INTRODUCTION:Since 2013, global HIV treatment guidelines have included recommendations for medication adherence support and monitoring for people on antiretroviral therapy (ART). We examined the implementation of recommended strategies for adherence support and monitoring for adults with HIV through serial cross-sectional structured surveys conducted by the International epidemiology Databases to Evaluate AIDS (IeDEA). METHODS:We used data from surveys completed by HIV clinics across 43 countries in 2017 (n = 206), 2020 (n = 200) and 2023 (n = 214); 131 clinics completed all three surveys. We used descriptive statistics to examine clinic resources and routine adherence support and monitoring at each time point, stratified by country income level (i.e. low/middle-income vs. high-income countries [LMICs/HICs]), and trends among clinics completing all three surveys. We created composite measures of the level or intensity of routine provision of adherence aids/reminders, adherence support and adherence monitoring, ranging from "none" to "enhanced" levels. Among clinics participating in the 2023 survey, we also examined adherence aids and support routinely provided to clients eligible for intensified support versus all clients. RESULTS:At each time point, surveyed clinics were predominantly in LMICs (68.4%-74.3%) and urban settings (65.0%-65.5%), situated within health centres (60.2%-64.0%) or regional/provincial or university hospitals (28.0%-33.5%). Among 131 clinics participating in all surveys, there was a decrease in the provision of multiple adherence readiness counselling sessions from 52.2% of clinics reporting ≥2 sessions before treatment initiation in 2017 to 26.0% in 2023, along with increased provision of 6-month ART refills (from 11.5% to 40.5%). The provision of "enhanced" levels of adherence support to all clients decreased from 2017 to 2023 in both LMICs (64.6% to 28.1%) and HICs (34.3% to 8.6%); in 2023, substantial proportions of clinics reported that such support was routinely provided only to clients eligible for intensive adherence support. At each time point, higher proportions of clinics in LMICs reported "enhanced" adherence monitoring than in HICs (63.5%-70.8% vs. 31.4%-54.3%). CONCLUSIONS:While streamlined provision of ART adherence support may reflect the implementation of guidelines recommending the targeting of support towards clients with known or suspected adherence challenges, further research should examine how evolving clinic adherence support practices are associated with care retention and virologic suppression outcomes.
INTRODUCTION:In eastern, central and southern Africa, HIV is a leading cause of mortality, and both HIV and depression contribute substantially to morbidity. Depression can impede effective HIV treatment and prevention, yet access to depression treatment remains limited. We estimated the impact and cost-effectiveness of scaling up depression screening and treatment to different population segments in western Kenya . METHODS:We adapted a previously validated HIV transmission model for western Kenya (EMOD-HIV) to include age- and sex-specific depression incidence, remission and recurrence. The model incorporated depression's effects on HIV risk; HIV testing and linkage to care; antiretroviral therapy (ART) adherence; and ART retention. We evaluated four depression screening and treatment scale-up strategies for adults aged 15+ years: (1) universal screening/treatment for all adults; (2) co-administering depression and HIV screening; (3) screening ART recipients; and (4) screening ART recipients with unsuppressed viral load. We assumed 62% depression treatment efficacy and calculated costs from the provider perspective, including US$3.35 for depression screening and US$20.32 per person for psychotherapy; future costs were discounted at 3%, and costs were varied in sensitivity analyses. We calculated incremental cost-effectiveness ratios as the cost (2024 USD) of depression screening and treatment per overall and HIV-related disability-adjusted life-year (DALY) averted. RESULTS:Without depression treatment, we projected 129,000 new HIV infections, 95,900 HIV-related deaths and 1.83 M depression episodes between 2025 and 2035. Universal screening had the highest impact, averting 29.3% (95% CI 29.2%-29.3%) of person-years lived with depression, 2.8% (95% CI 2.6%-3.1%) of HIV acquisitions and 1.4% (95% CI 1.3%-1.6%) of HIV deaths. The cost-effectiveness of universal screening and treatment was US$1291 per DALY averted (95% CI: $1288-1296). Screening ART clients was most cost-effective at $744 per DALY averted (95% CI: $730-760), followed by screening ART clients with unsuppressed viral load at $752 per DALY averted (95% CI: $710-799). Co-administering HIV and depression was dominated by other strategies. CONCLUSIONS:Integrating depression interventions into HIV care could substantially reduce both depression and HIV burden. Cost-effective scale-up could initially focus on individuals with unsuppressed viral load, then to all ART recipients, and finally expand to communities.
ABSTRACT Introduction While behavioural economics principles are widely used for public health interventions, a comprehensive understanding of their impact across the sexually transmitted and blood‐borne infections (STBBIs) care cascade remains limited. We systematically evaluated the effectiveness of behavioural economics‐informed interventions for an STBBI care cascade. Methods We systematically searched five major literature databases from their inception to 25 April 2024, with the search updated on 22 March 2025. We included randomized controlled trials (RCTs) evaluating behavioural economics‐informed interventions, that is strategies such as incentives, defaults, framing and reminders designed to influence health‐related decision‐making, at any stage of the care cascade for STBBIs. The cascade included three domains: prevention, care engagement and treatment adherence. Two reviewers independently extracted data and assessed the risk of bias using the Cochrane RoB‐2 tool. Due to significant heterogeneity, findings were synthesized narratively using a three‐stage care cascade framework. Results Our search identified 2546 records, of which 40 RCTs met the inclusion criteria and evaluated 12 distinct behavioural economics‐informed intervention types. Incentives were the most common intervention, including monetary, lottery and voucher‐based incentives (25/40; 63%). Monetary and voucher incentives effectively improved outcomes across multiple cascade stages, including prevention (such as safer sex, male medical circumcision), care engagement (testing for HIV, HBV and HCV) and treatment adherence (such as retention in care, viral suppression). Opt‐out defaults showed strong, sustained effects on HIV/HCV screening. Pay‐it‐forward strategies significantly increased dual STBBI testing and often demonstrated cost‐effectiveness. A substantial proportion of studies (27/40; 67.5%) reported a high risk of bias. Discussion Behavioural economics‐informed interventions showed stage‐specific effects across the STBBI care cascade. Monetary incentives were the most consistently effective, especially for prevention, testing and some adherence outcomes. Defaults and pay‐it‐forward were promising for screening uptake, whereas crowdsourcing appeared more useful for intervention design. Overall, effectiveness depended on intervention design and context. Conclusions Behavioural economics‐informed interventions hold substantial promise for optimizing the STBBI care cascade, but no single strategy was universally optimal. Future research should strengthen the evidence base and assess the transferability of these interventions across diseases and context‐specific settings to inform wider implementation and maximize global public health impact.
Abstract Introduction Despite an overall recent decline of 28% in the region, AIDS‐related deaths have increased among women in some Latin American countries. Low HIV risk perception among women may contribute to late diagnosis. We compared advanced HIV disease (AHD) at care enrolment between males and females in Latin America and the Caribbean. Methods Adults (≥18 years old) from clinical sites in the Central and South America network for HIV epidemiology who enrolled between 2003 and 2022 were stratified by sex‐at‐birth/HIV acquisition group as females, males with male‐to‐male sexual contact and heterosexual males (HMs). We classified location as within a generalized epidemic (GE: Haiti) or a concentrated epidemic (CE: Argentina, Brazil, Chile, Honduras and Mexico). We estimated the probability of AHD (AIDS diagnosis or CD4<200 cells/µL) at enrolment in care using logistic regression models, stratifying by sex‐at‐birth/acquisition group and CE/GE setting, adjusting for age, education level and calendar year of enrolment. Results Of 47,548 people living with HIV, 51% were from GE sites (58% females), and 49% were from CE sites (20% females, 22% HMs and 58% males with male‐to‐male sexual contact). In GE, 27.7% of persons presented with AHD (23.5% of females; 33.3% of males), while in CE, 44.9% of persons presented with AHD (37.4% of males with male‐to‐male sexual contact, 47.8% of females and 61.8% of HMs). Males in GE had higher odds of AHD compared with females (aOR: 1.48 [95% CI: 1.40–1.57]). The odds of AHD decreased from 2003 to 2022 (aOR: 0.29 [95% CI: 0.26–0.33] in GE and aOR: 0.32 [95% CI: 0.29–0.36] in CE). In sex‐at‐birth/acquisition stratified models, in CE sites, odds decreased more in males with male‐to‐male sexual contact (aOR: 0.22 [95% CI: 0.19–0.25]) than in females (aOR: 0.57 [95% CI: 0.46–0.79]) and HMs (aOR: 0.47 [95% CI: 0.38–0.58]) in 2022 versus 2003. Conclusions In CE sites, the slight decreasing trend of AHD at enrolment among females and HMs contrasts with the steeper decline among males with male‐to‐male sexual contact. In the GE site, risk of AHD at enrolment decreased in both males and females over time. Interventions to increase awareness, improve HIV testing, and hasten linkage to care among females and HMs are needed in CE settings in addition to addressing structural and social barriers.
ABSTRACT Introduction In Latin America, there are rising numbers of new HIV acquisitions, while the Caribbean has achieved decreases in both new acquisitions and AIDS‐related deaths. The Latin American and Caribbean (LAC) region has worked towards widely available treatment for people with HIV (PWHIV) within public health systems and, in Latin America, has relied principally on domestic financing to do so. Discussion While new methods of prevention are in the process of being incorporated into regional HIV programmes, the HIV cascade of care remains below the UNAIDS goals. Only 17 of the 32 LAC countries (53%) report on the three pillars. Only Chile achieved >95% in two of the three pillars, with 95% of PWHIV knowing their status and 95% of people on treatment having a suppressed viral load. However, only 75% of those who know their status were on treatment. In the Caribbean, very little data is available, with all three cascade pillars missing for six of the countries. Only the Bahamas reached the 95% threshold for any of the cascade steps. Additionally, in the Caribbean, the viral suppression step of the cascade is much lower on average than in Latin America, with no countries reaching 80%. Biomedical HIV prevention with pre‐exposure prophylaxis (PrEP) and post‐exposure prophylaxis (PEP) is still being adopted and scaled up among populations in need. Scale‐up of prevention efforts remains hindered by structural limitations of the health system, legal and policy limitations such as continuing to require informed consent for HIV testing and policies that block task‐shifting, as well as persistent stigma. Recent reductions in international funding for HIV may adversely influence HIV programmes in LAC, which have relied on these for initial scale‐up of innovations. Conclusions Accelerating differentiated and simplified delivery of PrEP and PEP, alongside sustained progress towards universal treatment coverage and viral suppression, are all essential for translating existing scientific advances into measurable progress towards HIV elimination in the region.
ABSTRACT Introduction From 2010 to 2024, the Latin America region experienced a 13% increase in new HIV acquisitions, while progress in reducing HIV acquisitions has slowed in the Caribbean. We conducted allocative efficiency studies for five countries in the Latin America and Caribbean region, aiming to estimate how HIV spending could be optimally allocated for maximal impact. Methods Between 2021 and 2025, we collaborated with national partners in Colombia, Costa Rica, Dominican Republic, El Salvador and Honduras to develop national Optima HIV models incorporating country‐specific key populations. Prevention, testing and antiretroviral therapy (ART) interventions were parameterized using country‐specific unit costs, coverage estimates and effectiveness values. For each country, we projected HIV incidence, mortality and treatment resource needs from 2025 to 2030 for multiple scenarios: fixed intervention coverage (status quo), fixed spending allocations (counterfactual), and most recent spending optimized across interventions to minimize cumulative HIV acquisitions and HIV‐related deaths. Results With the status quo continued, HIV incidence was projected to decline by 2030 in two countries, stabilize in two and increase in one country. Transgender women and men who have sex with men have the highest incidence rate. Due to ongoing increases in the number of diagnosed people living with HIV, by 2030, annual ART resources will need to increase by 1%–15% to maintain the existing treatment coverage. Compared with the counterfactual (fixed spending) scenario, optimization of existing resources could avert 18%–33% of new HIV acquisitions and 5%–31% of HIV‐related deaths over 2025–2030 by prioritizing primarily ART. If modelled ART unit costs reduce by 25%, then 23%–69% of projected HIV acquisitions and 8%–61% of HIV‐related deaths could be averted by reinvesting savings to scale‐up interventions for country‐specific key populations instead of lower‐yield interventions such as untargeted HIV testing. Conclusions This multi‐country modelling study demonstrates the potential to reduce new HIV acquisitions and HIV‐related deaths across Latin America and the Caribbean without increasing total spending. Recent reductions in treatment costs provide greater flexibility to invest in key population‐focused services which could amplify epidemic impact. The findings underscore the importance of aligning HIV resources with epidemic drivers and expanding targeted prevention for key populations.
ABSTRACT Introduction Female sex workers (FSWs) are at higher risk of sexually transmitted infections (STIs), including HIV, due to occupation‐related factors further exacerbated by gender‐specific vulnerability and marginalization. Stigma and fear of disclosing their occupation pose multiple barriers that limit access to sexual and reproductive health (SRH) services, as well as HIV testing, prevention and treatment. We describe the implementation of a tailored comprehensive SRH‐HIV prevention and care model for FSWs, and report HIV prevalence, pre‐exposure prophylaxis (PrEP) uptake and HIV treatment outcomes in our cohort. Methods “MAS por Nosotras” adopted a co‐creation and co‐production approach including a formative phase (focus groups with FSWs and semistructured interviews with stakeholders), and a prospective cohort of FSWs at a non‐governmental organization (NGO) in Argentina. Our conceived model focused on HIV treatment and combination prevention, including STI testing, cancer screening, contraception counselling and vaccination. Demographic, psychosocial and clinical information were collected. Results Between June 2023 and March 2024, 200 cisgender and transgender FSWs were enrolled in the prospective cohort, with a 66.5% retention rate at 6 months. HIV prevalence was 18.5% (34.3% in transgender women [TGW] and 3% in cisgender women [CGW]), with only one incident case during follow‐up. Among those with known HIV, 61% had a viral load <50 copies/mL. PrEP acceptance was higher in TGW (55.6%) versus 30.5% in CGW, but PrEP persistence was low (69% discontinued), especially in CGW. Nearly 78.5% of participants indicated they would be very likely to recommend the care package to their peers. Conclusions “MAS por Nosotras” implemented a community‐linked, gender‐informed integrated SRH‐HIV model of care, articulated with community‐based organizations, public health and an NGO research centre that facilitated access to HIV testing, prevention and treatment initiation or re‐engagement. We found a high prevalence of HIV, particularly among TGW, and low PrEP knowledge and use, especially among CGW. Our data reflect the need of expanding and tailoring HIV prevention strategies with a community‐focused approach. This proposed integrated SRH‐HIV model addressed these needs and generated preliminary evidence regarding operational feasibility and acceptability that may inform models to help close prevention and treatment gaps for FSWs in Latin America.
ABSTRACT Introduction Achieving and sustaining viral suppression among people living with HIV remains central to global HIV control efforts. Despite global 95–95–95 targets and the scale‐up of differentiated service delivery (DSD) models, many programmes continue to face structural and system‐level barriers to sustained treatment outcomes. Evidence on longitudinal HIV treatment outcomes using routinely collected programme data remains limited in Caribbean settings. This study aimed to describe longitudinal trends in HIV treatment outcomes at the Medical Research Foundation (MRF), a large HIV treatment site in Trinidad and Tobago. Methods A retrospective descriptive analysis was conducted using de‐identified electronic medical record (EMR) data for all clients receiving antiretroviral therapy (ART) at MRF. Data were analysed across seven fiscal quarters (FY2024 Q2–FY2025 Q4). The programme delivers differentiated, patient‐centred HIV care supported by routine EMR monitoring and quarterly programme performance reviews. Key indicators included ART coverage, viral load (VL) testing coverage, viral suppression (VL <1000 copies/mL) and treatment interruptions. Results The ART cohort ranged from 4913 to 5202 clients over the study period. VL testing coverage remained consistently high, ranging from 95% to 98% per quarter. Viral suppression was sustained at 94%–95%, reaching 95% in three quarters (FY2024 Q3, FY2025 Q3 and FY2025 Q4). Treatment interruptions declined by approximately 50% over time, while the number of clients active on ART remained stable with a gradual increase in later quarters. Conclusions This study demonstrates sustained high viral suppression and VL testing coverage within a large HIV treatment programme delivering DSD in Trinidad and Tobago. The reduction in treatment interruptions alongside stable high viral suppression highlights the value of routine programme data for monitoring HIV service delivery in real‐world settings. These findings provide implementation‐relevant insights for strengthening differentiated HIV care models and contribute to the limited evidence base on longitudinal treatment outcomes in Caribbean programme settings.
ABSTRACT Introduction Tenofovir‐based oral pre‐exposure prophylaxis (PrEP) is pivotal for HIV prevention in Latin America. Monitoring PrEP adherence is crucial for maximizing its impact and identifying individuals who may benefit from additional support. We evaluated the performance of indirect adherence measures and factors associated with PrEP non‐adherence in Brazil, Mexico and Peru. Methods ImPrEP was a prospective, multicentre, PrEP implementation study which enrolled 9509 persons from 6 February 2018 to 30 June 2021. For this analysis, we included men who have sex with men (MSM) aged 18–24 years and transgender women aged 18+ years with at least one dried blood spot (DBS) sample collected. Adherence was assessed objectively (tenofovir diphosphate [TFV‐DP] levels in DBS) and indirectly (medication possession rate [MPR] and self‐report). We estimated area under the curve (AUC) to evaluate the performance of each indirect adherence measure, and the optimal cut‐off points for discriminating protective TFV‐DP levels based on the Youden index. We used generalized estimating equations to identify factors associated with PrEP non‐adherence (TFV‐DP<900 fmol/punch). Results We included 2096 participants (1692 young MSM and 404 transgender women) with 4257 DBS samples. Overall, 62.3% DBS samples showed protective TFV‐DP levels, which declined over time (68.8% at week 4 to 33.8% at week 124). Both MPR and self‐report demonstrated moderate concordance (AUC: 0.74) with no difference between them (p = 0.79). Optimal cut‐offs were 97.6% for MPR and 93.3% for self‐report; self‐report showed higher sensitivity (84.6%), while MPR had higher specificity (62.9%). Among young adults, PrEP non‐adherence was higher among transgender women, participants with lower education and from Peru. Among transgender women, PrEP non‐adherence was higher among those with younger age, lower education, and from Peru and Mexico. Self‐reported sexual behaviours conveying elevated HIV exposure were associated with lower PrEP non‐adherence. Conclusions MPR and self‐report are pragmatic and clinically useful adherence monitoring tools for PrEP programmes in Latin America. Social determinants of health, particularly education, emerged as major drivers of PrEP non‐adherence among transgender women and young MSM. To maximize impact, PrEP programmes must prioritize person‐centred interventions that address stigma within health services, remove barriers to sustained engagement, strengthen health literacy and include long‐acting PrEP modalities.
ABSTRACT Introduction Although HIV pre‐exposure prophylaxis (PrEP) has been rapidly scaled up in Argentina to reach key populations with high HIV burden, evidence on real‐world persistence is lacking. Understanding who remains engaged in care, and why others discontinue, is essential to ensure the effectiveness of PrEP. This study evaluated oral PrEP persistence and identified demographic and behavioural factors associated with discontinuation in a cohort of individuals initiating PrEP in Buenos Aires. Methods We performed a retrospective cohort study including all users initiating daily or event‐driven oral PrEP at our centre between September 2021 and July 2025. The cohort consisted of transgender women (TGW), men who have sex with men (MSM) and cisgender women engaged in sex work (cSW), in line with national PrEP guidelines. Persistence on PrEP was defined as the time to first discontinuation (TFD), either self‐reported or estimated as the date when the last dispensed PrEP pill would have been exhausted if taken daily. Categories for discontinuation included participant‐reported causes and loss to follow‐up (LTFU). TFD was evaluated using survival analysis. Cox proportional hazards models were fitted to examine associations between TFD and sociodemographic and behavioural factors. Results Overall, 970 individuals initiated PrEP: 69% MSM, 24% TGW and 6% cSW. Median age was 31 years (IQR 26–36). During follow‐up, 447 participants (46%) discontinued PrEP. Persistence declined steadily over time: 91% at 1 month, 81% at 6 months, 72% at 12 months, 58% at 24 months and 43% at 36 months. Main categories for discontinuation were LTFU (44%), user decision or perceived low risk (46% combined) and adverse events (10%). In the multivariable model, younger age, identifying as TGW or cSW, cocaine use in the last month before baseline and the absence of basal/follow‐up syphilis or other bacterial sexually transmitted infections were associated with PrEP discontinuation. Conclusions Nearly half of the cohort discontinued PrEP over 3 years, with differences across key populations. These findings highlight the need for differentiated community‐tailored PrEP delivery models that address structural and behavioural barriers to improve long‐term PrEP engagement among key populations in Argentina and wider Latin America.
ABSTRACT Introduction Uruguay has one of the highest HIV incidence rates in Latin America, yet its molecular epidemiology remains underexplored. Characterizing the diversity, temporal and geographic dynamics of circulating HIV‐1 lineages is essential to detect lineage‐specific patterns across population groups and regions, inform tailored prevention and surveillance strategies, and understand cross‐border connectivity. Methods HIV‐1 pol (PR/RT) genotyping data from 1268 people living with HIV, generated during 2007–2021 through nationwide routine genotyping, were analysed. Viral lineages and recombinants were classified using automated subtyping tools, maximum‐likelihood phylogenies and recombination analyses. Associations with demographic and exposure characteristics were evaluated using Z‐tests and Fisher's exact tests, and temporal trends were assessed using Pearson correlations. Results Sixteen recognized HIV‐1 lineages were identified, including four subtypes/sub‐subtypes (B, C, A1 and F1) and twelve circulating recombinant forms (CRFs). Subtype B was the most frequent lineage (39.3%), followed by CRFs 12_BF (27.8%) and 38_BF1 (12.9%). An additional 8.5% of sequences formed a well‐supported B/F1 recombinant clade, provisionally designated BF1.UY and not assignable to any known CRF. Temporal analyses showed opposing trends, with a significant decline in subtype B and an increasing contribution of BF1 recombinants within the genotyped dataset. Subtype B was associated with men and transmission among men who have sex with men; 38_BF1 was enriched among women and people reporting injection‐related exposures; and BF1.UY predominate in reported heterosexual transmission. Geographic patterns suggested regional connectivity: 12_BF predominated in the West and the Atlantic coastal East, consistent with Argentina‐linked border and tourism‐related mobility, whereas Brazilian‐associated variants (subtype C, 31_BC and F1) were more frequent in the Northeast and East. Conclusions In Uruguay, HIV‐1 molecular diversity was largely shaped by sustained circulation of subtype B and BF1 recombinants, which showed distinct associations with gender, transmission‐route category and geography. These lineage‐specific patterns are consistent with partially overlapping transmission networks among Uruguayan subpopulations and viral exchange across border areas. The growing contribution of BF1 recombinants within the genotyped dataset, together with geographically structured diversity in areas connected to Argentina and Brazil, highlights the need for sustained molecular surveillance integrated with epidemiological data and regional collaboration to track HIV‐1 diversification and spread.
ABSTRACT Introduction HIV‐related stigma undermines prevention and treatment efforts, particularly among young adults. Social media offers a scalable platform for stigma‐reduction efforts; however, empirical evidence of its effectiveness remains limited. Social media influencers may enhance the effectiveness of stigma reduction messages delivered via social media. Methods From November 2024 to January 2025, we conducted a randomized controlled study in Lima, Peru, among young adults aged 18–29 years to evaluate the impact of brief exposure to tailored social media content designed to reduce HIV‐related stigma. Content featured widely recognized Peruvian influencers or young adult residents filmed in recognizable places in Lima. Participants were randomized to a simulated social media feed containing one of four HIV stigma‐reduction videos, including one featuring a top Peruvian influencer, or a control video. Stigma was evaluated using the Bogardus social distance scale, scored using standard and intensity‐based methods. Results Five hundred and sixty‐seven persons participated (53% male, median age: 21 years). Median social distance pre‐randomization score was 1 in controls (fifth–95th percentile: 1–7), 1 in Arm 1 (fifth–95th: 1–7), 1 in Arm 2 (fifth–95th: 1–6), 1 in Arm 3 (fifth–95th: 1–5) and 1 in Arm 4 (fifth–95th: 1–7). Comparisons of pre‐ and post‐changes by study arm supported modest intervention effects. Controls showed a median change of 0 (fifth–95th: –1–2). Arm 1, featuring influencer‐generated content, showed a median change of 0 (fifth–95th: –6–0), with a Wilcoxon rank‐sum test indicating a statistically significant difference from controls (p = 0.001). Arm 2 showed a median change of 0 (fifth–95th: –1–0, p = 0.08). Arm 3 showed a median change of 0 (fifth–95th: –2–0, p = 0.01). Arm 4 showed a median change of 0 (fifth–95th: –3–0, p = 0.01). Conclusions Brief exposure to culturally tailored social media content led to modest reductions in HIV‐related stigma among young adults in Peru immediately after viewing. Findings reinforce the potential role of social media and influencers in HIV stigma reduction efforts. Future research should examine whether social media interventions can reduce stigma among those with the most stigmatizing beliefs and identify dosing and delivery strategies that achieve durable reductions in stigma.
ABSTRACT Introduction Latin America is a key region in advancing efforts to end the HIV epidemic globally. Despite breakthroughs in HIV treatment and prevention in the last 20 years, as well as region‐wide improvements in health infrastructure and policies, there has been a 13% increase in new acquisitions in Latin America from 2010 to 2024. The Caribbean, Central and South America network for HIV epidemiology (CCASAnet), established in 2006, is one of seven regions in the International epidemiology Databases to Evaluate AIDS (IeDEA). CCASAnet contributes substantially to regional science and the development of national and region‐wide policies. Here, we describe data sources and operational methodologies employed by CCASAnet, as well as the current state of the cohort. Methods CCASAnet data are collected using standardized data elements, including demographic information, HIV disease history, laboratory data, antiretroviral regimens, co‐infections and comorbidities. Data collection has expanded to include prospective data such as substance use, antiretroviral therapy adherence, geriatric syndromes and tuberculosis treatment. All clinical sites retain ownership of their data, and CCASAnet data contribute as able to global IeDEA‐level projects. Robust data quality initiatives and statistical methods have strengthened the cohort. Results CCASAnet consists of nine clinics across seven countries (Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru). Over 61,000 adults and children living with HIV have contributed observational data through December 2023. While CD4 at enrolment has remained largely unchanged, time to antiretroviral therapy initiation has decreased, retention in care has improved and the proportion with undetectable HIV RNA has dramatically increased. Co‐infections and AIDS‐defining malignancies remain a cause of morbidity and mortality, but non‐communicable diseases have also increased. Overall mortality trends in the region have improved over time, with some notable exceptions. Conclusions Underscoring the importance of maintaining longitudinal collaborations and data collection, CCASAnet remains the largest source of high‐quality data for HIV epidemiology in Latin America and serves as an important evidence base for informing global and regional policy and stakeholder decisions related to the HIV epidemic.
ABSTRACT Introduction Since the onset of the 2022 multinational mpox outbreak, Brazil has reported one of the highest case burdens globally, disproportionately affecting sexual and gender diverse populations. Mpox vaccination efforts in Brazil have been limited by delayed procurement, restricted eligibility criteria and structural access barriers. Understanding vaccination use, correlates of uptake and characteristics of individuals previously diagnosed with mpox is essential to guide equitable prevention strategies. Methods We conducted an online cross‐sectional survey between August and December 2024 among individuals recruited through social media and dating apps. Eligible participants were aged ≥18 years, identified as a sexual and gender diverse person, and residing in Brazil. Primary outcomes were previous mpox vaccination and mpox diagnosis. Sociodemographic, behavioural, internalized LGBTQIAPN+phobia and HIV/sexually transmitted infections (STIs) variables were collected. Adjusted logistic regression models identified independent factors associated with both outcomes. Results Of 9546 respondents, most were cisgender men (91.8%), aged >30 years (81.5%) and residing in capital cities (77.2%). Overall, mpox vaccination coverage was 4.9%; nearly half received only one dose, and one quarter were vaccinated outside Brazil. Previous mpox diagnosis was reported by 2.1% of respondents, with 76.5% seeking healthcare and 7.0% requiring hospitalization. Factors associated with previous mpox vaccination were self‐identification as White (aOR = 1.36; 95% CI: 1.10−1.69), more than five sex partners (aOR = 1.29; 95% CI: 1.03–1.62), living with HIV (aOR = 3.40; 95% CI: 2.59–4.47), current/prior HIV pre‐exposure prophylaxis (PrEP) use (aOR = 1.88; 95% CI: 1.41–2.53) and internalized LGBTQIAPN+phobia score (aOR = 0.80; 95% CI: 0.71−0.90). Factors associated with previous mpox diagnosis were living in capital cities (aOR = 1.88; 95% CI: 1.17–3.20), more than five sex partners (aOR = 1.93; 95% CI: 1.35−2.79), stimulant drug use (aOR = 1.61; 95% CI: 1.14–2.25), any STI diagnosis (aOR = 2.41; 95% CI: 1.74–3.33), living with HIV (aOR = 3.73; 95% CI: 2.31–6.25) and current/prior PrEP use (aOR = 2.35; 95% CI: 1.43−4.01). Conclusions Mpox vaccination among sexual and gender diverse populations in Brazil remains critically low. Findings highlight structural barriers, including vaccine scarcity, delayed rollout and stigma, that hinder equitable vaccine access. Integrating mpox vaccination into combined HIV/STI prevention services, adopting differentiated care delivery models and partnering with community‐led organizations are essential to expanding reach, improving dose completion and reducing health inequities during ongoing and future outbreaks.
ABSTRACT Introduction HIV pre‐exposure prophylaxis (PrEP) users may be disproportionately vulnerable to sexually transmitted infections (STIs) in general, including several that are vaccine‐preventable. Understanding immunization patterns in this population is, therefore, crucial. However, data on vaccination coverage among Brazilian PrEP users remains limited. Methods We conducted a retrospective single‐centre study of adults using HIV PrEP at an STI clinic in São Paulo, Brazil, between 2017 and 2024, to assess vaccination adequacy for vaccine‐preventable STIs among PrEP users, as well as other STI prevention measures during follow‐up. Demographic characteristics, substance use, STI history and vaccination status for hepatitis A (HAV), hepatitis B (HBV), human papillomavirus (HPV) and MPox were extracted from medical records, immunization registries and laboratory results, and descriptive analyses were performed. Results Among 190 participants (median age: 36 years), 89.5% were gay or other men who have sex with men (MSM). Over a mean follow‐up period of 45 months, complete vaccination coverage was observed in 97.7% for HBV, 49.5% for HAV, 24.2% for HPV and 1.6% for MPox. Despite documented prior vaccination, a proportion of participants remained susceptible to HAV (16.3%) and HBV (2.3%). Furthermore, a substantial proportion of participants (32.1% for HAV, 53.7% for HPV and 81.0% for MPox) had neither a documented vaccination status nor a provider recommendation for vaccination recorded in their medical charts. HPV‐ and MPox‐related clinical lesions were documented in 17.9% and 2.1% of participants, respectively. Conclusions Notable gaps in immunization against preventable STIs were observed in this PrEP cohort in São Paulo, Brazil. While HBV coverage was high, uptake of HAV, HPV and MPox vaccines was low. Addressing these gaps in our cohort requires transitioning from mere provider recommendations to structural public health policies. Implementing on‐site vaccine administration within PrEP services, integrating immunization into STI screening, expanding free access and addressing key vulnerabilities are critical steps to eliminate structural barriers and reduce the STI burden.
ABSTRACT 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.
ABSTRACT Introduction Mpox virus (MPXV) re‐emerged in endemic countries in recent decades, resulting in large outbreaks in central and western Africa and a worldwide epidemic of clade IIb MPXV starting in 2022. Mpox cases in vaccinated persons, and a few documented reinfections, have raised questions about the durability of MPXV humoral immunity. Longitudinal studies conducted during the clade IIb global outbreak have enriched our understanding of immune responses during and after mpox. This commentary aims to summarize current knowledge about the durability of humoral immunity against MPXV and limitations in the available evidence. Discussion Studies following convalescent individuals show vigorous neutralizing antibody titres that peak within weeks after symptom onset and remain detectable for up to 2 years following acquisition. Binding IgG and IgA antibodies directed against MPXV antigens peak and wane more rapidly. Immunodominant epitopes, such as A35R, elicit robust responses. Older individuals who received historical replicating smallpox vaccines and acquired mpox had higher neutralizing and binding antibody titres than younger people, with no apparent difference in durability of humoral immune markers. In some studies, people living with HIV had less vigorous early antibody responses than people without HIV but without an observed difference in durability. Conclusions Long‐term protection following mpox involves both humoral and cellular immunity. There is no identified correlate of protection for mpox. The current evidence primarily includes studies of mild to moderate clade IIb infection among cohorts largely comprising men in non‐endemic countries. Research involving additional viral clades and cohorts with greater breadth of geography, age, gender, race, ethnicity and severity of disease is needed to more fully explore durability of the MPXV immune response. A more complete understanding of this complex picture would likely inform development of improved vaccines and therapeutics for mpox.
