Water, sanitation and hygiene at sex work venues to support menstrual needs.

Introduction: Adequate menstrual health and hygiene (MHH) is necessary for women's health and equity of all menstruators. Female sex workers (FSW) require good MHH to prevent discomfort and exposure to pathogens. No studies have evaluated water, sanitation, and hygiene (WASH) conditions of FSW. We report on a cross-sectional WASH assessment at FSW venues in Kisumu, western Kenya. Methods: Stakeholders identified 77 FSW venues in Kisumu, of which 47 were randomly sampled and visited between April-May 2023. A standardized structured survey of WASH conditions was deployed by trained research staff using Android tablets after proprietor's consent. WASH scores ranging 0-3 were computed based on point each for direct observation of water available, soap available, and acceptable latrine. MHH scores ranging between 0-4 were computed (one point each) for direct observation of: currently available soap and water, locking door on a usable latrine, functional lighting, and a private area for changing clothes or menstrual materials, separate from the latrine(s). WASH and MHH scores were compared by venue type using non-parametric Kruskal-Wallis tests, and non-parametric Spearman rank tests. Results: Full WASH criteria was met by 29.8% of venues; 34.0% had no adequate WASH facilities; 46.8% had no female latrine; and 25.5% provided soap and water in private spaces for women. While 76.6% had menstrual waste disposal only 14 (29.8%) had covered bins. One in 10 venues provided adequate MHM facilities. Poorest WASH facilities were in brothels and in bars, and three-quarters of bars with accommodation had no MHH facilities. Discussion: WASH and MHH services were sub-optimal in the majority of FSW venues, preventing menstrual management safely, effectively, with dignity and privacy. This study highlights the unmet need for MHH support for this population. Poor MHH can deleteriously impact FSW health and wellbeing and compound the stigma and shame associated with their work and ability to stay clean. Acceptable and cost-effective solutions to sustainably improve WASH facilities for these populations are needed. Trial registration: Clinicaltrial.gov NCT0566678.

Increased reproductive tract infections among secondary school girls during the COVID-19 pandemic: associations with pandemic related stress, mental health, and domestic safety.

Background: Kenya, like many countries, shuttered schools during COVID-19, with subsequent increases in poor mental health, sexual activity, and pregnancy. We sought to understand how the COVID-19 pandemic may mediate risk of reproductive tract infections. We hypothesized that greater COVID-19 related stress would mediate risk via mental health, feeling safe inside the home, and sexual exposure, given the pandemic mitigation-related impacts of school closures on these factors. Methods: We analyzed data from a cohort of 436 girls enrolled in secondary school in rural western Kenya. Baseline, 6-, 12-, and 18- month study visits occurred April 2018 - December 2019 (pre-COVID), and 30-, 36-, and 48- month study visits occurred September 2020 - July 2022 (COVID period). At study visits, participants self-completed a survey for sociodemographics and sexual practices, and provided self-collected vaginal swabs for Bacterial vaginosis (BV) testing, with STI testing at annual visits. COVID-related stress was measured with a standardized scale and dichotomized at highest quartile. Mixed effects modeling quantified how BV and STI changed over time, and longitudinal mediation analysis quantified how the relationship between COVID-19 stress and increased BV was mediated. Findings: BV and STI prevalence increased from 12.1% and 10.7% pre-COVID to 24.5% and 18.1% during COVID, respectively. This equated to a 26% (95% CI 1.00 - 1.59) and 36% (95% CI 0.98 - 1.88) increased relative prevalence of BV and STIs, respectively, in the COVID-19 period compared to pre-COVID, adjusted for numerous sociodemographic and behavioral factors. Higher COVID-related stress was associated with elevated depressive symptoms and feeling less safe inside the home, which were each associated with increased likelihood of having a boyfriend. In longitudinal mediation analyses, the direct effect of COVID-related stress on BV was small and non-significant, indicating increased BV was due to the constellation of factors that were impacted during the COVID-pandemic. Conclusions: In this cohort of adolescent girls, BV and STIs increased following COVID-related school closures. These results highlight modifiable factors to help maintain sexual and reproductive health resiliency, such as anticipating and mitigating mental health impacts, domestic safety concerns, and maintaining sexual health services to prevent and treat reproductive tract infections.

Research priorities for improving menstrual health across the life-course in low- and middle-income countries.

BACKGROUND: Research on menstrual health is required to understand menstrual needs and generate solutions to improve health, wellbeing, and productivity. The identification of research priorities will help inform where to invest efforts and resources. OBJECTIVES: To identify research priorities for menstrual health across the life-course, in consultation with a range of stakeholder groups from a variety of geographic regions, and to identify if menstrual health research priorities varied by expertise. METHODS: A modified version of the Child Health and Nutrition Research Initiative approach was utilized to reach consensus on a set of research priorities. Multisector stakeholders with menstrual health expertise, identified through networks and the literature, were invited to submit research questions through an online survey. Responses were consolidated, and individuals were invited to rank these questions based on novelty, potential for intervention, and importance/impact. Research priority scores were calculated and evaluated by participants' characteristics. RESULTS: Eighty-two participants proposed 1135 research questions, which were consolidated into 94 unique research questions. The mean number of questions did not differ between low- and middle-income country (LMIC) and high-income country (HIC) participants, but significantly more questions were raised by participants with expertise in mental health and WASH. Sixty-six participants then ranked these questions. The top ten-ranked research questions included four on 'understanding the problem', four on 'designing and implementing interventions', one on 'integrating and scaling up', and one on 'measurement'. Indicators for the measurement of adequate menstrual health over time was ranked the highest priority by all stakeholders. Top ten-ranked research questions differed between academics and non-academics, and between participants from HICs and LMICs, reflecting differences in needs and knowledge gaps. CONCLUSIONS: A list of ranked research priorities was generated through a consultative process with stakeholders across LMICs and HICs which can inform where to invest efforts and resources.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster randomised controlled trial.

Background: High rates of sexual and reproductive health (SRH) harms and interrupted schooling are global challenges for adolescent girls, requiring effective interventions. We assessed the impact of menstrual cups (MCs) or cash transfers conditioned on school attendance (CCTs), or both, on SRH and schooling outcomes in western Kenya. Methods: In this cluster-randomised Cups or Cash for Girls (CCG) trial, adolescent girls in Forms two and three at 96 secondary schools in Siaya County (western Kenya) were randomised to receive either CCT, MC, combined CCT and MC, or control (1:1:1:1) for an average of 30 months. The CCT intervention comprised 1500KES (US$15 in 2016) via a cash card each school trimester. All four treatment groups received puberty and hygiene training. Assenting girls with parent or guardian consent who were post-menarche, not pregnant, area residents, not boarding, and had no disabilities precluding participation were eligible. Socio-behavioural risk factors and incidence of HIV and herpes simplex virus type 2 (HSV-2) were measured annually. School retainment and adverse events were monitored throughout. The primary outcome comprised a composite of incident HIV, HSV-2 and/or all-cause school dropout by school exit examination. The primary analysis was by intention-to-treat (ITT) using generalised linear mixed models, controlling for a priori selected baseline covariates. The trial is registered with ClinicalTrials.gov, NCT03051789. Findings: Between February 28, 2017 and June 30, 2021, 4137 girls (median age 17.1 [interquartile range (IQR): 16.3-18.0]) were enrolled and followed annually until completion of secondary school (median 2.5 years [IQR: 2.4-2.7]); 4106 (99.3%) contributed to the ITT analysis. No differences in the primary composite outcome between intervention and control groups were seen (MC: 18.2%, CCT: 22.1%, combined: 22.1%, control: 19.6%; adjusted risk ratio [aRR]: 0.97, 95% confidence interval 0.76-1.24; 1.14, 0.90-1.45; and 1.13, 0.90-1.43, respectively). Incident HSV-2 occurred in 8.6%, 13.3%, 14.8%, and 12% of the MC, CCT, combined and control groups, respectively (MC: RR: 0.67, 0.47-0.95, p = 0.027; aRR: 0.71, 0.50-1.01, p = 0.057; CCT: aRR: 1.02, 0.73-1.41, p = 0.92; combined aRR: 1.16, 0.85-2.58, p = 0.36). Incident HIV was low (MC: 1.2%, CCT: 1.5%, combined: 1.0%, and control: 1.4%; aRR: 0.88, 0.38-2.05, p = 0.77, aRR: 1.16, 0.51-2.62, p = 0.72, aRR: 0.80, 0.33-1.94, p = 0.62, respectively). No intervention decreased school dropout (MC: 11.2%, CCT: 12.4%, combined: 10.9%, control: 10.5%; aRR: 1.16, 0.86-1.57; 1.23, 0.91-1.65; and 1.06, 0.78-1.44, respectively). No related serious adverse events were seen. Interpretation: MCs, CCTs, or both, did not protect schoolgirls against a composite of deleterious harms. MCs appear protective against HSV-2. Studies of longer follow-up duration with objective measures of health impact are needed in this population. Funding: Department of Health and Social Care, the Foreign, Commonwealth & Development Office, the Medical Research Council and Wellcome.

Indicators for National and Global Monitoring of Girls' Menstrual Health and Hygiene: Development of a Priority Shortlist.

PURPOSE: Despite the importance of menstrual health and hygiene (MHH) for adolescent girls' health, education, and gender equality, few countries monitor MHH. MHH needs remain underprioritized, and progress achieved through policies, programs, or investments go unmeasured. This article reports the systematic development of an indicator shortlist to monitor adolescent girls' MHH at the national and global levels across low- and middle-income countries. METHODS: A core group of MHH researchers and practitioners collaborated with stakeholders from three countries with demonstrated commitment to monitoring MHH (Bangladesh, Kenya, and the Philippines), measures experts, and a global advisory group. The approach included the following: (1) define domains for monitoring MHH; (2) review and map existing indicators and measures; (3) iteratively shortlist indicators through appraising quality, feasibility, and stakeholder input; and (4) refine the shortlist and develop guidance for use. RESULTS: The shortlist comprises 21 indicators across seven domains covering menstrual materials, water, sanitation, and hygiene facilities, knowledge, discomforts and disorders, supportive social environments, menstrual health impacts, and policies. Indicators are accompanied by measures that have been tested or are expected to provide reliable data, alongside justification for their selection and guidance for use. DISCUSSION: The shortlisted indicators reflect the multisectoral collaboration necessary for ensuring girls' MHH. Uptake requires integration into monitoring systems at national and global levels. Future work remains to evaluate the performance of the indicators over time and to support their widespread use. Governments and stakeholders can use these indicators to track the progress of programs and policies, monitor unmet MHH needs, identify disparities, and set targets for improvement.

Vaginal Microbial Network Analysis Reveals Novel Taxa Relationships among Adolescent and Young Women with Incident Sexually Transmitted Infection Compared with Those Remaining Persistently Negative over a 30-Month Period.

A non-optimal vaginal microbiome (VMB) is typically diverse with a paucity of Lactobacillus crispatus and is often associated with bacterial vaginosis (BV) and sexually transmitted infections (STIs). Although compositional characterization of the VMB is well-characterized, especially for BV, knowledge remains limited on how different groups of bacteria relate to incident STIs, especially among adolescents. In this study, we compared the VMB (measured via 16S ribosomal RNA gene amplicon sequencing) of Kenyan secondary school girls with incident STIs (composite of chlamydia, gonorrhea, and trichomoniasis) to those who remained persistently negative for STIs and BV over 30 months of follow-up. We applied microbial network analysis to identify key taxa (i.e., those with the greatest connectedness in terms of linkages to other taxa), as measured by betweenness and eigenvector centralities, and sub-groups of clustered taxa. VMB networks of those who remained persistently negative reflected greater connectedness compared to the VMB from participants with STI. Taxa with the highest centralities were not correlated with relative abundance and differed between those with and without STI. Subject-level analyses indicated that sociodemographic (e.g., age and socioeconomic status) and behavioral (e.g., sexual activity) factors contribute to microbial network structure and may be of relevance when designing interventions to improve VMB health.

Analysis of bacterial vaginosis, the vaginal microbiome, and sexually transmitted infections following the provision of menstrual cups in Kenyan schools: Results of a nested study within a cluster randomized controlled trial.

BACKGROUND: Nonhygienic products for managing menstruation are reported to cause reproductive tract infections. Menstrual cups are a potential solution. We assessed whether menstrual cups would reduce bacterial vaginosis (BV), vaginal microbiome (VMB), and sexually transmitted infections (STIs) as studies have not evaluated this. METHODS AND FINDINGS: A cluster randomized controlled trial was performed in 96 Kenyan secondary schools, randomized (1:1:1:1) to control, menstrual cup, cash transfer, or menstrual cup plus cash transfer. This substudy assessing the impact of menstrual cups on BV, VMB, and STIs, included 6 schools from the control (3) and menstrual cup only (3) groups, both receiving BV and STI testing and treatment at each visit. Self-collected vaginal swabs were used to measure VMB (16S rRNA gene amplicon sequencing), BV (Nugent score), and STIs. STIs were a composite of Chlamydia trachomatis and Neisseria gonorrhoeae (nucleic acid amplification test) and Trichomonas vaginalis (rapid immunochromatographic assay). Participants were not masked and were followed for 30 months. The primary outcome was diagnosis of BV; secondary outcomes were VMB and STIs. Intention-to-treat blinded analyses used mixed effects generalized linear regressions, with random effects term for school. The study was conducted between May 2, 2018, and February 7, 2021. A total of 436 participants were included: 213 cup, 223 control. There were 289 BV diagnoses: 162 among control participants and 127 among intervention participants (odds ratio 0.76 [95% CI 0.59 to 0.98]; p = 0.038). The occurrence of Lactobacillus crispatus-dominated VMB was higher among cup group participants (odds ratio 1.37 [95% CI 1.06 to 1.75]), as was the mean relative abundance of L. crispatus (3.95% [95% CI 1.92 to 5.99]). There was no effect of intervention on STIs (relative risk 0.82 [95% CI 0.50 to 1.35]). The primary limitations of this study were insufficient power for subgroup analyses, and generalizability of findings to nonschool and other global settings. CONCLUSIONS: Menstrual cups with BV and STI testing and treatment benefitted adolescent schoolgirls through lower occurrence of BV and higher L. crispatus compared with only BV and STI testing and treatment during the 30 months of a cluster randomized menstrual cup intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT03051789.

Cost-Effectiveness and Cost-Benefit Analyses of Providing Menstrual Cups and Sanitary Pads to Schoolgirls in Rural Kenya.

Objective: To analyze the relative value of providing menstrual cups and sanitary pads to primary schoolgirls. Design: Cost-effectiveness and cost-benefit analyses of three-arm single-site open cluster randomized controlled pilot study providing menstrual cups or sanitary pads for 1 year. Participants: Girls 14-16 years of age enrolled across 30 primary schools in rural western Kenya. Methods: Cost-effectiveness analysis was conducted based on the health effects (reductions in disability-adjusted life years [DALYs]) and education effects (reductions in school absenteeism) of both interventions. The health and education benefits were separately valued and compared with relative program costs. Results: Compared with the control group, the cost of menstrual cups was estimated at $3,270 per year for 1000 girls, compared with $24,000 for sanitary pads. The benefit of the menstrual cup program (1.4 DALYs averted, 95% confidence interval [CI]: -4.3 to 3.1) was higher compared with a sanitary pad program (0.48 DALYs averted, 95% CI: -4.2 to 2.3), but the health effects of both interventions were not statistically significant likely due to the limited statistical power. Using point estimates, the menstrual cup intervention was cost-effective in improving health outcomes ($2,300/DALY averted). The sanitary pad intervention had a cost-effectiveness of $300/student-school year in reducing school absenteeism. When considering improvements in future earnings from reduced absenteeism, the sanitary pad program had a net benefit of +$68,000 (95% CI: -$32,000 to +$169,000). Conclusions: The menstrual cup may provide a cost-effective solution for menstrual hygiene management in low-income settings. This study outlines a methodology for future analyses of menstrual hygiene interventions and highlights several knowledge gaps that need to be addressed. Trial registration: ISRCTN17486946.

Impact of COVID-19 lockdowns on adolescent pregnancy and school dropout among secondary schoolgirls in Kenya.

INTRODUCTION: Secondary school closures aimed at limiting the number of infections and deaths due to COVID-19 may have amplified the negative sexual and reproductive health (SRH) and schooling outcomes of vulnerable adolescent girls. This study aimed to measure pandemic-related effects on adolescent pregnancy and school dropout among school-going girls in Kenya. METHODS: We report longitudinal findings of 910 girls in their last 2 years of secondary school. The study took place in 12 secondary day schools in rural western Kenya between 2018 and 2021. Using a causal-comparative design, we compared SRH and schooling outcomes among 403 girls who graduated after completion of their final school examinations in November 2019 pre-pandemic with 507 girls who experienced disrupted schooling due to COVID-19 and sat examinations in March 2021. Unadjusted and adjusted generalised linear mixed models were used to investigate the effect of COVID-19-related school closures and restrictions on all outcomes of interest and on incident pregnancy. RESULTS: At study initiation, the mean age of participants was 17.2 (IQR: 16.4-17.9) for girls in the pre-COVID-19 cohort and 17.5 (IQR: 16.5-18.4) for girls in the COVID-19 cohort. Girls experiencing COVID-19 containment measures had twice the risk of falling pregnant prior to completing secondary school after adjustment for age, household wealth and orphanhood status (adjusted risk ratio (aRR)=2.11; 95% CI:1.13 to 3.95, p=0.019); three times the risk of school dropout (aRR=3.03; 95% CI: 1.55 to 5.95, p=0.001) and 3.4 times the risk of school transfer prior to examinations (aRR=3.39; 95% CI: 1.70 to 6.77, p=0.001) relative to pre-COVID-19 learners. Girls in the COVID-19 cohort were more likely to be sexually active (aRR=1.28; 95% CI: 1.09 to 1.51, p=0.002) and less likely to report their first sex as desired (aRR=0.49; 95% CI: 0.37 to 0.65, p<0.001). These girls reported increased hours of non-school-related work (3.32 hours per day vs 2.63 hours per day in the pre-COVID-19 cohort, aRR=1.92; 95% CI: 1.92 to 2.99, p=0.004). In the COVID-19 cohort, 80.5% reported worsening household economic status and COVID-19-related stress was common. CONCLUSION: The COVID-19 pandemic deleteriously affected the SRH of girls and amplified school transfer and dropout. Appropriate programmes and interventions that help buffer the effects of population-level emergencies on school-going adolescents are warranted. TRIAL REGISTRATION NUMBER: NCT03051789.

Experiences and Perpetration of Recent Intimate Partner Violence Among Women and Men Living in an Informal Settlement in Nairobi, Kenya: A Secondary Data Analysis.

Evidence suggests an overlap between intimate partner violence (IPV) experience and perpetration. However, few studies in sub-Saharan Africa have investigated experience and perpetration of IPV among women and men within the same community. This study reports prevalence of past-year IPV experience and perpetration among women and men living in an informal settlement in Nairobi, Kenya, and factors associated with IPV. Data analyzed for this study involved a geographically distributed random sample of 273 women and 429 men who participated in a community survey. We approximated prevalence of IPV experience and perpetration and used logistic regression for estimating associations between individual-level factors and IPV. Women and men experienced similar levels of IPV, but a significantly higher proportion of men reported physical and sexual IPV perpetration. Witnessing violence between parents in childhood was associated with women's physical and sexual, and men's sexual IPV experience; and with women perpetrating emotional, and men perpetrating sexual IPV. Less equitable gender attitudes were associated with men's perpetration of physical IPV. More equitable gender knowledge was associated with women's experience of sexual IPV, and with men perpetrating IPV. Perceived skills to challenge gender inequitable practices were negatively associated with men perpetrating sexual IPV. In conclusion, we found IPV experience and perpetration were highly correlated, and that, contrary to commonly reported gender gaps, men and women experienced similar rates of IPV. We make suggestions for future research, including on IPV prevention interventions in areas with such IPV prevalence that would be beneficial for women and men and future generations.

'You don't have to sleep with a man to get how to survive': Girl's perceptions of an intervention study aimed at improving sexual and reproductive health and schooling outcomes.

In sub-Saharan Africa, girls suffer from high rates of morbidity and mortality, enduring high exposure to sexual and reproductive health harms. Staying in school helps protect girls from such harms. Focus group discussions were conducted in a rural, impoverished area of Kenya with adolescent girls participating in a 4-arm cluster randomised controlled trial, evaluating menstrual cups, cash transfer, or combined cups plus cash transfer against controls. To explore girls' perceptions of how trial interventions affected their SRH risks and schooling, semi-structured discussions were held at baseline, midline, and study end. Data was explored using thematic analysis. At baseline there were no discernible differences between the 4 intervention groups regarding their perceptions of relationships with boys/men, and difficulties attending or remaining in school. Midline and endline discussions found that narratives from those receiving cash transfer only, or alongside a cup were similar; girls noted fewer pregnancies and less school dropout, attributed to the cash transfer reducing the need for transactional sex. Lower absenteeism was reported by the cup only group, with perceived minimal effect on pregnancy and dropout. Girls in control and cup only groups described feeling valued through inclusion, benefitting from puberty and hygiene education. Although seemingly having little effect on reducing pregnancy or dropout, these inputs reportedly empowered girls, whilst cash transfer girls were emboldened to refuse male sexual advances. Girls noticed benefits from trial interventions, with a reduction in transactional sex and resulting pregnancy impacting on school dropout, or reduced menstrual related absenteeism. Education and study inclusion were perceived as important. Future programmes should consider alleviating material deprivation which prevents girls from attending or performing at school through schemes such as cash transfer, alongside hygiene and education packages. This will empower girls to refuse unwanted sex and understand risks, in addition to motivating academic achievement and school completion. Trial registration: ClinicalTrials.gov NCT03051789.

Quality of life and well-being problems in secondary schoolgirls in Kenya: Prevalence, associated characteristics, and course predictors.

BACKGROUND: Adolescents in sub-Saharan Africa often report low levels of quality of life (QoL) and well-being, but reliable data are limited. This study examines which sociodemographic, health, and behavioral risk factors and adverse adolescent experiences are associated with, and predictive of, QoL in Kenyan secondary schoolgirls. METHODS AND FINDINGS: 3,998 girls at baseline in a randomised controlled trial in Siaya County, western Kenya were median age 17.1 years. Subjectively perceived physical, emotional, social and school functioning was assessed using the Pediatric Quality of Life (QoL) Inventory-23. Laboratory-confirmed and survey data were utilized to assess sociodemographic, health and behavioral characteristics, and adverse adolescent experiences. We identified a group of girls with Low QoL (n = 1126; 28.2%), Average QoL (n = 1445; 36.1%); and High QoL (n = 1427; 35.7%). Significantly higher scores on all well-being indicators in the LQoL compared with HQoL group indicated good construct validity (Odds Ratio's (ORs) varying from 3.31 (95% CI:2.41-4.54, p < .001) for feeling unhappy at home to 11.88 (95%CI:7.96-17.74, p< .001) for PHQ9 defined possible caseness (probable diagnosis) of depression. Adverse adolescent experiences were independently statistically significant in the LQoL compared to the HQoL group for threats of family being hurt (aOR = 1.35,1.08-1.68, p = .008), sexual harassment out of school (aOR = 2.17,1.79-2.64, p < .001), and for menstrual problems like unavailability of sanitary pads (aOR = 1.23,1.05-1.44, p = .008) and stopping activities due to menstruation (aOR = 1.77,1.41-2.24, p < .001). After 2-years follow-up of 906 girls in the LQoL group, 22.7% persisted with LQoL. Forced sex (aOR = 1.56,1.05-2.32, p = .028) and threats of family being hurt (aOR = 1.98,1.38-2.82, p < .001) were independent predictors of persistent LQoL problems. CONCLUSIONS: Persistent QoL problems in Kenyan adolescent girls are associated with adverse physical, sexual and emotional experiences and problems with coping with their monthly menstruation. A multi-factorial integral approach to reduce the rate of adverse adolescent experiences is needed, including provision of menstrual hygiene products. TRIAL REGISTRATION: ClinicalTrials.gov:NCT03051789.

High Prevalence of Lactobacillus crispatus Dominated Vaginal Microbiome Among Kenyan Secondary School Girls: Negative Effects of Poor Quality Menstrual Hygiene Management and Sexual Activity.

The vaginal microbiome (VMB) impacts numerous health outcomes, but evaluation among adolescents is limited. We characterized the VMB via 16S rRNA gene amplicon sequencing, and its association with Bacterial vaginosis (BV) and sexually transmitted infections (STIs; chlamydia, gonorrhea, trichomoniasis) among 436 schoolgirls in Kenya, median age 16.9 years. BV and STI prevalence was 11.2% and 9.9%, respectively, with 17.6% of girls having any reproductive tract infection. Three community state types (CST) accounted for 95% of observations: CST-I L.crispatus-dominant (N=178, BV 0%, STI 2.8%, sexually active 21%); CST-III L.iners-dominant (N=152, BV 3.3%, STI 9.7%, sexually active 35%); CST-IV G.vaginalis-dominant (N=83, BV 51.8%, STI 25.3%, sexually active 43%). In multivariable adjusted analyses, sexually active girls had increased odds of CST-III and CST-IV, and use of cloth to manage menses had 1.72-fold increased odds of CST-IV vs. CST-I. The predominance of L.crispatus-dominated VMB, substantially higher than observed in prior studies of young adult and adult women in sub-Saharan Africa, indicates that non-optimal VMB can be an acquired state. Interventions to maintain or re-constitute L.crispatus dominance should be considered even in adolescents.

Exploring menstrual products: A systematic review and meta-analysis of reusable menstrual pads for public health internationally.

BACKGROUND: Girls and women need effective, safe, and affordable menstrual products. Single-use menstrual pads and tampons are regularly provided by agencies among resource-poor populations. Reusable menstrual pads (RMPs: fabric layers sewn together by an enterprise for manufacture of menstrual products) may be an effective alternative. METHODS: For this review (PROSPERO CRD42020179545) we searched databases (inception to November 1, 2020) for quantitative and qualitative studies that reported on leakage, acceptability, or safety of RMPs. Findings were summarised or combined using forest plots (random-effects meta-analysis). Potential costs and environmental savings associated with RMPs were estimated. RESULTS: A total of 44 studies were eligible (~14,800 participants). Most were conducted in low- and middle-income countries (LMIC, 78%), and 20% in refugee settings. The overall quality of studies was low. RMP uptake in cohort studies ranged from 22-100% (12 studies). One Ugandan trial among schoolgirls found leakage with RMPs was lower (44.4%, n = 72) compared to cloths (78%, n = 111, p<0.001). Self-reported skin-irritation was 23.8% after 3 months among RMP-users in a Ugandan cohort in a refugee setting (n = 267), compared to 72.8% at baseline with disposable pad use. There were no objective reports on infection. Challenges with washing and changing RMP were reported in LMIC studies, due to lack of water, privacy, soap, buckets, and sanitation/drying facilities. Among 69 brands, the average price for an RMP was $8.95 (standard deviation [sd] $5.08; LMIC $2.06, n = 10, high-income countries [HIC] $10.11), with a mean estimated lifetime of 4.3 years (sd 2.3; LMIC 2.9, n = 11; HIC 4.9 years, n = 23). In 5-year cost-estimates, in LMICs, 4-25 RMPs per period would be cheaper (170-417 US$) than 9-25 single-use pads, with waste-savings of ~600-1600 single-use pads. In HICs, 4-25 RMPs would be cheaper (33-245 US$) compared to 20 single-use tampons per period, with waste-savings of ~1300 tampons. CONCLUSION: RMPs are used internationally and are an effective, safe, cheaper, and environmentally friendly option for menstrual product provision by programmes. Good quality studies in this field are needed.

Factors associated with the prevalence of HIV, HSV-2, pregnancy, and reported sexual activity among adolescent girls in rural western Kenya: A cross-sectional analysis of baseline data in a cluster randomized controlled trial.

BACKGROUND: Adolescence is a sensitive time for girls' sexual and reproductive health (SRH), as biological changes occur concurrently with heightening pressures for sexual activity. In western Kenya, adolescent girls are vulnerable to acquiring sexually transmitted infections (STIs), such as HIV and herpes simplex virus type 2 (HSV-2), and to becoming pregnant prior to reaching adulthood. This study examines associations between individual, household, and partner-related risk factors and the prevalence of sex, adolescent pregnancy, HIV, and HSV-2. METHODS AND FINDINGS: We report baseline findings among 4,138 girls attending secondary school who were enrolled between 2017 and 2018 in the Cups or Cash for Girls (CCG) cluster randomized controlled trial in Siaya County, rural western Kenya. Laboratory confirmed biomarkers and survey data were utilized to assess the effects of girls' individual, household, and partner characteristics on the main outcome measures (adolescent reported sex, prior pregnancy, HIV, and HSV-2) through generalized linear model (GLM) analysis. Complete data were available for 3,998 girls (97%) with median age 17.1 years (interquartile range [IQR] 16.3 to 18.0 years); 17.2% were HSV-2 seropositive (n = 686) and 1.7% tested positive for HIV (n = 66). Sexual activity was reported by 27.3% girls (n = 1,090), of whom 12.2% had been pregnant (n = 133). After adjustment, orphanhood (adjusted risk ratio [aRR] 2.81, 95% confidence interval [CI] 1.18 to 6.71, p-value [p] = 0.020), low body mass index (BMI) (aRR 2.07; CI: 1.00 to 4.30, p = 0.051), and age (aRR 1.34, 1.18 to 1.53, p < 0.001) were all associated with HIV infection. Girls reporting light menstrual bleeding (aRR 2.42, 1.22 to 4.79, p = 0.012) for fewer than 3 days (aRR 2.81, 1.16 to 6.82, p = 0.023) were over twice as likely to have HIV. Early menarche (aRR 2.05, 1.33 to 3.17, p = 0.001) was associated with adolescent pregnancy and HSV-2-seropositive girls reported higher rates of pregnancy (aRR 1.62, CI: 1.16 to 2.27, p = 0.005). High BMI was associated with HSV-2 (aRR 1.24, 1.05 to 1.46, p = 0.010) and sexual activity (aRR 1.14, 1.02 to 1.28, p = 0.016). High levels of harassment were detected in the cohort (41.2%); being touched indecently conveyed the strongest association related to reported sexual activity (aRR 2.52, 2.26 to 2.81, p < 0.001). Study limitations include the cross-sectional design of the study, which informs on the SRH burdens found in this population but limits causal interpretation of associations, and the self-reported exposure ascertainment, which may have led to possible underreporting of risk factors, most notably prior sexual activity. CONCLUSIONS: Our findings indicate that adolescent girls attending school in Kenya face frequent harassment for sex and are at high risk of pregnancy and HSV-2, with girls experiencing early menarche particularly vulnerable. Targeted interventions, such as earlier sexual education programs, are warranted to address their vulnerability to SRH harms. TRIAL REGISTRATION: ClinicalTrials.gov NCT03051789.

How addressing menstrual health and hygiene may enable progress across the Sustainable Development Goals.

There is increasing global attention to the importance of menstrual health and hygiene (MHH) for the lives of those who menstruate and gender equality. Yet, the global development community, which focuses on issues ranging from gender to climate change to health, is overdue to draw attention to how addressing MHH may enable progress in attaining the Sustainable Development Goals (SDGs). To address this gap, we undertook a collective exercise to hypothesize the linkages between MHH and the 17 SDGs, and to identify how MHH contributes to priority outcome measures within key sectoral areas of relevance to menstruating girls in low- and middle-income countries. These areas included Education, Gender, Health (Sexual and Reproductive Health; Psychosocial Wellbeing), and Water, Sanitation and Hygiene (WASH). These efforts were undertaken from February - March 2019 by global monitoring experts, together with select representatives from research institutions, non-governmental organizations, and governments (n = 26 measures task force members). Through this paper we highlight the findings of our activities. First, we outline the existing or potential linkages between MHH and all of the SDGs. Second, we report the identified priority outcomes related to MHH for key sectors to monitor. By identifying the potential contribution of MHH towards achieving the SDGs and highlighting the ways in which MHH can be monitored within these goals, we aim to advance recognition of the fundamental role of MHH in the development efforts of countries around the world.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western Kenya.

BACKGROUND: Adolescent girls in sub-Saharan Africa are disproportionally vulnerable to sexual and reproductive health (SRH) harms. In western Kenya, where unprotected transactional sex is common, young females face higher rates of school dropout, often due to pregnancy, and sexually transmitted infections (STIs), including HIV. Staying in school has shown to protect girls against early marriage, teen pregnancy, and HIV infection. This study evaluates the impact of menstrual cups and cash transfer interventions on a composite of deleterious outcomes (HIV, HSV-2, and school dropout) when given to secondary schoolgirls in western Kenya, with the aim to inform evidence-based policy to improve girls' health, school equity, and life-chances. METHODS: Single site, 4-arm, cluster randomised controlled superiority trial. Secondary schools are the unit of randomisation, with schoolgirls as the unit of measurement. Schools will be randomised into one of four intervention arms using a 1:1:1:1 ratio and block randomisation: (1) menstrual cup arm; (2) cash transfer arm, (3) cups and cash combined intervention arm, or (4) control arm. National and county agreement, and school level consent will be obtained prior to recruitment of schools, with parent consent and girls' assent obtained for participant enrolment. Participants will be trained on safe use of interventions, with all arms receiving puberty and hygiene education. Annually, the state of latrines, water availability, water treatment, handwashing units and soap in schools will be measured. The primary endpoint is a composite of incident HIV, HSV-2, and all-cause school dropout, after 3 years follow-up. School dropout will be monitored each term via school registers and confirmed through home visits. HIV and HSV-2 incident infections and risk factors will be measured at baseline, mid-line and end-line. Intention to treat analysis will be conducted among all enrolled participants. Focus group discussions will provide contextual information on uptake of interventions. Monitoring for safety will occur throughout. DISCUSSION: If proved safe and effective, the interventions offer a potential contribution toward girls' schooling, health, and equity in low- and middle-income countries. TRIAL REGISTRATION: ClinicalTrials.gov NCT03051789 , 15th February 2017.

Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis.

BACKGROUND: Girls and women need effective, safe, and affordable menstrual products. Single-use products are regularly selected by agencies for resource-poor settings; the menstrual cup is a less known alternative. We reviewed international studies on menstrual cup leakage, acceptability, and safety and explored menstrual cup availability to inform programmes. METHODS: In this systematic review and meta-analysis, we searched PubMed, Cochrane Library, Web of Science, Popline, Cinahl, Global Health database, Emerald, Google Scholar, Science.gov, and WorldWideScience from database inception to May 14, 2019, for quantitative or qualitative studies published in English on experiences and leakage associated with menstrual cups, and adverse event reports. We also screened the Manufacturer and User Facility Device Experience database from the US Food and Drug Administration for events related to menstrual cups. To be eligible for inclusion, the material needed to have information on leakage, acceptability, or safety of menstrual cups. The main outcome of interest was menstrual blood leakage when using a menstrual cup. Safety outcomes of interest included serious adverse events; vaginal abrasions and effects on vaginal microflora; effects on the reproductive, digestive, or urinary tract; and safety in poor sanitary conditions. Findings were tabulated or combined by use of forest plots (random-effects meta-analysis). We also did preliminary estimates on costs and environmental savings potentially associated with cups. This systematic review is registered on PROSPERO, number CRD42016047845. FINDINGS: Of 436 records identified, 43 studies were eligible for analysis (3319 participants). Most studies reported on vaginal cups (27 [63%] vaginal cups, five [12%] cervical cups, and 11 [25%] mixed types of cups or unknown) and 15 were from low-income and middle-income countries. 22 studies were included in qualitative or quantitative syntheses, of which only three were of moderate-to-high quality. Four studies made a direct comparison between menstrual cups and usual products for the main outcome of leakage and reported leakage was similar or lower for menstrual cups than for disposable pads or tampons (n=293). In all qualitative studies, the adoption of the menstrual cup required a familiarisation phase over several menstrual cycles and peer support improved uptake (two studies in developing countries). In 13 studies, 73% (pooled estimate: n=1144; 95% CI 59-84, I2=96%) of participants wished to continue use of the menstrual cup at study completion. Use of the menstrual cup showed no adverse effects on the vaginal flora (four studies, 507 women). We identified five women who reported severe pain or vaginal wounds, six reports of allergies or rashes, nine of urinary tract complaints (three with hydronephrosis), and five of toxic shock syndrome after use of the menstrual cup. Dislodgement of an intrauterine device was reported in 13 women who used the menstrual cup (eight in case reports, and five in one study) between 1 week and 13 months of insertion of the intrauterine device. Professional assistance to aid removal of menstrual cup was reported among 47 cervical cup users and two vaginal cup users. We identified 199 brands of menstrual cup, and availability in 99 countries with prices ranging US$0·72-46·72 (median $23·3, 145 brands). INTERPRETATION: Our review indicates that menstrual cups are a safe option for menstruation management and are being used internationally. Good quality studies in this field are needed. Further studies are needed on cost-effectiveness and environmental effect comparing different menstrual products. FUNDING: UK Medical Research Council, Department for International Development, and Wellcome Trust.

A Local View of Informal Urban Environments: a Mobile Phone-Based Neighborhood Audit of Street-Level Factors in a Brazilian Informal Community.

Street-level environment characteristics influence the health behaviors and safety of urban residents, and may particularly threaten health within informal communities. However, available data on how such characteristics vary within and among informal communities is limited. We sought to adapt street audit strategies designed to characterize the physical environment for use in a large informal community, Rio das Pedras (RdP) located in Rio de Janeiro, Brazil. A smartphone-based systematic observation protocol was used to gather street-level information for a high-density convenience sample of street segments (N = 630, estimated as 86% of all street segments in the community). We adapted items related to physical disorder and physical deterioration. Measures selected to illustrate the approach include the presence of the following: (1) low-hanging or tangled wires, (2) litter, (3) structural evidence of sinking, and (4) an unpleasant odor. Intercept-only spatial generalized additive models (GAM) were used to evaluate and visualize spatial variation within the RdP community. We also examined how our estimates and conclusions about spatial variation might have been affected by lower-density sampling from random subsets street observations. Random subsets were selected to determine the robustness of study results in scenarios with sparser street sampling. Selected characteristics were estimated to be present for between 18% (unpleasant odor) to 59% (low-hanging or tangled wires) of the street segments in RdP; estimates remain similar (± 6%) when relying on a random subset created to simulate lower-density spatial sampling. Spatial patterns of variation based on predicted probabilities across RdP differed by indicator. Structural sinking and low-hanging or tangled wires demonstrated relatively consistent spatial distribution patterns across full and random subset sample sizes. Smartphone-based systematic observations represent an efficient and potentially feasible approach to systematically studying neighborhood environments within informal communities. Future deployment of such tools will benefit from incorporating data collection across multiple time points to explore reliability and quantify neighborhood change. These tools can prove useful means to assess street-level exposures that can be modifiable health determinants across a wide range of informal urban settings. Findings can contribute to improved urban planning and provide useful information for identifying potential locations for neighborhood-scaled interventions that can improve living conditions for residents in Rio das Pedras.