Research and implementation interactions in a social accountability study: utilizing guidance for conducting process evaluations of complex interventions.

BACKGROUND: In recent years, researchers and evaluators have made efforts to identify and use appropriate and innovative research designs that account for the complexity in studying social accountability. The relationship between the researchers and those implementing the activities and how this impacts the study have received little attention. In this paper, we reflect on how we managed the relationship between researchers and implementers using the United Kingdom Medical Research Council (MRC) guidance on process evaluation of a complex intervention. MAIN BODY: The MRC guidance focuses on three areas of interaction between researchers and stakeholders involved in developing and delivering the intervention: (i) working with program developers and implementers; (ii) communication of emerging findings between researchers/evaluators and implementers; and (iii) overlapping roles of the intervention and research/evaluation. We summarize how the recommendations for each of the three areas were operationalized in the Community and Provider driven Social Accountability Intervention (CaPSAI) Project and provide reflections based on experience. We co-developed various tools, including standard operating procedures, contact lists, and manuals. Activities such as training sessions, regular calls, and meetings were also conducted to enable a good working relationship between the different partners. CONCLUSIONS: Studying social accountability requires the collaboration of multiple partners that need to be planned to ensure a good working relationship while safeguarding both the research and intervention implementation. The MRC guidance is a useful tool for making interaction issues explicit and establishing procedures. Planning procedures for dealing with research and implementers' interactions could be more comprehensive and better adapted to social accountability interventions if both researchers and implementers are involved. There is a need for social accountability research to include clear statements explaining the nature and types of relationships between researchers and implementers involved in the intervention.

Involving the health sector in the prevention and care of female genital mutilation: results from formative research in Guinea.

BACKGROUND: Despite efforts to reduce the burden of female genital mutilation (FGM) in Guinea, the practice remains prevalent, and health care providers are increasingly being implicated in its medicalization. This formative study was conducted to understand the factors that facilitate or impede the health sector in providing FGM prevention and care services to inform the development of health sector-based interventions. METHODS: Between April and May 2018, a mixed methods formative study was carried out using a rapid assessment methodology in three regions of Guinea-Faranah, Labe and Conakry. A structured questionnaire was completed by one hundred and fifty health care providers of different cadres and 37 semi-structured interviews were conducted with health care providers, women seeking services at public health clinics and key stakeholders, including health systems managers, heads of professional associations and schools of nursing, midwifery, and medicine as well as representatives of the Ministry of Health. Eleven focus group discussions were conducted with female and male community members. RESULTS: This study revealed health systems factors, attitudinal factors held by health care providers, and other factors, that may not only promote FGM medicalization but also impede a comprehensive health sector response. Our findings confirm that there is currently no standardized pre-service training on how to assess, document and manage complications of FGM nor are there interventions to promote the prevention of the practice within the health sector. This research also demonstrates the deeply held beliefs of health care providers and community members that perpetuate this practice, and which need to be addressed as part of a health sector approach to FGM prevention. CONCLUSION: As integral members of FGM practicing communities, health care providers understand community beliefs and norms, making them potential change agents. The health sector can support them by incorporating FGM content into their clinical training, ensuring accountability to legal and policy standards, and promoting FGM abandonment as part of a multi-sectoral approach. The findings from this formative research have informed the development of a health sector intervention that is being field tested as part of a multi-country implementation research study in Guinea, Kenya, and Somalia.

Despite the implementation of various interventions to prevent female genital mutilation (FGM), it is still widely practiced in Guinea, and health care providers are increasingly being implicated in the practice. We conducted research in three regions of Guinea, namely, Faranah, Labe and Conakry, to understand factors that might be addressed to strengthen the role of the health sector in prevention and care of women and girls who have undergone FGM. Our findings highlight the need to strengthen the capacity of health care providers to be able to identify cases of FGM and manage complications. The study also highlights the importance of engaging health care providers in efforts to prevent FGM, which will require that any trainings include an opportunity to discuss their own values and beliefs around FGM so that they are better equipped to communicate with their clients and patients in a sensitive and non-judgmental manner, whether during consultation visits or community health outreach activities. The results of this research have informed the development of a health system strengthening intervention package for the prevention and care of FGM, which is being tested in Kenya, Somalia, and Guinea.

Associations Between Vaginal Bacteria and Bacterial Vaginosis Signs and Symptoms: A Comparative Study of Kenyan and American Women.

Background: Bacterial colonization and associations with bacterial vaginosis (BV) signs and symptoms (Amsel criteria) may vary between populations. We assessed relationships between vaginal bacteria and Amsel criteria among two populations. Methods: Kenyan participants from the placebo arm of the Preventing Vaginal Infections (PVI) trial and participants from a Seattle-based cross-sectional BV study were included. Amsel criteria were recorded at study visits, and the vaginal microbiota was characterized using 16S rRNA gene sequencing. Logistic regression models, accounting for repeat visits as appropriate, were fit to evaluate associations between bacterial relative abundance and each Amsel criterion. Results: Among 84 PVI participants (496 observations) and 220 Seattle participants, the prevalence of amine odor was 25% and 40%, clue cells 16% and 37%, vaginal discharge 10% and 52%, elevated vaginal pH 69% and 67%, and BV 13% and 44%, respectively. BV-associated bacterium 1 (BVAB1) was positively associated with all Amsel criteria in both populations. Eggerthella type 1, Fannyhessea (Atopobium) vaginae, Gardnerella spp., Sneathia amnii, and Sneathia sanguinegens were positively associated with all Amsel criteria in the Seattle study, and all but discharge in the PVI trial. Conclusions: Core vaginal bacteria are consistently associated with BV signs and symptoms across two distinct populations of women.

A hybrid, effectiveness-implementation research study protocol targeting antenatal care providers to provide female genital mutilation prevention and care services in Guinea, Kenya and Somalia.

BACKGROUND: In settings with high prevalence of female genital mutilation (FGM), the health sector could play a bigger role in its prevention and care of women and girls who have undergone this harmful practice. However, ministries of health lack clear policies, strategic plans or dedicated funding to implement anti-FGM interventions. Along with limited relevant knowledge and skills to prevent the practice of FGM and care for girls and women living with FGM, health providers have limited interpersonal communication skills and self-efficacy, while some may have supportive attitudes towards FGM and its medicalization. We propose to test the effectiveness of a health system strengthening intervention that includes training antenatal care (ANC) providers on person-centred communication (PCC) for FGM prevention. METHODS: This will be a two-level, hybrid, effectiveness-implementation research study using a cluster randomized trial design in Guinea, Kenya and Somalia conducted over a 6 months period. In each country, within pre-selected regions/counties, 60 ANC clinics will be randomized to intervention and control arms. At baseline, all clinics will receive the level one intervention involving provision of FGM-related clinical guidelines and handbook as well as anti-FGM policies and posters. At month 3, intervention clinics will receive the level two intervention comprising of a training for ANC providers on PCC to challenge their FGM-related attitudes and build their communication skills to effectively provide FGM prevention counselling. A process evaluation will be conducted to understand 'how' and 'why' the intervention package achieves intended results. Multi-level regression modelling will be used for quantitative data analysis while qualitative data will be assessed using thematic content analysis to determine the effectiveness, feasibility and acceptability of the different intervention levels. DISCUSSION: The proposed study will strengthen the knowledge base regarding how to effectively involve health providers in FGM prevention and care. TRIAL REGISTRATION: Trial registration and date: PACTR201906696419769 (June 3rd, 2019).

Vaginal Bacteria and Risk of Incident and Persistent Infection With High-Risk Subtypes of Human Papillomavirus: A Cohort Study Among Kenyan Women.

BACKGROUND: Bacterial vaginosis (BV) is associated with an increased risk of high-risk human papillomavirus (hrHPV), whereas Lactobacillus-dominated vaginal microbiotas are associated with reduced burden of hrHPV. Few epidemiologic studies have prospectively investigated the relationships between vaginal bacteria and hrHPV, particularly among women from countries in Africa. METHODS: We conducted a prospective cohort study nested within the Preventing Vaginal Infections trial to evaluate associations between vaginal bacteria and hrHPV incidence and persistence. Sexually active, HIV-seronegative women aged 18 to 45 years who had a vaginal infection at screening were eligible to enroll. Analyses were restricted to participants enrolled in Kenya and randomized to placebo. At enrollment and months 2, 4, 6, 8, 10, and 12, hrHPV testing, quantitative polymerase chain reaction (measuring taxon quantity per swab), and 16S rRNA gene amplicon sequencing of the vaginal microbiota were performed. Generalized estimating equations multinomial logistic regression models were fit to evaluate associations between vaginal bacteria and incident and persistent hrHPV. RESULTS: Eighty-four participants were included in this analysis. Higher concentrations of Lactobacillus crispatus were inversely associated with persistent hrHPV detection. Specifically, 1 tertile higher L. crispatus concentration was associated with 50% reduced odds of persistent hrHPV detection (odds ratio, 0.50; 95% confidence interval, 0.29-0.85). CONCLUSIONS: This study is consistent with reports that vaginal L. crispatus is associated with reduced susceptibility to hrHPV persistence. Evidence from in vitro studies provides insight into potential mechanisms by which L. crispatus may mediate hrHPV risk. Future studies should further explore in vivo mechanisms that may drive this relationship and opportunities for intervention.

Venue-Based HIV Testing at Sex Work Hotspots to Reach Adolescent Girls and Young Women Living With HIV: A Cross-sectional Study in Mombasa, Kenya.

BACKGROUND: We estimated the potential number of newly diagnosed HIV infections among adolescent girls and young women (AGYW) using a venue-based approach to HIV testing at sex work hotspots. METHODS: We used hotspot enumeration and cross-sectional biobehavioral survey data from the 2015 Transition Study of AGYW aged 14-24 years who frequented hotspots in Mombasa, Kenya. We described the HIV cascade among young females who sell sex (YFSS) (N = 408) versus those young females who do not sell sex (YFNS) (N = 891) and triangulated the potential (100% test acceptance and accuracy) and feasible (accounting for test acceptance and sensitivity) number of AGYW that could be newly diagnosed through hotspot-based HIV rapid testing in Mombasa. We identified the profile of AGYW with an HIV in the past year using generalized linear mixed regression models. RESULTS: N = 37/365 (10.1%) YFSS and N = 30/828 (3.6%) YFNS were living with HIV, of whom 27.0% (N = 10/37) and 30.0% (N = 9/30) were diagnosed and aware (P = 0.79). Rapid test acceptance was 89.3%, and sensitivity was 80.4%. There were an estimated 15,635 (range: 12,172-19,097) AGYW at hotspots. The potential and feasible number of new diagnosis was 627 (310-1081), and 450 (223-776), respectively. Thus, hotspot-based testing could feasibly reduce the undiagnosed fraction from 71.6% to 20.2%. The profile of AGYW who recently tested was similar among YFSS and YFNS. YFSS were 2-fold more likely to report a recent HIV test after adjusting for other determinants [odds ratio (95% confidence interval): 2.2 (1.5 to 3.1)]. CONCLUSION: Reaching AGYW through hotspot-based HIV testing could fill gaps left by traditional, clinic-based HIV testing services.

Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study.

BACKGROUND: Maternal health outcomes in resource-limited settings are typically influenced by supply-side factors affecting the provision of quality health services. The extent to which demand-side factors contribute to this influence is unclear. We aimed to explore how individual and community-wide factors influenced uptake and utilization of maternal health services among the Digo community residing in Kwale County of coastal Kenya. METHODS: Between March and December 2015, we conducted 5 focus group discussions (FGDs) and 15 in-depth interviews (IDIs) with members of the Digo community predominant in Kwale county, Kenya. Respondents were sampled purposively and included female (pregnant and postpartum) as well as male adult community members. A thematic content analytic approach was used. RESULTS: There were a total of 47 FGD respondents, including 15 (32%) females with a median (interquartile, IQR) age of 38 (27-55) years and 6 (3-8) children. Majority (40%) reported attaining secondary-level education. All IDI respondents were female with a median (IQR) age of 27 (24-35) years and 4 (2-5) children. Majority (80%) had attained primary-level education. We found that religious and socio-cultural norms as well as gender stereotypes were important influences on the uptake and utilization of maternal health services, including facility-based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the decision-making process. CONCLUSIONS: Among the Digo community of coastal Kenya, a unique social-cultural context comprising of a religious and gendered value belief system influences women's reproductive health and rights. These findings highlight the important role of demand-side factors in influencing maternal health outcomes. In addition to addressing supply-side factors, programs in such settings should aim to address factors that leverage inherent social capital to drive demand for maternal health services ensuring that they are not only effective, but also responsive to the local context.

Correction to: Preference of specimen collection methods for human papillomavirus detection for cervical cancer screening: a cross-sectional study of high-risk women in Mombasa, Kenya.

Following publication of the original article [1], we have been notified that another author should be added to the team of authors. The Name and affiliation details are below.

Is sexual autonomy a protective factor for neonatal, child, and infant mortality? A multi-country analysis.

BACKGROUND: Sexual autonomy empowers women to set boundaries, take control of their bodies, prevent sexually transmitted diseases and avoid unplanned pregnancy. A woman's ability to negotiate safer sex is crucial for her survival and that of her child. Sexual autonomy among East African women is vital to the elimination of the deaths of neonates, infants, and children. The aim of our study was to explore the association of sexual autonomy on neonatal, infant, and child mortality. METHODOLOGY: This was a secondary analysis of demographic health survey (DHS) data on women of reproductive age (15-49 years) in five East African countries: Burundi, Kenya, Rwanda, Tanzania, and Uganda. Data on our outcome variables neonatal, infant, and under-five mortality which were in binary form was extracted from the database. Sexual autonomy was classified as a composite variable of "respondent can refuse sex," "respondent can ask partner to use condom," and "if spouse is justified in asking husband to use condom." Other sociodemographic, maternal, health system and paternal variables were included in the analysis. STATA version 14 was used for analysis. Proportions and frequencies were used to describe the three outcome variables and sociodemographic characteristics. Chi-square tests were used to compare associations between sexual autonomy and categorical variables. Adjusted hazard ratios were used to determine the association between sexual autonomy and independent variables. RESULTS: The sampled women were predominantly urban (75%; n = 5758) and poor (48.7%; n = 3702). A majority of those that experienced mortality (neonatal mortality 53.5%, infant mortality 54.3%, under-five mortality 55.7%) were young (under 20) at the time of their first child's birth while their male partners were older. The multivariate analysis supports the beneficial effects of women's sexual autonomy in East Africa. Women who exercised sexual autonomy experienced significantly lower rates of child mortality at all three stages: neonatal (NHR = 0.80, 95% CI: 0.68-0.94, p = 0.006), infant (IHR = 0.82, 95% CI: 0.72-0.93, p = 0.003), and under-five (UHR = 0.84, 95% CI: 0.75-0.94, p = 0.002), net of all other factors. Receiving antenatal care and using contraceptives also contributed significantly to lower child mortality rates. CONCLUSION: Our findings suggest that sexual autonomy among East African women is an urgent priority that is crucial to the survival of neonates, infants, and children in East Africa. Women should be informed, empowered, and autonomous concerning their reproductive and sexual health.

"Our voices matter": a before-after assessment of the effect of a community-participatory intervention to promote uptake of maternal and child health services in Kwale, Kenya.

BACKGROUND: Community-participatory approaches are important for effective maternal and child health interventions. A community-participatory intervention (the Dialogue Model) was implemented in Kwale County, Kenya to enhance uptake of select maternal and child health services among women of reproductive age. METHODS: Community volunteers were trained to facilitate Dialogue Model sessions in community units associated with intervention health facilities in Matuga, Kwale. Selection of intervention facilities was purposive based on those that had an active community unit in existence. For each facility, uptake of family planning, antenatal care and facility-based delivery as reported in the District Health Information System (DHIS)-2 was compared pre- (October 2012 - September 2013) versus post- (January - December 2016) intervention implementation using a paired sample t-test. RESULTS: Between October 2013 and December 2015, a total of 570 Dialogue Model sessions were held in 12 community units associated with 10 intervention facilities. The median [interquartile range (IQR)] number of sessions per month per facility was 2 (1-3). Overall, these facilities reported 15, 2 and 74% increase in uptake of family planning, antenatal care and facility-based deliveries, respectively. This was statistically significant for family planning pre- (Mean (M) = 1014; Standard deviation (SD) = 381) versus post- (M = 1163; SD = 400); t (18) = - 0.603, P = 0.04) as well as facility-based deliveries pre- (M = 185; SD = 216) versus post- (M = 323; SD = 384); t (18) = - 0.698, P = 0.03). CONCLUSIONS: A structured, community-participatory intervention enhanced uptake of family planning services and facility-based deliveries in a rural Kenyan setting. This approach is useful in addressing demand-side factors by providing communities with a stake in influencing their health outcomes.

Correlates of facility-based delivery among women of reproductive age from the Digo community residing in Kwale, Kenya.

OBJECTIVE: This study sought to describe factors associated with facility-based delivery among women of reproductive age in Kwale County, Kenya. RESULTS: Between March and December 2015, 745 women from 15 villages were interviewed through a cross-sectional household survey. Respondents were selected using stratified, systematic sampling and completed a sexual and reproductive health questionnaire. Of 632 (85%) women who had a previous birth, 619 (98%) reported antenatal care attendance. Of these, 491 (79%) subsequently had a facility-based delivery. Factors associated with increased likelihood of facility delivery included respondent's education (odds ratio, OR = 2.0, 95% confidence interval, CI 1.2-3.2, P = 0.004), ideal antenatal care attendance (OR = 2.3, 95% CI 1.4-3.7, P = 0.001) and pregnancy intention (OR = 1.5, 95% CI 1.0-2.2, P = 0.040). Being in a polygamous relationship (OR = 0.6, 95% CI 0.3-0.9, P = 0.024) and having a husband ≥ 40 years (OR = 0.5, 95% CI 0.3-0.9, P = 0.013) were associated with reduced likelihood of facility delivery. Respondent's education (aOR = 1.9, 95% CI 1.1-3.3, P = 0.030) as well as ideal ANC attendance (aOR = 2.0, 95% CI 1.0-3.8, P = 0.040) remained significantly associated with facility delivery in multivariate analyses.

Pattern and determinants of contraceptive usage among women of reproductive age from the Digo community residing in Kwale, Kenya: results from a cross-sectional household survey.

BACKGROUND: Contraceptive usage has been associated with improved maternal and child health (MCH) outcomes. Despite significant resources being allocated to programs, there has been sub-optimal uptake of contraception, especially in the developing world. It is important therefore, to granulate factors that determine uptake and utilization of contraceptive services so as to inform effective programming. METHODS: Between March and December 2015, we conducted a cross-sectional survey among women of reproductive age (WRA) from the Digo community residing in Kwale County, Kenya. The study aimed to describe the pattern and determinants of contraceptive usage in this population. Respondents were selected using stratified, systematic sampling and completed a household sexual and reproductive health (SRH) questionnaire. RESULTS: We interviewed 745 respondents from 15 villages in 2 out of 4 sub-counties of Kwale. Their median (interquartile range, IQR) age was 29 (23-37) years. 568 (76%) reported being currently in a marital union. Among these, 308 (54%) were using a contraceptive method. The total unmet need, unmet need for spacing and for limiting was 16%, 8% and 8%, respectively. Determinants of contraceptive usage were education [adjusted Odds Ratio, aOR = 2.1, 95% confidence interval, CI: 1.4-3.4, P = 0.001]; having children [aOR = 5.0, 95% CI: 1.7-15.0, P = 0.004]; having attended antenatal care (ANC) at last delivery [aOR = 4.0, 95% CI: 1.1-14.8, P = 0.04] as well as intention to stop or delay future birth [aOR = 6.7, 95% CI: 3.3-13.8, P < 0.0001]. CONCLUSIONS: We found high levels of contraceptive usage among WRA from the Digo community residing in Kwale. To further improve uptake and utilization of contraception in this setting, programs should address demand-side factors including ensuring female educational attainment as well as promotion of ANC and skilled birth attendance.

Bridging the Gap in Implementation Science: Evaluating a Capacity-Building Program in Data Management, Analysis, Utilization, and Dissemination in Low- and Middle-Income Countries.

Building capacity in implementation science within health programs is dependent on training in theory and practice of epidemiology, statistics, and research in addition to high self-efficacy toward application of training. This article describes a training program providing technical assistance to more than 300 health facilities in Kenya and Tanzania, its evaluation results, and its ability to improve participants' knowledge, competencies, and self-efficacy on data management, analysis, and dissemination among health care professionals. Two months prior to the training, participants (n = 98) were emailed a pre-course survey including 19 questions using a Likert-type response for planning the content of the workshop. Six to 12 weeks after the training, a post-course survey was emailed to all participants. Five different trainings were conducted indicating 5 participant cohorts. The questions posed involved course satisfaction, course impact on knowledge and skills, and self-efficacy in data analysis and utilization. Post-course survey results revealed that the participants had confidence in data analysis, which was significantly different from the pre-test results (0.05 α). Qualitative commentary complemented the findings of the impact of the workshop. Four manuscripts and 13 abstracts have been submitted post training. Results suggest that a short-term training program can achieve immediate gains in data and research self-efficacy among health care professionals. Although increasing self-efficacy is a necessary first step in developing skills, educators should engage in continuing education for sustainable dissemination practices. There is an urgent need to determine the current infrastructure to promote scientific dissemination. This will assist countries to produce better evidence to support their programs, policies, and overall health programs.

Improving postpartum care delivery and uptake by implementing context-specific interventions in four countries in Africa: a realist evaluation of the Missed Opportunities in Maternal and Infant Health (MOMI) project.

Postpartum care (PPC) has remained relatively neglected in many interventions designed to improve maternal and neonatal health in sub-Saharan Africa. The Missed Opportunities in Maternal and Infant Health project developed and implemented a context-specific package of health system strengthening and demand generation in four African countries, aiming to improve access and quality of PPC. A realist evaluation was conducted to enable nuanced understanding of the influence of different contextual factors on both the implementation and impacts of the interventions. Mixed methods were used to collect data and test hypothesised context-mechanism-outcome configurations: 16 case studies (including interviews, observations, monitoring data on key healthcare processes and outcomes), monitoring data for all study health facilities and communities, document analysis and participatory evaluation workshops. After evaluation in individual countries, a cross-country analysis was conducted that led to the development of four middle-range theories. Community health workers (CHWs) were key assets in shifting demand for PPC by 'bridging' communities and facilities. Because they were chosen from the community they served, they gained trust from the community and an intrinsic sense of responsibility. Furthermore, if a critical mass of women seek postpartum healthcare as a result of the CHWs bridging function, a 'buzz' for change is created, leading eventually to the acceptability and perceived value of attending for PPC that outweighs the costs of attending the health facility. On the supply side, rigid vertical hierarchies and defined roles for health facility workers (HFWs) impede integration of maternal and infant health services. Additionally, HFWs fear being judged negatively which overrides the self-efficacy that could potentially be gained from PPC training. Instead the main driver of HFWs' motivation to provide comprehensive PPC is dependent on accountability systems for delivering PPC created by other programmes. The realist evaluation offers insights into some of the contextual factors that can be pivotal in enabling the community-level and service-level interventions to be effective.

A prospective cohort study comparing the effect of single-dose 2 g metronidazole on Trichomonas vaginalis infection in HIV-seropositive versus HIV-seronegative women.

BACKGROUND: This analysis compared the frequency of persistent Trichomonas vaginalis (TV) among HIV-seropositive and HIV-seronegative women. METHODS: Data were obtained from women enrolled in an open cohort study of sex workers in Kenya. Participants were examined monthly, and those diagnosed as having TV by saline microscopy were treated with single-dose 2 g oral metronidazole. All women on antiretroviral therapy (ART) used nevirapine-based regimens. Generalized estimating equations with a logit link were used to compare the frequency of persistent TV (defined as the presence of motile trichomonads by saline microscopy at the next examination visit within 60 days) by HIV status. RESULTS: Three-hundred sixty participants contributed 570 infections to the analysis (282 HIV-seropositive and 288 HIV-seronegative). There were 42 (15%) persistent infections among HIV-seropositive participants versus 35 (12%) among HIV-seronegative participants (adjusted odds ratio, 1.14; 95% confidence interval [CI], 0.70-1.87). Persistent TV was highest among HIV-seropositive women using ART (21/64 [33%]) compared with HIV-seropositive women not using ART (21/217 [10%]). Concurrent bacterial vaginosis (BV) at TV diagnosis was associated with an increased likelihood of persistent TV (adjusted odds ratio, 1.90; 95% confidence interval, 1.16-3.09). CONCLUSIONS: The frequency of persistent TV infection after treatment with single-dose 2 g oral metronidazole was similar by HIV status. Alternative regimens including multiday antibiotic treatment may be necessary to improve cure rates for women using nevirapine-based ART and women with TV and concurrent BV.