Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger.

Previous research has demonstrated that the Reaching Married Adolescents intervention (RMA) was associated with changes in inequitable gender norms, intimate partner violence (IPV), and modern contraceptive use. This study seeks to understand if changes in inequitable gender norms mediate the RMA intervention's effects on contraceptive use and intimate partner violence (IPV). A four-arm cluster randomized control trial was conducted to evaluate effects of the RMA intervention (household visits, small groups, combination, control) on married adolescent girls and their husbands in Dosso, Niger (baseline: 1042 dyads; 24m follow-up: 737 dyads; 2016-2019). Mediation was assessed using inverse odds ratio weighting. In the small group intervention, of the total effect on IPV prevalence (8% reduction), indirect effects via inequitable gender norms is associated with a 2% decrease (95% CI: -0.07, 0.12) and direct effects with a 6% decrease (95% CI: -0.20, -0.02). For household visits, of the total effect on contraceptive use (20% increase), the indirect effect accounts for an 11% decrease (95% CI: -0.18, -0.01) and direct effect, a 32% increase (95% CI: 0.13, 0.44); similar to findings for the combination arm. This experimental evidence informs the value of changing underlying social norms to reduce IPV and increase contraception use.

Prevalence and Factors Associated With Alcohol-Related Road Traffic Injuries in Cameroon.

INTRODUCTION: While the negative effects of drunk driving, including road traffic injuries (RTIs) have been well documented in high-income countries, little has been reported in African countries like Cameroon. This study aimed to measure the prevalence of alcohol-related RTIs (ARRTIs), its associated factors, and its association with injury severity. METHODS: The Cameroon Trauma Registry prospectively collects trauma data from 10 hospitals in Cameroon. This study included patients enrolled between June 2022 and May 2023 for acute RTIs. We assessed the frequency of binge drinking episodes in the past year and self-reported alcohol consumption 6 h before RTI. Bivariate analysis using chi-squared or Fisher's exact test was used to test for associations between ARRTIs and independent variables. Multivariate logistic regression was performed with variables with a P value < 0.05. RESULTS: A total of 3761 RTI cases were recorded with 77.5% (n = 2909) males and a median age of 32 y (IQR = 20 y). Prevalence of ARRTI was 9.01% (n = 338). Any self-reported binge drinking episodes (less than monthly adjusted odds ratio [AOR] = 4.97, 95% confidence interval [CI] = 3.39-7.25; monthly AOR = 5.47, 95% CI = 3.66-8.11; weekly AOR = 6.55, 95% CI = 4.63-9.27; or daily AOR = 11.15, 95% CI = 7.52-16.52) was significantly associated with ARRTI compared to none reported. Male gender, higher educational status, tobacco use, depression, and means of transportation were other associated factors. CONCLUSIONS: Almost one in 10 patients had consumed alcohol 6 h prior to RTI with odds of ARRTI significantly increasing with increased frequency in binge drinking. There is a need for evidenced-based, integrated approaches targeting sociodemographic and behavioral factors toward prevention of ARRTIs in Cameroon.

Food Insecurity and Engagement in Transactional Sex Among Female Secondary Students in Rwanda.

The relationship between food insecurity and transactional sex is well recognized, but less is known about this relationship among adolescents. We analyzed cross-sectional baseline data from 3,130 female secondary students aged 12-19 enrolled in a three-arm, cluster randomized controlled trial to examine the association between food insecurity and transactional sex. The explanatory variable was food security and the outcome was ever engaging in transactional sex. Over one quarter (28.7%) reported any food insecurity and 1.9% of all participants (9.6% of sexually active participants) reported ever engaging in transactional sex. In adjusted models, ever experiencing any food insecurity was associated with a higher prevalence of ever transactional sex (PR: 1.60; 95% CI: 1.02, 2.49) compared to little to no food insecurity. These results provide insight into potential predictors of higher-risk sexual behavior in Rwanda; they also provide policy-makers with populations with whom to intervene on upstream determinants of transactional sex, notably poverty and food insecurity.

The impact of cash incentives on mental health among adults initiating antiretroviral therapy in Tanzania.

Mental illness is prevalent among people living with HIV (PLHIV) and hinders engagement in HIV care. While financial incentives are effective at improving mental health and retention in care, the specific effect of such incentives on the mental health of PLHIV lacks quantifiable evidence. We evaluated the impact of a three-arm randomized controlled trial of a financial incentive program on the mental health of adult antiretroviral therapy (ART) initiates in Tanzania. Participants were randomized 1:1:1 into one of two cash incentive (combined; provided monthly conditional on clinic attendance) or the control arm. We measured the prevalence of emotional distress, depression, and anxiety via a difference-in-differences model which quantifies changes in the outcomes by arm over time. Baseline prevalence of emotional distress, depression, and anxiety among the 530 participants (346 intervention, 184 control) was 23.8%, 26.6%, and 19.8%, respectively. The prevalence of these outcomes decreased substantially over the study period; additional benefit of the cash incentives was not detected. In conclusion, poor mental health was common although the prevalence declined rapidly during the first six months on ART. The cash incentives did not increase these improvements, however they may have indirect benefit by motivating early linkage to and retention in care.Clinical Trial Number: NCT03341556.

A Systematic Review of HIV Pre-exposure Prophylaxis (PrEP) Implementation in U.S. Emergency Departments: Patient Screening, Prescribing, and Linkage to Care.

In the pursuit of ending the HIV epidemic, U.S. emergency departments (EDs) have emerged as a valuable setting to increase HIV testing and linkage to care. There is limited data available, however, describing the incorporation of HIV prevention initiatives in U.S. EDs. Over the last decade, HIV pre-exposure prophylaxis (PrEP) has significantly changed the HIV prevention landscape globally and very little is known about the provision of PrEP in U.S. EDs. To address this gap in the literature, we conducted a systematic review of peer-reviewed quantitative studies and conference abstracts spanning July 2012 - October 2022. Of 433 citations, 11 articles and 13 abstracts meet our inclusion criteria, representing 18 unique studies addressing PrEP screening, prescribing, and/or linkage to PrEP care.Most studies describe screening processes to identify PrEP-eligible patients (n = 17); most studies leveraged a patient's STI history as initial PrEP eligibility screening criteria. Fewer studies describe PrEP prescribing (n = 2) and/or linkage to PrEP care (n = 8).Findings from this systematic review highlight the potential for U.S. EDs to increase PrEP uptake among individuals at risk for HIV infection. Despite a growing number of studies exploring processes for incorporating PrEP into the ED setting, such studies are small-scale and time limited. Models providing prescribing PrEP in the ED show higher initiation rates than post-discharge engagement models. Electronic health record (EHR)-based HIV screening is valuable, but post-ED linkage rates are low. Our findings emphasize the need to establish best practices for initiating and supporting prevention effective PrEP use in the ED setting.

"They call me the 'Great Queen'": implementing the Malkia Klabu program to improve access to HIV self-testing and contraception for adolescent girls and young women in Tanzania.

BACKGROUND: Adolescent girls and young woman (AGYW) comprise a significant proportion of new HIV infections and unintended pregnancies in sub-Saharan Africa yet face many barriers to accessing family planning and reproductive health (FPRH) information and services. Developed via human-centered design, the Malkia Klabu ("Queen Club") program aimed to facilitate access to HIV self-testing (HIVST) and FPRH information and products at privately-owned drug shops. We sought to understand barriers and facilitators to program implementation in a 4-month pilot in Tanzania. METHODS: Forty semi-structured interviews were conducted with participants in a cluster randomized trial of the Malkia Klabu program from November 2019 through March 2020, including 11 with AGYW, 26 with drug shopkeepers, and three with counselors at health facilities to whom AGYW were referred. Interviews were audio-recorded, transcribed, coded, and analyzed to identify key themes. The Consolidated Framework for Implementation Research (CFIR) was used to assess barriers and facilitators to program implementation at multiple levels. CFIR considers the outer setting (e.g., culture and systemic conditions), the inner setting where the intervention is implemented (e.g., incentives, relationships, and available resources), the individuals involved, the innovation as it relates to stakeholder needs, and the implementation process. RESULTS: The Malkia Klabu program reshaped and directed the role of drug shopkeepers as providers of information and resources rather than FPRH gatekeepers. Key implementation facilitators included the program's adaptability to a wide range of needs and stages of readiness among AGYW, ability to capitalize on AGYW social networks for driving membership, responsiveness to AGYW's need for privacy, and positive contributions to the income and community standing of drug shopkeepers. Components such as HIVST were highly acceptable to both AGYW and shopkeepers, and the introduction of the loyalty program and HIVST kits in shops opened doors to the provision of FPRH products and information, which was further facilitated by program tools such as videos, product displays, and symbol cards. Although some shopkeepers maintained beliefs that certain contraceptive methods were inappropriate for AGYW, most appeared to provide the products as part of the program. CONCLUSIONS: The Malkia Klabu intervention's success was due in part to its ability to address key motivations of both AGYW and drug shopkeepers, such as maintaining privacy and increasing access to FPRH products for AGYW and increasing business for shops. Better understanding these implementation barriers and facilitators can inform the program's future adaptation and scale-up. TRIAL REGISTRATION: clinicaltrials.gov #NCT04045912.

Adolescent girls and young women (AGYW) in sub-Saharan Africa have limited access to family planning and reproductive health products and information even though they are at greater risk of pregnancy and HIV infection. The Malkia Klabu intervention was designed with AGYW and shopkeepers from private drug shops to facilitate access to products and information through a loyalty program that included free products, prizes for purchases, educational videos, and a non-verbal system of requesting products through symbols. Qualitive interviews with AGYW, drug shop staff, and health system counselors suggested that the program helped provide greater privacy and confidence to AGYW while bringing new business to drug shops. These findings can help as the study team charts a pathway for scaling up the intervention.

Prehospital factors associated with mortality among road traffic injury patients: analysis of Cameroon trauma registry data.

BACKGROUND: Cameroon is amongst the worst affected countries by road traffic injuries with an estimated 1443 disability-adjusted life years per 100,000 population. There have been very limited reports on the crucial prehospital response to road traffic injuries in Cameroon. This study aimed to identify prehospital factors associated with RTI mortality in Cameroon. METHODS: We included patients enrolled between June 2022 and March 2023 in the Cameroon Trauma Registry. Information about prehospital factors and demographic data was obtained from patients or their proxies. We examined the association of prehospital care factors like care at the crash scene and type of transportation during crash with final patient outcome. We used Chi-squared test to investigate the association between selected independent variables and mortality. A multivariable logistic regression model was built to identify independent predictors of dying from an RTI. RESULTS: RTIs constituted 69.5% (n = 3203) of all injuries in the Cameroon Trauma Registry. Only 20.7% (n = 102) of 4 + wheel vehicle occupants had seatbelts on and just 2.7% (n = 53) of motorcycle riders were wearing helmets during the collision. Only 4.9% (n = 156) of patients received any form of scene care. In-hospital mortality was 4.3% (n = 139) and was associated with male sex (AOR = 1.7, 95%CI = 1.08-2.80), crashing on a motorcycle (AOR = 2.08, 95%CI = 1.1-3.67) and scene care (AOR = 0.25, 95%CI = 0.04-0.80). CONCLUSIONS: Receiving any type of care at the scene such as bleeding control or being placed in the recovery position by bystanders is associated with improved survival. Improving on existing informal prehospital care responses should be a priority in Cameroon.

Risks of Intimate Partner Violence for Women Living with HIV Receiving Cash Transfers: A Qualitative Study in Shinyanga, Tanzania.

Cash transfers are increasingly used to motivate adherence to HIV care. However, evidence on cash transfers and intimate partner violence (IPV) is mixed and little is known about their safety for women living with HIV. We conducted in-depth interviews with women living with HIV who participated in a randomized trial providing 6 months of cash transfers (~$4.5 or $11 USD) conditional on HIV clinic attendance in Shinyanga, Tanzania to assess how receiving cash affects IPV and relationship dynamics. Eligible participants were 18-49 years, received cash transfers, and in a partnership at baseline. Data were analyzed in Dedoose using a combined inductive-deductive coding approach. 25 interviews were conducted between November 2019-February 2020. Women's employment was found to be a source of household tension and violence. None of the participants reported physical or sexual IPV in relation to cash transfers, however, some women experienced controlling behaviors or emotional violence including accusations and withholding of money, particularly those who were unemployed. Cash transfers were predominantly used for small household expenses and were not viewed as being substantial enough to shift the financial dynamic or balance of power within relationships. Our findings suggest that small, short-term cash transfers do not increase physical or sexual IPV for women living with HIV however can exacerbate controlling behaviors or emotional violence. Modest incentives used as a behavioral nudge to improve health outcomes may affect women differently than employment or larger cash transfers. Nonetheless, consultations with beneficiaries should be prioritized to protect women from potential IPV risks.

Financial incentives to improve re-engagement in HIV care: results from a randomized pilot study.

OBJECTIVE: Determine the feasibility, acceptability, and preliminary effectiveness of financial incentives to motivate re-engagement in HIV care in Shinyanga, Tanzania. METHODS: Out-of-care people living with HIV (PLHIV) were identified from medical records in four clinics and home-based care providers (HBCs) from April 13, 2018 to March 3, 2020. Shinyanga Region residents, ≥18 years, who were disengaged from care were randomized 1:1 to a financial incentive (∼$10 USD) or the standard of care (SOC), stratified by site, and followed for 180 days. Primary outcomes were feasibility (located PLHIV who agreed to discuss the study), acceptability (enrollment among eligibles), and re-engagement in care (clinic visit within 90 days). RESULTS: HBCs located 469/1,309 (35.8%) out-of-care PLHIV. Of these, 215 (45.8%) were preliminarily determined to be disengaged from care, 201 (93.5%) agreed to discuss the study, and 157 eligible (100%) enrolled. Within 90 days, 71 (85.5%) PLHIV in the incentive arm re-engaged in care vs. 58 (78.4%) in the SOC (Adjusted Risk Difference [ARD] = 0.08, 95% CI: -0.03, 0.19, p = 0.09). A higher proportion of incentivized PLHIV completed an additional (unincentivized) visit between 90-180 days (79.5% vs. 71.6%, ARD = 0.10, 95% CI: -0.03, 0.24, p = 0.13) and remained in care at 180 days (57.8% vs. 51.4%, ARD = 0.07, 95% CI: -0.09, 0.22, p = 0.40). CONCLUSIONS: Short-term financial incentives are feasible, acceptable, and have the potential to encourage re-engagement in care, warranting further study of this approach.

Increased prevalence of depression and anxiety among adults initiating antiretroviral therapy during the COVID-19 pandemic in Shinyanga region, Tanzania.

BACKGROUND: Concerns about the interconnected relationship between HIV and mental health were heightened during the COVID-19 pandemic. This study assessed whether there were temporal changes in the mental health status of people living with HIV presenting for care in Shinyanga region, Tanzania. Specifically, we compared the prevalence of depression and anxiety before and during COVID-19, with the goal of describing the changing needs, if any, to person-centered HIV services. METHODS: We analyzed baseline data from two randomized controlled trials of adults initiating ART in Shinyanga region, Tanzania between April-December 2018 (pre-COVID-19 period, n = 530) and May 2021-March 2022 (COVID-19 period, n = 542), respectively. We compared three mental health indicators that were similarly measured in both surveys: loss of interest in things, hopelessness about the future, and uncontrolled worrying. We also examined depression and anxiety which were measured using the Hopkins Symptom Checklist-25 in the pre-COVID-19 period and the Patient Health Questionnaire-4 in the COVID-19 period, respectively, and classified as binary indicators per each scale's threshold. We estimated prevalence differences (PD) in adverse mental health status before and during the COVID-19 pandemic, using stabilized inverse probability of treatment weighting to adjust for underlying differences in the two study populations. RESULTS: We found significant temporal increases in the prevalence of feeling 'a lot' and 'extreme' loss of interest in things ['a lot' PD: 38, CI 34,41; 'extreme' PD: 9, CI 8,12)], hopelessness about the future [' a lot' PD: 46, CI 43,49; 'extreme' PD: 4, CI 3,6], and uncontrolled worrying [' a lot' PD: 34, CI 31,37; 'extreme' PD: 2, CI 0,4] during the COVID-19 pandemic. We also found substantially higher prevalence of depression [PD: 38, CI 34,42] and anxiety [PD: 41, CI 37,45]. CONCLUSIONS: After applying a quasi-experimental weighting approach, the prevalence of depression and anxiety symptoms among those starting ART during COVID-19 was much higher than before the pandemic. Although depression and anxiety were measured using different, validated scales, the concurrent increases in similarly measured mental health indicators lends confidence to these findings and warrants further research to assess the possible influence of COVID-19 on mental health among adults living with HIV. Trial Registration NCT03351556, registered November 24, 2017; NCT04201353, registered December 17, 2019.

Measuring social norms of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy: an item response modelling of the IPV-ASRA scale.

BACKGROUND: The field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms. METHODS: Using an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. RESULTS: A two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence. CONCLUSIONS: This brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

Long-term prevention of gender-based violence, like intimate partner violence and reproductive coercion, requires efforts to change the social environment that facilitates violence against women, yet limited research is available on how to change social environments. One reason is that there are few tools to accurately measure social environments, including social norms, which are the unspoken rules about what behavior is acceptable and what behavior is not. The present research assessed a new social norms measurement tool on the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy using data from a population-based sample of married adolescents and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. We found that this scale had strong reliability and validity, and that the group of questions about challenging husband authority were related to husband perpetration of intimate partner violence against his wife. This brief scale is a short (5 questions), practical measure with strong reliability and validity evidence that can help identify populations with high-need for social norms-focused prevention and to help measure the impact of such efforts. This evidence strengthens the current set of measurement tools on social norms available to researchers and practitioners.

COVID-19 outbreak in a state prison: a case study on the implementation of key public health recommendations for containment and prevention.

BACKGROUND: People incarcerated in US prisons have been disproportionately harmed by the COVID-19 pandemic. That prisons are such efficient superspreading environments can be attributed to several known factors: small, communal facilities where people are confined for prolonged periods of time; poor ventilation; a lack of non-punitive areas for quarantine/medical isolation; and staggeringly high numbers of people experiencing incarceration, among others. While health organizations have issued guidance on preventing and mitigating COVID-19 infection in carceral settings, little is known about if, when, and how recommendations have been implemented. We examined factors contributing to containment of one of the first California prison COVID-19 outbreaks and remaining vulnerabilities using an adapted multi-level determinants framework to systematically assess infectious disease risk in carceral settings. METHODS: Case study employing administrative data; observation; and informal discussions with: people incarcerated at the prison, staff, and county public health officials. RESULTS: Outbreak mitigation efforts were characterized by pre-planning (e.g., designation of ventilated, single-occupancy quarantine) and a quickly mobilized inter-institutional response that facilitated systematic, voluntary rapid testing. However, several systemic- and institutional-level vulnerabilities were unaddressed hindering efforts and posing significant risk for future outbreaks, including insufficient decarceration, continued inter-facility transfers, incomplete staff cohorting, and incompatibility between built environment features (e.g., dense living conditions) and public health recommendations. CONCLUSIONS: Our adapted framework facilitates systematically assessing prison-based infectious disease outbreaks and multi-level interventions. We find implementing some recommended public health strategies may have contributed to outbreak containment. However, even with a rapidly mobilized, inter-institutional response, failure to decarcerate created an overreliance on chance conditions. This left the facility vulnerable to future catastrophic outbreaks and may render standard public health strategies - including the introduction of effective vaccines - insufficient to prevent or contain those outbreaks.

Transportation cost as a barrier to contraceptive use among women initiating treatment for HIV in Tanzania.

Transportation cost is a barrier to HIV treatment, yet no studies have examined its association with contraceptive use among women living with HIV. We analyzed cross-sectional data from women attending three public healthcare facilities in Shinyanga, Tanzania where they initiated antiretroviral therapy for HIV infection in the previous 90 days; all facilities offered free contraception. Women self-reported current contraceptive use and the round-trip cost of transportation to the facility. Among 421 women aged 18-49, 86 (20.4%) were using any modern contraceptive method, of which half were using modern methods other than condoms. Women who paid more than 2,000 Tanzanian shillings for transportation had a significantly lower prevalence of any modern method use than women who paid nothing (9.1% vs. 21.3%; adjusted difference: -12.9; 95% confidence interval: -21.3, -4.4). A similar difference was observed for non-condom modern method use. We conclude that high transportation cost may impede contraceptive use even among women accessing HIV treatment.

Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers.

The unmet need for modern contraception remains high around the world, particularly for youth. While some of this unmet need is driven by limited health infrastructure and method mix availability, many adolescents who visit family planning providers still do not receive methods that fit their needs. This suggests that providers may be biased against youth and that interventions to change provider behavior could help close this gap. However, it is unclear if this bias is a result of age or other characteristics common among young women such as not being married and not having children. We use a discrete choice experiment in Burkina Faso, Pakistan, and Tanzania to disentangle the effects of age on providers' decisions to provide contraception from the effects of other potential confounding factors. We find that, although young women may experience the most bias, age is not the main driver. Rather, marital status and parity seem to influence provider decisions to offer services or counsel on modern methods. These findings suggest that interventions to reduce provider bias should focus on changing behavior towards unmarried and nulliparous women, regardless of their age.

HIV prevention at drug shops: awareness and attitudes among shop dispensers and young women about oral pre-exposure prophylaxis and the dapivirine ring in Shinyanga, Tanzania.

BACKGROUND: HIV risk remains high among adolescent girls and young women (AGYW, ages 15-24) in Tanzania. Many AGYW experience stigma and provider bias at health facilities, deterring their use of HIV prevention services. Privately-owned drug shops, ubiquitous in many communities, may be an effective and accessible channel to deliver HIV prevention products to AGYW, including oral pre-exposure prophylaxis (PrEP) and the dapivirine vaginal ring. METHODS: In July-August 2019, we enrolled 26 drug shops in Shinyanga, Tanzania in an ongoing study to create "girl-friendly" drug shops where AGYW can access HIV self-testing and contraception. At baseline, all shop dispensers were given basic information about oral PrEP and the dapivirine ring and were asked about their interest in stocking each. During the next 3-5 months, we surveyed AGYW (n = 56) customers about their interest in oral PrEP and the ring. RESULTS: Among dispensers, the median age was 42 years and 77% were female. Overall, 42% of dispensers had heard of a medication for HIV prevention. Almost all dispensers reported some interest in stocking oral PrEP (92%) and the dapivirine ring (96%). Most (85%) reported they would provide oral PrEP to AGYW who requested it. Among AGYW customers, the median age was 17 years; 29% of AGYW were married or had a steady partner and 18% had children. Only 20% of AGYW had heard of a medication to prevent HIV, yet 64% and 43% expressed some interest in using oral PrEP and the dapivirine ring, respectively, after receiving information about the products. PrEP interest was higher among AGYW who were partnered and had children. CONCLUSIONS: Despite low prior awareness of PrEP among shop dispensers and AGYW, we found high levels of interest in oral PrEP and the dapivirine ring in both groups. Community-based drug shops represent a promising strategy to make HIV prevention more accessible to AGYW.

Sales and pricing decisions for HIV self-test kits among local drug shops in Tanzania: a prospective cohort study.

BACKGROUND: Public health initiatives must look for ways to cost-effectively scale critical interventions to achieve high coverage. Private sector distribution channels, can potentially distribute preventive healthcare products to hard-to-reach populations, decongest public healthcare systems, and increase the sustainability of programs by getting customers to share costs. However, little is known about how sellers set prices for new products. By introducing a new product, HIV self-test kits, to local drug shops, we observed whether shops experimented with pricing, charged different buyers different prices, and whether prices converged within the local market over our study period. METHODS: From August to December 2019, we provided free HIV self-test kits, a new product, to 26 drug shops in Shinyanga, Tanzania to sell to the local community. We measured sales volume, price, customer age and sex using shop records. Using a multiple linear regression model, we conducted F-tests to determine whether shop, age, sex, and time (week) respectively were associated with price. We measured willingness-to-pay to restock test kits at the end of the study. RESULTS: 514 test kits were sold over 18 weeks; 69% of buyers were male, 40% were aged 25-34 and 32% aged 35-44. Purchase prices ranged from 1000 to 6000 Tsh (median 3000 Tsh; ~$1.30 USD). Within shops, prices were 11.3% higher for 25-34 and 12.7% higher for 45+ year olds relative to 15-19-year olds (p = 0.029) and 13.5% lower for men (p = 0.023) on average. Although prices varied between shops, prices varied little within shops over time, and did not converge over the study period or cluster geospatially. Mean maximum willingness-to-pay to restock was 2000 Tsh per kit. CONCLUSIONS: Shopkeepers charged buyers different prices depending on buyers' age and sex. There was limited variation in prices within shops over time and low demand among shopkeepers to restock at the end of the study. Given the subsidized global wholesale price ($2 USD or ~ 4600 Tsh), further demand creation and/or cost-reduction is required before HIV self-test kits can become commercially viable in drug shops in this setting. Careful consideration is needed to align the motivations of retailers with public health priorities while meeting their private for-profit needs.

Household flooring associated with reduced infant diarrhoeal illness in Zimbabwe in households with and without WASH interventions.

OBJECTIVES: Diarrhoeal illness is a leading cause of childhood morbidity and mortality and has long-term negative impacts on child development. Although flooring, water and sanitation have been identified as important routes of transmission of diarrhoeal pathogens, research examining variability in the association between flooring and diarrhoeal illness by water and sanitation is limited. METHODS: We utilised cross-sectional data collected for the evaluation of Zimbabwe's Prevention of Mother-to-Child HIV transmission programme in 2014 and 2017-18. Mothers of infants 9-18 months of age self-reported the household's source of drinking water and type of sanitation facility, as well as infant diarrhoeal illness in the four weeks prior to the survey. Household flooring was assessed using interviewer observation, and households in which the main material of flooring was dirt/earthen were classified as having unimproved flooring, and those with solid flooring (e.g. cement) were classified as having improved flooring. RESULTS: Mothers of infants living in households with improved flooring were less likely to report diarrhoeal illness in the last four weeks (PDa  = -4.8%, 95% CI: -8.6, -1.0). The association between flooring and diarrhoeal illness did not vary by the presence of improved/unimproved water (pRERI  = 0.91) or sanitation (pRERI  = 0.76). CONCLUSIONS: Our findings support the hypothesis that household flooring is an important pathway for the transmission of diarrhoeal pathogens, even in settings where other aspects of sanitation are sub-optimal. Improvements to household flooring do not require behaviour change and may be an effective and expeditious strategy for reducing childhood diarrhoeal illness irrespective of household access to improved water and sanitation.

OBJECTIFS: Les maladies diarrhéiques sont l'une des principales causes de morbidité et de mortalité infantiles et ont des effets négatifs à long terme sur le développement de l'enfant. Bien que le revêtement de sol, l'eau et l'assainissement aient été identifiés comme des voies de transmission importantes des agents pathogènes diarrhéiques, la recherche examinant la variabilité de l'association entre le revêtement de sol et les maladies diarrhéiques par l'eau et les sanitaires est rare. MÉTHODES: Nous avons utilisé des données transversales collectées pour l'évaluation du programme de prévention de la transmission du VIH de la mère à l'enfant au Zimbabwe en 2014 et 2017-18. Les mères de nourrissons âgés de 9 à 18 mois ont déclaré la source d'eau potable du ménage et le type d'installation sanitaire, ainsi que les maladies diarrhéiques de l'enfant au cours des quatre semaines précédant l'enquête. Le revêtement de sol des ménages a été évalué en utilisant l'observation de l'intervieweur. Les ménages dont le principal matériau de revêtement de sol était de la terre étaient classés comme ayant un revêtement de sol non amélioré et les ménages dont le revêtement de sol était en ciment étaient classés comme ayant un revêtement de sol amélioré. RÉSULTATS: Les mères de nourrissons vivant dans des ménages avec un revêtement de sol amélioré étaient moins susceptibles de déclarer une maladie diarrhéique au cours des quatre semaines précédentes (PDa = --9%, IC95%: -8,6 à -1,0). L'association entre les revêtements de sol et les maladies diarrhéiques ne variait pas selon la présence d'eau améliorée/non améliorée (p RERI = 0,91) ou de sanitaires (p RERI = 0,76). CONCLUSIONS: Nos résultats corroborent l'hypothèse selon laquelle le revêtement de sol domestique est une voie importante pour la transmission d'agents pathogènes diarrhéiques, même dans des contextes où d'autres aspects des sanitaires ne sont pas optimaux. L'amélioration du revêtement de sol domestique ne nécessite pas de changement de comportement et peut être une stratégie efficace et rapide pour réduire les maladies diarrhéiques infantiles, indépendamment de l'accès des ménages à une eau et à des sanitaires améliorés.

Interventions to Improve Linkage to HIV Care in the Era of "Treat All" in Sub-Saharan Africa: a Systematic Review.

PURPOSE OF THE REVIEW: In 2015, antiretroviral therapy (ART) was recommended for all people living with HIV (PLHIV) regardless of CD4 count ("Treat All"). To better understand how to improve linkage to care under these new guidelines, we conducted a systematic review of studies evaluating linkage interventions in Sub-Saharan Africa under Treat All. RECENT FINDINGS: We identified 14 eligible articles and qualitatively analyzed the effectiveness of the interventions. Increases in linkage were reported by supply-side and counseling interventions. Mobile testing and economic incentives did not increase linkage. Given the lag time between adoption and implementation, only two of the studies were conducted in a Treat All setting. None of the interventions specifically focused on re-linking PLHIV who had disengaged from care. Future studies must design interventions that target not only newly diagnosed or treatment naïve PLHIV, but should explicitly focus on PLHIV who have disengaged from care.

Effectiveness of Potential Interventions to Change Gendered Social Norms on Prevalence of Intimate Partner Violence in Uganda: a Causal Inference Approach.

Evidence of the effectiveness of programs to change gendered social norms related to intimate partner violence (IPV) is growing, but their potential to significantly impact actual occurrence of IPV at population level is lacking. We study whether modest changes in gendered social norms related to wife-beating can result in significant changes in the incidence of emotional, physical, and sexual IPV among ever married women in Uganda. We employ an imputation-based causal inference approach, based on nationally representative Demographic Health Survey data. The steps are (1) model the association between adjusted neighborhood norms and experiences of IPV using a random effects logistic regression model, (2) impute unobserved counterfactual probabilities of experiencing IPV for each woman while manipulating her neighborhood norms by setting it to different values, (3) average the probabilities across the population, and (4) bootstrap confidence intervals. Results show that statistically significant inverse associations between more prohibitive neighborhood IPV norms and women's experiences of different forms of IPV at the population level exist. The effect is however small, that even if an entire community disapproves of wife-beating, incidence of IPV falls by about 10 percentage points to 48.5% (95% CI 46.0%-50.9%) from the observed value of 57.6% (95% CI 55.2%-59.9%). Furthermore, changes in neighborhood social norms are found to have no statistical significant effect on the incidence of sexual violence. In conclusion, changing gendered social norms related to wife-beating will not result in significant reductions in different forms for IPV at the population level.

Women's Relationship Power Modifies the Effect of a Randomized Conditional Cash Transfer Intervention for Safer Sex in Tanzania.

This study tests whether women's relationship power modifies the effect of a conditional cash transfer (CCT) on STI risk. We analyzed 988 women enrolled in the RESPECT study in Tanzania, a yearlong, randomized-controlled trial testing the effectiveness of a CCT to reduce STI incidence. Women were randomized at the individual level to a no-cash control group, a low-cash, or a high-cash study arm. After one year, there was no main effect of study arm on risk of having an STI among women. However, in tests of heterogeneity, the effect of the CCT varied by a woman's relationship power (adjusted RRs of the interaction term for women with higher relationship power: RR 0.567 (95% CI 0.240-0.895) for high cash and RR 1.217 (95% CI 0.794-1.641) for low cash). Specifically, women with higher relationship power in the low cash transfer arm had an elevated risk of testing positive for an STI, whereas women with high relationship power in the high cash transfer arm had a decreased risk of testing positive for an STI.