Advancing Adolescent and Young Adult HIV Prevention and Care and Treatment Through Use of Multi-level Theories and Frameworks: A Scoping Review and Adapted HIV Ecological Framework.

While multi-level theories and frameworks have become a cornerstone in broader efforts to address HIV inequities, little is known regarding their application in adolescent and young adult (AYA) HIV research. To address this gap, we conducted a scoping review to assess the use and application of multi-level theories and frameworks in AYA HIV prevention and care and treatment empirical research. We systematically searched five databases for articles published between 2010 and May 2020, screened abstracts, and reviewed eligible full-text articles for inclusion. Of the 5890 citations identified, 1706 underwent full-text review and 88 met the inclusion criteria: 70 focused on HIV prevention, with only 14 on care and treatment, 2 on both HIV prevention and care and treatment, and 2 on HIV-affected AYA. Most authors described the theory-based multi-level framework as informing their data analysis, with only 12 describing it as informing/guiding an intervention. More than seventy different multi-level theories were described, with 38% utilizing socio-ecological models or the eco-developmental theory. Findings were used to inform the adaptation of an AYA World Health Organization multi-level framework specifically to guide AYA HIV research.

Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial.

BACKGROUND: Although evidence-based treatments for depression in low-resource settings are established, implementation strategies to scale up these treatments remain poorly defined. We aimed to compare two implementation strategies in achieving high-quality integration of depression care into chronic medical care and improving mental health outcomes in patients with hypertension and diabetes. METHODS: We conducted a parallel, cluster-randomised, controlled, implementation trial in ten health facilities across Malawi. Facilities were randomised (1:1) by covariate-constrained randomisation to either an internal champion alone (ie, basic strategy group) or an internal champion plus external supervision with audit and feedback (ie, enhanced strategy group). Champions integrated a three-element, evidence-based intervention into clinical care: universal depression screening; peer-delivered psychosocial counselling; and algorithm-guided, non-specialist antidepressant management. External supervision involved structured facility visits by Ministry officials and clinical experts to assess quality of care and provide supportive feedback approximately every 4 months. Eligible participants were adults (aged 18-65 years) seeking hypertension and diabetes care with signs of depression (Patient Health Questionnaire-9 score ≥5). Primary implementation outcomes were depression screening fidelity, treatment initiation fidelity, and follow-up treatment fidelity over the first 3 months of treatment, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03711786, and is complete. FINDINGS: Five (50%) facilities were randomised to the basic strategy and five (50%) to the enhanced strategy. Between Oct 1, 2019, and Nov 30, 2021, in the basic group, 587 patients were assessed for eligibility, of whom 301 were enrolled; in the enhanced group, 539 patients were assessed, of whom 288 were enrolled. All clinics integrated the evidence-based intervention and were included in the analyses. Of 60 774 screening-eligible visits, screening fidelity was moderate (58% in the enhanced group vs 53% in the basic group; probability difference 5% [95% CI -38% to 47%]; p=0·84) and treatment initiation fidelity was high (99% vs 98%; 0% [-3% to 3%]; p=0·89) in both groups. However, treatment follow-up fidelity was substantially higher in the enhanced group than in the basic group (82% vs 20%; 62% [36% to 89%]; p=0·0020). Depression remission was higher in the enhanced group than in the basic group (55% vs 36%; 19% [3% to 34%]; p=0·045). Serious adverse events were nine deaths (five in the basic group and four in the enhanced group) and 26 hospitalisations (20 in the basic group and six in the enhanced group); none were treatment-related. INTERPRETATION: The enhanced implementation strategy led to an increase in fidelity in providers' follow-up treatment actions and in rates of depression remission, consistent with the literature that follow-up decisions are crucial to improving depression outcomes in integrated care models. These findings suggest that external supervision combined with an internal champion could offer an important advance in integrating depression treatment into general medical care in low-resource settings. FUNDING: The National Institute of Mental Health.

Understanding motivations and resilience-associated factors to promote timely linkage to HIV care: a qualitative study among people living with HIV in western Kenya.

Understanding motivations and resilience-associated factors that help people newly diagnosed with HIV link to care is critical in the context of universal test and treat. We analyzed 30 in-depth interviews (IDI) among adults aged 18 and older in western Kenya diagnosed with HIV during home-based counseling and testing and who had linked to HIV care. A directed content analysis was performed, categorizing IDI quotations into a table based on linkage stages for organization and then developing and applying codes from self-determination theory and the concept of resilience. Autonomous motivations, including internalized concerns for one's health and/or to provide care for family, were salient facilitators of accessing care. Controlled forms of motivation, such as fear or external pressure, were less salient. Social support was an important resilience-associated factor fostering linkage. HIV testing and counseling programs which incorporate motivational interviewing that emphasizes motivations related to one's health or family combined with a social support/navigator approach, may promote timely linkage to care.

Population-Based Estimates and Predictors of Child and Adolescent Linkage to HIV Care or Death in Western Kenya.

BACKGROUND: Population-level estimates of linkage to HIV care among children and adolescents (CAs) can facilitate progress toward 95-95-95 goals. SETTING: This study was conducted in Bunyala, Chulaimbo, and Teso North subcounties, Western Kenya. METHODS: Linkage to care was defined among CAs diagnosed with HIV through Academic Model Providing Access to Healthcare (AMPATH)'s home-based counseling and testing initiative (HBCT) by merging HBCT and AMPATH Medical Record System data. Using follow-up data from Bunyala, we examined factors associated with linkage or death, using weighted multinomial logistic regression to account for selection bias from double-sampled visits. Based on the estimated model, we imputed the trajectory for each person in 3 subcounties until a simulated linkage or death occurred or until the end of 8 years when an individual was simulated to be censored. RESULTS: Of 720 CAs in the analytic sample, 68% were between 0 and 9 years and 59% were female. Probability of linkage among CAs in the combined 3 subcounties was 48%-49% at 2 years and 64%-78% at 8 years while probability of death was 13% at 2 years and 19% at 8 years. Single or double orphanhood predicted linkage (adjusted odds ratio [aOR]: 2.66, 95% confidence interval [CI]: 1.33 to 5.32) and death (aOR: 9.85 [95% CI: 2.21 to 44.01]). Having a mother known to be HIV-positive also predicted linkage (aOR = 1.94, 95% CI: 0.97 to 3.86) and death (aOR: 14.49, 95% CI: 3.32 to 63.19). CONCLUSION: HIV testers/counselors should continue to ensure linkage among orphans and CAs with mothers known to be HIV-positive and also to support other CAs to link to HIV care.

Addressing the Know-Do Gap in Adolescent HIV: Framing and Measuring Implementation Determinants, Outcomes, and Strategies in the AHISA Network.

Implementation science (IS) uses systematic methods to close gaps between research and practice by identifying and addressing barriers to implementation of evidence-based interventions (EBIs). To reach UNAIDS HIV targets, IS can support programs to reach vulnerable populations and achieve sustainability. We studied the application of IS methods in 36 study protocols that were part of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA). Protocols focused on youth, caregivers, or healthcare workers in high HIV-burden African countries and evaluated medication, clinical and behavioral/social EBIs. All studies measured clinical outcomes and implementation science outcomes; most focused on early implementation outcomes of acceptability (81%), reach (47%), and feasibility (44%). Only 53% used an implementation science framework/theory. Most studies (72%) evaluated implementation strategies. Some developed and tested strategies, while others adapted an EBI/strategy. Harmonizing IS approaches allows cross study learning and optimization of delivery of EBIs and could support attainment of HIV goals.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network.

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Research in the AHISA Network.

Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.

Associations between spousal gender equity and recent unintended pregnancy among married adolescent girls and their husbands in rural Niger.

This study in rural Niger examines if gender equity attitudes of married adolescent girls and their husbands are associated with recent unintended pregnancy (UIP) and ever-use of family planning (FP). Logistic regression models were used to calculate adjusted associations between husbands' and wives' equity (jointly and separately) and the two outcomes. UIP was less likely to be reported by adolescent girls with equitable husbands, controlling for wife's equity (adjusted odds ratio/aOR: 0.57, 95% confidence interval/CI: 0.41-0.80), and was more likely to be reported by equitable wives (aOR: 2.26, CI: 1.59-3.24). In stratified analyses, wife's equity was associated with a nearly three-fold likelihood of UIP in couples with inequitable husbands (aOR: 2.79, CI: 1.58-5.05). Ever having used FP was not associated with husbands' or wives' gender equity. Interventions targeting reproductive health outcomes for married adolescent girls should focus on spousal equity attitudes - improving wives' equity might be ineffective if husbands remain inequitable.

Health Beliefs and Preventive Behaviors Among Adults During the Early COVID-19 Pandemic in the United States: a Latent Class Analysis.

The objectives of this study are to (1) characterize patterns of preventive behaviors 3 months after the COVID-19 pandemic was declared a national emergency in the USA and (2) identify how health beliefs (e.g., perceived risk of infection, perceived risk of death upon infection, and perceived effectiveness of CDC-recommended preventive behaviors) and sociodemographic characteristics are associated with preventive behaviors. Data were obtained from two waves of the Understanding America Study (UAS) conducted in March (wave 1) and May to June of 2020 (wave 2) (n = 4445); UAS is a nationally representative panel of US adults. We conducted a latent class analysis (LCA) using wave 2 data to identify our outcome, patterns of 10 COVID-preventive behaviors (e.g., wearing a facemask, handwashing, social distancing), and then used a three-step regression (R3STEP) to test associations between the likelihood of class membership with (1) health beliefs and sociodemographic characteristics (age, sex, race/ethnicity, and educational attainment) in bivariate models and (2) health beliefs adjusted for sociodemographic characteristics in multivariate models. The LCA identified a three-class model of preventive behaviors characterized by high likelihood of engagement in the set of preventive behaviors ("high"), low likelihood of the preventive behaviors ("low"), or engagement in some behaviors ("mixed"). Respondents of older age (i.e., age 50 or older) and those with higher levels of educational attainment (i.e., a 4-year college degree or higher) were less likely to be in the low engagement versus the mixed engagement class compared to those who are younger (18-29) and have lower levels of educational attainment (i.e., high school), respectively. Women (compared to men) and respondents who were Black and/or Hispanic/Latinx (compared to White) were more likely to be in the high (vs. mixed) engagement class. In separate models adjusted for sociodemographic characteristics, respondents with a high perceived risk of infection, high perceived risk of death, and high perceived effectiveness of COVID-preventive behaviors were statistically significantly less likely to be in the low engagement relative to the mixed engagement class. Engagement in COVID-preventive behaviors varies by sociodemographic characteristics (i.e., age, sex, race/ethnicity and educational attainment) and health beliefs (i.e., perceived risk of infection, perceived risk of death, and perceived effectiveness of CDC-recommended behaviors). Our findings highlight the potential utility of using health beliefs to inform targeted prevention efforts to help reduce the spread of COVID-19 and future pandemics.

Women's and girls' experiences of reproductive coercion and opportunities for intervention in family planning clinics in Nairobi, Kenya: a qualitative study.

BACKGROUND: Reproductive coercion (RC), which includes contraceptive sabotage and pregnancy coercion, may help explain known associations between intimate partner violence (IPV) and poor reproductive health outcomes, such as unintended pregnancy. In Kenya, where 40% of ever-married women report IPV and 35% of ever-pregnant women report unintended pregnancy, these experiences are pervasive and co-occurring, yet little research exists on RC experiences among women and adolescent girls. This study seeks to qualitatively describe women's and girls' experiences of RC in Nairobi, Kenya and opportunities for clinical intervention. METHODS: Qualitative data were collected as part of the formative research for the adaptation of an evidence-based intervention to address reproductive coercion and IPV in clinical family planning counselling and provision in Nairobi, Kenya in April 2017. Focus group discussions (n = 4, 30 total participants) and in-depth interviews (n = 10) with family planning clients (ages 15-49) were conducted to identify specific forms of reproductive coercion, other partner-specific barriers to successful contraception use, and perceived opportunities for family planning providers to address RC among women and girls seeking family planning services. Additionally, data were collected via semi-structured interviews with family planning providers (n = 8) and clinic managers (n = 3) from family planning clinics. Data were coded according to structural and emergent themes, summarized, and illustrative quotes were identified to demonstrate sub-themes. Kenyan family planning providers and administrators informed interpretation. RESULTS: The results of this study identified specific forms of pregnancy coercion and contraceptive sabotage to be common, and often severe, impeding the use of contraceptives among female family planning clients. This study offers important examples of women's strategies for preventing pregnancy despite experiencing reproductive coercion, as well as opportunities for family planning providers to support clients experiencing reproductive coercion in clinical settings. CONCLUSIONS: Reproductive coercion is a critical barrier to modern contraceptive use in Kenya. Results from this study highlight opportunities for family planning providers to play a critical role in supporting women and girls in their use of contraception when reproductive coercion is present.

Married very young adolescent girls in Niger at greatest risk of lifetime male partner reproductive coercion and sexual violence.

OBJECTIVE: The purpose of this analysis was to compare and contrast reproductive health (RH), gender equity attitudes, and intimate partner violence (IPV) among married very young adolescent (VYA) girls with married older adolescent girls and young women (AGYW) in rural Niger given limited literature on the topic. METHODS: We conducted an exploratory analysis of baseline data from the Reaching Married Adolescents Trial in Dosso region, Niger. We report counts and percents, by age group (13-14 years (VYA), 15-16 years, 17-19 years), of AGYW's self-efficacy to use family planning (FP), accurate knowledge of FP, current use of modern FP, and unintended last pregnancy (UIP); lifetime reproductive coercion (RC), physical IPV, and sexual IPV; and gender equity attitudes. We also assess whether percents differ between VYA and older groups using Pearson's Chi-Square and Fisher's exact p-values. Results are stratified by parity. Finally, we use logistic regression to consider associations. RESULTS: There were 49 VYA, 248 girls aged 15-16, and 775 AGYW aged 17-19 in our sample (n = 1072). Accurate knowledge of FP, self-efficacy to use FP, current use of modern FP, and UIP increased with age; all percents between VYA and AGYW 17-19 were marginally or statistically significantly different. We also saw VYA report higher lifetime RC and sexual IPV versus older groups, with sexual IPV statistically different between VYA and girls 17-19. Parous VYA reported a significantly higher percent of lifetime RC versus older AGYW. Among 17-19 year-olds, odds of current use of FP were higher among AGYW who reported physical IPV, and odds of UIP were higher among those reporting more gender equitable attitudes, both adjusted for parity. CONCLUSIONS: We observed differences in RH, RC, and sexual IPV among married VYA and older AGYW in rural Niger. VYA should be prioritized in research to confirm and further understand their RH needs.

Longitudinal Trajectories of Physical Intimate Partner Violence Among Adolescent Girls in Rural South Africa: Findings From HPTN 068.

PURPOSE: Little is known about temporal patterns of physical intimate partner violence (PIPV) among South African adolescent girls. We sought to identify and describe PIPV risk trajectories and related correlates in this population. METHODS: Our analytical cohort came from the HPTN 068 Cash Transfer Trial in Mpumalanga Province, South Africa. Cohort members were eighth and ninth graders (median age 14 years) who enrolled in 2011 and had three to four annual, self-reported PIPV measurements. We used group-based trajectory models to identify groups of girls with similar longitudinal patterns of PIPV risk over 4 years and potential correlates of group membership. RESULTS: We identified two trajectory groups (n = 907): a higher-risk group (~52.8% of the cohort) with predicted PIPV probabilities of 13.5%-41.1% over time and a lower-risk group (~47.2% of the cohort) with predicted probabilities of 2.3%-10.3%. Baseline correlates of higher-risk group membership were ever having had sex (adjusted odds ratio [aOR]: 4.42, 95% confidence interval [CI]: 1.56-12.57), borrowing money (aOR: 1.95, 95% CI: 1.01-3.79), and older age (aOR per 1-year increase: 1.39, 95% CI: 1.11-1.73), while being in the 068 intervention arm (aOR: .29, 95% CI: .17-.51) and supporting more gender-equitable norms (aOR per 1-unit score increase: .89, 95% CI: .81-.97) were inversely associated. CONCLUSIONS: A high proportion of adolescent girls experience sustained PIPV risk in rural South Africa, suggesting a need for interventions in late primary school that encourage gender-equitable norms, healthy relationships, and safe ways to earn income during adolescence.

Protocol for cluster randomized evaluation of reaching married adolescents - a gender-synchronized intervention to increase modern contraceptive use among married adolescent girls and young women and their husbands in Niger.

BACKGROUND: Early marriage and early childbearing are highly prevalent in Niger with 75% of girls married before age 18 years and 42% of girls giving birth between ages 15 and 18 years. In 2012, only 7% of all 15-19-year-old married adolescents (male and female) reported use of a modern contraceptive method with barriers including misinformation, and social norms unsupportive of contraception. To meet the needs of married adolescents and their husbands in Niger, the Reaching Married Adolescents (RMA) program was developed with the goal of improving modern contraceptive method uptake in the Dosso region of Niger. METHODS: Using a four-arm cluster randomized control design, the RMA study seeks to assess whether household visits only (Arm 1), small group discussions only (Arm 2), or a combination of both (Arm 3), as compared to controls (no intervention - Arm 4), improve modern contraceptive method use among married adolescent girls and young women (AGYW), age 13-19 years-old, in three districts of the Dosso region. Intervention conditions were randomly assigned across the three districts, Dosso, Doutchi, and Loga. Within each district, eligible villages were assigned to either that intervention condition or to the control condition (12 intervention and 4 control per district). Across the three intervention conditions, community dialogues regarding modern contraceptive use were also implemented. Data for the study was collected at baseline (April - June 2016), at 24 months post-intervention (April - June 2018), and a final round of data collection will occur at 40 months post-intervention (October - December 2019). DISCUSSION: The RMA intervention is a gender-synchronized and community-based program implemented among married adolescent girls and their husbands in the context of rural Niger. The intervention is designed to provide education about modern contraception and to promote gender equity in order to increase uptake of modern contraceptive methods. Results from this cluster randomized control study will contribute to the knowledge base regarding the utility of male engagement as a strategy within community-level approaches to promote modern contraceptive method use in the high need context of West Africa. TRIAL REGISTRATION: Registered October 2017 - ClinicalTrials.gov NCT03226730.

Process elements contributing to community mobilization for HIV risk reduction and gender equality in rural South Africa.

Community mobilization has been recognized as a critical enabler for HIV prevention and is employed for challenging gender inequalities. We worked together with community partners to implement the 'One Man Can' intervention in rural Mpumalanga, South Africa to promote gender equality and HIV risk reduction. During the intervention, we conducted longitudinal qualitative interviews and focus group discussions with community mobilizers (n = 26), volunteer community action team members (n = 22) and community members (n = 52) to explore their experience of being part of the intervention and their experiences of change associated with the intervention. The objective of the study was to examine processes of change in community mobilization for gender equity and HIV prevention. Our analysis showed that over time, participants referred to three key elements of their engagement with the intervention: developing respect for others; inter-personal communication; and empathy. These elements were viewed as assisting them in adopting a 'better life' and associated with behaviour change in the intervention's main focus areas of promoting gender equality and HIV risk reduction behaviours. We discuss how these concepts relate to the essential domains contained within our theoretical framework of community mobilization-specifically critical consciousness, shared concerns and social cohesion -, as demonstrated in this community. We interpret the focus on these key elements as significant indicators of communities engaging with the community mobilization process and initiating movement towards structural changes for HIV prevention.

Prevalence and Associations, by Age Group, of IPV Among AGYW in Rural South Africa.

The prevalence of intimate partner violence (IPV) is alarmingly high among South African adolescent girls and young women (AGYW). Limited data exist exploring how IPV prevalence and its risk factors differ by age. Study data were from the baseline visit of HPTN 068, a randomized controlled trial (RCT) conducted from 2011 to 2015 in Mpumalanga, South Africa. A cohort of 2,533 AGYW, aged 13 years to 20 years, answered survey questions on demographics and behaviors, including their experiences of physical and sexual violence ever and in the past 12 months. We calculated the prevalence of IPV and related risk factors, as well as prevalence ratios with 95% confidence intervals, stratified by age. Nearly one quarter (19.5%, 95% CI = [18.0, 21.2]) of AGYW experienced any IPV ever (physical or sexual) by a partner. The prevalence of any IPV ever among AGYW aged 13 years to 14 years, 15 years to 16 years, and 17 years to 20 years was 10.8%, 17.7%, and 32.1%, respectively. Key variables significantly associated with any IPV ever across all age groups included borrowing money from someone outside the home in the past 12 months, ever having had vaginal sex, ever having had anal sex, and consuming any alcohol. Few statistically significant associations were unique to specific age groups. The history of IPV among the youngest AGYW is a critical finding and should be a focus of prevention efforts.

Community collective efficacy is associated with reduced physical intimate partner violence (IPV) incidence in the rural province of Mpumalanga, South Africa: findings from HPTN 068.

BACKGROUND: Intimate partner violence (IPV) is a human rights violation and is associated with a variety of adverse physical and mental health outcomes. Collective efficacy, defined as mutual trust among community members and willingness to intervene on the behalf of the common good, has been associated with reduced neighbourhood violence. Limited research has explored whether community collective efficacy is associated with reduced incidence of IPV. This is of particular interest among adolescent girls and young women (AGYW) in sub-Saharan Africa, where the burden of HIV is greatest and IPV is common. METHODS: We collected longitudinal data among 2533 AGYW (ages 13-20) enrolled in the HPTN 068 cohort in Mpumalanga province, South Africa between 2011 and 2016. We included participants from 26 villages where community surveys were collected during the HPTN 068 study. Collective efficacy was measured at the village level via two population-based cross-sectional surveys in 2012 and 2014. Multivariable Poisson generalised estimating equation regression models estimated the relative risk ratio (RR) between village collective efficacy scores and subsequent physical IPV 12 month incidence, adjusting for village-level clustering and covariates. RESULTS: Thirty-eight per cent of the cohort (n=950) reported at least one episode of recent physical IPV during follow-up. For every SD higher level of collective efficacy, there was a 6% lower level of physical IPV incidence (adjusted RR: 0.94; 95% CI 0.89 to 0.98) among AGYW after adjusting for covariates. CONCLUSIONS: Community-level interventions that foster the development of collective efficacy may reduce IPV among AGYW.

Starting the Conversation: Are Campus Sexual Assault Policies Related to the Prevalence of Campus Sexual Assault?

One goal of university campus sexual assault (CSA) policies is to help prevent CSA. Federal guidance in the 2014 White House Task Force to Protect Students From Sexual Assault Checklist for Campus Sexual Misconduct Policies suggests 10 elements for inclusion in CSA policies (e.g., Policy Introduction, Grievance/Adjudication), and outlines policy topics to be included within each element (Policy Introduction includes two topics: statement of prohibition against sex discrimination including sexual misconduct and statement of commitment to address sexual misconduct). However, no research has examined whether CSA policies impact CSA prevalence. To begin addressing this gap, we studied 24 universities participating in the 2015 Association of American Universities Campus Climate Survey on Sexual Assault and Sexual Misconduct. We linked 2014-2015 data from these universities' CSA policies and their CSA prevalence findings from the 2015 Association of American Universities (AAU) survey. To test whether the comprehensiveness of schools' CSA policies was related to schools' CSA prevalence, we examined the degree to which the CSA policies included recommended policy content from the aforementioned Checklist. Policies were characterized as more comprehensive if they included greater numbers of Checklist topics. We then correlated the number of topics within the policies with school-level CSA prevalence. We also explored whether there was lower CSA prevalence among schools with policies containing particular topics. Results suggested that greater comprehensiveness of schools' entire CSA policies was negatively correlated with CSA prevalence; however, these findings did not approach statistical significance. The number of negative correlations observed between schools' CSA policy elements and CSA prevalence among undergraduate women was greater than expected by chance alone, suggesting a possible connection between comprehensive CSA policies and CSA prevalence. Schools with policies that included a topic on their sexual assault response team had the lowest CSA prevalence for both women and men, and schools that included topics describing grievance/adjudication procedures had lower CSA prevalence. This study provides a novel examination of CSA and could inform needed research related to the impact of CSA policies on CSA.

Leveraging Data to Strengthen Campus Sexual Assault Policies.

The U.S. Department of Education recently announced that existing legislation and guidance on campus sexual assault (CSA) policies had created a "failed system" in institutions of higher education. This announcement raises the question of how CSA legislation and guidance should be evaluated and applied in practice. We believe researchers are well situated to not only leverage data and empirically evaluate the success (or failure) of CSA federal and university policies but also to facilitate development of improved, more effective CSA policy. This commentary first chronicles the pivotal role of federal policy and guidance in driving the collection of CSA data and increasing research efforts in this domain. Second, we present recommendations for increased collaboration among researchers, practitioners, and policy makers aimed at measuring the effectiveness of current CSA policies and promoting data-driven policy. These recommendations focus on (a) establishing a CSA data repository, (b) analyzing existing CSA data to gain knowledge and identify opportunities for improved data collection, and

WHO Global Salm-Surv external quality assurance system for serotyping of Salmonella isolates from 2000 to 2007.

An international external quality assurance system (EQAS) for the serotyping of Salmonella species was initiated in 2000 by WHO Global Salm-Surv to enhance the capacity of national reference laboratories to obtain reliable data for surveillance purposes worldwide. Seven EQAS iterations were conducted between 2000 and 2007. In each iteration, participating laboratories submitted serotyping results for eight Salmonella isolates. A total of 249 laboratories in 96 countries participated in at least one EQAS iteration. A total of 756 reports were received from the participating laboratories during the seven EQAS iterations. Cumulatively, 76% of participating laboratories submitted data for all eight strains, and 82% of strains were correctly serotyped. In each iteration, 84% to 96% of the laboratories correctly serotyped the Salmonella enterica serovar Enteritidis isolate that was included as an internal quality control strain. Regional differences in performance were observed, with laboratories in Central Asia and the Middle East performing less well overall than those in other regions. Errors that resulted in incorrect serovar identification were typically caused by difficulties in the detection of the phase two flagellar antigen or in differentiation within antigen complexes; some of these errors are likely related to the quality of the antisera available. The results from the WHO Global Salm-Surv EQAS, the largest of its kind in the world, show that most laboratories worldwide are capable of correctly serotyping Salmonella species. However, this study also indicates a continuing need for improvement. Future training efforts should be aimed at enhancing the ability to detect the phase two flagellar antigen and at disseminating information on where to purchase high-quality antisera.