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Giddings R, Indravudh P, Medley GF, Bozzani F, Gafos M, Malhotra S, Terris-Prestholt F, Torres-Rueda S, Quaife M. Infectious Disease Modelling of HIV Prevention Interventions: A Systematic Review and Narrative Synthesis of Compartmental Models. PHARMACOECONOMICS 2023; 41:693-707. [PMID: 36988896 PMCID: PMC10163138 DOI: 10.1007/s40273-023-01260-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND The HIV epidemic remains a major public health problem. Critical to transmission control are HIV prevention strategies with new interventions continuing to be developed. Mathematical models are important for understanding the potential impact of these interventions and supporting policy decisions. This systematic review aims to answer the following question: when a new HIV prevention intervention is being considered or designed, what information regarding it is necessary to include in a compartmental model to provide useful insights to policy makers? The primary objective of this review is therefore to assess suitability of current compartmental HIV prevention models for informing policy development. METHODS Articles published in EMBASE, Medline, Econlit, and Global Health were screened. Included studies were identified using permutations of (i) HIV, (ii) pre-exposure prophylaxis (PrEP), circumcision (both voluntary male circumcision [VMMC] and early-infant male circumcision [EIMC]), and vaccination, and (iii) modelling. Data extraction focused on study design, model structure, and intervention incorporation into models. Article quality was assessed using the TRACE (TRAnsparent and Comprehensive Ecological modelling documentation) criteria for mathematical models. RESULTS Of 837 articles screened, 48 articles were included in the review, with 32 unique mathematical models identified. The substantial majority of studies included PrEP (83%), whilst fewer modelled circumcision (54%), and only a few focussed on vaccination (10%). Data evaluation, implementation verification, and model output corroboration were identified as areas of poorer model quality. Parameters commonly included in the mathematical models were intervention uptake and effectiveness, with additional intervention-specific common parameters identified. We identified key modelling gaps; critically, models insufficiently incorporate multiple interventions acting simultaneously. Additionally, population subgroups were generally poorly represented-with future models requiring improved incorporation of ethnicity and sexual risk group stratification-and many models contained inappropriate data in parameterisation which will affect output accuracy. CONCLUSIONS This review identified gaps in compartmental models to date and suggests areas of improvement for models focusing on new prevention interventions. Resolution of such gaps within future models will ensure greater robustness and transparency, and enable more accurate assessment of the impact that new interventions may have, thereby providing more meaningful guidance to policy makers.
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Affiliation(s)
| | | | | | | | - Mitzy Gafos
- London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Matthew Quaife
- London School of Hygiene & Tropical Medicine, London, UK
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Gökengin D. HIV Pre-Exposure Prophylaxis in Central and Eastern Europe-Gains and Challenges in An Ever-Changing World. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2022; 4:223-228. [PMID: 38633717 PMCID: PMC10986726 DOI: 10.36519/idcm.2022.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/10/2022] [Indexed: 04/19/2024]
Abstract
Pre-exposure prophylaxis (PrEP) is an effective prevention tool for controlling the HIV epidemic. Since its approval in the United States in 2012 and Europe in 2016, it has become available on a global scale offered as a registered strategy in clinical studies or demonstration projects with a slow and steady increase. In the second quarter of 2022, PrEP became available in 78 countries globally, with around 3 million people having started using PrEP. Europe has been much slower than the rest of the world to roll out PrEP; nevertheless, currently, PrEP is nationally available and reimbursed in 21 countries; generics are available but not reimbursed in 14 countries. PrEP is not formally implemented in 20 countries, which are mostly Central and Eastern European countries. There are significant disparities between countries in terms of PrEP availability, accessibility, and usage, most likely due to social, cultural, and political differences. The major barriers to PrEP use are reported to be lack of knowledge of people in need, not being reimbursed, and low perception of HIV. PrEP uptake globally and regionally still lacks the power to have an impact on controlling the epidemic. High prioritization of PrEP targets will offer us a realistic chance of reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) goal of a 90% reduction in HIV infections by 2030 compared to 2010.
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Affiliation(s)
- Deniz Gökengin
- Department of Infectious Diseases and Clinical Microbiology, Ege University School of Medicine, İzmir, Turkey
- Ege University HIV/AIDS Research and Practice Center, İzmir, Turkey
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Mosha NR, Todd J, Mukerebe C, Marston M, Colombe S, Clark B, Beard J, Mtenga B, Slaymaker E, Boerma T, Zaba B, Urassa M. The prevalence and incidence of HIV in the ART era (2006-2016) in North West Tanzania. Int J STD AIDS 2022; 33:337-346. [PMID: 35040735 PMCID: PMC7612632 DOI: 10.1177/09564624211065232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Sub-Saharan countries bears a disproportionate percentage of HIV infections and HIV related deaths despite the efforts to strengthen HIV prevention and treatments services, including ART. It is important to demonstrate how these services have contributed to reducing the epidemic using available population data. Methods We estimated the prevalence and incidence rates from a cohort running over 23 years in Magu District, Mwanza Region-North West Tanzania. Adults 15 years and over who were residents of the Kisesa observational HIV cohort study between 2006 and 2016 were eligible for inclusion. Survival analysis was used to calculate person-time at risk, incidence rates and 95% confidence intervals (CI). Cox regression models were used for the risk factor analyses disaggregated by sex and age group. Results The HIV prevalence in the sero-surveys decreased from 7.2% in 2006/07 to 6.6% in 2016, with a notable decrease of over 50% for both men and women aged 15-24 years. The incidence rate for HIV was estimated to be 5.5 (95% CI 4.6 - 6.6) per 1000 person-years in women compared to 4.6 (95% CI 3.5 – 5.8) in men, with a decrease over time. Despite the availability of ART services, the uptake is still small. Conclusions New infections are still occurring, with high HIV incidence in individuals aged below 45 years. With new guidelines and the 95-95-95 UNAIDS target, prevalence and incidence must be adequately assessed. In addition, there is a need for additional efforts to assess the impact of HIV/AIDS prevention programmes and intervention services, especially in these areas where resources are limited.
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Affiliation(s)
- Neema R Mosha
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, 121470Stellenbosch University, Cape Town, South Africa.,Mwanza Intervention Trials Unit, Mwanza, Tanzania.,119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Jim Todd
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania.,Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Crispin Mukerebe
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Milly Marston
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | | | - Benjamin Clark
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - James Beard
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Baltazar Mtenga
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
| | - Emma Slaymaker
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Ties Boerma
- University of Manitoba, Winnipeg, MB, Canada
| | - Basia Zaba
- Department of Population Health, 4906London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Urassa
- 119151National Institute for Medical Research, Mwanza Centre, Mwanza, Tanzania
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Luong Nguyen LB, Freedberg KA, Wanjala S, Maman D, Szumilin E, Mendiharat P, Yazdanpanah Y. Comparative effectiveness of interventions to improve the HIV continuum of care and HIV Pre-Exposure Prophylaxis in Kenya: a model-based analysis. J Infect Dis 2020; 225:1032-1039. [PMID: 33106850 PMCID: PMC8922000 DOI: 10.1093/infdis/jiaa633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/12/2020] [Indexed: 11/14/2022] Open
Abstract
Background In Western Kenya up to one-quarter of the adult population was human immunodeficiency virus (HIV)-infected in 2012. The Ministry of Health, Médecins Sans Frontières, and partners implemented an HIV program that surpassed the 90-90-90 UNAIDS targets. In this generalized epidemic, we compared the effectiveness of preexposure prophylaxis (PrEP) with improving continuum of care. Methods We developed a dynamic microsimulation model to project HIV incidence and infections averted to 2030. We modeled 3 strategies compared to a 90-90-90 continuum of care base case: (1) scaling up the continuum of care to 95-95-95, (2) PrEP targeting young adults with 10% coverage, and (3) scaling up to 95-95-95 and PrEP combined. Results In the base case, by 2030 HIV incidence was 0.37/100 person-years. Improving continuum levels to 95-95-95 averted 21.5% of infections, PrEP averted 8.0%, and combining 95-95-95 and PrEP averted 31.8%. Sensitivity analysis showed that PrEP coverage had to exceed 20% to avert as many infections as reaching 95-95-95. Conclusions In a generalized HIV epidemic with continuum of care levels at 90-90-90, improving the continuum to 95-95-95 is more effective than providing PrEP. Continued improvement in the continuum of care will have the greatest impact on decreasing new HIV infections.
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Affiliation(s)
- Liem B Luong Nguyen
- From Université de Paris, IAME, INSERM, Paris, France.,Unité des Maladies Emergentes, Institut Pasteur, Paris
| | - Kenneth A Freedberg
- the Medical Practice Evaluation Center and Divisions of General Internal Medicine and Infectious Diseases, Massachusetts General Hospital, Harvard Medical School.,the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, both of Boston, MA, USA
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Abstract
Tenofovir disoproxil fumarate coformulated with emtricitabine (TDF/FTC) was shown to be effective in preventing HIV acquisition when used for pre-exposure prophylaxis (PrEP), but questions have arisen regarding optimal PrEP implementation strategies.
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Case KK, Gomez GB, Hallett TB. The impact, cost and cost-effectiveness of oral pre-exposure prophylaxis in sub-Saharan Africa: a scoping review of modelling contributions and way forward. J Int AIDS Soc 2019; 22:e25390. [PMID: 31538407 PMCID: PMC6753289 DOI: 10.1002/jia2.25390] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 08/06/2019] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Oral pre-exposure prophylaxis (PrEP) is a new form of HIV prevention being considered for inclusion in national prevention portfolios. Many mathematical modelling studies have been undertaken that speak to the impact, cost and cost-effectiveness of PrEP programmes. We assess the available evidence from mathematical modelling studies to inform programme planning and policy decision making for PrEP and further research directions. METHODS We conducted a scoping review of the published modelling literature. Articles published in English which modelled oral PrEP in sub-Saharan Africa, or non-specific settings with relevance to generalized HIV epidemic settings, were included. Data were extracted for the strategies of PrEP use modelled, and the impact, cost and cost-effectiveness of PrEP for each strategy. We define an algorithm to assess the quality and relevance of studies included, summarize the available evidence and identify the current gaps in modelling. Recommendations are generated for future modelling applications and data collection. RESULTS AND DISCUSSION We reviewed 1924 abstracts and included 44 studies spanning 2007 to 2017. Modelling has reported that PrEP can be a cost-effective addition to HIV prevention portfolios for some use cases, but also that it would not be cost-effective to fund PrEP before other prevention interventions are expanded. However, our assessment of the quality of the modelling indicates cost-effectiveness analyses failed to comply with standards of reporting for economic evaluations and the assessment of relevance highlighted that both key parameters and scenarios are now outdated. Current evidence gaps include modelling to inform service development using updated programmatic information and ex post modelling to evaluate and inform efficient deployment of resources in support of PrEP, especially among key populations, using direct evidence of cost, adherence and uptake patterns. CONCLUSIONS Updated modelling which more appropriately captures PrEP programme delivery, uses current intervention scenarios, and is parameterized with data from demonstration and implementation projects is needed in support of more conclusive findings and actionable recommendations for programmes and policy. Future analyses should address these issues, aligning with countries to support the needs of programme planners and decision makers for models to more directly inform programme planning and policy.
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Affiliation(s)
- Kelsey K Case
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
| | - Gabriela B Gomez
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Timothy B Hallett
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
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Grebe E, Welte A, Johnson LF, van Cutsem G, Puren A, Ellman T, Etard JF, Huerga H. Population-level HIV incidence estimates using a combination of synthetic cohort and recency biomarker approaches in KwaZulu-Natal, South Africa. PLoS One 2018; 13:e0203638. [PMID: 30212513 PMCID: PMC6136757 DOI: 10.1371/journal.pone.0203638] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/26/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction There is a notable absence of consensus on how to generate estimates of population-level incidence. Incidence is a considerably more sensitive indicator of epidemiological trends than prevalence, but is harder to estimate. We used a novel hybrid method to estimate HIV incidence by age and sex in a rural district of KwaZulu-Natal, South Africa. Methods Our novel method uses an ‘optimal weighting’ of estimates based on an implementation of a particular ‘synthetic cohort’ approach (interpreting the age/time structure of prevalence, in conjunction with estimates of excess mortality) and biomarkers of ‘recent infection’ (combining Lag-Avidity, Bio-Rad Avidity and viral load results to define recent infection, and adapting the method for age-specific incidence estimation). Data were obtained from a population-based cross-sectional HIV survey conducted in Mbongolwane and Eshowe health service areas in 2013. Results Using the combined method, we find that age-specific HIV incidence in females rose rapidly during adolescence, from 1.33 cases/100 person-years (95% CI: 0.98,1.67) at age 15 to a peak of 5.01/100PY (4.14,5.87) at age 23. In males, incidence was lower, 0.34/100PY (0.00-0.74) at age 15, and rose later, peaking at 3.86/100PY (2.52-5.20) at age 30. Susceptible population-weighted average incidence in females aged 15-29 was estimated at 3.84/100PY (3.36-4.40), in males aged 15-29 at 1.28/100PY (0.68-1.50) and in all individuals aged 15-29 at 2.55/100PY (2.09-2.76). Using the conventional recency biomarker approach, we estimated HIV incidence among females aged 15-29 at 2.99/100PY (1.79-4.36), among males aged 15-29 at 0.87/100PY (0.22-1.60) and among all individuals aged 15-59 at 1.66/100PY (1.13-2.27). Discussion HIV incidence was very high in women aged 15-30, peaking in the early 20s. Men had lower incidence, which peaked at age 30. The estimates obtained from the hybrid method are more informative than those produced by conventional analysis of biomarker data, and represents a more optimal use of available data than either the age-continuous biomarker or synthetic cohort methods alone. The method is mainly useful at younger ages, where excess mortality is low and uncertainty in the synthetic cohort estimates is reasonably small. Conclusion Application of this method to large-scale population-based HIV prevalence surveys is likely to result in improved incidence surveillance over methods currently in wide use. Reasonably accurate and precise age-specific estimates of incidence are important to target better prevention, diagnosis and care strategies.
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Affiliation(s)
- Eduard Grebe
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
- * E-mail:
| | - Alex Welte
- DST-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Leigh F. Johnson
- Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, Cape Town, South Africa
| | - Gilles van Cutsem
- Centre for Infectious Diseases Epidemiology and Research (CIDER), University of Cape Town, Cape Town, South Africa
- Médecins Sans Frontières, Cape Town, South Africa
| | - Adrian Puren
- National Institute for Communicable Diseases (NICD), National Health Laboratory Service, Johannesburg, South Africa
| | - Tom Ellman
- Médecins Sans Frontières, Cape Town, South Africa
| | - Jean-François Etard
- TransVIHMI, Institut de Recherche pour le Développement (IRD), Institut National de la Santé et de la Recherche Médicale (INSERM), Montpellier University, Montpellier, France
- Epicentre, Paris, France
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Kharsany ABM, Cawood C, Khanyile D, Lewis L, Grobler A, Puren A, Govender K, George G, Beckett S, Samsunder N, Madurai S, Toledo C, Chipeta Z, Glenshaw M, Hersey S, Abdool Karim Q. Community-based HIV prevalence in KwaZulu-Natal, South Africa: results of a cross-sectional household survey. Lancet HIV 2018; 5:e427-e437. [PMID: 30021700 PMCID: PMC7498647 DOI: 10.1016/s2352-3018(18)30104-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/28/2018] [Accepted: 05/11/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND In high HIV burden settings, maximising the coverage of prevention strategies is crucial to achieving epidemic control. However, little is known about the reach and effect of these strategies in some communities. METHODS We did a cross-sectional community survey in the adjacent Greater Edendale and Vulindlela areas in the uMgungundlovu district, KwaZulu-Natal, South Africa. Using a multistage cluster sampling method, we randomly selected enumeration areas, households, and individuals. One household member (aged 15-49 years) selected at random was invited for survey participation. After obtaining consent, questionnaires were administered to obtain sociodemographic, psychosocial, and behavioural information, and exposure to HIV prevention and treatment programmes. Clinical samples were collected for laboratory measurements. Statistical analyses were done accounting for multilevel sampling and weighted to represent the population. A multivariable logistic regression model assessed factors associated with HIV infection. FINDINGS Between June 11, 2014, and June 22, 2015, we enrolled 9812 individuals. The population-weighted HIV prevalence was 36·3% (95% CI 34·8-37·8, 3969 of 9812); 44·1% (42·3-45·9, 2955 of 6265) in women and 28·0% (25·9-30·1, 1014 of 3547) in men (p<0·0001). HIV prevalence in women aged 15-24 years was 22·3% (20·2-24·4, 567 of 2224) compared with 7·6% (6·0-9·3, 124 of 1472; p<0·0001) in men of the same age. Prevalence peaked at 66·4% (61·7-71·2, 517 of 760) in women aged 35-39 years and 59·6% (53·0-66·3, 183 of 320) in men aged 40-44 years. Consistent condom use in the last 12 months was 26·5% (24·1-28·8, 593 of 2356) in men and 22·7% (20·9-24·4, 994 of 4350) in women (p=0·0033); 35·7% (33·4-37·9, 1695 of 5447) of women's male partners and 31·9% (29·5-34·3, 1102 of 3547) of men were medically circumcised (p<0·0001), and 45·6% (42·9-48·2, 1251 of 2955) of women and 36·7% (32·3-41·2, 341 of 1014) of men reported antiretroviral therapy (ART) use (p=0·0003). HIV viral suppression was achieved in 54·8% (52·0-57·5, 1574 of 2955) of women and 41·9% (37·1-46·7, 401 of 1014) of men (p<0·0001), and 87·2% (84·6-89·8, 1086 of 1251) of women and 83·9% (78·5-89·3, 284 of 341; p=0·3670) of men on ART. Age, incomplete secondary schooling, being single, having more than one lifetime sex partner (women), sexually transmitted infections, and not being medically circumcised were associated with HIV-positive status. INTERPRETATION The HIV burden in specific age groups, the suboptimal differential coverage, and uptake of HIV prevention strategies justifies a location-based approach to surveillance with finer disaggregation by age and sex. Intensified and customised approaches to seek, identify, and link individuals to HIV services are crucial to achieving epidemic control in this community. FUNDING The President's Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention.
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Affiliation(s)
- Ayesha B M Kharsany
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
| | - Cherie Cawood
- Epicentre AIDs Risk Management (Pty) Limited, Cape Town, South Africa
| | - David Khanyile
- Epicentre AIDs Risk Management (Pty) Limited, Cape Town, South Africa
| | - Lara Lewis
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Anneke Grobler
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | - Adrian Puren
- Centre for HIV and STIs, National Institute for Communicable Diseases, National Health Laboratory Service (NICD/NHLS), Johannesburg, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Gavin George
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Sean Beckett
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Natasha Samsunder
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa
| | | | - Carlos Toledo
- Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA
| | - Zawadi Chipeta
- Centers for Disease Control and Prevention (CDC), Pretoria, South Africa; BroadReach, Cape Town, South Africa
| | - Mary Glenshaw
- Centers for Disease Control and Prevention (CDC), Pretoria, South Africa
| | - Sara Hersey
- Centers for Disease Control and Prevention (CDC), Pretoria, South Africa; Centers for Disease Control and Prevention (CDC), Freetown, Sierra Leone
| | - Quarraisha Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa; Department of Epidemiology, Columbia University, New York, NY, USA
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