THE IMPACT OF YOUTH FRIENDLY HEALTH SERVICES ON PREGNANCY RISK AMONG ADOLESCENT GIRLS AND YOUNG WOMEN IN LILONGWE, MALAWI

In 2020, approximately 22 million adolescent girls and young women aged 15-24 (AGYW) in sub-Saharan Africa (SSA) became pregnant, 45% of which were unintended. Interventions that enhance contraceptive use in this population may reduce risk of early and unintended pregnancy. Using rigorous epidemiologic methods, we investigated if—and how—access to youth-friendly health services (YFHS) shaped pregnancy risk among participants in the Girl Power study. In 2016, Girl Power assigned four government-run health clinics in Lilongwe, Malawi, to offer either standard of care (SOC; n=1) or YFHS (n=3). Each clinic enrolled 250 AGYW and followed them for 12 months. In Aim 1, we used longitudinal data on sexual activity and contraceptive use to evaluate the impact of YFHS on the probability of sustained pregnancy protection. Sustained pregnancy protection, defined as sustained use of contraception or abstinence over 12 months, was more common under YFHS than under SOC (45.7% vs 38.5%; RD: 7.2%, 95% CI: -2.6%, 17.0%). The effect of YFHS was concentrated among participants who were married and those with children, and was driven by greater sustained use of non-barrier methods of contraception among participants with access to YFHS than those in the SOC. In Aim 2, we leveraged longitudinal data on pregnancy (based self-report and results from urine pregnancy tests) to evaluate the impact of YFHS on the 12-month probability of pregnancy among study participants. Because of missing pregnancy test results, we used multiple imputation to correct for outcome misclassification in self-reported pregnancy status. After correcting for outcome misclassification, the probability of pregnancy was lower under the YFHS model of service delivery than under the SOC (15.8% vs. 23.2%; RD: -7.3%, 95% CI: -15.5%, 0.8%). Pregnancies were concentrated among participants who did not sustain pregnancy protection over the 12-month study period. Overall, our findings suggest that YFHS can improve contraceptive behaviors and decrease pregnancy risk, supporting ongoing efforts to introduce and expand access to YFHS in SSA. Future research is needed to identify interventions that enhance demand for contraception among unmarried and nulliparous AGYW, and to identify effective strategies for bringing YFHS to scale in SSA.Doctor of Philosoph

The SDGs Will Require Integrated Agriculture, Nutrition, and Health at the Community Level

Child malnutrition is an urgent and complex issue and requires integrated approaches across agriculture, nutrition, and health. This issue has gained prominence at the global level. While national-level efforts are underway in many countries, there is little information on how to integrate at the community level. Here, we offer a community-based approach using cadres of agricultural and community health workers, drawing on qualitative work we have conducted in Tanzania. Agriculture is an important driver of nutritional and health outcomes, and improving child health will require practical solutions for integration that can add to the evidence base

Combination adherence strategy to support HIV antiretroviral therapy and pre-exposure prophylaxis adherence during pregnancy and breastfeeding: protocol for a pair of pilot randomised trials.

INTRODUCTION To realise the expected gains from prevention of mother-to-child HIV transmission initiatives, adherence to preventative and therapeutic antiretroviral regimens is critical and interventions deployable in busy programmatic settings with a high HIV burden are needed. Based on formative research, we developed an approach that integrates patient-centred counselling and engagement of an adherence supporter for pregnant and breastfeeding women initiating HIV treatment (ie, antiretroviral therapy (ART)) or biomedical HIV prevention (ie, pre-exposure prophylaxis (PrEP)). METHODS Tonse Pamodzi 2 is a pilot study designed to provide acceptability, fidelity and clinical outcomes data on a set of behavioural interventions for adherence support. The study comprises two parallel randomised trials, enrolling HIV-positive pregnant women initiating ART (Trial 1, n=100) and HIV-negative pregnant women with risk of HIV acquisition and willing to initiate PrEP (Trial 2, n=200). Within each trial, participants are randomised 1:1 to either the intervention or control group. The Tonse Pamodzi adherence intervention comprises patient-centred counselling (adapted Integrated Next Step Counseling(iNSC)) and external adherence support tailored to the clinical context (ie, for ART or PrEP). Participants randomly assigned to the control group receive standard counselling based on local HIV guidelines. Participants are followed for 6 months. To assess intervention acceptability, we will employ a mixed method approach to describe participant engagement, satisfaction, and discussion content. We will audit and score recorded counselling sessions to evaluate the implementation fidelity of iNSC sessions. We will also assess clinical outcomes at 3 and 6 months for both Trial 1 (retention in care and viral suppression of HIV) and Trial 2 (retention in care, and plasma and intracellular tenofovir drug concentrations). ETHICS AND DISSEMINATION The study protocol was approved by the Malawi National Health Science Research Committee (19/05/2334) and the University of North Carolina at Chapel Hill Institutional Review Board (19-1060). TRIAL REGISTRATION NUMBER NCT04330989

Incident HIV among pregnant and breast-feeding women in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES: A previous meta-analysis reported high HIV incidence among pregnant and breast-feeding women in sub-Saharan Africa (SSA), but limited evidence of elevated risk of HIV acquisition during pregnancy or breast-feeding when compared with nonpregnant periods. The rapidly evolving HIV prevention and treatment landscape since publication of this review may have important implications for maternal HIV incidence. DESIGN: Systematic review and meta-analysis. METHODS: We searched four databases and abstracts from relevant conferences through 1 December 2018, for literature on maternal HIV incidence in SSA. We used random-effects meta-analysis to summarize incidence rates and ratios, and to estimate 95% prediction intervals. We evaluated potential sources of heterogeneity with random-effects meta-regression. RESULTS: Thirty-seven publications contributed 100 758 person-years of follow-up. The estimated average HIV incidence rate among pregnant and breast-feeding women was 3.6 per 100 person-years (95% prediction interval: 1.2--11.1), while the estimated average associations between pregnancy and risk of HIV acquisition, and breast-feeding and risk of HIV acquisition, were close to the null. Wide 95% prediction intervals around summary estimates highlighted the variability of HIV incidence across populations of pregnant and breast-feeding women in SSA. Average HIV incidence appeared associated with age, partner HIV status, and calendar time. Average incidence was highest among studies conducted pre-2010 (4.1/100 person-years, 95% prediction interval: 1.1--12.2) and lowest among studies conducted post-2014 (2.1/100 person-years, 95% prediction interval: 0.7--6.5). CONCLUSION: Substantial HIV incidence among pregnant and breast-feeding women in SSA, even in the current era of combination HIV prevention and treatment, underscores the need for prevention tailored to high-risk pregnant and breast-feeding women

Two strategies for partner notification and partner HIV self-testing reveal no evident predictors of male partner HIV testing in antenatal settings: A secondary analysis

BackgroundTo meet global targets for the elimination of mother-to-child HIV transmission, tailored approaches to HIV testing strategies need prioritizing. Herein, we sought to identify individual-level factors associated with male partner HIV testing.MethodsWe conducted a secondary analysis of data from two parallel randomized trials of pregnant women living with HIV and those HIV-negative in Lusaka, Zambia. Across both trials, control groups received partner notification services only, while intervention groups received partner notification services plus HIV self-test kits for their partners. Associations between baseline factors and male partner testing were estimated using a probability difference. The outcome of interest was uptake of male partner HIV testing of any kind within 30 days of randomization.ResultsThe parent study enrolled 326 participants. Among the 151 women in the control groups, no clear associations were noted between maternal or male partner characteristics and reported uptake of male partner HIV testing. There were positive trends favouring partner testing among women who completed primary school education, had larger households (>2 members), and whose partners were circumcised. Likewise, no clear predictors of male partner testing were identified among the 149 women in the intervention groups. However, negative trends favouring no testing were noted among older, multiparous women from larger households.ConclusionNo consistent predictors for male partner HIV testing across two compared strategies were observed. Our findings suggest that differentiated strategies for male partner HIV testing may not be necessary. Instead, consideration should be given to universal approaches when bringing such services to scale

Vitamin Status among Breastfed Infants in Bhaktapur, Nepal

Vitamin deficiencies are known to be common among infants residing in low- and middle-income countries but relatively few studies have assessed several biochemical parameters simultaneously. The objective of the study was to describe the status of vitamins (A, D, E, B₆, B12 and folate) in breastfed infants. We measured the plasma concentrations of trans retinol, 25 hydroxy vitamin D, α-tocopherol, pyridoxal 5'-phosphate, cobalamin, folate, methylmalonic acid, homocysteine, hemoglobin and C-reactive protein from 467 randomly selected infants. One in five (22%) was deficient in at least one vitamin. Mean (SD) plasma folate concentration was 73 (35) nmol/L, and no infant in the sample was folate deficient. Vitamin B₆ deficiency and vitamin B12 deficiency was found in 22% and 17% of the infants, respectively. Elevated plasma methylmalonic acid or total homocysteine concentration was found in 82% and 62% of infants, respectively. Fifteen percent of infants were vitamin A deficient and 65% were marginally deficient in vitamin A. Fewer than 5% of infants had low plasma vitamin D concentration or vitamin E concentration (α-tocopherol <9.3 µmol/L). Our results illustrate the importance of continued supplementation campaigns and support the expansion of food fortification and dietary diversification programs that target children and women in Nepal

The SDGs Will Require Integrated Agriculture, Nutrition, and Health at the Community Level

Child malnutrition is an urgent and complex issue and requires integrated approaches across agriculture, nutrition, and health. This issue has gained prominence at the global level. While national-level efforts are underway in many countries, there is little information on how to integrate at the community level. Here, we offer a community-based approach using cadres of agricultural and community health workers, drawing on qualitative work we have conducted in Tanzania. Agriculture is an important driver of nutritional and health outcomes, and improving child health will require practical solutions for integration that can add to the evidence base

Interactions of Polyproline II Helix Peptides with Iron(III) Oxide

Interactions of a peptide with polyproline II helical secondary structure with maghemite (iron(III) oxide, Fe2O3) surfaces were characterized using a variety of surface techniques. A quartz crystal microbalance with dissipation was used to measure the hydrated mass and thickness (92 ± 29 ng/cm2 and 0.89 ± 0.27 nm, respectively) of a layer which formed after a sensor coated with Fe2O3 was exposed to the peptide in aqueous solution. The analysis revealed that the peptide formed a stable thin layer on the sensor. X‐ray photoelectron spectroscopy and Fourier‐transform infrared spectroscopy of the monolayer were employed to study the relationship between the metal and the peptide. Finally, Fe2O3 nanoparticles were incubated with the peptide, and analysis of the settling and particle size revealed that the presence of the peptide reduced the occurrence of large aggregates in solution

Vitamin Status among Breastfed Infants in Bhaktapur, Nepal

Abstract: Vitamin deficiencies are known to be common among infants residing in low-and middle-income countries but relatively few studies have assessed several biochemical parameters simultaneously. The objective of the study was to describe the status of vitamins (A, D, E, B 6 , B 12 and folate) in breastfed infants. We measured the plasma concentrations of trans retinol, 25 hydroxy vitamin D, α-tocopherol, pyridoxal 5 1 -phosphate, cobalamin, folate, methylmalonic acid, homocysteine, hemoglobin and C-reactive protein from 467 randomly selected infants. One in five (22%) was deficient in at least one vitamin. Mean (SD) plasma folate concentration was 73 (35) nmol/L, and no infant in the sample was folate deficient. Vitamin B 6 deficiency and vitamin B 12 deficiency was found in 22% and 17% of the infants, respectively. Elevated plasma methylmalonic acid or total homocysteine concentration was found in 82% and 62% of infants, respectively. Fifteen percent of infants were vitamin A deficient and 65% were marginally deficient in vitamin A. Fewer than 5% of infants had low plasma vitamin D concentration or vitamin E concentration (α-tocopherol &lt;9.3 µmol/L). Our results illustrate the importance of continued supplementation campaigns and support the expansion of food fortification and dietary diversification programs that target children and women in Nepal

Strategies to increase couples HIV testing and counselling in sub‐Saharan Africa: a systematic review

Abstract Introduction Couple HIV testing and counselling (CHTC) is associated with measurable benefits for HIV prevention and treatment. However, the uptake remains limited in much of sub‐Saharan Africa, despite an expanded range of strategies designed to promote access. Methods Following PRIMSA guidelines, we conducted a systematic review to characterize CHTC uptake strategies. Five databases were searched. Full‐text articles were included if they were: conducted in sub‐Saharan Africa during the study period (1980–2019), targeted heterosexual couples, reported at least one strategy to promote CHTC and provided a quantifiable measure of CHTC uptake. After the initial and full‐text screening, key features of the studies were abstracted and synthesized. Results Of the 6188 unique records found in our search, 365 underwent full‐text review with 29 distinct studies included and synthesized. Most studies recruited couples through antenatal care (n = 11) or community venues (n = 8) and used provider‐based HIV testing (n = 25). The primary demand creation strategies included home‐based CHTC (n = 7); integration of CHTC into clinical settings (n = 4); distribution of HIV self‐testing kits (n = 4); verbal or written invitations (n = 4); community recruiters (n = 3); partner tracing (n = 2); relationship counselling (n = 2); financial incentives (n = 1); group education with CHTC coupons (n = 1); and HIV testing at other community venues (n = 1). CHTC uptake ranged from negligible to nearly universal. Discussion We thematically categorized a diverse range of strategies with varying levels of intensity and resources used across sub‐Saharan Africa to promote CHTC. Offering CHTC within couples’ homes was the most common approach, followed by the integration of CHTC into clinical settings. Due to heterogeneity in study characteristics, we were unable to compare the effectiveness across studies, but several trends were observed, including the high prevalence of CHTC promotion strategies in antenatal settings and the promising effects of home‐based CHTC, distribution of HIV self‐tests and integration of CHTC into routine health services. Since 2019, an updated literature search found that combining partner notification and secondary distribution of HIV self‐test kits may be an additionally effective CHTC strategy. Conclusions There are many effective, feasible and scalable approaches to promote CHTC that should be considered by national programmes according to local needs, cultural context and available resources