Creating allies: qualitative exploration of young women's preferences for PrEP methods and parents' role in PrEP uptake and user support in urban and rural Zambia.

BACKGROUND: Zambian adolescent girls and young women (AGYW) have high HIV incidence and face barriers to the use of pre-exposure prophylaxis (PrEP). Parental support improves PrEP use and adherence in some settings, but negative parental attitudes toward HIV prevention may inhibit engagement with AGYW. We explored perceptions of future PrEP methods among AGYW and parents and parent-youth engagement on HIV prevention and PrEP use. METHODS: We conducted a qualitative descriptive study among AGYW and parents of AGYW in five provinces in Zambia in September-October 2021. We conducted 10 focus group discussions (FGDs) and four in-depth interviews (IDIs) with AGYW participants (n = 87) and seven FGDs and four IDIs among parents of AGYW (n = 62). All FGDs and IDIs were audio-recorded, transcribed verbatim, and analyzed to identify qualitative themes. RESULTS: Most AGYW participants preferred the discreet nature and longer duration of injectable PrEP compared to the PrEP ring and oral PrEP. Many AGYWs reported inability to disclose PrEP use to their parents due to lack of parental support based on cultural taboos against premarital sex. Nevertheless, AGYW participants said they would like to talk to their parents about PrEP so their parents could support their use. Many parents also described difficulties discussing PrEP with their daughters because of cultural and religious beliefs about abstinence from sex before marriage. However, parents acknowledged that the threat of HIV is real and said they need PrEP knowledge and guidance on speaking with their children about HIV prevention and PrEP. CONCLUSIONS: Although many parents are currently not playing a role in daughters' decisions about PrEP use, both parents and AGYW are willing to engage with each other on HIV prevention issues. To foster parent-child engagement, HIV prevention programs should not only provide information about PrEP but also address social norms that impede discussion of HIV prevention and equip both parents and AGYW with skills and support for such conversations. Community sensitization is also needed as new PrEP products are introduced, to create an enabling environment for parent-child engagement by increasing awareness, countering misconceptions, and reducing stigma.

Safety and continued use of the levonorgestrel intrauterine system as compared with the copper intrauterine device among women living with HIV in South Africa: A randomized controlled trial.

BACKGROUND: Women living with HIV (WLHIV) have lower rates of contraceptive use than noninfected peers, yet concerns regarding contraceptive efficacy and interaction with antiretroviral therapy (ART) complicate counseling. Hormonal contraceptives may increase genital tract HIV viral load (gVL) and sexual transmission risk to male partners. We compared gVL, plasma VL (pVL), and intrauterine contraceptive (IUC) continuation between the levonorgestrel intrauterine system (LNG-IUS) and copper intrauterine device (C-IUD) in Cape Town, South Africa. METHODS AND FINDINGS: In this double-masked, randomized controlled noninferiority trial, eligible WLHIV were ages 18-40, not pregnant or desiring pregnancy within 30 months, screened and treated (as indicated) for reproductive tract infections (RTIs) within 1 month of enrollment, and virologically suppressed using ART or above treatment threshold at enrollment (non-ART). Between October 2013, and December 2016, we randomized consenting women within ART groups, using 1:1 permuted block randomization stratified by ART use, age (18-23, 24-31, 32-40), and recent injectable progestin contraceptive (IPC) exposure, and provided the allocated IUC. At all visits, participants provided specimens for gVL (primary outcome), pVL, RTI, and pregnancy testing. We assessed gVL and pVL across 6 and 24 months controlling for enrollment measures, ART group, age, and RTI using generalized estimating equation and generalized linear models (non-ART group pVL and hemoglobin) in as-treated analyses. We measured IUC discontinuation rates with Kaplan-Meier estimates and Cox proportional hazards models. We enrolled 71 non-ART (36 LNG-IUS, 31 C-IUD; 2 declined and 2 were ineligible) and 134 ART-using (65 LNG-IUS, 67 C-IUD; 1 declined and 1 could not complete IUC insertion) women. Participant median age was 31 years, and 95% had 1 or more prior pregnancies. Proportions of women with detectable gVL were not significantly different comparing LNG-IUS to C-IUD across 6 (adjusted odds ratio [AOR]: 0.78, 95% confidence interval [CI] 0.44-1.38, p = 0.39) and 24 months (AOR: 1.03, 95% CI: 0.68-1.57, p = 0.88). Among ART users, proportions with detectable pVL were not significantly different at 6 (AOR = 0.83, 95% CI 0.37-1.86, p = 0.65) and 24 months (AOR = 0.94, 95% CI 0.49-1.81, p = 0.85), whereas among non-ART women, mean pVL was not significantly different at 6 months (-0.10 log10 copies/mL, 95% CI -0.29 to 0.10, p = 0.50) between LNG-IUS and C-IUD users. IUC continuation was 78% overall; C-IUD users experienced significantly higher expulsion (8% versus 1%, p = 0.02) and elective discontinuation (adjusted hazard ratio: 8.75, 95% CI 3.08-24.8, p < 0.001) rates. Sensitivity analysis adjusted for differential IUC discontinuation found similar gVL results. There were 39 serious adverse events (SAEs); SAEs believed to be directly related to IUC use (n = 7) comprised 3 pelvic inflammatory disease (PID) cases and 4 pregnancies with IUC in place with no discernible trend by IUC arm. Mean hemoglobin change was significantly higher among LNG-IUS users across 6 (0.57 g/dL, 95% CI 0.24-0.90; p < 0.001) and 24 months (0.71 g/dL, 95% CI 0.47-0.95; p < 0.001). Limitations included not achieving non-ART group sample size following change in ART treatment guidelines and truncated 24 months' outcome data, as 17 women were not yet eligible for their 24-month visit at study closure. Also, a change in VL assay during the study may have caused some discrepancy in VL values because of different limits of detection. CONCLUSIONS: In this study, we found that the LNG-IUS did not increase gVL or pVL and had low levels of contraceptive failure and associated PID compared with the C-IUD among WLHIV. LNG-IUS users were significantly more likely to continue IUC use and had higher hemoglobin levels over time. The LNG-IUS appears to be a safe contraceptive with regard to HIV disease and may be a highly acceptable option for WLHIV. TRIAL REGISTRATION: ClinicalTrials.gov NCT01721798.

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.

Factors associated with reported modern contraceptive use among married men in Afghanistan.

BACKGROUND: Afghanistan has high maternal and infant mortality which is in part driven by high fertility and low modern contraceptive use. Using modern contraceptive methods can reduce maternal and infant mortality, however there are several barriers to modern contraceptive use in Afghanistan. Married men have the potential to hinder or facilitate their wives' contraceptive use. Internally displaced persons (IDP), a growing population in Afghanistan, are rarely included in reproductive health research. We explored whether married men's, including IDPs', gender-related attitudes and other factors were associated with reported modern contraceptive use to inform programming to meet reproductive health needs of married couples. METHODS: Cross-sectional study using data from 885 married men determined to have contraceptive need in seven Afghan provinces. We explored associations between sociodemographic factors, IDP status, wives' involvement in household decision-making and men's attitudes towards intimate partner violence (IPV) with reported modern contraceptive use using logistic regression analysis. RESULTS: Most men (78%) had ≥2 children, 60% reported any formal education, and 30% reported being IDPs. Only 38% of married men and 24% of IDPs with contraceptive need reported using modern contraception with their wives. Most (80% overall, 63% of IDPs) reported their wives' involvement in some/all household decisions, while 47% overall and 57% of IDPs reported IPV was justified in one or more listed circumstances. In bivariate analysis, men responding that IPV was not justified in any listed circumstance were more likely and IDPs less likely to report modern contraceptive use. In multivariable analysis, involvement by wives in household decision-making (AOR 2.57; 95% CI: 1.51, 4.37), owning a radio and/or television (AOR 1.69; 95% CI: 1.10, 2.59), having more children, age, and province of interview were independently associated with reported modern contraceptive use, while IDP status was not. CONCLUSIONS: Our findings reflect positive associations between wives' participation in household decisions and mass media exposure (television/radio ownership) with reported modern contraceptive use. Reproductive health initiatives engaging men to promote communication within couples and through mass media channels may further increase modern contraceptive use and advance Afghanistan's family planning goals. As fewer IDPs owned a radio/television, additional outreach methods should be tested for this group.

Multisector nutrition gains amidst evidence scarcity: scoping review of policies, data and interventions to reduce child stunting in Afghanistan.

BACKGROUND: Child health indicators have substantially improved across the last decade, yet Afghanistan has among the highest child stunting and malnutrition rates in Asia. Multisectoral approaches were recently introduced but evidence for this approach to improve support for and implementation of child nutrition programmes is limited compared to other countries. METHODS: We reviewed policy and programme data to identify best practices and gaps surrounding child malnutrition in Afghanistan. We conducted a scoping review using broad search categories and approaches, including database and website searches, reference hand-searches, purposive policy and programme document request, and key informant interviews. Inclusion and exclusion criteria were developed iteratively, with abstracts and documents assessed against the final criteria. We abstracted documents systematically and summarised and synthesised content to generate the main findings. RESULTS: We included 18 policies and strategies, 45 data sources and reports, and 20 intervention evaluations. Movement towards multisectoral efforts to address malnutrition at the policy level has started; however, integrated nutrition-specific and nutrition-sensitive interventions are not yet uniformly delivered at the community level. Many data sources capturing nutrition, food security and WASH (water, sanitation and hygiene) indicators are available but indicator definitions are not standardised and there are few longitudinal nutrition surveys. Political will to improve household nutrition status has shown increased government and donor investments in nutrition-sensitive and nutrition-specific programmes through combined small- and large-scale interventions between 2004 and 2013; however, evidence for interventions that effectively decrease stunting prevalence is limited. CONCLUSIONS: This review shows a breadth of nutrition programme, policy and data in Afghanistan. Multisector approaches faced challenges of reaching sufficient coverage as they often included a package of food security, livelihoods and health interventions but were each implemented independently. Further implementation evidence is needed to aid policy and programmes on effective integration of nutrition, food security and WASH in Afghanistan.

Review of policies, data, and interventions to improve maternal nutrition in Afghanistan.

Malnutrition contributes to direct and indirect causes of maternal mortality, which is particularly high in Afghanistan. Women's nutritional status before, during, and after pregnancy affects their own well-being and mortality risk and their children's health outcomes. Though maternal nutrition interventions have documented positive impact on select child health outcomes, there are limited data regarding the effects of maternal nutrition interventions on maternal health outcomes globally. This scoping review maps policies, data, and interventions aiming to address poor maternal nutrition outcomes in Afghanistan. We used broad search categories and approaches including database and website searches, hand searches of reference lists from relevant articles, policy and programme document requests, and key informant interviews. Inclusion and exclusion criteria were developed by type of source document, such as studies with measures related to maternal nutrition, relevant policies and strategies, and programmatic research or evaluation by a third party with explicit interventions targeting maternal nutrition. We abstracted documents systematically, summarized content, and synthesized data. We included 20 policies and strategies, 29 data reports, and nine intervention evaluations. The availability of maternal nutrition intervention data and the inclusion of nutrition indicators, such as minimum dietary diversity, have increased substantially since 2013, yet few nutrition evaluations and population surveys include maternal outcomes as primary or even secondary outcomes. There is little evidence on the effectiveness of interventions that target maternal nutrition in Afghanistan. Policies and strategies more recently have shifted towards multisectoral efforts and specifically target nutrition needs of adolescent girls and women of reproductive age. This scoping review presents evidence from more than 10 years of efforts to improve the maternal nutrition status of Afghan women. We recommend a combination of investments in measuring maternal nutrition indicators and improving maternal nutrition knowledge and behaviours.

Maternal nutrition intervention and maternal complications in 4 districts of Bangladesh: A nested cross-sectional study.

BACKGROUND: Maternal morbidity is common in Bangladesh, where the maternal mortality rate has plateaued over the last 6 years. Maternal undernutrition and micronutrient deficiencies contribute to morbidity, but few interventions have measured maternal outcomes. We compared reported prevalence of antepartum, intrapartum, and postpartum complications among recently delivered women between maternal nutrition intervention and control areas in Bangladesh. METHODS AND FINDINGS: We conducted a cross-sectional assessment nested within a population-based cluster-randomized trial comparing a nutrition counseling and micronutrient supplement intervention integrated within a structured home-based maternal, newborn, and child health (MNCH) program to the MNCH program alone in 10 sub-districts each across 4 Bangladesh districts. Eligible consenting women, delivering within 42-60 days of enrollment and identified by community-level health workers, completed an interviewer-administered questionnaire detailing the index pregnancy and delivery and allowed review of their home-based care register. We compared pooled and specific reported antepartum, intrapartum, and postpartum complications between study groups using hierarchical logistic regression. There were 594 women in the intervention group and 506 in the control group; overall, mean age was 24 years, 31% were primiparas, and 39% reported facility-based delivery, with no significant difference by study group. There were no significant differences between the intervention and control groups in household-level characteristics, including reported mean monthly income (intervention, 6,552 taka, versus control, 6,017 taka; p = 0.48), having electricity (69.6% versus 71.4%, p = 0.84), and television ownership (41.1% versus 38.7%, p = 0.81). Women in the intervention group had higher recorded iron and folic acid and calcium supplement consumption and mean dietary diversity scores, but reported anemia rates were similar between the 2 groups (5.7%, intervention; 6.5%, control; p = 0.83). Reported antepartum (69.4%, intervention; 79.2%, control; p = 0.12) and intrapartum (41.4%, intervention; 48.5%, control; p = 0.18) complication rates were high and not significantly different between groups. Reported postpartum complications were significantly lower among women in the intervention group than the control group (33.5% versus 48.2%, p = 0.02), and this difference persisted in adjusted analysis (adjusted odds ratio [AOR] = 0.51, 95% CI 0.32-0.82; p < 0.001). For specific conditions, odds of retained placenta (AOR = 0.35, 95% CI 0.19-0.67; p = 0.001), postpartum bleeding (AOR = 0.37, 95% CI 0.15-0.92; p = 0.033), and postpartum fever/infection (AOR = 0.27, 95% CI 0.11-0.65; p = 0.001) were significantly lower in the intervention group in adjusted analysis. There were no significant differences in reported hospitalization for antepartum (49.8% versus 45.1%, p = 0.37), intrapartum (69.9% versus 59.8%, p = 0.18), or postpartum (36.1% versus 29.9%, p = 0.49) complications between the intervention and control groups. The main limitations of this study are outcome measures based on participant report, non-probabilistic selection of community-level workers' catchment areas for sampling, some missing data for variables derived from secondary sources (e.g., dietary diversity score), and possible recall bias for reported dietary intake and supplement use. CONCLUSIONS: Reported overall postpartum and specific intrapartum and postpartum complications were significantly lower for women in intervention areas than control areas, despite similar rates of facility-based delivery and hospitalization for reported complications, in this exploratory analysis. Maternal nutrition interventions providing intensive counseling and micronutrient supplements may reduce some pregnancy complications or impact women's ability to accurately recognize complications, but more rigorous evaluation is needed for these outcomes.

Incidence of and temporal relationships between HIV, herpes simplex II virus, and syphilis among men who have sex with men in Bangkok, Thailand: an observational cohort.

BACKGROUND: High HIV incidence has been detected among men who have sex with men (MSM) in Thailand, but the relationship and timing of HIV, herpes simplex virus 2 (HSV-2), and syphilis is unknown. This analysis measures incidence, temporal relationships, and risk factors for HIV, HSV-2, and syphilis among at-risk MSM in the Bangkok MSM Cohort Study. METHODS: Between April 2006 and December 2010, 960 men negative for HIV, HSV-2, and syphilis at entry enrolled and contributed 12-60 months of follow-up data. Behavioral questionnaires were administered at each visit; testing for HIV antibody was performed at each visit, while testing for syphilis and HSV-2 were performed at 12 month intervals. We calculated HIV, HSV-2, and syphilis incidence, assessed risk factors with complementary log-log regression, and among co-infected men, measured temporal relationships between infections with Kaplan-Meier survival analysis and paired t-test. RESULTS: The total number of infections and incidence density for HIV, HSV-2, and syphilis were 159 infections and 4.7 cases/100 PY (95 % Confidence Interval (CI): 4.0-5.4), 128 infections and 4.5/100 PY (95 % CI: 3.9-5.5), and 65 infections and 1.9/100 PY (95 % CI: 1.5-2.5), respectively. Among men acquiring >1 infection during the cohort period, mean time to HIV and HSV-2 infection was similar (2.5 vs. 2.9 years; p = 0.24), while syphilis occurred significantly later following HIV (4.0 vs. 2.8 years, p < 0.01) or HSV-2 (3.8 vs. 2.8 years, p = 0.04) infection. The strongest independent predictor of any single infection in adjusted analysis was acquisition of another infection; risk of syphilis (Adjusted Hazards Ratio (AHR) = 3.49, 95 % CI: 1.89-6.42) or HIV (AHR = 2.26, 95 % CI: 1.47-3.48) acquisition during the cohort was significantly higher among men with incident HSV-2 infection. No single independent behavioral factor was common to HIV, HSV-2, and syphilis acquisition. CONCLUSION: HIV and HSV-2 incidence was high among this Thai MSM cohort. However, acquisition of HIV and co-infection with either HSV-2 or syphilis was low during the time frame men were in the cohort. Evaluation of behavioral risk factors for these infections suggests different risks and possible different networks.

Prevalence and Correlates of Chlamydia trachomatis and Neisseria gonorrhoeae by Anatomic Site Among Urban Thai Men Who Have Sex With Men.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection are prevalent among men who have sex with men (MSM) and may infect multiple anatomic sites. We measured site-specific prevalence and correlates of CT and NG infection among Bangkok MSM Cohort Study participants. METHODS: In April 2006 to November 2010, 1744 men enrolled in the Bangkok MSM Cohort Study. Participants provided historical information and underwent physical examination. Rectal, urethral, and pharyngeal CT and NG screening were performed by nucleic acid amplification and/or culture. Logistic regression was used to identify correlates of site-specific CT, NG, and coinfection. RESULTS: Among 1743 participants, 19.2% were infected with CT and/or NG. CT, NG, and CT-NG coinfection were detected in 11.6%, 4.6%, and 2.9%, of participants, respectively. Rectal, urethral, and pharyngeal CT infections were detected in 9.5%, 4.5%, and 3.6% of cases. N. gonorrhoeae was present at these sites in 6.1%, 1.8%, and 0.5% of cases. Most infections were asymptomatic (CT: 95.3%, NG: 83.2%). Rectal CT and NG infections were mutually associated (CT: adjusted odds ratio [AOR], 5.4; 95% confidence interval [CI], 3.4-8.7; NG: AOR, 2.4; 95% CI, 1.1-5.2) and independently associated with HIV infection (CT: AOR, 1.6, 95% CI, 1.0-2.4; NG: AOR, 2.0, 95% CI, 1.3-3.1). Numerous behavioral correlates of infection were observed. CONCLUSIONS: CT and NG infections are highly prevalent among MSM in Bangkok, most frequently affect the rectum, and are most often asymptomatic. Routine screening of asymptomatic MSM for CT and NG infection should include rectal sampling and focus on men with HIV and a history of other sexually transmitted infections.

Strategic information is everyone's business: perspectives from an international stakeholder meeting to enhance strategic information data along the HIV Cascade for people who inject drugs.

People who inject drugs (PWID) are at increased HIV transmission risk because of unsafe injecting practices and a host of other individual, network, and structural factors. Thus, PWID have a great need for services within the Cascade of HIV prevention, diagnosis, care, and treatment (HIV Cascade). Yet the systems that monitor their progress through the Cascade are often lacking. Subsequently, fewer reliable data are available to guide programs targeting this key population (KP). Programmatic data, which are helpful in tracking PWID through the Cascade, also are limited because not all countries have harm reduction programming from which to estimate Cascade indicators. Also, due to stigma and the illegal nature of drug use, PWID may not disclose their drug use behavior or HIV status when accessing services. Consequently, PWID appear to have low HIV testing rates and, for those living with HIV, lower access to health services and lower viral suppression rates than do other KP groups. This commentary, based on outcomes from an international stakeholder meeting, identifies data gaps and proposes solutions to strengthen strategic information (SI), the systematic collection, analysis, and dissemination of information, to optimize HIV prevention, care, and treatment programming for PWID.

Hepatitis C and HIV incidence and harm reduction program use in a conflict setting: an observational cohort of injecting drug users in Kabul, Afghanistan.

BACKGROUND: Armed conflict may increase the risk of HIV and other pathogens among injecting drug users (IDUs); however, there are few prospective studies. This study aimed to measure incidence and potential predictors, including environmental events and needle and syringe distribution and collection program (NSP) use, of hepatitis C virus (HCV) and HIV among IDUs in Kabul, Afghanistan. METHODS: Consenting adult IDUs completed interviews quarterly in year 1 and semi-annually in year 2 and HCV and HIV antibody testing semi-annually through the cohort period (November 2007-December 2009). Interviews detailed injecting and sexual risk behaviors, NSP service use, and conflict-associated displacement. Quarters with peak conflict or local displacement were identified based on literature review, and key events, including insurgent attacks and deaths, were reported with simple counts. Incidence and predictors of HCV and HIV were measured with Cox proportional hazards models. RESULTS: Of 483 IDUs enrolled, 385 completed one or more follow-up visits (483.8 person-years (p-y)). All participants were male with a median age of 28 years and a median duration of injecting of 2 years. Reported NSP use among the participants ranged from 59.9 to 70.5 % in the first year and was 48.4 and 55.4 % at 18 and 24 months, respectively. There were 41 confirmed deaths, with a crude death rate of 93.4/1000 p-y (95 % confidence interval (CI) 67.9-125) and overdose as the most common cause. HCV and HIV incidence were 35.6/100 p-y (95 % CI 28.3-44.6) and 1.5/100 p-y (95 % CI 0.6-3.3), respectively. Changing from injecting to smoking was protective for HCV acquisition (adjusted hazard ratio (AHR) = 0.53, 95 % CI 0.31-0.92), while duration of injecting (AHR = 1.09, 95 % CI 1.01-1.18/year) and sharing syringes (AHR = 10.09, 95 % CI 1.01-100.3) independently predicted HIV infection. CONCLUSION: There is high HCV incidence and high numbers of reported deaths among male Kabul IDUs despite relatively consistent levels of harm reduction program use; peak violence periods did not independently predict HCV and HIV risk. Programming should increase awareness of HCV transmission and overdose risks, prepare clients for harm reduction needs during conflict or other causes of displacement, and continue efforts to engage community and police force support.

Prevalence and correlates of willingness to participate in a rectal microbicide trial among men who have sex with men in Bangkok.

Rectal microbicides (RMs) hold promise as a HIV prevention method to reduce transmission among men who have sex with men (MSM). To assess RM trial feasibility in Bangkok, we measured prevalence and correlates of willingness to participate among Thai MSM observational cohort participants. Between April 2006 and December 2010, 1744 MSM enrolled in the Bangkok MSM Cohort Study; at 12 months, RM trial participation willingness was measured. We evaluated correlates of RM trial participation willingness using logistic regression analysis. Participants completing the 12-month visit (81.4%, n = 1419) had a mean age of 27.3 years (SD = 6.1), and 65.5% and 86.1% reported having a steady partner or anal intercourse (AI) in the past four months, respectively. Most (79.1%, n = 1123) participants reported willingness to participate in an RM trial, which, in multivariable analysis, was independently associated with insertive only (adjusted odds ratio [AOR] = 3.25, 95% CI: 1.82-5.81) or receptive/versatile role AI (AOR = 3.07, 95% CI: 1.88-5.01), and being paid for sex (AOR = 12.15, 95% CI: 1.67-88.21) in the past four months, and believing that people with AIDS look sick (AOR = 1.92, 95% CI: 1.23-2.98). Of hypothetical RM trial features to increase enrollment likelihood, the most (91.1%) compelling was that the study be approved by the Thai ethics committee, followed by the study site offering evening hours (88.9%). Reasons not to participate were not wanting a rectal examination (29.5%) or fluid collected from the penis or anus (24.6%) and not wanting the placebo (23.0%). RM trial participation willingness was high, particularly for those with greater HIV acquisition risk, within this Thai MSM cohort, suggesting feasibility of an RM trial. Addressing potential barriers to trial entry may be useful in educational materials to optimize recruitment.

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.

Hepatitis C genotype distribution and homology among geographically disparate injecting drug users in Afghanistan.

Hepatitis C virus (HCV) prevalence is high among injecting drug users in Afghanistan, but transmission dynamics are poorly understood. Samples from HCV-infected injecting drug users were sequenced to determine circulating genotypes and potential transmission linkages. Serum samples were obtained from injecting drug user participants in Hirat, Jalalabad, and Mazar-i-Sharif between 2006 and 2008 with reactive anti-HCV rapid tests. Specimens with detected HCV viremia were amplified and underwent sequence analysis. Of 113 samples evaluated, 25 samples (35.2%) were only typeable in NS5B, nine samples (12.7%) were only typeable in CE1, and 37 samples (52.1%) were genotyped in both regions. Of those with typeable HCV, all were Afghan males with a mean age of 31.1 (standard deviation [SD] ± 8.0) years and mean duration of injecting of 3.9 (SD ± 4.3) years. Most reported residence outside Afghanistan in the last decade (90.1%) and prior incarceration (76.8%). HCV genotypes detected were: 1a, (35.2%, n = 25), 3a (62.0%, n = 44), and 1b (2.8%, n = 2). Cluster formation was detected in NS5B and CE1 and were generally from within the same city. All participants within clusters reported being a refugee in Iran compared to 93.5% of those outside clusters. Only 22.2% (4/11) of those within clusters had been refugees in Pakistan and these four individuals had also been refugees in Iran. Predominance of genotype 3a and the association between HCV viremia and having been a refugee in Iran potentially reflects migration between Afghanistan and Iran among IDUs from Mazar-i-Sharif and Hirat and carry implications for harm reduction programs for this migratory population.

A national mapping assessment of blood collection and transfusion service facilities in Afghanistan.

BACKGROUND: The purpose of this study was to assess functionality and resources of facilities providing blood collection and transfusion services in Afghanistan. STUDY DESIGN AND METHODS: This national cross-sectional assessment included facilities collecting or transfusing blood identified through official data sources and private key informants. At each facility, study representatives completed a standardized instrument assessing presence of records logbook, electricity, refrigeration, and required transfusion-transmitted infection (TTI; human immunodeficiency virus, syphilis, and hepatitis B and C) test kits. Descriptive statistics were generated, with differences analyzed using chi-square or Fisher's exact tests. RESULTS: Between August and November 2010, a total of 243 facilities were surveyed with public (52.3%, n = 127) and private (43.2%, n = 105) sector comprising the majority. Most (63%) facilities were urban, with 23.5% located in Kabul province. Of 92,682 units collected nationally in the 12 months before evaluation, 7.5% (n = 6952) had no disposition record. Many (62%, n = 151) facilities had an established recordkeeping system; the remainder provided estimates. Half of surveyed facilities had regular power supply (57.8%), refrigerators for storing blood (52.3%), or all necessary TTI test kits (62.1%). Military (83.3%) and public (74.8%) facilities were more likely to have all TTI test kits present compared to private (46.7%, p < 0.01) but not nongovernmental organization (40.0%, p = 0.37) facilities. CONCLUSION: In Afghanistan, blood donation and transfusion occur with substantial differences in data recording and TTI test availability, with private facilities less likely to have these resources. Efforts are needed to improve available resources and ensure that facilities are in compliance with national standards for donor screening.

Blood supply safety in Afghanistan: a national assessment of high-volume facilities.

BACKGROUND: Little information is available regarding blood supply safety in Afghanistan. The purpose of this study was to assess blood safety through serologic and observational measures in Afghanistan. STUDY DESIGN AND METHODS: This cross-sectional assessment included the 40 highest-volume facilities collecting and transfusing blood nationally identified in a previous survey. At each facility, study representatives completed a standardized instrument assessing staff performance of transfusion-related activities and performed rapid testing for human immunodeficiency virus, syphilis, and hepatitis B and C with rapid diagnostic tests on clinically discarded specimens. Reactive samples received confirmatory testing. Descriptive statistics were generated, with differences analyzed using chi-square or Fisher's exact tests. RESULTS: Between November 2010 and May 2011, a total of 332 blood donor collection procedures were observed. Only 52.4% of observed encounters correctly screened and deferred donors by international criteria. Public and private facilities demonstrated glove use, proper sharps disposal, and patient counseling and relayed screening test results in less than 75% of observed events, significantly less likely than military facilities (p < 0.01). Of 1612 specimens assessed, confirmed cases of hepatitis B (n = 6), hepatitis C (n = 1), and syphilis (n = 3) were detected among units already prescreened and accepted for transfusion. CONCLUSION: Lapses in proper donor screening contributed to the presence of confirmed-positive units available for transfusion, as detected in this study. Steps must be taken to ensure standardization of testing kits requirements, documentation, and mandatory training and continuing education for blood bank staff with regard to counseling, drawing, processing, and transfusion of blood products.

Intrauterine contraceptive discontinuation reasons among female trial participants living with HIV in Cape Town, South Africa: A qualitative analysis.

Introduction: While young women in South Africa may navigate both HIV infection and pregnancy risks, intrauterine contraceptive (IUC) use is low. Though IUCs have low failure rates, concerns exist about whether the IUC is an appropriate method choice for women living with HIV (WLHIV). In this qualitative study, we explore WLHIVs' experiences of using IUC and reasons for discontinuation. Methods: This qualitative study included in-depth interviews (IDIs) with 17 WLHIV who electively discontinued their allocated IUC while participating in a randomized controlled trial comparing the safety of the levonorgestrel intrauterine system (LNG-IUS) and the copper intrauterine device (C-IUD) in Cape Town, South Africa. The transcripts were coded and emergent themes were grouped to examine women's experiences with IUC use and reasons for discontinuation, highlighting experiential differences between the two methods. Results: Women's experience with the allocated IUC related most commonly to bleeding and/or abdominal pain just after insertion. Most C-IUD discontinuers, but only one LNG-IUS discontinuer, complained of pain and/or increased bleeding as the main reason for removal. Three women (two LNG-IUS, one C-IUD) requested removal because they desired pregnancy, while two others discontinued due to fears the IUC was exacerbating non-gynecologic conditions (hypertension, diabetes). Generally, women acknowledged advantages of IUC use and many expressed their desire to continue use if not for the side effects. Conclusions: In the South African context, IUC use for WLHIV should be promoted with specific counseling considerations. Both providers and potential users should receive specific information about potential menstrual-related side effects and countering common misperceptions to enable informed contraceptive decision-making.

Cross-sectional assessment of prevalence and correlates of blood-borne and sexually-transmitted infections among Afghan National Army recruits.

BACKGROUND: Few data are available in Afghanistan to shape national military force health practices, particularly with regard to sexually-transmitted infections (STIs). We measured prevalence and correlates of HIV, syphilis, herpes simplex 2 virus (HSV-2), and hepatitis C virus (HCV) among Afghan National Army (ANA) recruits. METHODS: A cross-sectional sample of male ANA recruits aged 18-35 years were randomly selected at the Kabul Military Training Center between February 2010 and January 2011. Participants completed an interviewer-administered questionnaire and serum-based rapid testing for syphilis and hepatitis C virus antibody on-site; HIV and HSV-2 screening, and confirmatory testing were performed off-site. Prevalence of each infection was calculated and logistic regression analysis performed to identify correlates. RESULTS: Of 5313 recruits approached, 4750 consented to participation. Participants had a mean age of 21.8 years (SD±3.8), 65.5% had lived outside Afghanistan, and 44.3% had no formal education. Few reported prior marijuana (16.3%), alcohol (5.3%), or opiate (3.4%) use. Of sexually active recruits (58.7%, N = 2786), 21.3% reported paying women for sex and 21.3% reported sex with males. Prevalence of HIV (0.063%, 95% CI: 0.013- 0.19), syphilis (0.65%, 95% CI: 0.44 - 0.93), and HCV (0.82%, 95% CI: 0.58 - 1.12) were quite low. Prevalence of HSV-2 was 3.03% (95% CI: 2.56 - 3.57), which was independently associated with age (Adjusted Odds Ratio (AOR) = 1.04, 95% CI: 1.00 - 1.09) and having a television (socioeconomic marker) (AOR = 1.46, 95% CI: 1.03 - 2.05). CONCLUSION: Though prevalence of HIV, HCV, syphilis, and HSV-2 was low, sexual risk behaviors and intoxicant use were present among a substantial minority, indicating need for prevention programming. Formative work is needed to determine a culturally appropriate approach for prevention programming to reduce STI risk among Afghan National Army troops.

Awareness and interest in intrauterine contraceptive device use among HIV-positive women in Cape Town, South Africa.

OBJECTIVE: To assess awareness of and interest in intrauterine contraceptive device (IUCD) use among HIV-positive women in Cape Town, South Africa. DESIGN: Cross-sectional survey. METHODS: HIV-positive women aged 18 through 45 years presenting for care at a primary health care clinic in Cape Town, South Africa participated in this study. Consented participants completed a staff-administered questionnaire in a private setting. Descriptive statistics were generated. Comparisons between demographic and reproductive health-related variables and IUCD awareness and interest were performed with multiple logistic regression. Analyses for IUCD interest excluded women with prior surgical sterilization. RESULTS: Of 277 HIV-positive women, 37% were aware of the IUCD; awareness was independently associated with greater age (adjusted odds ratio (AOR)=1.15, 95%; confidence interval (CI): 1.10-1.20) and not switching contraceptive methods in the last year (AOR=2.45, 95% CI: 1.03-5.83). Following an IUCD information session, 86% of women (n=206/240) were interested in IUCD use. IUCD interest was inversely associated with age (AOR=0.91, 95% CI: 0.86-0.97) and marginally positively associated with current menstrual bleeding pattern complaints (AOR=2.14, 95% CI: 0.98-4.68). CONCLUSIONS: Despite low levels of method awareness, HIV-positive women in this setting are frequently interested in IUCD use, indicating need for programming to expand method access.

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.