Zambart

ABSTRACTWhile much progress has been made in reducing the incidence of HIV-1 infection in sub-Saharan Africa in recent years, bringing the epidemic to an end will require identification of the demographic groups that continue to contribute to transmission. Pathogen phylogenetics and individual-based mathematical models (IBMs) of transmission are approaches that enable researchers to explore such questions. Here, we used both methods to characterise the ages and sexes of the individuals involved in heterosexual transmission in the context of the HPTN 071 (PopART) trial in Zambia.The two methods produced largely concordant results, strengthening confidence in both. A principal finding was that when the age gap in transmission (the difference of ages between the two individuals) was stratified by recipient age, the largest differences were for the youngest female recipients and the smallest for the youngest males. For women under 21 this stood at a male 9.87 years older (95% CI: 8.02 - 11.59) in the phylogenetics, compared to 6.93 (95% HDI: 6.56 - 7.32) in the IBM. As the age of female recipients increased, this gap decreased towards parity. Conversely, the under-21 male recipients saw the smallest gaps with the female older by 0.14 years (95% CI: −2.95 - 3.23) in the phylogenetics and 1.38 years (95% HDI: 0.98 - 1.68) in the IBM. As the age of male recipients decreased, this gap steadily increased. The consequence of this pattern is that transmission to new age cohorts first entering into sexual activity is driven predominantly by male-to-female transmission.We also showed that targeting interventions at younger adults captures most of the benefit of population-wide approaches. We used the IBM to simulate the PopART universal testing and treatment intervention into the future, showing that effective treatment of under-35-year-olds would account for 94.3% (95% HDI: 65.8% - 126.6%) of the reduction in incidence by 2039 that would be achieved by treating the entire population, while effective treatment of under-35 men accounts for 60% (95% HDI: 23.2% - 92.1%).Finally, we simulated a one-year cessation of ART treatment for the whole population, which resulted in an immediate increase in both incidence and the average age at transmission of both sources and recipients. The magnitude of this was 4.6 years (95% HDI: 2.17 - 6.24) for female recipients, 5.3 (95% HDI: 2.74 - 7.09) for male recipients, 5.24 (95% HDI: 2.78 - 6.97) for female sources, and 6.04 (95% HDI: 2.92 - 8.09) for male sources. These changes would be slow to reverse even after ART was restored.These findings indicate that substantial reductions in HIV incidence can be achieved through intensified testing and treatment of individuals aged under 35, and in particular young men, a group that drives the infection of younger women and for whom engagement with care remains disproportionately low.

<title>Abstract</title> <bold>Background</bold> Female genital schistosomiasis (FGS) is a neglected gynaecological disease that affects over 50 million girls and women in sub-Saharan Africa. It is caused by the waterborne parasite <italic>Schistosoma (S.) haematobium</italic> and has been associated with HIV infection, with human papillomavirus (HPV) and cervical precancer. FGS alters the normal sexual and reproductive health of girls and women. Diagnosis is bottlenecked, but previous studies have shown acceptability of genital self-sampling at home for individual diagnosis of FGS, HPV and selected STIs. Here, we aim to determine the acceptability and feasibility of home-based multi-pathogen self-sampling and testing. <bold>Methods</bold> The Zipime Weka Schista study is an ongoing longitudinal cohort integrating a one-stop home-based genital self-sampling for <italic>S. haematobium</italic> and HPV DNA detection with self-testing for HIV and <italic>Trichomonas vaginalis (Tv</italic> ) in three communities in Zambia. Sexually active women aged 15-50 years were randomly selected by community health workers and visited at home where they were invited to provide two cervicovaginal self-swabs and a urine sample, and to conduct self-tests for HIV and <italic>Tv</italic> . During the home visit, community health workers collected information on the acceptability and feasibility of the multi-pathogen genital self-sampling approach using a questionnaire. A follow-up visit was done in clinic. <bold>Results</bold> A total of 2,701 women were initially approached by community health workers and 2,532 were enrolled between January 2022 – March 2023. A total of 100% (2,532) women provided self-swabs, and 94.3% (2,389) and 55.4% (1,404) undertook <italic>Tv</italic> and HIV self-tests, respectively. Of these, 67% (1,694) were followed up in clinic. There was high acceptability 76.4% (1,934) on the procedures for home multi-genital self-sampling. Many participants 87.2% (2,208) preferred to be seen at home than in clinic. Some reasons stated were convenience 62.6% (1,585); privacy 47.9% (1,215); going to the clinic was not convenient 10.4% (264); lack of transport to go to the clinic 8.2% (208); unavailability due to work 4.6% (118) and availability of childcare 2.7% (69). <bold>Conclusion</bold> Home-based multi-pathogen self-sampling and testing is highly acceptable and feasible in three communities in Zambia. This has potential to increase access to diagnosis, treatment and care for different infections co-existing in women.

HIV self-testing (HIVST) has the potential to overcome barriers to conventional clinic-based HIV testing services by offering a convenient, private, and confidential way to test. This study aimed to explore the concerns about HIV self-testing among adolescents and young people (AYP) aged 15-24 years in Uganda, where HIV self-testing is still not widely available. This exploratory qualitative study conducted 14 audio-recorded in-depth interviews and six focus group discussions with adolescents and young people in Wakiso district, Uganda, between March 2021 to February 2022. These interviews were transcribed verbatim and analysed thematically using the socio-ecological model. All participants provided written informed consent and assent before participating in the study. AYP viewed HIVST as a potentially helpful and acceptable testing method. However, several concerns emerged and these are presented using five themes. At the individual level, participants expressed fear of suicidal thoughts if one tested HIV positive, lack of adequate information, anticipated increased risky sexual behaviours, neglect of other HIV preventive measures, and misinterpretation of test kit results. Interpersonal concerns were centred on partner violence, parental coercion, and social rejection. At the community level, participants noted the potential for stigma, unintended pregnancies, and discrimination. Institutional concerns focused on the lack of referral services and inadequate counselling following HIV self-testing. At the structural level, limited accessibility for persons with disabilities was a key concern. While AYP have established that HIVST is essential, various concerns need to be addressed to improve its acceptability, up-take and utilisation. Providing more explicit information about the testing procedure, clarifying any misinterpretation of results, and providing easy access to counselling services, especially at distribution points, is crucial towards guaranteeing the effective roll-out of HIVST among young people. Special attention must also be given to marginalised populations, including people living with disabilities, to ensure fairness in their access and utilisation of services. Implementation of all this will be crucial towards maximising the potential benefits of HIVST in Uganda's HIV prevention efforts.

BackgroundMobility among adolescents and young people (AYP) is a key factor influencing their access to sexual and reproductive health rights (SRHR) services. Young migrants are more likely to experience gender-based violence and their access to SRHR services and education is often limited in their new communities. We conducted a scoping review which aimed to map what is known about the extent and type of interventions focused on SRHR for mobile adolescents and young people (mAYP) in sub-Saharan Africa.MethodsWe followed Arksey and O’Mally’s (2005) steps for conducting scoping reviews: 1. Identifying the research question; 2. Identifying relevant studies; 3. Study selection; 4. Charting the data and 5. Collating, summarising and reporting the results. We searched four databases identifying 1,069 articles. After screening, 25 articles were included.ResultsMany studies were conducted in Uganda (n = 12), reported on conflict-related mobility (n = 15), and focused on HIV (n = 11). Two main intervention types were identified: Links to service provision and Knowledge, information, and skills development. Implementation facilitators included recruiting community health promoters, mentors and peer supporters. Implementation barriers included limited literacy, social norms, access to facilities and stigma associated with accessing services.ConclusionsResearch exploring SRHR interventions for mAYP is limited in sub-Saharan Africa. Future research and interventions should be underpinned by an understanding of young people’s health and wellbeing more broadly, and foreground the social, cultural, religious and economic factors shaping mAYP’s SRH needs.

In southern Africa, men are less likely than women to access HIV services, including HIV testing, antiretroviral therapy (ART), and HIV prevention services. As a result, men living with HIV are less likely to be virally suppressed and more likely to transmit HIV than their female peers. Using the socio-ecological model as a framework, we explored factors that influence men’s motivation and capability to access available HIV services, including how social norms and social networks influence men’s engagement with services, in Lusaka, Zambia. We conducted seven focus group discussions (FGDs) with men and women in an urban community in Lusaka. Five FGDs were conducted with men; two with young men aged 20–24; two with men aged 25–35 and one with men aged 20–35. We conducted two FGDs with women, stratified by age 18–24 and 25–35. The total number of participants was 70. Data were coded and analysed thematically. Pervasive negative community narratives around HIV, negative social and gender norms, the influence of men’s social networks, including stigma related to a positive HIV test result and fear of social isolation, were among the key factors influencing men’s access to HIV services. For HIV testing, the organization and delivery of services in health facilities, including location of HIV testing, waiting times, and likelihood of being seen accessing services, dissuaded men from testing for HIV. In general, health facilities were seen as women’s spaces and unresponsive to men’s needs. However, provider-initiated initiatives, including couples testing in antenatal care and an offer of HIV testing prior to medical male circumcision, and community-based HIV testing facilitated service use. Though condoms were the primary HIV prevention tool mentioned by study participants, norms of their use in marriage and sexual relations limited use. Despite HIV having evolved to a chronic condition and various HIV prevention tools available, fear, social isolation, stigma, and harmful gender norms continue to negatively impact men’s motivation and capability to engage with available HIV services. Measures to facilitate men’s use of these services should consider how to increase social support alongside the delivery of services in spaces that meet men’s needs.

Abstract While much progress has been made in reducing the incidence of HIV-1 infection in sub-Saharan Africa in recent years, bringing the epidemic to an end will require identification of the demographic groups that continue to contribute to transmission. Pathogen phylogenetics and individual-based mathematical models (IBMs) of transmission are approaches that enable researchers to explore such questions. Here, we used both methods to characterise the ages and sexes of the individuals involved in heterosexual transmission in the context of the HPTN 071 (PopART) trial in Zambia. The results were concordant, and show that the male partner was on average older than the female by less than seven years, with larger age gaps in male-to-female than female-to-male transmissions. We found that the largest gaps for female recipients were amongst the youngest of those recipients. Conversely, the youngest male recipients saw the smallest gaps. We further used the IBM to demonstrate that transmission to new age cohorts first entering into sexual activity is driven predominantly by male-to-female transmission. We also simulated the PopART universal testing and treatment intervention into the future to show that effective treatment of under-35-year-olds accounts for 93.8% of the reduction in incidence by 2039, while effective treatment of under-35-year-old men accounts for 62.1%. Finally, we simulated a one-year cessation of ART treatment for the whole population, which resulted in an immediate increase in the average age at transmission of both sources and recipients. With it becoming ever more expensive and difficult to find treatment-naive individuals and link them to care, targeted interventions for demographic groups such as under-35 men may be the key to finally ending HIV.

Like in many countries, coverage of sexual and reproductive health (SRH) services among adolescents and young people (AYP) aged 15-24 remains low in Zambia. Increasing coverage of SRH services requires interventions that are responsive to the needs and preferences of AYP. We conducted a discrete choice experiment (DCE) to elicit AYP's preferences for SRH service delivery in Lusaka, Zambia. A cross-sectional DCE was conducted with AYP aged 15-24 years. Consenting participants were presented with alternative SRH service delivery strategies represented by six attributes, namely: location, type of provider, type of services, service differentiation by sex, availability of edutainment, and opening hours. Multinomial logit and random parameters logit models were used to analyse the data. All variables were effect coded. A total of 423 AYP aged 15-24 years (61% female) completed the DCE. Respondents preferred SRH services that were integrated with other healthcare services (b = 0.65, p < 0.001), delivered by medical staff and peer support workers (b = 0.44, p < 0.001), and provided at a hub within a health facility (b = 0.62, p < 0.001). AYP also preferred services to be available on weekends during the daytime (b = 0.37, p < 0.001). Participants also preferred alternatives which included edutainment (b = 0.22, p < 0.001). Service differentiation by sex had little effect on the preference for SRH service delivery (b = - 0.05, p = 0.08). The coefficient for the "neither" option was negative and statistically significant (b = - 5.31, p < 0.001), implying that AYP did not favor routine SRH service delivery in an outpatient department. Efforts to increase SRH service utilization among AYP should focus on providing comprehensive SRH services that are integrated with other healthcare services. These services should be delivered by a combination of medical staff and peer supporter workers in youth-friendly spaces. Careful attention should be paid to opening times to ensure that these are convenient to AYP.

Home reading practices played a crucial role in the early literacy development of children. Understanding how facilitators engaged in these practices and how they influenced kindergarten learners’ pre-reading skills helped shape effective instructional programs. This study aimed to determine the home reading practices of facilitators and pre-reading skill levels of Kindergarten learners in public and private schools in Masinloc District, Schools Division of Zambales, during the School Year 2024-2025. A descriptive-correlational research design was employed. The study involved 119 home reading facilitators and 119 kindergarten learners, selected through total population sampling. Data were gathered using a validated researcher-designed questionnaire with reliability coefficients of α = .99 for home reading practices and α = .94 for pre-reading skill levels. Most home reading facilitators were female, aged 30-39, married, with one child, a college graduate, and had a monthly family income of ₱20,000 to ₱39,999. They spent 1.0 to 1.9 hours daily on pre-reading instruction and had attended one training session. Frequently practiced home reading activities included picture walks, book exploration, storytelling time, and family reading. Kindergarten learners exhibited proficiency in print awareness, phonological awareness, alphabet knowledge, and vocabulary development. A significant difference was found between the home reading practices of facilitators and their age and sex, while other profile variables showed no significant difference. A moderate positive significant correlation was found between facilitators' home reading practices and learners' pre-reading skill levels. Based on the findings, an enhanced pre-reading program was developed. Home reading practices significantly influenced the prereading skill levels of kindergarten learners. The findings highlighted the need for continuous parental engagement and structured home reading activities. This study provided insights into the relationship between home reading practices and early literacy skills, serving as a basis for refining pre-reading programs in early childhood education.

Tuberculosis (TB) mortality in Zambia remains high at 86 per 100,000 populations, translating to approximately 15,000 TB-related deaths annually. We conducted a nationwide retrospective cohort study to understand predictors, time to death, and probable causes of mortality among persons on TB treatment in Zambia. We reviewed medical records for persons with TB registered in 54 purposively selected hospitals in Zambia between January and December 2019. We fitted a Cox proportional hazards model to identify predictors of mortality. Of the 13,220 records abstracted, 10,987 were analyzed after excluding records of persons who transferred in from other hospitals, those with inconsistent dates and those whose treatment outcome was not evaluated. The majority of persons with TB were men, (61.5%, n = 6,761) with a median age of 36 years (IQR: 27-46 years). Overall, 1,063 (9.7%) died before completing TB treatment (incidence rate = 16.9 deaths per 1,000 person-months). Median age at death was 40 years (IQR: 31-52). The majority of deaths (75.7%, n = 799) occurred in the first two months of TB treatment, with a median time to death of 21 days (IQR: 6-57). Independent risk factors for TB mortality included age >54 years, being treated in Eastern, Southern, Western, Muchinga and Central provinces, receiving treatment from a third-level or mission hospital, methods of diagnosis other than Xpert MTB/RIF, extrapulmonary TB (EPTB), and positive HIV status. Probable causes of death were septic shock (18.8%), TB Immune Reconstitution Inflammatory Syndrome (TB IRIS) (17.8%), end-organ damage (13.4%), pulmonary TB (11.4%), anemia (9.6%) and TB meningitis (7.8%). These results show high mortality among people undergoing TB treatment in Zambia. Interventions targeted at persons most at risk such as the elderly, those with EPTB, and those living with HIV, can help reduce TB-related mortalities in Zambia.