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IntroductionPeople living with HIV have high rates of hypertension. Integrated HIV and hypertension care with aligned multi-month dispensing of medications (MMD) could decrease the burden of care for individuals and health systems. We sought to describe hypertension control and evaluate its association with different durations of MMD among Malawian adults receiving integrated care with aligned dispensing of antiretroviral therapy (ART) and antihypertensive medication.MethodsWe conducted a cross-sectional survey and retrospective chart review of adults (≥18 years) receiving integrated HIV and hypertension care on medications for both conditions for at least 1 year, with aligned MMD at seven clinics in Malawi. Data were collected from July 2021 to April 2022 and included socio-demographics, clinical characteristics, antihypertensive medications and up to the three most recent blood pressure measurements. Bivariate analyses were used to characterize associations with hypertension control. Uncontrolled hypertension was defined as ≥2 measurements ≥140 and/or ≥90 mmHg. Chart reviews were conducted for a random subset of participants with uncontrolled hypertension to describe antihypertensive medication adjustments in the prior year.ResultsWe surveyed 459 adults receiving integrated care with aligned dispensing (58% female; median age 54 years). Individuals most commonly received a 3-month aligned dispensing of ART and antihypertensive medications (63%), followed by every 6 months (16%) and every 4 months (15%). Hypertension control was assessed in 359 respondents, of whom only 23% had controlled hypertension; 90% of individuals in this group reported high adherence to blood pressure medications (0-1 missed days/week). Control was more common among those with longer aligned medication dispensing intervals (20% among those with 1- to 3-month dispensing vs. 28% with 4-month dispensing vs. 40% with 6-month dispensing, p = 0.011). Chart reviews were conducted for 147 individuals with uncontrolled hypertension. Most had high self-reported adherence to blood pressure medications (89% missing 0-1 days/week); however, only 10% had their antihypertensive medication regimen changed in the prior year.ConclusionsUncontrolled hypertension was common among Malawian adults receiving integrated care with aligned MMD and was associated with shorter refill intervals and few antihypertensive medication escalations. Integrated care with aligned MMD is promising, but further work is needed to understand how to optimize hypertension outcomes.

BackgroundGlobal surgery research efforts have been criticized for failure to transition from problem identification to intervention implementation. We developed a context-appropriate trauma quality improvement (TQI) bundle to ameliorate care gaps at a regional referral hospital in Cameroon. We determined associations between bundle implementation and improvement in trauma resuscitation practices.MethodsWe implemented a TQI bundle consisting of a hospital-specific trauma protocol, staff training, a trauma checklist, provision of essential emergency trauma supplies in the resuscitation area, and monthly quality improvement meetings. We compared trends in target process measures (e.g., frequency and timing of vital sign collection and primary survey interventions) in the six-month period pre- and post-bundle implementation using Wilcoxon rank-sum and Fisher's exact tests.ResultsWe compared 246 pre-bundle patients with 203 post-bundle patients. Post-bundle patients experienced a greater proportion of all vital signs collected compared to the pre-intervention cohort (0 % pre-bundle vs. 69 % post-bundle, p < 0.001); specifically, the proportion of respiratory rate (0.8 % pre-bundle vs. 76 % post-bundle, p < 0.001) and temperature (7 % pre-bundle vs. 91 % post-bundle, p < 0.001) vital sign collection significantly increased. The post-bundle cohort had vital signs measured sooner (74 % vital signs measured within 15 min of arrival pre-bundle vs. 90 % post-bundle, p < 0.001) and more frequently per patient (7 % repeated vitals pre-bundle vs 52 % post-bundle, p < 0.001). Key primary survey interventions such as respiratory interventions (1 % pre-bundle vs. 8 % post-bundle, p < 0.001) and cervical collar placement (0 % pre-bundle vs. 7 % post-bundle, p < 0.001) also increased in the post-bundle cohort.ConclusionsThe implementation of a context-appropriate TQI bundle was associated with significant improvements in previously identified trauma care deficits at a single regional hospital. Data-derived interventions targeting frontline capacity at the local level can bridge the gap between identifying care limitations and improvement in resource-limited settings.

Across sub-Saharan Africa, men are less likely to know their HIV status than women, leading to later treatment initiation. Little is known about how experiences with general health services affect men's use of HIV testing. We used data from a 2019 community-representative survey of men in Malawi to understand frequency and cause of men's negative health service experiences (defined as men reporting they "would not recommend" a facility) and their association with future HIV testing. We conducted univariable and multivariable logistic regressions to determine which aspects of health facility visits were associated with would-not-recommend experiences and to determine if would-not-recommend experiences 12-24 months prior to the survey were associated with HIV testing in the 12 months prior to the survey. Among 1,098 men eligible for HIV testing in the 12 months prior to the survey, median age was 34 years; 9% of men reported at least one would-not-recommend experience, which did not differ by sociodemographics, gender norm beliefs, or HIV stigma beliefs. The factors most strongly associated with would-not-recommend experiences were cost (aOR 5.8, 95%CI 2.9-11.4), cleanliness (aOR 4.2, 95%CI 1.8-9.9), medicine availability (aOR 3.3, 95%CI 1.7-6.4), and wait times (aOR 2.7, 95%CI 1.5-5.0). Reporting a would-not-recommend experience 12-24 months ago was associated with a 59% decrease in likelihood of testing for HIV in the last 12 months (aOR 0.41; 95% CI:0.17-0.96). Dissatisfaction with general health services was strongly associated with reduced HIV testing. Coverage of high-priority screening services like HIV testing may benefit from improving overall health system quality.

Comparative studies on gender among Muslims and worshippers of other traditional religions in West Africa are limited in number. The paper makes use of a combination of social sciences and humanistic research instruments through structured interviews and participant observation to study gender politics within Islam, Vodun (a traditional religion in Lome, Togo), and Sango (or Shango, one of the deities in Yoruba culture) in Western Africa. This study reveals that gender inequality transcends all barriers, be it the profane or the sacred. In fact, in large parts of West African societies where traditional and Islamic norms and values hold sway, religion is deployed by patriarchal entities as a tool to oppress women. Questions of importance to this study, therefore, are: what are the foundations of Vodun, Sango, and Islamic beliefs that say women cannot achieve the highest echelons of the religions in question? How has this reinforced the existing gender inequality among the Yoruba of Southwest Nigeria and Ewe speakers of Lome (Togo) in West Africa? How is gender constructed in Ewe and Yoruba cultures? And how can we begin to deconstruct the patriarchal reading of Islamic texts? Keywords: Gender inequality, Sango, Vodun, Islam, Religion, West Africa, Introduction Despite their potential to increase our understanding of gender politics across cultures and civilizations, comparative studies of gender practices among the various religions in parts of West Africa are [...]

Objective To evaluate the effect of a mobile health (mHealth) intervention on early retention of female sex workers in human immunodeficiency virus (HIV) pre-exposure prophylaxis services in the United Republic of Tanzania. Methods The study involved 783 female sex workers: 470 from Dar es Salaam who were given the Jichunge mHealth application (app) in addition to standard HIV pre-exposure prophylaxis (intervention arm), and 313 from Tanga who received pre-exposure prophylaxis alone (control arm). Participants were recruited using respondent-driven sampling and followed up for 12 months. Early retention was defined as attending a pre-exposure prophylaxis follow-up clinic within 28 days of an appointment scheduled for 1 month after starting treatment. To assess if the Jichunge app led to higher retention, we conducted intention-to-treat and per-protocol analyses using a regression model adjusted by inverse probability weighting. Findings Early retention in HIV pre-exposure prophylaxis care was observed in 27.6% (130/470) of participants in the intervention arm and 20.1% (63/313) in the control arm. In the adjusted, intention-to-treat analysis, early retention was observed in 29.4% in the intervention arm and 17.7% in the control arm (risk difference: 11.8 percentage points; 95% confidence interval: 5.3-18.3). Conclusion Early retention in HIV pre-exposure prophylaxis care was significantly greater among female sex workers in the United Republic of Tanzania who used the Jichunge app than in those who did not. Nevertheless, more than two thirds of sex workers using the application did not attend follow-up services after 1 month, suggesting that additional interventions are needed. [phrase omitted] [phrase omitted] Objectif Evaluer l'impact d'une intervention de sante mobile (mHealth) sur l'adhesion precoce des travailleuses du sexe vis-a-vis des services de prophylaxie preexposition pour le virus de l'immunodeficience humaine (VIH) en Republique-Unie de Tanzanie. Methodes Cette etude a ete menee aupres de 783 travailleuses du sexe: 470 d'entre elles etaient a Dar es Salaam et ont eu acces a l'application mHealth (app) Jichunge en complement d'une prophylaxie preexposition standard pour le VIH (volet d'intervention), tandis que les 313 autres provenaient de Tanga et n'ont beneficie que d'une prophylaxie preexposition (volet de controle). Les participantes ont ete selectionnees par le biais d'un echantillonnage fonde sur les repondants, puis suivies pendant 12 mois. Une adhesion precoce signifiait assister a une consultation de suivi de la prophylaxie preexposition dans les 28 jours suivant un rendez-vous fixe un mois apres le debut du traitement. Enfin, pour determiner si l'app Jichunge ameliorait le taux d'adhesion, nous avons effectue des analyses selon l'intention de traiter et selon le respect du protocole, a l'aide d'un modele de regression ajuste en fonction d'une ponderation par l'inverse de la probabilite. Resultats Nous avons observe une adhesion precoce au traitement de prophylaxie preexposition pour le VIH chez 27,6% (130/470) des participantes dans le volet d'intervention, contre 20,1% (63/313) dans le volet de controle. Lanalyse ajustee selon l'intention de traiter a permis de constater une adhesion precoce de 29,4% dans le volet d'intervention et de 17,7% dans le volet de controle (difference de risque: 11,8 points de pourcentage; intervalle de confiance de 95%: 5,3-18,3). Conclusion En Republique-Unie de Tanzanie, l'adhesion precoce au traitement de prophylaxie preexposition pour le VIH s'est revelee sensiblement plus elevee parmi les travailleuses du sexe ayant utilise l'app Jichunge que parmi celles n'y ayant pas eu recours. Cependant, plus des deux tiers des travailleuses du sexe utilisant l'application ne se sont pas presentees aux services de suivi un mois plus tard, ce qui indique que d'autres mesures sont requises. [phrase omitted] Objetivo Evaluar el efecto de una intervencion de salud movil (mHealth) sobre la retencion temprana de las trabajadoras del sexo en los servicios de profilaxis previa a la exposicion al virus de la inmunodeficiencia humana (VIH) en la Republica Unida de Tanzania. Metodos En el estudio, participaron 783 trabajadoras del sexo: 470 de Dar es Salaam que recibieron la aplicacion Jichunge mHealth ademas de la profilaxis estandar previa a la exposicion al VIH (grupo de intervencion) y 313 de Tanga que solo recibieron profilaxis previa a la exposicion (grupo de control). Se selecciono a los participantes mediante un muestreo dirigido por los propios encuestados y se les hizo un seguimiento durante 12 meses. La retencion temprana se definio como la asistencia a una consulta de seguimiento de profilaxis previa a la exposicion en los 28 dias siguientes a una cita programada para 1 mes despues de iniciar el tratamiento. Para evaluar si la aplicacion Jichunge conducia a una mayor retencion, se realizaron analisis por intencion de tratar y por protocolo mediante un modelo de regresion ajustado por ponderacion de probabilidad inversa. Resultados El 27,6% (130/470) de los participantes del grupo de intervencion y el 20,1% (63/313) del grupo de control mantuvieron la profilaxis previa a la exposicion al VIH. En el analisis ajustado por intencion de tratar, se observo una retencion temprana del 29,4% en el grupo de intervencion y del 17,7% en el grupo de control (diferencia de riesgo: 11,8 puntos porcentuales; intervalo de confianza del 95%: 5,3-18,3). Conclusion La retencion temprana en la atencion profilactica previa a la exposicion al VIH fue significativamente mayor entre las trabajadoras del sexo de la Republica Unida de Tanzania que utilizaron la aplicacion Jichunge que entre las que no lo hicieron. No obstante, mas de dos tercios de las trabajadoras del sexo que utilizaron la aplicacion no acudieron a los servicios de seguimiento al cabo de un mes, lo que sugiere que se necesitan intervenciones adicionales., Introduction Oral pre-exposure prophylaxis against human immunodeficiency virus (HIV) infection is recommended for high-risk groups as part of efforts to end the public health threat of HIV and acquired immune [...]

BACKGROUND: Safer conception services are needed to minimize HIV transmission among HIV sero-discordant couples desiring pregnancy. Few studies have evaluated the choices couples make when they are offered multiple safer conception methods or real-world method acceptability. This paper addresses an important knowledge gap regarding factors that influence the choice of safer conception methods, couples actual experiences using safer conception methods, and why some couples switch safer conception methods. METHODS: Between February and June 2019, we conducted semi-structured in-depth interviews among 14 men and 17 women, representing 17 couples who exited the SAFER study-a pilot safer conception study for HIV sero-discordant couples in Zimbabwe that offered couples a choice of ART with monthly viral load monitoring (ART/VL), oral PrEP, vaginal insemination, and semen washing. All couples in SAFER had used at least two safer conception methods. RESULTS: We found that safer conception method choice often centered around a desire for intimacy, condomless sex, and certainty in the conception process, particularly for men. Method-related attributes such as familiarity, perceived ease of use, side effects, and perceived level of effectiveness in preventing HIV and achieving pregnancy influenced method choice, switching, and satisfaction. Concerns were expressed about each safer conception method and couples were willing to try different methods until they found method(s) that worked for them. The majority of participants reported having positive experiences using safer conception, especially those using ART/VL + PrEP, citing that they were able to attempt pregnancy for the first time with peace of mind and experienced joy and satisfaction from being able to achieve pregnancy safely. CONCLUSIONS: The differences in method preferences and experiences voiced by participants in this study and in other studies from the region point to the importance of having a variety of safer conception options in the service delivery package and addressing concerns about paternity, intimacy, and method-related attributes to enable HIV sero-discordant couples to safely achieve their reproductive goals.

IntroductionIdentifying the optimal approaches to offering HIV prevention to meet the needs of those at risk is a high priority, particularly given the expanding toolkit of biomedical HIV prevention options. An ongoing study in rural East African communities evaluated the uptake of choices in product, testing mode and location of care delivery through a structured patient-centred HIV prevention delivery model. In this qualitative study, we sought to understand clients' experiences of this "dynamic choice prevention model" (DCP) and highlight pathways of action to inform HIV prevention delivery models.MethodsIn-depth semi-structured interviews were conducted from November 2021 through March 2022 with a purposively selected sample of n = 56 participants in DCP trials (across outpatient departments, antenatal clinics and community settings), and n = 21 healthcare providers (total n = 77). A seven-person multi-regional team translated and inductively coded transcript data. We used a framework analysis approach to identify emergent themes.ResultsIndividuals taking up HIV pre-exposure prophylaxis (PrEP) reported feelings of relief, liberation from fears of acquiring HIV and satisfaction with being able to take action despite partners' behaviours. Couples used a range of approaches afforded by the study to persuade partners to get tested and opt for PrEP. Post-exposure prophylaxis (PEP) use was less common, although women welcomed it in the event of sexual coercion or assault. Participants discussed switching from PEP to PrEP after familiarizing themselves with usage and ascertaining ongoing risk. Participants felt respected by providers, trusted them and appreciated being able to contact them directly for telephone support. Prevention uptake was hindered by stigma, limited experience with and knowledge of prevention methods, gendered and generational power dynamics within intimate partnerships and families, and negative perceptions of methods due to the products themselves. Participants anticipated long-acting injectable PrEP could solve their challenges regarding pill size, daily pill burden and the likelihood of unwanted disclosure.ConclusionsDiverse preferences and barriers to uptake of prevention require a choice of HIV prevention options, locations and delivery modalities-but in addition, flexible, competent and friendly care provision is crucial to promote uptake. Helping clients feel valued, and addressing their unique needs and challenges, enables their agency to prioritize their health.

BACKGROUND: Across sub-Saharan Africa, mid-level healthcare managers oversee implementation of national guidelines. It remains unclear whether leadership and management training can improve population health outcomes. METHODS: We sought to evaluate leadership/management skills among district-level health managers in Uganda participating in the SEARCH-IPT randomised trial to promote isoniazid preventive therapy (IPT) for persons with HIV (PWH). The intervention, which led to higher IPT rates, included annual leadership/management training of managers. We conducted a cross-sectional survey assessing leadership/management skills among managers at trial completion. The survey evaluated self-reported use of leadership/management tools and general leadership/management. We conducted a survey among a sample of providers to understand the interventions impact. Targeted minimum loss-based estimation (TMLE) was used to compare responses between trial arms. RESULTS: Of 163 managers participating in the SEARCH-IPT trial, 119 (73%) completed the survey. Intervention managers reported more frequent use of leadership/management tools taught in the intervention curriculum than control managers (+3.64, 95% CI 1.98-5.30, P < 0.001). There were no significant differences in self-reported leadership skills in the intervention as compared to the control group. Among providers, the average reported quality of guidance and supervision was significantly higher in intervention vs control districts (+1.08, 95% CI 0.63-1.53, P = 0.001). CONCLUSIONS: A leadership and management training intervention increased the use of leadership/management tools among mid-level managers and resulted in higher perceived quality of supervision among providers in intervention vs control districts in Uganda. These findings suggest improved leadership/management among managers contributed to increased IPT use among PWH in the intervention districts of the SEARCH-IPT trial.

Introduction Onchocerciasis, more commonly known as river blindness, is a neglected tropical disease caused by the parasitic worm Onchocerca volvulus. The disease is transmitted to humans through the bite of [...]