Prevalence and psychosocial factors associated with self-injurious thoughts among people living with HIV presenting for HIV testing in Mozambique.

Self-injurious thoughts have been associated with psychiatric morbidity and suicide. Little is known about psychosocial factors associated with self-injurious thoughts among people newly diagnosed with HIV in sub-Saharan Africa. This study examined whether food insufficiency, mental health symptoms, or social support were associated with recent self-injurious thoughts among people newly diagnosed with HIV in Mozambique. The sample included 2001 PLWH aged ≥ 18 newly diagnosed with HIV at 10 health clinics in Mozambique between April 2013 and June 2015. Data were collected at time of HIV diagnosis. Multivariable logistic regression modeled the association of social support, affective mental health symptom severity, somatic mental health symptom severity, and food insufficiency on recent self-injurious thoughts. Ten percent of respondents reported recent self-injurious thoughts, which was higher among women than men (11% vs 7%). In multivariable analyses, food insufficiency [adjusted odds ratio (aOR) 1.7 (95% CI 1.3, 2.2)], and low [aORvs no = 4.8, 95% CI 1.7, 13.4) and moderate/high affective symptom severity [aORvs no = 8.7, 95% CI 2.8, 27.6) were associated with greater odds of self-injurious thoughts. Interventions to address self-injurious thoughts should consider accompanying psychosocial stressors. Longitudinal research to examine mechanisms through which psychosocial stressors are associated with self-injurious thoughts is warranted.

Evaluation of health system readiness and coverage of intermittent preventive treatment of malaria in infants (IPTi) in Kambia district to inform national scale-up in Sierra Leone.

BACKGROUND: Intermittent preventive treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a proven strategy to protect infants against malaria. Sierra Leone is the first country to implement IPTi nationwide. IPTi implementation was evaluated in Kambia, one of two initial pilot districts, to assess quality and coverage of IPTi services. METHODS: This mixed-methods evaluation had two phases, conducted 3 (phase 1) and 15-17 months (phase 2) after IPTi implementation. Methods included: assessments of 18 health facilities (HF), including register data abstraction (phases 1 and 2); a knowledge, attitudes and practices survey with 20 health workers (HWs) in phase 1; second-generation sequencing of SP resistance markers (pre-IPTi and phase 2); and a cluster-sample household survey among caregivers of children aged 3-15 months (phase 2). IPTi and vaccination coverage from the household survey were calculated from child health cards and maternal recall and weighted for the complex sampling design. Interrupted time series analysis using a Poisson regression model was used to assess changes in malaria cases at HF before and after IPTi implementation. RESULTS: Most HWs (19/20) interviewed had been trained on IPTi; 16/19 reported feeling well prepared to administer it. Nearly all HFs (17/18 in phase 1; 18/18 in phase 2) had SP for IPTi in stock. The proportion of parasite alleles with dhps K540E mutations increased but remained below the 50% WHO-recommended threshold for IPTi (4.1% pre-IPTi [95%CI 2-7%]; 11% post-IPTi [95%CI 8-15%], p < 0.01). From the household survey, 299/459 (67.4%) children ≥ 10 weeks old received the first dose of IPTi (versus 80.4% for second pentavalent vaccine, given simultaneously); 274/444 (62.5%) children ≥ 14 weeks old received the second IPTi dose (versus 65.4% for third pentavalent vaccine); and 83/217 (36.4%) children ≥ 9 months old received the third IPTi dose (versus 52.2% for first measles vaccine dose). HF register data indicated no change in confirmed malaria cases among infants after IPTi implementation. CONCLUSIONS: Kambia district was able to scale up IPTi swiftly and provide necessary health systems support. The gaps between IPTi and childhood vaccine coverage need to be further investigated and addressed to optimize the success of the national IPTi programme.

Life in the Balance: Young Female Sex Workers in Kenya Weigh the Risks of COVID-19 and HIV.

The COVID-19 pandemic has had serious health, economic and psychosocial consequences. Marginalized populations including female sex workers face the stark choice of risking exposure to SARS-CoV-2 as they engage with clients or prioritizing their health at the cost of losing a primary source of income. As part of an ongoing open-label, randomized controlled trial providing daily oral pre-exposure prophylaxis and adherence support, we interviewed 193 of 200 enrolled young female sex workers (18-24 years) in Kisumu, Kenya, about COVID-19 awareness and precautions, access to health services, and sex work during Kenya's pandemic-related lockdown. Nearly all participants were aware of COVID-19 and reported taking protective measures, but only half reported concerns about acquiring SARS-CoV-2. Night curfews and bar closures adversely affected participants' sex work business, reducing the number of clients and payment amounts from clients. Nearly 15% experienced violence from a client or regular, non-paying sex partner during the lockdown period. Participants' access to healthcare services was not disrupted.

RESUMEN: La pandemia de COVID-19 puede tener graves consecuencias sanitarias, económicas y psicosociales. Poblaciones marginadas como las mujeres trabajadoras sexuales se enfrentan a la dura elección de arriesgarse a exponerse al SARS-CoV-2 mientras interactúan con los clientes o priorizar su salud a riesgo de perder su principal fuente de ingresos. Como parte de un ensayo controlado aleatorio abierto en curso que proporcionaba profilaxis pre-exposición (PrEP) oral diaria y apoyo para la adherencia, entrevistamos a 193 de 200 las mujeres trabajadoras sexuales jóvenes (de 18 a 24 años) en Kisumu, Kenia, sobre su conocimiento y precauciones frente al COVID-19, acceso a servicios de salud, y trabajo sexual durante el confinamiento por la pandemia en Kenia. Casi todas las participantes conocían el COVID-19 y reportaron que tomaron medidas de protección, pero sólo la mitad dijeron estar preocupadas por infectarse con el SARS-CoV-2. Los toques de queda nocturnos y los cierres de bares afectaron negativamente al negocio del trabajo sexual, reduciendo el número de clientes y la cantidad que recibieron de los clientes. Casi el 15% experimentó violencia por parte de un cliente o por una pareja sexual habitual que no paga durante el periodo de confinamiento. El acceso de las participantes a los servicios de salud no se vio interrumpido.

PMTCT care cascade and factors associated with attrition in the first four years after Option B+ implementation in Mozambique.

OBJECTIVE: To evaluate the effectiveness of the prevention of mother-to-child transmission (PMTCT) Option B+ programme in two provinces with high human immunodeficiency virus (HIV) burden in Mozambique over the first four years of programme implementation. METHODS: We assessed the PMTCT cascade in antenatal care (ANC) from July 2013 to December 2017 using facility-level data and performed a retrospective cohort analysis with patient-level data. We compared the 12-month antiretroviral therapy (ART) retention rates between women with HIV infection who initiated ART under Option B+ ('B+ pregnant') and those who initiated ART for their own health ('own health'). RESULTS: A total of 916 280 pregnant women enrolled in ANC. The proportion of women with a documented HIV status increased from 93% in 2013 to 96% in 2017. The proportion of those tested HIV-positive decreased from 8% to 6% while that of those HIV-positive on ART increased from 42% to 95%. Of the 44 377 HIV-positive women included in the analysis, 35% were lost to care. 'B+ pregnant' women initiating ART in 2015 were less likely to have no follow-up (NFU) compared with 'own health' women starting ART during the same period (adjusted odds ratio: 0.77, 95% confidence interval [CI]: 0.64-0.94, P = 0.01). There was no statistical difference between the two groups during the other years in which ART was initiated. Of those returning for care after their first visit (N = 39 801), the 'B+ pregnant' women showed a higher risk of non-retention than the other group (adjusted hazard ratio: 1.14, 95% CI: 1.03-1.25) when ART was initiated in 2013. The risk decreased during the subsequent years, with no difference observed between the groups. CONCLUSION: PMTCT Option B+ programme scale-up has yielded positive results, including the maintenance of high HIV testing and ART initiation rates in ANC. Challenges still remain, however, in improving immediate engagement in care and long-term retention. Seeking alternative service delivery models to support existing health systems and prevent defaulters is required to achieve the UNAIDS 95-95-95 targets for PMTCT in Mozambique.

OBJECTIF: Evaluer l'efficacité du programme de la prévention de la transmission mère-enfant (PTME) Option B+ dans deux provinces avec une charge élevée du virus de l' immunodéficience humaine (VIH) au Mozambique, au cours des quatre premières années de la mise en œuvre du programme. MÉTHODES: Nous avons évalué la cascade PTME dans les soins des cliniques prénatales (SCP) de juillet 2013 à décembre 2017 à l'aide de données à l'échelle de l'établissement et avons effectué une analyse de cohorte rétrospective avec des données à l'échelle du patient. Nous avons comparé les taux de rétention à 12 mois de la thérapie antirétrovirale (ART) entre les femmes infectées par le VIH qui ont commencé l'ART dans le cadre de l'option B+ (''enceintes B+'') et celles qui ont commencé l'ART pour leur propre santé (''propre santé''). RÉSULTATS: Au total, 916.280 femmes enceintes ont été inscrites dans les SCP. La proportion de femmes avec un statut VIH documenté est passée de 93% en 2013 à 96% en 2017. La proportion de celles testées positives pour le VIH est passée de 8% à 6% tandis que celle des femmes positives au VIH sous ART est passée de 42% à 95%. Sur les 44.377 femmes séropositives incluses dans l'analyse, 35% ont été perdues au cours des soins. Les femmes ''enceintes B+'' qui ont commencé l'ART en 2015 étaient moins susceptibles de ne pas avoir de suivi (NFU) que les femmes ''propre santé'' ayant commencé l'ART au cours de la même période (rapport de cotes ajusté: 0,77 ; intervalle de confiance à 95% [IC]: 0,64-0,94 ; P = 0,01). Il n'y avait aucune différence statistique entre les deux groupes durant les autres années au cours desquelles l'ART a été initiée. Parmi celles retournant pour des soins après leur première visite (N = 39.801), les femmes ''enceintes B+'' présentaient un risque plus élevé de non-rétention que l'autre groupe (rapport de risque ajusté: 1,14 ; IC95%: 1,03-1,25) lorsque l'ART a été initiée en 2013. Le risque diminuait au cours des années suivantes, sans différence observée entre les groupes. CONCLUSION: Le déploiement du programme PTME Option B+ a donné des résultats positifs, notamment le maintien de taux élevés de dépistage du VIH et d'initiation de l'ART dans les SCP. Il reste cependant des défis à relever pour améliorer l'engagement immédiat dans les soins et la rétention à long terme. La recherche de modèles de prestation de services alternatifs pour soutenir les systèmes de santé existants et prévenir les défaillances est nécessaire pour atteindre les objectifs de l'ONUSIDA 95-95-95 pour la PTME au Mozambique.

Measuring retention in care for HIV-positive pregnant women in Prevention of Mother-to-Child Transmission of HIV (PMTCT) option B+ programs: the Mozambique experience.

BACKGROUND: Failure to retain HIV-positive pregnant women on antiretroviral therapy (ART) leads to increased mortality for the mother and her child. This study evaluated different retention measures for women's engagement along the continuum of care for prevention of mother-to-child transmission (PMTCT) option B+ services in Mozambique. METHODS: We compared 'point' retention (patient's presence in care 12-month post-ART initiation or any time thereafter) with the following definitions: alive and in care 12 month post-ART initiation (Ministry of Health; MOH); attendance at a health facility up to 15-month post-ART initiation (World Health Organization; WHO); alive and in treatment at 1-, 2-, 3-, 6-, 9-, and 12-month post-ART initiation (Inter-Agency Task Team; IATT); and alive and in care 12-month post-ART initiation with ≥75% appointment adherence during follow-up (i.e. 'appointment adherence' retention) or with ≥75% of appointments met on time during follow-up (i.e. 'on-time adherence' retention). Kaplan-Meier survival curves were produced to assess variability in retention rates. We used 'on-time adherence' retention as our reference to estimate sensitivity, specificity, and proportion of misclassified patients. RESULTS: Considering the 'point' retention definition, 16,840 HIV-positive pregnant women enrolled in option B+ PMTCT services were identified as 'retained in care' 12-month post-ART initiation. Of these, 60.3% (95% CI 59.6-61.1), 84.8% (95% CI 84.2-85.3), and 16.4% (95% CI 15.8-17.0) were classified as 'retained in care' using MOH, WHO, and IATT definitions, respectively, and 1.2% (95% CI 1.0-1.4) were classified as 'retained in care' using the '≥75% on-time adherence' definition. All definitions provided specificity rates of ≥98%. The sensitivity rates were 3.0% with 78% of patients misclassified according to the WHO definition and 4.3% with 54% of patients misclassified according to the MOH definition. The 'point' retention definition misclassified 97.6% of patients. Using IATT and 'appointment adherence' retention definitions, sensitivity rates (9.0 and 11.7%, respectively) were also low; however, the proportion of misclassified patients was smaller (15.9 and 18.3%, respectively). CONCLUSION: More stringent definitions indicated lower retention rates for PMTCT programs. Policy makers and program managers should include attendance at follow-up visits when measuring retention in care to better guide planning, scale-up, and monitoring of interventions.

HIV Prevalence and Related Risk Factors in Men Who Have Sex with Men in Bamako, Mali: Findings from a Bio-behavioral Survey Using Respondent-Driven Sampling.

Using respondent driven sampling, we conducted a cross-sectional bio-behavioral survey among men who have sex with men (MSM) in Bamako, Mali. Eligibility criteria included age ≥18 years and having had sex with another man in the last 6 months. We enrolled 552 MSM, 99.6% were tested for HIV. MSM in Bamako were young (69.6% ≤24 years) and educated (63.7% ≥secondary). HIV prevalence among MSM in Bamako was 13.7; 90.1% of HIV-infected men were unaware of their HIV status. Almost one-third had never been tested for HIV. Factors associated with higher odds of HIV included younger age, being receptive with last partner, condom breaking during anal sex in last 6 months, talking to peer educator about HIV, and having sexually transmitted infection symptoms in past year. The results suggest the need for enhanced HIV prevention and treatment services targeted at MSM in Bamako, with emphasis on repeated HIV testing.

A combination intervention strategy to improve linkage to and retention in HIV care following diagnosis in Mozambique: A cluster-randomized study.

BACKGROUND: Concerning gaps in the HIV care continuum compromise individual and population health. We evaluated a combination intervention strategy (CIS) targeting prevalent barriers to timely linkage and sustained retention in HIV care in Mozambique. METHODS AND FINDINGS: In this cluster-randomized trial, 10 primary health facilities in the city of Maputo and Inhambane Province were randomly assigned to provide the CIS or the standard of care (SOC). The CIS included point-of-care CD4 testing at the time of diagnosis, accelerated ART initiation, and short message service (SMS) health messages and appointment reminders. A pre-post intervention 2-sample design was nested within the CIS arm to assess the effectiveness of CIS+, an enhanced version of the CIS that additionally included conditional non-cash financial incentives for linkage and retention. The primary outcome was a combined outcome of linkage to care within 1 month and retention at 12 months after diagnosis. From April 22, 2013, to June 30, 2015, we enrolled 2,004 out of 5,327 adults ≥18 years of age diagnosed with HIV in the voluntary counseling and testing clinics of participating health facilities: 744 (37%) in the CIS group, 493 (25%) in the CIS+ group, and 767 (38%) in the SOC group. Fifty-seven percent of the CIS group achieved the primary outcome versus 35% in the SOC group (relative risk [RR]CIS vs SOC = 1.58, 95% CI 1.05-2.39). Eighty-nine percent of the CIS group linked to care on the day of diagnosis versus 16% of the SOC group (RRCIS vs SOC = 9.13, 95% CI 1.65-50.40). There was no significant benefit of adding financial incentives to the CIS in terms of the combined outcome (55% of the CIS+ group achieved the primary outcome, RRCIS+ vs CIS = 0.96, 95% CI 0.81-1.16). Key limitations include the use of existing medical records to assess outcomes, the inability to isolate the effect of each component of the CIS, non-concurrent enrollment of the CIS+ group, and exclusion of many patients newly diagnosed with HIV. CONCLUSIONS: The CIS showed promise for making much needed gains in the HIV care continuum in our study, particularly in the critical first step of timely linkage to care following diagnosis. TRIAL REGISTRATION: ClinicalTrials.gov NCT01930084.

High Prevalence of Concurrent Male-Male Partnerships in the Context of Low Human Immunodeficiency Virus Testing Among Men Who Have Sex With Men in Bamako, Mali.

BACKGROUND: Concurrent male-male sexual partnerships have been understudied in sub-Saharan Africa and are especially important because human immunodeficiency virus (HIV) prevalence and acquisition probability are higher among men who have sex with men (MSM) than among heterosexual men and women. METHODS: We conducted a respondent-driven sampling survey of 552 men who have sex with men in Bamako, Mali from October 2014 to February 2015. Eligibility criteria included 18 years or older, history of oral or anal sex with another man in the last 6 months, residence in or around Bamako in the last 6 months, ability to communicate in French. RESULTS: HIV prevalence was 13.7%, with 86.7% of MSM with HIV unaware of their infection. Concurrent male-male sexual partnerships were common, with 60.6% of MSM having a concurrent male sexual partnerships or believing their sex partner did in the last 6 months, and 27.3% having a concurrent male sexual partnerships and believing their sex partner did in the last 6 months. Over half (52.5%) of MSM had sex with women, and 30.8% had concurrent male partnerships and sex with a woman in the last 6 months. Concurrency was more likely among MSM with limited education, telling only MSM of same-sex behaviors, high social cohesion, and not knowing anyone with HIV. CONCLUSIONS: The high proportion of HIV-infected MSM in Bamako who are unaware of their HIV infection and the high prevalence of concurrent partnerships could further the spread of HIV in Bamako. Increasing testing through peer educators conducting mobile testing could improve awareness of HIV status and limit the spread of HIV in concurrent partnerships.

Disclosure History Among Persons Initiating Antiretroviral Treatment at Six HIV Clinics in Oromia, Ethiopia, 2012-2013.

HIV status disclosure can help patients obtain support which may influence treatment adherence and subsequent healthcare needs. We examined the extent of disclosure and correlates of non-disclosure among 1180 adults newly initiating antiretroviral treatment (ART). While 91 % of those in a relationship shared their status with their partners, 14 % of the overall sample had not disclosed to anyone. Non-disclosure was positively associated with older age; control over household resources; and concerns about unintended disclosure, life disruptions, and family reactions. Knowing other HIV-positive people and longer time since diagnosis were associated with lower odds of non-disclosure. Most respondents reporting disclosure experienced supportive responses, frequently including decision to get an HIV test by confidants who had not known their own status. Although HIV status disclosure prior to ART initiation was high, some individuals cited concerns about unintended disclosure, gossip, and partner violence, and may benefit from additional disclosure support.

Informing efforts to reach UNAIDS' 90-90-90 targets: a comparison of characteristics of people diagnosed with HIV in health facilities to the general population of people living with HIV in Mozambique.

Global targets aim to increase the number of people living with HIV (PLWH) who know their status. Using data from Mozambican facility-based HIV testing and counseling (HTC) and a population-based survey, we compared characteristics of PLWH diagnosed in HTC to the general population of PLWH to identify subgroups that are missing from the health system and may be undiagnosed. Male and female PLWH aged 50+ (PPR = 0.47, p = .0001) and with higher HIV knowledge (PPR = 0.52, p = .004) were underrepresented in HTC. A higher proportion of patients diagnosed in health facilities were aged 25-39 (PPR = 1.23, p = .02). Female PLWH with lower economic (PPR = 0.70, p = .04) and educational status (PPR = 0.86, p = .02) and male PLWH aged 18-24 (PPR = 0.47, p = .03) were underrepresented in HTC. Comparing HTC data to population-based data can inform efforts to increase HIV diagnoses and to ensure that all PLWH know their status.

HIV Care and Treatment Beliefs among Patients Initiating Antiretroviral Treatment (ART) in Oromia, Ethiopia.

To better understand patient beliefs, which may influence adherence to HIV care and treatment, we examined three dimensions of beliefs among Ethiopian adults (n = 1177) initiating antiretroviral therapy (ART). Beliefs about benefits of ART/HIV clinical care were largely accurate, but few patients believed in the ability of ART to prevent sexual transmission and many thought Holy Water could cure HIV. Factors associated with lower odds of accurate beliefs included advanced HIV, lack of formal education, and Muslim religion (benefits of ART/clinical care); secondary or university education and more clinic visits (ART to prevent sexual transmission); and pregnancy and Orthodox Christian religion (Holy Water). Assessment of patient beliefs may help providers identify areas needing reinforcement. In this setting, counselors also need to stress the benefits of ART as prevention and that Holy Water should not be used to the exclusion of HIV care and ART.

Advanced HIV disease at entry into HIV care and initiation of antiretroviral therapy during 2006-2011: findings from four sub-saharan African countries.

BACKGROUND: Timely antiretroviral therapy (ART) initiation requires early diagnosis of human immunodeficiency virus (HIV) infection with prompt enrollment and engagement in HIV care. METHODS: We examined programmatic data on 334 557 adults enrolling in HIV care, including 149 032 who initiated ART during 2006-2011 at 132 facilities in Kenya, Mozambique, Rwanda, and Tanzania. We examined trends in advanced HIV disease (CD4+ count <100 cells/µL or World Health Organization disease stage IV) and determinants of advanced HIV disease at ART initiation. RESULTS: Between 2006-2011, the median CD4+ count at ART initiation increased from 125 to 185 cells/µL an increase of 10 cells/year. Although the proportion of patients initiating ART with advanced HIV disease decreased from 42% to 29%, sex disparities widened. In 2011, the odds of advanced disease at ART initiation were higher among men (adjusted odds ratio [AOR], 1.4; 95% CI, 1.3-1.5), those on tuberculosis treatment (AOR, 1.6; 95% CI, 1.3-2.0), and those with a ≥ 12 month gap in pre-ART care (AOR, 2.0; 95% CI, 1.6-2.6). CONCLUSIONS: Intensified efforts are needed to identify and link HIV-infected individuals to care earlier and to retain them in continuous pre-ART care to facilitate more timely ART initiation.

A combination strategy for enhancing linkage to and retention in HIV care among adults newly diagnosed with HIV in Mozambique: study protocol for a site-randomized implementation science study.

BACKGROUND: Despite the extraordinary scale up of HIV prevention, care and treatment services in sub-Saharan Africa (SSA) over the past decade, the overall effectiveness of HIV programs has been significantly hindered by high levels of attrition across the HIV care continuum. Data from "real-life" settings are needed on the effectiveness of an easy to deliver package of services that can improve overall performance of the HIV care continuum. METHODS/DESIGN: We are conducting an implementation science study using a two-arm cluster site-randomized design to determine the effectiveness of a combination intervention strategy (CIS) using feasible, evidence-based, and practical interventions-including (1) point-of-care (POC) CD4 count testing, (2) accelerated antiretroviral therapy initiation for eligible individuals, and (3) SMS reminders for linkage to and retention in care-as compared to the standard of care (SOC) in Mozambique in improving linkage and retention among adults following HIV diagnosis. A pre-post intervention two-sample design is nested within the CIS arm to assess the incremental effectiveness of the CIS plus financial incentives (CIS + FI) compared to the CIS without FI on study outcomes. Randomization is done at the level of the study site, defined as a primary health facility. Five sites are included from the City of Maputo and five from Inhambane Province. Target enrollment is a total of 2,250 adults: 750 in the SOC arm, 750 in the CIS cohort of the intervention arm and 750 in the CIS + FI cohort of the intervention arm (average of 150 participants per site). Participants are followed for 12 months from time of HIV testing to ascertain a combined endpoint of linkage to care within 1 month after testing and retention in care 12 months from HIV test. Cost-effectiveness analyses of CIS compared to SOC and CIS + FI compared to CIS will also be conducted. DISCUSSION: Study findings will provide evidence on the effectiveness of a CIS and the incremental effectiveness of a CIS + FI in a "real-life" service delivery system in a SSA country severely impacted by HIV. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01930084.

Non-pharmaceutical interventions for COVID-19 transiently reduced pneumococcal and Haemophilus influenzae carriage in a cross-sectional pediatric cohort in Southampton, UK.

The Southampton pneumococcal carriage study of children under 5 years old continued during the coronavirus disease 2019 (COVID-19) pandemic. Here, we present data from October 2018 to March 2023 describing prevalence of pneumococci and other pathobionts during the winter seasons before, during, and after the introduction of non-pharmaceutical interventions (NPIs) to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. Nasopharyngeal swabs were collected from children attending outpatient clinics at a secondary care hospital and community healthcare sites. Pre-NPIs, in 2019/2020, the carriage prevalence of pneumococci at the hospital site was 32% (n = 161 positive/499 participants). During NPIs, this fell to 19% (n = 12/64), although based on fewer participants compared to previous years due to COVID-19 restrictions on health-care attendance. In 2021/2022, after NPIs had eased, prevalence rebounded to 33% (n = 15/46) [compared to NPIs period, χ2 (1, N = 110) =2.78, P = 0.09]. Carriage prevalence at community healthcare sites fell significantly from 27% (n = 127/470) in 2019/2020 to 19% during the NPI period (n = 44/228) in 2020/2021 [χ2 (1, N = 698) =4.95, P = 0.026]. No rebound was observed in 2021/2022 [19% (n = 56/288)]. However, in a multivariate logistic regression model, neither site had a significantly lower carriage prevalence during the NPI period compared to the post NPI period. A reduction in serotype diversity was observed in 2020/2021. Carriage of Haemophilus influenzae was particularly affected by NPIs with a significant reduction observed. In conclusion, among children under 5 years of age, transient, modest, and statistically non-significant alterations in carriage of both Streptococcus pneumoniae and H. influenzae were associated with SARS-CoV-2 NPIs.IMPORTANCEStreptococcus pneumoniae (the pneumococcus) continues to be a major contributor to global morbidity and mortality. Using our long-running pediatric study, we examined changes in pneumococcal carriage prevalence in nearly 3,000 children under the age of 5 years between the winters of 2018/2019 and 2022/2023. This period coincided with the severe acute respiratory syndrome coronavirus 2 pandemic and, in particular, the implementation of national strategies to limit disease transmission in the UK. We observed a transient reduction of both Streptococcus pneumoniae and Haemophilus influenzae in these populations during this period of non-pharmaceutical interventions. This aligned with the reduction in invasive pneumococcal disease seen in the UK and is therefore a likely contributor to this phenomenon.

Surveillance of pneumococcal serotypes in adults hospitalised with acute lower respiratory tract infection in Bristol, UK.

INTRODUCTION: Pneumococcus remains a major cause of adult lower respiratory tract infections (LRTI). Few data exist on the relative contribution of serotypes included in pneumococcal vaccines to community-acquired pneumonia (CAP) and non-pneumonic (NP) LRTI. We measured the burden of all and vaccine-serotype pneumococcal respiratory infection following SARS-CoV-2 emergence to inform evidence-based vaccination policy. METHODS: A prospective cohort study at two Bristol hospitals (UK) including all adults age ≥ 18-years hospitalised with acute lower respiratory tract disease (aLRTD) from Nov2021-Nov2022. LRTI patients were classified as: a) radiographically-confirmed CAP (CAP+/RAD+), b) clinically-diagnosed CAP without radiological confirmation (CAP+/RAD-), or c) NP-LRTI. Pneumococcus was identified by blood culture, BinaxNOW™and serotype-specific urine antigen detection assays (UAD). RESULTS: Of 12,083 aLRTD admissions, 10,026 had LRTI and 2,445 provided urine: 1,097 CAP + RAD+; 207 CAP + RAD-; and 1,141 NP-LRTI. Median age was 71.1y (IQR57.9-80.2) and Charlson comorbidity index = 4 (IQR2-5); 2.7 % of patients required intensive care, and 4.4 % died within 30-days of hospitalisation. Pneumococcus was detected in 280/2445 (11.5 %) participants. Among adults aged ≥ 65y and 18-64y, 12.9 % (198/1534) and 9.0 % (82/911), respectively, tested pneumococcus positive. We identified pneumococcus in 165/1097 (15.0 %) CAP + RAD+, 23/207 (11.1 %) CAP + RAD-, and 92/1141 (8.1 %) NP-LRTI cases. Of the 280 pneumococcal cases, 102 (36.4 %) were due to serotypes included in PCV13 + 6C, 115 (41.7 %) in PCV15 + 6C, 210 (75.0 %) in PCV20 + 6C/15C and 228 (81.4 %) in PPV23 + 15C. The most frequently identified serotypes were 8 (n = 78; 27.9 % of all pneumococcus), 7F (n = 25; 8.9 %), and 3 (n = 24; 8.6 %). DISCUSSION: Among adults hospitalised with respiratory infection, pneumococcus is an important pathogen across all subgroups, including CAP+/RAD- and NP-LRTI. Despite 20-years of PPV23 use in adults ≥ 65-years and herd protection due to 17-years of PCV use in infants, vaccine-serotype pneumococcal disease still causes a significant proportion of LRTI adult hospitalizations. Direct adult vaccination with high-valency PCVs may reduce pneumococcal disease burden.

Sexual risk behaviours and barriers to HIV testing among clients of female sex workers in Guatemala: a qualitative study.

Few interventions have targeted clients of female sex workers in Central America, despite their potential role in HIV/STI prevention. Semi-structured interviews were conducted with 30 clients of female sex workers on attitudes towards prevention of HIV/STIs, barriers to condom use and behaviour towards HIV/STI testing and treatment in Escuintla, Guatemala. Despite high knowledge of condoms as an HIV/STI preventive measure, the decision to use them was often based on the client's social judgment of the woman's sexual conduct. Regular clients reported lower condom use. Clients' risk perception diminished with the awareness of the public HIV/STI clinic addressed to female sex workers. Most preferred private clinics to increase confidentiality and were reluctant to take the HIV test for fear of a positive result. Outreach programmes offering HIV/STI counselling and testing to clients of female sex workers could increase their test uptake and health-seeking behaviour and reduce potential transmission to the general population.

Impacts of COVID-19 on sexual risk behaviors, safe injection practices, and access to HIV services among key populations in Zambia: Findings from a rapid qualitative formative assessment.

BACKGROUND: Despite achievements in the HIV response, social and structural barriers impede access to HIV services for key populations (KP) including men who have sex with men (MSM), transgender women (TGW), and people who inject drugs (PWID). This may be worsened by the COVID-19 pandemic or future pandemic threats. We explored the impact of COVID-19 on HIV services and sexual and substance use behaviors among MSM/TGW and PWID in Zambia as part of a formative assessment for two biobehavioral surveys. METHODS: From November-December 2020, 3 focus groups and 15 in-depth interviews (IDIs) with KP were conducted in Lusaka, Livingstone, Ndola, Solwezi, and Kitwe, Zambia. Overall, 45 PWID and 60 MSM/TGW participated in IDIs and 70 PWID and 89 MSM/TGW participated in focus groups. Qualitative data were analyzed using framework matrices according to deductive themes outlined in interview guides. RESULTS: KP reported barriers to HIV testing and HIV treatment due to COVID-19-related disruptions and fear of SARS-CoV-2 exposure at the health facility. MSM/TGW participants reported limited supply of condoms and lubricants at health facilities; limited access to condoms led to increased engagements in condomless sex. Restrictions in movement and closure of meet-up spots due to COVID-19 impeded opportunities to meet sex partners for MSM/TGW and clients for those who sold sex. COVID-19 restrictions led to unemployment and loss of income as well as to shortages and increased price of drugs, needles, and syringes for PWID. Due to COVID-19 economic effects, PWID reported increased needle-sharing and re-use of needles. CONCLUSIONS: Participants experienced barriers accessing HIV services due to COVID-19 and PWID attributed unsafe needle use and sharing to loss of income and lack of affordable needles during pandemic-related restrictions. To maintain gains in the HIV response in this context, strengthening harm reduction strategies and improvements in access to HIV services are necessary.

Impact of SARS-CoV-2 infective exacerbation of chronic obstructive pulmonary disease on clinical outcomes in a prospective cohort study of hospitalised adults.

OBJECTIVES: To determine whether acute exacerbations of chronic obstructive pulmonary disease (AECOPD) triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have worse outcomes than AECOPD caused by other infectious agents or non-infective AECOPD (NI-COPD). DESIGN: A two-hospital prospective cohort study of adults hospitalised with acute respiratory disease. We compared outcomes with AECOPD and a positive test for SARS-CoV-2 (n = 816), AECOPD triggered by other infections (n = 3038) and NI-COPD (n = 994). We used multivariable modelling to adjust for potential confounders and assessed variation by seasons associated with different SARS-CoV-2 variants. SETTING: Bristol UK, August 2020-May 2022. PARTICIPANTS: Adults (≥18 y) hospitalised with AECOPD. MAIN OUTCOME MEASURES: We determined the risk of positive pressure support, longer hospital admission and mortality following hospitalisation with AECOPD due to non-SARS-CoV-2 infection compared with SARS-CoV-2 AECOPD and NI-COPD. RESULTS: Patients with SARS-CoV-2 AECOPD, in comparison to non-SARS-CoV-2 infective AECOPD or NI-COPD, more frequently required positive pressure support (18.5% and 7.5% vs. 11.7%, respectively), longer hospital stays (median [interquartile range, IQR]: 7 [3-15] and 5 [2-10] vs. 4 [2-9] days, respectively) and had higher 30-day mortality (16.9% and 11.1% vs. 5.9%, respectively) (all p < 0.001). In adjusted analyses, SARS-CoV-2 AECOPD was associated with a 55% (95% confidence interval [95% CI]: 24-93), 26% (95% CI: 15-37) and 35% (95% CI: 10-65) increase in the risk of positive pressure support, hospitalisation length and 30-day mortality, respectively, relative to non-SARS-CoV-2 infective AECOPD. The difference in risk remained similar during periods of wild-type, Alpha and Delta SARS-CoV-2 strain dominance, but diminished during Omicron dominance. CONCLUSIONS: SARS-CoV-2-related AECOPD had worse patient outcomes compared with non-SARS-CoV-2 AECOPD or NI-AECOPD, although the difference in risks was less pronounced during Omicron dominance.

Qualitative assessment of caregiver experiences when navigating childhood immunisation in urban communities in Sierra Leone.

OBJECTIVE: To gain in-depth understanding of the caregiver experience when navigating urban immunisation services for their children. DESIGN: An exploratory qualitative assessment comprising 16 in-depth interviews using an interpretative phenomenology approach. SETTING: Caregivers were purposively recruited from slums (n=8) and other urban communities (n=8) in the capital city of Sierra Leone. PARTICIPANTS: Caregivers of children ages 6-36 months old who were fully vaccinated (n=8) or undervaccinated (n=8). RESULTS: Emotional enablers of vaccination were evident in caregivers' sense of parental obligation to their children while also anticipating reciprocal benefits in children's ability to take care of their parents later in life. Practical enablers were found in the diversity of immunisation reminders, information access, information trust, getting fathers more involved, positive experiences with health workers and postvaccination information sharing in the community. Underlying barriers to childhood vaccination were due to practical constraints such as overcrowding and long waiting times at the clinic, feeling disrespected by health workers, expecting to give money to health workers for free services and fear of serious vaccine side effects. To improve vaccination outcomes, caregivers desired more convenient and positive clinic experiences and deeper community engagement. CONCLUSIONS: Health system interventions, community engagement and vaccination outreach need to be tailored for urban settings. Vaccine communication efforts may resonate more strongly with caregivers when vaccination is framed both around parental responsibilities to do the right thing for the child and the future benefits to the parent.

MPrEP+ study protocol: a prospective cohort study assessing the feasibility and acceptability of an HIV pre-exposure prophylaxis (PrEP) strategy for male clients of female sex workers in Kisumu, Kenya.

INTRODUCTION: Male clients (MCs) are integral to sex work-driven HIV transmission dynamics as sexual partners of female sex worker (FSW). MCs contribute disproportionately to incident HIV globally and in sub-Saharan Africa, with 27% of new infections attributed to MCs of FSW and other partners of key populations. Gaps in coverage of HIV testing and prevention services for men, including MCs, are well-documented, yet research and innovative interventions to improve MC uptake of effective prevention services, including pre-exposure prophylaxis (PrEP), are scarce. METHODS AND ANALYSIS: MPrEP+ is a cohort study designed to assess the feasibility and acceptability of a PrEP-focused HIV prevention strategy providing daily oral tenofovir/emtricitabine (TDF/FTC) in combination with three adherence self-management interventions: (1) use of a validated point-of-care urine drug-level assay with real-time feedback and tailored self-management counselling; (2) frequent HIV self-testing; and (3) weekly one-way text messaging. This package of interventions is being delivered to 120 MCs enrolled in the study in Kisumu, Kenya over a 6-month period. The primary outcome is PrEP adherence at 6 months as measured by PrEP drug levels. Bivariate and multivariable regression models will be used to identify predictors of PrEP adherence. We will also explore associations of sociodemographic characteristics and PrEP beliefs with PrEP adherence. ETHICS AND DISSEMINATION: The study was approved by the Columbia University Irving Medical Center Institutional Review Board and the Maseno University Ethical Review Committee. Study enrolment was initiated in November 2021 with participant follow-up planned through August 2022. Study results will be submitted for publication in peer-reviewed journals. Summaries and infographics of study findings will be developed and distributed to MC, FSW and stakeholders working in HIV prevention and support for people who sell and buy sex, including Kenya's Ministry of Health. TRIAL REGISTRATION NUMBER: NCT04898699; Registered on 24 May 2021.