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What combination of interventions can optimise HIV prevention for adolescent girls and young women? Cohort analysis of DREAMS participation in urban and rural Kenya.
Get PDFComprehensive intervention packages are recommended to address multiple sources of HIV risk for adolescent girls and young women (AGYW). DREAMS is a multi-component HIV prevention program designed to reduce HIV incidence among AGYW. We conducted a prospective cohort study among AGYW aged 13-22 years, randomly selected in rural Gem and urban Nairobi informal settlements followed from 2017/2018-2019. AGYW were classified into three groups: (1) invited to DREAMS and received a "complete" package, (2) invited and received a "partial" package, or (3) not invited to DREAMS. We defined the "complete" package as 4-5 primary interventions in Gem and 5 in Nairobi: the "partial" package as 3 specific interventions in Gem and any 3-4 interventions in Nairobi. We used propensity score-adjusted logistic regression to estimate the causal effect of DREAMS on outcomes under three counterfactual scenarios: all AGYW accessed the complete package, all accessed a partial package, or none were invited. In Nairobi, 1081 AGYW were enrolled. By 2019, 26% accessed the complete package and 32% accessed the partial package. Among those receiving the complete package, there was increase in HIV status knowledge(24.8% [95%CI:16.4,32.6]),social support(13.9% [95%CI:3.3,23.6]) and self-efficacy(10.3% [95%CI:0.5,20.4]) and a decrease in the proportion with ≥2 lifetime partners(-8.0% [95%CI:-15.9,0.0]). In Gem, 1171 AGYW were enrolled. By 2019, 24% received the complete package and 21% received the partial package. We found evidence of an increase in HIV status knowledge(10.0% [95%CI:4.5,15.2]), social support(27.2% [95%CI:19.2,35.5]) and a decrease in condomless sex(-9.1% [95%CI:-13.6,-4.1]), and the proportion with ≥2 lifetime partners(-7.6% [95%CI:-12.4,-2.2]) for the complete package. Among those receiving the partial package, there was a decrease in condomless sex(-12.2% [95%CI: -17.0,-6.4]), and an increase in self-efficacy(8.0% [95%CI:0.0,17]). A package of 4-5 primary DREAMS interventions had positive impacts on multiple HIV-related outcomes in both settings. A partial package was effective in Gem, but not in Nairobi, suggesting the need for context-specific intervention strategies
Improving measurement of girls and young women's reproductive experiences: qualitative findings from research in Kenyan family planning clinics.
Get PDFINTRODUCTION: Girls and young women's reproductive health and autonomy are shaped by multiple interconnected factors. Quantitative research, including widely used measurement scales, may overlook or misrepresent key dimensions of girls and young women's experiences, limiting our ability to understand, characterise and advance their reproductive health and rights. Strengthening measurement tools can yield deeper insights and drive more effective policies and programmes. METHODS: We conducted a qualitative study exploring girls and young women's (aged 15-19 years) experiences accessing and using family planning services and contraceptive methods in Uasin Gishu County, Kenya. This included reflexive thematic analysis of 35 in-depth interviews and seven focus group discussions (FGDs) with 42 girls and young women, along with five FGDs with 27 family planning clinic providers. RESULTS: We identified three dimensions of girls and young women's family planning experiences that challenge existing reproductive health scales. First, reproductive intentions were complex. Second, with support, girls and women asserted their agency and resisted barriers to autonomy. Third, health policies, clinic infrastructure, cultural, religious and social beliefs, and key institutional actors-such as healthcare providers and teachers-inhibited girls and young women's contraceptive access and use. CONCLUSIONS: Qualitative insights can help refine existing scales and guide the development of new ones. Scales should strive to capture diverse reproductive intentions, acknowledge agency and resistance and account for structural and systemic influences. Alongside expanded qualitative research, improving quantitative approaches will yield more person-centred, holistic and context-inclusive insights into girls and young women's reproductive health and lives
Integrating point-of-care screening for curable sexually transmitted infections with HIV, syphilis and hepatitis B screening in antenatal care services in Zimbabwe: a mixed-methods process evaluation.
Get PDFINTRODUCTION: Sexually transmitted infections (STIs) in pregnancy are associated with adverse birth outcomes. We investigated the uptake and yield of point-of-care screening for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis, integrated with HIV, syphilis and hepatitis B virus (HBV) screening in antenatal care (ANC) in Zimbabwe, and conducted a mixed-methods process evaluation of the strategy. METHODS: A prospective interventional study was conducted in two public-sector ANC clinics in Harare. Clients attending for ANC were screened in parallel for C. trachomatis, N. gonorrhoeae, T. vaginalis, HBV, HIV and syphilis, using four different point-of-care tests. Uptake of STI testing and treatment was recorded. Interviews and focus group discussions with pregnant women, healthcare professionals and the intervention team were conducted and analysed thematically. Implementation, mechanisms of impact and context were explored using the Medical Research Council Process Evaluation Framework. RESULTS: Between 12 January 2023 and 23 October 2023, there were 13 500 ANC attendances over 207 implementation days. Of 1105 (8.2%) assessed for eligibility, 1103 (99.8%) were eligible, of whom uptake of the full screening package was 91.0% (1004/1103). Curable STI prevalence was 30.7% (308/1003), of whom 303 (98.4%) received same-day treatment. HBV prevalence was 1.4% (14/1003). The prevalence of HIV was 10.5% (105/1003), with 20 (19.0%) being new diagnoses.Although the intervention was highly acceptable, diagnostic capacity and workload were barriers to recruitment. In particular, the collection and testing of multiple sample types with different tests, with a range of reading times, was challenging. CONCLUSION: We demonstrated high levels of acceptability, screening uptake and same-day treatment. However, a low proportion of ANC attendees were enrolled overall, and current technological limitations preclude this particular testing strategy from being scaled up beyond low-volume settings. We recommend investment into the development of STI point-of-care tests with shorter analytic times and research into alternative strategies involving laboratory-based high-throughput testing. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT05541081; registered 15 September 2022
Global age-sex-specific all-cause mortality and life expectancy estimates for 204 countries and territories and 660 subnational locations, 1950-2023: a demographic analysis for the Global Burden of Disease Study 2023.
Get PDFBACKGROUND: Comprehensive, comparable, and timely estimates of demographic metrics-including life expectancy and age-specific mortality-are essential for evaluating, understanding, and addressing trends in population health. The COVID-19 pandemic highlighted the importance of timely and all-cause mortality estimates for being able to respond to changing trends in health outcomes, showing a strong need for demographic analysis tools that can produce all-cause mortality estimates more rapidly with more readily available all-age vital registration (VR) data. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is an ongoing research effort that quantifies human health by estimating a range of epidemiological quantities of interest across time, age, sex, location, cause, and risk. This study-part of the latest GBD release, GBD 2023-aims to provide new and updated estimates of all-cause mortality and life expectancy for 1950 to 2023 using a novel statistical model that accounts for complex correlation structures in demographic data across age and time. METHODS: We used 24 025 data sources from VR, sample registration, surveys, censuses, and other sources to estimate all-cause mortality for males, females, and all sexes combined across 25 age groups in 204 countries and territories as well as 660 subnational units in 20 countries and territories, for the years 1950-2023. For the first time, we used complete birth history data for ages 5-14 years, age-specific sibling history data for ages 15-49 years, and age-specific mortality data from Health and Demographic Surveillance Systems. We developed a single statistical model that incorporates both parametric and non-parametric methods, referred to as OneMod, to produce estimates of all-cause mortality for each age-sex-location group. OneMod includes two main steps: a detailed regression analysis with a generalised linear modelling tool that accounts for age-specific covariate effects such as the Socio-demographic Index (SDI) and a population attributable fraction (PAF) for all risk factors combined; and a non-parametric analysis of residuals using a multivariate kernel regression model that smooths across age and time to adaptably follow trends in the data without overfitting. We calibrated asymptotic uncertainty estimates using Pearson residuals to produce 95% uncertainty intervals (UIs) and corresponding 1000 draws. Life expectancy was calculated from age-specific mortality rates with standard demographic methods. For each measure, 95% UIs were calculated with the 25th and 975th ordered values from a 1000-draw posterior distribution. FINDINGS: In 2023, 60·1 million (95% UI 59·0-61·1) deaths occurred globally, of which 4·67 million (4·59-4·75) were in children younger than 5 years. Due to considerable population growth and ageing since 1950, the number of annual deaths globally increased by 35·2% (32·2-38·4) over the 1950-2023 study period, during which the global age-standardised all-cause mortality rate declined by 66·6% (65·8-67·3). Trends in age-specific mortality rates between 2011 and 2023 varied by age group and location, with the largest decline in under-5 mortality occurring in east Asia (67·7% decrease); the largest increases in mortality for those aged 5-14 years, 25-29 years, and 30-39 years occurring in high-income North America (11·5%, 31·7%, and 49·9%, respectively); and the largest increases in mortality for those aged 15-19 years and 20-24 years occurring in Eastern Europe (53·9% and 40·1%, respectively). We also identified higher than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 5-14 years (87·3% higher in GBD 2023 than GBD 2021 on average across countries and territories over the 1950-2021 period) and for females aged 15-29 years (61·2% higher), as well as lower than previously estimated mortality rates in sub-Saharan Africa for all sexes combined aged 50 years and older (13·2% lower), reflecting advances in our modelling approach. Global life expectancy followed three distinct trends over the study period. First, between 1950 and 2019, there were considerable improvements, from 51·2 (50·6-51·7) years for females and 47·9 (47·4-48·4) years for males in 1950 to 76·3 (76·2-76·4) years for females and 71·4 (71·3-71·5) years for males in 2019. Second, this period was followed by a decrease in life expectancy during the COVID-19 pandemic, to 74·7 (74·6-74·8) years for females and 69·3 (69·2-69·4) years for males in 2021. Finally, the world experienced a period of post-pandemic recovery in 2022 and 2023, wherein life expectancy generally returned to pre-pandemic (2019) levels in 2023 (76·3 [76·0-76·6] years for females and 71·5 [71·2-71·8] years for males). 194 (95·1%) of 204 countries and territories experienced at least partial post-pandemic recovery in age-standardised mortality rates by 2023, with 61·8% (126 of 204) recovering to or falling below pre-pandemic levels. There were several mortality trajectories during and following the pandemic across countries and territories. Long-term mortality trends also varied considerably between age groups and locations, demonstrating the diverse landscape of health outcomes globally. INTERPRETATION: This analysis identified several key differences in mortality trends from previous estimates, including higher rates of adolescent mortality, higher rates of young adult mortality in females, and lower rates of mortality in older age groups in much of sub-Saharan Africa. The findings also highlight stark differences across countries and territories in the timing and scale of changes in all-cause mortality trends during and following the COVID-19 pandemic (2020-23). Our estimates of evolving trends in mortality and life expectancy across locations, ages, sexes, and SDI levels in recent years as well as over the entire 1950-2023 study period provide crucial information for governments, policy makers, and the public to ensure that health-care systems, economies, and societies are prepared to address the world's health needs, particularly in populations with higher rates of mortality than previously known. The estimates from this study provide a robust framework for GBD and a valuable foundation for policy development, implementation, and evaluation around the world. FUNDING: Gates Foundation
IOL use at Kilimanjaro Christian Medical Centre, Tanzania
Get PDFThe use of intraocular lenses (IOLs) at KCMC in Tanzania dates back to 1990, when we started using anterior chamber intraocular lenses. Posterior chamber intraocular lenses were introduced in 1992. By the year 2000, phacoemulsification services were available and foldable intraocular lenses were in common use
Antibody responses against influenza A decline with successive years of annual influenza vaccination.
Get PDFInfluenza vaccine effectiveness and immunogenicity can be compromised with repeated vaccination. We assessed immunological markers in a cohort of healthcare workers (HCW) from six public hospitals around Australia during 2020-2021. Sera were collected pre-vaccination and ~14 and ~180 days post-vaccination and assessed in haemagglutination inhibition assay against egg-grown vaccine and equivalent cell-grown viruses. Responses to vaccination were compared by the number of prior vaccinations. Baseline sera were available for 595 HCW in 2020 and 1031 in 2021. 5% had not been vaccinated during five years prior to enrolment and 55% had been vaccinated every year. Post-vaccination titres for all vaccine antigens were lowest among HCW vaccinated in all 5-prior years and highest among HCW with 0 or 1 prior vaccinations, even after adjustment. This was observed for both influenza A subtypes and was dependent on pre-vaccination titre. Expanded cohorts are needed to better understand how this translates to vaccine effectiveness
Social norms relating to gender and dating and relationship violence in English secondary schools: Exploring student, staff and parent/carer accounts.
Get PDFDating and relationship violence (DRV) among young people is widespread. DRV is associated with subsequent mental ill health, substance use and sexual risk among girls and boys and is a leading cause of morbidity and mortality among girls globally. Harmful social norms are widely recognised for their role in sustaining DRV, and interventions often seek to change these. However, little evidence is available to suggest which specific norms are most salient and where protective norms might be strengthened. We conducted, audio-recorded and transcribed consultations and semi-structured interviews with students (years 9 and 10), school staff and parents/carers from ten secondary schools in England. We also audio-recorded discussions in staff DRV trainings in four of these schools. Data collection took place between April 2017 and July 2018. This research explored participant accounts of social norms relating to gender and to DRV in schools and their influence on DRV behaviours. Drawing on Giddens' structuration theory, our thematic analysis found that sexist social norms subjugating girls to boys facilitated gendered practices of harassment and abuse, including DRV; and that these practices, in turn, reproduced this gendered power structure. Our data suggest that while physical DRV is socially proscribed, norms supporting controlling behaviours and inhibiting disclosure of victimisation directly underpin DRV. They further suggest that indirectly, gender norms concerning cross-gender friendships; sexual harassment; the policing of girls' sexuality; homophobic abuse; and dominance, control and sexual activity as masculine ideals indirectly sustain DRV. Accounts demonstrated that students and staff challenge harmful norms, but that these efforts can be ineffective and socially punished. Our findings can inform DRV interventions, which should draw on evidence to foster protective norms and shift those that sustain DRV
Consent and violence amongst men in the context of sexualised drug use: A systematic scoping review.
Get PDFSexualised drug use (SDU) is a highly prevalent phenomenon of increasing public health significance in communities of men who have sex with men (MSM). This prospectively registered PRISMA-ScR-adherent systematic scoping review examines the current state of knowledge surrounding violence amongst MSM in the context of SDU. A broad search was conducted across four databases, with no restrictions. Studies citing or cited by all database-identified records retained for full-text review were retrieved and screened. Three journals were hand-searched across the past five years, and three searches were conducted on Google Scholar. In addition, 13 key opinion leaders were contacted via email to request any additional published or unpublished data. The twenty-eight studies included in the final synthesis reported mostly qualitative data from geographically diverse non-representative samples, predominantly relating to sexual violence with other typologies seldom investigated or reported. Although quantitative data were limited, sexual violence appeared common in this context and was directly associated with impaired mental health and suicidality. Some participants reported first- or second-hand accounts of non-consensual administration of incapacitating doses of GHB/GBL to men who were subsequently raped. This was frequently perpetrated by men whose age, status, or financial privilege afforded them power over their victims. While reports from some participants suggested context-specific blurring of the lines of consent, a few quotes demonstrated a dearth of knowledge surrounding the centrality of consent in lawful sex. Given the historical denigration of MSM, any efforts to further investigate or address this issue must be community-led
The Impact of WHO-2023 Malnutrition Criteria on Caseload of Infants Aged Under Six Months: Secondary Data Analysis.
Get PDFBACKGROUND/OBJECTIVES: The 2023 World Health Organization (WHO) guideline on infants aged under six months (u6m) wasting now includes mid-upper arm circumference (MUAC) and weight for age Z score (WAZ) as malnutrition treatment programme enrolment criteria. Evidence for the new criteria and optimal cut-offs is, however, sparse. We aimed to explore the potential caseload implications of the new criteria and explore how different cut-offs might affect them. METHODS: We conducted a secondary analysis of data from 1048 Ethiopian infants u6m using STATA software version 17. Frequency tables and percentages were used to present malnutrition across various characteristics. The chi-square test with 95% confidence intervals (CIs) at a p value of <0.05 was used to compare infant caseload identified by the WHO-2023 versus WHO-2013 criteria. RESULTS: We found substantial overlaps among anthropometric indicators of malnutrition in infants defined by the WHO-2023 programme enrolment criteria. New WHO criteria result in a larger potential caseload (19.2% for 6 weeks to 6 months and 15.1% for infants under 6 weeks) compared with WHO-2013 criteria (2.4%). Whilst there are marked overlaps between low WAZ, low WLZ, and low MUAC, they capture different infants. An MUAC of <110 mm alone would capture only a third of all cases identified by WAZ and/or WLZ < -2. CONCLUSIONS: In Ethiopia, the WHO-2023 criteria markedly increase malnutrition caseloads compared with WHO-2013 criteria. There might be a case for increasing MUAC thresholds in MUAC-focused programs where WLZ or WAZ measurements are difficult. Future longitudinal data are needed to know which criteria best identify infants at highest risk of mortality/morbidity/poor development
Flies as carriers of antimicrobial resistant (AMR) bacteria in Nigerian hospitals: A workflow for surveillance of AMR bacteria carried by arthropod pests in hospital settings.
Get PDFThe dissemination of antimicrobial resistant (AMR) bacteria by flies in hospitals is concerning as nosocomial AMR infections pose a significant threat to public health. This threat is compounded in low- and middle-income countries (LMICs) by several factors, including limited resources for sufficient infection prevention and control (IPC) practices and high numbers of flies in tropical climates. In this pilot study, 1,396 flies were collected between August and September 2022 from eight tertiary care hospitals in six cities (Abuja, Enugu, Kaduna, Kano, Lagos and Sokoto) in Nigeria. Flies were screened via microbiological culture and bacterial isolates were phenotypically and genetically characterised to determine carriage of clinically important antibiotic resistance genes (ARGs). Several clinically relevant ARGs were found in bacteria isolated from flies across all hospitals. blaNDM was detected in 8% of flies and was predominantly carried by Providencia spp. alongside clinically relevant Enterobacter spp, Escherichia coli and Klebsiella pneumoniae isolates, which all exhibited a multidrug resistant phenotype. mecA was detected at a prevalence of 6.4%, mostly in coagulase-negative Staphylococci (CoNS) as well as some Staphylococcus aureus, of which 86.8% were multidrug resistant. 40% of flies carried bacteria with at least one of the two ESBL genes tested (blaOXA-1 and blaCTX-M-15). This multi-site study emphasised that flies in hospital settings carry bacteria that are resistant to multiple classes of antibiotics, including both routinely used and reserve antibiotics. A greater understanding of the global clinical significance and burden of AMR attributable to insect pests is required