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IntroductionUnderstanding the impact of curable sexually transmitted infections (STIs) on HIV transmissibility is essential for effective HIV prevention programs. Investigating the impact of longitudinally measured recurrent STIs on HIV seroconversion is the interest of the current paper.MethodsIn this prospective study, data from a total of 1456 HIV‐negative women who enrolled in a HIV biomedical trial were used. It was hypothesized that women who had recurrent STI diagnoses during the study share a common biological heterogeneity which cannot be quantified. To incorporate this "unobserved" correlation in the analysis, times to HIV seroconversion were jointly modelled with repeated STI diagnoses using Cox regression with random effects.Results and discussionA total of 110 HIV seroconversions were observed (incidence rate of 6.00 per 100 person‐years). In a multivariable model, women who were diagnosed at least once were more likely to seroconvert compared to those who had no STI diagnosis [hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.04, 2.57]; women who had recurrent STI diagnoses during the study were 2.5 times more likely to be at increased risk of HIV infection (95% CI: 1.35, 4.01) with an estimated frailty variance of 1.52, with p<0.001, indicating strong evidence that there is a significant correlation (heterogeneity) among women who had recurrent STIs. In addition to this, factors associated with incidence of STIs, namely not being married and having a new sexual partner during the study follow‐up, were all significantly associated with increased risk for HIV seroconversion (HR: 2.92, 95% CI: 1.76, 5.01 and HR: 2.25, 95% CI: 1.63, 3.83 respectively).ConclusionsThe results indicated that women who were at risk for STIs were also at risk of HIV infection. In fact, they share the similar risk factors. In addition to this, repeated STI diagnoses also increased women's susceptibility for HIV infection significantly. Decreasing STIs by increasing uptake of testing and treatment and reducing partner change plays a significant role in the trajectory of the epidemic.

ObjectiveTo describe and quantify the differences in risk behaviours, HIV prevalence and incidence rates by birth cohorts among a group of women in Durban, South Africa.MethodsCross‐sectional and prospective cohort analyses were conducted for women who consented to be screened and enrolled in an HIV prevention trial. Demographic and sexual behaviours were described by five‐year birth cohorts. Semiparametric regression models were used to investigate the bivariate associations between these factors and the birth cohorts. HIV seroconversion rates were also estimated by birth cohorts.ResultsThe prevalence of HIV‐1 infection at the screening visit was lowest (20.0%) among the oldest (born before 1960) cohorts, while the highest prevalence was observed among those born between 1975 and 79. Level of education increased across the birth cohorts while the median age at first sexual experience declined among those born after 1975 compared to those born before 1975. Only 33.03% of the oldest group reported ever using a condom while engaging in vaginal sex compared to 73.68% in the youngest group; however, HIV and other sexually transmitted infection (STI) incidence rates were significantly higher among younger women compared to older women.ConclusionsThese findings clearly suggest that demographic and sexual risk behaviours are differentially related to the birth cohorts. Significantly high HIV and STI incidence rates were observed among the younger group. Although the level of education increased, early age at sexual debut was more common among the younger group. The continuing increase in HIV and STI incidence rates among the later cohorts suggests that the future trajectory of the epidemic will be dependent on the infection patterns in younger birth cohorts.

BackgroundIn South Africa, the severity of the HIV/AIDS epidemic varies according to geographical location; hence, localized monitoring of the epidemic would enable more effective prevention strategies. Our objectives were to assess the core areas of HIV infection in KwaZulu‐Natal, South Africa, using epidemiological data among sexually active women from localized communities.MethodsA total of 5753 women from urban, peri‐rural and rural communities in KwaZulu‐Natal were screened from 2002 to 2005. Each participant was geocoded using a global information system, based on residence at time of screening. The Spatial Scan Statistics programme was used to identify areas with disproportionate excesses in HIV prevalence and incidence.ResultsThis study identified three hotspots with excessively high HIV prevalence rates of 56%, 51% and 39%. A total of 458 sexually active women (19% of all cases) were included in these hotspots, and had been exclusively recruited by the Botha's Hill (west of Durban) and Umkomaas (south of Durban) clinic sites. Most of these women were Christian and Zulu‐speaking. They were also less likely to be married than women outside these areas (12% vs. 16%, p = 0.001) and more likely to have sex more than three times a week (27% vs. 20%, p < 0.001) and to have had more than three sexual partners (55% vs. 45%, p < 0.001). Diagnosis of genital herpes simplex virus type 2 was also more common in the hotspots. This study also identified areas of high HIV incidence, which were broadly consistent with those with high prevalence rates.ConclusionsGeographic excesses of HIV infections at rates among the highest in the world were detected in certain rural communities of Durban, South Africa. The results reinforce the inference that risk of HIV infection is associated with definable geographical areas. Localized monitoring of the epidemic is therefore essential for more effective prevention strategies ‐ and particularly urgent in a region such as KwaZulu‐Natal, where the epidemic is particularly rampant.

BackgroundWe set out to estimate historical trends in HIV incidence in Australian men who have sex with men with respect to age at infection and birth cohort.MethodsA modified back‐projection technique is applied to data from the HIV/AIDS Surveillance System in Australia, including "newly diagnosed HIV infections", "newly acquired HIV infections" and "AIDS diagnoses", to estimate trends in HIV incidence over both calendar time and age at infection.ResultsOur results demonstrate that since 2000, there has been an increase in new HIV infections in Australian men who have sex with men across all age groups. The estimated mean age at infection increased from ~35 years in 2000 to ~37 years in 2007. When the epidemic peaked in the mid 1980s, the majority of the infections (56%) occurred among men aged 30 years and younger; 30% occurred in ages 31 to 40 years; and only ~14% of them were attributed to the group who were older than 40 years of age. In 2007, the proportion of infections occurring in persons 40 years or older doubled to 31% compared to the mid 1980s, while the proportion of infections attributed to the group younger than 30 years of age decreased to 36%.ConclusionThe distribution of HIV incidence for birth cohorts by infection year suggests that the HIV epidemic continues to affect older homosexual men as much as, if not more than, younger men. The results are useful for evaluating the impact of the epidemic across successive birth cohorts and study trends among the age groups most at risk.

IntroductionAntiretroviral therapy (ART) substantially improves the health of people living with HIV and contributes to preventing new infections. While HIV incidence is decreasing in most regions, the epidemic in eastern Europe continues to rise, as new infections currently outnumber the rate of ART initiation. In this study, we assess ART use in Armenia and its impact on the number of AIDS diagnoses and mortality.MethodsNational surveillance data were obtained from the National Centre for AIDS Prevention, Armenia. Cox‐proportional hazard models were used to determine the effect of demographic and clinical risk factors, including access to ART, on AIDS and mortality.ResultsAmong people diagnosed with HIV since 2005, approximately 40% per year were diagnosed with CD4<200 cells per mL. Overall, 232 people (57.1%) with AIDS or a low CD4 count had not received ART by the end of 2010. Mortality was 34.1% among people living with HIV who did not initiate ART, and 0.3% among people who received ART. Among people diagnosed with HIV from 1996 to 2010, age at diagnosis, no use of ART, likely mode of transmission, likely place of transmission, low baseline CD4 count and no STI diagnosis at last contact are significantly associated with death.DiscussionIn Armenia, HIV is frequently diagnosed at a late stage of disease, indicating low testing rates. Of people diagnosed with HIV and in need of ART, a large proportion (approximately 60%) either do not provide consent for treatment, or are who migrants who cannot be located.ConclusionsGlobally, the scale‐up of ART has resulted in substantial reductions in mortality among individuals initiating therapy. However, in an era of momentum for treatment as prevention, treatment levels are not at adequate levels for preventing morbidities and mortality in some settings. Particular focus should be placed on key at‐risk subgroups.

Abstract Background In Australia, higher rates of chronic hepatitis B (HBsAg) have been reported among Aboriginal and Torres Strait Islander (Indigenous) compared with non-Indigenous people. In 2000, the Australian government implemented a universal infant/adolescent hepatitis B vaccination program. We undertook a systematic review and meta-analysis to assess the disparity of HBsAg prevalence between Indigenous and non-Indigenous people, particularly since 2000. Methods We searched Medline, Embase and public health bulletins up to March 2011. We used meta-analysis methods to estimate HBsAg prevalence by Indigenous status and time period (before and since 2000). Results There were 15 HBsAg prevalence estimates (from 12 studies) among Indigenous and non-Indigenous people; adults and pregnant women (n = 9), adolescents (n = 3), prisoners (n = 2), and infants (n = 1). Of these, only one subgroup (adults/pregnant women) involved studies before and since 2000 and formed the basis of the meta-analysis. Before 2000, the pooled HBsAg prevalence estimate was 6.47% (95% CI: 4.56-8.39); 16.72% (95%CI: 7.38-26.06) among Indigenous and 0.36% (95%CI:-0.14-0.86) in non-Indigenous adults/pregnant women. Since 2000, the pooled HBsAg prevalence was 2.25% (95% CI: 1.26-3.23); 3.96% (95%CI: 3.15-4.77) among Indigenous and 0.90% (95% CI: 0.53-1.28) in non-Indigenous adults/pregnant women. Conclusions The disparity of HBsAg prevalence between Indigenous and non-Indigenous people has decreased over time; particularly since the HBV vaccination program in 2000. However HBsAg prevalence remains four times higher among Indigenous compared with non-Indigenous people. The findings highlight the need for opportunistic HBV screening of Indigenous people to identify people who would benefit from vaccination or treatment.

There is currently no information about the prevalence of, and factors contributing to psychological distress experienced by re-education through labour camp detainees in China. [Methods:] A cross-sectional face-to-face survey was conducted in three labour camps in Guangxi, China. The questionnaire covered socio-demographic characteristics; sexually transmissible infections (STIs); drug use; psychological distress (K-10); and health service usage and access inside the labour camps. K-10 scores were categorised as ≤30 (low to moderate distress) and  >30 or more (highly distressed). Univariate and multivariate logistic regression models identified factors independently associated with high K-10 scores for men and women separately. [Results:] In total, 755 detainees, 576 (76%) men and 179 (24%) women, participated in the health survey. The study found 11.6% men versus 11.2% women detainees experienced high psychological distress, but no significant gender differences were observed (p> 0.05). Multivariate logistic regression showed that multiple physical health problems were significantly associated with high psychological distress among men. [Conclusion:] Drug treatment and forensic mental health services need to be established in detention centres in China to treat more than 10% of detainees with drug use and mental health disorders.

BACKGROUND: In small community-based trials, mass drug administration of ivermectin has been shown to substantially decrease the prevalence of both scabies and secondary impetigo; however, their effect at large scale is untested. Additionally, combined mass administration of drugs for two or more neglected diseases has potential practical advantages, but efficacy of potential combinations should be confirmed. METHODS: The azithromycin ivermectin mass drug administration (AIM) trial was a prospective, single-arm, before-and-after, community intervention study to assess the efficacy of mass drug administration of ivermectin for scabies and impetigo, with coadministration of azithromycin for trachoma. Mass drug administration was offered to the entire population of Choiseul Province, Solomon Islands, and of this population we randomly selected two sets of ten sentinel villages for monitoring, one at baseline and the other at 12 months. Participants were offered a single dose of 20 mg/kg azithromycin, using weight-based bands. Children weighing less than 12·5 kg received azithromycin oral suspension (20 mg/kg), and infants younger than 6 months received topical 1% tetracycline ointment. For ivermectin, participants were offered two doses of oral ivermectin 200 μg/kg 7–14 days apart using weight-based bands, or 5% permethrin cream 7–14 days apart if ivermectin was contraindicated. Our study had the primary outcomes of safety and feasibility of large-scale mass coadministration of oral ivermectin and azithromycin, which have been previously reported. We report here the prevalence of scabies and impetigo in residents of the ten baseline villages compared with those in the ten 12-month villages, as measured by examination of the skin, which was a secondary outcome of the trial. Further outcomes were comparison of the number of all-cause outpatient attendances at government clinics in Choiseul Province at various timepoints before and after mass drug administration. The trial was registered with the Australian and New ...

BACKGROUND: In small community-based trials, mass drug administration of ivermectin has been shown to substantially decrease the prevalence of both scabies and secondary impetigo; however, their effect at large scale is untested. Additionally, combined mass administration of drugs for two or more neglected diseases has potential practical advantages, but efficacy of potential combinations should be confirmed. METHODS: The azithromycin ivermectin mass drug administration (AIM) trial was a prospective, single-arm, before-and-after, community intervention study to assess the efficacy of mass drug administration of ivermectin for scabies and impetigo, with coadministration of azithromycin for trachoma. Mass drug administration was offered to the entire population of Choiseul Province, Solomon Islands, and of this population we randomly selected two sets of ten sentinel villages for monitoring, one at baseline and the other at 12 months. Participants were offered a single dose of 20 mg/kg azithromycin, using weight-based bands. Children weighing less than 12·5 kg received azithromycin oral suspension (20 mg/kg), and infants younger than 6 months received topical 1% tetracycline ointment. For ivermectin, participants were offered two doses of oral ivermectin 200 μg/kg 7-14 days apart using weight-based bands, or 5% permethrin cream 7-14 days apart if ivermectin was contraindicated. Our study had the primary outcomes of safety and feasibility of large-scale mass coadministration of oral ivermectin and azithromycin, which have been previously reported. We report here the prevalence of scabies and impetigo in residents of the ten baseline villages compared with those in the ten 12-month villages, as measured by examination of the skin, which was a secondary outcome of the trial. Further outcomes were comparison of the number of all-cause outpatient attendances at government clinics in Choiseul Province at various timepoints before and after mass drug administration. The trial was registered with the Australian and New Zealand Trials Registry (ACTRN12615001199505). FINDINGS: During September, 2015, over 4 weeks, 26 188 people (99·3% of the estimated population of Choiseul [n=26 372] as determined at the 2009 census) were treated. At baseline, 1399 (84·2%) of 1662 people living in the first ten villages had their skin examined, of whom 261 (18·7%) had scabies and 347 (24·8%) had impetigo. At 12 months after mass drug administration, 1261 (77·6%) of 1625 people in the second set of ten villages had their skin examined, of whom 29 (2·3%) had scabies (relative reduction 88%, 95% CI 76·5-99·3) and 81 (6·4%) had impetigo (relative reduction 74%, 63·4-84·7). In the 3 months after mass drug administration, 10 614 attended outpatient clinics for any reason compared with 16 602 in the 3 months before administration (decrease of 36·1%, 95% CI 34·7-37·6), and during this period attendance for skin sores, boils, and abscesses decreased by 50·9% (95% CI 48·6-53·1). INTERPRETATION: Ivermectin-based mass drug administration can be scaled to a population of over 25 000 with high efficacy and this level of efficacy can be achieved when mass drug administration for scabies is integrated with mass drug administration of azithromycin for trachoma. These findings will contribute to development of population-level control strategies. Further research is needed to assess durability and scalability of mass drug administration in larger, non-island populations, and to assess its effect on the severe bacterial complications of scabies. FUNDING: International Trachoma Initiative, Murdoch Children's Research Institute, Scobie and Claire Mackinnon Trust, and the Wellcome Trust.

AbstractIntroduction: Various forms of penile foreskin cutting are practised in Papua New Guinea. In the context of an ecological association observed between HIV infection and the dorsal longitudinal foreskin cut, we undertook an investigation of this relationship at the individual level.Methods: We conducted a cross‐sectional study among men attending voluntary confidential HIV counselling and testing clinics. Following informed consent, participants had a face‐to‐face interview and an examination to categorize foreskin status. HIV testing was conducted on site and relevant specimens collected for laboratory‐based Herpes simplex type‐2 (HSV‐2), syphilis, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), and Trichomonas vaginalis (TV) testing.Results: Overall, 1073 men were enrolled: 646 (60.2%) were uncut; 339 (31.6%) had a full dorsal longitudinal cut; 72 (6.7%) a partial dorsal longitudinal cut; and 14 (1.3%) were circumcised. Overall, the prevalence of HIV was 12.3%; HSV‐2, 33.6%; active syphilis, 12.1%; CT, 13.4%; NG, 14.1%; and TV 7.6%. Compared with uncut men, men with a full dorsal longitudinal cut were significantly less likely to have HIV (adjusted odds ratio [adjOR] 0.25, 95%CI: 0.12, 0.51); HSV‐2 (adjOR 0.60, 95%CI: 0.41, 0.87); or active syphilis (adjOR 0.55, 95%CI: 0.31, 0.96). This apparent protective effect was restricted to men cut prior to sexual debut. There was no difference between cut and uncut men for CT, NG or TV.Conclusions: In this large cross‐sectional study, men with a dorsal longitudinal foreskin cut were significantly less likely to have HIV, HSV‐2 and syphilis compared with uncut men, despite still having a complete (albeit morphologically altered) foreskin. The protective effect of the dorsal cut suggests that the mechanism by which male circumcision works is not simply due to the removal of the inner foreskin and its more easily accessible HIV target cells. Exposure of the penile glans and inner foreskin appear to be key mechanisms by which male circumcision confers protection.Further research in this unique setting will help improve our understanding of the fundamental immunohistologic mechanisms by which male circumcision provides protection, and may lead to new biomedical prevention strategies at the mucosal level.