Background:Engaging men in HIV prevention remains a critical challenge in sub-Saharan Africa. While HIV self-testing (HIVST) and pre-exposure prophylaxis (PrEP) are efficacious prevention methods, uptake among men remains low. Peer network distribution of HIVST has shown promise, but no large-scale studies have evaluated its impact on PrEP uptake combined with mobile phone support, especially among men. This protocol describes a cluster randomised controlled trial evaluating a multi-component intervention to increase HIVST use and PrEP uptake among men through peer network distribution with enhanced risk perception counselling and telephone support. Methods/Design:This trial will be implemented in 44 clusters across eight sites in Manicaland Province, Eastern Zimbabwe. Eligible men aged 18 and above will be recruited through peer network distribution initiated by primary distributors. The intervention includes: (1) HIVST kit distribution through male peer networks, (2) toll-free helpline for pre- and post-test support, (3) SMS-based self-administered HIV risk assessment, and (4) facilitated linkage to confirmatory testing and PrEP at local clinics, including incentivisation and compensation. The primary outcome is the proportion of men initiating PrEP. Secondary outcomes include ART initiation, clinic-based HIV testing rates, and PrEP retention at one-month follow-up. The study is powered to detect an increase from 2% to 8.5% in PrEP initiation. A comprehensive process evaluation will assess implementation fidelity and network characteristics affecting outcomes. Mathematical modelling will project population-level impact and cost-effectiveness. Discussion:This will be the first large-scale randomised trial to evaluate whether peer network-based HIVST distribution combined with mobile health support and improved risk perception increases PrEP uptake among men in a high HIV-burden setting. If successful, this scalable intervention could inform national HIV prevention programmes across sub-Saharan Africa seeking to improve male engagement with prevention services. Trial registration:ClinicalTrials.gov NCT06370923. Registered on 12-Apr-2024.

Abstract While much progress has been made in reducing the incidence of HIV-1 infection in sub-Saharan Africa in recent years, bringing the epidemic to an end will require identification of the demographic groups that continue to contribute to transmission. Pathogen phylogenetics and individual-based mathematical models (IBMs) of transmission are approaches that enable researchers to explore such questions. Here, we used both methods to characterise the ages and sexes of the individuals involved in heterosexual transmission in the context of the HPTN 071 (PopART) trial in Zambia. The results were concordant, and show that the male partner was on average older than the female by less than seven years, with larger age gaps in male-to-female than female-to-male transmissions. We found that the largest gaps for female recipients were amongst the youngest of those recipients. Conversely, the youngest male recipients saw the smallest gaps. We further used the IBM to demonstrate that transmission to new age cohorts first entering into sexual activity is driven predominantly by male-to-female transmission. We also simulated the PopART universal testing and treatment intervention into the future to show that effective treatment of under-35-year-olds accounts for 93.8% of the reduction in incidence by 2039, while effective treatment of under-35-year-old men accounts for 62.1%. Finally, we simulated a one-year cessation of ART treatment for the whole population, which resulted in an immediate increase in the average age at transmission of both sources and recipients. With it becoming ever more expensive and difficult to find treatment-naive individuals and link them to care, targeted interventions for demographic groups such as under-35 men may be the key to finally ending HIV.

Background An individual's HIV risk, and consequently their HIV prevention needs, change over time. In this study we aimed to quantify these changes, examine which life-course events were associated with them, and investigate the extent to which those life-course events were associated with HIV acquisition. Methods We used longitudinal data from eight rounds of a general population cohort in Manicaland province, eastern Zimbabwe, on sociodemographic and HIV risk behaviours, as well as HIV serostatus from the first seven rounds. We first visualised how HIV risk behaviours, comprised of having multiple, concurrent, non-regular, or transactional partners, condom non-use, drug use, and visiting bars, changed for individuals over time using Sankey diagrams. We then examined whether logistic regression models incorporating life-course events-namely, changes in marital or employment status, in-migration, or birth of a child-were more strongly associated with changes in HIV risk behaviour than models using only sociodemographic variables. Finally, we compared how well sociodemographic, HIV risk behaviour, and life-course events were associated with the person's risk of HIV acquisition as follows: we used logistic regression to identify which states (divided into sociodemographic, HIV risk behaviour, and life-course events) were most strongly associated with risk of HIV acquisition; based on this we use three models (corresponding to the three divisions) to identify the top 20% of individuals predicted to be at risk of acquiring HIV by each model, and computed what proportion of the actual HIV infection events occurred in that group. Findings Between 1998 and 2021, 21 213 individuals were interviewed at least twice, contributing a total of 34 212 participant observations. In this setting, individuals had periods of HIV risk lasting less than 3 years; only 123% (102 of 831) of those reporting transactional sex had also reported this in the previous round. We found that life-course events such as changes in marital status, employment status, and in-migrant status were associated with these changes in HIV risk behaviour. Using life-course events, particularly ones related to changes in marital status, 23% and 30% more HIV acquisitions were identified than using HIV risk behaviours or sociodemographic information, respectively. Interpretation HIV risk changes dynamically in this population, and life-course events could be a powerful way to understand changes in HIV risk behaviour and risk of HIV acquisition. Funding Bill and Melinda Gates Foundation, UK Medical Research Council, and Department for International Development. Copyright (c) 2025 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

BACKGROUND:The risk of secondary primary malignancies (SPMs) in meningioma patients is not well understood. In this unidirectional analysis, we evaluated the risk of SPMs occurring following a primary diagnosis of meningioma. METHODS:The Surveillance, Epidemiology, and End Results (SEER-17) database (2000-2020) was used to identify 124,769 meningioma patients from a total of 9,208,295 cancer cases. Standardized incidence ratios (SIRs) were calculated using SEER's statistical analysis package to evaluate SPM risk. Basic demographic and treatment information was collected as well. RESULTS:Of the 124,769 patients, 11,411 (9.2%) received diagnoses of an SPM, which correlates to a higher risk than the general population (SIR, 1.17; 99% confidence interval [CI], 1.15-1.19). Patients with meningiomas had an increased risk of the following cancers: cutaneous melanoma (SIR, 1.40; 99% CI, 1.26-1.56), kidney and renal pelvis (SIR, 1.66; 99% CI, 1.47-1.86), brain and other nervous system (SIR, 3.45; 99% CI, 2.99-3.97), thyroid (SIR, 2.48; 99% CI, 2.19-2.80), and non-Hodgkin's lymphoma (SIR, 1.29; 99% CI, 1.15-1.44). Females were more predisposed to cancers of the lung (SIR, 1.19; 99% CI, 1.12-1.26), digestive system (SIR, 1.06; 99% CI, 1.01-1.12), and breast (SIR, 1.09; 99% CI, 1.04-1.14). Older patients demonstrated an increased risk of SPM development, with the 65-85-year-old group having an odds ratio of 9.06 (P = 0.009). CONCLUSIONS:SEER data confirm an increased risk of SPMs following meningioma diagnosis. Further research may uncover shared genetic factors between meningioma and these SPMs, and increased awareness of SPM risk could inform future screening strategies.

Introduction: Understanding how HIV epidemics are likely to behave in the future is key to informing HIV response strategies in low-income countries. Up-to-date HIV epidemiological estimates are important for policy decision- making, but surveillance data can be out of date. This study compared forecasts from HIV epidemiological models.Methods: Five independent modelling groups (EMOD-HIV, Goals, HIV Synthesis, Optima and PopART-IBM) calibrated their mathematical models to datapoints provided by the Ministry of Health and produced several indicators of the HIV epidemic in Zimbabwe for the period 1990 to 2040, under a status quo scenario in which it was assumed continuation of interventions at the current level.Results: All models predicted a continuous decline in HIV incidence and prevalence. However, there was variability in the estimated 2023 incidence rate (range: 2.0-3.3 per 1 000 person-years) and prevalence (range: 12.1%-14.3%). Variance was even larger in 2040 for incidence (range: 1.0-3.0 per 1 000 person-years), while this was not the case for prevalence (range: 3.9%-6.0%). All the models predicted that the country would reach a target of less than 7 800 new HIV infections per year by 2025.Conclusion: Five independent mathematical models fitted to the Zimbabwe Ministry of Health and Child Care's HIV surveillance data provided consistent predictions of continued decline in HIV incidence and prevalence in Zimbabwe if interventions continue to be implemented at the current levels, with prevalence predicted to be around a third of its level in 2000 by 2040.

In public health research, diverse perspectives are vital to identify biases that homogenous teams might miss. Since publication metrics influence career progression, we investigated publication rate disparities within a School of Public Health. We analysed 18 322 peer-reviewed publications by 513 affiliated researchers between 2014 and 2023 using multivariable regression models and network analysis to assess the impact of gender, ethnicity, job level and centrality in the School's research network on publication rates. We found a persistent gender gap in publication rates across job levels and ethnicities, with men publishing more than women (incidence rate ratio 1.30, 95% confidence interval (CI): 1.15-1.46). This disparity was present from early career levels and amplified in senior roles, where men were over-represented (71.2% of men at Professor level). Unadjusted analyses indicated higher publication rates for white researchers (median of one publication more per person per year). The COVID-19 pandemic led to increased publication rates for both genders, but the gender gap persisted, with men publishing 1.27 (95% CI: 1.10-1.46) times more than women in 2020/2021. This study underscores the need to identify and address root causes of these disparities to foster an inclusive research environment where diverse contributions are recognized and valued.

BACKGROUND:Although HIV incidence has considerably decreased in eastern, central, and southern Africa, new HIV infections continue to be a major public health challenge in the region. We aimed to investigate where in the HIV treatment cascade new transmissions are occurring in Malawi, Zimbabwe, and South Africa (the three countries involved in the Modelling to Inform HIV Programmes in Sub-Saharan Africa project). METHODS:In this model comparison study, we used six well described and independently calibrated HIV transmission dynamics models that have been used to inform HIV policy in Africa (Optima HIV, EMOD, Goals, Thembisa, PopART-IBM, and HIV Synthesis) to estimate and predict the proportion of annual new HIV transmissions attributable to people living with HIV who are undiagnosed, have been diagnosed but have not yet started antiretroviral therapy (ART), are receiving ART, and have interrupted ART in Malawi, Zimbabwe, and South Africa from 2010 to 2040 stratified by the age and sex of the individual acquiring HIV. FINDINGS:Despite the different model structures and underlying assumptions, the six models were well aligned in relation to key HIV epidemic characteristics (including population estimates and HIV prevalence) in each of the three settings. There was, however, considerable variation in the predicted number of new infections, particularly in Malawi and Zimbabwe where this number ranged from fewer than 10 000 new infections to over 30 000 new infections in 2024. Most model results suggested that the mean age of HIV acquisition has been increasing since 2000, with men acquiring HIV at an older age than women in all three settings. All models attributed fewer than 5% of transmissions to individuals who had been diagnosed but had not yet started ART. In Malawi, the proportion of transmissions attributable to undiagnosed people with HIV in 2024 ranged from 33·3% to 75·3% across the models, and transmissions attributable to individuals who had experienced interrupted treatment ranged from 8·4% to 20·1%. In Zimbabwe, the proportion of transmissions attributable to undiagnosed individuals in 2024 ranged from 29·8% to 64·6% across the models and the proportion of transmissions attributable to individuals who had interrupted treatment ranged from 4·7% to 21·5%. In South Africa, 21·8-46·4% of transmissions in 2024 were attributable to undiagnosed individuals and 27·6-58·9% of transmissions were attributable to individuals who had interrupted treatment. INTERPRETATION:Across the three study settings, a substantial proportion of new HIV transmissions were attributable to undiagnosed individuals and people who have received interrupted ART, reinforcing the importance of continuing HIV testing and ART re-engagement and retention interventions. FUNDING:The Bill & Melinda Gates Foundation.

BACKGROUND:Major geopolitical events and structural shocks are thought to play a significant role in shaping HIV epidemics by influencing individual behaviours, reshaping social networks, and impacting HIV prevention and treatment programs. Here, we describe individual-level measures of estimated time since HIV infection (ETI) from viral next-generation sequencing data among female sex workers and their clients in relation to significant geopolitical events in Ukraine. METHODS:The Dynamics Study is a cross-sectional integrated biological and behavioural survey conducted among female sex workers and their clients in Dnipro, Ukraine (December 2017 to March 2018). We were able to successfully sequence a portion of the HIV pol gene on dried blood spot specimens among n = 5/9 clients and n = 5/16 female sex workers who tested positive for HIV (total n = 10/25) using an in-house drug resistance genotyping assay. The "HIV EVO" Intrapatient HIV Evolution web-based tool was used to infer ETI from viral diversity. RESULTS:The median ETIs for female sex workers and their clients were 5.4 years (IQR = 2.9, 6.6) and 6.5 years (IQR = 5.4, 10.8), respectively. Nearly all HIV acquisition events (n = 7/10; 70%) were estimated to have occurred between the Great Recession (2008-2009) and the War in Donbas (May 2014-February 2022). In general, ETI suggests that HIV acquisition occurred earlier among clients (2012 [IQR = 2007, 2013]) compared to sex workers (2013 [IQR = 2012, 2016]). CONCLUSION:Our findings suggest that most HIV acquisition in this small subset of female sex workers and clients living with HIV occurred during periods of economic decline. Molecular studies on timing of HIV acquisition against timing of major geopolitical events offer a novel way to contextualize how such events may shape transmission patterns.

Introduction Military personnel are a unique population with heightened vulnerability to sexually transmitted infections (STIs), often exhibiting higher prevalence rates than civilians due to demographic, environmental and occupational factors. These vulnerabilities underscore the need for global prevalence estimates to guide effective, evidence-based interventions. This study aims to quantify the global burden of STIs among military personnel, providing a comprehensive and up-to-date assessment.Methods and analysis This systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines (2020). Using the CoCoPop (Condition, Context, and Population) framework, a comprehensive search strategy will be conducted in MEDLINE, Embase, Global Health and Scopus to retrieve peer-reviewed records published between January 2010 and June 2025. Eligible studies will report numerical STI prevalence data among military personnel. Studies with insufficient information to calculate prevalence or those relying on self-reported STI data will be excluded. Data extraction will include study details, military descriptors, STI prevalence and diagnostic methods. Risk of bias will be assessed using the Joanna Briggs Institute critical assessment tool for prevalence and incidence studies. Prevalence estimates with 95% CIs will be reported for each STI and, where appropriate, pooled for curable STIs. Subgroup analyses will stratify prevalence by geographic region, service status, deployment status and socioeconomic factors. Heterogeneity will be evaluated within predefined subgroups using the I² statistic. Data will be presented in comprehensive tables and visualised with graphical tools, including forest plots for subgroup analyses and pooled estimates.Ethics and dissemination Ethical approval is not required for this review. The results will be disseminated through a peer-reviewed publication and conference presentations.PROSPERO registration number CRD42023472113.

This systematic review and meta-analysis assessed viral suppression among adults receiving WHO-recommended first-line dolutegravir-based ART in programmatic settings in low- and middle-income countries (LMICs). A systematic search of Ovid MEDLINE, Embase, and major HIV conferences (IAS, AIDS, and CROI) from January 2019 to September 2024 identified cohort and cross-sectional studies reporting viral suppression among adults receiving WHO-recommended first-line dolutegravir-based ART in LMICs. Studies with follow-ups ≤ 4 months or using non-WHO-recommended regimens were excluded. Pooled estimates were calculated using random-effects meta-analysis. Sensitivity analyses excluded outliers. Subgroup analyses distinguished adults initiating versus transitioning to dolutegravir-based ART. Both on-treatment and intention-to-treat outcomes were assessed. Twenty-two studies (n = 47 to 50,742) from 13 countries were included. On-treatment pooled viral suppression was 95

BACKGROUND:The USA has traditionally been the largest donor to health programmes in low-income and middle-income countries (LMICs). In January 2025, almost all such funding was stopped and prospects for its resumption are uncertain. The suddenness of the funding cuts makes it difficult for national health programmes in LMICs to adapt. We aimed to estimate the impact of these cuts on deaths and other outcomes (new infections, number of family planning users, and unplanned pregnancies) for four health areas that have been a focus of a substantial amount of US foreign assistance: HIV, tuberculosis, family planning, and maternal and child health. METHODS:We applied established mathematical models to the countries receiving US foreign assistance in each domain to estimate health impacts over the period 2025 to 2030. We used six models of HIV, three different approaches to estimate family planning impact, and one model each for tuberculosis and maternal and child health, applying these models to as many as 80 countries. We compared model projections assuming constant funding (status quo) with projections assuming complete elimination of US funding in each country. Some models also considered partial cuts or restoration of funding over time. FINDINGS:A complete cessation of US funding without replacement by other sources would lead to drastic increases in deaths from 2025 to 2030: 4·1 million (range 1·6-6·6) additional AIDS-related deaths across 55 countries, 606 900 (95% uncertainty interval [UI] 466 000-768 800) additional tuberculosis deaths across 79 countries, 40-55 million additional unplanned pregnancies and 12-16 million unsafe abortions across 51 countries, and 2·5 million (1·3-4·5) additional child deaths from causes other than HIV and tuberculosis across 24 countries. Restoration of funding for HIV treatment but not prevention would avoid most of the increase in deaths but still result in nearly 1 million more new HIV infections from 2025 to 2030. INTERPRETATION:Substantial progress has been made in improving global health in the past few decades. This progress has strengthened hope in reaching global development goals. However, the recent funding cuts threaten to change these trajectories and could lead to sharp increases in avoidable mortality for the poorest countries. Even a partial restoration of US funding would combat the most severe effects and provide time for countries that have received substantial US foreign assistance to adjust to the new funding landscape. FUNDING:Economic and Social Research Council; Engineering and Physical Sciences Research Council; European and Developing Countries Clinical Trials Partnership; Gates Foundation; Global Fund to Fight AIDS, Tuberculosis, and Malaria; Open Philanthropy; UK Foreign, Commonwealth & Development Office; UK Medical Research Council; UN Population Fund; UNAIDS; US National Institute of Allergy and Infectious Diseases; University of Edinburgh; US National Institutes of Health; US President's Emergency Plan for AIDS Relief; Wellcome Trust; World Bank; WHO.

The HIV epidemic in sub-Saharan Africa is historically characterised by high levels of prevalence and incidence. With the global effort to reach UNAIDS 95-95-95 targets, the scaling-up of HIV treatment, and focused preventive interventions, incidence has been declining over the past decade, albeit non-consistently across different sex and age groups. Two questions remain to be addressed to help tailor setting-specific interventions and allocate resources optimally. Firstly, are there unidentified demographic groups that are sources of transmission? Secondly, what are the patterns of decline in incidence across different groups? Model-based assessment is a valuable tool for the design of focused interventions and to answer these questions. PopART-IBM, an individual-based model calibrated to (anonymised) age-and-sex stratified data, was developed in the context of the HPTN-071 (PopART) trial, and it offers a unique opportunity to explore such questions in the context of high-burden HIV communities in Zambia and South Africa. The outputs of the model include the full HIV transmission and partnership networks. In this work, we explore these and show that the sexual partnership network exhibits a large connected component, usually comprising over 40 % of the population, in each of the studied communities. An analysis of the large connected component reveals that it is formed by young people (20-40 years old) and is centered around the most sexually active individuals of the community. At the same time, many individuals in the large connected component only have one partner, highlighting the complex dynamics of risk correlations in a population. Inspecting the transmission network reveals that, on average, more than 80% of transmissions occur among individuals belonging to the large connected component. These findings indicate that populations consisting of young and highly sexually active individuals should be given high priority when designing or deploying interventions.

Background While the COVID-19 pandemic disrupted HIV preventative services in sub-Saharan Africa, little is known about the specific impacts the pandemic has had on men who have sex with men (MSM) in Kenya. Methods Data were from an HIV self-testing intervention implemented in Kisumu, Mombasa and Kiambu counties in Kenya. Baseline data collection took place from May to July 2019, and endline in August–October 2020, coinciding with the lifting of some COVID-19 mitigation measures. Using endline data, this study characterised the impact the pandemic had on participants’ risk behaviours, experience of violence and behaviours related to HIV. Logistic regression was used to understand factors related to changes in risk behaviours and experiences of violence; adjusted AORs (AORs) and 95% CIs are reported. Results Median age was 24 years (IQR: 21–27). Most respondents (93.9%) reported no change or a decrease in the number of sexual partners (median number of male sexual partners: 2, IQR: 2–4). Some participants reported an increase in alcohol (10%) and drug (16%) consumption, while 40% and 28% reported decreases in alcohol and drug consumption, respectively. Approximately 3% and 10% reported an increase in violence from intimate partners and police/authorities, respectively. Compared with those with primary education, those with post-secondary education were 60% less likely to report an increase in the number of male sexual partners per week (AOR: 0.4, 95% CI: 0.2 to 0.9), while those who were HIV positive were at twofold the odds of reporting an increase or sustained levels of violence from intimate partners (AOR: 2.0, 95% CI: 1.1 to 4.0). Conclusion The results of this study demonstrate heterogeneity in participants’ access to preventative HIV and clinical care services in Kenya after the onset of the COVID-19 epidemic. These results indicate the importance of responding to specific needs of MSM and adapting programmes during times of crisis.

BACKGROUND:The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk. SETTING:This study took place in Mombasa, Kenya. METHODS:We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors. RESULTS:Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW. CONCLUSION:AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Abstract Background The HIV epidemic in Kenya remains a significant public health concern, particularly among gay, bisexual, and other men who have sex with men (GBMSM), who continue to bear a disproportionate burden of the epidemic. This study’s objective is to describe HIV phylogenetic clusters among different subgroups of Kenyan GBMSM, including those who use physical hotspots, virtual spaces, or a combination of both to find male sexual partners. Methods Dried blood spots (DBS) were collected from GBMSM in Kisumu, Mombasa, and Kiambu counties, Kenya, in 2019 (baseline) and 2020 (endline). HIV pol sequencing was attempted on all seropositive DBS. HIV phylogenetic clusters were inferred using a patristic distance cutoff of ≤ 0.02 nucleotide substitutions per site. We used descriptive statistics to analyze sociodemographic characteristics and risk behaviors stratified by clustering status. Results Of the 2,450 participants (baseline and endline), 453 (18.5%) were living with HIV. Only a small proportion of seropositive DBS specimens were successfully sequenced (n = 36/453; 7.9%), likely due to most study participants being virally suppressed (87.4%). Among these sequences, 13 (36.1%) formed eight distinct clusters comprised of seven dyads and one triad. The clusters mainly consisted of GBMSM seeking partners online (n = 10/13; 76.9%) and who tested less frequently than recommended by Kenyan guidelines (n = 11/13; 84.6%). Conclusions Our study identified HIV phylogenetic clusters among Kenyan GBMSM who predominantly seek sexual partners online and test infrequently. These findings highlight potential unmet HIV prevention, testing, and treatment needs within this population. Furthermore, these results underscore the importance of tailoring HIV programs to address the diverse needs of GBMSM in Kenya across different venues, including both physical hotspots and online platforms, to ensure comprehensive prevention and care strategies.

Abstract Background Including structural determinants (e.g. criminalisation, stigma, inequitable gender norms) in dynamic HIV transmission models is important to help quantify their population-level impacts and guide implementation of effective interventions that reduce the burden of HIV and inequalities thereof. However, evidence-based modelling of structural determinants is challenging partly due to a limited understanding of their causal pathways and few empirical estimates of their effects on HIV acquisition and transmission. Methods We conducted a scoping review of dynamic HIV transmission modelling studies that evaluated the impacts of structural determinants, published up to August 28, 2023, using Ovid Embase and Medline online databases. We appraised studies on how models represented exposure to structural determinants and causal pathways. Building on this, we developed a new methodological framework and recommendations to support the incorporation of structural determinants in transmission dynamics models and their analyses. We discuss the data and analyses that could strengthen the evidence used to inform these models. Results We identified 17 HIV modelling studies that represented structural determinants and/or interventions, including incarceration of people who inject drugs (number of studies [n] = 5), violence against women (n = 3), HIV stigma (n = 1), and housing instability (n = 1), among others (n = 7). Most studies (n = 10) modelled exposures dynamically. Almost half (8/17 studies) represented multiple exposure histories (e.g. current, recent, non-recent exposure). Structural determinants were often assumed to influence HIV indirectly by influencing mediators such as contact patterns, condom use, and antiretroviral therapy use. However, causal pathways’ assumptions were sometimes simple, with few mediators explicitly represented in the model, and largely based on cross-sectional associations. Although most studies calibrated models using HIV epidemiological data, less than half (7/17) also fitted or cross-validated to data on the prevalence, frequency, or effects of exposure to structural determinants. Conclusions Mathematical models can play a crucial role in elucidating the population-level impacts of structural determinants and interventions on HIV. We recommend the next generation of models reflect exposure to structural determinants dynamically and mechanistically, and reproduce the key causal pathways, based on longitudinal evidence of links between structural determinants, mediators, and HIV. This would improve the validity and usefulness of predictions of the impacts of structural determinants and interventions.

AbstractPeople living with HIV (PLHIV) report lower health-related quality-of-life (HRQoL) than HIV-negative people. HIV stigma may contribute to this. We explored the association between HIV stigma and HRQoL among PLHIV. We used cross-sectional data from 3991 randomly selected PLHIV who were surveyed in 2017–2018 for HPTN 071 (PopART), a cluster randomised trial in Zambia and South Africa. Participants were 18–44 years, had laboratory-confirmed HIV infection, and knew their status. HRQoL was measured using the EuroQol-5-dimensions-5-levels (EQ-5D-5L) questionnaire. Stigma outcomes included: internalised stigma, stigma experienced in the community, and stigma experienced in healthcare settings. Associations were examined using logistic regression. Participants who had experienced community stigma (n = 693/3991) had higher odds of reporting problems in at least one HRQoL domain, compared to those who had not (adjusted odds ratio, aOR: 1.51, 95% confidence interval, 95% Cl: 1.16–1.98, p = 0.002). Having experienced internalised stigma was also associated with reporting problems in at least one HRQoL domain (n = 552/3991, aOR: 1.98, 95% CI: 1.54–2.54, p < 0.001). However, having experienced stigma in a healthcare setting was less common (n = 158/3991) and not associated with HRQoL (aOR: 1.04, 95% CI: 0.68–1.58, p = 0.850). A stronger focus on interventions for internalised stigma and stigma experienced in the community is required.