Background:Optimising tuberculosis (TB) diagnosis involves combining screening and confirmatory tests within diagnostic algorithms. Their impact depends on accuracy, feasibility, and acceptability. This study assessed stakeholder perspectives on TB diagnostic tests and algorithms across high TB burden settings. Methods:A qualitative study was conducted across seven high TB burden countries within Start4All. Between October 2024 and June 2025, 38 key informants were interviewed and 18 focus groups conducted with healthcare providers and people affected by TB. Discussions covered C-reactive protein (CRP), lateral flow lipoarabinomannan (LF-LAM), computer-aided detection for chest X-ray (CAD-CXR), pooled molecular testing, and diagnostic algorithms. Data were analysed deductively using feasibility and acceptability frameworks. Findings:Feasibility and acceptability were shaped by tests' roles within diagnostic pathways rather than individual characteristics. CRP and LF-LAM were simple and acceptable, with concerns about CRP's low specificity and LF-LAM's limited sensitivity; LF-LAM was most useful among people living with HIV. CAD-CXR enabled rapid, decentralised screening but required confirmatory testing and system investment. Pooled molecular testing was resource-efficient, with concerns about reduced sensitivity and workflow complexity. Multistep algorithms strengthened diagnostic confidence but became less feasible with increasing complexity, particularly in lower-level and community facilities. Across approaches, clinical coherence and trust underpinned acceptability, while infrastructure, workforce, and system organisation shaped feasibility. Interpretation:Diagnostic tests should be complementary components of context-specific pathways rather than standalone technologies. Stakeholders valued combinations with clearly defined roles aligned with clinical reasoning and system capacity. Implementation requires adequate infrastructure, workforce, and coordinated service delivery. Funding: Funded by Unitaid (Grant 2022-50-START-4-ALL).

Although men bear the brunt of TB morbidity and mortality globally and in Nigeria, understanding of men’s barriers to TB care is limited, including in peri-urban settlements where the risk of TB exposure is high. This research explored how masculinities combine with layers of disadvantage among men in peri-urban communities to limit their access to TB services. We conducted 20 in-depth interviews among 12 men and 8 women with presumptive or confirmed TB, 3 focus group discussions among 24 men in their workplaces, and interviews with 12 key informants exploring experiences of TB symptoms and care seeking. Audio recordings were transcribed and analysed using a reflexive thematic approach. Findings suggest many men in peri-urban settlements could not afford to show TB symptoms due to strict masculine gender expectations and norms (Theme 1), while official TB information was not tailored to reach them (Theme 2). When developing symptoms presumptive of TB, men negotiated the least disruptive way to wellbeing (Theme 3). After TB diagnosis, female healthcare workers used strategies such as baiting and negotiating to engage and retain men in care (Theme 4). In conclusion, health systems need to address the compounded barriers facing different groups of men in high-burden peri-urban settlements in Nigeria highlighted by this study and leverage existing community resources to create scalable adaptations to care that make services more responsive to their realities.

Gender impacts exposure and vulnerability to tuberculosis (TB) evidenced by a higher prevalence of both TB disease and missed TB diagnoses among men, who significantly contribute to new TB infections. We present the formative research phase of a study, which used participatory methods to identify gender-specific interventions for systematic screening of TB among men in Uganda. Health facility-level data were collected at four Ugandan general hospitals (Kawolo, Gombe, Mityana and Nakaseke) among 70 TB stakeholders, including healthcare workers, TB survivors, policymakers and researchers. Using health-seeking pathways, they delineated and compared men's ideal and actual step-by-step TB health-seeking processes to identify barriers to TB care. The stepping stones method, depicting barriers as a 'river' and each 'steppingstone' as a solution, was employed to identify interventions which would help link men with TB symptoms to care. These insights were then synthesized in a co-analysis meeting with 17 participants, including representatives from each health facility to develop a consensus on proposed interventions. Data across locations revealed the actual TB care pathway diverted from the ideal pathway due to health system, community, health worker and individual-level barriers such as delayed health seeking, unfavourable facility operating hours and long waiting times that conflicted with men's work schedules. Stakeholders proposed to address these barriers through the introduction of male-specific services; integrated TB services that prioritize X-ray screening for men with cough; healthcare worker training modules on integrated male-friendly services; training and supporting TB champions to deliver health education to people seeking care; and engagement of private practitioners to screen for TB. In conclusion, our participatory co-design approach facilitated dialogue, learning and consensus between different health actors on context-specific, person-centred TB interventions for men in Uganda. The acceptability, effectiveness and cost effectiveness of the package will now be evaluated in a pilot study.

BACKGROUND:In Nigeria, men constitute over half of the people notified with tuberculosis (TB), experience longer delays before reaching care, and are estimated to account for two thirds of people who miss out on care. The higher TB risk and burden in men has implications for the whole population and reaching them earlier with TB services will reduce onward transmission in households, communities, and workplaces. The absence of a comprehensive guidance and the lack of substantial empirical evidence on TB care approaches that are responsive to the needs of men in Nigeria exacerbates this problem. Therefore, this research aimed to co-create a gender-responsive intervention for men in peri-urban communities in Nigeria. METHODS:Our study utilised a researcher-led collaborative approach to engage local TB stakeholders including communities adversely affected by the disease to co-create a gender-responsive TB intervention. Between March and November 2022, we engaged 13 local TB stakeholders in a three-phase participatory intervention design process. This engagement involved two iterative cycles of Delphi research online, and an in-person workshop. In the first and second phases, participants described the potential impact of 15 listed interventions and prioritised combinations of nine interventions deemed to be effective in overcoming identified gendered barriers. Responses were analysed using a combination of qualitative framework approach, content analysis, and summary descriptive statistics assisted by NVivo software. Stakeholder consensus on a preferred intervention package was reached during the participatory workshop. RESULTS:Overall, participants prioritised approaches that sought to actively find and systematically screen men for TB including awareness creation as a crucial component. The stakeholders placed significant considerations on the synergy between interventions and their programmatic sustainability when making their final choices. Consequently, a complex intervention package comprising three components was developed. These included targeted awareness creation among men in communities; TB screening in male-dominated socio-cultural congregate settings; and the use of digital chest X-ray screening. Anticipated early outputs of this intervention included improved TB knowledge, increased care-seeking, reduced TB-related costs and TB stigma, and accelerated early diagnosis among men in Nigeria. CONCLUSION:Leveraging the insights and experiences of local stakeholders through iterative engagements yielded consensus on a viable gender-responsive TB intervention.

Mathematical models are increasingly adopted for setting disease prevention and control targets. As model-informed policies are implemented, however, the inaccuracies of some forecasts become apparent, for example overprediction of infection burdens and intervention impacts. Here, we attribute these discrepancies to methodological limitations in capturing the heterogeneities of real-world systems. The mechanisms underpinning risk factors of infection and their interactions determine individual propensities to acquire disease. These factors are potentially so numerous and complex that to attain a full mechanistic description is likely unfeasible. To contribute constructively to the development of health policies, model developers either leave factors out (reductionism) or adopt a broader but coarse description (holism). In our view, predictive capacity requires holistic descriptions of heterogeneity which are currently underutilised in infectious disease epidemiology, in comparison to other population disciplines, such as non-communicable disease epidemiology, demography, ecology and evolution.

Background HIV partner disclosure rates remain low among pregnant women living with HIV in many African countries despite potential benefits for women and their families. Partner disclosure can trigger negative responses like blame, violence, and separation. Women diagnosed with HIV late in pregnancy have limited time to prepare for partner disclosure. We sought to understand challenges around partner disclosure and non-disclosure faced by women diagnosed with HIV late in pregnancy in South Africa and Uganda and to explore pathways to safe partner disclosure. Methods We conducted in-depth interviews and focus group discussions with pregnant women and lactating mothers living with HIV ( n = 109), disaggregated by antenatal care (ANC) initiation before and after 20 weeks of gestation, male partners ( n = 87), and health workers ( n = 53). All participants were recruited from DolPHIN2 trial sites in Kampala (Uganda) and Gugulethu (South Africa). Topic guides explored barriers to partner disclosure, effects of non-disclosure, strategies for safe disclosure. Using the framework analysis approach, we coded and summarised data based on a socio-ecological model, topic guides, and emerging issues from the data. Data was analysed in NVivo software. Results Our findings illustrate pregnant women who initiate ANC late experience many difficulties which are compounded by the late HIV diagnosis. Various individual, interpersonal, community, and health system factors complicate partner disclosure among these women. They postpone or decide against partner disclosure mainly for own and baby’s safety. Women experience stress and poor mental health because of non-disclosure while demonstrating agency and resilience. We found many similarities and some differences around preferred approaches to safe partner disclosure among female and male participants across countries. Women and male partners preferred healthcare workers to assist with disclosure by identifying the ‘right’ time to disclose, mentoring women to enhance their confidence and communication skills, and providing professional mediation for partner disclosure and couple testing. Increasing the number of counsellors and training them on safe partner disclosure was deemed necessary for strengthening local health services to improve safe partner disclosure. Conclusion HIV diagnosis late in pregnancy amplifies existing difficulties among pregnant women. Late ANC initiation is an indicator for the likelihood that a pregnant woman is highly vulnerable and needs safeguarding. Respective health programmes should be prepared to offer women initiating ANC late in pregnancy additional support and referral to complementary programmes to achieve safe partner disclosure and good health.

People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal urban settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies.

Structured summaryBackgroundPulmonary tuberculosis (PTB) due toMycobacterium tuberculosis(Mtb) can be challenging to diagnose because of difficulty obtaining samples, and suboptimal sensitivity of existing tests. We investigated the performance characteristics and diagnostic accuracy of upper respiratory tract tests for diagnosing PTB and hypothesised they would have sufficient accuracy and utility to improve PTB diagnosis.MethodsA systematic review and meta-analysis was conducted by searching MEDLINE, Cinahl, Web of Science, Global Health, and Global Health Archive databases up to 31/01/2021, a second search was conducted for the period 1/1/2021 - 27/5/2022 (subsequently extended to 6/12/2022) to identify studies that reported on the accuracy of upper respiratory tract sampling for TB diagnosis compared to microbiological reference standards. We used a random-effects meta-analysis with a bivariate hierarchical model to estimate pooled sensitivity and specificity, stratified by sampling method. Bias was assessed using QUADAS- 2 criteria. Study registered with PROSPERO (CRD42021262392).Findings10,159 titles were screened for inclusion, 274 studies were assessed for full text review, and 71, comprising 119 test comparisons published between 1933 and 2022 were included in the systematic review (53 in meta-analysis). For laryngeal swabs, pooled sensitivity was 57.8% (95% CI 50.5-65.0%), specificity was 93.8% (95% CI 88.4-96.8%) and diagnostic odds ratio (DOR) was 20.7 (95% CI 11.1-38.8). Nasopharyngeal aspirate sensitivity was 65.2% (95% CI 52.0-76.4%), specificity was 97.9% (95% CI 96.0-99.0%) and DOR was 91.0 (95% CI 37.8-218.8). Oral swabs sensitivity was 56.7% (95% CI 44.3-68.2%), specificity was 91.3% (95% CI 81.0-96.3%), and DOR was 13.8 (95% CI 5.6-34.0).InterpretationUpper respiratory tract sampling holds promise to expand access to TB diagnosis, including for people who can’t produce sputum. Exploring historical methods using modern microbiological techniques may further increase the options for alternative sample types.Prospective studies are needed to optimise accuracy and utility of sampling methods in clinical practice.FundingHRS is funded by the MRC through the MRC DTP programme at LSTM [Grant number MR/N013514/1].Research in contextEvidence before this studyGlobally in 2021, an estimated 4.2 million of 10.6 million people with incident tuberculosis (TB) disease went undiagnosed, emphasising the urgent need for new diagnostic methodologies. Most TB diagnostics are performed on sputum samples, but people who need TB tests are often unable to produce sputum. Upper respiratory tract sampling for TB diagnosis was widely used historically and holds promise to expand non-sputum-based diagnosis.Added value of this studyWe systematically reviewed and synthesised through meta-analysis diagnostic accuracy evaluations of upper respiratory tract sampling for TB. Historically, upper respiratory tract sampling for TB diagnosis was commonly used, with 39/71 studies conducted before 1970, although in recent years there has been a resurgence of interest in oral sampling. We show that upper respiratory tract samples have acceptable sensitivity and specificity compared to sputum culture, and, if testing is optimised using newer molecular and culture-based methods, may be capable of meeting WHO target produce profiles.Implications of all the available evidenceUpper respiratory tract sampling methodologies for TB (oral sampling, and sampling from the larynx and nasopharynx) may hold promise to expand access to TB diagnosis, including for people who can’t produce sputum. These sampling strategies can be optimised using modern microbiological techniques to increase access to diagnostics for TB.

Although urban areas are diverse and urban inequities are well documented, surveys commonly differentiate intimate partner violence (IPV) rates only by urban versus rural residence. This study compared rates of current IPV victimization among women and men by urban residence (informal and formal settlements). Data from the 2014 Kenya Demographic and Health Survey, consisting of an ever-married sample of 1,613 women (age 15-49 years) and 1,321 men (age 15-54 years), were analyzed. Multilevel logistic regression was applied to female and male data separately to quantify the associations between residence and any current IPV while controlling for regional variation and other factors. Results show gendered patterns of intra-urban variation in IPV occurrence, with the greatest burden of IPV identified among women in informal settlements (across all types of violence). Unadjusted analyses suggest residing in informal settlements is associated with any current IPV against women, but not men, compared with their counterparts in formal urban settlements. This correlation is not statistically significant when adjusting for women's education level in multivariate analysis. In addition, reporting father beat mother, use of current physical violence against partner, partner's alcohol use, and marital status are associated with any current IPV against women and men. IPV gets marginal attention in urban violence and urban health research, and our results highlight the importance of spatially disaggregate IPV data-beyond the rural-urban divide-to inform policy and programming. Future research may utilize intersectional and syndemic approaches to investigate the complexity of IPV and clustering with other forms of violence and other health issues in different urban settings, especially among marginalized residents in informal urban settings.

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.

Objectives: Acute breathlessness is a common and distressing symptom experienced by patients presenting to the emergency department (ED). Adoption of clinician-performed bedside ultrasound could promote accurate, early diagnosis and treatment to acutely breathless patients. This may be particularly pertinent in low resource settings with limited human resources and lack of access to advanced (gold standard) diagnostic testing. The aim of the study was to explore the experience of point-of-care ultrasound (PoCUS) users in the emergency department, and to understand the facilitators and constraints of PoCUS incorporation into patient investigation pathways. Materials and Methods: This was an exploratory qualitative study. Data collection entailed key informant interviews using a semi-structured interview guide between September 2019 and February 2020. Participants were purposively sampled according to role and responsibility in the acute care system at Kenyatta National Hospital, including front-line health practitioners and mid-level clinical hospital managers. Data collection proceeded until no new concepts emerged (thematic saturation). The analytical framework method was used for the thematic analysis of interview transcripts. Results: At individual level, the lack of training on the use of PoCUS, as well as fears and beliefs impacted on capability and motivation of the clinicians to perform PoCUS for clinical diagnosis. Hospital level influencers such as hospital norms, workloads, and staffing influenced the use of PoCUS by impacting on the clinician’s capability, motivation, and opportunity. General health system influencers such as relationships and power dynamics between clinical specialties and key stakeholders, and the lack of policy and practice guidelines challenged the uptake of the bedside ultrasound by the clinicians. Conclusion: Lack of PoCUS training for clinicians, limited resources and a fragmented health system structure impacted the clinician’s capability, motivation, and opportunity in performing PoCUS in diagnostics. PoCUS for diagnosis of acute breathlessness requires: (1) Well-maintained and accessible equipment; (2) highly trained individuals with time to perform the examination with access to ongoing support for the operators; and (3) finally, researchers must more accurately identify the optimal scope of ultrasound examination, the diagnostic benefits, and the opportunity costs. All three will be required to ensure patient’s benefit.

Mathematical models are increasing adopted for setting targets for disease prevention and control. As model-informed policies are implemented, however, the inaccuracies of some forecasts become apparent, for example overprediction of infection burdens and overestimation of intervention impacts. Here, we attribute these discrepancies to methodological limitations in capturing the heterogeneities of real-world systems. The mechanisms underpinning single factors for infection and their interactions determine individual propensities to acquire disease. These are potentially so numerous that to attain a full mechanistic description may be unfeasible. To contribute constructively to the development of health policies, model developers either leave factors out (reductionism) or adopt a broader but coarse description (holism). In our view, predictive capacity requires holistic descriptions of heterogeneity which are currently underutilised in infectious disease epidemiology but common in other disciplines.

heterogeneity estimating much occurs as susceptible subpopulations are depleted through These methods on unfolding selection gradients Abstract: Mathematical models are increasing adopted for setting targets for disease prevention and control. As model-informed policies are implemented, however, the inaccuracies of some forecasts become apparent, for example overprediction of infection burdens and overestimation of intervention impacts. Here, we

Objectives: The current study identifies young people's preferences for HIV self-testing (HIVST) delivery, determines the relative strength of preferences and explores underlying behaviors and perceptions to inform youth-friendly services in southern Africa. Design: A mixed methods design was adopted in Malawi and Zimbabwe and includes focus group discussions, in-depth interviews and discrete choice experiments. Methods: The current study was conducted during the formative phase of cluster-randomized trials of oral-fluid HIVST distribution. Young people aged 16–25 years were purposively selected for in-depth interviews (n = 15) in Malawi and 12 focus group discussions (n = 107) across countries. Representative samples of young people in both countries (n = 341) were administered discrete choice experiments on HIVST delivery, with data analyzed to estimate relative preferences. The qualitative results provided additional depth and were triangulated with the quantitative findings. Results: There was strong concordance across methods and countries based on the three triangulation parameters: product, provider and service characteristics. HIVST was highly accepted by young people, if provided at no or very low cost. Young people expressed mixed views on oral-fluid tests, weighing perceived benefits with accuracy concerns. There was an expressed lack of trust in health providers and preference for lay community distributors. HIVST addressed youth-specific barriers to standard HIV testing, with home-based distribution considered convenient. Issues of autonomy, control, respect and confidentiality emerged as key qualitative themes. Conclusion: HIVST services can be optimized to reach young people if products are provided through home-based distribution and at low prices, with respect for them as autonomous individuals.

Objectives: The current study identifies young people's preferences for HIV self-testing (HIVST) delivery, determines the relative strength of preferences and explores underlying behaviors and perceptions to inform youth-friendly services in southern Africa. Design: A mixed methods design was adopted in Malawi and Zimbabwe and includes focus group discussions, in-depth interviews and discrete choice experiments. Methods: The current study was conducted during the formative phase of cluster-randomized trials of oral-fluid HIVST distribution. Young people aged 16–25 years were purposively selected for in-depth interviews (n = 15) in Malawi and 12 focus group discussions (n = 107) across countries. Representative samples of young people in both countries (n = 341) were administered discrete choice experiments on HIVST delivery, with data analyzed to estimate relative preferences. The qualitative results provided additional depth and were triangulated with the quantitative findings. Results: There was strong concordance across methods and countries based on the three triangulation parameters: product, provider and service characteristics. HIVST was highly accepted by young people, if provided at no or very low cost. Young people expressed mixed views on oral-fluid tests, weighing perceived benefits with accuracy concerns. There was an expressed lack of trust in health providers and preference for lay community distributors. HIVST addressed youth-specific barriers to standard HIV testing, with home-based distribution considered convenient. Issues of autonomy, control, respect and confidentiality emerged as key qualitative themes. Conclusion: HIVST services can be optimized to reach young people if products are provided through home-based distribution and at low prices, with respect for them as autonomous individuals.