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Background: The measurement of cause-specific mortality is critical for health system planning but remains a challenge in many low-resource settings due to societal, legal, and logistical barriers. We present a co-development process with community members for the design and implementation of an autopsy program to improve cause of death data in a historically underserved population., Methods: We sought to develop an autopsy program at the Africa Health Research Institute (AHRI) Health and Demographic Surveillance Site (HDSS). The project proposes to obtain consent from families of deceased adults, to perform diagnostic autopsies by a trained pathologist, and to process samples to determine causes of death. Prior to launching the program, we engaged key partners in learning their perspectives about such a program and understanding the landscape of challenges needed for successful implementation. Herein, we describe lessons from interactions with these partners, including 1) the AHRI community advisory board (CAB), 2) the South Africa Department of Health (SA DoH), 3) local traditional authorities, 4) funeral home personnel, 5) traditional healers, and 6) healthcare providers. We also detail the development of community outreach efforts used to inform the public about the program., Results: The partners provided valuable feedback on the study design and informed us of issues that needed to be addressed: community concerns about organ retention and sale (CAB), implications of how autopsy findings could spur litigation and erode trust in healthcare providers who determined alternate causes of death (SA DoH), a cultural practice that conflicts with the autopsy procedure (traditional healers), the need to educate families before they engage with funeral businesses (funeral homes), and enhancing our death referral network through healthcare providers. This led to protocol changes and an adapted community engagement strategy, which included educating healthcare providers, hosting community dialogs, broadcasting radio advertisements, and developing a film to describe autopsy procedures to families considering participation., Conclusions: We present a comprehensive model of partner engagement for a community-based autopsy program in South Africa, leading to the co-development of a program that incorporates local customs around death while promoting buy-in and support from the government, civil society, and medical partners., Competing Interests: CI received grant funding from Gilead Sciences paid to his Institution for investigator-sponsored research. CI received support from the International Vaccine Institute to attend the Indo-Pacific Climate Resilience Forum. All other authors declare that they have no competing interests.

Introduction: Cancer imposes significant financial burden on patients in low and middle-income countries like Nigeria, where breast cancer (BC) is the most common cancer and has the highest mortality. This study aims to investigate the financial burden of BC care at Lakeshore Cancer Center (LCC) in Nigeria and identify risk factors for financial catastrophe (FC)., Methods: LCC was queried for uninsured patients diagnosed with breast cancers between 2013 and 2023, linked to cost data through chart abstraction of billing data and adjusted to 2023 USD. All costs were out-of-pocket costs (OOP) as all patients were uninsured. Risk for financial catastrophe was defined as OOP exceeding 20 ​% of Nigeria's 2023 per capita GDP ($467). Total OOP and risk for financial catastrophe were measured with descriptive statistics and stratified by clinical characteristics., Results: 352 BC patients (99 ​% female, median age 47, 41 ​% stage 4, 28 ​% stage 3) were included. 260 (74 ​%) patients risked financial catastrophe, despite only 30 ​% completing treatment. Patients with HER2+/HR ​+ ​disease exhibited the highest treatment costs. Among patients that underwent multiple treatment modalities (n ​= ​130), the average OOP was $17992 with 100 ​% risking financial catastrophe. The highest contributors to the cohort's total costs were chemotherapy (29 ​%), immunotherapy (18 ​%), and other drugs (12 ​%). Surgery contributed 7 ​%., Discussion: Less than one-third of BC patients completed treatment, and the majority faced financial catastrophe, especially those with HER2+/HR ​+ ​disease and patients who underwent multiple treatment modalities or immunotherapy. Targeted efforts are essential to ensure equitable access to quality cancer care while minimizing risk of financial catastrophe., Competing Interests: Declaration of competing interest No conflicting interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The United Nations' 95-95-95 (95% of people with HIV being aware of their diagnosis, 95% of those aware of their diagnosis being on treatment and 95% achieving viral suppression) target aims to reduce morbidity and mortality of HIV. However, with 60% of new HIV infections occurring in sub-Saharan Africa (SSA), achieving this target in the region is challenging. Viral load (VL) monitoring is the gold-standard approach of assessing treatment efficacy, and its implementation into national health systems is a global health priority if elimination of HIV as a public health threat is to be achieved by 2030. This systematic review aims to investigate VL monitoring outcomes in SSA, and to identify gaps and possible interventions to help nations meet their 2030 targets., Methods: A literature search of three electronic platforms (MEDLINE, EMBASE and Global Health) was undertaken from 1 January to 9 August 2024 to identify studies published in English and conducted in SSA. The primary outcome was the proportion of people living with HIV (PLHIV) on antiretroviral therapy (ART) with routine VL monitoring at the recommended time points (initially, 6 months, 12 months and annually). Secondary outcomes reported proportions of PLHIV who received routine VL monitoring who went on to complete the cascade of care after identified virological failure [enhanced adherence counselling (EAC), switch to second-line ART, and finally viral suppression]., Results: The initial search identified 342 papers, of which 35 studies were included for narrative synthesis. Included studies reported on findings from 14 African countries and demonstrated extensive variation in rates of VL monitoring (range: 24.3-99.7%, mean: 63.8%). Results were more unfavourable in the latter steps of the viral load monitoring cascade, with a range of 0-88%, and a switch to second-line ART mean of 42% (range: 4.4-93%). Studies with additional support, and those with community-based models of care, had higher rates of VL testing and viral suppression., Conclusions: VL monitoring and management of virological failure are suboptimal in many SSA countries due to individual and health system-related challenges. Health system strengthening is vital to ensure the sustainability of HIV treatment programmes and the achievement of 95-95-95 targets by 2030., (© 2024. The Author(s).)

Introduction: Possible resistance to recommended treatments for scabies has emerged recently. In response to anecdotal reports of a recent increase in treatment failure with permethrin, the British Association for Sexual Health and HIV (BASHH) released a statement alerting members to this., Aims: To examine attendances and the treatment pathways for scabies cases seen at local sexual health clinics., Methodology: A case note review of scabies attendances between January 2017 and December 2023 was conducted. Data collected included patient demographics, clinical information, and scabies treatment histories. Statistical analysis was performed., Results: 143 patients attended with scabies. The number of scabies cases did not appear to increase significantly from 2017 to 2023 ( p = .09). There was significant increase in median number of treatments per case per year over time ( p = .013). The number of individuals needing second-line treatments increased significantly over time ( p -trend < 0.001)., Discussion: Individuals with scabies are requiring more treatments to clear infection. Use of ivermectin has risen in the last year suggesting that second-line treatment is increasingly needed for eradication. Whilst treatment failure may be due to non-compliance with treatment and decontamination efforts for both index and contacts, the more recent change in findings could be attributed to a fall in permethrin efficacy., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The World Health Organisation (WHO) has set targets for the elimination of Hepatitis B virus (HBV), which include preventing new infections and reducing deaths. We explored beliefs, behaviours and barriers to diagnosis, prevention and treatment for people living with HBV infection (PLWHB) and those with liver disease in a rural South African population in KwaZulu-Natal, to gather information to inform research and support the development of improved clinical and public health services., Methods: Using an interdisciplinary approach (combining public engagement, social science, clinical and laboratory team members) we conducted a community dialogue with members of the Africa Health Research Institute (AHRI) Community Advisory Board (CAB). Notes from the discussions were used to write up an account from which themes were identified during a team debrief session for data analysis., Results: There was a lack of knowledge and awareness of HBV infection and transmission and prevention amongst CAB members, also reported among community members and healthcare workers. The participants recognised liver disease symptoms. Perceived causes of liver disease reported by the CAB were alcohol and non-adherence to HIV treatment. Barriers to care included stigma, poverty, and delays in referrals for HBV diagnosis and management., Conclusion: Understanding barriers to care is important to shape future services for diagnosis, treatment and prevention of HBV and liver disease which are accessible, affordable and acceptable to the local population. Education, awareness and advocacy for improved liver health care pathways are required to make them effective for local communities., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper., (© 2024 The Authors.)

Bacteriophage Rummer is a siphovirus morphology actinophage isolated from Mycobacterium smegmatis . Rummer has a 50,908 base pair genome encoding 89 predicted protein-coding genes and three tRNAs. Based on gene content similarity to sequenced actinobacteriophages, Rummer is assigned to phage subcluster A3., Competing Interests: The authors declare no conflict of interest.

The WHO African region bears a disproportionate burden of morbidity and mortality related to chronic hepatitis B virus (HBV) infection and accounts for an estimated 70% of new HBV infections worldwide. We investigated the extent to which HBV clinical trials represented populations in this region by searching the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov for interventional clinical trials published in English between database inception and May 29, 2023, using the search term "Hepatitis B". We identified 1804 unique clinical trials, of which 18 (1·0%) recorded involvement of the WHO African region. There is no evidence that the number of HBV clinical trials in this region has improved over time. The diversity of new interventions and industry sponsorship in the WHO African region were low, with trials of HBV comparing poorly with those of other endemic infectious diseases (eg, malaria, HIV, and SARS-CoV-2). HBV research and clinical trial investigations have neglected the WHO African region, leading to profound health inequities. HBV clinical trials are urgently needed to evaluate the efficacy of newly discovered therapeutics and to ensure that interventions can be equitably distributed and deployed as they become available., Competing Interests: Declaration of interests MD, EW, and PCM receive funding from The Francis Crick Institute. PCM is funded by a Wellcome fellowship (ref 110110/Z/15/Z) and the University College London National Institute for Health and Care Research Biomedical Research Centre and receives funding from GlaxoSmithKline to support a doctoral student in her team. LOD and SFL receive doctoral funding from the Wellcome Trust. CI has received research grant funding from Gilead Sciences. All other authors declare no competing interests. Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in published maps, text, and institutional affiliations., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

The global HIV response has made tremendous progress but is entering a new phase with additional challenges. Scientific innovations have led to multiple safe, effective, and durable options for treatment and prevention, and long-acting formulations for 2-monthly and 6-monthly dosing are becoming available with even longer dosing intervals possible on the horizon. The scientific agenda for HIV cure and remission strategies is moving forward but faces uncertain thresholds for success and acceptability. Nonetheless, innovations in prevention and treatment have often failed to reach large segments of the global population (eg, key and marginalised populations), and these major disparities in access and uptake at multiple levels have caused progress to fall short of their potential to affect public health. Moving forward, sharper epidemiologic tools based on longitudinal, person-centred data are needed to more accurately characterise remaining gaps and guide continued progress against the HIV epidemic. We should also increase prioritisation of strategies that address socio-behavioural challenges and can lead to effective and equitable implementation of existing interventions with high levels of quality that better match individual needs. We review HIV epidemiologic trends; advances in HIV prevention, treatment, and care delivery; and discuss emerging challenges for ending the HIV epidemic over the next decade that are relevant for general practitioners and others involved in HIV care., Competing Interests: Declaration of interests EHG receives educational grants from ViiV Healthcare outside the submitted work. AHS receives grants to her institution from ViiV Healthcare and Gilead Sciences outside the submitted work. CI has received conference support and research grants from Gilead Sciences outside the submitted work. FV receives drug donations from ViiV Healthcare, Merck, Johnson & Johnson, and Gilead Sciences for investigator-led clinical studies. FV's unit perfoms investigator-led studies with the financial support of Merck, Johnson & Johnson, and ViiV Healthcare, and is performing commercial drug studies for Merck. FV's unit performs evaluations of diagnostic devices for multiple biotech companies. Individually, FV receives honoraria for educational talks and advisory board membership for Gilead, ViiV, Mylan/Viatris, Merck, Adcock-Ingram, Aspen, Abbott, Roche, Johnson & Johnson, Sanofi, and Virology Education. AM and RKJT declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: Despite strengthening HIV prevention with the introduction of pre-exposure prophylaxis (PrEP), STI services have remained relatively unchanged and the standard of care remains syndromic management. We used a discrete choice experiment to investigate service users' preferences for the diagnosis and treatment of STIs in South Africa., Methods: Between 1 March 2021 and 20 April 2021, a cross-sectional online questionnaire hosted on REDCap was administered through access links sent to WhatsApp support groups for HIV PrEP users and attendees of two primary healthcare clinics and two mobile facilities in the Eastern Cape and Gauteng provinces aged between 18 and 49 years. Participants either self-completed the questionnaire or received support from a research assistant. We used a conditional logit model for the initial analysis and latent class model (LCM) to establish class memberships, with results displayed as ORs and probabilities., Results: We enrolled 496 individuals; the majority were female (69%) and <30 years (74%). The LCM showed two distinct groups. The first group, comprising 68% of the participants, showed a strong preference for self-sampling compared with no sampling (OR 2.16, 95% CI 1.62 to 2.88). A clinic follow-up appointment for treatment was less preferable to same-day treatment (OR 0.78, 95% CI 0.63 to 0.95). Contact slip from index patient (OR 0.86, 95% CI 0.76 to 0.96) and healthcare professional (HCP)-initiated partner notification (OR 0.63, 95% CI 0.55 to 0.73) were both less preferable than expedited partner treatment (EPT). The second group included 32% of participants with a lower preference for self-sampling compared with no sampling (OR 0.65, 95% CI 0.41 to 1.04). There was no treatment option that was significantly different from the others; however, there was a strong preference for HCP-initiated partner notification to EPT (OR 1.53, 95% CI 1.10 to 2.12)., Conclusions: Our results suggest that service users preferred STI testing prior to treatment, with the majority preferring self-taken samples and receiving aetiology-based treatment on the same day., Competing Interests: Competing interests: CI has received conference support and research grants from Gilead Sciences., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Midlife, beginning at 40 years and extending to 65 years, a range that encompasses the late reproductive to late menopausal stages, is a unique time in women's lives, when hormonal and physical changes are often accompanied by psychological and social evolution. Access to sexual health and sexual well-being (SHSW) services, which include the prevention and management of sexually transmitted infections, contraception and the support of sexual function, pleasure and safety, is important for the health of midlife women, their relationships and community cohesion. The objective was to use the socio-ecological model to synthesise the barriers and enablers to SHSW services for midlife women in high-income countries. A systematic review of the enablers and barriers to women (including trans-gender and non-binary people) aged 40-65 years accessing SHSW services in high-income countries was undertaken. Four databases (PubMed, PsycINFO, Web of Science and Google Scholar) were searched for peer-reviewed publications. Findings were thematically extracted and reported in a narrative synthesis. Eighty-one studies were included; a minority specifically set out to study SHSW care for midlife women. The key barriers that emerged were the intersecting disadvantage of under-served groups, poor knowledge, about SHSW, and SHSW services, among women and their healthcare professionals (HCPs), and the over-arching effect of stigma, social connections and psychological factors on access to care. Enablers included intergenerational learning, interdisciplinary and one-stop women-only services, integration of SHSW into other services, peer support programmes, representation of minoritised midlife women working in SHSW, local and free facilities and financial incentives to access services for under-served groups. Efforts are needed to enhance education about SHSW and related services among midlife women and their healthcare providers. This increased education should be leveraged to improve research, public health messaging, interventions, policy development and access to comprehensive services, especially for midlife women from underserved groups.