Transporting monovalent rotavirus vaccine efficacy estimates to an external target population: a secondary analysis of data from a randomised controlled trial in Malawi.

Oral rotavirus vaccine efficacy estimates from randomised controlled trials are highly variable across settings. Although the randomised study design increases the likelihood of internal validity of findings, results from trials may not always apply outside the context of the study due to differences between trial participants and the target population. Here, we used a weight-based method to transport results from a monovalent rotavirus vaccine clinical trial conducted in Malawi between 2005 and 2008 to a target population of all trial-eligible children in Malawi, represented by data from the 2015-2016 Malawi Demographic and Health Survey (DHS). We reweighted trial participants to reflect the population characteristics described by the Malawi DHS. Vaccine efficacy was estimated for 1008 trial participants after applying these weights such that they represented trial-eligible children in Malawi. We also conducted subgroup analyses to examine the heterogeneous treatment effects by stunting and tuberculosis vaccination status at enrolment. In the original trial, the estimates of one-year vaccine efficacy against severe rotavirus gastroenteritis and any-severity rotavirus gastroenteritis in Malawi were 49.2% (95% CI 15.6%-70.3%) and 32.1% (95% CI 2.5%-53.1%), respectively. After weighting trial participants to represent all trial-eligible children in Malawi, vaccine efficacy increased to 62.2% (95% CI 35.5%-79.0%) against severe rotavirus gastroenteritis and 38.9% (95% CI 11.4%-58.5%) against any-severity rotavirus gastroenteritis. Rotavirus vaccine efficacy may differ between trial participants and target populations when these two populations differ. Differences in tuberculosis vaccination status between the trial sample and DHS population contributed to varying trial and target population vaccine efficacy estimates.

Advances in monitoring and evaluation in low- and middle-income countries.

Data to inform and improve health care systems in low- and middle-income countries (LMICs) has been facilitated by the development of monitoring and evaluation (M&E) systems. The drivers of change in M&E systems over the last 50 years have included a series of health concerns that have animated global donors (e.g., family planning, vaccination campaigns, and HIV/AIDS); the data requirements of donors; improved national economies enabling LMICs to invest more in M&E systems; and rapid advances in digital technologies. Progress has included the training and expansion of an M&E workforce, the creation of systems for data collection and use, and processes for assessing and ensuring data quality. Controversies have included the development of disease-specific systems that do not coordinate with each other, and a growing burden on health care deliverers to collect data for a proliferating number of health and process indicators. Digital technologies offer the promise of real time data and quick adaptation but also raise ethical and privacy concerns. The desire for speed can cast large-scale evaluations, considered by some to be the gold standard, in an unfavorable light as slow and expensive. Accordingly, there is a growing demand for speedy evaluations that rely on routine health information systems and privately collected "big data" from electronic health records and social media.

Reliability, validity and measurement invariance of the Simplified Medication Adherence Questionnaire (SMAQ) among HIV-positive women in Ethiopia: a quasi-experimental study.

BACKGROUND: Adherence to antiretroviral therapy is critical to the achievement of the third target of the UNAIDS Fast-Track Initiative goals of 2020-2030. Reliable, valid and accurate measurement of adherence are important for correct assessment of adherence and in predicting the efficacy of ART. The Simplified Medication Adherence Questionnaire is a six-item scale which assesses the perception of persons living with HIV about their adherence to ART. Despite recent widespread use, its measurement properties have yet to be carefully documented beyond the original study in Spain. The objective of this paper was to conduct internal consistency reliability, concurrent validity and measurement invariance tests for the SMAQ. METHODS: HIV-positive women who were receiving ART services from 51 service providers in two sub-cities of Addis Ababa, Ethiopia completed the SMAQ in a HIV treatment referral network study between 2011 and 2012. Two cross-sections of 402 and 524 female patients of reproductive age, respectively, from the two sub-cities were randomly selected and interviewed at baseline and follow-up. We used Cronbach's coefficient alpha (α) to assess internal consistency reliability, Pearson product-moment correlation (r) to assess concurrent validity and multiple-group confirmatory factor analysis to analyze factorial structure and measurement invariance of the SMAQ. RESULTS: All participants were female with a mean age of 33; median: 34 years; range 18-45 years. Cronbach's alphas for the six items of the SMAQ were 0.66, 0.68, 0.75 and 0.75 for T1 control, T1 intervention, T2 control, and T2 intervention groups, respectively. Pearson correlation coefficients were 0.78, 0.49, 0.52, 0.48, 0.76 and 0.80 for items 1 to 6, respectively, between T1 compared to T2. We found invariance for factor loadings, observed item intercepts and factor variances, also known as strong measurement invariance, when we compared latent adherence levels between and across patient-groups. CONCLUSIONS: Our results show that the six-item SMAQ scale has adequate reliability and validity indices for this sample, in addition to being invariant across comparison groups. The findings of this study strengthen the evidence in support of the increasing use of SMAQ by interventionists and researchers to examine, pool and compare adherence scores across groups and time periods.

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

BACKGROUND: In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services. METHODS: We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility. RESULTS: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI - 1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births. CONCLUSIONS: Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.

Improving Referrals for HIV Care Through Organizational Network Analysis.

CONTEXT: The link between testing for HIV and obtaining antiretroviral therapy (ART) is central to the HIV/AIDS control strategies of UNAIDS (the "90-90-90" goals) and the International Association of Providers of AIDS Care ("Test and Start"). To ensure that 90% of those diagnosed with HIV/AIDS begin ART and 90% of those on ART achieve viral suppression, service providers not providing all services need to refer patients to other organizations. SETTING: Homa Bay, Kenya. OBJECTIVE: Homa Bay county's HIV/AIDS prevalence is one of the country's highest. We identified the organizations providing some aspect of HIV/AIDS care and investigated ways in which they work together, or do not, to cover the comprehensive needs of those they serve. DESIGN AND PARTICIPANTS: We identified 56 organizations and interviewed a representative from each about his or her organization's services and its connections with the other 55, with particular interest in referrals from sites that test for HIV but do not treat infections to sites that do treat infections. MAIN OUTCOME MEASURE: Referral connections. RESULTS: Referral connections among the 56 in the past 30 days were relatively rare, averaging fewer than 2; 13 organizations made no referrals at all. Notably, 5 facilities that test for HIV did not refer their clients to an ART provider. We found 2 distinct clusters of connected organizations: one in Homa Bay Township and the other in Rangwe subcounty. When we convened the organizations and presented our results to them, they expressed interest in establishing better connections and referrals. CONCLUSIONS: Homa Bay has an opportunity to improve care for people with HIV/AIDS, in particular ensuring that those testing positive receive treatment, simply by making better use of the services already available. This can be achieved by informing each organization of the services provided by each of the others and by bringing the organizations together to plan and monitor the services' coordination. These steps could be implemented separately in each of the 2 organizational clusters.

Timing of Rotavirus Vaccine Doses and Severe Rotavirus Gastroenteritis Among Vaccinated Infants in Low- and Middle-income Countries.

BACKGROUND: Altering rotavirus vaccine schedules may improve vaccine performance in low- and middle-income countries. We analyzed data from clinical trials of the monovalent (RV1) and pentavalent (RV5) rotavirus vaccines in low- and middle-income countries to understand the association between vaccine dose timing and severe rotavirus gastroenteritis incidence. METHODS: We assessed the association between variations in rotavirus vaccine administration schedules and severe rotavirus gastroenteritis risk. We used the complement of the Kaplan-Meier survival estimator to estimate risk differences for different schedules. To adjust risk differences (RDs) for confounding, we calibrated estimates in the vaccinated arm using estimates from the placebo arm. RESULTS: There were 3,114 and 7,341 children included from the RV1 and RV5 trials, respectively. The 18-month adjusted severe rotavirus gastroenteritis risk was 4.0% (95% confidence interval [CI] = 1.1, 7.1) higher for those receiving their first RV5 dose at <6 versus ≥6 weeks. For RV1, there was a 4.0% (95% CI = 0.0, 8.2) increase in 12-month adjusted risk for a 4- versus 6-week interval between doses. Further analysis revealed those receiving their first RV5 dose at 3-4 and 5-7 weeks had 2.9% (95% CI = 0.8, 5.3) and 1.3% (95% CI = -0.3, 3.0), respectively, higher risk compared with those at 9-12 weeks. Those receiving their first dose at 8 weeks had the lowest risk (RD: -2.6% [95% CI = -5.4, -0.1]) compared with those at 9-12 weeks. CONCLUSIONS: A modest delay in rotavirus vaccination start and increase in interval between doses may be associated with lower severe rotavirus gastroenteritis risk in low- and middle-income countries.

Organizational network strengthening effects on antiretroviral therapy initiation and adherence.

The WHO recommends antiretroviral therapy (ART) initiation immediately after HIV diagnosis. When HIV services are fragmented and poorly coordinated, initiation of ART can be delayed. MEASURE Evaluation conducted an organizational network intervention in Addis Ababa, Ethiopia, which increased referral network density and client satisfaction in the intervention versus control networks. The objective of our study was to extend the parent study by assessing effects of network density on the speed of ART initiation and adherence to ART. Measures of client-time since HIV diagnosis, use of ART, satisfaction with HIV-related services, and adherence were obtained from cross-sectional interviews with female service recipients with HIV/AIDS at baseline (T1, 402) and at 18-month follow-up (T2, 524) and compared between network sites. We used weighted least squares estimation with probit regression techniques in a structural equation modeling framework for analyses. On average at follow-up, clients in the intervention network were more likely to have quicker ART initiation, and were initiated on ART 15 days faster than clients in the control network. Moreover, quicker ART initiation was associated with higher adherence. A unit increase in speed of ART initiation was associated with 0.5 points increase in latent adherence score in the intervention group (p < .05). Satisfaction with care positively predicted adherence to ART. Network density had no direct effect on ART adherence. This quasi-experiment demonstrated that increased referral network density, through improved HIV client referrals, can enhance speed of ART initiation, resulting in improved adherence.

Interactions among poverty, gender, and health systems affect women's participation in services to prevent HIV transmission from mother to child: A causal loop analysis.

Retention in care remains an important issue for prevention of mother-to-child transmission (PMTCT) programs according to WHO guidelines, formerly called the "Option B+" approach. The objective of this study was to examine how poverty, gender, and health system factors interact to influence women's participation in PMTCT services. We used qualitative research, literature, and hypothesized variable connections to diagram causes and effects in causal loop models. We found that many factors, including antiretroviral therapy (ART) use, service design and quality, stigma, disclosure, spouse/partner influence, decision-making autonomy, and knowledge about PMTCT, influence psychosocial health, which in turn affects women's participation in PMTCT services. Thus, interventions to improve psychosocial health need to address many factors to be successful. We also found that the design of PMTCT services, a modifiable factor, is important because it affects several other factors. We identified 66 feedback loops that may contribute to policy resistance-that is, a policy's failure to have its intended effect. Our findings point to the need for a multipronged intervention to encourage women's continued participation in PMTCT services and for longitudinal research to quantify and test our causal loop model.

Lattice-Matched Epitaxial Graphene Grown on Boron Nitride.

Lattice-matched graphene on hexagonal boron nitride is expected to lead to the formation of a band gap but requires the formation of highly strained material and has not hitherto been realized. We demonstrate that aligned, lattice-matched graphene can be grown by molecular beam epitaxy using substrate temperatures in the range 1600-1710 °C and coexists with a topologically modified moiré pattern with regions of strained graphene which have giant moiré periods up to ∼80 nm. Raman spectra reveal narrow red-shifted peaks due to isotropic strain, while the giant moiré patterns result in complex splitting of Raman peaks due to strain variations across the moiré unit cell. The lattice-matched graphene has a lower conductance than both the Frenkel-Kontorova-type domain walls and also the topological defects where they terminate. We relate these results to theoretical models of band gap formation in graphene/boron nitride heterostructures.

Engaging men to promote and support exclusive breastfeeding: a descriptive review of 28 projects in 20 low- and middle-income countries from 2003 to 2013.

BACKGROUND: Lay support has been associated with improved breastfeeding practices, but studies of programs that engage men in breastfeeding support have shown mixed results and most are from high-income countries. The purpose of our research is to review strategies to engage men in exclusive breastfeeding (EBF) promotion or support in 28 project areas across 20 low- and middle-income countries. This information may be used to inform program implementers and policymakers seeking to increase EBF. METHODS: We tested the difference between baseline and final EBF proportions using Pearson's chi-square (a = 0.05) and identified project areas with a significant increase. We categorized male engagement strategies as low- and high-intensity, using information from project reports. We looked for patterns by intensity and geography and described strategies used to engage men in different places. RESULTS: Twenty-eight projects were reviewed; 21 (75%) were in areas where a statistically significant increase in EBF was observed between the beginning and end of the project. A variety of high- and low-intensity male engagement strategies was used in areas with an increase in EBF prevalence and in all geographic regions. High-intensity strategies engaged men directly during home or health visits by forming men's groups and by working with male community leaders or members to promote EBF. Low-intensity strategies included large community meetings that included men, and radio messages, and other behavior change materials directed towards men. CONCLUSION: Male engagement strategies took many forms in these project areas. We did not find consistent associations between the intensities or types of male engagement strategies and increases in EBF proportions. There is a gap in understanding how gender norms might impact male involvement in women's health behaviors. This review does not support the broad application of male engagement to improve EBF practices, and we recommend considering local gender norms when designing programs to support women to EBF.

Deficit Irrigation and Fertility Effects on NO3-N Exports from St. Augustinegrass.

Proper management of turfgrass systems is critical for reducing the risk of nutrient loss and protecting urban surface waters. In the southern United States, irrigation can be the most significant management practice regulating the biogeochemical and hydrological cycles of turfgrass systems. A turfgrass runoff research facility was used to assess the effects of deficit irrigation and fertilizer applications on turfgrass canopy cover and nitrate-N (NO-N) exports in runoff from St. Augustinegrass [Stenotaphrum secundatum (Walt.) Kuntze] turf over a 2-yr period. Treatments were arranged as a randomized complete block design having eight combinations of irrigation (100, 75, or 50% of estimated turfgrass water requirements) and fertility level (0, 88, and 176 kg N ha yr). Runoff from 31 rainfall events and one irrigation excess event were used to estimate annual and seasonal NO-N exports. The majority of annual NO-N exports occurred during the late winter and spring. Deficit irrigation reduced summer and early autumn runoff volumes. Lower summer and autumn runoff volumes (from deficit irrigation) coincided with reduced NO-N exports from runoff during Year 1. Deficit irrigation combined with fertilizer applications increased runoff [NO-N] in Year 2, suggesting that the previous year's export reduction contributed to higher N accumulation in the system and thus a higher N loss potential. These findings suggest that deficit irrigation can be a tool for reducing seasonal nutrient exports from St. Augustinegrass lawns so long as fertilizer inputs are moderate.

Achieving sustainability in health information systems: a field tested measure of country ownership.

BACKGROUND: A country will trust, value, and use, its health information system (HIS) to the extent it has had a role in its creation and maintenance. A sense of ownership contributes in turn to the long-term sustainability of the HIS, and thus the country's ability to monitor and evaluate population health and health services. To facilitate progress toward greater ownership, we developed and tested a tool to measure the country's ownership of its monitoring and evaluation (M&E) system. METHODS: Through a systematic review of the literature, we identified four dimensions of country ownership of an M&E system: partnership, commitment and responsibility, capacity, and accountability. We identified relevant indicators of the dimensions already in use in other tools used to assess M&E systems. We tested the data collection tool with 95 stakeholders of the Tanzanian HIS for HIV/AIDS control. RESULTS: We identified 56 items that addressed elements of the four dimensions. The respondents found our tool for assessing country ownership of an HIS to be clear and relevant, leading to the identification of important issues to be discussed. For example, all stakeholder groups affirmed that the Tanzanian Commission for AIDS is "playing a leadership role in addressing HIV through collaborative partnerships and work across borders to achieve greater impact." While many respondents disagreed with the statement, "There is an adequate number of government monitoring and evaluation posts at the sub-national level." CONCLUSIONS: Stakeholders found the M&E country ownership tool to address relevant questions clearly. It enabled them to identify successes and challenges within four dimensions of country ownership. It thus holds the potential to lead to an agenda for strengthening country ownership. If implemented every few years, the tool can provide a means of monitoring progress through a set of standardized indicators. As country ownership of M&E increases, so will the long-term sustainability of the HIS.

Contextual factors affecting health information system strengthening.

At the turn of the century, several major efforts were initiated to combat HIV/AIDS and other major epidemics affecting low- and middle-income countries (LMICs). They were accompanied by initiatives to enable recipient countries to collect and use data to guide their public health programmes. These health information systems (HIS) typify systems in that they have multiple interacting components, and they are embedded within larger systems. Components of a larger system act as the context for all lower-level systems. Their effects can be pervasive, and thus be taken for granted or regarded as unchangeable. We identify four contextual factors that affect efforts to strengthen HIS: hierarchical roles, aid funding, corruption, and competing priorities. We provide examples of each as experienced by those working to strengthen HIS in LMICs. Each of these contextual factors can seriously diminish the effectiveness of HIS strengthening efforts and their long-term sustainability. We propose research questions about each that would enable those engaged in HIS strengthening to work effectively and sustainably.

Key Ethical Issues Discussed at CDC-Sponsored International, Regional Meetings to Explore Cultural Perspectives and Contexts on Pandemic Influenza Preparedness and Response.

BACKGROUND: Recognizing the importance of having a broad exploration of how cultural perspectives may shape thinking about ethical considerations, the Centers for Disease Control and Prevention (CDC) funded four regional meetings in Africa, Asia, Latin America, and the Eastern Mediterranean to explore these perspectives relevant to pandemic influenza preparedness and response. The meetings were attended by 168 health professionals, scientists, academics, ethicists, religious leaders, and other community members representing 40 countries in these regions. METHODS: We reviewed the meeting reports, notes and stories and mapped outcomes to the key ethical challenges for pandemic influenza response described in the World Health Organization's (WHO's) guidance, Ethical Considerations in Developing a Public Health Response to Pandemic Influenza: transparency and public engagement, allocation of resources, social distancing, obligations to and of healthcare workers, and international collaboration. RESULTS: The important role of transparency and public engagement were widely accepted among participants. However, there was general agreement that no "one size fits all" approach to allocating resources can address the variety of economic, cultural and other contextual factors that must be taken into account. The importance of social distancing as a tool to limit disease transmission was also recognized, but the difficulties associated with this measure were acknowledged. There was agreement that healthcare workers often have competing obligations and that government has a responsibility to assist healthcare workers in doing their job by providing appropriate training and equipment. Finally, there was agreement about the importance of international collaboration for combating global health threats. CONCLUSION: Although some cultural differences in the values that frame pandemic preparedness and response efforts were observed, participants generally agreed on the key ethical principles discussed in the WHO's guidance. Most significantly the input gathered from these regional meetings pointed to the important role that procedural ethics can play in bringing people and countries together to respond to the shared health threat posed by a pandemic influenza despite the existence of cultural differences.

What systems are essential to achieving the sustainable development goals and what will it take to marshal them?

The sustainable development goal (SDG) for health is linked to 67 indicators, eight times more than their predecessor, the Millenium Development Goals. In many low- and middle-income countries (LMICs), the information infrastructure is not yet able to collect and use the data needed for the indicators. As they seek to be responsive to the SDG agenda, LMICs must not lose sight of their local data needs; they should be cautious about embracing untested electronic technologies for data collection, analysis, and use; carefully balance the care provision and data collection responsibilities of care providers; and use evidence of what works in strengthening their health information systems (HIS). While attending to these concerns, countries can look for instances in which SDG indicators are in sync with their own HIS goals.

Improving referrals and integrating family planning and HIV services through organizational network strengthening.

BACKGROUND: The service needs of people with human immunodeficiency virus (HIV) in low-income settings are wide-ranging. Service provision in a community is often disjointed among a variety of providers. We sought to reduce unmet patient needs by increasing referral coordination for HIV and family planning, measured as network density, with an organizational network approach. METHODS: We conducted organizational network analysis on two networks in sub-cities of Addis Ababa, Ethiopia. There were 25 organizations in one sub-city network and 26 in the other. In one of them we sought to increase referrals through three network strengthening meetings. We then conducted the network analysis again in both sub-cities to measure any changes since baseline. We also quantitatively measured reported client service needs in both sub-cities before and after the intervention with two cross-sectional samples of face-to-face interviews with clients (459 at baseline and 587 at follow-up). RESULTS: In the sub-city with the intervention, the number of referral connections between organizations, measured as network density, increased 55%. In the control community, the density decreased over the same period. Reported unmet client service needs declined more consistently across services in the intervention community. DISCUSSION: This quasi experiment demonstrated that (1) an organizational network analysis can inform an intervention, (2) a modest network strengthening intervention can enhance client referrals in the network, (3) improvement in client referrals was accompanied by a decrease in atient-reported unmet needs and (4) a series of network analyses can be a useful evaluation tool.

Nitrogen Runoff Losses during Warm-Season Turfgrass Sod Establishment.

Concern exists over the potential loss of nitrogen (N) and phosphorus (P) in runoff from newly established and fertilized lawns. Nutrient losses can be higher from turf when shoot density and surface cover are low and root systems are not fully developed. This study was conducted to evaluate fertilizer source and timing effects on nutrient losses from newly sodded lawns of St. Augustinegrass [ (Walt.) Kuntze]. For each study, 12 33.6-m plots were established on an undisturbed Alfisol having a 3.7% slope. Each plot was equipped with a runoff collection system, instrumentation for runoff flow rate measurement, and automated samplers. A 28-d establishment study was initiated on 8 Aug. 2012 and repeated on 9 Sept. 2012. Treatments included unfertilized plots, fertilized plots receiving 4.88 g N m as urea 6 d after planting, fertilized plots receiving 4.88 g N m as sulfur-coated urea 6 d after planting, and fertilized plots receiving 4.88 g N m as urea 19 d after planting. Runoff events were created by irrigating with 17 mm of water over 27 min. Runoff water samples were collected after every 37.8 L and analyzed for NO-N, NH-N, dissolved organic N (DON), and PO-P. Increases of approximately 2 to 4 mg L NO-N and 8 to 12 mg L PO-P occurred in runoff 1 d after fertilization, which returned to background levels within 7 d. Total fertilizer N lost to runoff was 0.6 to 4.2% of that applied. Delaying fertilizer application until 19 d after planting provided no reduction in nutrient loss compared with a similar application 6 d after planting. Approximately 33% of the N lost in runoff was as DON. This large amount of DON suggests significant N loss from decomposing organic matter may occur during sod establishment.

The effect of women's property rights on HIV: a search for quantitative evidence.

In recent years, efforts to reduce HIV transmission have begun to incorporate a structural interventions approach, whereby the social, political, and economic environment in which people live is considered an important determinant of individual behaviors. This approach to HIV prevention is reflected in the growing number of programs designed to address insecure or nonexistent property rights for women living in developing countries. Qualitative and anecdotal evidence suggests that property ownership may allow women to mitigate social, economic, and biological effects of HIV for themselves and others through increased food security and income generation. Even so, the relationship between women's property and inheritance rights (WPIR) and HIV transmission behaviors is not well understood. We explored sources of data that could be used to establish quantitative links between WPIR and HIV. Our search for quantitative evidence included (1) a review of peer-reviewed and "gray" literature reporting on quantitative associations between WPIR and HIV, (2) identification and assessment of existing data-sets for their utility in exploring this relationship, and (3) interviews with organizations addressing women's property rights in Kenya and Uganda about the data they collect. We found no quantitative studies linking insecure WPIR to HIV transmission behaviors. Data-sets with relevant variables were scarce, and those with both WPIR and HIV variables could only provide superficial evidence of associations. Organizations addressing WPIR in Kenya and Uganda did not collect data that could shed light on the connection between WPIR and HIV, but the two had data and community networks that could provide a good foundation for a future study that would include the collection of additional information. Collaboration between groups addressing WPIR and HIV transmission could provide the quantitative evidence needed to determine whether and how a WPIR structural intervention could decrease HIV transmission.