Effectiveness of Linkage to Care and Prevention Interventions Following HIV Self-Testing: A Global Systematic Review and Meta-analysis.

Over 38.4 million people were living with HIV globally in 2021. The HIV continuum includes HIV testing, diagnosis, linkage to combined antiretroviral therapy (cART), and retention in care. An important innovation in the HIV care continuum is HIV self-testing. There is a paucity of evidence regarding the effectiveness of interventions aimed at linking self-testers to care and prevention, including pre-exposure prophylaxis (PrEP). To bridge this gap, we carried out a global systematic review and meta-analysis to ascertain the effectiveness of interventions post-HIV self-testing regarding: (1) linkage to care or ART, (2) linkage to PrEP, and (3) the impact of HIV self-test (HIVST) interventions on sexual behaviors. We searched PubMed, Web of Science, SCOPUS, Cochrane Library, CINAHL Plus (EBSCO), MEDLINE (Ovid), Google Scholar, and ResearchGate. We included only published randomized controlled trials (RCTs) and quasi-experiment that compared HIVST to the standard of care (SoC). Studies with sufficient data were aggregated using meta-analysis on RevMan 5.4 at a 95% confidence interval. Cochrane's Q test was used to assess heterogeneity between the studies, while Higgins and Thompson's I2 was used to quantify heterogeneity. Subgroup analyses were conducted to identify the source of heterogeneity. Of the 2669 articles obtained from the databases, only 15 studies were eligible for this review, and eight were included in the final meta-analysis. Overall, linkage to care was similar between the HIVST arm and SoC (effect size: 0.92 [0.45-1.86]; I2: 51%; p: 0.04). In the population subgroup analysis, female sex workers (FSWs) in the HIVST arm were significantly linked to care compared to the SoC arm (effect size: 0.53 [0.30-0.94]; I2: 0%; p: 0.41). HIVST interventions did not significantly improve ART initiation in the HIVST arm compared to the SoC arm (effect size: 0.90 [0.45-1.79]; I2: 74%; p: < 0.001). We found that more male partners of women living with HIV in the SoC arm initiated PrEP compared to partners in the HIVST arm. The meta-analysis showed no difference between the HIVST and SoC arm regarding the number of clients (effect size: - 0.66 [1.35-0.02]; I2: 64%; p: 0.09) and non-clients FSWs see per night (effect size: - 1.45 [- 1.45 to 1.38]; I2: 93%; p: < 0.001). HIVST did not reduce the use of condoms during insertive or receptive condomless anal intercourse among MSM. HIVST does not improve linkage to care in the general population but does among FSWs. HIVST intervention does not improve linkage to ART nor significantly stimulate healthy sexual behaviors among priority groups. The only RCT that linked HIVST to PrEP found that PrEP uptake was higher among partners of women living with HIV in the SoC arm than in the HIVST arm. More RCTs among priority groups are needed, and the influence of HIVST on PrEP uptake should be further investigated.

Trauma-Informed HIV Care Interventions: Towards a Holistic Approach.

PURPOSE OF REVIEW: The prevalence of trauma is higher among people living with HIV compared to the general population and people living without HIV. Trauma may be a major barrier in attaining HIV treatment outcomes, such as linkage to HIV care, engagement in HIV care, adherence to antiretroviral therapy (ART), and viral suppression. The purpose of this review was to highlight trauma-informed interventions that are geared towards improving treatment outcomes among people living with HIV. RECENT FINDINGS: Recent studies suggest that a trauma-informed approach to developing interventions may help to improve treatment outcomes, such as engagement in care and adherence to ART. However, studies have also shown that depending on the operationalization of usual care, a trauma-informed approach may result in similar outcomes. Very few studies have examined the impact of trauma-informed interventions on HIV care and treatment outcomes. Additional research is needed on the acceptability, feasibility, and efficacy of trauma-informed interventions among affected populations such as older adults, and racial/ethnic and sexual minorities living with HIV.

Acceptability of a tablet-based application to support early HIV testing among men in rural KwaZulu-Natal, South Africa: a mixed method study.

Uptake of HIV testing remains low among men in South Africa. As part of a trial, we assessed the acceptability of a theoretically derived and adapted tablet-based-application (EPIC-HIV1) in rural South Africa. We conducted 20 in-depth interviews with men aged ≥18 years and offered a tablet-based survey to all men aged ≥15 years who received EPIC-HIV1 (Sep-Dec 2018). We conducted a descriptive analysis of the survey and used Self-Determination Theory (SDT) to guide our thematic analysis. A total of 232/307 (75%) completed the survey, 55% of whom were aged 15-24 years. 96%[ CI: 92.8-98.2%; n = 223] found EPIC-HIV1 acceptable and 77% [95% CI: 71.8-82.6%; n = 179] found it user-friendly. 222 [96%] reported that EPIC-HIV1 motivated them to test; 83% (192/232) tested for HIV, of which 33% (64/192) were first time testers. Those who did not consent (n = 40) were more likely to have had an HIV-positive test result. Participants reported that the app boosted their confidence to test. However, they were unsure that the app would help them overcome barriers to test in local clinics. Given reach and usability, an adapted SDT male-tailored app was found to be acceptable and could encourage positive health-seeking behavioural change among men.

Thetha Nami: participatory development of a peer-navigator intervention to deliver biosocial HIV prevention for adolescents and youth in rural South Africa.

BACKGROUND: Despite effective biomedical tools, HIV remains the largest cause of morbidity/mortality in South Africa - especially among adolescents and young people. We used community-based participatory research (CBPR), informed by principles of social justice, to develop a peer-led biosocial intervention for HIV prevention in KwaZulu-Natal (KZN). METHODS: Between March 2018 and September 2019 we used CBPR to iteratively co-create and contextually adapt a biosocial peer-led intervention to support HIV prevention. Men and women aged 18-30 years were selected by community leaders of 21 intervention implementation areas (izigodi) and underwent 20 weeks of training as peer-navigators. We synthesised quantitative and qualitative data collected during a 2016-2018 study into 17 vignettes illustrating the local drivers of HIV. During three participatory intervention development workshops and community mapping sessions, the peer-navigators critically engaged with vignettes, brainstormed solutions and mapped the components to their own izigodi. The intervention components were plotted to a Theory of Change which, following a six-month pilot and process evaluation, the peer-navigators refined. The intervention will be evaluated in a randomised controlled trial ( NCT04532307 ). RESULTS: Following written and oral assessments, 57 of the 108 initially selected participated in two workshops to discuss the vignettes and co-create the Thetha Nami (`talk to me'). The intervention included peer-led health promotion to improve self-efficacy and demand for HIV prevention, referrals to social and educational resources, and aaccessible youth-friendly clinical services to improve uptake of HIV prevention. During the pilot the peer-navigators approached 6871 young people, of whom 6141 (89%) accepted health promotion and 438 were linked to care. During semi-structured interviews peer-navigators described the appeal of providing sexual health information to peers of a similar age and background but wanted to provide more than just "onward referral". In the third participatory workshop 54 peer-navigators refined the Thetha Nami intervention to add three components: structured assessment tool to tailor health promotion and referrals, safe spaces and community advocacy to create an enabling environment, and peer-mentorship and navigation of resources to improve retention in HIV prevention. CONCLUSION: Local youth were able to use evidence to develop a contextually adapted peer-led intervention to deliver biosocial HIV prevention.

Exploring People's Candidacy for Mobile Health-Supported HIV Testing and Care Services in Rural KwaZulu-Natal, South Africa: Qualitative Study.

BACKGROUND: The use of mobile communication technologies (mHealth: mobile health) in chronic disease management has grown significantly over the years. mHealth interventions have the potential to decentralize access to health care and make it convenient, particularly in resource-constrained settings. It is against this backdrop that we aimed to codevelop (with potential users) a new generation of mobile phone-connected HIV diagnostic tests and Web-based clinical care pathways needed for optimal delivery of decentralized HIV testing, prevention, and care in low- and middle-income countries. OBJECTIVE: The aim of this study was to understand ways in which an mHealth intervention could be developed to overcome barriers to existing HIV testing and care services and promote HIV self-testing and linkage to prevention and care in a poor, HIV hyperendemic community in rural KwaZulu-Natal, South Africa. METHODS: A total of 54 in-depth interviews and 9 focus group discussions were conducted with potential users (including health care providers) in 2 different communities. Theoretically informed by the candidacy framework, themes were identified from the interview transcripts, manually coded, and thematically analyzed. RESULTS: Participants reported barriers, such as fear of HIV identity, stigma, long waiting hours, clinic space, and health care workers' attitudes, as major impediments to effective uptake of HIV testing and care services. People continued to reassess their candidacy for HIV testing and care services on the basis of their experiences and how they or others were treated within the health systems. Despite the few concerns raised about new technology, mobile phone-linked HIV testing was broadly acceptable to potential users (particularly men and young people) and providers because of its privacy (individual control of HIV testing over health provider-initiated testing), convenience (individual time and place of choice for HIV testing versus clinic-based testing), and time saving. CONCLUSIONS: Mobile phone-connected HIV testing and Web-based clinical care and prevention pathways have the potential to support access to HIV prevention and care, particularly for young people and men. Although mHealth provides a way for individuals to test their candidacy for HIV services, the barriers that can make the service unattractive at the clinic level will also need to be addressed if potential demand is to turn into actual demand.

Barriers and facilitators to pre-exposure prophylaxis uptake among Black/African American men who have sex with other men in Iowa: COM-B model analysis.

Background: In Iowa, men who have sex with men (MSM) accounted for 54% of persons with HIV in 2022 and Non-Hispanic Black/African Americans were over 10 times more likely to be diagnosed with HIV than Non-Hispanic white Iowans. To address this disparity in HIV incidence and prevalence, the United States (US) government ending the HIV epidemic (EHE) initiative seeks to expand pre-exposure prophylaxis (PrEP) coverage across the United States. Recent data showed that PrEP coverage is suboptimal in Iowa (a rural state), and Black Iowans were less likely to engage with PrEP services. Objectives: Using capability, opportunity, motivation and behavior (COM-B) model for behavior change, this study sought to identify the key barriers and facilitators to PrEP uptake among Black/African American MSM in small urban areas in Iowa. Design: This was a phenomenological study aimed to explore subjective views of Black MSM on PrEP use. Methods: In-depth semistructured interviews were conducted with 12 Black MSM aged 20-42 years in two small urban counties. Broad themes identified from the interview transcripts were analyzed inductively and mapped onto the COM-B constructs deductively. Results: Results showed that barriers to PrEP uptake were closely associated with five (of six) COM-B subcomponents: physical capability, psychological capability, social opportunity, reflective motivation, and automatic motivation. The thematized barriers were (1) lack of medical insurance; (2) limited PrEP awareness; (3) PrEP stigma; (4) fear of distrust among partners; (5) anticipated side effects; and (6) doubt about PrEP effectiveness. Similarly, facilitators to PrEP uptake were aligned with four subcomponents of COM-B model: physical capability, psychological capability, social opportunity, and physical opportunity. The thematized facilitators were (1) increased PrEP awareness; (2) PrEP access without discrimination; (3) state provision of PrEP to uninsured; and (4) physicians buy-in and recommendation. No motivation-related facilitators were reported. Conclusion: To reduce the current disparity in HIV incidence and to achieve the EHE goals of expanding PrEP coverage in Iowa, efforts should be directed toward the provision of low-cost or free PrEP services, healthcare providers' training on cultural competence, and the development of culturally appropriate strategies to deliver PrEP to the Black MSM community.

Investigating the emigration intention of health care workers: A cross-sectional study.

AIMS: To (1) explore the intramigration experience of HCWs within Nigeria, (2) explore the migration intention of health care workers (HCWs) in Nigeria and (3) identify the predictors of migration intention among HCWs in Nigeria. DESIGN: Cross-sectional study. METHODS: The online survey was used to collect data from 513 HCWs in Nigeria between May and June 2023. Crude and adjusted logistic regression were used to identify factors associated with emigration intention. Analyses were performed on SPSS version 26 at a 95% confidence interval. RESULTS: The study found that 34.4% had intramigration experience, and the rate of intention to emigrate to work in another country was 80.1%. The United Kingdom was the most preferred destination (109 HCWs), followed by Canada (92 HCWs) and the United States (82 HCWs). At the multivariate level, emigration intention was associated with the experience of burnout and duration of practice as a HCW. Nurses had higher emigration intentions than medical doctors. CONCLUSIONS: Many HCWs in Nigeria appear to have emigration intent, and nurses are more likely to be willing to migrate than doctors. The Nigerian government may want to explore strategies to reverse the emigration intent of the HCWs in Nigeria.

Increasing HIV testing and linkage to care among men in rural South Africa using conditional financial incentives and a decision support app: A process evaluation.

Men in sub-Saharan Africa are less likely to accept HIV testing and link to HIV care than women. We conducted a trial to investigate the impact of conditional financial incentives and a decision support application, called EPIC-HIV, on HIV testing and linkage to care. We report the findings of the trial process evaluation to explore whether the interventions were delivered as intended, identify mechanisms of impact and any contextual factors that may have impacted the trial outcomes. Between August 2018 and March 2019, we conducted in-depth interviews and focus group discussions with trial participants (n = 31) and staff (n = 14) to examine views on the implementation process, participant responses to the interventions and the external factors that may have impacted the implementation and outcomes of the study. Interviews were audio-recorded, transcribed, and translated where necessary, and thematically analyzed using ATLAS-ti and NVivo. Both interventions were perceived to be acceptable and useful by participants and implementers. EPIC-HIV proved challenging to implement as intended because it was difficult to ensure consistent use of earphones, and maintenance of privacy. Some participants struggled to navigate the EPIC-HIV app independently and select stories that appealed to them without support. Some participants stopped exploring the app before the end, resulting in an incomplete use of EPIC-HIV. While the financial incentive was implemented as intended, there were challenges with eligibility. The convenience and privacy of home testing influenced the uptake of HIV testing. Contextual barriers including fear of HIV stigma and disclosure if diagnosed with HIV, and expectations of poor treatment in clinics may have inhibited linkage to care. Financial incentives were relatively straightforward to implement and increased uptake of home-based rapid HIV testing but were not sufficient as a 'stand-alone' intervention. Barriers like fear of stigma should be addressed to facilitate linkage to care.

The impact of a conditional financial incentive on linkage to HIV care: Findings from the HITS cluster randomized clinical trial in rural South Africa.

Introduction: HIV elimination requires innovative approaches to ensure testing and immediate treatment provision. We investigated the effectiveness of conditional financial incentives on increasing linkage to HIV care in a 2×2 factorial cluster randomized controlled trial-Home-Based Intervention to Test and Start (HITS) - in rural South Africa. Methods: Of 45 communities in uMkhanyakude, KwaZulu-Natal, 16 communities were randomly assigned to the arms to receive financial incentives for home-based HIV counseling and testing (HBHCT) and linkage to care within 6 weeks (R50 [US$3] food voucher each) and 29 communities to the arms without financial incentives. We examined linkage to care (i.e., initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 6 weeks of a home visit, the eligibility period to receive the second financial incentive. Linkage to care was ascertained from individual clinical records. Intention-to-treat analysis (ITT) was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., male-targeted HIV-specific decision support app) and clustering of standard errors at the community level. Results: Among 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, which resulted in 122 HIV-positive tests. Of these, 27 linked to care within 6 weeks of HBHCT. Additionally, of eligible men who did not receive HBHCT, 66 linked to care. In the ITT analysis, the proportion of linkage to care among men did not differ in the arms which received financial incentives and those without financial incentives (adjusted Risk Ratio [aRR]=0.78, 95% CI: 0.51-1.21). Among 19,884 eligible women, 29.1% received HBHCT, which resulted in 375 HIV-positive tests. Of these, 75 linked to care. Among eligible women who did not receive HBHCT, 121 linked to care within 6 weeks. Women in the financial incentive arms had a significantly higher probability of linkage to care, compared to those in the arms without financial incentives (aRR=1.50; 95% CI: 1.03-2.21). Conclusion: While a small once-off financial incentive did not increase linkage to care among men during the eligibility period of 6 weeks, it significantly improved linkage to care among women over the same period. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

Effect of a male-targeted digital decision support application aimed at increasing linkage to HIV care among men: Findings from the HITS cluster randomized clinical trial in rural South Africa.

Introduction: Linkage to HIV care remains suboptimal among men. We investigated the effectiveness of a male-targeted HIV-specific decision support app, Empowering People through Informed Choices for HIV (EPIC-HIV), on increasing linkage to HIV care among men in rural South Africa. Methods: Home-Based Intervention to Test and Start (HITS) was a multi-component cluster-randomized controlled trial among 45 communities in uMkhanyakude, KwaZulu-Natal. The development of EPIC-HIV was guided by self-determination theory and human-centered intervention design to increase intrinsic motivation to seek HIV testing and care among men. EPIC-HIV was offered in two stages: EPIC-HIV 1 at the time of home-based HIV counseling and testing (HBHCT), and EPIC-HIV 2 at 1 month after positive HIV diagnosis. Sixteen communities were randomly assigned to the arms to receive EPIC-HIV, and 29 communities to the arms without EPIC-HIV. Among all eligible men, we compared linkage to care (initiation or resumption of antiretroviral therapy after >3 months of care interruption) at local clinics within 1 year of a home visit, which was ascertained from individual clinical records. Intention-to-treat analysis was performed using modified Poisson regression with adjustment for receiving another intervention (i.e., financial incentives) and clustering at the community level. We also conducted a satisfaction survey for EPIC-HIV 2. Results: Among all 13,894 eligible men (i.e., ≥15 years and resident in the 45 communities), 20.7% received HBHCT, resulting in 122 HIV-positive tests. Among these, 54 men linked to care within 1 year after HBHCT. Additionally, of the 13,765 eligible participants who did not receive HBHCT or received HIV-negative results, 301 men linked to care within 1 year. Overall, only 13 men received EPIC-HIV 2. The proportion of linkage to care did not differ in the arms assigned to EPIC-HIV compared to those without EPIC-HIV (adjusted risk ratio=1.05; 95% CI:0.86-1.29). All 13 men who used EPIC-HIV 2 reported the app was acceptable, user-friendly, and useful for getting information on HIV testing and treatment. Conclusion: Reach was low although acceptability and usability of the app was very high among those who engaged with it. Enhanced digital support applications could form part of interventions to increase knowledge of HIV treatment for men. Clinical Trial Number: ClinicalTrials.gov # NCT03757104.

Population impacts of conditional financial incentives and a male-targeted digital decision support application on the HIV treatment cascade in rural KwaZulu Natal: findings from the HITS cluster randomized clinical trial.

INTRODUCTION: In South Africa, the HIV care cascade remains suboptimal. We investigated the impact of small conditional financial incentives (CFIs) and male-targeted HIV-specific decision-support application (EPIC-HIV) on the HIV care cascade. METHODS: In 2018, in uMkhanyakude district, 45 communities were randomly assigned to one of four arms: (i) CFI for home-based HIV testing and linkage to care within 6 weeks (R50 [US$3] food voucher each); (ii) EPIC-HIV which are based on self-determination theory; (iii) both CFI and EPIC-HIV; and (iv) standard of care. EPIC-HIV consisted of two components: EPIC-HIV 1, provided to men through a tablet before home-based HIV testing, and EPIC-HIV 2, offered 1 month later to men who tested positive but had not yet linked to care. Linking HITS trial data to national antiretroviral treatment (ART) programme data and HIV surveillance programme data, we estimated HIV status awareness after the HITS trial implementation, ART status 3 month after the trial and viral load suppression 1 year later. Analysis included all known individuals living with HIV in the study area including those who did not participated in the HITS trial. RESULTS: Among the 33,778 residents in the study area, 2763 men and 7266 women were identified as living with HIV by the end of the intervention period and included in the analysis. After the intervention, awareness of HIV-positive status was higher in the CFI arms compared to non-CFI arms (men: 793/908 [87.3%] vs. 1574/1855 [84.9%], RR = 1.03 [95% CI: 0.99-1.07]; women: 2259/2421 [93.3%] vs. 4439/4845 [91.6%], RR = 1.02 [95% CI: 1.00-1.04]). Three months after the intervention, no differences were found for linkage to ART between arms. One year after the intervention, only 1829 viral test results were retrieved. Viral suppression was higher but not significant in the EPIC-HIV intervention arms among men (65/99 [65.7%] vs. 182/308 [59.1%], RR = 1.11 [95% CI: 0.88-1.40]). CONCLUSIONS: Small CFIs can contribute to achieve the first step of the HIV care cascade. However, neither CFIs nor EPIC-HIV was sufficient to increase the number of people on ART. Additional evidence is needed to confirm the impact of EPIC-HIV on viral suppression.

Does adherence to antiretroviral therapy differ by place of residence in Nigeria? A systematic review and meta-analysis protocol.

INTRODUCTION: Retention in care is still a significant challenge in the HIV treatment cascade and varies extensively across regions, leading to poor adherence to antiretroviral therapy (ART). Several factors across different socioecological levels, such as health and community-level factors, inhibit ART adherence among people living with HIV (PLWH) in Nigeria. This review seeks to ask whether adherence to ART differs by place of residence in Nigeria. METHOD AND ANALYSIS: This systematic review and meta-analysis will follow the updated Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search PubMed, SCOPUS, CINAHL, Web of Science, MEDLINE (Ovid) and Google Scholar from onset to 30 April 2023. We will include only quantitative observational studies or mixed-method studies that measured the association between place of residence (urban and rural) and adherence to ART among PLWH aged ≥15 years. Title and abstract screening, full-text screening, data extraction and quality assessment will be done by two reviewers independently. A third reviewer will resolve disagreements. We will extract the author's name and year of publication, study aim(s), participant's characteristics, sample size, sampling method, region and state, adherence definition and adherence level in urban and rural areas. Data will be analysed with Review Manager V.5.4. The Q statistical test will be used to assess between-study heterogeneity, while Higgins and Thompson's I2 will be used to quantify the heterogeneity level. Several subgroups and sensitivity analyses will be conducted. ETHICS AND DISSEMINATION: Ethical approval is not warranted for this study since primary published data will be utilised. The findings of this review will be published in a high-impact peer-reviewed journal and presented at a conference. PROSPERO REGISTRATION NUMBER: CRD42022371965.

Determinants of social support among people living with HIV in Nigeria-a multicenter cross-sectional study.

Background: More than 38.4 million people were living with HIV worldwide in 2021. Sub-Saharan Africa bears two-thirds of the burden, with Nigeria having nearly two million people living with HIV (PLWH). Social support from social networks such as family and friends improve the quality of life, and reduces enacted and perceived stigma, but social support for PLWH remains suboptimal in Nigeria. This study aimed to assess the prevalence of social support and associated factors among PLWH in Nigeria and to test whether stigma reduces types of social support. Methods: This cross-sectional study was conducted in Lagos State, Nigeria, between the months of June and July 2021. A total of 400 PLWH were surveyed across six health facilities providing antiretroviral therapy. Social support (family, friends, and significant others) and stigma were measured with the Multidimensional Scale of Perceived Social Support and Berger's HIV Stigma Scale, respectively. Binary logistic regression was used to identify determinants of social support. Results: More than half (50.3%) of the respondents had adequate social support overall. The prevalence of family, friends, and significant others support was 54.3, 50.5, and 54.8%, respectively. Stigma (Adjusted Odds Ratio [AOR]: 0.945; 95% Confidence Interval [CI]: 0.905-0.987) was negatively associated with adequate friend support. Female gender (AOR: 6.411; 95% CI: 1.089-37.742), higher income (AOR: 42.461; 95% CI: 1.452-1241.448), and seropositive disclosure (AOR: 0.028; 95% CI: 0.001-0.719) were associated with adequate significant others support. Stigma (AOR:0.932; 95% CI: 0.883-0.983) was negatively associated with adequate support overall. Our findings corroborate the social support theory, as stigma reduces the chance of receiving social support. Conclusion: PLWH that enjoy support from families or friends were less likely to be affected by HIV-related stigma. More support is needed by PLWH from family, friends, and significant others to improve the quality of life and reduce stigma among PLWH in Lagos State.

Multidisciplinary approach to community engagement in global public health research.

  Recently, there has been a renewed interest in the role of community engagement in knowledge production and ethical issues such as 'helicopter research', indicating exploitative research activities of some researchers as well as short-term relationships with research communities especially in low- and middle-income countries. This approach is detrimental to both communities and the larger scientific community as this may breed mistrust. Major institutions such as the National Institute of Health and Care Research in the United Kingdom have highlighted the importance of community engagement as a tool to improve the reach, quality, and impact of the research by incorporating the voices and concerns of marginalized communities. Similarly, in its 2022 guidance, the American Society for Human Genetics (ASGH) highlights the need to address underrepresentation in genomics research through community engagement. Establishing ethical and meaningful long-term relationships can be challenging especially for researchers who are not members of the community or those from other countries. This article describes how 'community-engaged research' can address some ethical challenges in global public health in different cultural settings.

Increased investment in Universal Health Coverage in Sub-Saharan Africa is crucial to attain the Sustainable Development Goal 3 targets on maternal and child health.

Universal Health Coverage (UHC) is considered a strategic component of the Sustainable Development Goals specifically for goal 3 which seeks to ensure healthy lives and promote well-being for all, where all individuals and communities have equal access to key promotive, preventive, curative, and rehabilitative health interventions without financial constraints. Despite Sub-Saharan Africa (SSA) accelerated gains on the UHC effective coverage of 2.6% between 2010 to 2019, many countries in the sub-region show lagging performance. The major challenges faced in attaining the UHC in many countries include inadequate capital investment for health and their equitable distribution, fiscal space to finance UHC policies and programs. This paper discusses how increased investment in Universal Health Coverage in SSA is crucial to attain the Sustainable Development Goal 3 targets on maternal and child health. The Universal Health Monitoring Framework (UHMF) is adopted in this paper as the underpinning framework. The delivery of essential maternal and child health services to achieve UHC in SSA requires strategic actions such as policies, plans and programs with focus on maternal and child health. We report findings from recently published papers that clearly highlighted the strong connection between health insurance coverage and maternal health care utilization. Strategic actions such as implementing national health insurance scheme (NHIS) that directly incorporates free maternal and child health care could strengthen maternal health services and transform health systems in order to achieve UHC in SSA. We argue that achieving the SDG 3 on maternal and child health will only be possible if significant progress in made in increasing UHC. This is key to ensure optimal maternal health care utilization, and consequently reducing maternal and child deaths.

Measurement of and training for NCD guideline implementation in LMICs: a scoping review protocol.

INTRODUCTION: Globally, non-communicable diseases (NCDs) are the leading causes of morbidity and mortality with an estimated 41 million deaths (74% of all global deaths) annually. Despite the WHO's Global Action Plan for the Prevention and Control of NCDs since 2013, progress on implementation of the guidelines has been slow. Although research has shown success of some NCD prevention and treatment interventions, there is a dearth of research on NCD care delivery approaches, cost-effectiveness and larger implementation research, especially in low/middle-income countries (LMICs). The objective of this scoping review is to identify the existing variation in how, why and by whom implementation of NCD guidelines is measured as part of implementation research or non-research programme improvement. METHODS AND ANALYSIS: Using the methods established by Arksey and O'Malley, the search strategy was developed in consultation with a research librarian together with stakeholder feedback from content experts. We will apply the search to multiple electronic databases and grey literature sources. Two reviewers will independently screen title and abstract for inclusion followed by a full-text screening and all included records will be abstracted using a standardised tool that will be piloted with a sample of articles before application to all records. We will conduct a narrative synthesis of abstracted data and simple quantitative descriptive statistics. DISSEMINATION: The results will enable stakeholders in LMICs to leverage existing tools and resources for implementation and ongoing evaluation of NCD guidelines, to improve education and capacity building, and ultimately NCD care across the lifespan.

The Impacts of Stigma Against Sexual Minority Men Within and Between Various Socioecological Levels: Breaking the Vicious Cycle in Zambia.

Sexual minority men (SMM) face persistent stigma in Zambia. From a holistic perspective, we aim to explore its impacts within and between multiple socioecological levels, demonstrating how their interactions create a vicious cycle of barriers to the well-being of SMM. In-depth interviews were conducted with 20 purposively recruited SMM from Lusaka, Zambia. All interviews were audio-recorded, after written consent, transcribed verbatim, and iteratively coded employing inductive (i.e., data-driven) approaches for thematic analysis using NVivo. Results suggest three key themes: (1) interpersonal socially perpetuated sexual minority stigma (SMS); (2) multidirectional interactions between psychosocial well-being and risk-taking behaviors; and (3) institutionally perpetuated SMS as a barrier to seeking and receiving health care. SMS permeates across all levels of the socioecological model to negatively impact the psychosocial well-being of SMM while acting also as a barrier to accessing HIV prevention and care. Our study necessitates structural public health intervention to decrease stigma and discrimination against SMM in Zambia, in efforts to increase their psychosocial well-being as well as their access to and utilization of HIV care by breaking the vicious cycle of SMS that pervades through the intrapersonal, interpersonal, and institutional levels of the socioecological model.

Impact of family networks on uptake of health interventions: evidence from a community-randomized control trial aimed at increasing HIV testing in South Africa.

INTRODUCTION: While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network. METHODS: The "Home-Based Intervention to Test and Start" (HITS) was a 2×2 factorial community-randomized controlled trial in Umkhanyakude, KwaZulu-Natal, South Africa, embedded in the Africa Health Research Institute's population-based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro-incentive and a male-targeted HIV-specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro-incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co-residents, a socio-centric family network was constructed among HITS-eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level. RESULTS: Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3-7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9-22.3). The difference in efficacy was statistically significant (21.1-6.5 = 14.6%; 95% CI: 9.3-19.9). CONCLUSIONS: Micro-incentives appear to have synergistic effects when distributed within family networks. These effects support family network-based approaches for the design of health interventions.

Adaptation and pre-test of a shortened Stepping Stones and Creating Futures intervention focused on HIV for young men in rural South Africa.

Men's engagement in HIV prevention and treatment is suboptimal, including in South Africa. We sought to address this through adapting an evidence-based intervention, Stepping Stones and Creating Futures (SSCF), to strengthen its HIV content and provide a more scalable (shorter) intervention in rural South Africa. We then conducted a mixed methods pre-test of the intervention among young men aged 18-35 years. To adapt SSCF, we reviewed the current evidence base and worked with male Peer Navigators to update the SSCF theory of change (ToC) and manual. The revised intervention was ~45 hours (9 sessions) as opposed to ~63 hours and included a greater focus on HIV prevention and treatment technologies. Overall, 64% (n = 60) of men approached agreed to participate in the intervention, uptake (attending one session) among those who agreed was n = 35(58%) and retention (attending 6 or more sessions) was n = 25(71%). Qualitative data emphasized the intervention was acceptable, with young men describing it as something they liked. The qualitative data also broadly supported the intervention ToC, including the normalization of HIV in men's lives, and the importance of health for men in achieving their life goals. However, it also highlighted the need to focus more on HIV-related stigma and fear, and the importance of HIV self-testing kits in encouraging testing. We revised the ToC and manual in light of this data. The adapted SSCF is acceptable and supports the ToC. Next steps is an evaluation to look at effectiveness of the intervention.

Task shifting and task sharing in the health sector in sub-Saharan Africa: evidence, success indicators, challenges, and opportunities.

This review explores task shifting and task sharing in sub-Saharan African healthcare to address workforce shortages and cost-effectiveness. Task shifting allocates tasks logically, while task sharing involves more workers taking on specific duties. Challenges include supply chain issues, pay inadequacy, and weak supervision. Guidelines and success measures are lacking. Initiating these practices requires evaluating factors and ensuring sustainability. Task shifting saves costs but needs training and support. Task sharing boosts efficiency, enabling skilled clinicians to contribute effectively. To advance task shifting and sharing in the region, further research is needed to scale up effective initiatives. Clear success indicators, monitoring, evaluation, and learning plans, along with exploration of sustainability and appropriateness dimensions, are crucial elements to consider.