Amee Schwitters

Context: In response to the first reported mpox cases in May 2022, the US government implemented plans to bring testing, treatment, and vaccines to communities disproportionately affected by mpox—including the population of men who have sex with men (MSM) and Black/African American and Hispanic/Latino men, 2 subpopulations experiencing vaccination disparities. We describe the development and implementation of the US Mpox Vaccine Equity Pilot Program (MVEPP), characteristics of completed vaccination projects, and challenges that occurred. We also discuss opportunities for reducing vaccination disparities in future outbreaks. Program: To address reported vaccination disparities, the US government launched MVEPP in 2 phases. Phase 1 centered around public events attended by large numbers of gay, bisexual, and other MSM, such as Pride festivals. Phase 2 asked health departments to propose mpox vaccination projects specifically aimed at reducing or eliminating racial/ethnic and other demographic disparities in mpox vaccination. Implementation: MVEPP received 35 vaccination project proposals. We analyzed data from 22 completed projects that resulted in 25 675 doses of JYNNEOS administered. We note 3 innovative strategies that were implemented in several projects: direct collaboration with organizations providing services to MSM and transgender women; implementation of MVEPP projects in unique nonclinical community settings and at venues frequented by MSM and transgender women; and offering an array of services as part of mpox vaccination projects, rather than offering only mpox vaccination. Evaluation: MVEPP highlighted the importance of recognizing and working to eliminate racial/ethnic and other disparities in access to medical countermeasures during a public health emergency. Jurisdictions developed and implemented innovative strategies to bring mpox vaccination and related services to communities disproportionately affected by mpox—including MSM and the subpopulations of Black/African American and Hispanic/Latino MSM. Lessons learned from MVEPP may inform efforts to reduce disparities during future public health responses.

Background: Nigeria has the fourth largest burden of HIV globally. Key populations, including female sex workers, men who have sex with men, and people who inject drugs, are more vulnerable to HIV than the general population due to stigmatized and criminalized behaviors. Reliable key population size estimates are needed to guide HIV epidemic response efforts. Objective: The objective of our study was to use empirical methods for sampling and analysis to improve the quality of population size estimates of female sex workers, men who have sex with men, and people who inject drugs in 7 states (Akwa Ibom, Benue, Cross River, Lagos, Nasarawa, Rivers, and the Federal Capital Territory) of Nigeria for program planning and to demonstrate improved statistical estimation methods. Methods: From October to December 2018, we used 3-source capture-recapture to produce population size estimates in 7 states in Nigeria. Hotspots were mapped before 3-source capture-recapture started. We sampled female sex workers, men who have sex with men, and people who inject drugs during 3 independent captures about one week apart. During hotspot encounters, key population members were offered inexpensive, memorable objects unique to each capture round. In subsequent rounds, key population members were offered an object and asked to identify objects received during previous rounds (if any). Correct responses were tallied and recorded on tablets. Data were aggregated by key population and state for analysis. Median population size estimates were derived using Bayesian nonparametric latent-class models with 80% highest density intervals. Results: Overall, we sampled approximately 310,000 persons at 9015 hotspots during 3 independent captures. Population size estimates for female sex workers ranged from 14,500 to 64,300; population size estimates for men who have sex with men ranged from 3200 to 41,400; and population size estimates for people who inject drugs ranged from 3400 to 30,400. Conclusions: This was the first implementation of these 3-source capture-recapture methods in Nigeria. Our population size estimates were larger than previously documented for each key population in all states. The Bayesian models account for factors, such as social visibility, that influence heterogeneous capture probabilities, resulting in more reliable population size estimates. The larger population size estimates suggest a need for programmatic scale-up to reach these populations, which are at highest risk for HIV.

Background In 2019, 36% of the 150,000 children less than 15 years of age living with HIV in Nigeria knew their status, and were receiving antiretroviral therapy. Literature on HIV-positive parents getting their children tested for HIV is limited. Methods Semi-structured interviews were conducted across six geopolitical zones of Nigeria with 101 eligible people living with HIV who had at least one living biological child Results Facilitators to HTS for children of PLHIV included: PLHIV’s positive status, PLHIV’s partner’s HIV status, and continuous education by health care workers. Reported barriers included the parent’s perception of the child’s health status, family dynamics, and structural and socio-economic challenges. Conclusion The right combination of interventions including those that encourage care providers to render services in a way that elicits a demand for services from clients is critical for improving uptake of HTS for children of PLHIV.

Despite extensive global efforts, sub-Saharan Africa remains disproportionately affected by the HIV epidemic. This generalized epidemic can be seen in Lesotho which in 2014 the HIV prevalence rate of those aged 15–49 years was 24.6%, with and incidence of 1.9 new infections per 100-person-year exposures. To better understand the impact of Lesotho’s national HIV response and significant predictors associated with HIV infection, the Lesotho Population-based HIV Impact Assessment was conducted. This survey provided a nationally representative sample of individuals aged 15–59 years old in which participants were tested for HIV and given an individual questionnaire that included socio-demographic and behavioral risk questions. The association of factors between survey questions and HIV incident was assessed using logistic regression. Multivariate logistic regression models for men and women were constructed for each outcome using variables known to be or plausibly associated with recent or chronic infection. Overall annualized incidence among people aged 15–49 was 1.19% (95% CI 0.73–1.65) per year. The overall prevalence of HIV was 25.6% with women having significantly higher prevalence. Multiple variables, including decreased wealth status, lower education levels, marital status, condom use at first sex, and circumcision (men only) were identified as being significantly associated with HIV infection for both men and women. In combination with improving the awareness of HIV status, an increased focus is needed on AGYW and men 35–49 years old to prevent new infections. HIV education and prevention programs should focus heavily on younger age groups prior to and soon after sexual debut to prevent HIV transmission. The findings of the survey showed significant room for improvement in increasing awareness of HIV status and reinforcing the need for continued HIV prevention and treatment efforts in Lesotho to prevent new infections.

Objective To assess the potential bidirectional relationship between food insecurity and HIV infection in sub-Saharan Africa. Design Nationally representative HIV impact assessment household-based surveys. Setting Zambia, Eswatini, Lesotho, Uganda and Tanzania and Namibia. Participants 112 955 survey participants aged 15–59 years with HIV and recency test results. Measures Recent HIV infection (within 6 months) classified using the HIV-1 limited antigen avidity assay, in participants with an unsuppressed viral load (>1000 copies/mL) and no detectable antiretrovirals; severe food insecurity (SFI) defined as having no food in the house ≥three times in the past month. Results Overall, 10.3% of participants lived in households reporting SFI. SFI was most common in urban, woman-headed households, and in people with chronic HIV infection. Among women, SFI was associated with a twofold increase in risk of recent HIV infection (adjusted relative risk (aRR) 2.08, 95% CI 1.09 to 3.97). SFI was also associated with transactional sex (aRR 1.28, 95% CI 1.17 to 1.41), a history of forced sex (aRR 1.36, 95% CI 1.11 to 1.66) and condom-less sex with a partner of unknown or positive HIV status (aRR 1.08, 95% CI 1.02 to 1.14) in all women, and intergenerational sex (partner ≥10 years older) in women aged 15–24 years (aRR 1.23, 95% CI 1.03 to 1.46). Recent receipt of food support was protective against HIV acquisition (aRR 0.36, 95% CI 0.14 to 0.88). Conclusion SFI increased risk for HIV acquisition in women by twofold. Heightened food insecurity during climactic extremes could imperil HIV epidemic control, and food support to women with SFI during these events could reduce HIV transmission.

BACKGROUND Nigeria has the fourth largest burden of HIV globally. Key populations (KP) including female sex workers (FSW), men who have sex with men (MSM), and people who inject drugs (PWID) often have poor social visibility and are more vulnerable to HIV than the general population due to stigma, discrimination, and criminalization of KP-defining behaviors. Reliable, empirical population size estimates (PSE) are needed to guide focused and appropriately scaled HIV epidemic response efforts for KP. We used novel approaches to sampling and analysis to calculate PSE in Nigeria. OBJECTIVE We sampled the population using three-source capture-recapture (3S-CRC) and analyzed results using Bayesian nonparametric latent-class models to generate median PSE with 80% highest density intervals. METHODS During October–December 2018, we used three-source capture-recapture (3S-CRC) to estimate the size of KP in seven United States President’s Emergency Plan for AIDS Relief (PEPFAR) priority states in Nigeria. Hotspots were mapped before 3S-CRC started. We sampled FSW, MSM, and PWID during three independent captures approximately one week apart. During encounters in KP hotspots, distributors offered inexpensive and memorable objects to KP, unique to each capture round and KP type. In subsequent rounds, participants were offered an object and asked to produce or identify objects received during previous rounds (if any); affirmative responses were tallied upon producing or identifying the correct object. Distributors recorded responses on tablets and uploaded to a secure server after each encounter. Data were aggregated by KP and state for analysis. Median PSE were derived using Bayesian nonparametric latent-class models with 80% highest density intervals for precision. RESULTS We sampled approximately 310,000 persons at 9,015 hotspots during three independent captures in all seven states. Overall, FSW PSE ranged from 14,500-64,300; MSM PSE, 3,200-41,400; and PWID PSE, 3,400-30,400. CONCLUSIONS This study represents the first implementation of these 3S-CRC sampling and novel analysis methods for large-scale population size estimation in Nigeria. Overall, our estimates were larger than previously documented for each KP in all states. The current Bayesian models account for factors (i.e., social visibility and stigma) that influence heterogeneous capture probabilities resulting in more reliable PSE. The larger estimates suggest a need for programmatic scale-up to reach these populations at highest risk for HIV.

Background: With the fourth highest HIV burden globally, Nigeria is characterized as having a mixed HIV epidemic with high HIV prevalence among key populations, including female sex workers, men who have sex with men, and people who inject drugs. Reliable and accurate mapping of key population hotspots is necessary for strategic placement of services and allocation of limited resources for targeted interventions. Objective: We aimed to map and develop a profile for the hotspots of female sex workers, men who have sex with men, and people who inject drugs in 7 states of Nigeria to inform HIV prevention and service programs and in preparation for a multiple-source capture-recapture population size estimation effort. Methods: In August 2018, 261 trained data collectors from 36 key population–led community-based organizations mapped, validated, and profiled hotspots identified during the formative assessment in 7 priority states in Nigeria designated by the United States President’s Emergency Plan for AIDS Relief. Hotspots were defined as physical venues wherein key population members frequent to socialize, seek clients, or engage in key population–defining behaviors. Hotspots were visited by data collectors, and each hotspot’s name, local government area, address, type, geographic coordinates, peak times of activity, and estimated number of key population members was recorded. The number of key population hotspots per local government area was tabulated from the final list of hotspots. Results: A total of 13,899 key population hotspots were identified and mapped in the 7 states, that is, 1297 in Akwa Ibom, 1714 in Benue, 2666 in Cross River, 2974 in Lagos, 1550 in Nasarawa, 2494 in Rivers, and 1204 in Federal Capital Territory. The most common hotspots were those frequented by female sex workers (9593/13,899, 69.0%), followed by people who inject drugs (2729/13,899, 19.6%) and men who have sex with men (1577/13,899, 11.3%). Although hotspots were identified in all local government areas visited, more hotspots were found in metropolitan local government areas and state capitals. Conclusions: The number of key population hotspots identified in this study is more than that previously reported in similar studies in Nigeria. Close collaboration with key population–led community-based organizations facilitated identification of many new and previously undocumented key population hotspots in the 7 states. The smaller number of hotspots of men who have sex with men than that of female sex workers and that of people who inject drugs may reflect the social pressure and stigma faced by this population since the enforcement of the 2014 Same Sex Marriage (Prohibition) Act, which prohibits engaging in intimate same-sex relationships, organizing meetings of gays, or patronizing gay businesses.

Introduction: The global target for 2020 is that ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) will achieve viral load suppression (VLS). We examined VLS and its determinants among adults receiving ART for at least four months.Methods: We analysed data from the population‐based HIV impact assessment (PHIA) surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe (2015 to 2017). PHIA surveys are nationally representative, cross‐sectional household surveys. Data collection included structured interviews, home‐based HIV testing and laboratory testing. Blood samples from PLHIV were analysed for HIV RNA, CD4 counts and recent exposure to antiretroviral drugs (ARVs). We calculated representative estimates for the prevalence of VLS (viral load <1000 copies/mL), nonsuppressed viral load (NVL; viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL) and rates of switching to second‐line ART (protease inhibitors present) among PLHIV aged 15 to 59 years who participated in the PHIA surveys in Eswatini, Lesotho, Malawi, Zambia and Zimbabwe, initiated ART at least four months before the survey and were receiving ART at the time of the survey (according to self‐report or ARV testing). We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second‐line ART.Results: We included 9200 adults receiving ART of whom 88.8% had VLS and 11.2% had NVL including 8.2% who experienced VF and 3.0% who interrupted ART. Younger age, male sex, less education, suboptimal adherence, receiving nevirapine, HIV non‐disclosure, never having married and residing in Zimbabwe, Lesotho or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female sex, shorter ART duration, higher CD4 count and alcohol use were associated with lower odds for VF and higher odds for interrupted ART. Many people with VF (44.8%) had CD4 counts <200 cells/µL, but few (0.31% per year) switched to second‐line ART.Conclusions: Countries are approaching global VLS targets for adults. Treatment support, in particular for younger adults, and people with higher CD4 counts, and switching of people to protease inhibitor‐ or integrase inhibitor‐based regimens may further reduce NVL prevalence.

BACKGROUND With the fourth highest HIV burden globally, Nigeria is characterized as having a mixed HIV epidemic with high HIV prevalence among key populations, including female sex workers, men who have sex with men, and people who inject drugs. Reliable and accurate mapping of key population hotspots is necessary for strategic placement of services and allocation of limited resources for targeted interventions. OBJECTIVE We aimed to map and develop a profile for the hotspots of female sex workers, men who have sex with men, and people who inject drugs in 7 states of Nigeria to inform HIV prevention and service programs and in preparation for a multiple-source capture-recapture population size estimation effort. METHODS In August 2018, 261 trained data collectors from 36 key population–led community-based organizations mapped, validated, and profiled hotspots identified during the formative assessment in 7 priority states in Nigeria designated by the United States President’s Emergency Plan for AIDS Relief. Hotspots were defined as physical venues wherein key population members frequent to socialize, seek clients, or engage in key population–defining behaviors. Hotspots were visited by data collectors, and each hotspot’s name, local government area, address, type, geographic coordinates, peak times of activity, and estimated number of key population members was recorded. The number of key population hotspots per local government area was tabulated from the final list of hotspots. RESULTS A total of 13,899 key population hotspots were identified and mapped in the 7 states, that is, 1297 in Akwa Ibom, 1714 in Benue, 2666 in Cross River, 2974 in Lagos, 1550 in Nasarawa, 2494 in Rivers, and 1204 in Federal Capital Territory. The most common hotspots were those frequented by female sex workers (9593/13,899, 69.0%), followed by people who inject drugs (2729/13,899, 19.6%) and men who have sex with men (1577/13,899, 11.3%). Although hotspots were identified in all local government areas visited, more hotspots were found in metropolitan local government areas and state capitals. CONCLUSIONS The number of key population hotspots identified in this study is more than that previously reported in similar studies in Nigeria. Close collaboration with key population–led community-based organizations facilitated identification of many new and previously undocumented key population hotspots in the 7 states. The smaller number of hotspots of men who have sex with men than that of female sex workers and that of people who inject drugs may reflect the social pressure and stigma faced by this population since the enforcement of the 2014 Same Sex Marriage (Prohibition) Act, which prohibits engaging in intimate same-sex relationships, organizing meetings of gays, or patronizing gay businesses.

Introduction: The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set a target of ≥90% of people living with HIV (PLHIV) receiving antiretroviral therapy (ART) to have viral load suppression (VLS). We examined factors associated with nonsuppressed viral Load (NVL). Methods: We included PLHIV receiving ART aged 15–59 years from Eswatini, Lesotho, Malawi, Zambia, and Zimbabwe. Blood samples from PLHIV were analyzed for HIV RNA and recent exposure to antiretroviral drugs (ARVs). Outcomes were NVL (viral load ≥1000 copies/mL), virologic failure (VF; ARVs present and viral load ≥1000 copies/mL), interrupted ART (ARVs absent and viral load ≥1000 copies/mL), and receiving second-line ART. We calculated odds ratios and incidence rate ratios for factors associated with NVL, VF, interrupted ART, and switching to second-line ART. Results: The prevalence of NVL was 11.2%: 8.2% experienced VF, and 3.0% interrupted ART. Younger age, male gender, less education, suboptimal adherence, receiving nevirapine, HIV non-disclosure, never having married, and residing in Zimbabwe, Lesotho, or Zambia were associated with higher odds of NVL. Among people with NVL, marriage, female gender, shorter ART duration, higher CD4 count, and alcohol use were associated with higher odds for interrupted ART and lower odds for VF. Many people with VF (44.8%) had CD4 counts <200 cells/µL, but few (0.31% per year) switched to second-line ART. Conclusions: Countries are approaching UNAIDS VLS targets for adults. Treatment support for people initiating ART with asymptomatic HIV infection, scale-up of viral load monitoring, and optimized ART regimens may further reduce NVL prevalence.