Protocol for a parallel group, two-arm, superiority cluster randomised trial to evaluate a community-level complementary-food safety and hygiene and nutrition intervention in Mali: the MaaCiwara study (version 1.3; 10 November 2022).

BACKGROUND: Diarrhoeal disease remains a significant cause of morbidity and mortality among the under-fives in many low- and middle-income countries. Changes to food safety practices and feeding methods around the weaning period, alongside improved nutrition, may significantly reduce the risk of disease and improve development for infants. We describe a protocol for a cluster randomised trial to evaluate the effectiveness of a multi-faceted community-based educational intervention that aims to improve food safety and hygiene behaviours and enhance child nutrition. METHODS: We describe a mixed-methods, parallel group, two-arm, superiority cluster randomised controlled trial with baseline measures. One hundred twenty clusters comprising small urban and rural communities will be recruited in equal numbers and randomly allocated in a 1:1 ratio to either treatment or control arms. The community intervention will be focussed around an ideal mother concept involving all community members during campaign days with dramatic arts and pledging, and follow-up home visits. Participants will be mother-child dyads (27 per cluster period) with children aged 6 to 36 months. Data collection will comprise a day of observation and interviews with each participating mother-child pair and will take place at baseline and 4 and 15 months post-intervention. The primary analysis will estimate the effectiveness of the intervention on changes to complementary-food safety and preparation behaviours, food and water contamination, and diarrhoea. Secondary outcomes include maternal autonomy, enteric infection, nutrition, child anthropometry, and development scores. A additional structural equation analysis will be conducted to examine the causal relationships between the different outcomes. Qualitative and health economic analyses including process evaluation will be done. CONCLUSIONS: The trial will provide evidence on the effectiveness of community-based behavioural change interventions designed to reduce the burden of diarrhoeal disease in the under-fives and how effectiveness varies across different contexts. TRIAL REGISTRATION: ISRCTN14390796. Registration date December 13, 2021.

Stakeholder engagement in the development of genetically modified mosquitoes for malaria control in West Africa: lessons learned from 10 years of Target Malaria's work in Mali.

From 2012 to 2023, the Malaria Research and Training Center (MRTC), based out of the University of Sciences, Techniques and Technologies of Bamako (USTTB), was part of the Target Malaria research consortium working towards developing novel gene drive-based tools for controlling populations of malaria vector mosquitoes. As part of this work, Target Malaria Mali has undertaken a range of in-depth engagement activities with the communities where their research is conducted and with other stakeholders nationally. These activities were meant to ensure that the project's activities took place with the agreement of those communities, and that those communities were able to play a role in shaping the project's approach to ensure that its eventual outcomes were in line with their needs and concerns. This paper aims to conduct a critical assessment of those 10 years of stakeholder engagement in order to identify good practices which can inform future engagement work on gene drive research in West Africa. It sets out a range of approaches and practices that enabled the Target Malaria Mali team to engage a variety of stakeholders, to share information, collect feedback, and determine community agreement, in a manner that was inclusive, effective, and culturally appropriate. These can be useful tools for those working on gene drive research and other area-wide vector control methods in West African contexts to ensure that their research is aligned with the interests of the communities who are intended to be its ultimate beneficiaries, and to allow those communities to play a meaningful role in the research process.

Water, sanitation, and hygiene access in Senegal and its impact on the occurrence of diarrhea in children under 5 years old.

Diarrheal diseases are the second leading cause of child mortality worldwide, occurring in about one in every nine child deaths, and were associated with water, sanitation, and hygiene (WASH) access. In this study, we provided an overview of WASH indicators' evolution from 2000 to 2017 and their impact on the occurrence of diarrhea in children under 5 years old in Senegal. It was a retrospective cross-sectional study, in which we did a secondary analysis of data from the Joint Monitoring Program (JMP) for water supply and sanitation and from the Senegal Demographic and Health Survey 2018. Our results showed that access to safely managed services increased by 18.1 and 19.1%, respectively, for water and sanitation. The prevalence of diarrhea estimated at 18.16% was associated with straining water through a cloth (adjusted odds ratio (AOR) [95% confidence interval (CI)]: 1.21 [1.00-1.45]) and getting water supplies from a source not located in a dwelling (AOR [95% CI]: 1.59 [1.21-2.09]). The prevalence of diarrhea among children under 5 years old was still relatively high in Senegal and was significantly associated with a lack of WASH access. Although the latter continues to increase, additional efforts to make water safer to drink will significantly reduce the occurrence of diarrheal diseases among children under 5 years old in Senegal.

Spillover, hybridization, and persistence in schistosome transmission dynamics at the human-animal interface.

Zoonotic spillover and hybridization of parasites are major emerging public and veterinary health concerns at the interface of infectious disease biology, evolution, and control. Schistosomiasis is a neglected tropical disease of global importance caused by parasites of the Schistosoma genus, and the Schistosoma spp. system within Africa represents a key example of a system where spillover of animal parasites into human populations has enabled formation of hybrids. Combining model-based approaches and analyses of parasitological, molecular, and epidemiological data from northern Senegal, a region with a high prevalence of schistosome hybrids, we aimed to unravel the transmission dynamics of this complex multihost, multiparasite system. Using Bayesian methods and by estimating the basic reproduction number (R0 ), we evaluate the frequency of zoonotic spillover of Schistosoma bovis from livestock and the potential for onward transmission of hybrid S. bovis × S. haematobium offspring within human populations. We estimate R0 of hybrid schistosomes to be greater than the critical threshold of one (1.76; 95% CI 1.59 to 1.99), demonstrating the potential for hybridization to facilitate spread and establishment of schistosomiasis beyond its original geographical boundaries. We estimate R0 for S. bovis to be greater than one in cattle (1.43; 95% CI 1.24 to 1.85) but not in other ruminants, confirming cattle as the primary zoonotic reservoir. Through longitudinal simulations, we also show that where S. bovis and S. haematobium are coendemic (in livestock and humans respectively), the relative importance of zoonotic transmission is predicted to increase as the disease in humans nears elimination.

COVID-19 economic vulnerability and resilience indexes: Global evidence.

This study complements the extant literature by constructing COVID-19 economic vulnerability and resilience indexes using a global sample of 150 countries categorised into four principal regions: Africa, Asia-Pacific and the Middle East, America, and Europe. Seven variables are used for the vulnerability index and nine for the resilience index. Both regions and sampled countries are classified in terms of the two proposed and computed indexes. The classification of countries is also provided in terms of four scenarios pertaining to vulnerability and resilience characteristics: low vulnerability-low resilience, high vulnerability-low resilience, high vulnerability-high resilience, and low vulnerability-high resilience to illustrate sensitive, severe, asymptomatic, and best cases, respectively. The findings are relevant to policy makers, especially as they pertain to decision-making in resource allocation in the fight against the global pandemic.

Hybridized Zoonotic Schistosoma Infections Result in Hybridized Morbidity Profiles: A Clinical Morbidity Study amongst Co-Infected Human Populations of Senegal.

Hybridization of infectious agents is a major emerging public and veterinary health concern at the interface of evolution, epidemiology, and control. Whilst evidence of the extent of hybridization amongst parasites is increasing, their impact on morbidity remains largely unknown. This may be predicted to be particularly pertinent where parasites of animals with contrasting pathogenicity viably hybridize with human parasites. Recent research has revealed that viable zoonotic hybrids between human urogenital Schistosoma haematobium with intestinal Schistosoma species of livestock, notably Schistosoma bovis, can be highly prevalent across Africa and beyond. Examining human populations in Senegal, we found increased hepatic but decreased urogenital morbidity, and reduced improvement following treatment with praziquantel, in those infected with zoonotic hybrids compared to non-hybrids. Our results have implications for effective monitoring and evaluation of control programmes, and demonstrate for the first time the potential impact of parasite hybridizations on host morbidity.

Experimenting with co-development: A qualitative study of gene drive research for malaria control in Mali.

We investigate how technology 'co-development' (between researchers, stakeholders and local communities) is framed in practice by those developing gene drive mosquitos for malaria eradication. Our case study focuses on UK and Mali-based researchers planning to undertake the first field trials in Mali of gene drive mosquitos for malaria control. While they and the wider gene drive research community are explicitly committed to the principle of co-development, how this is framed and practiced is not clear. Through qualitative analysis of 34 interviews complemented by observation and documentary research conducted in 2018, we identify and compare ten framings of co-development mobilised by UK and Malian researchers and stakeholders. For Malians, co-development reflected Mali's broader socio-political context and a desire for African scientific independence and leadership. It was mobilised to secure community and stakeholder support for gene drive mosquito field trials, through outreach, building local scientific capacity and developing those institutions (e.g. regulatory) necessary for field trials to go ahead. For UK participants, co-development was also concerned with scientific capacity-building, knowledge exchange between researchers, and stakeholder and community outreach to secure consent for field trials. Overall, our findings suggest co-development is opening up previously expert-dominated spaces as researchers attempt to take responsibility for the societal implications of their work. However, its main function is as a project management tool to enable and instrumentally support technological development, field trials and eventual deployment. This function extends into areas which are traditionally the responsibility of the state, such as regulatory development, facilitated by Mali's fragile political and economic situation. Paradoxically, co-development simultaneously depoliticises gene drive, masking power relations and closing down substantive debate and agency. Characterised by extreme poverty, conflict and weak institutions, Mali may become a site for technological experimentation where there is little interrogation of gene drive or its governance.

Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali.

BACKGROUND: In Mali, nomadic populations are spread over one third of the territory. Their lifestyle, characterized by constant mobility, excludes them from, or at best places them at the edge of, health delivery services. This study aimed to describe nomadic populations' characteristics, determine their perception on the current health services, and identify issues associated with community-based health interventions. METHODS: To develop a better health policy and strategic approaches adapted to nomadic populations, we conducted a cross-sectional study in the region of Timbuktu to describe the difficulties in accessing health services. The study consisted in administering questionnaires to community members in the communes of Ber and Gossi, in the Timbuktu region, to understand their perceptions of health services delivery in their settings. RESULTS: We interviewed 520 individuals, all members of the nomadic communities of the two study communes. Their median age was 38 years old with extremes ranging from 18 to 86 years old. Their main activities were livestock breeding (27%), housekeeping (26.4%), local trading (11%), farming (6%) and artisans (5.5%). The average distance to the local health center was 40.94 km and 23.19 km respectively in Gossi and Ber. In terms of barriers to access to health care, participants complained mainly about the transportation options (79.4%), the quality of provided services (39.2%) and the high cost of available health services (35.7%). Additionally, more than a quarter of our participants stated that they would not allow themselves to be examined by a health care worker of the opposite gender. CONCLUSION: This study shows that nomadic populations do not have access to community-based health interventions. A number of factors were revealed to be important barriers per these communities' perception including the quality of services, poverty, lifestyle, gender and current health policy strategies in the region. To be successful, future interventions should take these factors into account by adapting policies and methods.

Prevalence and distribution of schistosomiasis in human, livestock, and snail populations in northern Senegal: a One Health epidemiological study of a multi-host system.

BACKGROUND: Schistosomiasis is a neglected tropical disease of global medical and veterinary importance. As efforts to eliminate schistosomiasis as a public health problem and interrupt transmission gather momentum, the potential zoonotic risk posed by livestock Schistosoma species via viable hybridisation in sub-Saharan Africa have been largely overlooked. We aimed to investigate the prevalence, distribution, and multi-host, multiparasite transmission cycle of Haematobium group schistosomiasis in Senegal, West Africa. METHODS: In this epidemiological study, we carried out systematic surveys in definitive hosts (humans, cattle, sheep, and goats) and snail intermediate hosts, in 2016-18, in two areas of Northern Senegal: Richard Toll and Lac de Guiers, where transmission is perennial; and Barkedji and Linguère, where transmission is seasonal. The occurrence and distribution of Schistosoma species and hybrids were assessed by molecular analyses of parasitological specimens obtained from the different hosts. Children in the study villages aged 5-17 years and enrolled in school were selected from school registers. Adults (aged 18-78 years) were self-selecting volunteers. Livestock from the study villages in both areas were also randomly sampled, as were post-mortem samples from local abattoirs. Additionally, five malacological surveys of snail intermediate hosts were carried out at each site in open water sources used by the communities and their animals. FINDINGS: In May to August, 2016, we surveyed 375 children and 20 adults from Richard Toll and Lac de Guiers, and 201 children and 107 adults from Barkedji and Linguère; in October, 2017, to January, 2018, we surveyed 386 children and 88 adults from Richard Toll and Lac de Guiers, and 323 children and 85 adults from Barkedji and Linguère. In Richard Toll and Lac de Guiers the prevalence of urogenital schistosomiasis in children was estimated to be 87% (95% CI 80-95) in 2016 and 88% (82-95) in 2017-18. An estimated 63% (in 2016) and 72% (in 2017-18) of infected children were shedding Schistosoma haematobium-Schistosoma bovis hybrids. In adults in Richard Toll and Lac de Guiers, the prevalence of urogenital schistosomiasis was estimated to be 79% (52-97) in 2016 and 41% (30-54) in 2017-18, with 88% of infected samples containing S haematobium-S bovis hybrids. In Barkedji and Linguère the prevalence of urogenital schistosomiasis in children was estimated to be 30% (23-38) in 2016 and 42% (35-49) in 2017-18, with the proportion of infected children found to be shedding S haematobium-S bovis hybrid miracidia much lower than in Richard Toll and Lac de Guiers (11% in 2016 and 9% in 2017-18). In adults in Barkedji and Linguère, the prevalence of urogenital schistosomiasis was estimated to be 26% (17-36) in 2016 and 47% (34-60) in 2017-18, with 10% of infected samples containing S haematobium-S bovis hybrids. The prevalence of S bovis in the sympatric cattle population of Richard Toll and the Lac de Guiers was 92% (80-99), with S bovis also found in sheep (estimated prevalence 14% [5-31]) and goats (15% [5-33]). In Barkedji and Linguère the main schistosome species in livestock was Schistosoma curassoni, with an estimated prevalence of 73% (48-93) in sheep, 84% (61-98) in goats and 8% (2-24) in cattle. S haematobium-S bovis hybrids were not found in livestock. In Richard Toll and Lac de Guiers 35% of infected Bulinus spp snail intermediate hosts were found to be shedding S haematobium-S bovis hybrids (68% shedding S haematobium; 17% shedding S bovis); however, no snails were found to be shedding S haematobium hybrids in Barkedji and Linguère (29% shedding S haematobium; 71% shedding S curassoni). INTERPRETATION: Our findings suggest that hybrids originate in humans via zoonotic spillover from livestock populations, where schistosomiasis is co-endemic. Introgressive hybridisation, evolving host ranges, and wider ecosystem contexts could affect the transmission dynamics of schistosomiasis and other pathogens, demonstrating the need to consider control measures within a One Health framework. FUNDING: Zoonoses and Emerging Livestock Systems programme (UK Biotechnology and Biological Sciences Research Council, UK Department for International Development, UK Economic and Social Research Council, UK Medical Research Council, UK Natural Environment Research Council, and UK Defence Science and Technology Laboratory).

Multihost Transmission of Schistosoma mansoni in Senegal, 2015-2018.

In West Africa, Schistosoma spp. are capable of infecting multiple definitive hosts, a lifecycle feature that may complicate schistosomiasis control. We characterized the evolutionary relationships among multiple Schistosoma mansoni isolates collected from snails (intermediate hosts), humans (definitive hosts), and rodents (definitive hosts) in Senegal. On a local scale, diagnosis of S. mansoni infection ranged 3.8%-44.8% in school-aged children, 1.7%-52.6% in Mastomys huberti mice, and 1.8%-7.1% in Biomphalaria pfeifferi snails. Our phylogenetic framework confirmed the presence of multiple S. mansoni lineages that could infect both humans and rodents; divergence times of these lineages varied (0.13-0.02 million years ago). We propose that extensive movement of persons across West Africa might have contributed to the establishment of these various multihost S. mansoni clades. High S. mansoni prevalence in rodents at transmission sites frequented by humans further highlights the implications that alternative hosts could have on future public health interventions.

Association of Mycobacterium africanum Infection with Slower Disease Progression Compared with Mycobacterium tuberculosis in Malian Patients with Tuberculosis.

Mycobacterium africanum (MAF) is known to endemically cause up to 40-50% of all pulmonary TB in West Africa. The aim of this study was to compare MAF with Mycobacterium tuberculosis (MTB) with regard to time from symptom onset to TB diagnosis, and clinical and radiological characteristics. A cross-sectional study was conducted in Bamako, Mali, between August 2014 and July 2016. Seventy-seven newly diagnosed pulmonary TB patients who were naive to treatment were enrolled at Mali's University Clinical Research Center. Sputum cultures were performed to confirm the diagnosis and spoligotyping to identify the mycobacterial strain. Univariate and multivariate analyses were used to identify factors associated with disease progression. Overall, the frequency of female patients was 25% in MAF infection and only 10.0% in MTB infection (OR = 2.9), and MAF was more represented in patients aged ≥ 30 years (57.1% versus 36.7% [OR = 2.3]). More MAF- than MTB-infected patients had a history of a prior TB contact (32.1% versus 14.3% [OR = 2.8]). The mean duration between cough onset and TB diagnosis was 111 days (∼3.7 months) for MAF and 72 days (∼2.4 months) for MTB (P = 0.007). In a multivariate regression, weight loss (body mass index [BMI] < 18.5 kg/m2) and cough duration (> 4 months) were strongly associated with MAF infection (OR = 5.20 [1.49-18.26], P = 0.010, and 4.74 [1.2-18.58], P = 0.02), respectively. Our data show that MAF infection was significantly associated with lower BMI and a longer time between symptom onset and TB diagnosis than MTB. This supports the concept that MAF infection may have slower disease progression and less severe cough symptoms than MTB.

Why Do Women with Breast Cancer Get Diagnosed and Treated Late in Sub-Saharan Africa? Perspectives from Women and Patients in Bamako, Mali.

BACKGROUND: Breast cancer, the most common cancer among women worldwide, has a high mortality rate in low-income countries. In sub-Saharan Africa, most breast cancer patients are diagnosed with advanced disease. Some studies have quantified the time delay to diagnosis in sub-Saharan Africa, but very few have used qualitative methods to understand barriers leading to delay. This study analyses barriers throughout a breast cancer patient's pathway from symptom recognition to treatment in Mali. METHOD: Three focus group discussions were conducted. The model of pathways to treatment was used to structure the results into 4 time intervals: appraisal, help-seeking, diagnosis, and treatment, with a focus on barriers during each interval. RESULTS: The main barriers during the appraisal interval were a low level of breast cancer knowledge among women, their families, and medical professionals, and during the help-seeking interval, mistrust in the community health care centers and economic hardship. Barriers during the diagnosis interval were low quality of health care services and lack of social support, and during the pretreatment interval high costs and lack of specialized services. CONCLUSION: Multilevel interventions are needed to ensure access, availability, and affordability of a minimum standard of care for breast cancer patients in sub-Saharan Africa.

Knowledge, Attitudes and Practices of Doctors and Dental Surgeons in Bamako on the Relationship Between Periodontal Diseases and Chronic Non-Communicable Diseases

Objective: To assess the level of knowledge, attitudes and practices of doctors and dentists in Bamako on the relationship between chronic non-communicable diseases and periodontal diseases. Material and Methods: A cross-sectional study of 420 physicians and dental surgeons was conducted from March to August 2016. Data analysis involved descriptive statistics (frequency distribution). All statistical analyses were performed using the Epi Info 3.5.4 Software. Results: The male sex was the most represented with 58% for a sex ratio of 1.3. The most represented age group was 30-40 years old (48.8%) with an average age of 33 ± 8.2 years. General practitioners were the most represented in 93.6% of cases. Physicians with no knowledge of periodontal disease accounted for 60% of all cases, and all dental surgeons reported knowledge of chronic noncommunicable conditions in 100% of cases. Physicians and dental surgeons rated their knowledge levels of periodontal disease and chronic disease as inadequate in 98% and 90% of cases, respectively. Examination of the oral cavity by the doctors was "sometimes" carried out in 66% of the cases and the non-demand of the clinical signs of the gingival bleeding (64%) and dental migration (80.5%). They did not make recommendations on oral hygiene in 61.7% of cases. Conclusion: This study shows shortcomings among doctors and dentists in Bamako on the relationship between periodontal diseases and chronic non-communicable diseases. Capacity building and multidisciplinary collaboration are needed to support people's health.

Prevalence of Gingivitis among Malian Children

Objective: To determine the prevalence of gingivitis among Malian children in Bamako, Mali. Material and Methods: This cross-sectional study evaluated 2640 children aged between 3 to 14 years old and two examiners collected the data. The gingival index was used to determine the degree of gingival. Gingival inflammation has been classified localized and / or generalized according to site rate achieved. Descriptive statistics were used to calculate the absolute and relative frequencies. Results: The prevalence of gingivitis was 87.5%. Regarding the distribution according to sex, the girls presented 60.6% while the boys 39.4%, with a sex ratio of 0.6. The most represented age group was 11-14 years old with 52.5% of cases. Plaque-induced gingivitis was the most common (58.2%), while moderate gingival inflammation affected 67% of the students with localized gingival inflammation involving 64.7% of the participants. Conclusion: The prevalence of gingivitis was high, so that early and correct management of this condition in children avoids complications and requires good oral hygiene.

Oral Hygiene: Knowledge and Practices of Students in Three Quranic Schools in Koutiala, Mali

Objective: To evaluate the knowledge, attitudes, and practices on oral hygiene (OH) of students of three Quranic schools of Koutiala, Mali. Material and Methods: It was carried out a descriptive prospective study with 300 students in three Quranic schools in the city of Koutiala, Mali. The data analyzed with the Epi Info 3.5.4 software. Results: The male sex was the most represented with 57.7% and the sex ratio = 0.73. The most represented age group was 8-12 with 52% with an average age of 17 years and minimum and maximum age of was 8 and 26 years. It was observed that 98.3% of students had a notion of knowledge about oral hygiene and this information was given by parents / elders in 60% of cases. They claimed that people who do not brush their teeth properly are the most likely to get tooth decay in 93.3% of cases. Regarding dental caries, 61.3% of students said that caries is transmitted by lack of oral hygiene; 33.3% of students said that using toothbrushes and having good oral hygiene are ways to avoid oral diseases. It was thought in 93.3% of cases that a good oral hygiene prevents oral diseases. The students brushed their teeth every day (98%) and they had a consultation with the dental surgeon in 8.7% of the cases. Conclusion: This study shows that students had knowledge of oral hygiene and preventive measures. Efforts should be made to promote, prevent, screen and manage oral diseases in Quranic schools while involving parents in the processes.

Knowledge and Practical Attitudes of Surgeons-Dentists of Bamako District Facing the Septum Syndrome

Objective: To determine the knowledge and attitude of dental surgeons in Bamako regarding the management of septal syndromes. Material and Methods: It was a crosssectional and descriptive study conducted in the Bamako District, Mali. The following variables were collected: sociodemographic, training, knowledge of septal syndrome, therapeutic decisions and treatment. The data was collected from a survey sheet and processed by Epi-info Software version 3.5.3 and by the language R. Results: A total of 67 professionals participated in this study, of which 88.1% were men. Seventy-six point one percent of the Dental Surgeons have recognized septum syndrome as an emergency. The management of the emergency, followed by the completion of the comprehensive care later represents the attitude of 71.6% of the dentists. Sixty-four point two percent of dentists remove irritating elements under gingival, 80.6% prescribe an antiinflammatory, 38.8% prescribe chlorhexidine gel and 26.9% reconstruct the point of contact. Conclusion: This study demonstrates that Dental Surgeons in general have adequate average knowledge and attitude for their management of septal syndrome.

Underreporting and Missed Opportunities for Uptake of Intermittent Preventative Treatment of Malaria in Pregnancy (IPTp) in Mali.

OBJECTIVES: To identify factors contributing to low uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) in rural Mali. METHODS: We conducted secondary data analysis on Mali's 2012-2013 Demographic and Health Survey (DHS) to determine the proportion of women who failed to take IPTp-SP due to ineligibility or non-attendance at antenatal care (ANC). We also identified the proportion who reported taking other or unknown medications to prevent malaria in pregnancy and those who did not know if they took any medication to prevent malaria in pregnancy. We conducted qualitative interviews, focus groups and ANC observations in six rural sites in Mali's Sikasso and Koulikoro regions to identify reasons for missed opportunities. RESULTS: Our secondary data analysis found that reported IPTp-SP coverage estimates are misleading due to their dependence on a variable ("source of IPTp") that is missing 62% of its data points. Among all women who gave birth in the two years prior to the survey, 56.2% reported taking at least one dose of IPTp-SP. Another 5.2% reported taking chloroquine, 1.9% taking another drug to prevent malaria in pregnancy, 4.4% not knowing what drug they took to prevent malaria, and 1.1% not knowing if they took any drug to prevent malaria. The majority of women who did not receive IPTp-SP were women who also did not attend ANC. Our qualitative data revealed that many health centers neither administer IPTp-SP by directly observed therapy, nor give IPTp-SP at one month intervals through the second and third trimesters, nor provide IPTp-SP free of charge. Women generally reported IPTp-SP as available and tolerable, but frequently could not identify its name or purpose, potentially affecting accuracy of responses in household surveys. CONCLUSION: We estimate IPTp-SP uptake to be significantly higher than stated in Mali's 2012-13 DHS report. Increasing ANC attendance should be the first priority for increasing IPTp-SP coverage. Reducing cost and access barriers, ensuring that providers follow up-to-date guidelines, and improving patient counseling on IPTp-SP would also facilitate optimal uptake.

"There is no free here, you have to pay": actual and perceived costs as barriers to intermittent preventive treatment of malaria in pregnancy in Mali.

BACKGROUND: "There is no free here," the words of a Malian husband, illustrate how perceptions of cost can deter uptake of intermittent preventive treatment of malaria in pregnancy (IPTp). The Malian Ministry of Health (MOH) recommends a minimum of three doses of IPTp at monthly intervals. However, despite a national policy that IPTp be provided free of charge, only 35% of pregnant women receive at least one dose and less than 20% receive two or more doses. METHODS: This study explored perceptions and experiences of IPTp cost in Mali and their impact on uptake, using qualitative interviews and focus groups with pregnant women, husbands and mothers-in-law. Study team members also interviewed and observed health workers at four health centres, two in Sikasso Region and two in Koulikoro. RESULTS: Despite national-level policies, actual IPTp costs varied widely at study sites-between facilities, and visits. Pregnant women may pay for IPTp, receive it free, or both at different times. Health centres often charge a lump sum for antenatal care (ANC) visits that includes both free and fee-based drugs and services. This makes it difficult for women and families to distinguish between free services and those requiring payment. As a result, some forego free care that, because it is bundled with other fee-based services and medications, appears not to be free. Varying costs also complicate household budgeting for health care, particularly as women often rely on their husbands for money. Finally, while health facilities operating under the cost-recovery model strive to provide free IPTp, their own financial constraints often make this impossible. CONCLUSIONS: Both actual and perceived costs are currently barriers to IPTp uptake. Given the confusion around cost of services in the two study regions, more detailed national-level studies of both perceived and actual costs could help inform policy and programme decisions promoting IPTp. These studies should evaluate both quantitatively and qualitatively the cost information provided to and understood by pregnant women and their families. Meanwhile, unbundling free and fee-based services, making clear that IPTp is free, and ensuring that it is provided at no cost could help increase uptake. Free community-based distribution might be another route to increased uptake and adherence.

FACTORS ASSOCIATED WITH HIV VOLUNTARY DISCLOSURE TO ONE'S STEADY SEXUAL PARTNER IN MALI: RESULTS FROM A COMMUNITY-BASED STUDY.

Despite the widespread dissemination of HIV information through public awareness campaigns in Mali, disclosing seropositivity to one's steady sexual partner (SSP) remains difficult for people living with HIV (PLHIV). Disclosure is a public health concern with serious implications and is also strongly linked to the quality of life of PLHIV. This study aimed to analyse factors associated with voluntary HIV disclosure to one's SSP, using a community-based cross-sectional study on 300 adult PLHIV in contact with a Malian community-based organization working in the field of AIDS response. A 125-item questionnaire was administered by trained personnel to study participants between May and October 2011. Analysis was restricted to the 219 participants who both reported having a SSP and answered to the question on disclosure to their SSP. A weighted multivariate logistic regression was used to determine variables independently associated with disclosure. In total, 161 participants (73%) reported HIV disclosure to their SSP. Having children (odds ratio [95% confidence interval]: 4.52 [1.84-11.12]), being accompanied to the survey site (3.66 [1.00-13.33]), knowing others who had publicly declared their seropositivity (3.12 [1.59-6.12]), having higher self-esteem (1.55 [1.09-2.19]) and using means other than anti-retroviral treatment to treat HIV (0.33 [0.11-1.00]) were independently associated with disclosure. This study identified several factors that should be considered for the design of interventions aimed at facilitating disclosure if/when desired in this cultural context.