Joseph Larmarange

Female sex workers (FSWs) experience a disproportionately high burden of HIV. To inform future research and policy efforts on HIV prevention, this study synthesizes global evidence on HIV pre-exposure prophylaxis (PrEP) among cisgender FSWs worldwide. This scoping review was conducted using six multidisciplinary databases searched up to December 2024. Titles and abstracts, then full texts, were independently screened. Data extraction comprised i) general study characteristics (UNAIDS region, country, study type, outcomes, type of PrEP, and study years), ii) detailed data of each outcome (including PrEP knowledge, a priori acceptability – interest, and effective acceptability – use, retention and adherence). Drivers and barriers to PrEP acceptability were analyzed using an adapted conceptual framework encompassing six domains: patient characteristics, individual knowledge and perceptions, medication-related factors, social processes, structural and health system factors, and sex work characteristics. After selection, 120 eligible studies were identified, mostly conducted in Eastern and Southern Africa. PrEP knowledge was initially low but increased quickly once programs were introduced. PrEP interest was consistently high across regions, driven by perceived HIV risk and desire for self‑protection. PrEP uptake, retention and adherence varied widely. Main barriers included sex work realities (i.e., unstable housing, alcohol use), social processes (i.e., stigma), individual characteristics (i.e., mobility), treatment-related characteristics (i.e., side effects), and health system challenges (i.e., clinic access constraints). Drivers included social support and reminder tools. While evidence on long‑acting PrEP remained limited, interest was consistently high as reducing daily burden. Overall, the findings support a socio-ecological understanding of PrEP engagement among FSWs, including the sex work context as a distinct intermediary layer. They highlight the need for differentiated and structurally responsive PrEP delivery models tailored to the realities of sex work. Expanding long‑acting PrEP options and improving service accessibility, community engagement, and stigma reduction strategies will be critical to strengthening HIV prevention among FSWs globally.

Introduction: Nearly 10% of sex workers in sub‐Saharan Africa live with chronic hepatitis B virus (HBV). HIV pre‐exposure prophylaxis (PrEP) using tenofovir/emtricitabine (TDF/FTC) has not been studied in this population, possibly due to concerns of hepatitis flares following TDF/FTC cessation. Methods: Using a microsimulation model of HIV and HBV disease and data from 2016 to 2024, we compared the clinical impact of TDF/FTC as PrEP versus no TDF/FTC among women who sell sex with HBV in Côte d'Ivoire. We incorporated the anti‐HBV effects of TDF/FTC and the increased probability of hepatitis flares and HBV surface antigen (HBsAg) loss following TDF/FTC cessation. We estimated input parameters from published literature: HIV incidence (1.9–3.0 per 100 person‐years), PrEP adherence (55%), disengagement from PrEP care (4% per month for the first 12 months, then 12.5% per month), hepatitis flare incidence (2.0−4.0 per 100 person‐years) and rate of HBsAg loss (1.0 per 100 person‐years), which both increase following TDF/FTC cessation. Model outcomes included cumulative HIV incidence, average hepatitis flares, HBsAg loss and survival over 2, 5 and 10 years. We conducted sensitivity analyses varying HIV incidence, PrEP adherence, disengagement from PrEP care and hepatitis flare rate. Results: Compared with no TDF/FTC , TDF/FTC would reduce cumulative HIV incidence: 4.1% versus 5.6% at 2 years and 10.1% versus 12.7% at 5 years. TDF/FTC would result in more hepatitis flares (mean 0.76 vs. 0.19 per person) and more HBsAg loss (8.4% vs. 5.7%) than no TDF/FTC after 5 years. Two‐ and five‐year survival would be similar between the two strategies, and TDF/FTC would improve survival over longer horizons. Improving adherence and reducing disengagement from care would increase clinical benefits. Even with high disengagement from care and high risk of hepatitis flares, TDF/FTC would reduce HIV acquisition and improve overall long‐term survival. Conclusions: Women who sell sex with HBV in Côte d'Ivoire would benefit from TDF/FTC as PrEP to avoid HIV acquisition. The increased risk of hepatitis flares, while challenging to manage in resource‐limited settings, would be outweighed by the benefits of HIV prevention. Efforts should be made to scale up PrEP in sex workers, including women with chronic HBV.

Background. Female sex workers (FSWs) experience a disproportionately high burden of HIV, driven by structural vulnerabilities, limited power to negotiate condom use, exposure to violence, and inconsistent access to prevention services. In this context, oral HIV pre-exposure prophylaxis (PrEP) has been recommended since 2015 by the World Health Organization, and new forms of PrEP have since been developed. To inform future research and policy efforts, this study synthesizes global evidence on PrEP among FSWs worldwide. Methods. We conducted a scoping review within six multidisciplinary databases searched up to December 2024. All original papers on PrEP among cisgender FSWs were included worldwide. Titles and abstracts, then full texts, were independently screened and papers were excluded if: not presenting specific or stratified results on FSWs; study protocols; modelling studies; conference abstracts; not written in English or French. Data extraction was independently conducted in two stages using standardized tools: i) general study characteristics (Unaids region, country, study type, outcomes, type of PrEP, and study years), ii) detailed data of each outcome (including PrEP knowledge, a priori acceptability, effective acceptability). Drivers and barriers to PrEP acceptability were analyzed using an adapted conceptual framework encompassing six domains: patient characteristics, individual knowledge and perceptions, medication-related factors, social processes, structural and health system factors, and sex work characteristics.Results. After selection, 120 eligible studies were identified, mostly conducted in Eastern and Southern Africa. PrEP knowledge was initially low but increased quickly once programs were introduced. PrEP interest was consistently high across regions, driven by perceived HIV risk and desire for self‑protection, and enhanced by greater PrEP knowledge. PrEP uptake, retention and adherence varied widely. Main barriers included sex work realities (i.e. unstable housing, alcohol use), social processes (i.e. stigma), individual characteristics (i.e. mobility), treatment-related characteristics (i.e. side effects), health system challenges (i.e. clinic access constraints). Drivers included social support and reminder tools. While evidence on long‑acting PrEP remains limited, interest was consistently high, particularly for injectable formulations due to discretion and reduced daily burden. No increase in sexual risk-taking or STI incidence was observed among PrEP users.Conclusions. Overall, the findings highlight the need for differentiated and structurally responsive PrEP delivery models tailored to the realities of sex work. Expanding long‑acting PrEP options and improving service accessibility, community engagement, and stigma reduction strategies will be critical to strengthening HIV prevention among FSWs globally.

Introduction: Evidence from routine, national programme data on HIV self‐testing (HIVST) scale‐up is limited. This study examines HIVST scale‐up in eight African countries, describing how HIVST has been integrated into testing strategies and how testing coverage, test positivity, and linkage to antiretroviral therapy (ART) have evolved. Methods: We conducted a retrospective descriptive analysis of national programme data from January 2019 to December 2023 across Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda and Zimbabwe. Data were disaggregated by quarter and subnational district. Indicators included HIVST kits distributed, conventional testing volumes, new HIV diagnoses and new ART initiations. We derived testing rates, testing positivity, ART linkage, and stability of HIVST distribution by district and over time. Results: HIVST scale‐up varied across countries. By the most recent quarter, HIVST accounted for 63% of total testing in Lesotho, 19%–25% in Malawi and Zimbabwe, but <15% in Kenya, Tanzania, Uganda and South Africa. In Malawi, Lesotho and Zimbabwe, large volumes of HIVST partially offset declines in conventional testing during the COVID‐19 pandemic. HIVST remained modest (<15% of total tests) in Kenya and Tanzania. In Mozambique, both conventional testing and HIVST expanded. In South Africa, conventional testing remained high after COVID‐19, while HIVST expanded slowly. Despite divergent trajectories, new HIV diagnoses and ART initiations remained stable in most settings, indicating programmes adapted to maintain case‐finding even as testing volumes shifted. Conclusions: This descriptive analysis shows HIVST has been scaled to different degrees, with its contribution to overall testing shaped by national contexts, and distribution models. Interpretation is constrained by incomplete reporting, the inability to identify kits used out of kits distributed and distinguishing first‐time from repeat testers. These findings can guide optimizing HIV testing services, an essential step towards meeting global HIV targets and ending AIDS by 2030.

Background: HIV incidence in sub-Saharan Africa has declined substantially since 2000 according to epidemic estimates published by UNAIDS. These estimates, derived by fitting mathematical models to national surveillance data, guide HIV programmes and epidemic response strategies. We assessed whether the level and age distribution of HIV incidence from modelled estimates were consistent with empirical HIV incidence observations, and whether incidence levels and trends were systematically different between study types, populations, and age groups. Methods: We conducted an updated systematic review of adult HIV incidence data from sub-Saharan Africa published July 2019-February 2024 by searching Scopus, PubMed, Embase, and OVID databases, and combined with earlier systematic review data. We matched empirical incidence measurements between 1990-2023 to UNAIDS HIV incidence estimates by study area, sex, age group, and year. We used Bayesian mixed-effect Poisson regression to estimate (1) incidence rate ratios (IRR) between empirical observations and matched modelled incidence estimates adjusted for sex, year and study type/population; and (2) time trends in age-specific incidence from population-based cohort studies and household surveys. Results: 3560 HIV empirical incidence measurements were included from 179 studies conducted in 21 countries, comprising 23,000 new infections and 3.1 million person-years. Incidence observations from nationally-representative household surveys (IRR 1.07 95%CI 0.68, 1.67) and population-representative study populations (IRR 0.98 95%CI 0.51, 1.89) were not significantly different from matched modelled estimates, and declined at the same rate as modelled estimates (annual aRR 0.99 95%CI 0.98, 1.01). Studies among pregnant women (IRR 2.60 95%CI 1.58, 4.28), control arms of clinical trials (IRR 3.01 95%CI 1.90, 4.77) and key populations (FSW IRR: 6.46 95%CI 4.18, 10.00; MSM 44.02 95%CI 27.35, 70.87) had significantly higher incidence than modelled total population incidence estimates. Across population cohorts in Eastern and Southern Africa, HIV incidence among adults aged 15-49 declined by 75-90% between 2010-2023, and declined 7% (95%CI 4-10%) faster per year among young adults 15-24 compared to age 25+ years. Modelled incidence declined similarly to cohort data, but did not reflect the aging of the epidemic. Conclusion: Observed incidence in population-representative studies in sub-Saharan Africa has declined steeply. Mathematical models that infer incidence from cross-sectional HIV surveillance data estimated the same incidence level and decline over time as population-representative studies. Studies with non-representative inclusion criteria had significantly higher incidence, including those among pregnant women and most HIV prevention/vaccine efficacy trials. The age pattern of incidence in modelled estimates should be reconsidered to capture the aging of the epidemic indicated by cohort studies.

Background: Awareness of HIV status is crucial for accessing HIV care and prevention but remains suboptimal in West Africa. The ATLAS initiative, launched in Côte d’Ivoire, Mali, and Senegal, addressed this gap by distributing approximately 380,000 HIV self-testing (HIVST) kits from 2019 to 2021, primarily to key populations and their social networks. This study assessed levels and correlates of Knowledge, Attitudes, and Practices (KAP) related to HIVST in the Bas-Sassandra region of Côte d’Ivoire following ATLAS’s introduction. Method: A cross-sectional population-based survey was conducted in the Bas-Sassandra region in 2021 among individuals aged 15–49. A total of 6,271 people (3,203 men and 3,068 women) were interviewed. They were selected using a three-stage stratified sampling approach in the Bas-Sassandra region. Bivariate statistics and multivariable logistic regressions were used to assess KAP levels and the associated factors. Results: Although few participants reported having heard about HIVST (11%) or having used it (3%), most of them reported that if it were freely available, they would be interested/very interested in using it for themselves (76%), as well as for their sexual partners (75%). Education and wealth were positively associated with knowledge and positive attitudes towards HIVST among both men and women, whereas age was positively correlated to knowledge and use of HIVST among men only. The number of sexual partners over the last 12 months was positively associated with knowledge of HIVST and willingness to use HIVST for themselves or their sexual partners among both sexes. We also found that high HIV-related knowledge and low levels of negative attitude were positively associated with positive attitudes towards HIVST, while exposure to the media appeared to be correlated to knowledge of HIVST. Conclusion: The high level of positive attitudes towards HIVST calls for a scaling up of access to HIVST in the region. Specific attention to groups with the worst KAP, such as the less educated, the poor or those with more HIV-related negative attitude, could enhance the success of such initiatives.

Background: Regular testing is recognized as a key strategy for HIV control. The 2023 Integrated Biological and Behavioral Survey (IBBS) in Cambodia revealed that nearly one-third of men who have sex with men (MSM) and one-fourth of transgender women (TGW) were never tested for HIV or not for more than 12 months. The majority of MSM and TGW were tested at community-based organizations (CBOs) facilities and by CBO outreach workers, while private facilities are poorly used for HIV testing (6% for MSM and 9% for TGW). Private pharmacies could be able to deliver HIV self-testing kits giving the advantage of confidentiality, anonymity, and time savings, in particular for those reluctant to visit CBOs. The recruitment of participants using a respondent-driven sampling method could provide the opportunity to reach MSM and TGW outside the network of CBOs. Objective: This pilot study aims to evaluate the feasibility of free HIV self-testing delivery by a private pharmacy combined with a respondent-driven sampling method to improve HIV testing among MSM and TGW in Phnom Penh, Cambodia. Methods: Both qualitative and quantitative approaches are used in this prospective feasibility study. The protocol was approved by the National Ethics Committee for Health Research in Cambodia (N0 351 NECHR). MSM and TGW aged more than 18 years old will be recruited via a respondent-driven sampling method with seeds recruited at hot spots and on social networks. The seeds will then distribute electronic and paper coupons to their networks physically and via social media, messaging, and calling applications. Each recruited peer will bring the coupon to receive direct and free access to one HIV self-testing kit at partner pharmacies as well as 10 additional coupons to recruit members of their networks. As for quantitative analysis, data from the study website will be imported, appended into a single matrix using Stata version 18SE (StataCorp), and analyzed using descriptive statistics, with a statistical significance level of .05. After 6 months, a qualitative assessment will be conducted among users, providers, and policymakers or key stakeholders to evaluate the acceptability and appropriateness of the strategy and to identify the barriers, facilitators, and recommendations. All transcripts will be analyzed according to the 6-phase reflexive thematic approach by Braun and Clarke. The results will be reported by participant-based and provider-based issues. QSR NVivo V.14 for Windows will be used to manage the data. Results: The study was funded by Agence nationale de recherches sur le sida, les hépatites, et les maladies infectieuses émergentes (ANRS) in September 2023. Approval of the study protocol was successfully obtained from the NECHR in Cambodia and the Commission Nationale de l'Informatique et des Libertés (CNIL) in France (Autorisation Tacite) in February 2025. Data collection will be conducted between September 2024 and December 2025. The initial results are expected to be published in February 2026. Conclusions: This public-private partnership intervention could allow the hidden population of MSM and TGW in Phnom Penh to be reached and tested. Trial Registration: ClinicalTrials.gov NCT05745168; https://clinicaltrials.gov/study/NCT05745168 International Registered Report Identifier (IRRID): PRR1-10.2196/65351

Introduction: Breast cancer is a global public health challenge. It is the most commonly diagnosed cancer and the leading cause of cancer-related death in women. Several inequalities remain among women facing this disease, depending on their country of birth and their sociodemographic characteristics. The SENOVIE study (Therapeutic mobility and breast cancer) aims to understand the life trajectories of women born in France and in sub-Saharan Africa treated for breast cancer in four hospitals in the greater Paris area. Methods and analysis: The SENOVIE study is a mixed methods study, combining a quantitative and a qualitative approach. A quantitative retrospective life-event survey is conducted in four hospital centres in the greater Paris area, France, to (1) understand how breast cancer (diagnosis, treatment and possibly reconstruction) impacts the life trajectories of women in many spheres (migration, family life, professional life, financial situation, etc); (2) study the access to healthcare by women living with breast cancer and their determinants; and (3) examine how gender relations may shape breast cancer experience. Women born in France and women born in sub-Saharan Africa are recruited: 1000 women, including 500 per group. In the standardised, face-to-face questionnaire, each dimension of interest is collected year by year from birth until the time of the survey. Clinical and laboratory information is documented with a short medical questionnaire filled out by the medical teams. The qualitative survey is conducted specifically with women born in sub-Saharan Africa who came to France for treatment to better understand their trajectories and the specific obstacles they faced. To analyse the quantitative data collected, descriptive analyses will be used to visualise trajectories (sequence analysis), along with longitudinal analysis methods (survival models and duration models). Ethics and dissemination: The study is conducted in accordance with the Declaration of Helsinki. The French Data Protection Authority (Commission Nationale de l’Informatique et des Libertés, declaration number 2231238) and the Committee for Persons’ Protection East I (Comité de Protection des Personnes Est I, national number 2023-A01311-44) approved it. We will disseminate the findings through scientific publications, policy briefs, conferences and workshops. Trial registration number: The SENOVIE France study is registered on Clinicaltrial.gov (NCT06503393; registration date: 7 September 2024; https://clinicaltrials.gov/study/NCT06503393).

Companion package for the manual 'guide-R : Guide pour l’analyse de données d’enquêtes avec R' available at . 'guideR' implements miscellaneous functions introduced in 'guide-R' to facilitate statistical analysis and manipulation of survey data.

Background: Awareness of HIV status is crucial for accessing HIV care and prevention but remains suboptimal in West Africa. The ATLAS initiative, launched in Côte d’Ivoire, Mali, and Senegal, addressed this gap by distributing approximately 380,000 HIV self-testing (HIVST) kits from 2019 to 2021, primarily to key populations and their social networks. This study assessed levels and correlates of Knowledge, Attitudes, and Practices (KAP) related to HIVST in the Bas-Sassandra region of Côte d’Ivoire following ATLAS’s introduction. Method: A cross-sectional population-based survey was conducted in the Bas-Sassandra region in 2021 among individuals aged 15-49. Bivariate statistics and multivariable logistic regressions were used to assess KAP levels and the associated factors. Results: Although few participants reported having heard about HIVST (11%) or having used it (3%), most of them reported that if it were freely available, they would be interested/very interested in using it for themselves (76%), as well as for their sexual partners (75%). Education and wealth were positively associated with knowledge and positive attitudes towards HIVST among both men and women, whereas age was positively correlated to knowledge and use of HIVST among men only. The number of sexual partners over the last 12 months was positively associated with knowledge of HIVST and willingness to use HIVST for themselves or their sexual partners among both sexes. We also found that high HIV-related knowledge and low levels of stigma were positively associated with positive attitudes towards HIVST, while exposure to the media appeared to be correlated to knowledge of HIVST. Conclusion: The high level of positive attitudes towards HIVST calls for a scaling up of access to HIVST in the region. Specific attention to groups with the worst KAP, such as the less educated, the poor or groups that are highly stigmatised, could enhance the success of such initiatives.