Drug-Drug Interactions between Antiretrovirals and Hormonal Contraception: An Updated Systematic Review.

OBJECTIVE: To summarize and update information regarding drug-drug interactions (DDIs) between antiretrovirals (ARVs) and hormonal contraceptives (HCs). DESIGN: Systematic review METHODS: We searched seven databases for peer-reviewed publications from January 1, 2015, through December 31, 2023, including studies of women using ARVs and HCs concurrently with outcomes including therapeutic effectiveness or toxicity, pharmacokinetics (PK), or pharmacodynamics. We summarized findings and used checklists to assess evidence quality. RESULTS: We included 49 articles, with clinical, ARV or HC PK outcomes reported by 39, 25, and 30 articles, respectively, with some articles reporting outcomes in two or more categories. Fifteen of 18 articles assessing DDIs between efavirenz and progestin implants, emergency contraception, or combined hormonal intravaginal rings found higher pregnancy rates, luteal progesterone levels suggesting ovulation, or reduced progestin PK values. Five studies documented that CYP2B6 single nucleotide polymorphisms exacerbated this DDI. One cohort detected doubled bone density loss with concomitant depot medroxyprogesterone acetate (DMPA) and tenofovir disoproxil fumarate (TDF)-containing ART use versus TDF alone. No other studies described DDIs impacting clinical outcomes. Few adverse events were attributed to ARV-HC use with none exceeding Grade 2. Evidence quality was generally moderate, with dis-similar treatment and control groups, identifying and controlling for confounding, and minimizing attrition bias in the study design being the most frequent limitations. CONCLUSION: Most ARVs and HCs may be used safely and effectively together. TDF-DMPA DDIs warrant longer-term study on bone health and consideration of alternate combinations. For efavirenz-based ART, client counselling on relative risks, including both potential increase in pregnancy rate with concomitant efavirenz and implant use and lower pregnancy rates compared to other HCs even with concomitant efavirenz use, should continue to allow users comprehensive method choice.

Use of a hybrid digital training approach for hormonal IUD providers in Nigeria: results from a mixed method study.

BACKGROUND: In Nigeria, in-service trainings for new family planning (FP) methods have typically been conducted using a combination of classroom-based learning, skills labs, and supervised practicums. This mixed-methods study evaluated the feasibility, acceptability, provider competency, and costs associated with a hybrid digital and in-person training model for the hormonal intrauterine device (IUD). METHODS: The study was conducted in Enugu, Kano, and Oyo states, Nigeria, and enrolled FP providers previously trained on non-hormonal IUDs. Participants completed a digital didactic training, an in-person model-based practicum with an Objective Structured Clinical Examination (OSCE), followed by supervised provision of service to clients. Provider knowledge gains and clinical competency were assessed and described descriptively. Data on the feasibility, acceptability, and scalability of the approach were gathered from participating providers, clinical supervisors, and key stakeholders. Training costs were captured using an activity-based approach and used to calculate a cost per provider trained. All analyses were descriptive. RESULTS: Sixty-two providers took the hybrid digital training, of whom 60 (91%) were included in the study (n = 36 from public sector, n = 15 from private sector, and n = 9 both public/private). The average knowledge score increased from 62 to 86% pre- and post-training. Clinical competency was overall very high (mean: 94%), and all providers achieved certification. Providers liked that the digital training could be done at the time/place of their choosing (84%), was self-paced (79%), and reduced risk of COVID-19 exposure (75%). Clinical supervisors and Ministry of Health stakeholders also had positive impressions of the training and its scalability. The hybrid training package cost $316 per provider trained. CONCLUSIONS: We found that a hybrid digital training approach to hormonal IUD service provision in Nigeria was acceptable and feasible. Providers demonstrated increases in knowledge following the training and achieved high levels of clinical competency. Both providers and clinical supervisors felt that the digital training content was of high quality and an acceptable (sometimes preferable) alternative to classroom-based, in-person training. This study provided insights into a hybrid digital training model for a long-acting contraceptive, relevant to scale-up in Nigeria and similar settings.

Systematic review of the values and preferences regarding the use of injectable pre-exposure prophylaxis to prevent HIV acquisition.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an important HIV prevention option. Two randomized trials have provided efficacy evidence for long-acting injectable cabotegravir (CAB-LA) as PrEP. In considering CAB-LA as an additional PrEP modality for people at substantial risk of HIV, it is important to understand community response to injectable PrEP. We conducted a systematic review of values, preferences and perceptions of acceptability for injectable PrEP to inform global guidance. METHODS: We searched nine databases and conference websites for peer-reviewed and grey literature (January 2010-September 2021). There were no restrictions on location. A two-stage review process assessed references against eligibility criteria. Data from included studies were organized by constructs from the Theoretical Framework of Acceptability. RESULTS: We included 62 unique references. Most studies were observational, cross-sectional and qualitative. Over half of the studies were conducted in North America. Men who have sex with men were the most researched group. Most studies (57/62) examined injectable PrEP, including hypothetical injectables (55/57) or placebo products (2/57). Six studies examined CAB-LA specifically. There was overall interest in and often a preference for injectable PrEP, though there was variation within and across groups and regions. Many stakeholders indicated that injectable PrEP could help address adherence challenges associated with daily or on-demand dosing for oral PrEP and may be a better lifestyle fit for individuals seeking privacy, discretion and infrequent dosing. End-users reported concerns, including fear of needles, injection site pain and body location, logistical challenges and waning or incomplete protection. DISCUSSION: Despite an overall preference for injectable PrEP, heterogeneity across groups and regions highlights the importance of enabling end-users to choose a PrEP modality that supports effective use. Like other products, preference for injectable PrEP may change over time and end-users may switch between prevention options. There will be a greater understanding of enacted preference as more end-users are offered anti-retroviral (ARV)-containing injectables. Future research should focus on equitable implementation, including real-time decision-making and how trained healthcare providers can support choice. CONCLUSIONS: Given overall acceptability, injectable PrEP should be included as part of a menu of prevention options, allowing end-users to select the modality that suits their preferences, needs and lifestyle.

Nutritional Content of Popular Menu Items from Online Food Delivery Applications in Bangkok, Thailand: Are They Healthy?

The rise in online food delivery (OFD) applications has increased access to a myriad of ready-to-eat options, which may lead to unhealthier food choices. Our objective was to assess the nutritional profile of popular menu items available through OFD applications in Bangkok, Thailand. We selected the top 40 popular menu items from three of the most commonly used OFD applications in 2021. Each menu item was collected from the top 15 restaurants in Bangkok for a total of 600 items. Nutritional contents were analysed by a professional food laboratory in Bangkok. Descriptive statistics were employed to describe the nutritional content of each menu item, including energy, fat, sodium, and sugar content. We also compared nutritional content to the World Health Organization's recommended daily intake values. The majority of menu items were considered unhealthy, with 23 of the 25 ready-to-eat menu items containing more than the recommended sodium intake for adults. Eighty percent of all sweets contained approximately 1.5 times more sugar than the daily recommendation. Displaying nutrition facts in the OFD applications for menu items and providing consumers with filters for healthier options are required to reduce overconsumption and improve consumer food choice.

Safety and efficacy of long-acting injectable cabotegravir as preexposure prophylaxis to prevent HIV acquisition.

OBJECTIVE: HIV remains a significant burden, despite expanding HIV prevention tools. Long-acting injectable cabotegravir (CAB-LA) is a new preexposure prophylaxis (PrEP) product. We reviewed existing evidence to determine the efficacy and safety of CAB-LA as PrEP to inform global guidelines. DESIGN: Systematic review and meta-analysis. METHODS: We systematically reviewed electronic databases and conference abstracts for citations on CAB-LA from January 2010 to September 2021. Outcomes included HIV infection, adverse events, drug resistance, pregnancy-related adverse events, and sexual behavior. We calculated pooled effect estimates using random-effects meta-analysis and summarized other results narratively. RESULTS: We identified 12 articles/abstracts representing four multisite randomized controlled trials. Study populations included cisgender men, cisgender women, and transgender women. The pooled relative risk of HIV acquisition comparing CAB-LA to oral PrEP within efficacy studies was 0.21 (95% confidence interval: 0.07-0.61), resulting in a 79% reduction in HIV risk. Rates of adverse events were similar across study groups. Of 19 HIV infections among those randomized to CAB-LA with results available, seven had integrase strand transfer inhibitor (INSTI) resistance. Data on pregnancy-related adverse events were sparse. No studies reported on sexual behavior. CONCLUSIONS: CAB-LA is highly efficacious for HIV prevention with few safety concerns. CAB-LA may lead to an increased risk of INSTI resistance among those who have acute HIV infection at initiation or become infected while taking CAB-LA. However, results are limited to controlled studies; more research is needed on real-world implementation. Additional data are needed on the safety of CAB-LA during pregnancy (for mothers and infants) and among populations not included in the trials.

Exploring public perceptions of vaccine-derived poliovirus and a novel oral polio vaccine in the Democratic Republic of the Congo, Kenya, and Nigeria.

BACKGROUND: The Global Polio Eradication Initiative introduced novel oral polio vaccine Type 2 (nOPV2) to address circulating vaccine-derived poliovirus Type 2 (cVDPV2). Although nOPV2 is a more genetically stable vaccine, it may not have the immediate trust of communities and health workers due to its novelty, potential side effects, and introduction under an Emergency Use Listing (EUL). We explored how nOPV2 introduction might be perceived by stakeholders and identified communications barriers related to nOPV2 hesitancy. METHODS: This work was conducted in the Democratic Republic of the Congo, Kenya, and Nigeria between January and March 2020. We used a rapid qualitative approach to conduct focus group discussions and in-depth interviews with four stakeholder groups: caregivers of children under 5, polio frontline workers, healthcare practitioners, and social/health influencers. Data are presented according to awareness, attitudes/beliefs, and concerns about cVDPV2 and nOPV2. RESULTS: Stakeholders were largely unaware of cVDPV2. The causes of recent polio outbreaks were characterized as poor sanitation, under-immunization/in-migration, or poor vaccine management procedures. Caregivers were aware of and concerned by repeated vaccination campaigns. All stakeholder groups anticipated initial hesitancy, fear, and suspicion from caregivers due to nOPV2 introduction, with primary concerns linked to vaccine testing, safety, effectiveness, side effects, and support from authorities. Stakeholders thought the term "genetic modification" could be controversial but that introduction under an EUL would be acceptable given the emergency nature of cVDPV2 outbreaks. Stakeholders called for adequate and timely information to counter concerns. CONCLUSIONS: Despite initial concerns, stakeholders felt nOPV2 would ultimately be accepted by caregivers. However, public health officials have a small window for "getting things right" when introducing nOPV2. Strategic communication interventions addressing key concerns and targeted communications with stakeholder groups, especially frontline workers, could improve community acceptance of nOPV2.

Analyzing program data and promotional approaches to inform best practices from a mobile phone-based reproductive health message program in Afghanistan.

Objective: Digital health technologies have contributed to the adoption of beneficial reproductive, maternal, newborn, and child health (RMNCH) behaviors through social and behavior change programming, including in hard-to-reach settings. On-demand digital health interventions rely on promotions to build awareness and increase use among target audiences. There is little research on preferred content and use of promotional approaches for RMNCH digital health activities. Methods: We conducted a retrospective descriptive analysis of Mobile for Reproductive Health (m4RH) data in Afghanistan to assess the use and changes in call volume via the 2-3-4 platform by promotional approaches over 23 months between October 2017 and August 2019. Results: There were 103,859 completed messages (CM) heard. Most callers reporting demographics were under 18 years, with roughly even distribution by gender. The number of CMs listened to across all menus increased with time. The basic m4RH family planning menu was most popular, with callers most frequently selecting information on intrauterine contraceptive devices. Nine types of promotional approaches were implemented. Compared against call volume, SMS blast promotion was the most productive promotional approach, radio broadcasts had modest increases, and social media and interpersonal communication demonstrated no clear change. Conclusions: m4RH use increased over time, particularly among younger people. The number of promotional approaches used does not appear as important as the type of approach used to generate program awareness. Mass media communications, including SMS blast promotions and radio broadcasts, may be the most effective strategies. Deeper program data analysis can guide tailoring of message content and promotional approaches to reach target audiences with the RMNCH content they most value.

The financial lives of female sex workers in Addis Ababa, Ethiopia: Implications for economic strengthening interventions for HIV prevention.

Understanding the financial context of the lives of female sex workers (FSWs) is essential to address structural drivers of HIV risk. We used a financial diary methodology to record daily financial transactions over six weeks from a stratified purposive sample (n = 34) of FSWs in Addis Ababa, Ethiopia. FSWs also provided information on their experience with gender-based violence and condom use. FSWs generated 90.1% of total cash from sex work, with a median weekly income of USD 60.53. They engaged mostly in protected vaginal sex, earning approximately USD 4.57 per act. Food, housing, and clothing represented the largest areas of expenditure. Around 17% of expenses were recorded as costs of sex work (e.g., alcohol). Median weekly expenditures accounted for 62% of median weekly income. Nearly all participants reported depositing money into savings at least once over six weeks, while 71% reported a loan transaction during the six-week period, most as borrowers. Findings suggest that financial literacy and formalized savings activities, with life skills and empowerment training, have potential to build FSW's economic resilience, mitigating a structural driver of sex work and HIV risk.

Using financial diaries to understand the economic lives of HIV-positive pregnant women and new mothers in PMTCT in Zomba, Malawi.

BACKGROUND: Economic strengthening (ES) interventions can address economic barriers to retention and adherence (R&A) to antiretroviral therapy in prevention of mother-to-child transmission (PMTCT) services. To inform tailoring of ES activities for PMTCT, we used financial diaries to understand the economic lives of women in PMTCT and examine associations between participants' finances and their R&A. METHODS: We collected financial data from a stratified sample (n = 241) of HIV-positive pregnant women and new mothers enrolled in PMTCT from three clinics in Zomba, Malawi. For 30 weeks, participants met with staff to record cash and in-kind inflows and outflows. We used clinical records to calculate a measure of R&A for each participant. We summarized diary data using R and used cox proportional hazard models to examine the relationship between R&A and participant characteristics and behavior. RESULTS: There were 68,097 cash transactions over 30 weeks, with 10% characterized as inflows. The median value of cash inflows was US$3.54 compared with US$0.42 for cash outflows. Fewer than 7% of total transactions were considered related to PMTCT, with the majority classified as food or drink. Participants in the rural site had the lowest hazard of non-adherence. Decreased hazard of non-adherence was also linked to having dependents and years on ART. There were significant differences in cash inflows and outflows between those who were always adherent and those who were not. CONCLUSIONS: Financial inflows were large and erratic, whereas outflows were small but consistent. PMTCT expenses comprised a small proportion of overall expenses and focused on proper nutrition. The influence of inflows and outflows on adherence was significant but small; however, always adherent participants demonstrated smoother inflows and outflows, indicating an association between greater adherence and economic stability. Participants would benefit from interventions that bolster and stabilize their economic lives, including income generating activities in the agricultural industry and inclusion in village banks.

Adapting a health video library for use in Afghanistan: provider-level acceptability and lessons for strengthening operational feasibility.

BACKGROUND: Community health workers (CHWs) in Afghanistan are a critical care extender for primary health services, including reproductive, maternal, neonatal, and child health (RMNCH) care. However, volunteer CHWs face challenges including an ever-expanding number of tasks and insufficient time to conduct them. We piloted a health video library (HVL) intervention, a tablet-based tool to improve health promotion and counseling by CHWs. We qualitatively assessed provider-level acceptability and operational feasibility. METHODS: CHWs implemented the HVL pilot in three rural districts of Balkh, Herat, and Kandahar provinces. We employed qualitative methods, conducting 47 in-depth interviews (IDIs) with male and female CHWs and six IDIs with community health supervisors. We used semi-structured interview guides to explore provider perceptions of program implementation processes and solicit feedback on how to improve the HVL intervention to inform scale-up. We conducted a thematic analysis. RESULTS: CHWs reported that the HVL increased time efficiencies, reduced work burden, and enhanced professional credibility within their communities. CHWs felt video content and format were accessible for low literacy clients, but also identified challenges to operational feasibility. Although tablets were considered easy-to-use, certain technical issues required continued support from supervisors and family. Charging tablets was difficult due to inconsistent electricity access. Although some CHWs reported reaching most households in their catchment area for visits with the HVL, others were unable to visit all households due to sizeable populations and gender-related barriers, including women's limited mobility. CONCLUSIONS: The HVL was acceptable and feasible for integration into existing CHW duties, indicating it may improve RMNCH counseling, contributing to increased care-seeking behaviors in Afghanistan. Short-term challenges with technology and hardware can be addressed through continued training and provision of solar chargers. Longer-term challenges, including tablet costs, community coverage, and gender issues, require further consideration with an emphasis on equitable distribution.

Evaluating the effect of integrated microfinance and health interventions: an updated review of the evidence.

BACKGROUND: Solutions delivered within firm sectoral boundaries are inadequate in achieving income security and better health for poor populations. Integrated microfinance and health interventions leverage networks of women to promote financial inclusion, build livelihoods, and safeguard against high cost illnesses. Our understanding of the effect of integrated interventions has been limited by variability in intervention, outcome, design, and methodological rigour. This systematic review synthesises the literature through 2015 to understand the effect of integrated microfinance and health programs. METHODS: We searched PubMed, Scopus, Embase, EconLit, and Global Health databases and sourced bibliographies, identifying 964 articles exclusive of duplicates. Title, abstract, and full text review yielded 35 articles. Articles evaluated the effect of intentionally integrated microfinance and health programs on client outcomes. We rated the quality of evidence for each article. RESULTS: Most interventions combined microfinance with health education, which demonstrated positive effects on health knowledge and behaviours, though not health status. Among programs that integrated microfinance with other health components ( i.e. health micro-insurance, linkages to health providers, and access to health products), results were generally positive but mixed due to the smaller number and quality of studies. Interventions combining multiple health components in a given study demonstrated positive effects, though it was unclear which component was driving the effect. Most articles (57%) were moderate in quality. DISCUSSION: Integrated microfinance and health education programs were effective, though longer intervention periods are necessary to measure more complex pathways to health status. The effect of microfinance combined with other health components was less clear. Stronger randomized research designs with multiple study arms are required to improve evidence and disentangle the effects of multiple component microfinance and health interventions. Few studies attempted to understand changes in economic outcomes, limiting our understanding of the relationship between health and income effects.