African Security Review

AbstractIntroductionThere has been significant progress in the rollout of oral pre‐exposure prophylaxis (PrEP) for the prevention of HIV. The introduction of long‐acting prevention methods holds the potential to improve HIV prevention uptake and use, however, presents unique complexities regarding HIV diagnosis and potential for resistance. Quantifying and understanding the scenarios within which seroconversions occur may help to inform approaches to identifying acute HIV in programmes delivering PrEP at scale.MethodsThis paper documents ctra series of seroconversions within a large implementation study conducted in eight Department of Health facilities and four linked mobile clinics in four areas of South Africa. Using routinely collected data, we conducted a descriptive analysis of clients who seroconverted after initiating oral PrEP and determined the distribution of time from oral PrEP initiation to seroconversion as well as the proportion of days covered by oral PrEP. A seroconversion was defined as any HIV‐positive diagnosis after initiation of PrEP. Time to seroconversion was calculated as the number of days between the first PrEP initiation and the date of HIV diagnosis. The proportion of days covered by PrEP was calculated as the number of days of PrEP prescribed over the number of days between PrEP initiation and HIV seroconversion. We conducted a logistic regression to determine factors associated with seroconversion.ResultsOf the 11,882 clients initiated on PrEP between January 2019 and October 2022 who attended at least one follow‐up visit, 112 (0.9%) seroconverted after PrEP initiation. Among those who seroconverted, the median proportion of days covered by PrEP between initiation and seroconversion was 33%. In the period between PrEP initiation and seroconversion, almost all (n = 93, 83.0%) had not used PrEP consistently, with only 19 (17.0%) having consistent PrEP use, all of whom were identified at the 1‐month follow‐up visit and were likely missed acute acquisitions. Younger age and geographical area were associated with seroconversion.ConclusionsThis study reports a low number of seroconversions among a large cohort of PrEP users in a real‐world implementation study, the majority of which occurred among clients who had interrupted or discontinued PrEP use.

AbstractIntroductionLong‐acting HIV pre‐exposure prophylaxis promises to improve uptake, adherence and persistence challenges experienced with daily oral tablets. We assessed the acceptability of an annual tenofovir alafenamide (TAF) implant in South African women enrolled from 9 July 2020 until 31 May 2022 in a Phase I trial.MethodsSix women received one TAF implant for 4 weeks (Group 1), after which 30 women were randomized (4:1, TAF to placebo ratio) to receive 1 or 2 TAF or placebo implants for 48 weeks (Group 2), before trial discontinuation. Acceptability assessments were conducted pre‐ and post‐implant removal. Implant attributes (size, quantity, insertion site, palpability, visibility) and physical experiences (insertion/removal procedures, implant site reactions [ISRs]) were rated on a scale of 1 (highly unacceptable) to 6 (highly acceptable), with 4 being the acceptability threshold. The mean (range) of the mean acceptability scores across all pre‐removal visits were calculated, including stratification by removal timing (early vs. scheduled). Implant likes and dislikes were also assessed.ResultsThe median participant age was 26 years. Prior to implant removal, the mean (range) acceptability scores were 5.4 (3.6–6.0) for product attributes and 5.1 (1.7–6.0) for physical experiences. Eleven (31%) participants had early implant removals, occurring on average 19 weeks (range 2–27 weeks) after insertion. The proportion of study visits reporting adherence measure as unacceptable in early versus scheduled removals: ISRs (50% vs. 19%), visibility (30% vs. 15%), palpability (14% vs. 8%), pain (16% vs. 4%) and implant quantity (13% vs. 1%). Pre‐removal acceptability scores for ISRs (p = 0.003) and physical experiences (p = 0.05) were significantly associated with early removal. Overall, mean (range) acceptability scores were 5.8 (4.0–6.0) and 5.9 (4.7–6.0) for lifestyle compatibility and likelihood of recommendation, respectively. After removal, 39% of participants found ISRs unacceptable, followed by 22% citing implant visibility. Potential for long‐term HIV protection, followed by discreet and convenient use, were most liked, while ISRs were the most disliked aspect.ConclusionsWhile implant attributes, physical experiences and insertion/removal procedures were largely acceptable, local ISRs significantly reduced tolerability and acceptability, resulting in higher‐than‐expected early removals. The potential benefits of an annual TAF implant may be undermined unless tolerability is improved.

ABSTRACTIntroductionOral HIV pre‐exposure prophylaxis (PrEP) is highly effective, but adherence is challenging for young women. Products centred around women's preferences could address adherence barriers. Using a longitudinal discrete choice experiment (DCE), we examined young African women's preferences around PrEP product formulation and delivery attributes before and after initiating oral PrEP.MethodsWe enrolled HIV‐negative women from six African countries in a prospective cohort from August 2022 to June 2023. Women completed two DCEs on PrEP products and PrEP delivery. At enrolment and month 1, participants completed the DCE about PrEP products with 16 randomly assorted choice sets assessing product form and dosing, dose forgiveness, drug reversibility, weight change and antiretroviral or immune‐based mechanism attributes. At month 3, participants completed the DCE about PrEP delivery evaluating preferences related to location to collect doses, packaging, product storage, type of HIV test and costs. Preference weights (PW) were estimated with a hierarchical Bayesian model; higher positive numbers indicate greater preference for an attribute. Importance scores compare relative importance across the five attributes; higher scores indicate greater importance.ResultsTwo thousand eight hundred and forty‐seven women completed enrolment and month 1 DCEs; the median age was 24 years (range: 16–30) and 92.8% initiated daily oral PrEP. Product form and dosing was the most important attribute at enrolment and month 1. At enrolment, women preferred small oral pills taken monthly (preference weight [PW]: 0.67; 95% confidence interval [CI]: 0.58−0.77), and at month 1, they preferred a 6‐monthly injection (PW: 0.56; 95% CI: 0.46−0.65). In the month 3 DCE, location was the most important PrEP delivery attribute with a strong preference for a youth‐friendly or non‐governmental organization (PW: 0.25; 95% CI: 0.19−0.30) or health facility (PW: 0.21; 95% CI: 0.17−0.25); mobile clinic or van was least preferred. The cost of the product was the second most important product delivery attribute.ConclusionsYoung African women preferred discreet, less frequently administered PrEP formulations, particularly after 1 month of taking daily oral PrEP. Long‐acting formulations are needed to meet women's preferences. Coupled with the preferred PrEP delivery location and cost, the highlighted PrEP product characteristics have the potential to increase PrEP uptake.

AbstractIntroductionHepatitis C virus (HCV) prevalence and adverse outcomes are higher among people with human immunodeficiency virus (HIV) than people without HIV. Yet, HCV prevalence among people with HIV in Cameroon remains unknown, with HCV diagnosis and treatment largely inaccessible due to care centralization by specialists with high out‐of‐pocket costs. Integration of HCV services into routine HIV care by general practitioners could improve diagnosis and treatment coverage. We aimed to examine HCV prevalence and treatment cure rate among people with HIV attending 11 HIV clinics in the Centre Region of Cameroon.MethodsWe offered HCV rapid antibody testing, and, if positive, RNA testing to all persons ≥21 years, on HIV ART for ≥6 months and with suppressed HIV RNA (<1000 copies) who attended HIV counselling and treatment appointments between 20 April 2021 and 31 May 2022. Participants with an HCV RNA positive test received 12 weeks of pangenotypic sofosbuvir/velpatasvir. We calculated the cure rate as the proportion of participants with a sustained virological response 12 weeks after treatment completion (SVR12) among all starting and completing treatment.ResultsWe tested 8266 persons for HCV antibodies, 316 (3.8%, 95% CI = 3.4−4.3%) of whom were anti‐HCV positive. Of these, 286 (90.5%) were sampled for HCV RNA, 20 (6.3%) ineligible, 5 (1.6%) declined, 4 (1.3%) left before sampling and 1 (0.3%) had an unknown reason. Among 286 sampled, 251 (87.8%) had detectable HCV RNA. Of these, 173 (68.9%) enrolled for treatment, 55 (21.9%) were eligible but not enrolled (49 lost‐to‐follow‐up, 6 denied) and 23 (9.2%) were ineligible. Of 173 enrolled, 165 completed treatment, 6 were lost‐to‐follow‐up and 2 were excluded due to treatment interruption. SVR12 was achieved in 93.6% (n = 162; 95% CI: 88.9–96.8%) of those enrolled and 98.2% (95% CI: 94.8–99.6%) of treatment completers. All three initially not achieving SVR12 were cured with second‐line treatment (sofosbuvir/velpatasvir/voxilaprevir).ConclusionsOur study demonstrates the viability of integrating HCV testing and treatment into routine HIV care in Cameroon, yielding new HCV diagnoses and high cure rates. Cameroon can use this strategy to achieve HCV elimination goals, although improvements in testing uptake, diagnosis and treatment access, and laboratory capacity are needed.

AbstractIntroductionIn the current era of universal antiretroviral treatment (ART), health systems have the dual challenge of a growing number of people living with HIV and on ART who are also receiving chronic, life‐long treatment for non‐communicable diseases. Current evidence suggests that 6‐month multi‐month dispensing (6MMD) can maintain at least equivalent clinical outcomes to conventional care and reduce costs, but little is known when integrating 6MMD for multiple conditions. We examined the cost‐effectiveness of integrated multi‐month drug dispensing for people living with HIV and hypertension.MethodsUsing an age‐ and sex‐specific hybrid decision tree and Markov state‐transition model, we constructed a 100,000‐person simulated population cohort who may develop HIV and hypertension and initiate treatment at clinics in South Africa over a 10‐year time horizon. We assessed the incremental costs and effectiveness of 6MMD versus conventional care from a health system perspective under different conditions of care‐seeking, eligibility and uptake of 6MMD for clinically stable patients. Model inputs were sourced from previously published literature. 6MMD was defined as reducing the frequency of clinic visits by increasing the number of medications dispensed to stable patients at each visit from 3 to 6 months. For the integrated 6MMD, we assumed that comorbid patients receive both HIV and hypertension drugs at the same facility on the same day.ResultsOur study demonstrates that integrated 6MMD for HIV and hypertension in South Africa can avert between 0.8 and 1 DALYs and increase health systems costs between $24 and $49 per patient per year, compared to the status quo. One‐way sensitivity analysis showed that HTN drug cost and prevalence of HIVHTN and HIV were key drivers in the cost per DALYs averted. Overall, integrated 6MMD with a greater proportion of well‐controlled patients and lower mortality rates led to greater cost savings or better cost‐effectiveness (less than $50 per DALY averted) across a wide range of loss‐to‐follow‐up (LTFU) factor variation.ConclusionsBy better controlling disease among patients already in care, integrated 6MMD can be more beneficial than the status quo treatment by resulting in fewer cases of LTFU and fewer deaths through high‐quality care.

AbstractIntroductionDifferentiated service delivery (DSD) models have been widely implemented for patients in stable HIV care. However, DSD has rarely been offered to newly diagnosed patients. We assessed the effectiveness of early fast‐track care during a period of severe civil unrest in Port‐au‐Prince, Haiti.MethodsWe conducted a pilot randomized trial among adults presenting with early HIV disease to determine whether early fast‐track care (8−12 weeks after same‐day HIV testing and antiretroviral therapy [ART] initiation) was associated with superior outcomes compared with standard (deferred eligibility for fast‐track care). All participants received tenofovir/lamivudine/dolutegravir (TLD), and HIV‐1 RNA <200 copies/ml was required prior to initiating fast‐track care. The primary outcome was 48‐week HIV‐1 RNA <200 copies/ml, with intention‐to‐treat analysis.ResultsFrom December 2020 to August 2022, 245 participants were randomized to standard (n = 116) and early fast‐track (n = 129) groups. All initiated TLD on the day of HIV diagnosis. In the early fast‐track group, one (0.8%) died, 12 (9.3%) were internally displaced/emigrated, five (3.9%) were lost‐to‐follow‐up (LTFU), two (1.6%) had a gap in care/later return, one (0.8%) was transferred and 108 (83.7%) were retained; 88 (68.2%) received 48‐week viral load testing and 80 (90.9% of tested; 62.0% of randomized) had HIV‐1 RNA <200 copies/ml. In the standard group, two (1.7%) died, six (5.2%) were internally displaced/emigrated, three (2.6%) were LTFU, one (0.9%) had a gap in care/later return, one (0.9%) was transferred and 103 (88.8%) were retained; 78 (67.2%) received 48‐week viral load testing and 66 (84.6% of tested; 56.9% of randomized) had HIV‐1 RNA <200 copies/ml. By design, the sample size of this pilot study was too small to provide definitive evidence of treatment effect, but the primary outcome was numerically higher in the early fast‐track group (62.0% vs. 56.9%; RD: 0.051: 95% CI: −0.072, 0.174).ConclusionsEarly fast‐track care was associated with high levels of viral suppression among adults initiating same‐day TLD, despite severe civil unrest in Haiti. Completion of 48‐week viral load testing was suboptimal, due to the need for participants to leave Port‐au‐Prince during peak periods of gang‐related violence, and the lack of availability of viral load testing for those receiving non‐facility‐based ART.

AbstractIntroductionRecent studies have indicated a high enduring burden of advanced HIV disease, but estimates across regions and settings are lacking. The aim of this study was to estimate the prevalence of advanced HIV disease since 2015 among those people with CD4 measured in healthcare settings, disaggregated by age group, level of healthcare and region.MethodsWe searched MedLine via Pubmed and Hinari for studies that reported the proportion of individuals with advanced HIV disease (defined as CD4 cell count <200 cells/mm3) in healthcare settings since 2015; this search was complemented by conference abstracts and data from the International epidemiology Databases to Evaluate AIDS Consortium (IeDEA). We estimated pooled prevalence of advanced HIV disease using random‐effects models and performed subgroup and sensitivity analyses to explore heterogeneity.ResultsWe obtained data from 117 cohorts, representing 1,814,362 individuals from 52 countries across all six World Health Organization regions. The majority of studies (n = 83) were conducted among adults and recorded CD4 cell count among treatment naïve individuals at antiretroviral therapy start (n = 86). Studies included data reported up to 2023. The proportion of individuals with advanced HIV disease was higher in inpatient settings (44.3%, 95% CI 39.1−49.6%) compared to outpatient settings (33.5%, 95% CI 31.5−35.4%). Prevalence was similar across age groups, time since HIV diagnosis and treatment status, and highest in West and Central Africa, South‐East Asia and the Eastern Mediterranean region.DiscussionThis review finds that at least a third of people presenting to healthcare settings have advanced HIV disease, with no evidence that this has changed in recent years. Screening for advanced HIV remains important to be able to direct appropriate preventive, diagnostic and therapeutic interventions to prevent progression to severe illness and death.ConclusionsThis review summarizes recent evidence of the continued high proportion of individuals who (re)present to care with advanced HIV disease. These findings underscore the urgent need to reinforce programme capacity to diagnose, prevent and treat advanced HIV disease as an essential pillar of the global AIDS response.

AbstractIntroductionElvitegravir/cobicistat/emtricitabine/tenofovir alafenamide (E/C/F/TAF) was efficacious and well tolerated in children/adolescents with HIV (aged ≥6 years, weighing ≥25 kg) in a Phase 2/3 study. Here, we report data from children aged ≥2 years and weighing ≥14–<25 kg.MethodsThis is an analysis of data from the youngest cohort in an open‐label, multicentre, multi‐cohort, single‐group, international study of children/adolescents with HIV. Participants in this cohort were children aged ≥2 years, weighing ≥14–<25 kg at screening and able to swallow tablets, on stable antiretroviral therapy with virologic suppression (HIV‐1 RNA <50 copies/ml for ≥6 consecutive months) and a CD4 count ≥400 cells/µl. Eligible participants received low‐dose E/C/F/TAF (90/90/120/6 mg) once daily through Week 48. The study included pharmacokinetic evaluation of the low‐dose E/C/F/TAF tablet at Week 2. Safety, efficacy, palatability and acceptability were also evaluated.ResultsBetween 16 January and 25 November 2019, 27 participants were enrolled with a median (quartile [Q]1, Q3) age of 6 (4, 8) years, body weight of 19.3 (17.0, 20.5) kg, CD4 count of 1061 (895, 1315) cells/µl and CD4 cell percentage of 37.4 (30.6, 40.3). Most (92.6%) participants acquired HIV through vertical transmission. On 6 October 2020 (data‐cut), median (Q1, Q3) exposure to E/C/F/TAF was 48.3 (48.0, 60.1) weeks. Pharmacokinetic parameters were within the safe and efficacious range of previous data in adult and paediatric populations. Drug‐related treatment‐emergent adverse events occurred in 4/27 (15%) participants. There were no Grade 3/4 adverse events, or adverse events leading to E/C/F/TAF discontinuation. One participant experienced a serious treatment‐emergent adverse event (Grade 2 pneumonia not considered E/C/F/TAF related). Virologic suppression (US FDA Snapshot algorithm) was maintained by 26/27 (96%) participants at Weeks 24 and 48. At Week 48, most children reported positive palatability (84.6%) and acceptability (96.2%).ConclusionsThese data support the use of single‐tablet E/C/F/TAF (90/90/120/6 mg) regimen for the treatment of HIV in children aged ≥2 years and weighing ≥14–<25 kg.Clinical Trial NumberNCT01854775

AbstractIntroductionGlobally, children living with HIV continue to lag behind UNAIDS targets for viral suppression (VS). Because studies with linked mother‐child data are limited, we describe VS and associated factors among young children in a setting with early infant HIV testing (at birth, age 10 weeks and 6 months) and early protease inhibitor‐based first‐line antiretroviral therapy (ART).MethodsWe analysed routinely collected mother‐child data for children living with HIV born 2018–2022 in Western Cape province, South Africa (followed through mid‐2023). We assessed associations between child and maternal viral load (VL) results at 12 and 24 months after child ART start using logistic regression, adjusted for child sex, birthyear, severity of child immunodeficiency at ART start, maternal age and timing of maternal HIV diagnosis.ResultsAmong 2219 children living with HIV; 30% were diagnosed at birth (≤7 days), 41% before age 1 year (8−365 days) and 29% at age >1 year. Overall, 5% (n = 112/2219) of children died, a third of whom had not started ART; 90% of children (n = 1990) started ART, at median age 5 months (IQR 1–16). Median follow‐up from ART start was 26 months (IQR 14–40). Among children with available VL at 12 months (n = 853/1582), 24 months (n = 614/1129) and 36 months (n = 350/658) after ART start, 36%, 43% and 48% were virally suppressed, respectively (VL<100 copies/ml). VS among children at 12 and 24 months was more likely if maternal VL was <100 versus ≥100 copies/ml at 12 months (adjusted odds ratio [aOR] = 3.5; 95% CI 1.9−6.5) and 24 months (aOR = 6.1; 95% CI 2.8−13.1) after child ART start. Children with no/mild versus advanced/severe immunodeficiency at ART start were more likely to achieve VS at 12 months (aOR = 2.3; 95% CI 1.3−4.2) but not at 24 months. Eligible children with missing VL at 24 months (39%) were more likely to have gaps in care of >6 months than those with VL≥100 or VL<100 copies/ml (84% vs. 28% vs. 14%, respectively; p<0.001).ConclusionsLess than half of children on ART achieved VS, and children were more likely to achieve VS if their mothers were also virally suppressed. Significant efforts are needed to support mother‐child dyads to achieve optimal VS.

AbstractIntroductionMolecular surveillance is an important tool for detecting chains of transmission and controlling the HIV epidemic. This can also improve our knowledge of molecular and epidemiological factors for the optimization of prevention. Our objective was to illustrate this by studying the molecular and epidemiological evolution of the cluster including the new circulating recombinant form (CRF) 94_cpx of HIV‐1, detected in 2017 and targeted by preventive actions in 2018.MethodsIn June 2022, 32 HIV‐1 sequence databases from French laboratories were screened to identify all individuals who had acquired CRF94_cpx or a similar strain, whatever the date of diagnosis. Phylogenetic analyses were performed with the sequences identified, and biological parameters were collected at the time of diagnosis and after the start of treatment to analyse the evolution of the cluster. Full genomes were sequenced to characterize the new strains.ResultsWe analysed 98 HIV‐1 isolates: 63 were CRF94, three were unclassifiable, and the other 32 formed a new cluster containing a new recombinant, CRF132_94B, derived from CRF94 and a subtype B strain. At least 95% of the individuals in both the CRF94 and CRF132 clusters were men who have sex with men (MSM), most of whom had acquired HIV less than 12 months before diagnosis. The number of CRF94 diagnoses declined drastically after 2018, but CRF132 strains spread widely between 2020 and 2022, into a different area of Ile‐de‐France region and within a younger population nevertheless aware of pre‐exposure prophylaxis. Higher viraemia, lower CD4 cell counts and delayed treatment efficacy suggested that CRF94 was more virulent than CRF132, possibly due to the F subtype fragment of the vif gene.ConclusionsThese findings highlight the role of the MSM transmission cluster in spreading HIV and new variants. They show also the benefits of cluster surveillance for improving the targeting of preventive interventions, detecting the emergence of new strains and enriching our knowledge on virulence mechanisms. However, these investigations require support with sufficient resources dedicated to a regional or national programme to be responsive and effective.

AbstractIntroductionSexually transmitted infections (STIs) in pregnancy are associated with an increased risk of vertical HIV transmission and adverse pregnancy and birth outcomes. In South Africa, syndromic management is the standard of care for STI management. We assessed the potential impact of point‐of‐care (POC) screening for curable STIs (Chlamydia trachomatis [CT], Trichomonas vaginalis [TV] and Neisseria gonorrhoeae [NG]) during pregnancy on vertical HIV transmission and adverse pregnancy and birth outcomes.MethodWe developed a static mathematical model to estimate the impact of syndromic management compared to POC screening of STIs in pregnant women attending antenatal clinics in South Africa over one calendar year (2022). Our model assumptions regarding the effect of CT, NG and TV on adverse pregnancy/birth outcomes and vertical HIV transmission were informed by two separate meta‐analyses that we conducted. Local studies informed estimates of STI prevalence, POC screening uptake and treatment, and sensitivity of syndromic management.ResultsIn the absence of POC screening for curable STIs, 25.5% of pregnant women without HIV and 34.6% of pregnant women living with HIV were estimated to have undiagnosed and untreated STIs. In the POC scenario, 92% (95% CI: 85−100%) of STIs were diagnosed and treated during pregnancy, reducing antenatal maternal HIV incidence by 10.0% (95% CI: 1.0−20.1%). Overall, vertical HIV transmission was anticipated to reduce by 8.6% (5.2−13.8%), with reductions of 20.9% (15.2−27.0%) at birth and 2.5% (−0.9% to 9.0%) postnatally, in the POC screening scenario compared to current syndromic management. POC screening of curable STIs is further estimated to reduce the incidence of stillbirth by 10.1% (1.3–18.7%), preterm delivery by 6.3% (3.4–9.7%), infants born small for gestational age by 2.7% (0.7–4.9%) and low birth weight by 9.1% (0.9–18%).ConclusionsPOC STI screening and treatment may modestly reduce maternal HIV incidence, vertical HIV transmission, and the risk of adverse pregnancy and birth outcomes, and would substantially reduce the burden of curable STIs in pregnancy. The study provides evidence to move beyond the syndromic management of STIs in South Africa, particularly in antenatal care.

AbstractIntroductionThe World Health Organization (WHO) recommends the use of antiretroviral drugs as post‐exposure prophylaxis (PEP) for preventing HIV acquisition for occupational and non‐occupational exposures. To inform the development of global WHO recommendations on PEP, we reviewed national guidelines of PEP for their recommendations.MethodsPolicies addressing PEP from 38 WHO HIV priority countries were obtained by searching governmental and non‐governmental websites and consulting country and regional experts; these countries were selected based on HIV burden, new HIV acquisitions and the number of HIV‐associated deaths. We reviewed national guidelines to collate data on where PEP can be offered, who can prescribe PEP, PEP eligibility, recommended drug regime, linkage to other interventions, recommended investigations prescribed with PEP, HIV self‐test recommendation related to PEP and stopping rules for PEP.ResultsIn total, 46 guidelines from January 2010 to May 2023 across 36 countries were included, with 70% of documents published during or after 2020. There was significant variation across national guidelines regarding where PEP can be accessed and who can provide or prescribe PEP. Six countries (17%) described being able to access PEP from a primary care facility, four countries (11%) from hospitals and two (6%) from community‐based services. Only three countries (8%) specifically considered dispensing PEP by professionals other than doctors (e.g. nurses). None mentioned pharmacists as prescribers. We found a lack of consistency across countries regarding who is eligible for PEP, regimens used, interventions integrated into PEP provision and recommended investigations for PEP users. No country guidance provided considerations on using HIV self‐tests for starting or stopping PEP.DiscussionDespite PEP being recommended for more than three decades, many national policies were lacking in terms of PEP guidance. There are opportunities for countries to update and optimize guidance to consider ways to improve the accessibility of PEP. Greater efforts are needed to support the development of global consensus on how best to implement and integrate PEP, as well as how to include decentralization and task‐sharing to achieve sufficient scale for impact.ConclusionsImproving timely access to PEP and promoting PEP adherence could help contribute to reducing the incidence of HIV globally.

AbstractIntroductionIn 2010, China launched the 10‐year National Syphilis Prevention and Control Program to curb the spread of syphilis by integrating syphilis screening and treatment with HIV services. Herein, we aimed to evaluate changes in the prevalence of syphilis among people living with HIV (PLHIV) in China.MethodsWe conducted this systematic review and meta‐analysis by searching the PubMed, Embase, Web of Science, China Biomedical Literature, China National Knowledge Infrastructure, Wanfang and CQVIP databases from inception to 1 June 2024 to obtain relevant articles. A total of 75 studies were ultimately included. We used a DerSimonian‒Laird random effects model to estimate the prevalence and 95% confidence interval of syphilis among PLHIV.ResultsThe overall prevalence of syphilis among PLHIV in China was 18.6% (95% CI 16.5–21.0). Regional differences (R2 = 15.29%) were observed in the prevalence rates: 22.2% (18.9–25.8) in the eastern region, 19.0% (15.1–23.8) in the central region and 14.0% (11.1–17.5) in the western region. The prevalence decreased from 22.8% (18.4–27.9) before 2010 to 17.0% (14.6–19.6) in 2010 and thereafter (R2 = 5.82%). Among PLHIV via homosexual transmission, the prevalence of syphilis was 24.9% (21.3–28.9), which significantly declined from 33.8% (27.5–40.8) to 21.4% (18.3–24.9) in 2010 and thereafter (R2 = 22.35%). The prevalence of syphilis was significantly higher in men living with HIV than in women living with HIV (pooled odds ratio 1.67, 95% CI 1.29–2.15), with the highest prevalence in the eastern region (2.55, 95% CI 1.80–3.59).DiscussionThe prevalence of syphilis among PLHIV, particularly in cases of homosexual transmission, has declined. There was a correlation between the prevalence of syphilis and regional economic conditions, with a greater burden in developed eastern coastal areas. Additionally, the risk of syphilis differed across sexes, with men living with HIV having a higher risk.ConclusionsThere has been preliminary success in the control of syphilis among PLHIV, but there is still a long way to go to meet the WHO's 2030 syphilis prevention and control goal. Syphilis prevention measures should be integrated into broader health policies and development plans, particularly in high‐burden regions and populations.