Cellulose sulfate did not prevent HIV infection and may have increased the risk of HIV acquisition. (ClinicalTrials.gov number, NCT00153777; and Current Controlled Trials number, ISRCTN95638385.)

IntroductionOf the two million new HIV infections in adults in 2014, 70% occurred in sub-Saharan Africa. Several African countries have already approved guidelines for pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV as part of combination HIV prevention but key questions remain about how to identify and deliver PrEP to those at greatest need. Throughout the continent, individuals in sero-discordant relationships, and members of key populations (sex workers, men who have sex with men (MSM), transgender women and injection drug users) are likely to benefit from the availability of PrEP. In addition, adolescent girls and young women (AGYW) are at substantial risk in some parts of the continent. It has been estimated that at least three million individuals in Africa are likely to be eligible for PrEP according to WHO's criteria. Tens of demonstration projects are planned or underway across the continent among a range of countries, populations and delivery settings.DiscussionIn each of the target populations, there are overarching issues related to (i) creating demand for PrEP, (ii) addressing supply-side issues and (iii) providing appropriate and tailored adherence support. Critical for creating demand for PrEP is the normalization of HIV prevention. Community-level interventions which engage opinion leaders as well as empowerment interventions for those at highest risk will be key. Critical to supply of PrEP is that services are accessible for all, including for stigmatized populations. Establishing accessible integrated services provides the opportunity to address other public health priorities including the unmet need for HIV testing, contraception and sexually transmitted infections treatment. National policies need to include minimum standards for training and quality assurance for PrEP implementation and to address supply chain issues. Adherence support needs to recognize that social and structural factors are likely to have an important influence. Combining interventions that build self-efficacy, empowerment and social cohesion, with evidence-based individualized adherence support for PrEP, are most likely to be effective.ConclusionsEfficacy of tenfovir-based PrEP is proven but many issues related to implementation remain unclear. Here, we have summarized some of the important implementation questions that need to be assessed as PrEP is rolled out across Africa.

IntroductionIn sub‐Saharan Africa, HIV prevalence remains high, especially among key populations. In such situations, combination prevention including clinical, behavioural, structural and biological components, as well as adequate treatment are important. We conducted a demonstration project at the Dispensaire IST, a clinic dedicated to female sex workers (FSWs) in Cotonou, on early antiretroviral therapy (E‐ART, or immediate “test‐and‐treat”) and pre‐exposure prophylaxis (PrEP). We present key indicators such as uptake, retention and adherence.MethodsIn this prospective observational study, we recruited FSWs from October 4th 2014 to December 31st 2015 and followed them until December 31st 2016. FSWs were provided with daily tenofovir disoproxil fumarate/emtricitabine (Truvada®) for PrEP or received a first‐line antiretroviral regimen as per Benin guidelines. We used generalized estimating equations to assess trends in adherence and sexual behaviour.ResultsAmong FSWs in the catchment area, HIV testing coverage within the study framework was 95.5% (422/442). At baseline, HIV prevalence was 26.3% (111/422). Among eligible FSWs, 95.5% (105/110) were recruited for E‐ART and 88.3% (256/290) for PrEP. Overall retention at the end of the study was 59.0% (62/105) for E‐ART and 47.3% (121/256) for PrEP. Mean (±SD) duration of follow‐up was 13.4 (±7.9) months for E‐ART and 11.8 (±7.9) months for PrEP. Self‐reported adherence was over 90% among most E‐ART participants. For PrEP, adherence was lower and the proportion with 100% adherence decreased over time from 78.4% to 56.7% (p‐trend < 0.0001). During the 250.1 person‐years of follow‐up among PrEP initiators, two seroconversions occurred (incidence 0.8/100 person‐years (95% confidence interval: 0.3 to 1.9/100 person‐years)). The two seroconverters had stopped using PrEP for at least six months before being found HIV‐infected. In both groups, there was no evidence of reduced condom use.ConclusionsThis study provides data on key indicators for the integration of E‐ART and PrEP into the HIV prevention combination package already offered to FSWs in Benin. PrEP may be more useful as an individual intervention for adherent FSWs rather than a specific public health intervention. E‐ART was a more successful intervention in terms of retention and adherence and is now offered to all key populations in Benin.Study registrationClinicalTrials.gov NCT02237

This is the first theoretically based study identifying determinants of intention to undergo regular HIV testing among FSWs in sub-Saharan Africa. The results can inform development of interventions to maintain and increase regular HIV testing among FSWs, thus reinforcing primary prevention and supporting early access to care.

BackgroundAutism is a complex polygenic neurodevelopmental disorder characterized by deficits in communication and social interactions as well as specific stereotypical behaviors. Both genetic and environmental factors appear to contribute to the pathogenesis of autism. Accumulating data including changes in immune responses, linkage to major histocompatibility complex antigens, and the presence of autoantibodies to neural tissues/antigens suggest that the immune system plays an important role in its pathogenesis.SummaryIn this brief review, we discuss the data regarding changes in both innate and adaptive immunity in autism and the evidence in favor of the role of the immune system, especially of maternal autoantibodies in the pathogenesis of a subset of patients with autism. The rationale for possible therapeutic use of intravenous immunoglobulin is also discussed.

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Though the cross-sectional design of the study precludes directional interpretation of the findings, the data do suggest that IVF may be as important as BV in HIV acquisition. The authors recommend prospective research to better understand the association between IVF and HIV acquisition.

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