Service-seeking behaviors among male victims of violence in five African countries: The effects of positive and adverse childhood experiences.

BACKGROUND: Violence against boys and men is widely under-reported. Boys and men face unique and gendered barriers to accessing services following experiences of violence. PARTICIPANTS AND SETTING: The study is a secondary data analysis of five nationally representative population-based Violence Against Children and Youth Surveys (VACS) conducted in Kenya (2019), Côte d'Ivoire (2018), Lesotho (2018), Mozambique (2019), and Namibia (2019). Analysis was limited to males between 18 and 24 years who experienced lifetime physical or sexual violence. OBJECTIVE AND METHODS: We analyzed the association between positive and adverse childhood experiences (PCEs and ACEs), and seeking post-violence services among males using bivariate chi-squared tests and multivariable logistic regression. RESULTS: 8.02 % (5.55-10.50 %) of male victims between the ages of 18 and 24 sought services for any lifetime physical or sexual violence. Witnessing interparental violence and experiencing death of one or both parents were each associated with increased odds of having sought post-violence services (aOR 2.43; 95 % CI: 1.25-4.79; aOR 2.27; 95 % CI: 1.14-4.50), controlling for education, violence frequency, and violence type. High parental monitoring was associated with increased odds of service seeking (aOR 1.79; 95 % CI: 1.02-3.16), while strong father-child relationship was associated with lower odds (aOR 0.45; 95 % CI: 0.23-0.89). CONCLUSION: These findings contribute to limited research on service-seeking behaviors among men and boys. While some parent-youth relationship factors were associated with higher odds of service-seeking, the outcome remained rare. Age and gender-related barriers should be addressed where post-violence care services are offered.

Patterns of adverse childhood experiences and their associations with mental distress, substance use and sexual risk behaviors in Sub-Saharan Africa.

BACKGROUND: Multiple adverse childhood experiences (ACEs) are associated with poor sexual and mental health outcomes in low- and middle-income countries (LMICs). Less well understood is how discrete and gendered clustering of ACEs may influence health. OBJECTIVE: To assess how multiple ACEs co-occur and how dominant patterns of co-occurrence are associated with mental distress, substance use, and sexual risk behaviors among young women and men in Sub-Saharan Africa. PARTICIPANTS AND SETTING: We used pooled data of young men and women aged 19-24 from comparable, nationally representative Violence Against Children and Youth Surveys (VACS) conducted in Cote d'Ivoire, Kenya, Lesotho, Mozambique, and Namibia (nf = 7183; nm = 2207). METHODS: We estimated sex-disaggregated latent classes of six ACEs among young women and men. We ran Bolck-Croon-Hagenaars (BCH) distal outcome analysis to test the sex-stratified relationships between ACEs latent classes and health outcomes. RESULTS: A six class solution best fit the female data. Classes included witnessing violence and experiencing physical violence (PV); experiencing PV; high ACEs; witnessing community violence; orphanhood; and low ACEs exposure. Among males, the best-fitting three-class solution included experiencing PV and witnessing community violence; high ACEs; and low ACEs exposure. Membership in the high ACEs class was associated with mental distress among females and males, and substance use among males. No differences in sexual risk behavior were identified by class membership among either females or males. CONCLUSIONS: Discrete clusters of co-occurring ACEs are associated with elevated odds of mental distress among females, and mental distress and substance use among males. Preventing ACEs may improve mental health among young women and men in LMICs in Sub-Saharan Africa.

Adverse childhood experiences, HIV and sexual risk behaviors - Five sub-Saharan countries, 2018-2020.

BACKGROUND: Adverse childhood experiences (ACEs) have been shown to have negative, lasting effects on health including increasing the likelihood of engaging in sexual risk behaviors. OBJECTIVE: This study aimed to identify associations between exposures to ACEs and sexual risk behaviors and HIV service utilization among young people. PARTICIPANTS AND SETTING: A sample of 8023 sexually active young people (19-24 year olds) from five sub-Saharan African countries participated Violence Against Children and Youth Surveys (VACS). METHODS: Descriptive analysis of demographic variables, individual ACEs, cumulative ACEs, sexual risk behaviors, HIV testing, antiretroviral treatment (ART) and Antenatal Care (ANC) attendance were completed. Bivariate and multivariable logistic regression analyses were conducted to assess the associations between both individual and cumulative ACEs, sexual HIV risk behaviors, and service utilization while controlling for important covariates such as demographic, having ever been pregnant, had an STI, and used contraception. RESULTS: Exposure to three or more ACEs was higher among males (26.1 %) compared to females (21.3 %); p = 0.003. The most prominent sexual risk behavior for females was having sexual partners who were at least 5 years older (45.7 % compared to males 3.7 %; p < 0.0001) whereas in males it was no or infrequent condom use (45.3 % compared to females 30.1 %; p < 0.0001). Males and females exposed to childhood sexual violence had seven and four times the odds of engaging in transactional sex (aOR = 7.34, 95 % CI: [3.5-15.0]) and (aOR =3.75, 95 % CI: [2.3-6.2], respectively. Females exposed to three or more ACEs were four times more likely to engage in transactional sex (aOR = 4.85, 95 %, CI: [1.6-14.4]) compared to those who did not experience any ACEs. Males exposed to three or more ACEs were two times more likely to engage in early sexual debut (aOR = 2.2, 95 % CI: [1.3-3.4]),]) compared to those who did not experience any ACEs. Females who had witnessed IPV or violence in the community had significantly higher odds of getting tested for HIV (aOR = 2.16, 95 % CI: [1.63-2.87]) and (aOR = 1.36, 95 % CI: [1.03-1.81]), respectively. CONCLUSIONS: This study demonstrated that experiencing ACEs during childhood is associated with higher HIV risk behaviors in sub-Saharan Africa (SSA) with unique differences between males and females.

SARS-CoV-2 Rebound With and Without Use of COVID-19 Oral Antivirals.

Early treatment with a first-line therapy (nirmatrelvir/ritonavir [Paxlovid] or remdesivir) or second-line therapy (molnupiravir) prevents hospitalization and death among patients with mild-to-moderate COVID-19 who are at risk for severe disease and is recommended by the National Institutes of Health COVID-19 Treatment Guidelines. On May 25, 2023, the Food and Drug Administration approved nirmatrelvir/ritonavir for treatment of adults at high risk for severe disease. Although antiviral therapies are widely available, they are underutilized, possibly because of reports of SARS-CoV-2 rebound after treatment. To enhance current understanding of rebound, CDC reviewed SARS-CoV-2 rebound studies published during February 1, 2020- November 29, 2023. Overall, seven of 23 studies that met inclusion criteria, one randomized trial and six observational studies, compared rebound for persons who received antiviral treatment with that for persons who did not receive antiviral treatment. In four studies, including the randomized trial, no statistically significant difference in rebound rates was identified among persons receiving treatment and those not receiving treatment. Depending on the definition used, the prevalence of rebound varied. No hospitalizations or deaths were reported among outpatients who experienced rebound, because COVID-19 signs and symptoms were mild. Persons receiving antiviral treatment might be at higher risk for rebound compared with persons not receiving treatment because of host factors or treatment-induced viral suppression early in the course of illness. The potential for rebound should not deter clinicians from prescribing lifesaving antiviral treatments when indicated to prevent morbidity and mortality from COVID-19.

Awareness of and willingness to use oral pre-exposure prophylaxis (PrEP) for HIV prevention among sexually active adults in Malawi: results from the 2020 Malawi population-based HIV impact assessment.

BACKGROUND: The World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi. METHODS: MPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted. RESULTS: We included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2-15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2-1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4-4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8-74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1-1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4-1.9), were associated higher willingness to use PrEP. CONCLUSIONS: In this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.

Fostering Access to PrEP Among Adolescent Girls and Young Women Aged 16 to 24 Years at High Risk of HIV Through the DREAMS Initiative in Four Districts in Zambia.

Adolescent girls and young women (AGYW) in sub-Saharan Africa remain at high risk for HIV, yet limited data exist on implementation of HIV pre-exposure prophylaxis (PrEP) for this group. We examined PrEP uptake among AGYW using a retrospective cohort enrolled in the Determined Resilient Empowered AIDS-free Mentored Safe (DREAMS) initiative in Zambia between October 2020 and March 2022. Consent was obtained from eligible AGYW at substantial risk for HIV, and they voluntarily participated in PrEP. Multivariable logistic regression was used to examine factors associated with PrEP refills following initiation. Of 4,162 HIV-negative AGYW, 3,233 (77%) were at substantial risk and initiated on PrEP. Overall, 68% of AGYW had at least one refill, but this differed significantly by age group and district. DREAMS was successful at reaching AGYW with PrEP services. More evidence is needed to assess reasons for discontinuation and to improve persistence for those with sustained HIV risk.

Understanding Gender-Based Violence Service Delivery in CDC-Supported Health Facilities: 15 Sub-Saharan African Countries, 2017-2021.

Gender-based violence (GBV) is a complex issue deeply rooted in social structures, making its eradication challenging. GBV increases the risk of HIV transmission and is a barrier to HIV testing, care, and treatment. Quality clinical services for GBV, which includes the provision of HIV postexposure prophylaxis (PEP), vary, and service delivery data are lacking. We describe GBV clinical service delivery in 15 countries supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention. Through a descriptive statistical analysis of PEPFAR Monitoring, Evaluation, and Reporting (MER) data, we found a 252% increase in individuals receiving GBV clinical services, from 158,691 in 2017 to 558,251 in 2021. PEP completion was lowest (15%) among 15-19-year-olds. Understanding GBV service delivery is important for policy makers, program managers, and providers to guide interventions to improve the quality of service delivery and contribute to HIV epidemic control.

HIV Recent Infection and Past HIV Testing History Among Newly HIV-Diagnosed 15-24-Year-Olds in Malawi: An Analysis of 2019-2022 HIV Recent Infection Surveillance Data.

Awareness of HIV status in Malawi is 88.3% and lowest among 15-24-year-olds (76.2%). There is a need to understand HIV testing history and transmission in this age group. We analyzed pooled HIV surveillance data to describe testing history and HIV recent infection among 8,389 HIV-positive 15-24-year-olds from 251 sites in Malawi between 2019 and 2022. Most HIV-positive 15-24-year-olds were female; aged 23-24 years; rural residents; and diagnosed at voluntary counseling and testing. No prior HIV testing was reported in 43.5% and 32.9% of 15-19-year-olds and males, respectively. Overall, 4.9% of HIV-positive diagnoses were classified as recent HIV infections, with the highest proportions among breastfeeding women (8.2%); persons tested at sexually transmitted infection clinics (9.0%); persons with a prior negative test within 6 months (13.0%); and 17-18-year-olds (7.3%). Tailored and innovative HIV prevention and testing strategies for young adolescents, young males, and pregnant and breastfeeding women are needed for HIV epidemic control.

Population Estimates of HIV Risk Factors to Inform HIV Prevention Programming for Adolescent Girls and Young Women.

Violence Against Children and Youth Survey (VACS) data from seven countries were analyzed to estimate population-level eligibility for the President's Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) HIV prevention program for adolescent girls and young women (AGYW). The prevalence of overall eligibility and individual risk factors, including experiences of violence, social, and behavioral risks differ across countries and age groups. A large proportion of AGYW across all countries and age groups examined have at least one risk factor making them eligible for DREAMS. Experiencing multiple risks is also common, suggesting that researchers and programs could work together to identify combinations of risk factors that put AGYW at greatest risk of HIV acquisition, or that explain most new HIV infections, to more precisely target the most vulnerable AGYW. The VACS provides important data for such analyses to refine DREAMS and other youth programming.

Strong Father-Child Relationships and Other Positive Childhood Experiences, Adverse Childhood Experiences, and Sexual Risk Factors for HIV among Young Adults Aged 19-24 Years, Namibia, 2019: A Cross-Sectional Study.

Using cross-sectional data from the 2019 Namibia Violence Against Children and Youth Survey and sex-stratified multivariable models, we assessed the associations between four different positive childhood experiences (PCEs) and having ≥3 adverse childhood experiences (ACEs), including ≥3 ACE-PCE interaction terms, and seven sexual risk factors for HIV acquisition among young adults aged 19-24 years. One PCE, having a strong father-child relationship, was inversely associated with two risk factors among women (lifetime transactional sex (OR, 0.4; 95% CI, 0.2-0.7) and recent age-disparate sexual relationships (OR, 0.3; 95% CI, 0.2-0.5)), and significantly interacted with having ≥3 ACEs for three risk factors among women (not knowing a partner's HIV status, infrequently using condoms, and ever having an STI) and one among men (having multiple sexual partners in the past year). The other PCEs were significantly associated with ≤1 HIV risk factor and had no significant interaction terms. Strong father-child relationships may reduce HIV acquisition risk and mitigate the effect of childhood adversity on HIV risk among young adults in Namibia.

Information for Persons Who Are Immunocompromised Regarding Prevention and Treatment of SARS-CoV-2 Infection in the Context of Currently Circulating Omicron Sublineages - United States, January 2023.

As of January 20, 2023, >90% of circulating SARS-CoV-2 variants in the United States, specifically Omicron BQ.1, BQ.1.1, XBB, and XBB.1.5 sublineages, are unlikely to be susceptible to the combined monoclonal antibodies, tixagevimab and cilgavimab (Evusheld) used for preexposure prophylaxis against SARS-CoV-2 infection (1). The Food and Drug Administration announced on January 26, 2023, that Evusheld is not currently authorized for preexposure prophylaxis against SARS-CoV-2 infection in the United States (2). It is important that persons who are moderately to severely immunocompromised,* those who might have an inadequate immune response to COVID-19 vaccination, and those with contraindications to receipt of COVID-19 vaccines, exercise caution and recognize the need for additional preventive measures (Box). In addition, persons should have a care plan that includes prompt testing at the onset of COVID-19 symptoms and rapid access to antivirals if SARS-CoV-2 infection is detected.

Gender-Based Violence Laws in Ten African Countries with High HIV Prevalence and Incidence Among Adolescent Girls and Young Women.

To understand laws pertaining to gender-based violence (GBV) in countries with high HIV prevalence particularly among adolescent girls and young women (AGYW), we reviewed GBV laws and regulations from initial ten eastern and southern African countriesparticipating in the United States President's Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, AIDS-free, Mentored, and Safe (DREAMS) Initiative and highlighted similarities and differences across these jurisdictions. All ten countries (Eswatini, Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe) have GBV legislation in place but lack robust information on its implementation and enforcement. Given the known association between GBV and HIV acquisition among AGYW, an increased understanding of GBV laws, their variation across countries and respective gaps, as well as the interplay between enabling, protective, and punitive laws can strengthen policy environments for improved GBV prevention and response, which in turn can lower incidental HIV acquisition among AGYW. For greater impact, GBV policies would require reform, implementation, monitoring, and enforcement.

Notes From the Field: Dispensing of Oral Antiviral Drugs for Treatment of COVID-19 by Zip Code-Level Social Vulnerability - United States, December 23, 2021-August 28, 2022.

Equitable access to COVID-19 therapeutics is a critical aspect of the distribution program led by the U.S. Department of Health and Human Services (HHS).* Two oral antiviral products, nirmatrelvir/ritonavir (Paxlovid)† and molnupiravir (Lagevrio),§ received emergency use authorization (EUA) from the Food and Drug Administration (FDA) in December 2021, to reduce the risk for COVID-19-associated hospitalization and death for those patients with mild to moderate COVID-19 who are at higher risk for severe illness (1,2). HHS has been distributing these medications at no cost to recipients since their authorization. Data collected from provider sites during December 23, 2021-May 21, 2022, indicated substantial disparities in the population-adjusted dispensing rates in high social vulnerability (high-vulnerability) zip codes compared with those in medium- and low-vulnerability zip codes (3). Specifically, dispensing rates for the 4-week period during April 24-May 21, 2022, were 122 per 100,000 residents (19% of overall population-adjusted dispensing rates) in high-vulnerability zip codes compared with 247 (42%) in medium-vulnerability and 274 (39%) in low-vulnerability zip codes. This report provides an updated analysis of dispensing rates by zip code-level social vulnerability and highlights important intervention strategies.

Global Challenges with Oral Antivirals for COVID-19.

Oral antivirals for COVID-19 can be game changers in low- and middle-income countries (LMICs). Challenges that may hinder current and future oral antiviral rollouts span use in special populations, drug-drug and herb-drug interactions, adverse events, development of resistance, black markets, and equity in access and prescribing. Future antivirals may address some of these barriers; however, health systems around the world should be equipped to receive and administer COVID-19 oral antivirals. Improvements in manufacturing capacity, community engagement, capacity for testing and linkage to care, and systems for surveillance and safety monitoring could "change the game" for LMICs, irrespective of any specific antiviral drug. Investments in health care infrastructure can promote resilience, not only for COVID-19 but also for future local and global health crises.

Summary of Guidance for Minimizing the Impact of COVID-19 on Individual Persons, Communities, and Health Care Systems - United States, August 2022.

As SARS-CoV-2, the virus that causes COVID-19, continues to circulate globally, high levels of vaccine- and infection-induced immunity and the availability of effective treatments and prevention tools have substantially reduced the risk for medically significant COVID-19 illness (severe acute illness and post-COVID-19 conditions) and associated hospitalization and death (1). These circumstances now allow public health efforts to minimize the individual and societal health impacts of COVID-19 by focusing on sustainable measures to further reduce medically significant illness as well as to minimize strain on the health care system, while reducing barriers to social, educational, and economic activity (2). Individual risk for medically significant COVID-19 depends on a person's risk for exposure to SARS-CoV-2 and their risk for developing severe illness if infected (3). Exposure risk can be mitigated through nonpharmaceutical interventions, including improving ventilation, use of masks or respirators indoors, and testing (4). The risk for medically significant illness increases with age, disability status, and underlying medical conditions but is considerably reduced by immunity derived from vaccination, previous infection, or both, as well as timely access to effective biomedical prevention measures and treatments (3,5). CDC's public health recommendations change in response to evolving science, the availability of biomedical and public health tools, and changes in context, such as levels of immunity in the population and currently circulating variants. CDC recommends a strategic approach to minimizing the impact of COVID-19 on health and society that relies on vaccination and therapeutics to prevent severe illness; use of multicomponent prevention measures where feasible; and particular emphasis on protecting persons at high risk for severe illness. Efforts to expand access to vaccination and therapeutics, including the use of preexposure prophylaxis for persons who are immunocompromised, antiviral agents, and therapeutic monoclonal antibodies, should be intensified to reduce the risk for medically significant illness and death. Efforts to protect persons at high risk for severe illness must ensure that all persons have access to information to understand their individual risk, as well as efficient and equitable access to vaccination, therapeutics, testing, and other prevention measures. Current priorities for preventing medically significant illness should focus on ensuring that persons 1) understand their risk, 2) take steps to protect themselves and others through vaccines, therapeutics, and nonpharmaceutical interventions when needed, 3) receive testing and wear masks if they have been exposed, and 4) receive testing if they are symptomatic, and isolate for ≥5 days if they are infected.

From policy to practice: uptake of pre-exposure prophylaxis among adolescent girls and young women in United States President's Emergency Plan for AIDS Relief-supported countries, 2017-2020.

BACKGROUND: The US President's Emergency Plan for AIDS Relief's (PEPFAR) first implemented pre-exposure prophylaxis (PrEP) for HIV prevention through the Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe (DREAMS) partnership in 2016. PrEP is a critical intervention to achieve the main objective of DREAMS, reducing new HIV infections among 15-14 year old adolescent girls and young women (AGYW) in 15 high HIV burdened countries. METHODS: We describe uptake of PrEP among AGYW in PEPFAR. Most PrEP programs screened persons who tested HIV-negative for eligibility and offered PrEP as part of combination prevention with follow-up, including repeat HIV testing and counseling, at 3-month intervals. Platforms providing comprehensive services for AGYW were also leveraged. We examined two PEPFAR monitoring indicators, using the FY20Q4 Monitoring, Evaluation, Reporting (MER) indicator dataset to assess progress in PrEP uptake, and descriptive narratives to understand successes and challenges from fiscal year 2017 to 2020. To assess coverage, we calculated the PrEP to Need ratio (PnR) using a published methodology. RESULTS: From FY2017 to FY2020, 576570 total clients initiated PrEP and the number of PEPFAR countries offering PrEP doubled from 12 to 24. Of 360073 (62% of total) initiations among women, 52% were among AGYW with steady increases from year to year. Among all AGYW, 20-24-year-old women represented a significantly higher proportion of PrEP initiators than adolescents (15-19years) (64 versus 36%, P  < 0.05). Of all 186985 PrEP initiations among AGYW, 99% were in DREAMS countries. Barriers, such as low demand and adherence, were addressed through outreach efforts, including mobile sites, use of technology to educate and support AGYW, media campaigns, and engaging peers in program implementation. We saw a 2.5-fold increase in PrEP uptake among AGYW from 2018 to 2019; by 2020, all DREAMS countries were implementing PrEP. However, PrEP coverage among AGYW in DREAMS countries remains low (PnR range: 0-4.1); only two have a PnR greater than 1 where there were more PrEP users than new HIV diagnoses. CONCLUSION: PrEP uptake among AGYW has grown since 2016; however, challenges remain. Tools to improve adherence are needed to improve PrEP persistence among AGYW. National policies to facilitate greater PrEP uptake among adolescents would be beneficial. A greater need for PrEP in DREAMS countries is evident and if realized, will contribute to epidemic control.