect measure modification by food insecurity level in the household in the past month. We used survey-weighted logistic regression, pooled and by country, adjusting for individual, partner, and household-level variables.Among women with a cohabitating male partner, 8.0% reported transactional sex, ranging from 2.7% in Lesotho to 13.4% in Uganda. Women's mobility [aOR 1.35 (95% CI: 1.08 to 1.68)], but not their partner's mobility [aOR 0.91 (0.74-1.12)], was associated with transactional sex. Food insecurity was associated with transactional sex independent of mobility [aOR 1.29 (1.10-1.52)]. Among those who were food insecure, mobility was not associated with increased odds of transactional sex.Food insecurity and women's mobility each increased the odds of transactional sex. Because transactional sex is associated with HIV risk, prevention programs can address the needs of mobile and food-insecure women, including those in cohabitating relationships.

To describe effects of the COVID-19 pandemic on older adults living in non-institutionalized settings in New York City (NYC) we used random digit dial sampling of landlines phones to sample then interview residents 70 years and older in NYC from December 2020–March 2021. Socio-demographic, health characteristics and effects of the COVID-19 pandemic were solicited. Of 676 respondents, the average age was 78, 60% were female, and 63% had ever been tested for SARS-CoV-2, with 12% testing positive. Sixty-three percent of respondents knew someone who had been diagnosed with COVID-19 and 51% reported knowing at least one person who had died from COVID-19. Eight percent of respondents reported sometimes or often not having enough to eat, with 31% receiving food from a food pantry program. Significantly more Latinx respondents (24%) reported a positive SARS-CoV-2 test, whereas 17% of those of another race, 8% of white, and 7% of Black respondents had a positive COVID-19 test (p

BACKGROUND HIV population viral load (PVL) can reflect antiretroviral therapy program effectiveness and transmission potential in a community. Using nationally representative data from household surveys conducted in Zimbabwe, Malawi, and Zambia in 2015-16, we examined the association between various VL measures and the probability of at least one recent HIV-1 infection in the community. METHODS We used limiting-antigen avidity enzyme immunoassay, viral load suppression (VLS) (HIV RNA

Background The population-based HIV impact assessment (population-based HIV impact assessments) surveys are among the first to estimate national adult HIV incidence, subnational prevalence of viral load suppression, and pediatric HIV prevalence. We summarize the survey methods implemented in Zimbabwe, Malawi, and Zambia, as well as response rates and quality metrics. Methods Each cross-sectional, household-based survey used a 2-stage cluster design. Survey preparations included sample design, questionnaire development, tablet programming for informed consent and data collection, community mobilization, establishing a network of satellite laboratories, and fieldworker training. Interviewers collected demographic, behavioral, and clinical information using tablets. Blood was collected for home-based HIV testing and counseling (HBTC) and point-of-care CD4+ T-cell enumeration with results immediately returned. HIV-positive blood samples underwent laboratory-based confirmatory testing, HIV incidence testing, RNA polymerase chain reaction (viral load), DNA polymerase chain reaction (early infant diagnosis), and serum antiretroviral drug detection. Data were weighted for survey design, and chi square automatic interaction detection-based methods were used to adjust for nonresponse. Results Each survey recruited a nationally representative, household-based sample of children and adults over a 6-10-month period in 2015 and 2016. Most (84%-90%) of the 12,000-14,000 eligible households in each country participated in the survey, with 77%-81% of eligible adults completing an interview and providing blood for HIV testing. Among eligible children, 59%-73% completed HIV testing. Across the 3 surveys, 97.8% of interview data were complete and had no errors. Conclusion Conducting a national population-based HIV impact assessment with immediate return of HIV and other point-of-care test results was feasible, and data quality was high.

Background Adolescents aged 10–19 years living with human immunodeficiency virus (HIV) (ALHIV), both perinatally infected adolescents (APHIV) and behaviorally infected adolescents (ABHIV), are a growing population with distinct care needs. We characterized the epidemiology of HIV in adolescents included in Population-based HIV Impact Assessments (2015–2017) in Zimbabwe, Malawi, Zambia, Eswatini, and Lesotho. Methods Adolescents were tested for HIV using national rapid testing algorithms. Viral load (VL) suppression (VLS) was defined as VL, Based on national surveys, fewer than half of adolescents living with human immunodeficiency virus (HIV) in 5 countries in southern Africa were virally suppressed, and 68.7% classified as perinatally infected had undiagnosed HIV or HIV diagnosed at age ≥10 years.

Routine data on vaccine uptake are not disaggregated by lesbian, gay, bisexual, transgender, queer, and other sexual identities (LGBTQ+) populations, despite higher risk of infection and severe disease. We found comparable vaccination uptake patterns among 1032 LGBTQ+ New Yorkers and the general population. We identified critical socioeconomic factors that were associated with vaccine hesitancy in this economically vulnerable population.

Large public-health training events may result in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. Universal SARS-CoV-2 testing during trainings for the Uganda Population-based HIV Impact Assessment identified 28 of 475 (5.9%) individuals with coronavirus disease 2019 (COVID-19) among attendees; most (89.3%) were asymptomatic. Until COVID-19 vaccine is readily available for staff and participants, effective COVID-19 mitigation measures, along with SARS-CoV-2 testing, are recommended for in-person trainings, particularly when trainees will have subsequent contact with survey participants.

The narrative is framed within the context of ways that public health interventions balance the rights of individuals and community when related to infectious diseases. This central example is from a community-based HIV testing program in an area with high HIV prevalence. We describe a breach of confidentiality resulting from an involuntary disclosure of a participant’s HIV status. This breach of confidentiality occurs within a family. The narrative considers the respective rights of individuals and community members related to disclosure of HIV status and pays attention to how roles (e.g., health care worker, sexual partner) influence decisions regarding disclosure of someone’s HIV status. There were clear testing program guidelines for how, when, and where to disclose HIV status of household members. Standard operating procedures and careful training were meant to protect data confidentiality and privacy of patients. In practice, things were messier and less clear. The narrative describes how this confidentiality breach occurred, what was done to ensure the participant was safe after the fact and ways to amend the breach on a systems level.

Globally, adolescent girls and young women (AGYW) are disproportionately impacted by economic, demographic, and social factors associated with a wide range of negative outcomes.The objective of this study was to use latent class analysis (LCA) to identify groupings of AGYW in Lesotho based on patterns of gendered risk factors, and to assess the association between the identified groupings and intimate partner violence (IPV) and low educational attainment.Data were from the 2018 Lesotho Violence Against Children and Youth Survey. AGYW reported gendered risk factors: teen pregnancy, child marriage, intergenerational sex, early sexual debut, being HIV positive, transactional sex, endorsement of one or more negative traditional gender norms, and one or more norms supportive of violence against women.LCA identified latent classes of eight gendered risk factors. Multivariable logistic regression assessed associations between latent classes and IPV victimization and low educational attainment.A three-class solution was selected, and classes were named as: Low Risk class, Behavioral Risk class, and Attitudinal Risk class. Odds of low educational attainment and IPV were higher in the Attitudinal Risk class than the Low Risk class. Odds of low educational attainment and IPV were higher in the Behavioral Risk class than the Low Risk class and the Attitudinal Risk class.In Lesotho, gendered risk factors form distinct classes that have variable associations with low educational attainment and IPV. LCA can be an important approach to better understand the complicated relationship gendered risk factors have with each other and with certain outcomes, to further elucidate the influence that gender has on the health of AGYW and to provide more targeted prevention programming.

IntroductionFood insecurity has a bidirectional relationship with HIV infection, with hunger driving compensatory risk behaviors, while infection can increase poverty. We used a laboratory recency assay to estimate the timing of HIV infection vis-à-vis the timing of severe food insecurity (SFI).MethodsData from population-based surveys in Zambia, Eswatini, Lesotho, Uganda, and Tanzania and Namibia were used. We defined SFI as having no food ≥three times in the past month. Recent HIV infection was identified using the HIV-1 LAg avidity assay, with a viral load (>1000 copies/ml) and no detectable antiretrovirals indicating an infection in the past 6 months. Logistic regression was conducted to assess correlates of SFI. Poisson regression was conducted on pooled data, adjusted by country to determine the association of SFI with recent HIV infection and risk behaviors, with effect heterogeneity evaluated for each country. All analyses were done using weighted data.ResultsOf 112,955 participants aged 15-59, 10.3% lived in households reporting SFI. SFI was most common in urban, woman-headed households. Among women and not men, SFI was associated with a two-fold increase in risk of recent HIV infection (adjusted relative risk [aRR] 2.08, 95% CI 1.09-3.97), with lower risk in high prevalence countries (Eswatini and Lesotho). SFI was associated with transactional sex (aRR 1.28, 95% CI 1.17-1.41), a history of forced sex (aRR 1.36, 95% CI 1.11-1.66), and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02-1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15-24 (aRR 1.23, 95% CI 1.03-1.46), although this was heterogeneous. Recent receipt of food support was protective (aRR 0.36, 95% CI 0.14-0.88).ConclusionSFI increased risk for HIV acquisition in women by two-fold. Worsening food scarcity due to climactic extremes could imperil HIV epidemic control.SUMMARYWhat is already knownThe link between food insecurity and the adoption of high-risk sexual behaviors as a coping mechanism has been shown in several settings.HIV infection can also drive food insecurity due to debilitating illness reducing productivity, the costs of treatment diverting money from supplies, and potentially reduced labor migration.Food insecurity has been associated with chronic HIV infection, but it has not been linked with HIV acquisition.What are the new findingsThis study of 112,955 adults across six countries in sub-Saharan Africa provides unique information on the association between acute food insecurity and recent HIV infection in women, as well as the potential behavioral and biological mediators, including community viremia as a measure of infectiousness.The data enabled a comprehensive analysis of factors associated with risk of infection, and how these factors differed by country and gender. Women living in food insecure households had a two-fold higher risk of recent HIV acquisition, and reported higher rates of transactional sex, early sexual debut, forced sex, intergenerational sex and sex without a condom with someone of unknown or positive HIV status. This pattern was not seen in men.This study is also the first to demonstrate a protective association for food support, which was associated with a lower risk of recent HIV infection in women.What do the new findings implyIn light of worsening food insecurity due to climate change and the recent COVID-19 pandemic, our results support further exploration of gender-specific pathways of response to acute food insecurity, particularly how women’s changes in sexual behavior heighten their risk of HIV acquisition.These and other data support the inclusion of food insecurity in HIV risk assessments for women, as well as the exploration of provision of food support to those households at highest risk based on geographic and individual factors.

Background Identifying men living with HIV in sub-Saharan Africa (SSA) is critical to end the epidemic. We describe the underlying factors of unawareness among men aged 15-59 years who ever tested for HIV in 13 SSA countries. Methods Using pooled data from the nationally representative Population-based HIV Impact Assessments, we fit a log-binomial regression model to identify characteristics related to HIV positivity among HIV-positive unaware and HIV-negative men ever tested for HIV. Results A total of 114,776 men were interviewed and tested for HIV; 4.4% were HIV-positive. Of those, 33.7% were unaware of their HIV-positive status, (range: 20.2%-58.7%, in Rwanda and Cote d'Ivoire). Most unaware men reported they had ever received an HIV test (63.0%). Age, region, marital status, and education were significantly associated with HIV positivity. Men who had HIV-positive sexual partners (adjusted prevalence ratio [aPR]: 5.73; confidence interval [95% CI]: 4.13 to 7.95) or sexual partners with unknown HIV status (aPR: 2.32; 95% CI: 1.89 to 2.84) were more likely to be HIV-positive unaware, as were men who tested more than 12 months compared with HIV-negative men who tested within 12 months before the interview (aPR: 1.58; 95% CI: 1.31 to 1.91). Tuberculosis diagnosis and not being circumcised were also associated with HIV positivity. Conclusion Targeting subgroups of men at risk for infection who once tested negative could improve yield of testing programs. Interventions include improving partner testing, frequency of testing, outreach and educational strategies, and availability of HIV testing where men are accessing routine health services.

BACKGROUND The increase in cell phone ownership in low- and middle-income countries (LMIC) has created an opportunity for low-cost, rapid data collection by calling participants on their cell phones. Cell phones can be mobilized for a myriad of data collection purposes, including surveillance. In LMIC, cell phone–based surveillance has been used to track Ebola, measles, acute flaccid paralysis, and diarrheal disease, as well as noncommunicable diseases. Phone-based surveillance in LMIC is a particularly pertinent, burgeoning approach in the context of the COVID-19 pandemic. Participatory surveillance via cell phone could allow governments to assess burden of disease and complements existing surveillance systems. OBJECTIVE We describe the protocol for the LeCellPHIA (Lesotho Cell Phone PHIA) project, a cell phone surveillance system that collects weekly population-based data on influenza-like illness (ILI) in Lesotho by calling a representative sample of a recent face-to-face survey. METHODS We established a phone-based surveillance system to collect ILI symptoms from approximately 1700 participants who had participated in a recent face-to-face survey in Lesotho, the Population-based HIV Impact Assessment (PHIA) Survey. Of the 15,267 PHIA participants who were over 18 years old, 11,975 (78.44%) consented to future research and provided a valid phone number. We followed the PHIA sample design and included 342 primary sampling units from 10 districts. We randomly selected 5 households from each primary sampling unit that had an eligible participant and sampled 1 person per household. We oversampled the elderly, as they are more likely to be affected by COVID-19. A 3-day Zoom training was conducted in June 2020 to train LeCellPHIA interviewers. RESULTS The surveillance system launched July 1, 2020, beginning with a 2-week enrollment period followed by weekly calls that will continue until September 30, 2022. Of the 11,975 phone numbers that were in the sample frame, 3020 were sampled, and 1778 were enrolled. CONCLUSIONS The surveillance system will track COVID-19 in a resource-limited setting. The novel approach of a weekly cell phone–based surveillance system can be used to track other health outcomes, and this protocol provides information about how to implement such a system. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/31236

Background The increase in cell phone ownership in low- and middle-income countries (LMIC) has created an opportunity for low-cost, rapid data collection by calling participants on their cell phones. Cell phones can be mobilized for a myriad of data collection purposes, including surveillance. In LMIC, cell phone–based surveillance has been used to track Ebola, measles, acute flaccid paralysis, and diarrheal disease, as well as noncommunicable diseases. Phone-based surveillance in LMIC is a particularly pertinent, burgeoning approach in the context of the COVID-19 pandemic. Participatory surveillance via cell phone could allow governments to assess burden of disease and complements existing surveillance systems. Objective We describe the protocol for the LeCellPHIA (Lesotho Cell Phone PHIA) project, a cell phone surveillance system that collects weekly population-based data on influenza-like illness (ILI) in Lesotho by calling a representative sample of a recent face-to-face survey. Methods We established a phone-based surveillance system to collect ILI symptoms from approximately 1700 participants who had participated in a recent face-to-face survey in Lesotho, the Population-based HIV Impact Assessment (PHIA) Survey. Of the 15,267 PHIA participants who were over 18 years old, 11,975 (78.44%) consented to future research and provided a valid phone number. We followed the PHIA sample design and included 342 primary sampling units from 10 districts. We randomly selected 5 households from each primary sampling unit that had an eligible participant and sampled 1 person per household. We oversampled the elderly, as they are more likely to be affected by COVID-19. A 3-day Zoom training was conducted in June 2020 to train LeCellPHIA interviewers. Results The surveillance system launched July 1, 2020, beginning with a 2-week enrollment period followed by weekly calls that will continue until September 30, 2022. Of the 11,975 phone numbers that were in the sample frame, 3020 were sampled, and 1778 were enrolled. Conclusions The surveillance system will track COVID-19 in a resource-limited setting. The novel approach of a weekly cell phone–based surveillance system can be used to track other health outcomes, and this protocol provides information about how to implement such a system. International Registered Report Identifier (IRRID) DERR1-10.2196/31236

BackgroundHIV incidence is increasing in eastern Europe and central Asia, primarily driven by injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy are suboptimal, with many people who inject drugs (PWID) being incarcerated. We aimed to assess whether use of monies saved as a result of decriminalisation of drug use or possession to scale up ART and opioid agonist therapy could control HIV transmission among PWID in eastern Europe and central Asia.MethodsA dynamic HIV transmission model among PWID incorporating incarceration, ART, and opioid agonist therapy was calibrated to Belarus, Kazakhstan, Kyrgyzstan, and St Petersburg (Russia). Country-specific costs for opioid agonist therapy, ART, and incarceration were collated or estimated. Compared with baseline, the model prospectively projected the life-years gained, incremental costs (2018 euros), and infections prevented over 2020–40 for three scenarios. The decriminalisation scenario removed incarceration resulting from drug use or possession for personal use, reducing incarceration among PWID by 24·8% in Belarus, Kazakhstan, and Kyrgyzstan and 46·4% in St Petersburg; the public health approach scenario used savings from decriminalisation to scale up ART and opioid agonist therapy; and the full scale-up scenario included the decriminalisation scenario plus investment of additional resources to scale up ART to the UNAIDS 90-90-90 target of 81% coverage and opioid agonist therapy to the WHO target of 40% coverage. The incremental cost-effectiveness ratios per life-year gained for each scenario were calculated and compared with country-specific gross domestic product per-capita willingness-to-pay thresholds. Costs and life-years gained were discounted 3% annually.FindingsCurrent levels of incarceration, opioid agonist therapy, and ART were estimated to cost from €198 million (95% credibility interval 173–224) in Kyrgyzstan to €4129 million (3897–4358) in Kazakhstan over 2020–40; 74·8–95·8% of these total costs were incarceration costs. Decriminalisation resulted in cost savings (€38–773 million due to reduced prison costs; 16·9–26·1% reduction in overall costs) but modest life-years gained (745–1694). The public health approach was cost saving, allowing each setting to reach 81% ART coverage and 29·7–41·8% coverage of opioid agonist therapy, resulting in 17 768–148 464 life-years gained and 58·9–83·7% of infections prevented. Results were similar for the full scale-up scenario.InterpretationCost savings from decriminalisation of drug use could greatly reduce HIV transmission through increased coverage of opioid agonist therapy and ART among PWID in eastern Europe and central Asia.FundingAlliance for Public Health, US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse, and Economist Intelligence Unit.

ObjectiveTo assess the potential bidirectional relationship between food insecurity and HIV infection in sub-Saharan Africa.DesignNationally representative HIV impact assessment household-based surveys.SettingZambia, Eswatini, Lesotho, Uganda and Tanzania and Namibia.Participants112 955 survey participants aged 15–59 years with HIV and recency test results.MeasuresRecent HIV infection (within 6 months) classified using the HIV-1 limited antigen avidity assay, in participants with an unsuppressed viral load (>1000 copies/mL) and no detectable antiretrovirals; severe food insecurity (SFI) defined as having no food in the house ≥three times in the past month.ResultsOverall, 10.3% of participants lived in households reporting SFI. SFI was most common in urban, woman-headed households, and in people with chronic HIV infection. Among women, SFI was associated with a twofold increase in risk of recent HIV infection (adjusted relative risk (aRR) 2.08, 95% CI 1.09 to 3.97). SFI was also associated with transactional sex (aRR 1.28, 95% CI 1.17 to 1.41), a history of forced sex (aRR 1.36, 95% CI 1.11 to 1.66) and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02 to 1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15–24 years (aRR 1.23, 95% CI 1.03 to 1.46). Recent receipt of food support was protective against HIV acquisition (aRR 0.36, 95% CI 0.14 to 0.88).ConclusionSFI increased risk for HIV acquisition in women by twofold. Heightened food insecurity during climactic extremes could imperil HIV epidemic control, and food support to women with SFI during these events could reduce HIV transmission.

Background: Conflicting evidence obscures the role of partnerships with older men in the HIV epidemic in adolescent girls and young women (AGYW, aged 15-24) in sub-Saharan Africa. We assessed the effect of partner age and potential mediators on AGYW HIV infection using data from Population-based HIV Impact Assessments in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia, and Zimbabwe. Methods: PHIA surveys collect data on HIV-related outcomes. Recent infection was estimated using an HIV-1 LAg avidity assay algorithm. We examined the association between reported partner age and recent AGYW HIV infection, incorporating population-level HIV prevalence and viremia from the reported male age-band. Logistic regression analyses compared the odds of recent infection in AGYW with older male partners to those reporting same-age male partner, adjusting for AGYW age, country, and urban/rural residence. Dyadic analysis examined observed cohabitating partner age, HIV status, and viremia to assess associations with recent and prevalent infection in their AGYW spouses. Findings: Among 17,813 AGYW, increasing reported partner age was associated with higher odds of recent infection, with the highest odds for partners aged 35-44 years (adjusted odds ratio (aOR) 8·94, 95% CI 2·63-30·37) compared to partners aged 15-24. Population-level viremia was highest in this male age-band. Dyadic analyses of 5,432 partnerships confirmed the association between partner age-band of 35-44 and prevalent HIV infection (aOR 3·82, 95% CI 2·17-6·75). However, most new infections were in AGYW with partners aged 25-34, as the majority of AGYW had partners in this age-band. Interpretation: These results provide evidence that men aged 25-34 drive most AGYW infections, but partners over 9 years older than AGYW in the 35-44 age-band confer greater risk. Population-level infectiousness and male age should be incorporated into identifying high-risk typologies. Funding Information: This research publication has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention (CDC) under the terms of cooperative agreements U2GGH001226 and U2GGH001271. Joanne Mantell and Susie Hoffman were supported by a NIMH Center Grant P30-MH43520 (Principal Investigator: Robert H. Remien, PhD). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the funding agencies. Declaration of Interests: Authors declare that they have no competing interests. Ethics Approval Statement: A guardian or parent provided permission for interviewers to approach 10-17-year-olds who then assented. Informed consent/assent was documented via electronic signature, with witnesses verifying consent for illiterate individuals The PHIA protocols were approved by national ethics committees, and the institutional review boards at Columbia University Irving Medical Center, the University of California in San Francisco for Namibia, and the US Centers for Disease Control and Prevention.

Background In the 21st century, understanding how population migration impacts human health is critical. Namibia has high migration rates and HIV prevalence, but little is known about how these intersect. We examined the association between migration and HIV-related outcomes using data from the 2017 Namibia Population-based HIV Impact Assessment (NAMPHIA). Methods and findings The NAMPHIA survey selected a nationally representative sample of adults in 2017. All adults aged 15–64 years were invited to complete an interview and home-based HIV test. Recent infection (1000 copies/mL) and antiretroviral analyte data. Awareness of HIV status and antiretroviral use were based on self-report and/or detectable antiretrovirals in blood. Viremia was defined as having a viral load ≥1000 copies/mL, including all participants in the denominator regardless of serostatus. We generated community viremia values as a weighted proportion at the EA level, excluding those classified as recently infected. Significant migrants were those who had lived outside their current region or away from home >one month in the past three years. Recent cross-community in-migrants were those who had moved to the community two years ago to determine the association of migration and timing with recent infection or viral load suppression (VLS). All proportions are weighted. Of eligible adults, we had HIV results and migration data on 9,625 (83.9%) of 11,474 women and 7,291 (73.0%) of 9,990 men. Most respondents (62.5%) reported significant migration. Of cross-community in-migrants, 15.3% were recent. HIV prevalence was 12.6% and did not differ by migration status. Population VLS was 77.4%. Recent cross-community in-migration was associated with recent HIV infection (aOR: 4.01, 95% CI 0.99–16.22) after adjusting for community viremia. Significant migration (aOR 0.73, 95% CI: 0.55–0.97) and recent cross-community in-migration (aOR 0.57, 95% CI: 0.35–0.92) were associated with lower VLS, primarily due to lack of awareness of HIV infection. The study was limited by lack of precise data on trajectory of migration. Conclusions Despite a high population-level VLS, Namibia still has migrant populations that are not accessing effective treatment for HIV. Targeting migrants with effective prevention and testing programs in communities with viremia could enable further epidemic control.

Objectives: interleukin 11 (IL11) is highly upregulated in skin and lung fibroblasts from patients with systemic sclerosis (SSc). Here we tested whether IL11 is mechanistically linked with activation of human dermal fibroblasts (HDFs) from patients with SSc or controls. Methods: we measured serum IL11 levels in volunteers and patients with early diffuse SSc and manipulated IL11 signalling in HDFs using gain- and loss-of-function approaches that we combined with molecular and cellular phenotyping. Results: in patients with SSc, serum IL11 levels are elevated as compared to healthy controls. All transforming growth factor beta (TGFβ) isoforms induced IL11 secretion from HDFs, which highly express IL11RA and the gp130 co-receptor, suggestive of an autocrine loop of IL11 activity in HDFs. IL11 stimulated ERK activation in HDFs and resulted in HDF-to-myofibroblast transformation and extracellular matrix secretion. The pro-fibrotic action of IL11 in HDFs appeared unrelated to STAT3 activity, independent of TGFβ upregulation and was not associated with phosphorylation of SMAD2/3. Inhibition of IL11 signaling using either a neutralizing antibody against IL11 or siRNA against IL11RA reduced TGFβ-induced HDF proliferation, matrix production and cell migration, which was phenocopied by pharmacologic inhibition of ERK. Conclusions: these data reveal that autocrine IL11-dependent ERK activity alone, or downstream of TGFβ stimulation, promotes fibrosis phenotypes in dermal fibroblasts and suggest IL11 as a potential therapeutic target in SSc., Singapore STaR Awards; National Medical Research Council (NMRC) Centre Grants; BMRC; Goh Foundation;Tanoto Foundation; Duke-NUS; SingHealth Core Funding

Background: We assessed the associations between severe food insecurity (SFI) and HIV risk in six sub-Saharan African countries. Methods: Data from nationally representative Population-based HIV Impact Assessments (PHIAs) in Zambia, Eswatini, Lesotho, Uganda, and Tanzania and Namibia were used. SFI was defined as having no food in the house at least three times in the past month. Recent HIV infection was identified using the HIV-1 LAg avidity assay, with viral load (>1000 copies/ml) and antiretroviral data. Logistic regression was conducted to assess correlates of SFI. Poisson regression was conducted on pooled data, stratified by sex and adjusted by country, urbanicity, wealth quintile and age, to determine the association of SFI with recent HIV infection and risk behaviors. All analyses were done using weighted data. Findings: Of the 112,955 survey participants aged 15-59, 10·3% lived in households reporting SFI. SFI was most common in poor, urban, woman-headed households with many dependents. Among women, SFI was associated with a two-fold increase in risk of recent HIV infection (adjusted relative risk [aRR] 2·04, 95% CI 1·04-3·98), and receipt of food support was protective (aRR 0·36, 95% CI 0·14-0·91), associations not observed among men. SFI was also associated with transactional sex (aRR 1·29, 95% CI 1·17-1·41), a history of forced sex (aRR 1·42, 95% CI 1·16-1·74), and condom-less sex with a partner of unknown or positive HIV status (aRR 1·08, 95% CI 1·02-1·14) in all women, and intergenerational sex (sexual partner ≥10 years older) in women aged 15-24 (aRR 1·23, 95% CI 1·03-1·46). Interpretation: The findings demonstrate that food insecurity increases risk for HIV acquisition. Worsening food scarcity due to climactic extremes could imperil HIV epidemic control, while food support programs might mitigate this risk. Funding Information: President’s Emergency Plan for AIDS Relief (PEPFAR) through the US Centers for Disease Control and Prevention under the terms of cooperative agreement #U2GGH001226. Declaration of Interests: The authors declare that they have no conflicts of interest. Ethics Approval Statement: Written informed consent/assent was documented via electronic signature, with witnesses verifying consent for illiterate individuals. The PHIA protocol and data collection tools were approved by national ethics committees for each country, and the institutional review boards at Columbia University Irving Medical Center, the US Centers for Disease Control and Prevention (CDC) and the University of California, San Francisco in the case of Namibia.

Background Eswatini continues to have the highest prevalence of HIV in the world, and one of the highest HIV incidences among adult populations (aged 15–49). This analysis reports on both key elements of study design/protocol and baseline results from an impact evaluation of an intervention incentivizing (i) initiation, enrolment, attendance or completion of some form of education, and (ii) lower risk sexual behaviour. Methods The impact evaluation employs a two by two factorial design in which participants are enrolled in either the incentive for education arm (‘education treatment arm’ providing a conditional cash incentive) or the control arm (‘education control arm’). In each of these arms, 50% of participants were randomized to also be eligible for selection – three times a year – to participate in a conditional raffle conditional on testing negative for curable STIs (syphilis and Trichomonas vaginalis). Results Baseline recruitment and screening occurred in 2016 when a total of 6055 individuals were screened of which 4863 participated in the baseline survey, and 4819 individuals were randomized into one of the study arms. The baseline prevalence of HIV, Trichomonas vaginalis, and syphilis among adolescent girls and young women 8.20% (397/4840), 3.31% (150/4533) and 0.17% (8/4830) respectively. Conclusions An educational cash incentive and raffle incentive impact evaluation that addresses adolescent girls and young women who are in-education and out-of-education has the potential to reduce HIV risk in adolescent girls and young women in Eswatini. Trial registration Name of the registry: Pan African Clinical Trials Registry. Trial registration number: PACTR201811609257043. Date of registration: May 11, 2018 ‘Retrospectively registered’. URL of trial registry record: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=4685

IntroductionThe Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a target of ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) to have viral load suppression (VLS). We examined factors associated with nonsuppressed viral Load (NVL).MethodsWe included PLHIV receiving ART aged 15–59 years from Eswatini, Lesotho, Malawi, Zambia, and Zimbabwe. Blood samples from PLHIV were analyzed for HIV RNA and recent exposure to antiretroviral drugs (ARVs). Outcomes were NVL (viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL), and receiving second-line ART. We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second-line ART.ResultsThe prevalence of NVL was 11.2%: 8.2% experienced VF, and 3.0% interrupted ART. Younger age, male gender, less education, suboptimal adherence, receiving nevirapine, HIV non-disclosure, never having married, and residing in Zimbabwe, Lesotho, or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female gender, shorter ART duration, higher CD4 count, and alcohol use were associated with higher odds for interrupted ART and lower odds for VF. Many people with VF (44.8%) had CD4 counts ConclusionsCountries are approaching UNAIDS VLS targets for adults. Treatment support for people initiating ART with asymptomatic HIV infection, scale-up of viral load monitoring, and optimized ART regimens may further reduce NVL prevalence.

OBJECTIVE: The Lesotho Population-based HIV Impact Assessment survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic, and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or antiretroviral biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA below 1000 copies/ml. RESULTS: Overall, 25.6% of adults aged 15–59 years were HIV-positive. Among seropositive adults, 81.0% (male 76.6%, female 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male 91.6%, female 92.0%) who reported knowing their status reporting taking antiretrovirals, and 87.7% (male and female 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related interventions are critical to achieving epidemic control.

Systemic sclerosis (SSc) is an autoimmune disease characterised by excessive fibrosis of skin and internal organs, and vascular dysfunction. Association of T and B cell subsets have been reported in SSc, however there is lack of systematic studies of functional relations between immune cell subsets in this disease. This lack of mechanistic knowledge hampers targeted intervention. In the current study we sought to determine differential immune cell composition and their interactions in peripheral blood of SSc patients. Mononuclear cells from blood of SSc patients and healthy controls (HC) were analysed by mass cytometry using a 36 marker (cell-surface and intracellular) panel. Transcriptome analysis (m-RNA sequencing) was performed on sorted T and B cell subsets. Unsupervised clustering analysis revealed significant differences in the frequencies of T and B cell subsets in patients. Correlation network analysis highlighted an overall dysregulated immune architecture coupled with domination of inflammatory senescent T cell modules in SSc patients. Transcriptome analysis of sorted immune cells revealed an activated phenotype of CD4 and MAIT cells in patients, accompanied with increased expression of inhibitory molecules, reminiscent of phenotype exhibited by functionally adapted, exhausted T cells in response to chronic stimulation. Overall this study provides an in-depth analysis of the systemic immunome in SSc, highlighting the potential pathogenic role of inflammation and chronic stimulation mediated “premature senescence” of immune cells.ONE SENTENCE SUMMARYThe immune architecture in Systemic sclerosis is altered and reminiscent of chronic stimulatory environment led premature senescence of immune cells.