Despite substantial recent declines, general population HIV incidence in sub-Saharan Africa remains above international targets. Better description of risk factors for new infections would improve prioritisation of interventions. Using data from population-based cohorts in Kenya, Malawi, Tanzania, South Africa, Uganda, Zimbabwe we described the prevalence of risk factors for men and women aged 15-24 and 25-49 and estimated the association between individual and community-level risk factors and HIV acquisition between 2005 and 2016. Among 43,434 men and 55,919 women aged 15 to 49 there were 4,612 seroconversions. Education, marital status, male circumcision, new sexual partners, types of partner, prevalence of untreated HIV infection in the community and community partner acquisition rates were associated with HIV incidence. Only the prevalence of untreated HIV was a risk for both sexes and apparent at all ages. The prevalence of risk factors varied by age, sex and study. HIV incidence was higher in people aged 25-49 living in communities where men had high partner acquisition rates. Our results show potential for improved prevention through changed timing of prevention interventions relative to behaviour and the utility of using community characteristics to target prevention.

The rapid increase in global temperatures coupled with persistent malaria transmission presents substantial health burdens in sub-Saharan Africa. Here this randomized pilot field study assessed the feasibility of sustainable housing modifications via passive cooling approaches and vector proofing. Forty houses were randomly allocated to four arms: cool-roof, cross-ventilation, mat-ceiling or control. Doors, windows and eaves of the intervention houses (not control) were screened for malaria mosquito vectors. Indoor temperature and humidity were monitored continuously to assess Heat Index (HI), predicted mean value and psychrometric charts. The HI in cool-roof houses was the lowest (daytime -3.3 °C, P < 0.001; nighttime -2.4 °C, P < 0.01). Mat-ceiling houses lowered daytime HI but increased nighttime HI compared to control. No differences in HI were observed for cross-ventilation houses. Screening reduced the number of female Anopheles funestus mosquitoes by 77% and the number of Culex mosquitoes by 58% compared to control houses. Eighty-five percent of the households expressed willingness to use their resources for housing intervention. Cool-roofs combined with vector proofing is an effective, practical and sustainable housing modification for heat adaptation and for reducing indoor mosquito numbers in rural African households.

BACKGROUND:Widowed women in sub-Saharan Africa bear a disproportionate burden of HIV/AIDS. OBJECTIVES:We examined the likely period of HIV exposure among widows living with HIV and the patterns and predictors of widowed women's HIV risk behaviors. METHODS:We performed a cross-sectional survey with an age-stratified random sample of widowed women in Siaya County, Kenya. We estimated the period of HIV exposure and the prevalence of HIV-risk behaviors, and used Firth's penalized multivariable logistic regression to determine the association of socio-economic characteristics with HIV risk behaviors since widowhood. RESULTS:Of the 480 widowed women, 178 (37.1%) had HIV. Of the 168 widows with confirmed dates of HIV diagnosis, 51.2% and 36.9% may have been exposed 2 and 5 years after widowhood, respectively. At least one in two widows engaged in condomless sex since widowhood. Widowhood during reproductive age was associated with higher odds of culturally sanctioned sexual behaviours. Specifically, young widowhood (<30 years old) was associated with condomless sex (AOR: 64.5, 95%CI: 15.0-277.1), widow inheritance (AOR: 34.5, 95%CI: 9.0-133.0), sexual cleansing (AOR: 41.5, 95%CI: 10.1-171.0), sex with a 10-year‑older partner (AOR: 227.4, 95%CI: 12.0-4324.5), and sex with an inheritor who had a wife (AOR: 16.8, 95%CI: 2.8-100.8). Living with HIV was associated with condomless sex (AOR: 2.9, 95%CI: 1.5-5.5), widow inheritance (AOR: 3.4, 95%CI: 1.8-6.5) and sexual cleansing (AOR: 3.2, 95%CI: 1.7-6.2). CONCLUSIONS:One in three widows living with HIV may have acquired the virus during widowhood. Young widowhood and living with HIV were associated with higher HIV risk behaviours. HIV testing, pre-exposure prophylaxis, and condom use in culturally sanctioned sexual practices should be studied further.

BACKGROUND:All-cause mortality among people with HIV (PWH) in sub-Saharan Africa declined after antiretroviral therapy's introduction, but data in rural settings on evolving causes of death as this population age remain limited. OBJECTIVES:To compare all-cause and cause-specific mortality trends among PWH and people without HIV (PWOH) in western Kenya using a prospective cohort study. METHODS:Data from the Siaya Health and Demographic Surveillance System were used to estimate mortality rates from 2011 to 2018 among persons aged 15-64 years, with the study population (PWH/PWOH) determined through HIV testing. InterVA-4 was used to ascertain the cause of death. RESULTS:45,581 individuals with an HIV test result contributed 209,078 person-years (py) of follow-up. The HIV prevalence was 14.5%. Median age among PWH increased from 37 to 42 years from 2011 to 2018. For PWOH, this was between 29 and 31 years. 1386 individuals died, 48.8% were PWH. HIV/AIDS/tuberculosis (319 deaths; 58.2%) was the leading mortality cause for PWH and non-communicable diseases (NCDs) (235; 40.9%) for PWOH. From 2011 to 2017, HIV/AIDS/tuberculosis mortality rates declined among PWH from 19.0 to 7.0 deaths/1,000py, and mortality due to NCDs increased from 3.7 in 2014 to 5.1/1,000py in 2017. For PWOH, cause-specific mortality trends were stable over time. CONCLUSION:Among PWH, HIV/AIDS/tuberculosis mortality decreased from 2011 to 2017, while mortality rates due to NCDs rose over time as the population aged. Among PWOH, NCDs were the leading cause of death. Managing HIV and the increasing burden of NCDs in this community requires education on prevention, active screening, and delivery of treatment and palliative care services.

Sub-Saharan Africa, including Siaya County in Kenya, has a high prevalence of chronic HIV infection, which may increase vulnerability to climate-induced heat stress among agricultural workers. Understanding how HIV moderates the relationship between environmental heat exposure and labour capacity is essential for designing targeted, equitable public health interventions in climate-vulnerable settings. This study aims to quantify the effects of heat exposure on labour capacity and sleep, assess whether physiological strain mediates these effects, and examine whether HIV status and sex affect the observed relationships. This is an ongoing 24-month longitudinal observational study involving 124 participants (62 male–female pairs) stratified by HIV status. HIV-positive participants are recruited from the Wagai Health Centre’s HIV clinic, and HIV-negative participants are recruited from the general population via the Siaya County Health and Demographic Surveillance System (HDSS) registry. The participants are aged 20–45 years and engaged in agricultural livelihoods. Environmental heat exposure (indoor and outdoor wet bulb globe temperature), actigraphy (physical activity and sleep), and physiological metrics (heart rate and core body temperature) are continuously or periodically monitored using research-grade wearables. GPS data and monthly questionnaires on thermal comfort, work timing, and heat-related symptoms are collected to contextualize physiological responses. Data collection occurs sequentially—first 12 months for the HIV-negative group and then another 12-months for the HIV-positive group—ensuring seasonal alignment across cohorts. Mixed-effects models will assess the associations between heat exposure and residual labour capacity (primary outcome) and sleep quality (secondary outcome), examining mediation by physiological strain and moderation by HIV status and sex. The models will be adjusted for age, body composition, and other potential confounders. This study will generate novel evidence on the impact of heat stress on labour capacity and sleep in HIV-positive populations, addressing a critical gap in climate-health research in sub-Saharan Africa. Findings will inform equitable adaptation strategies, such as work-rest cycles and hydration protocols, tailored to vulnerable subgroups, including women and individuals living with HIV.

Introduction Climate change and HIV are interconnected epidemics that increase vulnerability in people living with HIV (PLWH), particularly in sub-Saharan Africa. Despite their public health significance, research on the synergistic effects of these epidemics on the health of PLWH is limited. The advancement of non-invasive wearable technology offers an opportunity to leverage objective health data for large-scale research, addressing this knowledge gap. This study will examine the impact of weather events on distinct health variables of PLWH within the Siaya Health and Demographic Surveillance System (HDSS) in rural Kenya. Methods and analysis Over a period of 6 months, we continuously monitored health parameters of a total of 200 participants including heart rate, activity and sleep, using consumer-grade wearable devices. We will correlate these health data with real-time weather parameters (ambient temperature, wet bulb globe temperature, precipitation level) from five weather stations within the HDSS area and compare between HIV-positive participants and an HIV-negative control group. Additionally, a convergent mixed-methods approach will explore participants’ perceptions of the impact of weather events on their health and personal experiences. The study aims to inform future research on the complex relationship between HIV and weather events, which are projected to increase in frequency in this region due to climate change and provide valuable insights for policymakers to develop effective measures to protect this vulnerable population amid the growing climate crisis. Ethics and dissemination This study has been approved by the Research Ethics Committees at Kenya Medical Research Institute, Nairobi (approved on 23 October 2023; SERU 4826) and Heidelberg University Hospital, Germany (approved on 14 February 2023; S-824/2022). Written informed consent was obtained from all participants prior to enrolment, with data anonymised and handled according to Kenyan and German data protection regulations. Research findings will be disseminated through peer-reviewed publications and presented at scientific conferences.

Despite global commitments to girls’ education, many dropout prematurely facing health, social, and economic hardships. Using ten focus group discussions and ten in-depth interviews, this study explored issues identified as important in the lives of girls who had dropped out of school. Thematic analysis first revealed rejection as a central theme in the girls' experiences, prompting a deductive approach that identified five interrelated themes: (a) perpetrators, (b) school dropout, (c) pregnancy, (d) illness and disease, and (e) consequences. School dropout and pregnancy were key events perpetuating further rejection. These findings highlight the urgent need for targeted interventions including addressing the drivers of school dropout and adolescent pregnancy. Moreover, interventions are needed to challenge and change negative societal views. Rather than being overlooked, these girls require focused support and care to improve their well-being and life chances.

Sub-Saharan Africa faces increasing heat events due to climate change, affecting health and productivity. Wearable technology, though promising for monitoring these impacts, is underexplored in this region. This pilot study evaluated the acceptability and feasibility of research-grade wearables for monitoring heat stress among Kenyan subsistence farmers. In Siaya, 48 farmers (50% women) were monitored for 14 days using sensors to measure heart rate, core temperature, sleep, activity, and geo-location, alongside environmental data loggers for wet bulb globe temperature. Participants mostly rated their experience on a 5-point Likert scale and provided additional non-Likert feedback, with over 95% reporting high device likability and minimal disruption. Data availability was 88% for actigraphy and 100% for core temperature, with a median completeness of 100% for most devices. Women experienced greater heat strain than men. These findings demonstrate that research-grade wearables are acceptable and feasible for real-time heat stress monitoring in rural Africa.

BACKGROUND:Climate change-related heat stress disproportionately affects people in sub-Saharan Africa, impairing physical performance and increasing the risk of heat-related illnesses. Despite subsistence farming's key role in food security, scarce studies have measured farmers' physical effort during labour and the impact of behavioural adaptations to heat stress in real-life settings. This long-term, empirical study in Burkina Faso, one of the world's resource-poorest countries, aimed to measure the heat stress-labour effort relationships among subsistence farmers, accounting for gender-related differences in labour roles. METHODS:We conducted a 1-year observational study using the Nouna Health and Demographic Surveillance System in Burkina Faso. We included participants who were healthy, actively practising farmers aged 20-45 years who were neither overweight nor underweight, had no chronic illnesses, no planned pregnancy or breastfeeding status, and resided within a 10-km radius of the weather station. Using research-grade wearables, we collected time-series data on environmental conditions, tracking indoor and outdoor wet-bulb globe temperature (WBGT) and physiological responses such as daily activity, estimated core body temperature, heart rate, and GPS-tracked movements. To operationalise physical effort during labour, we evaluated the physiological strain index (PSI; 0-10 scale with 10 being highest strain) and activity intensity during fieldwork, measured as functions of WBGT. Behavioural adaptations were measured using working patterns including work duration, break times, and seasonal work distribution. The main outcomes are compared across genders and complemented by analyses of monthly vital sign assessments and heat impact surveys. FINDINGS:Between Aug 9, 2021, and Aug 30, 2022, we recruited 39 subsistence farmer households (39 women, 39 men). One household dropped out of follow-up, and 38 households (76 participants [38 men, 38 women]) were included in the analysis. During fieldwork, PSI decreased as WBGT increased (-0·04 [95% CI -0·07 to -0·01], p=0·0056), suggesting adaptive pacing. Men reduced their average activity intensity once WBGT exceeded 27°C. By contrast, women experienced a higher PSI and activity intensity during fieldwork than men (PSI: 0·47 [0·07-0·87], p=0·025). Each 1°C WBGT rise extended daily working time by 12·3 min (95% CI 2·75-21·89, p=0·013) and participants shifted work patterns in response to heat stress by increasing break duration and shifting work to cooler times. INTERPRETATION:Heat stress significantly reduces the physical effort during labour. Self-employed subsistence farmers appear to adapt to heat stress by lowering labour intensity, redistributing tasks throughout the day, and shifting work to cooler months. As climate change worsens, these adaptations could become inadequate. Women, who often balance household chores and fieldwork, have limited pacing strategies, heightening their vulnerability to increasing heat stress. Our findings highlight the urgent need for targeted adaptation strategies to sustain physical effort during labour and protect vulnerable groups, especially women, from escalating heat stress. FUNDING:Deutsche Forschungsgemeinschaft (DFG-German Research Foundation).

Comprehensive intervention packages are recommended to address multiple sources of HIV risk for adolescent girls and young women (AGYW). DREAMS is a multi-component HIV prevention program designed to reduce HIV incidence among AGYW. We conducted a prospective cohort study among AGYW aged 13-22 years, randomly selected in rural Gem and urban Nairobi informal settlements followed from 2017/2018-2019. AGYW were classified into three groups: (1) invited to DREAMS and received a "complete" package, (2) invited and received a "partial" package, or (3) not invited to DREAMS. We defined the "complete" package as 4-5 primary interventions in Gem and 5 in Nairobi: the "partial" package as 3 specific interventions in Gem and any 3-4 interventions in Nairobi. We used propensity score-adjusted logistic regression to estimate the causal effect of DREAMS on outcomes under three counterfactual scenarios: all AGYW accessed the complete package, all accessed a partial package, or none were invited. In Nairobi, 1081 AGYW were enrolled. By 2019, 26% accessed the complete package and 32% accessed the partial package. Among those receiving the complete package, there was increase in HIV status knowledge(24.8% [95%CI:16.4,32.6]),social support(13.9% [95%CI:3.3,23.6]) and self-efficacy(10.3% [95%CI:0.5,20.4]) and a decrease in the proportion with ≥2 lifetime partners(-8.0% [95%CI:-15.9,0.0]). In Gem, 1171 AGYW were enrolled. By 2019, 24% received the complete package and 21% received the partial package. We found evidence of an increase in HIV status knowledge(10.0% [95%CI:4.5,15.2]), social support(27.2% [95%CI:19.2,35.5]) and a decrease in condomless sex(-9.1% [95%CI:-13.6,-4.1]), and the proportion with ≥2 lifetime partners(-7.6% [95%CI:-12.4,-2.2]) for the complete package. Among those receiving the partial package, there was a decrease in condomless sex(-12.2% [95%CI: -17.0,-6.4]), and an increase in self-efficacy(8.0% [95%CI:0.0,17]). A package of 4-5 primary DREAMS interventions had positive impacts on multiple HIV-related outcomes in both settings. A partial package was effective in Gem, but not in Nairobi, suggesting the need for context-specific intervention strategies.

BACKGROUND:The majority (66%) of the 1.3 million people living with HIV in Kenya are women. Identification of factors associated with living with HIV, and trends in the burden of HIV among widowed women over time could inform health strategies for this group. METHODS:We used serial cross-sectional data collected between 2011 and 2022 among widowed and married women aged 15 + years enrolled in any of five periodic HIV serological and behavioural surveys conducted in Siaya County, Kenya. HIV status was determined either by blood test or evidence of a previous diagnosis. We estimated the weighted HIV prevalence stratified by marital status and age, and assessed factors associated with living with HIV for both married and widowed women using logistic regression. RESULTS:Of 14,445 women, 27.2% (3,930) were ever widowed and 72.8% (10,515) were currently married. Median age among widowed women was 64 years (interquartile range [IQR] 49-76) vs. 32 years (IQR 24-44) among married women. Overall weighted HIV prevalence was 26.2% (95% Confidence Interval [CI]: 25.3-27.0%) among widows and 17.1% (CI:16.6-17.6%) among married women. In 2011-2022, HIV prevalence increased among widowed (21.5-26.2%) and married (15.0-17.1%) women. In the adjusted analysis, the odds of HIV was six-fold higher among widowed than married women (AOR: 5.93, CI: 4.90-7.18). The odds of HIV were higher among younger (< 45 years) than older (60 + years) widowed women (AOR: 5.74, CI:1.94-17.0); among women with younger versus older male sexual partners (AOR 2.19, CI:1.03-4.64 [widowed] and AOR 2.11, CI:1.52-2.95 [married]); and among those who had ever experienced forced sex (AOR 1.75, CI:1.01-3.01 [widowed] and AOR 1.23, CI:1.08-1.41 [married]). CONCLUSION:From a decade long follow-up, we show a disproportionately high and increasing prevalence of HIV among widowed women in Siaya, Kenya. Among both widowed and married women, there was an association between living with HIV and younger age, 10-year younger sexual partners and experiencing forced sex. Policies that prioritize widowed women could assist in the development of targeted interventions that address the unique challenges of this important subpopulation.

Introduction Out-of-school girls are at higher risk of sexual and reproductive health (SRH) harms. Schools provide a protective environment for adolescents and lessen their exposure to such risks. This paper explores factors associated with school dropout, sexual activity, marriage and pregnancy among out-of-school girls in western Kenya.Methods Eligible adolescents were systematically recruited from area households in Siaya County. Generalised linear models were fit to obtain adjusted ORs (aOR) and 95% CIs of key covariates against individual outcomes. Factors with p values <0.1 in the univariate analysis were added to a multivariable model using backward stepwise regression techniques, and factors significant at p<0.05 were retained in the final adjusted models. Models were bootstrapped at 1000 replications to validate factor selection.Results Of the 915 girls enrolled (mean 18.3 years, SD: 1.3), 2.1% had never attended school. Of those who started school, 34.6% dropped out during primary education. Reasons for dropout included marriage, pregnancy and needing childcare (42.5%), financial reasons (eg, lack of school fees, needing to work, 42.5%), lack of interest (5.6%), illness (3.0%), failing school (2.2%) and other factors (4.1%). Reaching menarche prior to age 13 (aOR 1.50, 95% CI 1.00 to 2.23, p=0.048), experiencing physical violence (aOR 1.48, 95% CI 1.01 to 2.17, p=0.042) or sexual partner violence (aOR 2.16, 95% CI 1.08 to 4.34, p=0.030) were associated with not completing primary school. Experiencing sexual harassment (aOR 2.20, 95% CI 1.35 to 3.58, p=0.002) or needing to engage in transactional sex (aOR 1.74, 95% CI 1.20 to 2.51, p=0.003) were associated with being sexually active. Low socioeconomic status (aOR 1.98, 95% CI 1.36 to 2.90, p<0.001), having an older partner (aOR 1.65, 95% CI 1.10 to 2.47, p=0.016) and higher parity (aOR 2.56, 95% CI 1.42 to 4.62, p=0.002) were associated with being married or cohabiting with a partner. Girls identified provision of school fees and schooling items (67.9%) as the primary solution to resuming school; obtaining counselling, mentorship and support services (22.2%) for their general health; and provision of menstrual products (24.2%) for daily challenges.Conclusions Out-of-school girls in western Kenya face numerous SRH challenges related to menstruation, sexual and physical violence, and poverty. Social and financial support and interventions for school re-entry are warranted for this neglected population. National policies and multisectoral strategies to support adolescent girls’ education and health should be prioritised, enforced and monitored for impact.

BACKGROUND:Many adolescent girls drop out of school in sub-Saharan Africa. Mental health problems in this population and their risk factors are a neglected research area. METHODS:This community-based cross-sectional survey studied 904 out-of-school girls in rural western Kenya. Outcome variables were a positive screen for anxiety (GAD-7), depression (PHQ-A), post-traumatic stress disorder (PTSD; PCL-C), and a composite measure for overall symptom severity. Survey data were analysed with univariable and multivariable binary logistic and multiple linear regression analyses using SPSS 29.0. FINDINGS:The prevalence of probable anxiety was 10.6%, of probable depression 15.9%, and of probable PTSD 18.0%. One of the three items on suicidal ideation or past suicide attempt was reported by 40.2% of girls. In multivariable analyses controlling for age, fear of sexual assault and functional limitations due to menstruation were uniquely associated with each of the outcome variables, and exposure to physical violence to each outcome except anxiety. Other risk factors showed a less consistent relationship with outcome. The cross-sectional study design precludes any temporal and causal inference for the reported significant associations. CONCLUSION:Out-of-school girls constitute a vulnerable group with high levels of PTSD and suicide risk. Multi-level and multi-sector interventions are needed to help these girls cope with their mental health problems and to address mutable risk factors such as gender-based partner and non-partner sexual and physical violence, poor menstrual hygiene, and poverty.

Empowerment is key to person-centered HIV prevention. This study aims to evaluate the extent to which the Determined, Resilient, Empowered, AIDS-free, Mentored, Safe (DREAMS) Partnership promotes empowerment of adolescent girls and young women (AGYW) in Kenya. We conducted a mixed-methods study to examine DREAMS influence on empowerment precursors (resources, agency, institutional structures) and outcomes, guided by Kabeer's framework for women's empowerment. With representative cohorts of AGYW aged 13-22, followed since 2017/18, we estimated the impact of DREAMS on social support and self-efficacy by 2022. With a nested sample of cohort participants in 2022, we conducted qualitative inquiry through in-depth interviews and participatory action learning with DREAMS participants, implementers, and community members, for evidence of mechanisms, achievement and contextual influences on AGYW empowerment. We found statistical evidence of a causal impact of DREAMS on social support and self-efficacy among adolescent girls. Qualitatively, DREAMS enhanced AGYW's access to and control of resources, including coveted material assets like educational subsidies, hygiene products, and business support, which reportedly reduced transactional sex through economic autonomy and bodily integrity. DREAMS enhanced intangible resources like HIV knowledge and financial skills. Greater confidence, courage, and critical consciousness enabled some AGYW to act on health choices, assume leadership roles, and continue education. In mentor-led activities, AGYW demonstrated collective action and solidarity and group saving skills for financial autonomy. DREAMS aimed to engage the broader community including leaders, parents, and young men, but social structures, dominant gender norms, gender-based violence, and widespread poverty mitigated its empowering impact for AGYW. We found compelling evidence that DREAMS strengthened many young women's access to and control of resources and their intrinsic and collective agency. These are important precursors to empowerment but insufficient for the transformation of power relations without supportive institutional structures, including gender-equitable norms and viable livelihood strategies.

The impact of the COVID-19 pandemic on pediatric mortality, including measures to ensure continuity of HIV care, is not well described in Kenya. We evaluated causes of death (COD) among decedents under 5 years of age both before and during the COVID-19 pandemic in Kenya. We analyzed Child Health and Mortality Prevention Surveillance (CHAMPS) data collected in February 2018–March 2022. We describe the proportional contribution of specific conditions in the causal chain of death among decedents aged 28 days to 59 months who underwent minimally invasive tissue (MITS) sampling, had an HIV polymerase chain reaction, and a COD determination. We also calculated all-cause and HIV cause-specific mortality rates using data from two health and demographic surveillance system (HDSS) sites in western Kenya. Results were stratified by time periods: February 2018 to February 2020, and March 2020 to March 2022. Among 269 MITS-eligible decedents, 55.8% died during the pre-COVID period. Of these, 53.7% were infants (28 days to 11 months), and 9.7% were HIV-positive. Leading causes of death for infants included malnutrition (20.5%), pneumonia (17.5%), sepsis (17.1%), and malaria (14.5%). For older children (12–59 months), the predominant causes were malaria (25.6%), malnutrition (21.1%), pneumonia (14.1%), and sepsis (13.1%). All-cause mortality rates did not differ significantly between the periods (53.9 vs. 52.8 per 1,000 live births, p=0.77), but HIV cause-specific mortality rates were significantly lower during March 2020–March 2022 compared to February 2018–February 2020 (1.2 vs. 3.1 per 1,000 live births, p=0.01). Malaria, malnutrition, pneumonia, and sepsis were the leading COD among decedents aged 28 days to 59 months enrolled in CHAMPS between February 2018 and March 2022. These findings may point to the need for urgent, focused efforts to prevent avoidable child deaths. Continued monitoring of HIV-related mortality could provide insights into the ongoing impact of the HIV program in the region.

Background Climate change increasingly impacts health, particularly of rural populations in sub-Saharan Africa due to their limited resources for adaptation. Understanding these impacts remains a challenge, as continuous monitoring of vital signs in such populations is limited. Wearable devices (wearables) present a viable approach to studying these impacts on human health in real time. Objective The aim of this study was to assess the feasibility and effectiveness of consumer-grade wearables in measuring the health impacts of weather exposure on physiological responses (including activity, heart rate, body shell temperature, and sleep) of rural populations in western Kenya and to identify the health impacts associated with the weather exposures. Methods We conducted an observational case study in western Kenya by utilizing wearables over a 3-week period to continuously monitor various health metrics such as step count, sleep patterns, heart rate, and body shell temperature. Additionally, a local weather station provided detailed data on environmental conditions such as rainfall and heat, with measurements taken every 15 minutes. Results Our cohort comprised 83 participants (42 women and 41 men), with an average age of 33 years. We observed a positive correlation between step count and maximum wet bulb globe temperature (estimate 0.06, SE 0.02; P=.008). Although there was a negative correlation between minimum nighttime temperatures and heat index with sleep duration, these were not statistically significant. No significant correlations were found in other applied models. A cautionary heat index level was recorded on 194 (95.1%) of 204 days. Heavy rainfall (>20 mm/day) occurred on 16 (7.8%) out of 204 days. Despite 10 (21%) out of 47 devices failing, data completeness was high for sleep and step count (mean 82.6%, SD 21.3% and mean 86.1%, SD 18.9%, respectively), but low for heart rate (mean 7%, SD 14%), with adult women showing significantly higher data completeness for heart rate than men (2-sided t test: P=.003; Mann-Whitney U test: P=.001). Body shell temperature data achieved 36.2% (SD 24.5%) completeness. Conclusions Our study provides a nuanced understanding of the health impacts of weather exposures in rural Kenya. Our study’s application of wearables reveals a significant correlation between physical activity levels and high temperature stress, contrasting with other studies suggesting decreased activity in hotter conditions. This discrepancy invites further investigation into the unique socioenvironmental dynamics at play, particularly in sub-Saharan African contexts. Moreover, the nonsignificant trends observed in sleep disruption due to heat expose the need for localized climate change mitigation strategies, considering the vital role of sleep in health. These findings emphasize the need for context-specific research to inform policy and practice in regions susceptible to the adverse health effects of climate change.

Background: Sexually transmitted infections (STIs) cause adverse health outcomes, including increasing HIV acquisition/transmission risk. We analyzed data from an HIV biomarker and behavioral survey to estimate STI prevalence, and explore associated factors in the setting of a generalized HIV epidemic in Siaya County, western Kenya. Methods: Data were collected in March-September 2022 through face-to-face interviews using structured questionnaires; records from 9643 sexually active participants aged 13+ years were included in the analysis. We calculated weighted self-reported STI prevalence, by sex, age, and HIV status and explored associated factors using multivariable logistic regression. Results: Median age was 37 years and 59.9% were female; HIV prevalence was 18.0%. Overall STI prevalence was 1.8%; 1.5-fold higher among males vs. females, and 2.6-fold higher among participants living with HIV vs. those without. HIV status and multiple sexual partners were independently associated with STI in both sexes. Mind-altering substance use and being circumcised were associated with STI among males. Conclusions: This study estimates STI prevalence in the setting of high HIV prevalence. Findings underscore the importance of: effective STI screening in HIV clinics and HIV testing and counseling in STI clinics; screening and counseling on substance use, and HIV pre-exposure prophylaxis; and intensive sexual health counseling in male circumcision programmes.

Background The rapid increase in global temperatures coupled with persistent malaria transmission has significant public health ramifications, especially in Sub-Saharan Africa. Indoor thermal comfort and malaria transmission depend on building designs and structural properties of houses. This study assessed the impact of housing modification, combining passive cooling options with vector proofing for indoor temperature reduction and mosquito control. Methods Forty houses were randomly allocated to one of four arms: reflective roof, cross ventilation, mat ceiling or control. Additionally, doors, windows and eaves of the intervention houses were screened for vector proofing. Indoor temperatures and humidity were monitored daily whereas, mosquito numbers were assessed monthly. Community knowledge, attitude, and perception were assessed using structured questionnaires. Findings Female An. funestus were 67% lower in screened compared to unscreened houses after modification and 6-fold higher before compared to after screening. Houses with reflective roofs and mat ceilings had significantly lower mean day temperature compared to the control, RR=0.08: 95%CI (0.04-0.17) and RR=0.35: 95%CI (0.17-0.74) respectively. At night, houses with cross ventilation and mat ceiling had significantly higher temperatures compared to the control, RR=2.35:95%CI (1.45-3.84) and RR=6.66: 95%CI (4.09-10.85) respectively. Up to 85% of the households expressed willingness to use their resources to modify their houses. Interpretation The combinations of cool roofs and vector proofing are effective for the reduction of indoor temperatures and mosquito control in rural African houses. Cross ventilation is prone to user bias as it relies on household members keeping their doors and windows open for air circulation and cooling whereas mat ceilings are effective in keeping indoor temperature low during the day but are relatively warm at night. Funding Funded by SeaFright Labs through Habitat for Humanity International.

The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS' effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15-22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017-18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017-18) and AGYW's attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI:-3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI:-5.3,+6.5; Gem: 44.3% vs 48.2%,-3.9; 95%CI:-11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.

Objective: To compare the causes of death for women who died during pregnancy and within the first 42 days postpartum with those of women who died between >42 days and within 1 year postpartum. Design: Open population cohort (Health and Demographic Surveillance Systems). Setting: Ten Health and Demographic Surveillance Systems (HDSS) in The Gambia, Kenya, Malawi, Tanzania, Ethiopia and South Africa. Population: 2114 deaths which occurred within 1 year of the end of pregnancy where a verbal autopsy interview was conducted from 2000 to 2019. Methods: InterVA5 and InSilicoVA verbal autopsy algorithms were used to attribute the most likely underlying cause of death, which were grouped according to adapted International Classification of Diseases-Maternal Mortality categories. Multinomial regression was used to compare differences in causes of deaths within 42 days versus 43-365 days postpartum adjusting for HDSS and time period (2000-2009 and 2010-2019). Main outcome measures: Cause of death and the verbal autopsy Circumstances of Mortality Categories (COMCATs). Results: Of 2114 deaths, 1212 deaths occurred within 42 days postpartum and 902 between 43 and 365 days postpartum. Compared with deaths within 42 days, deaths from HIV and TB, other infectious diseases, and non-communicable diseases constituted a significantly larger proportion of late pregnancy-related deaths beyond 42 days postpartum, and health system failures were important in the circumstances of those deaths. The contribution of HIV and TB to deaths beyond 42 days postpartum was greatest in Southern Africa. The causes of pregnancy-related mortality within and beyond 42 days postpartum did not change significantly between 2000-2009 and 2010-2019. Conclusions: Cause of death data from the extended postpartum period are critical to inform prevention. The dominance of HIV and TB, other infectious and non-communicable diseases to (late) pregnancy-related mortality highlights the need for better integration non-obstetric care with ante-, intra-and postpartum care in high-burden settings.