BACKGROUND:Globally, approximately half of new HIV acquisitions occur among African adults. This analysis examines which cisgender men are at highest risk of acquiring HIV-1 and in greatest need of HIV pre-exposure prophylaxis (PrEP). SETTING:National population-based surveys from Eswatini, Ivory Coast, Kenya, Lesotho, Malawi, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. METHODS:The 13 surveys were pooled and sampling weights were applied to represent all susceptible men aged 15-59 years old. HIV-1 incidence was calculated based on a recent HIV-1 testing algorithm. A least absolute shrinkage and selection operator (Lasso) regression model was fit with 28 variables to predict recent HIV-1. Models were trained and internally cross-validated to estimate area under the receiver-operating characteristic curve (AUC). Along the receiver-operating characteristic curve, at sensitivity levels from 10% to 90%, performance tradeoffs were evaluated. RESULTS:Of 167,121 participants, 112 had recent HIV-1, representing 256,000 new annual infections among 122 million men. Only 2 variables were retained-reporting a male sexual partner and living in a subnational area where a high proportion of adults have detectable HIV-1 viremia. Overall AUC was 0.80 (95% Confidence Interval: 0.71 to 0.89); cross-validated AUC was 0.76 (95% CI: 0.64 to 0.87). At 10% sensitivity, 25,000 cases could be averted if 357,000 men adhered to PrEP (Number Needed to Treat = 14). At 90% sensitivity, 229,000 cases could be averted if 50 million men adhered to PrEP (Number Needed to Treat = 219). CONCLUSIONS:This predictive, parsimonious, generalizable risk assessment tool could help policymakers weigh tradeoffs between PrEP reach and efficiency.

Abstract Background People living with HIV who interrupt treatment often face challenges when re-engaging in care and remain at risk for future interruptions. Understanding the provider perspective on the healthcare context in which re-engagement occurs is essential for designing effective and scalable support interventions. We aimed to characterize the implementation context for re-engaging in HIV care in Cape Town, South Africa, with a view to inform the design of future interventions in this setting. Methods We conducted semi-structured in-depth interviews with nurses ( n = 5), counsellors ( n = 3) and administrative clerks ( n = 3) at two public-sector health facilities. Data collection and thematic analysis were guided by the inner setting of the Consolidated Framework for Implementation Research (CFIR), including structural characteristics, organizational culture, relational dynamics, and communication. Results We identified compounding and interconnected challenges within the CFIR inner setting. Limited staffing and fragmented clinic organization contributed to delays and frustration for both clients of HIV services and providers, reinforcing negative client-provider interactions. Despite valuing person-centred care, providers struggled to uphold these principles amid high workloads and systemic pressures relating to physical, information system, and human resource infrastructure limitations. Additionally, a cross-cutting theme was the challenge of inter-facility transfers, driven by geographic mobility and stigmatizing clinic interactions. Difficulties in linking client information across clinics intersected with the structural and relational barriers, adding another layer of complexity to providing supportive care for people returning to HIV services. Conclusions Providers in this context were empathetic but layered inner setting barriers made it challenging to provide person-centred care. Addressing these challenges requires interventions that not only accommodate the changing life circumstances of people living with HIV but crucially facility- and system-level changes to support the providers and their working environments, which together will foster strong reciprocal client-provider relationships. Future interventions must prioritize strengthening staffing and workload capacity, physical infrastructure, and information systems alongside simplified, responsive service delivery models to ease the path back into care for people living with HIV and their providers.

OBJECTIVE:To compare maternal safety and pregnancy outcomes among women who did and did not use daily oral emtricitabine-tenofovir disoproxil fumarate (FTC/TDF) for preexposure prophylaxis (PrEP) during pregnancy and postpartum. DESIGN:Parallel cohort design, with follow-up from pregnancy to 6 months postpartum. SETTING:Seven research clinics in Malawi, South Africa, Uganda, and Zimbabwe. PARTICIPANTS:Three hundred fifty pregnant women aged 16-24 years at 32 weeks or less gestation, meeting local criteria for PrEP. At entry, PrEP initiators and decliners were enrolled 2 : 1. Participants could start or stop PrEP at any time. MAIN OUTCOME MEASURES:Maternal adverse events were defined as grade ≥3 signs, symptoms, and diagnoses, and grade ≥2 chemistry abnormalities according to Division of AIDS toxicity tables. Adverse pregnancy outcomes included fetal loss, preterm birth, and small-for-gestational-age. RESULTS:From March to December 2022, 350 eligible participants enrolled: 229 initiating and 121 declining PrEP at entry. Median duration of PrEP use was 34 weeks (interquartile range [IQR]: 16-40). Sixty maternal adverse events were reported over 230.3 person-years (incidence rate: 25.6, 95% confidence interval [95% CI]: 20.0-32.8). Although those on PrEP had higher rates of adverse events, this was not statistically significant (adjusted incidence rate ratio: 1.84, 95% CI: 0.53-6.30). Most frequent grade ≥3 adverse events were complications of pregnancy or delivery. Five (8%) were considered related to PrEP use. Among those with delivery information, 79 (24%) participants reported adverse pregnancy outcomes, with no differences between PrEP groups. No participants acquired HIV infections during follow-up. CONCLUSION:Daily oral FTC-TDF remains a well tolerated and essential component of HIV prevention in pregnancy.

BACKGROUND:An HIV risk assessment tool for pregnant and lactating women was developed in Kenya. We evaluated the performance of this tool in Malawi. METHODS:We conducted a case-control study among pregnant women in Lilongwe, Malawi (2017-2020) to externally validate the Kenyan HIV risk assessment tool. Pregnant women with a recent HIV infection at their first antenatal care (ANC) visit served as cases (n = 44), whereas those who tested HIV-negative at their first ANC visit served as controls (n = 349). Recent HIV infections were identified using a validated, laboratory-based, recent infection testing algorithm with a mean duration of infection of 130 days. We used the Kenyan tool to assign each participant a risk score according to their syphilis status, number of lifetime sex partners, and partner's HIV status. The predictive performance of the risk score was assessed using the area under the receiver-operator characteristic curve (AUC). RESULTS:Risk scores were somewhat higher among cases (median 5.6, IQR: 3.0-8.1) than controls (median: 3.0, IQR: 2.0-7.0). The AUC of the risk score was 0.67 (95% CI: 0.58 to 0.76). When the risk score was dichotomized at the recommended threshold of >6, 48% of cases and 26% of controls were classified as high risk. Lowering this threshold improved sensitivity but decreased specificity. DISCUSSION:The Kenyan HIV risk assessment tool was modestly predictive of recent HIV infection in our setting. Use of this tool should consider the benefits and shortcomings of different strategies within the context of local programmatic priorities and resource availability.

Long-acting injectable antiretroviral therapy (LAI ART) has proven effective in maintaining viral suppression among people living with HIV but recommendations to switch to LAI ART are limited to individuals stable and virologically suppressed on oral ART. Understanding LAI perceptions among diverse populations living with HIV is essential. In a cross-sectional survey at two peri-urban clinics in Cape Town, adults starting or restarting treatment rated their hypothetical interest in LAI ART on a quantitative Likert-scale (1= not at all interested to 5 = very interested) and provided open-ended explanations. Among 329 participants (61% women; median age 39 years), 74% were very interested, 15% were unsure or somewhat interested (response 3 or 4) and 11% were not very or not at all interested (response 1 or 2). In thematic analysis of open-ended responses, participants commonly viewed LAI ART as a way to avoid daily pills, reduce adherence-related stress, and maintain privacy, noting that injections offered convenience and discretion. Concerns centred on fear of injections, potential side effects, and desire to hear others' experiences before deciding. The substantial interest observed suggests, once accessible, LAI ART as a treatment option in this population could move us closer to individual- and population-level HIV treatment goals.

Patient-centered PrEP choice in antenatal care may promote effective use of PrEP to reduce the risk of maternal HIV acquisition. To inform patient-centered counseling, we sought to understand values that pregnant women considered in their PrEP decision-making and their relationship with PrEP use in the context of an adherence support trial in Lilongwe, Malawi. 200 women completed an enrollment survey reporting values (motivations and concerns) they considered when deciding to use PrEP. We examined the associations of these values with study retention and adherence to PrEP (pharmacologic assessment), at 3 and 6 months after enrollment by estimating probability differences (PD). Thirty women and 10 study staff also completed in-depth interviews on the influence of women’s values on PrEP adherence. We thematically analyzed interview transcripts through topical coding and summary matrices. Quantitatively, women reporting concerns related to PrEP disclosure and stigma were less likely to be retained. At 6 months, women concerned about partner disclosure (65.0

Global health research training programs have traditionally emphasized methodological competencies, yet technical skills alone cannot ensure equitable partnerships, effective crosscultural collaboration, or durable and locally relevant research impact in international settings. The Research Leadership Academy (RLA) was developed to fill this gap. The RLA is a structured leadership curriculum embedded within the NIH Fogarty-funded UJMT LAUNCH global health research fellowship grounded in experiential learning and established global leadership frameworks. The RLA aligns leadership training with key fellowship milestones, enabling fellows to learn and apply skills in real time at their international research sites. The curriculum was iteratively refined based on trainee feedback, transitioning from didactic instruction to case-based and discussion-oriented learning. The RLA provides a practical model for strengthening global health research leadership capacity and advancing collaborative, contextually grounded global health research.

In sub-Saharan Africa, adolescent girls and young women aged 15-24 (AGYW) experience high risk of early and unintended pregnancy. We assessed the impact of youth-friendly health services (YFHS) on pregnancy risk among AGYW who participated in the Girl Power study. In 2016, Girl Power randomly assigned four government-run health centers in Lilongwe, Malawi, to provide a standard (n=1) or youth-friendly (n=3) model of service delivery. At six and 12 months, study participants (n=250 at each health center) self-reported their current pregnancy status and received a urine pregnancy test. Because of missing pregnancy test results, we used multiple imputation to correct for outcome misclassification in self-reported pregnancy status, and applied the parametric g-formula on the corrected data to estimate the effect of YFHS on the 12-month risk of pregnancy. After correcting for outcome misclassification, the risk of pregnancy under the scenario where all health centers offered YFHS was 15.8% compared to 23.2% under the scenario where all health centers offered standard of care (risk difference: -7.3%, 95% CI: -15.5%, 0.8%). Access to a model of YFHS that integrates provider training with youth-friendly clinic modifications and community outreach activities may decrease risk of pregnancy among AGYW relative to standard of care.

BackgroundHIV preexposure prophylaxis (PrEP) has potential for preventing HIV during the perinatal period, but few strategies promote person-centered shared decision-making (SDM) about PrEP use in these contexts. The MyChoice study aims to evaluate the feasibility, acceptability, and appropriateness of an SDM approach to support pregnant and breastfeeding women in Lilongwe, Malawi, integrating PrEP into antenatal care to encourage consistent use. ObjectiveTwo pilot studies will assess the feasibility, acceptability, and appropriateness of an SDM intervention to support pregnant and breastfeeding women in making informed HIV prevention choices. The intervention will also explore the perspectives of participants, their male partners, and implementers. Each study compares the MyChoice intervention to standard-of-care PrEP counseling, with different HIV prevention method choices available. MethodsWe will conduct 2 pilot randomized trials to evaluate the MyChoice intervention, designed to support PrEP decision-making among pregnant women in Lilongwe. Both studies will compare the MyChoice intervention to standard-of-care PrEP counseling. Study 1 will include 100 participants who will be offered oral PrEP and condoms for 3 months. Study 2 will include 50 participants who will be offered oral PrEP or injectable long-acting cabotegravir and condoms for 2 months. The primary end points for MyChoice study 1 are intervention acceptability, intervention appropriateness, and intervention feasibility, whereas for MyChoice study 2 they are intervention acceptability and intervention appropriateness. The secondary end point for MyChoice study 1 is decisional conflict, and for MyChoice study 2, it is the feasibility of study procedures. Exploratory end points include PrEP uptake assessment and dried blood spot measurement of PrEP adherence for MyChoice study 1 and PrEP uptake assessment for MyChoice study 2. ResultsData collection started on July 30, 2024, for study 1 and on February 10, 2025, for study 2. A total of 100 participants were enrolled in MyChoice study 1, and 50 participants were enrolled in MyChoice study 2. Study follow-up has been completed. Data analysis is expected to be completed by November 2025. ConclusionsThe MyChoice pilot studies will provide critical evidence on a novel intervention for PrEP decision-making during pregnancy and breastfeeding. If feasible and acceptable, these results will form the basis for larger efficacy trials to promote PrEP uptake during pregnancy. Trial RegistrationClinicalTrials.gov NCT06394323; https://clinicaltrials.gov/study/NCT06394323 and ClinicalTrials.gov NCT06397690; https://www.clinicaltrials.gov/study/NCT06397690 International Registered Report Identifier (IRRID)DERR1-10.2196/76442

Women recovering from preeclampsia with elevated vascular biomarkers have a higher risk of future cardiovascular diseases. We investigated whether HIV on treatment was associated with biomarkers of cardiovascular risk in the weeks following delivery. We analyzed data from a six-month prospective cohort study conducted from January 2022 to June 2023. Following delivery and at six weeks postpartum, we measured cystatin C, high sensitivity C-reactive protein (hs-CRP), Interleukine-2 (IL-2), Interleukine-6 (IL-6) and Tumor necrosis factor-alpha (TNFa). A generalized linear regression model with Poisson distribution estimated the association between vascular biomarkers and HIV on treatment. This study included 75 participants with a median age of 29 years (interquartile range [IQR] = 27–34 years), with 35 (46.7

Lack of Lactobacillus and/or dysbiosis is linked to spontaneous preterm birth (sPTB). The impact of antiretrovirals (ARVs) for HIV treatment or prevention on the vaginal microbiome during pregnancy remains unclear. We examined vaginal microbiome changes in pregnant women in Lilongwe, Malawi. Women living with HIV (WLHIV) initiated antiretroviral therapy (ART), while HIV-negative women began oral pre-exposure prophylaxis (PrEP). Of 255 participants (191 HIV-negative, 64 WLHIV) who provided baseline vaginal swabs, 181 provided follow-up swabs one month after ARV initiation. At enrollment, WLHIV had higher Shannon diversity and were more likely to have CST IV-B than CST I or III. After ARV initiation, α-diversity decreased in WLHIV but increased in HIV-negative women. Women initiating PrEP had a lower risk of sPTB compared to WLHIV initiating ART, but transitioning to CST IV during pregnancy increased the odds of sPTB. Larger studies are needed to explore ARV impact on pregnancy outcomes.

Introduction:HIV risk perception is seen as a key motivation for individuals to use biomedical HIV prevention interventions, including pre-exposure prophylaxis (PrEP). We determined HIV risk perception and associated factors among pregnant and breastfeeding women in Lusaka, Zambia. Methodology:We conducted a cross sectional study among pregnant and breastfeeding women not living with HIV in a hospital setting in Lusaka, Zambia. Study team members administered a structured questionnaire to pregnant and breastfeeding women at the hospital's maternal and child health clinic to get information on socio-demographics, obstetrics and pregnancy history, sexual behavior and HIV risk perception. Participants assessed their HIV risk perception (outcome variable) as no, low, moderate, or high; these were later collapsed into a binary variable of lower vs. higher risk. Logistic regression analysis was used to determine factors associated with high HIV self-risk perception. Results:From September to December 2021, we recruited 389 pregnant and breastfeeding women in our study. Of these, 172 (44%) were pregnant and 217 (56%) were breastfeeding. Most participants were aged between 25 and 34 years 181 (47%), and the majority 338 (87%) never used a condom with their regular sexual partner. About 129 (33%) of participants perceived higher HIV risk. This appeared higher in breastfeeding vs. pregnant women (40% vs. 25%).Over half (52%) of participants with unknown partner HIV status and one-third (33%) of those who never used condoms with their regular sexual partners perceived higher HIV risk. In adjusted models, higher HIV self-risk perception was associated with breastfeeding status (AOR = 1.82; 95% CI: 1.14-2.91), having more than 5 lifetime sexual partners (AOR = 4.27; 95% CI: 1.84-9.90), and having a partner of unknown HIV status (AOR = 2.15; 95% CI: 1.22-3.78). Conclusion:A low proportion of women perceived higher HIV risk, even when their sexual behaviours and partner characteristics would suggest HIV exposure. HIV prevention programs should focus on the accurate assessment of HIV risk to improve uptake of PrEP in the study population.

BACKGROUND:There has been tremendous progress in reducing vertical transmission of HIV in the past two decades due to the broad availability of antiretroviral therapy (ART) globally. Despite this progress, new paediatric infections are still occurring. METHODS:In a pilot study, we evaluated a combination adherence support package, which included an adapted motivational interviewing-informed counselling approach (Integrated Next Step Counselling, iNSC) and an optional adherence supporter, for pregnant and breastfeeding women living with HIV. Participants were recruited from the antenatal clinic in Lilongwe, Malawi. Eligible participants were randomly allocated 1:1 to receive either the combination adherence package (intervention) or standard care (control) at the health facility. Our clinical outcome, measured at three- and six-month follow-up, was a composite endpoint of study retention with HIV viral suppression (HIV RNA <40 copies per mL). RESULTS:We screened 106 women living with HIV between March and July 2020. Of these, 100 women enrolled and were randomly assigned to intervention (n=51) or control (n=49). The majority of participants (94 of 100; 94%) were newly diagnosed with HIV. Retention in care was 92% at three months and 84% at six months. Three-quarters of women retained in care were virally suppressed at the three- and six-month study visits. At three months, our composite outcome (retention & viral suppression) was achieved by 70.6% (36/51) and 69.4% (34/49) of women in the intervention and control groups, respectively. At six months, this composite outcome was achieved by 68.6% (35/51) of the intervention group and 61.2% (30/49) of the control group (probability difference: 7.4%, 95% CI: -11.3%, 26.1%). CONCLUSION:These encouraging pilot findings suggest that this combination adherence package could be used to support ART adherence among pregnant and breastfeeding women living with HIV. We demonstrate feasibility of using a combined measure of adherence and viral suppression as an outcome measure. TRIAL REGISTRATION:ClinicalTrials.gov (NCT04330989).

OBJECTIVE:When measured continuously, adherence to HIV pre-exposure prophylaxis (PrEP) is consistently low in studies of pregnant and postpartum women. We investigated how PrEP adherence aligned with HIV exposure risk. METHODS:We conducted a trial of a PrEP adherence support intervention in Lilongwe, Malawi. Pregnant women who met eligibility criteria for PrEP had visits at three and six months following enrollment. At each visit, HIV exposure risk was categorized as low or moderate/high (i.e., higher) risk based on an algorithm. PrEP adherence was measured via tenofovir concentrations, with functional adherence defined at levels consistent with ≥4 doses/week. HIV exposure risk and PrEP adherence were classified as either aligned (i.e., higher HIV risk/PrEP adherence, low HIV risk/PrEP non-adherence) or not aligned (i.e., higher HIV risk/PrEP non-adherence, low HIV risk/PrEP adherence). Probability differences (PD) were used to estimate the effect of the PrEP adherence intervention on aligned PrEP adherence. RESULTS:164 women were included in the analysis. HIV exposure risk was higher for 81 participants (49%) at three months and 89 (54%) at six months. PrEP adherence was low at three months (34%) and at six months (29%). Aligned PrEP adherence was observed in 89 (54%) participants at three months and 83 (51%) at six months. 62% at higher HIV exposure risk were not aligned at month three, which increased to 68% at month six. The probability of aligned PrEP adherence was greater among those randomized to the intervention than those receiving standard of care at three months (PD:15.7%; 95%CI:0.8%, 30.6%). This was also evident in analyses that considered women with high HIV risk but low adherence. CONCLUSION:Alignment of PrEP adherence with HIV exposure risk was dynamic. PrEP adherence should be considered in the context of evolving HIV exposure risk during pregnancy and postpartum, with greater emphasis on periods of elevated HIV risk exposure.

The use of antiretroviral drugs has been proven effective in preventing and treating HIV; however, adherence remains a challenge. In two parallel pilot studies, we implemented a combination adherence intervention involving patient-centered counseling and adherence supporter training, tailored for HIV treatment (ART) or prevention (PrEP) during pregnancy and breastfeeding. The intervention included Integrated Next Step Counseling (iNSC), focused on well-being and medication adherence, with an option to involve a social support member. Independent auditors assessed implementation fidelity for 151 participants (51 women living with HIV and 100 PrEP-eligible women) by scoring iNSC sessions using a standard checklist. High fidelity was observed overall in both study populations, with variability between counselors observed. The results demonstrate the ability to assess implementation fidelity in a behavioral intervention aimed at supporting adherence to antiretroviral drugs among pregnant women and offers critical information on the complexities of implementation of iNSC in a real-world setting.

Data to Care (D2C) strategies– using routine data to identify and re-engage people living with HIV who are not in care– have shown promise in high-income settings but remain underexplored in lower-resource and vertical HIV transmission prevention (VTP) contexts. In this prospective, single-arm, proof-of-concept study, we used facility-linked public sector electronic medical records (Provincial Health Data Centre [PHDC] data) to identify, validate and trace postpartum VTP gaps among 336 mothers living with HIV and their infants in Cape Town, South Africa (March 2021–April 2022). Of 302 observed gaps, 123 (41%) were false, while 179 (59%) were probable gaps affecting 133 mother-infant pairs. Overall, 16% of mothers did not link to HIV care within 12 weeks postpartum and 13% had ART dispensing gaps, while 10% and 17% of infants had no HIV test around 10 weeks and six months, respectively. Only 100 (56%) probable gaps were confirmed through telephonic tracing, with 47 mothers subsequently re-linked to care. Mobility, stigma, and employment challenges contributed to disengagement. While our D2C approach streamlined tracing efforts, re-engagement remained difficult. Strategies integrating D2C approaches with interventions addressing social determinants are needed.

This review explores the promise and challenges of integrating long-acting antiretroviral agents—cabotegravir, lenacapavir, and cabotegravir-rilpivirine—into HIV prevention and treatment programs for pregnant and breastfeeding populations. It aims to examine current evidence, implementation experiences, and barriers to equitable access. Emerging data support the efficacy and safety of long-acting agents during pregnancy and breastfeeding. Recent clinical trials have begun to include pregnant women by design, and national demonstration projects have successfully introduced injectable PrEP in maternal health settings. These developments signal growing recognition of the need for inclusive research and service delivery models. Long-acting antiretrovirals have the potential to transform maternal HIV prevention and treatment. However, challenges such as delayed inclusion in trials, policy constraints, limited product choice, high costs, and funding limitations persist. Addressing these gaps is critical to ensuring equitable access and informing future research and implementation strategies.

Worldwide, an estimated five million children under the age of five die each year; 47% of these deaths occur during the neonatal period, and the vast majority in low- and middle-income countries. Events during labor are the cause of one quarter of neonatal deaths globally. Basic resuscitation with positive pressure ventilation reduces these deaths but is challenging to execute. To characterize barriers to implementation of basic neonatal resuscitation, we conducted a qualitative study using focus group discussions with midwives at three health facilities in Kinshasa, Democratic Republic of the Congo. We analyzed qualitative data using an inductive content approach in order to identify emergent themes and trends. Twenty-four midwives participated with a median age of 49 and over 80% with more than 10 years of clinical experience. We categorized challenges to implementing basic neonatal resuscitation into three themes with subthemes: 1) limited resources (subthemes: human resource limitations, inadequate and unprepared equipment, insufficient monitoring during labor); 2) inadequate simulated and clinical experience (subthemes: poor systems to support maintenance of skills, infrequent opportunity to resuscitate); 3) emotional burden of resuscitation (subthemes: decision-making under time pressure, tendency to stick to the routine, acute stress during resuscitation, moral distress after unsuccessful outcome). Our findings suggest that while simulation training is key, learning from clinical events may be a critical companion to address these barriers. We call for a new focus on developing and evaluating strategies that support providers in learning from every newborn resuscitation.

Mother-to-child transmission (MTCT) of HIV remains a challenge in Eastern and Southern Africa. Oral pre-exposure prophylaxis (PrEP) is a powerful tool to reduce MTCT, but women face barriers to effective use including those related to inaccurate comprehension of PrEP To understand women's misconceptions about PrEP and their potential impact on PrEP use, we conducted interviews with 33 pregnant and lactating women in Malawi using PrEP, and ten PrEP counselors and clinicians. The results indicate that, although pregnant women generally understood PrEP's features and functions, many held misconceptions that persisted over the course of their PrEP use and impacted their perceptions and use of the medication. Some women erroneously believed that PrEP could treat and prevent sexually transmitted infections other than HIV, which motivated some to keep taking PrEP while motivating others to stop using PrEP once their STI had resolved. Some were confused about PrEP's function, with some believing it was the same as antiretroviral therapy for HIV treatment, and others believing that PrEP could be used for overall enhancement of health. Rarer misconceptions included fears that PrEP was connected to satanic practices, could cause cancer, or was solely for individuals engaged in sex work. These misconceptions stemmed from a mix of prior knowledge, societal influences, and miscommunications during counseling sessions. Ensuring accurate knowledge and addressing common misconceptions head-on is crucial to promote continued PrEP use among women. Both clinic- and community-based communication efforts with a particular focus on the difference between PrEP, STI treatments, and ART are needed.

While antenatal recommendations regarding preterm birth are essential to preventing neonatal morbidity and mortality, implementation of these recommendations underscore how health system capacity and systemic factors, such as access and quality, greatly influence their utilization. To date, there is limited synthesis focused on the implementation of antenatal preterm birth interventions. Our objectives were to focus on implementation science studies intended to 1) increase referral mechanisms of pregnant people to higher levels of care where the management of preterm labor or delivery is possible and 2) map the implementation of preterm birth interventions, including the administration of antenatal corticosteroids, magnesium sulfate, and antibiotics. We conducted a scoping review using key terms in online databases to identify implementation science strategies focused on referral mechanisms and preterm birth interventions. Studies were selected based on the strength of existing literature. Quality assessment was conducted with the Mixed Methods Assessment Tool (MMAT). To evaluate study intervention strategies, we used the RE-AIM framework – a comprehensive evaluative framework composed of 5 dimensions: reach, effectiveness, adoption, implementation, and maintenance. Of the 1178 articles that were screened, 18 were evaluated, and 13 included in this review. The studies were conducted in 12 countries, the majority of which were lower to lower-middle income countries. Designs ranged from quantitative non-randomized studies to qualitative and mixed methods. By using the RE-AIM framework, we found that there was heterogeneity among the studies with regards to whether they addressed reach, effectiveness, adoption, implementation, or maintenance. Common interventions for referring pregnant women to higher levels of care included the use of skilled birth attendants, referral systems, financial incentives, quality of emergency obstetric care, and community health workers. Implementation studies on preterm birth interventions with corticosteroids or magnesium sulfate focused on increasing awareness and knowledge of evidence-based practices using care bundles, online or in person training sessions, focus groups, interviews, and surveys. Overall, we identified how implementation studies increased the use of antenatal corticosteroids and magnesium sulfate and also identified how community health workers, skilled birth attendants, and referral systems can reduce complications from preterm birth. With further review of implementation science research, implementation science can be used to further understand and integrate evidence based-knowledge into practice in a consistent and reproducible matter.