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Sub-Saharan Africa (SSA) has the highest cervical cancer (CC) burden globally-worsened by its HIV epidemics. In 2020, the World Health Organization (WHO) introduced a CC elimination strategy with goals for vaccination, screening, and treatment. To benchmark progress, we examined temporal trends in screening coverage, percent screened at least twice by the age of 45, screening coverage among women living with HIV (WLHIV), and pre-cancer treatment coverage in SSA. We conducted a systematic analysis of cross-sectional population-based surveys. It included 52 surveys from 28 countries (2000 to 2020) with information on CC screening among women aged 25 to 49 years (N = 151,338 women). We estimated lifetime and past 3-year screening coverage by age, year, country, and HIV serostatus using a Bayesian multilevel model. Post-stratification and imputations were done to obtain aggregate national, regional, and SSA-level estimates. To measure re-screening by age 45, a life table model was developed. Finally, self-reported pre-cancer treatment coverage was pooled across surveys using a Bayesian meta-analysis. Overall, an estimated 14% (95% credible intervals [95% CrI]: 11% to 21%) of women aged 30 to 49 years had ever been screened for CC in 2020, with important regional and country-level differences. In Eastern and Western/Central Africa, regional screening coverages remained constant from 2000 to 2020 and WLHIV had greater odds of being screened compared to women without HIV. In Southern Africa, however, screening coverages increased and WLHIV had equal odds of screening. Notably this region was found to have higher screening coverage in comparison to other African regions. Rescreening rates were high among women who have already been screened; however, it was estimated that only 12% (95% CrI: 10% to 18%) of women had been screened twice or more by age 45 in 2020. Finally, treatment coverage among 4 countries with data was 84% (95% CrI: 70% to 95%). Limitations of our analyses include the paucity of data on screening modality and the few countries that had multiple surveys. Overall, CC screening coverage remains sub-optimal and did not improve much over the last 2 decades, outside of Southern Africa. Action is needed to increase screening coverage if CC elimination is to be achieved.

Introduction Men who have sex with men (MSM) and people who inject drugs (PWID) are disproportionately impacted by the HIV epidemic in Canada. Having the second‐highest provincial diagnosis rate, an improved understanding of the epidemic among these populations in Québec could aid ongoing elimination efforts. We estimated HIV incidence and other epidemic indicators among MSM and PWID in Montréal and across Québec using a back‐calculation model synthesizing surveillance data. Methods We developed a deterministic, compartmental mathematical model stratified by age, HIV status and disease progression, and clinical care stages. Using AIDS and HIV diagnoses data, including self‐reported time since the last negative test and laboratory results of CD4 cell count at diagnosis, we estimated HIV incidence in each population over 1975–2020 by modelling a cubic M‐spline. The prevalence, undiagnosed fraction, fraction diagnosed that started antiretroviral treatment (ART) and median time to diagnosis were also estimated. Since the COVID‐19 pandemic disrupted testing, we excluded 2020 data and explored this in sensitivity analyses. Results HIV incidence in all populations peaked early in the epidemic. In 2020, an estimated 97 (95% CrI: 33–227) and 266 (95% CrI: 103–508) HIV acquisitions occurred among MSM in Montréal and Québec, respectively. Among PWID, we estimated 2 (95% CrI: 0–14) and 6 (95% CrI: 1–26) HIV acquisitions in those same regions. With 2020 data, unless testing rates were reduced by 50%, these estimates decreased, except among Québec PWID, whose increased. Among all, the median time to diagnosis shortened to <2 years before 2020 and the undiagnosed fraction decreased to <10%. This fraction was higher in younger MSM, with 22% of 15–24 year‐olds living with HIV in Montréal (95% CrI: 9–39%) and 31% in Québec (95% CrI: 17–48%) undiagnosed by 2020 year‐end. Finally, ART access neared 100% in all diagnosed populations. Conclusions HIV incidence has drastically decreased in MSM and PWID across Québec, alongside significant improvements in diagnosis and treatment coverage—and the 2013 introduction of pre‐exposure prophylaxis. Despite this, HIV transmission continued. Effective efforts to halt this transmission and rapidly diagnose people who acquired HIV, especially among younger MSM, are needed to achieve elimination. Further, as the impacts of the COVID‐19 pandemic on HIV transmission are understood, increased efforts may be needed to overcome these.

Key populations, including sex workers, are at high risk of HIV acquisition and transmission. Men who pay for sex can contribute to HIV transmission through sexual relationships with both sex workers and their other partners. To characterize the population of men who pay for sex in sub-Saharan Africa (SSA), we analyzed population size, HIV prevalence, and use of HIV prevention and treatment. We performed random-effects meta-analyses of population-based surveys conducted in SSA from 2000 to 2020 with information on paid sex by men. We extracted population size, lifetime number of sexual partners, condom use, HIV prevalence, HIV testing, antiretroviral (ARV) use, and viral load suppression (VLS) among sexually active men. We pooled by regions and time periods, and assessed time trends using meta-regressions. We included 87 surveys, totaling over 368,000 male respondents (15-54 years old), from 35 countries representing 95% of men in SSA. Eight percent (95% CI 6%-10%; number of surveys [Ns] = 87) of sexually active men reported ever paying for sex. Condom use at last paid sex increased over time and was 68% (95% CI 64%-71%; Ns = 61) in surveys conducted from 2010 onwards. Men who paid for sex had higher HIV prevalence (prevalence ratio [PR] = 1.50; 95% CI 1.31-1.72; Ns = 52) and were more likely to have ever tested for HIV (PR = 1.14; 95% CI 1.06-1.24; Ns = 81) than men who had not paid for sex. Men living with HIV who paid for sex had similar levels of lifetime HIV testing (PR = 0.96; 95% CI 0.88-1.05; Ns = 18), ARV use (PR = 1.01; 95% CI 0.86-1.18; Ns = 8), and VLS (PR = 1.00; 95% CI 0.86-1.17; Ns = 9) as those living with HIV who did not pay for sex. Study limitations include a reliance on self-report of sensitive behaviors and the small number of surveys with information on ARV use and VLS. Paying for sex is prevalent, and men who ever paid for sex were 50% more likely to be living with HIV compared to other men in these 35 countries. Further prevention efforts are needed for this vulnerable population, including improved access to HIV testing and condom use initiatives. Men who pay for sex should be recognized as a priority population for HIV prevention.

Introduction Women living with HIV (WLHIV) face an increased risk of cervical cancer (CC). With inequitable human papillomavirus (HPV) vaccine access globally and a programmatic focus on girls‐only school‐based delivery, many WLHIV in high HIV prevalence countries remain vulnerable to HPV and CC. We assessed the incremental impact of adding catch‐up vaccination for WLHIV in South Africa. Methods We used two independently developed HPV/CC and HIV transmission models to predict the incremental impact of catch‐up HPV vaccination for WLHIV compared to routine‐only vaccination of girls aged 9−14 (90% cohort coverage) from 2020 onwards using a nonavalent vaccine (lifelong 100% protection). We assessed catch‐up scenarios vaccinating WLHIV aged 15−24 or ≥15 (attaining 90% cohort coverage), maintaining baseline CC screening. We report the predicted median annual prevalence of vaccine‐type high‐risk HPV (VT HR‐HPV), CC incidence and cumulative fraction of CC cases averted compared to routine‐only vaccination among WLHIV overall (age‐standardized) and by age. Results With routine‐only vaccination, overall coverage among all WLHIV remained substantially (>50%) lower than in all women for 35−40 years, with gaps persisting even after 80 years. Adding catch‐up vaccination for WLHIV aged 15−24 increased coverage and benefits mainly among young WLHIV, with the largest annual reductions (relative to routine‐only vaccination) in VT HR‐HPV prevalence and CC incidence for WLHIV <30 years, reaching up to 36%–52% across models within 15 years and 38%–100% after 15−25 years, respectively. If catch‐up included WLHIV aged ≥15, overall vaccination coverage among WLHIV would immediately increase to 90%, extending benefits to older WLHIV—reducing peak annual relative reductions in CC incidence among WLHIV ≥50 by an extra 19% points compared to catch‐up vaccination of WLHIV aged 15−24, and shifting the peak 25 years earlier. Over 55−60 years, catch‐up vaccination of WLHIV aged 15−24 and ≥15 could avert up to 3%–8% and 14% of CC cases among WLHIV, respectively. Conclusions Catch‐up vaccination of WLHIV can reduce their CC burden in the short to medium term, even in the presence of girls‐only routine vaccination programmes with high cohort coverage. To maximize impact, vaccines should be offered to WLHIV of all ages, not only younger women.

Introduction Socio‐demographic and geographic disparities in HIV prevalence, uptake of HIV testing and access to antiretroviral therapy (ART) persist in high HIV burden countries. Understanding demographic, spatial and temporal factors can guide interventions. Methods We analysed 108 geo‐referenced population‐based surveys conducted over 2000–2023 across 33 African countries, involving 2.3 million respondents. Multilevel Bayesian logistic regression models assessed associations between HIV outcomes (HIV prevalence, recent HIV testing and ART coverage) and socio‐demographic characteristics (age, education, place of residence, relative wealth), geographic location (country, district) and time trends. Separate models were estimated for men and women in central, eastern, southern and western Africa. Results Inequalities in HIV risk and access to testing and treatment services were driven by differences in educational attainment and within‐country variations. In southern Africa, women with tertiary education had a 12%‐point lower HIV prevalence (95% Credible Interval [CrI]: −27% to −2%) than those with less than primary education. In eastern Africa, they had a 13%‐points (95% CrI: 2−22%) higher probability of recent HIV testing. Associations with relative wealth were weaker and more heterogeneous: in southern Africa, HIV prevalence shifted over time from higher to lower wealth quintiles, and adolescent girls and young women became the most frequently tested age group. In central Africa, wealthier men maintained higher recent testing and ART coverage levels. District‐level variations accounted for disparities in HIV outcomes. In western Africa, the expected difference in ART coverage between individuals with similar socio‐demographic characteristics living in different districts was 14%‐points (95% CrI: 3−32%) for men and 10%‐points (95% CrI: 3−27%) for women. Conclusions Disparities in HIV outcomes are strongly associated with differences in education, and across districts of the same country. Higher education levels are associated with lower HIV prevalence, greater testing and higher ART coverage, while districts with limited services sustain higher population viraemia. Despite the scale‐up of HIV prevention and treatment programmes, important disparities remain, and renewed education‐centred and geographically targeted efforts are needed to close gaps.

Introduction Long‐acting injectable cabotegravir (CAB‐LA) demonstrated superiority to daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV pre‐exposure prophylaxis (PrEP) in the HPTN 083/084 trials. We compared the potential impact of expanding PrEP coverage by offering CAB‐LA to men who have sex with men (MSM) in Atlanta (US), Montreal (Canada) and the Netherlands, settings with different HIV epidemics. Methods Three risk‐stratified HIV transmission models were independently parameterized and calibrated to local data. In Atlanta, Montreal and the Netherlands, the models, respectively, estimated mean TDF/FTC coverage starting at 29%, 7% and 4% in 2022, and projected HIV incidence per 100 person‐years (PY), respectively, decreasing from 2.06 to 1.62, 0.08 to 0.03 and 0.07 to 0.001 by 2042. Expansion of PrEP coverage was simulated by recruiting new CAB‐LA users and by switching different proportions of TDF/FTC users to CAB‐LA. Population effectiveness and efficiency of PrEP expansions were evaluated over 20 years in comparison to baseline scenarios with TDF/FTC only. Results Increasing PrEP coverage by 11 percentage points (pp) from 29% to 40% by 2032 was expected to avert a median 36% of new HIV acquisitions in Atlanta. Substantially larger increases (by 33 or 26 pp) in PrEP coverage (to 40% or 30%) were needed to achieve comparable reductions in Montreal and the Netherlands, respectively. A median 17 additional PYs on PrEP were needed to prevent one acquisition in Atlanta with 40% PrEP coverage, compared to 1000+ in Montreal and 4000+ in the Netherlands. Reaching 50% PrEP coverage by 2032 by recruiting CAB‐LA users among PrEP‐eligible MSM could avert >45% of new HIV acquisitions in all settings. Achieving targeted coverage 5 years earlier increased the impact by 5–10 pp. In the Atlanta model, PrEP expansions achieving 40% and 50% coverage reduced differences in PrEP access between PrEP‐indicated White and Black MSM from 23 to 9 pp and 4 pp, respectively. Conclusions Achieving high PrEP coverage by offering CAB‐LA can impact the HIV epidemic substantially if rolled out without delays. These PrEP expansions may be efficient in settings with high HIV incidence (like Atlanta) but not in settings with low HIV incidence (like Montreal and the Netherlands).

Keywords: AIDS; epidemiology; estimates; global; HIV; indicators; modelling; projections; surveillance; UNAIDS

ObjectivesDoxycycline as post-exposure prophylaxis (doxy-PEP) has emerged as an efficacious strategy to reduce Chlamydia trachomatis (C. trachomatis), Neisseria gonorrhoeae (N. gonorrhoeae) and syphilis (sexually transmitted infections (STIs)) among gay, bisexual and other men who have sex with men (GBM). There is a need to identify prescribing criteria that maximise the number of STIs averted while minimising excessive use.DesignIn this prospective longitudinal cohort study with repeated measures and biobehavioural data collection, participants completed a questionnaire and tested for STIs at each visit.SettingCommunity-based, population-level study conducted in three large Canadian cities between February 2017 and July 2023.Participants2449 GBM were recruited through respondent-driven sampling (RDS); 1998 had ≥1 follow-up visit, contributing 7551 person-years of observation. Eligible participants were aged ≥16 years, cis- or transgender men, reported sex with another man in the past 6 months and resided in Montreal, Toronto or Vancouver.Primary and secondary outcome measuresAdjusted rate ratios (aRR) of STIs, accounting for RDS recruitment, loss to follow-up and confounding were estimated using generalised estimating equations (GEE) Poisson regression. For identified STI risk factors, the proportions of STIs averted through doxy-PEP prescription (based on the efficacy of doxy-PEP for each bacterial STI) and the number needed to treat (NNT) for 1 year to avert one STI, assuming 100% adherence, were calculated.ResultsAmong 1998 participants, the combined incidence rate of any C. trachomatis, N. gonorrhoeae and syphilis infection was 29.5 (95%CI 27.3 to 31.9) per 100 person-years. STI risk factors that had the most impact as doxy-PEP criteria were history of any of the three STIs in the past 12 months (P12M) (aRR=2.0, 95% CI 1.8 to 2.2, 36% STI averted, NNT=2.1); ≥10 male sexual partners in the past 6 months (P6M) (aRR=3.8, 95% CI 3.0 to 4.9, 41% STI averted, NNT=2.4); HIV-pre-exposure prophylaxis (PrEP) use P6M (aRR=1.7, 95% CI 1.5 to 2.0, 29% STI averted, NNT=2.5); use of any chemsex-related substance P6M (aRR=1.2, 95% CI 1.1 to 1.4, 28% STI averted, NNT=2.6); and group sex event attendance P6M (aRR=1.2, 95% CI 1.1 to 1.3, 27% STI averted, NNT=2.3). Reporting≥10 male sex partners P6M represented the most useful criterion for syphilis prevention (52% syphilis infections averted, NNT=20). Prescribing doxy-PEP to GBM having any of the following STI risk factors, namely, ≥1 bacterial STI P12M, ≥10 male sex partners P6M, or HIV-PrEP use P6M, would substantially increase the proportion of all STI diagnoses potentially averted (60%) with minimal increase of the NNT (2.7).ConclusionThis work informs on the impact of various doxy-PEP clinical prescribing criteria and demonstrates the benefit of focusing on any of the following three criteria: ≥1 bacterial STI P12M, ≥10 male sex partners P6M or HIV-PrEP use P6M.

Introduction Long‐acting injectable cabotegravir (CAB‐LA) is superior to daily oral tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) for HIV pre‐exposure prophylaxis (PrEP) and could expand PrEP usage. Given price differentials between CAB‐LA and TDF/FTC, evaluating the cost‐effectiveness of potential PrEP coverage scenarios is warranted. Methods We simulated PrEP coverage expansion among men who have sex with men (MSM) via introducing CAB‐LA using two age‐ and risk‐stratified HIV transmission models separately calibrated to local data from a high‐incidence (Atlanta, USA) and a low‐incidence (Montréal, Canada) North American setting. PrEP coverage of HIV‐negative MSM was simulated to increase from 6% to 15%, 30%, 40% or 50% (Montréal) or from 29% to 40% or 50% (Atlanta), within 5 or 10 years, with 0%, 15%, 30%, 50% or 100% of current TDF/FTC users switching to CAB‐LA. Costing took a healthcare payer perspective and included PrEP pharmaceuticals, PrEP programmatic costs and HIV‐related care. Atlanta scenarios considered oral PrEP acquired at average recent market prices (primary analysis), and both settings modelled universal acquisition at the lowest available generic price (LAGP). Simulations were compared to baseline projections without CAB‐LA‐based expansions over 20 years, with costs and disability‐adjusted life years (DALYs) discounted 3% annually. Incremental cost‐effectiveness ratios (ICERs) of expansions were assessed against a$100,000 per DALY averted threshold. Results In Atlanta, scenario median ICERs at recent prices ranged from $ 141,600 (90% CI$60,100−$ 256,000) to$203,800 ($ 99,300− $359,200) per DALY averted. All uncertainty intervals covered $ 100,000. Under universal LAGP TDF‐FTC, median ICERs ranged from$255,800 ($ 112,900− $452,30) to $ 370,700 ( $172,200−$ 669,100). The strongest expansion scenarios were expected to remain cost‐effective until approximately$2800/dose, or approximately $ 1350 with universal LAGP TDF/FTC. In Montréal, scenarios had median ICERs from$920,000 to $ 2,540,000, excluding dominated runs. Conclusions In a high‐incidence Atlanta MSM population, CAB‐LA‐based PrEP expansions are not projected to be cost‐effective, though a minority of simulations achieved cost‐effectiveness. However, lower prices could achieve cost‐effectiveness. In a low‐incidence Montréal MSM population, broad expansions are not expected to be cost‐effective at modelled prices. Prioritizing CAB‐LA to Montréal MSM facing access, adherence or persistence barriers to oral PrEP warrants a cost‐effectiveness assessment.

Introduction HIV self‐testing (HIVST) is a promising strategy to improve diagnosis coverage among key populations (KP). The ATLAS (Auto Test VIH, Libre d'Accéder à la connaissance de son Statut) programme implemented HIVST in three West African countries, distributing over 380,000 kits up between 2019 and 2021, focussing on community‐led distribution by KP to their peers and subsequent secondary distribution to their partners and clients. We aim to evaluate the cost‐effectiveness of community‐led HIVST in Côte d'Ivoire, Mali and Senegal. Methods An HIV transmission dynamics model was adapted and calibrated to country‐specific epidemiological data and used to predict the impact of HIVST. We considered the distribution of HIVST among two KP—female sex workers (FSW), and men who have sex with men (MSM)—and their sexual partners and clients. We compared the cost‐effectiveness of two scenarios against a counterfactual without HIVST over a 20‐year horizon (2019–2039). The ATLAS‐only scenario mimicked the 2‐year implemented ATLAS programme, whereas the ATLAS‐scale‐up scenario achieved 95% coverage of HIVST distribution among FSW and MSM by 2025 onwards. The primary outcome is the number of disability‐adjusted life‐years (DALY) averted. Scenarios were compared using incremental cost‐effectiveness ratios (ICERs). Costing was performed using a healthcare provider's perspective. Costs were discounted at 4%, converted to$USD 2022 and estimated using a cost‐function to accommodate economies of scale. Results The ATLAS‐only scenario was highly cost‐effective over 20 years, even at low willingness‐to‐pay thresholds. The median ICERs were $ 126 ( $88–$ 210) per DALY averted in Côte d'Ivoire,$92 ($ 88– $210) in Mali and 27$( $88–$ 210) in Senegal. Scaling‐up the ATLAS programme would also be cost‐effective, and substantial epidemiological impacts would be achieved. The ICERs for the scale‐up scenario were$199 ($ 122– $338) per DALY averted in Côte d'Ivoire, $ 224 ( $118–$ 415) in Mali and$61 ($ 18–$128) in Senegal. Conclusions Both the implemented and the potential scale‐up of community‐led HIVST programmes in West Africa, where KP are important to overall transmission dynamics, have the potential to be highly cost‐effective, as compared to a scenario without HIVST. These findings support the scale‐up of community‐led HIVST to reach populations that otherwise may not access conventional testing services.