Divergent preferences for enhanced HIV testing options among high-risk populations in northern Tanzania: a short report.

To achieve the UNAIDS target of diagnosing 95% of all persons living with HIV, enhanced HIV testing services with greater attractional value need to be developed and implemented. We conducted a discrete choice experiment (DCE) to quantify preferences for enhanced HIV testing features across two high-risk populations in the Kilimanjaro Region in northern Tanzania. We designed and fielded a survey with 12 choice tasks to systematically recruited female barworkers and male mountain porters. Key enhanced features included: testing availability on every day of the week, an oral test, integration of a general health check or an examination for sexually transmitted infections (STI) with HIV testing, and provider-assisted confidential partner notification in the event of a positive HIV test result. Across 300 barworkers and 440 porters surveyed, mixed logit analyses of 17,760 choices indicated strong preferences for everyday testing availability, health checks, and STI examinations. Most participants were averse to oral testing and confidential partner notification by providers. Substantial preference heterogeneity was observed within each risk group. Enhancing HIV testing services to include options for everyday testing, general health checks, and STI examinations may increase the appeal of HIV testing offers to high-risk populations.Trial registration: ClinicalTrials.gov identifier: NCT02714140.

Feasibility, Acceptability, and Potential Cost-Effectiveness of a Novel Mobile Phone Intervention to Promote Human Immunodeficiency Virus Testing Within Social Networks in Tanzania.

ABSTRACT: Among 145 individuals surveyed in Tanzania, 42% indicated willingness to test for human immunodeficiency virus in response to a confidential, phone-based text message. On average, participants were likely to provide contact information for 1.5 members of their social networks, suggesting high feasibility and moderate acceptability of a novel mHealth human immunodeficiency virus testing intervention.

Understanding hard-to-reach communities: local perspectives and experiences of trachoma control among the pastoralist Maasai in northern Tanzania.

As progress to eliminate trachoma is made, addressing hard-to-reach communities becomes of greater significance. Areas in Tanzania, inhabited by the Maasai, remain endemic for trachoma. This study assessed the effectiveness of Mass Drug Administration (MDA) through an ethnographic study of trachoma amongst a Maasai community. The MDA experience in the context of the livelihoods of the Maasai in a changing political economy was explored using participant observation and household interviews. Factors influencing MDA effectiveness within five domains were analysed. 1) Terrain of intervention: Human movement hindered MDA, including seasonal migration, domestic chores, grazing and school. Encounters with wildlife were significant. 2) Socio-cultural factors and community agency: Norms around pregnancy led women to accept the drug but hide refusal to swallow the drug. Timing of Community Drug Distributor (CDD) visits conflicted with livestock grazing. Refusals occurred among the ilmurrani age group and older women. Mistrust significantly hindered uptake of drugs. 3) Strategies and motivation of drug distributors: Maa-speaking CDDs were critical to effective drug delivery. Maasai CDDs, whilst motivated, faced challenges of distances, encounters with wildlife and compensation. 4) Socio-materiality of technology: Decreases in side-effects over years have improved trust in the drug. Restrictions to swallowing drugs and/or water were relevant to post-partum women and the ilmurrani. 5) History and health governance: Whilst perceptions of the programme were positive, communities questioned government priorities for resources for hospitals, medicines, clean water and roads. They complained of a lack of information and involvement of community members in health care services. With elimination in sight, hard-to-reach communities are paramount as these are probably the last foci of infection. Effective delivery of MDA programmes in such communities requires a critical understanding of community experiences and responses that can inform tailored approaches to trachoma control. Application of a critical social science perspective should be embedded in planning and evaluation of all NTD programmes.

Immunopathogenesis of Progressive Scarring Trachoma: Results of a 4-Year Longitudinal Study in Tanzanian Children.

Trachoma is initiated during childhood following repeated conjunctival infection with Chlamydia trachomatis, which causes a chronic inflammatory response in some individuals that leads to scarring and in-turning of the eyelids in later life. There is currently no treatment to halt the progression of scarring trachoma due to an incomplete understanding of disease pathogenesis. A cohort study was performed in northern Tanzania in 616 children aged 6 to 10 years at enrollment. Every 3 months for 4 years, children were examined for clinical signs of trachoma, and conjunctival swabs were collected for C. trachomatis detection and to analyze the expression of 46 immunofibrogenic genes. Data were analyzed in relation to progressive scarring status between baseline and the final time point. Genes that were significantly associated with scarring progression included those encoding proinflammatory chemokines (CXCL5, CCL20, CXCL13, and CCL18), cytokines (IL23A, IL19, and IL1B), matrix modifiers (MMP12 and SPARCL1), immune regulators (IDO1, SOCS3, and IL10), and a proinflammatory antimicrobial peptide (S100A7). In response to C. trachomatis infection, IL23A and PDGF were significantly upregulated in scarring progressors relative to in nonprogressors. Our findings highlight the importance of innate proinflammatory signals from the epithelium and implicate interleukin 23A (IL-23A)-responsive cells in driving trachomatous scarring, with potential key mechanistic roles for PDGFB, MMP12, and SPARCL1 in orchestrating fibrosis.

Enrollment in HIV Care and Treatment Clinic and Associated Factors Among HIV Diagnosed Patients in Magu District, Tanzania.

HIV care and treatment clinics (CTC) are important for management of HIV morbidity and mortality, and to reduce HIV transmission. Enrollment in HIV care and treatment clinics remains low in many developing countries. We followed up 632 newly diagnosed HIV patients aged 15 years and above from Magu District, Tanzania. Logistic regression was used to assess factors significantly associated with enrollment for CTC services. Kaplan-Meier plots and log-rank tests were used to evaluate differences in timing uptake of services. Among 632 participants, 214 (33.9%) were enrolled in CTC, and of those enrolled 120 (56.6%) took longer than 3 months to enroll. Those living in more rural villages were less likely to be enrolled than in the villages with semi-urban settings (OR 0.36; 95% CI 0.17-0.76). Moreover, those with age group 35-44 years and with age group 45 years and above were 2 times higher odds compared to those with age group 15-24 years, (OR 2.03; 95% CI 1.05-3.91) and (OR 2.69; 95% CI 1.40-5.18) respectively. Enrollment in the CTC in Tanzania is low. To increase uptake of antiretroviral therapy, it is critical to improve linkage between HIV testing and care services, and to rollout these services into the primary health facilities.

Physical activity and associated factors from a cross-sectional survey among adults in northern Tanzania.

BACKGROUND: Insufficient physical activity (PA) is a major contributing factor in the growing problem of non-communicable diseases (NCDs) in urban and rural Sub-Saharan Africa. This study aimed to determine PA and associated factors among adults in Northern Tanzania. METHODS: We analyzed secondary data from a cross-sectional serological survey nested within the Magu health and demographic sentinel surveillance population in Magu District Northwestern Tanzania. All resident adults aged 15 years and older were invited to participate in the study, and physical activity data were analyzed for 5663 participants. Data were analyzed using Stata version 13.0. We used logistic regression to obtain odds ratios and 95% confidence intervals (CI) for risk factors associated with differences in PA. RESULTS: In this mainly rural population, 96% reported sufficient PA, with a higher proportion in males (97.3%) compared to females (94.8%). In males the odds of sufficient PA were lower in rural areas compared to urban areas (OR = 0.19; P < 0.001; 95% CI = 0.08-0.42), while in females the odds of sufficient PA were higher in rural areas compared to urban areas (OR = 2.27; P < 0.001; 95%CI = 1.59-3.24). Leisure-related activity was low compared to work-related and transport-related activity. Farmers had a higher odds of sufficient PA than those in professional jobs in both males (OR = 9.75; P < 0.001; 95% CI = 3.68-5.82) and females (OR = 2.83; P = 0.021; 95% CI = 1.17-6.86). CONCLUSION: The prevalence of PA in this population was high. However, there is need for PA programs to maintain the high level of compliance during and following the transition to a more urban-based culture.

Differential frequency of NKG2C/KLRC2 deletion in distinct African populations and susceptibility to Trachoma: a new method for imputation of KLRC2 genotypes from SNP genotyping data.

NKG2C is an activating receptor that is preferentially expressed on natural killer (NK) cells. The gene encoding NKG2C (killer cell lectin-like receptor C2, KLRC2) is present at different copy numbers in the genomes of different individuals. Deletion at the NKG2C locus was investigated in a case-control study of 1522 individuals indigenous to East- and West-Africa and the association with the ocular Chlamydia trachomatis infection and its sequelae was explored. The frequency of homozygous KLRC2 deletion was 13.7 % in Gambians and 4.7 % in Tanzanians. A significantly higher frequency of the deletion allele was found in West-Africans from the Gambia and Guinea-Bissau (36.2 % p = 2.105 × 10(-8), 26.8 % p = 0.050; respectively) in comparison to East-African Tanzanians where the frequency of the deletion is comparable to other human populations (20.9 %). We found no evidence for an association between the numbers of KLRC2 gene copies and the clinical manifestations of trachoma (follicular trachoma or conjunctival scarring). A new method for imputation of KLRC2 genotypes from single nucleotide polymorphism (SNP) data in 2621 individuals from the Gambia further confirmed these results. Our data suggest that NKG2C does not play a major role in trachomatous disease. We found that the deletion allele is present at different frequencies in different populations but the reason behind these differences is currently not understood. The new method offers the potential to use SNP arrays from genome wide association studies to study the frequency of KLRC2 deletion in other populations and its association with other diseases.

One size does not fit all: HIV testing preferences differ among high-risk groups in Northern Tanzania.

In order to maximize the effectiveness of "Seek, Test, and Treat" strategies for curbing the HIV epidemic, new approaches are needed to increase the uptake of HIV testing services, particularly among high-risk groups. Low HIV testing rates among such groups suggest that current testing services may not align well with the testing preferences of these populations. Female bar workers and male mountain porters have been identified as two important high-risk groups in the Kilimanjaro Region of Tanzania. We used conventional survey methods and a discrete choice experiment (DCE), a preference elicitation method increasingly applied by economists and policy-makers to inform health policy and services, to analyze trade-offs made by individuals and quantify preferences for HIV testing services. Bivariate descriptive statistics were used to analyze differences in survey responses across groups. Compared to 486 randomly selected community members, 162 female bar workers and 194 male Kilimanjaro porters reported 2-3 times as many lifetime sexual partners (p < 0.001), but similar numbers of lifetime HIV tests (median 1-2 across all groups). For the DCE, participants' stated choices across 12,978 hypothetical HIV testing scenarios (422 female and 299 male participants × 9 choice tasks × 2 alternatives) were analyzed using gender-specific mixed logit models. Direct assessments and the DCE data demonstrated that barworkers were less likely to prefer home testing and were more concerned about disclosure issues compared with their community counterparts. Male porters preferred testing in venues where antiretroviral therapy was readily available. Both high-risk groups were less averse to traveling longer distances to test compared to their community counterparts. These results expose systematic differences in HIV testing preferences across high-risk populations compared to their community peers. Tailoring testing options to the preferences of high-risk populations should be evaluated as a means of improving uptake of testing in these populations.

Effectiveness of prevention of mother-to-child HIV transmission programmes in Kilimanjaro region, northern Tanzania.

OBJECTIVE: To monitor the effectiveness of the prevention of mother-to-child transmission (PMTCT) components in reducing mother-to-child transmission of HIV in Kilimanjaro region, Tanzania. METHODS: We conducted a retrospective registry-based cohort study of HIV-exposed children aged 4 weeks to 18 months. Eligible children had a DNA polymerase chain reaction HIV antigen test between January 2009 and August 2012. We collected and analysed the data on the PMTCT components provided. We used logistic regression to explore factors associated with successful PMTCT usage and with infant infection. RESULTS: We studied 561 children; 283 (50.5%) were from rural areas. Breastfeeding was reported by 519 (92.5%) of mothers. In 469 (83.6%) mother-baby pairs, both received chemoprophylaxis, whereas in 9 (1.6%) pairs, neither mother nor baby received any chemoprophylaxis. Of the 522 (93.0%) infants with known outcomes at 6 months, 227 (43.5%) were alive, 258 (49.4%) were lost to follow-up, 34 (6.5%) had transferred and 3 (0.6%) had died. A total of 54 (9.6%) children were infected. Transmission rates of HIV when only the mother (adjusted odds ratio [aOR] 1.49, 95% CI: 0.47-4.77) or only the baby (aOR 1.06, 95% CI: 0.23-5.01) received chemoprophylaxis were not significantly different from transmission rates when both mother and baby received antiretroviral chemoprophylaxis. Mixed feeding practices were not associated with significantly increased risk (aOR 4.09, 95% CI: 0.58-28.76) compared with exclusive breastfeeding. CONCLUSION: This study showed that rate of MTCT of HIV was 9.6% in Tanzania between 2009 and 2012. The intrapartum and child chemoprophylaxis components of the PMTCT programme were well implemented with 84% of both mothers and their babies getting full chemoprophylaxis, and effective in reducing mother-to-child transmission.

Mobile Phone-Based Confidential Social Network Referrals for HIV Testing (CONSORT): Protocol for a Randomized Controlled Trial.

BACKGROUND: Critical to efforts to end the HIV epidemic is the identification of persons living with HIV who have yet to be diagnosed and engaged in care. Expanded HIV testing outreach efforts need to be both efficient and ambitious, targeting the social networks of persons living with HIV and those at above-average risk of undiagnosed HIV infection. The ubiquity of mobile phones across many high HIV prevalence settings has created opportunities to leverage mobile health (mHealth) technologies to engage social networks for HIV testing outreach, prevention, and treatment. OBJECTIVE: The purpose of this study is to evaluate the acceptability and efficacy of a novel mHealth intervention, "Confidential Social Network Referrals for HIV Testing (CONSORT)," to nudge at-risk individuals to test for HIV using SMS text messages. METHODS: We will conduct the CONSORT study in Moshi, Tanzania, the commercial center and administrative capital of the Kilimanjaro Region in northern Tanzania. After qualitative formative work and pilot testing, we will enroll 400 clients presenting for HIV counseling and testing and 200 persons living with HIV and receiving care at HIV care and treatment centers as "inviters" into a randomized controlled trial. Eligible participants will be aged 18 years or older and live, work, or regularly receive care in Moshi. We will randomize inviters into 1 of 2 study arms. All inviters will be asked to complete a survey of their HIV testing and risk behaviors and to think of social network contacts who would benefit from HIV testing. They will then be asked to whom they would prefer to extend an HIV testing invitation in the form of a physical invitation card. Arm 1 participants will also be given the opportunity to extend CONSORT invitations in the form of automated confidential SMS text messages to any of their social network contacts or "invitees." Arm 2 participants will be offered physical invitation cards alone. The primary outcome will be counselor-documented uptake of HIV testing by invitees within 30 days of inviter enrollment. Secondary outcomes will include the acceptability of CONSORT among inviters, the number of new HIV diagnoses, and the HIV risk of invitees who present for testing. RESULTS: Enrollment in the randomized controlled trial is expected to start in September 2024. The findings will be disseminated to stakeholders and published in peer-reviewed journals. CONCLUSIONS: If CONSORT is acceptable and effective for increasing the uptake of HIV testing, given the minimal costs of SMS text reminders and the potential for exponential but targeted growth using chain referrals, it may shift current practices for HIV testing programs in the area. TRIAL REGISTRATION: ClincalTrials.gov NCT05967208; https://clinicaltrials.gov/study/NCT05967208. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55068.

Stigma experiences, effects and coping among individuals affected by Buruli ulcer and yaws in Ghana.

BACKGROUND: Stigma related to skin neglected tropical diseases like Buruli ulcer (BU) and yaws has remained underexplored and existing studies are limited to individual diseases despite the WHO call for integration in disease management. Within two districts in central Ghana, we explored stigma associated with BU and yaws to understand overlaps and disease-specific nuances to help guide integrated interventions. METHODOLOGY/PRINCIPAL FINDINGS: In-depth interviews were conducted with 31 current or formerly affected individuals to assess the experiences, effects and coping strategies adopted to manage disease related stigma. Data were analysed along broad themes based on the sociological construct of macro and micro interaction and Goffman's treatise on stigma. Disapproving community labels fueled by misconceptions were noted among BU participants which contributed to macro stigma experiences, including exclusion, discrimination and avoidance. In contrast, a high level of social acceptance was reported among yaws participants although some micro-level stigma (anticipated, felt and self-stigma) were noted by individuals with both diseases. While younger participants experienced name-calling and use of derogatory words to address affected body parts, older participants and caregivers discussed the pain of public staring. Stigma experiences had negative consequences on psychosocial well-being, schooling, and social relations, particularly for BU affected people. Problem-focused strategies including confrontation, selective disclosure and concealment as well as emotion-focused strategies (religious coping and self-isolation) were noted. CONCLUSIONS AND SIGNIFICANCE: The types and levels of stigma varied for BU and yaws. Stigma experiences also differed for adults and children in this setting and these differences should be accounted for in integrated interventions for these skin NTDs. School health programs need to prioritize educating school teachers about skin NTDs and the negative impact of stigma on the wellbeing of children.

Acceptability and feasibility of tests for infection, serological testing, and photography to define need for interventions against trachoma.

BACKGROUND: Trachoma causes blindness due to repeated conjunctival infection by Chlamydia trachomatis (Ct). Transmission intensity is estimated, for programmatic decision-making, by prevalence of the clinical sign trachomatous inflammation-follicular (TF) in children aged 1-9 years. Research into complementary indicators to field-graded TF includes work on conjunctival photography, tests for ocular Ct infection, and serology. The perceived acceptability and feasibility of these indicators among a variety of stakeholders is unknown. METHODOLOGY: Focus group discussions (FGDs) with community members and in-depth interviews (IDIs) with public health practitioners in Tanzania were conducted. FGDs explored themes including participants' experience with, and thoughts about, different diagnostic approaches. The framework method for content analysis was used. IDIs yielded lists of perceived strengths of, and barriers to, implementation for programmatic use of each indicator. These were used to form an online quantitative survey on complementary indicators distributed to global stakeholders via meetings, mailing lists, and social media posts. RESULTS: Sixteen FGDs and 11 IDIs were conducted in October-November 2022. In general, all proposed sample methods were deemed acceptable by community members. Common themes included not wanting undue discomfort and a preference for tests perceived as accurate. Health workers noted the importance of community education for some sample types. The online survey was conducted in April-May 2023 with 98 starting the questionnaire and 81 completing it. Regarding barriers to implementing diagnostics, the highest agreement items related to feasibility, rather than acceptability. No evidence of significant differences was found in responses pertaining to community acceptability based on participant characteristics. CONCLUSIONS: All of the indicators included were generally deemed acceptable by all stakeholders in Tanzania, although community education around the benefits and risks of different sample types, as well as addressing issues around feasibility, will be key to successful, sustainable integration of these indicators into trachoma programs.

The role of economic factors in shaping and constituting the household burden of neglected tropical diseases of the skin: Qualitative findings from Ghana and Ethiopia.

Tracers of health system equity, neglected tropical diseases (NTDs) disproportionately affect marginalized populations. NTDs that manifest on the skin - "skin NTDs" - are associated with scarring, disfigurement, physical disability, social exclusion, psychological distress, and economic hardship. To support development and evaluation of appropriate intervention strategies, we aimed to improve understanding of the role of economic factors in shaping and constituting the burden that skin NTDs place on households. We collected data in 2021 in two predominantly rural districts: Atwima Mponua in Ghana (where Buruli ulcer, yaws, and leprosy are endemic) and Kalu in Ethiopia (where cutaneous leishmaniasis and leprosy are endemic). We conducted interviews (n = 50) and focus group discussions (n = 14) that explored economic themes with affected individuals, caregivers, and community members and analysed the data thematically using a pre-defined framework. We found remarkable commonalities across countries and diseases. We developed a conceptual framework which illustrates skin NTDs' negative economic impact, including financial costs of care-seeking and reductions in work and schooling; categorises coping strategies by their degree of risk-pooling; and clarifies the mechanisms through which skin NTDs disproportionately affect the poorest. Despite health insurance schemes in both countries, wide-ranging, often harmful coping strategies were reported. Traditional healers were often described as more accessible, affordable and offering more flexible payment terms than formal health services, except for Ethiopia's well-established leprosy programme. Our findings are important in informing strategies to mitigate the skin NTD burden and identifying key drivers of household costs to measure in future evaluations. To reduce skin NTDs' impact on households' physical, mental, and economic wellbeing, intervention strategies should address economic constraints to prompt and effective care-seeking. While financial support and incentives for referrals and promotion of insurance enrolment may mitigate some constraints, structural interventions that decentralise care may offer more equitable and sustainable access to skin NTD care.

Development of an integrated and decentralised skin health strategy to improve experiences of skin neglected tropical diseases and other skin conditions in Atwima Mponua District, Ghana.

Integrated strategies are recommended to tackle neglected tropical diseases of the skin (skin NTDs), which pose a substantial health and economic burden in many countries, including Ghana. We describe the development of an integrated and decentralised skin health strategy designed to improve experiences of skin NTDs in Atwima Mponua district in Ashanti Region. A multidisciplinary research team led an iterative process to develop an overall strategy and specific interventions, based on a theory of change informed by formative research conducted in Atwima Mponua district. The process involved preparatory work, four co-development workshops (August 2021 to November 2022), collaborative working groups to operationalise intervention components, and obtaining ethical approval. Stakeholders including affected individuals, caregivers, other community members and actors from different levels of the health system participated in co-development activities. We consulted these stakeholders at each stage of the research process, including discussion of study findings, development of our theory of change, identifying implementable solutions to identified challenges, and protocol development. Participants determined that the intervention should broadly address wounds and other skin conditions, rather than only skin NTDs, and should avoid reliance on non-governmental organisations and research teams to ensure sustainable implementation by district health teams and transferability elsewhere. The overall strategy was designed to focus on a decentralised model of care for skin conditions, while including other interventions to support a self-care delivery pathway, community engagement, and referral. Our theory of change describes the pathways through which these interventions are expected to achieve the strategy's aim, the assumptions, and problems addressed. This complex intervention strategy has been designed to respond to the local context, while maximising transferability to ensure wider relevance. Implementation is expected to begin in 2023.

HLA-A, -B, -C, -DPB1, -DQB1 and -DRB1 allele frequencies of North Tanzanian Maasai.

Locus-specific amplicon sequencing was used to HLA type 336 participants of Maasai ethnicity at the HLA-A, -B, -C, -DRB1, -DQB1 and -DPB1 loci. Participants were recruited from three study villages in North Tanzania, for the purpose of investigating risk factors for trachomatous scarring in children. Other than HLA-A, all loci significantly deviated from Hardy-Weinberg equilibrium, possibly due to high relatedness between individuals: 238 individuals shared a house with at least one another participant. The most frequent allele for each locus were A*68:02 (14.3 %), B*53:01 (8.4 %), C*06:02 (19.2 %), DRB1*13:02 (17.7 %), DQB1*02:01 (16.9 %) and DPB1*01:01 (15.7 %), while the most common inferred haplotype was A*68:02 âˆ¼ B*18:01 âˆ¼ C*07:04 âˆ¼ DRB1*08:04 âˆ¼ DQB1*04:02 âˆ¼ DPB1*04:01 (1.3 %).

Longitudinal changes in tear cytokines and antimicrobial proteins in trachomatous disease.

BACKGROUND: Trachoma is a neglected tropical disease caused by ocular infection with Chlamydia trachomatis, where repeated infections and chronic inflammation can ultimately result in scarring, trichiasis and blindness. While scarring is thought to be mediated by a dysregulated immune response, the kinetics of cytokines and antimicrobial proteins in the tear film have not yet been characterised. METHODOLOGY: Pooled tears from a Gambian cohort and Tanzanian cohort were semi-quantitatively screened using a Proteome Profiler Array to identify cytokines differentially regulated in disease. Based on this screen and previous literature, ten cytokines (CXCL1, IP-10, IFN-γ, IL-1ß, IL-8, IL-10, IL-12 p40, IL-1RA, IL-1α and PDGF), lysozyme and lactoferrin were assayed in the Tanzanian cohort by multiplex cytokine assay and ELISA. Finally, CXCL1, IP-10, IL-8, lysozyme and lactoferrin were longitudinally profiled in the Gambian cohort by multiplex cytokine assay and ELISA. RESULTS: In the Tanzanian cohort, IL-8 was significantly increased in those with clinically inapparent infection (p = 0.0086). Lysozyme, IL-10 and chemokines CXCL1 and IL-8 were increased in scarring (p = 0.016, 0.046, 0.016, and 0.037). CXCL1, IP-10, IL-8, lysozyme and lactoferrin were longitudinally profiled over the course of infection in a Gambian cohort study, with evidence of an inflammatory response both before, during and after detectable infection. CXCL1, IL-8 and IP-10 were higher in the second infection episode relative to the first (p = 0.0012, 0.044, and 0.04). CONCLUSIONS: These findings suggest that the ocular immune system responds prior to and continues to respond after detectable C. trachomatis infection, possibly due to a positive feedback loop inducing immune activation. Levels of CXC chemokines in successive infection episodes were increased, which may offer an explanation as to why repeated infections are a risk factor for scarring.

The role of cultural safety and ethical space within postcolonial healthcare for Maasai in Tanzania.

The history of the Maasai tribe in northern Tanzania is characterised by marginalisation, discrimination and political subjugation. Inequities, enacted through power relations, influence healthcare access, practices and outcomes among the Maasai. Cultural safety and ethical space provide lenses into social, political and historical influences on access to care, helping to understand the realities of historically marginalised populations such as the Maasai, and responses to health services. This study aims to examine Maasai experiences of accessing and uptake of health services within a postcolonial discourse in Tanzania. In an ethnographic study examining access and perceptions of healthcare services in Maasai communities, lead authors conducted participant observations and at health facilities to document experiences. Household interviews, a group oral history and interviews with NGOs working with Maasai communities, contributed to the data analysed. Inductive thematic analysis was used to understand healthcare experiences within a framework of cultural safety and ethical space. Despite trust in biomedicine, Maasai people have a strong desire for health services with particular characteristics. Quality of care, including facilities and diagnostics available and used, was important. A sense of fairness was a determinant in respecting services including 'first come first serve' system and transparency when unable to treat a condition. Trust in health services was also influenced by personal interactions with health workers, including provision of health information provided to patients and instances of being mistreated. These findings offer an understanding of ways in which spaces of healthcare can be more approachable and trusted by Maasai. Incorporating cultural safety and ethical spaces to understand healthcare access can help to reduce the power imbalance possibly resulting from a history of marginalisation. This can inform development of culturally appropriate programmes, used to educate healthcare professionals and advocate for improved healthcare services for marginalised groups.

Adherence to Optimal Breastfeeding Practices Among HIV-Positive Mothers in Kilimanjaro, Tanzania.

Purpose: We sought to assess how HIV-positive mothers enrolled in the PMTCT program adhere to breastfeeding recommendations concerning early initiation of breastfeeding (EIBF), ie, within one hour of birth, pre-lacteal feeds, exclusive breastfeeding until six months (EBF), and continued breastfeeding to one year of age. This study was designed to assess the practices in response to changing recommendations for breastfeeding in HIV, which have differed drastically over the years. Patients and Methods: We recruited 524 mother-child pairs from 37 PMTCT clinics across Kilimanjaro, Tanzania. The 5 clinics with the highest patient load in each of the 7 districts of Kilimanjaro were chosen, plus the zonal and municipal referral hospitals. The children were below two years of age and currently in the PMTCT program. We administered a questionnaire to assess the mother's practices in feeding the child. We used multiple logistic regression models to determine factors associated with EIBF, EBF, and continued breastfeeding. Results: EIBF was achieved for 73.1% of babies. Cesarean delivery, low birth weight, and partner disclosure of HIV status were significant risk factors for not achieving EIBF. About 19% of children did not breastfeed exclusively. Of the 247 children ≥12 months old, 43.3% had stopped breastfeeding before 12 months. Counseling on ARV, having had >2 pregnancies while HIV-positive and EBF were associated with breastfeeding until 12 months old. Using ART for more than two years decreased the odds of EBF and continued breastfeeding to 12 months of age. Conclusion: Adherence to breastfeeding recommendations for HIV-positive women is suboptimal, particularly in aspects of recent changes in recommendations such as continuing breastfeeding for one year. There is a missed opportunity for interventions such as counseling, which has shown to favor adherence. Health education and counseling are needed for providers and mothers to keep them abreast with the frequently changing recommendations.

The conjunctival microbiome before and after azithromycin mass drug administration for trachoma control in a cohort of Tanzanian children.

Background: Trachoma, caused by ocular infection with Chlamydia trachomatis, is a neglected tropical disease that can lead to blinding pathology. Current trachoma control programmes have successfully used mass drug administration (MDA) with azithromycin to clear C. trachomatis infection and reduce transmission, alongside promoting facial cleanliness for better personal hygiene and environmental improvement. In areas of low-trachoma endemicity, the relationship between C. trachomatis infection and trachomatous disease weakens, and non-chlamydial bacteria have been associated with disease signs. Methods: We enrolled a cohort of children aged 6-10 years from three adjacent trachoma endemic villages in Kilimanjaro and Arusha regions, Northern Tanzania. Children were divided into four clinical groups based on the presence or absence of ocular C. trachomatis infection and clinical signs of trachomatous papillary inflammation (TP). To determine the impact of treatment on the ocular microbiome in these clinical groups, we performed V4-16S rRNA sequencing of conjunctival DNA from children 3-9 months pre-MDA (n = 269) and 3 months post-MDA (n = 79). Results: Chlamydia trachomatis PCR-negative, no TP children had the highest pre-MDA ocular microbiome alpha diversity, which was reduced in C. trachomatis infected children and further decreased in those with TP. Pre-MDA, Haemophilus and Staphylococcus were associated with C. trachomatis infection with and without concurrent TP, while Helicobacter was increased in those with TP in the absence of current C. trachomatis infection. Post-MDA, none of the studied children had ocular C. trachomatis infection or TP. MDA increased ocular microbiome diversity in all clinical groups, the change was of greater magnitude in children with pre-MDA TP. MDA effectively reduced the prevalence of disease causing pathogenic non-chlamydial bacteria, and promoted restoration of a normal, healthy conjunctival microbiome. Conclusion: We identified Helicobacter as a non-chlamydial bacterium associated with the clinical signs of TP. Further investigation to determine its relevance in other low-endemicity communities is required. MDA was shown to be effective at clearing C. trachomatis infection and other non-chlamydial ocular pathogens, without any detrimental longitudinal effects on the ocular microbiome. These findings suggest that azithromycin MDA may be valuable in trachoma control even in populations where the relationship between clinical signs of trachoma and the prevalence of current ocular C. trachomatis infection has become dissociated.