Abstract Background Little is known about the effect of menstrual knowledge, and of menstrual education interventions, on broader dimensions of menstrual health. We assessed factors associated with menstrual knowledge and attitudes, and the association of menstrual knowledge with menstrual health related outcomes among female Ugandan adolescents enrolled in the control arm of a menstrual health intervention trial. Methods We conducted a secondary data analysis of longitudinal data from control arm participants in a cluster-randomised trial conducted in Ugandan secondary schools. Endline data were collected one year after baseline. We identified baseline factors associated with the menstrual knowledge and attitudes at endline, and estimated associations of menstrual knowledge items with menstrual practice needs and menstrual confidence at endline, using random-effects Poisson and linear regression analyses to estimate adjusted incidence rate ratios (aIRR) and mean differences (aMD) respectively. Results Among 1453 female and 317 male participants in 30 control arm schools who completed both baseline and endline surveys, there was evidence of small associations between better menstrual knowledge at endline with better baseline knowledge (both male and female participants), and in females only, being in a private school (aIRR = 1.05, 95%CI 1.00-1.11), and knowledge about menstruation prior to menarche (aIRR = 1.08, 95%CI 1.03–1.14). Positive attitudes towards menstruation at endline were associated with baseline positive attitudes (male and female participants), and with knowledge prior to menarche (aIRR = 1.10, 95%CI 1.01–1.21). Participants with better knowledge scores had better menstrual experiences (Menstrual Practice Needs Scale: aMD = 0.19, 95%CI 0.08–0.30, p < 0.001 for high versus low knowledge scores). Conclusions Female adolescents who know about menstruation before menarche have slightly greater menstrual knowledge and positive attitudes towards menstruation. In turn, menstrual knowledge is associated with fewer unmet menstrual practice needs. Future interventions should consider tailoring educational content to address specific knowledge gaps and cultural attitudes and include boys. Trial registration number ISRCTN45461276 Registration date: 16/09/2021

We assessed the association between dolutegravir (DTG)-based antiretroviral therapy and kidney abnormalities among young people living with HIV in Kampala, Uganda. Cross-sectional albumin–creatinine ratio (ACR), proteinuria, and estimated glomerular filtration rate (eGFR) were measured. Among 483 participants, the mean serum creatinine was higher (0.68 vs. 0.59) and creatinine-based eGFR lower (118.8 vs. 113.9), among those on TDF/DTG. Cystatin C–based eGFR, prevalences of elevated ACR (9.6

PROBLEM:Most Herpes simplex virus type 2 (HSV-2) infection is asymptomatic but increases the risk of HIV acquisition, possibly due to alterations in genital immunology. We examine associations of HSV-2 prevalence and incidence with epithelial barrier disruption. METHOD OF STUDY:The study was nested within the longitudinal Maisha Fiti cohort of women who sell sex in Nairobi, Kenya. HSV-2 serostatus was assessed by Kalon HSV-2 IgG assay. Socio-behavioural characteristics were assessed by questionnaire and analysed by logistic regression. Immune factors (including soluble E-cadherin (sE-cad)) were assayed in cervicovaginal secretions by multiplex immunoassay, log-transformed and analysed through linear regression. RESULTS:Among 731 HIV-negative participants, 414 (57%) were HSV-2 seropositive. These women were older (median age 35 vs 28 years; p < 0.001) and reported increased intravaginal washing (64 vs 56%; p = 0.027) than those who were HSV-2 seronegative. Genital sE-cad levels were similar, and IL-6 levels were lower in seropositive participants (1.15 vs 1.28 pg/mL, p < 0.01). Seroincidence was 10.7/100 person (95% CI: 7.3, 15.2) years among the 317 initially seronegative participants. Incident infection was associated with older age (31 vs 28 years, p = 0.001), increased number of clients (6 vs 4 clients/week, p = 0.005), and bacterial vaginosis (BV) (32 vs 15%, p = 0.009). Although women who acquired HSV-2 had higher sE-cad and lower MIP-3α levels, there was no association after controlling for Nugent score. CONCLUSIONS:Subclinical epithelial barrier disruption is unlikely to be underpinning HIV acquisition in asymptomatic HSV-2 infection. There was no evidence of genital immune predictors of HSV-2 acquisition, whereas the vaginal microbiome is important.

Female sex workers (FSWs) in sub-Saharan Africa commonly experience violence, mental health problems, and harmful substance use. Stressful life events can harm the functioning of the hypothalamic-pituitary-adrenal (HPA) axis, serving as a pathway to increased poor health, including HIV susceptibility through cortisol levels. In this paper, we examine changes in hair cortisol concentration (HCC) levels and associations with experiences of violence, mental health problems and harmful substance use among FSWs in Nairobi, Kenya. We used baseline and endline data from the Maisha Fiti study of FSWs in Nairobi. Participants reported recent violence, poor mental health, and harmful alcohol/substance use at both time points. Hair samples proximal to the scalp were collected to measure HCC levels determined by ELISA technique. We analysed data from 285 HIV-negative respondents who provided a 2 cm hair sample at baseline and endline. Multivariable linear regression models were used to assess the associations between the trajectory of the main exposure variables and the change in HCC levels at endline. Findings showed that HCC levels decreased significantly (p-value = 0.001) from baseline (mean HCC = 316 ng/g) to endline (mean HCC = 238.1 ng/g). Reported prevalence of violence, mental health problems and harmful alcohol/other substances decreased. There was evidence of associations between change in HCC at endline and the trajectories of physical violence (p-value = 0.007) and physical and/or sexual violence (p-value = 0.048). There was weak evidence of an association between the trajectory of exposure to emotional violence but no evidence of other associations. These findings suggest that physical violence and physical and/or sexual violence may lead to HPA axis dysfunction, possibly serving as a pathway linking violence to increased poor health, including HIV acquisition. However, further research with repeated measurements and a larger sample size is needed to examine the associations between violence, HCC levels, and HIV infection.

Introduction Trachoma is caused by the bacterium Chlamydia trachomatis (Ct). The WHO recommends the SAFE strategy for trachoma elimination: Surgery for trichiasis, Antibiotics, Facial cleanliness and Environmental improvement. Multiple rounds of SAFE implementation have proven insufficient to eliminate trachoma in Ethiopia, where over 50% of the global trachoma burden remains. More effective antibiotic treatment schedules and transmission-suppressing approaches are needed. The aim of stronger SAFE is to evaluate the impact of a novel package of interventions to strengthen the A, F and E of SAFE on the prevalence of ocular Ct and trachoma in Oromia, Ethiopia.Methods and analysis 68 clusters were randomised in a 1:1:1:1 ratio to one of (1) standard A/standard F&E (standard SAFE), (2) standard A/enhanced F&E, (3) enhanced A/standard F&E or (4) enhanced A/enhanced F&E (stronger SAFE). Enhanced A includes two height-based doses of oral azithromycin (equivalent to 20 mg/kg) given as single doses 2 weeks apart, as mass drug administration, annually. Enhanced F&E includes fly control measures (permethrin-treated headwear and odour-baited traps) and face-washing hygiene behaviour change implemented at household level in selected communities. The interventions will be implemented and reinforced over 3 years.The primary outcome is the prevalence of ocular Ct by quantitative PCR in children aged 1–9 years at 36 months. A key secondary outcome is the prevalence of active (inflammatory) trachoma in the same children, assessed by validated trachoma graders and conjunctival photography. Laboratory technicians and photo-graders are masked to treatment allocation. Other important secondary analyses include process evaluations, assessment of behaviour change, fly indicators, adherence and coverage of interventions and a cost analysis.Ethics and dissemination Study protocols have been approved by the National Research Ethics Review Committee of the Ethiopian Ministry of Science and Higher Education and the London School of Hygiene & Tropical Medicine Ethics Committee. An independent data safety and monitoring board oversees the trial. Results will be disseminated through peer-reviewed publications, presentations and reports.Trial registration number ISRCTN40760473.

We assessed the association between dolutegravir (DTG)-based antiretroviral therapy and kidney abnormalities among young people living with HIV aged 10-24 years in Kampala, Uganda. In this cross-sectional study, albumin-creatinine ratio (ACR), proteinuria, and estimated glomerular filtration rate (eGFR) were measured. Among 483 participants, 78% received tenofovir (TDF)/DTG. Mean serum creatinine was higher and creatinine-based eGFR lower among those on TDF/DTG, while cystatin C and cystatin C-based eGFR were similar. The prevalence of elevated ACR, proteinuria, and eGFR <90 ml/min/1.73m2 was similar. Kidney abnormalities were common, supporting the need for longitudinal studies to clarify chronic kidney disease risk.

Objectives Few studies have examined sleep health among African adolescents. We aimed to understand sleep health among Ugandan secondary school students. Methods We collected quantitative data in two schools through a survey with items on sleep health and insomnia (using the Cleveland Adolescent Sleepiness Questionnaire, Munich Chronotype Questionnaire and Insomnia Severity Index [ISI]) and mental health with the UNICEF Measuring Mental Health Among Adolescents and Young People at the Population Level (MMAPP) tool. We used regression models to assess characteristics associated with ISI score, and of sleep health with depression and anxiety. We conducted focus group discussions and in-depth interviews with students, parents, teachers, and officials. Quantitative and qualitative analyses were guided by the social ecological model of sleep health. Results The 358 participants generally reported poor sleep health (assessed by satisfaction, alertness, timing, efficiency and duration), especially among boarding students. The median sleep duration was 5.1 hours (interquartile range 4.2-6.2). Overall, 36 (10.1%) participants screened positive for moderate/severe insomnia (ISI ≥15), with higher prevalence among females than males (12.7% vs. 6.2%; p = .05). Qualitative interviews highlighted that individual (knowledge and attitudes), social-cultural (religious beliefs, family dynamics, academic demands, peer pressure), environmental (school and home conditions, technological influences), and societal factors (national school schedule guidelines) influenced sleep patterns. Depression and anxiety were associated with multiple dimensions of poor sleep health. Conclusions Ugandan adolescents face substantial sleep challenges, which are associated with poor mental health. Evidence-based interventions should be adapted for specific social-ecological contexts to improve sleep and mental health in this population.

Chronic kidney disease (CKD) is often complicated by disorders in multiple body systems, associated with higher mortality and morbidity. Young people living with HIV (YPLHIV) have an increased risk of multisystem chronic comorbidities. However, there are few data describing comorbidities associated with CKD among YPLHIV. We conducted a case-control study in seven ART clinics in Kampala, Uganda. Cases were YPLHIV (aged 10–24 years) diagnosed with CKD and controls were those without CKD. We collected data on demographic and clinical factors: HIV viral load, CD4 T cell count, blood pressure, fasting glucose levels, anaemia, electrolytes, parathyroid hormone, and cognitive impairment. We summarized the demographic and clinical factors and used logistic regression to estimate odds ratios (OR) and 95

Poor menstrual health (MH) has been associated with reduced participation in school activities and diminished psychosocial wellbeing among adolescent girls. Despite increasing recognition of the importance of MH interventions, there is limited economic evidence to inform large-scale adoption and financial planning. We conducted an incremental costing analysis of an MH intervention (MENISCUS) alongside a cluster-randomized trial in 60 secondary schools in Uganda. MENISCUS delivered puberty education, a drama skit, an MH kit, pain management strategies and improvements to water, sanitation and hygiene (WASH) facilities. We categorized the provider costs into start-up and implementation, and calculated unit costs per school, per student (male and female) and per female student respectively. We modelled two potential national scale-up scenarios (basic and enhanced) to 2,995 secondary schools using government delivery structures. The total cost of the basic scenario is US$10,224,685 and the enhanced scenario is US$16,549,123. The unit cost of scaling the intervention nationwide was estimated at US$28 per student and US$58 per female student (basic scenario) and US$46 per student and US$95 per female student (enhanced scenario). The primary cost drivers were the MH kit and associated training, followed by pain management activities and improvements to WASH facilities. The enhanced scenario generated a higher unit cost per student and unit cost per female student due to additional components. Compared with trial costs, unit costs were lower in national scale-up, demonstrating economies of scale. This study provides the first economic analysis of a potential national implementation of a school-based MH intervention in a low-resource setting. The findings provide critical benchmarks for governments seeking to integrate MH into national education curriculum and inform future investment decisions in adolescent health. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial ISRCTN45461276 ### Clinical Protocols ### Funding Statement This study was supported by the Joint Global Health Scheme with funding from the UK Foreign, Commonwealth and Development Office (FCDO), the UK Medical Research Council (MRC), the UK Department of Health and Social Care (DHSC) through the National Institute for Health Research (NIHR) and Wellcome (grant ref MR/V005634/1). The funders had no role in the identification, design, conduct, reporting of the analysis and in the writing of the article. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: We obtained ethics approval from the Uganda Virus Research Institute (UVRI) & Ethics Committee (reference GC/127/819), the Uganda National Council of Science and Technology (reference HS1525ES), and the London School of Hygiene & Tropical Medicine (reference 22952). An independent Trial Steering Committee provided scientific guidance and monitored the progress of the trial. The Independent Data Monitoring and Ethics Committee (IDMEC) reviewed the trial recruitment and safety data and provided scientific guidance. The trial was prospectively registered ([ISRCTN45461276][1]). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes the data will be available on the LSHTM repositary [1]: /external-ref?link_type=ISRCTN&access_num=ISRCTN45461276

Background Menstrual health (MH) is vital to women’s overall health and well-being. Yet many women, especially in resource-limited settings, face challenges due to insufficient resources and support. Most MH research has focused on school-going adolescents while limited research has investigated MH experiences across the lifecourse. This study aims to understand menstrual experiences across women’s lifecourse in Zimbabwe, including MH-related pain and discomfort and women’s MH-related healthcare seeking behaviours.Methods From February to April 2024, we conducted eight participatory workshops in Harare and Bulawayo, Zimbabwe with a total of 53 women aged over 18 years. Workshops aimed to explore lived experiences of MH and included participatory collage activities. We conducted thematic and visual analyses of the workshops and participant collages to explore participants’ MH perceptions and lived experiences.Results Menstruation was seen as a central signifier of fertility and embodiment of womanhood. Women of all ages had limited access to education and support for menstrual-related issues (particularly menarche and menopause). Stigma and ill-informed healthcare providers were key barriers to menstrual-related healthcare and treatment. Women reported using alternative methods, including traditional herbs, while younger women, in particular, turned to online platforms to address menstrual-related issues.Conclusions MH is central to women’s identity, health and well-being across the lifecourse. Persistent stigma, inadequate support and limited healthcare, especially during transitions such as menopause, highlight the need for inclusive policies and programming and adequately trained providers. Further research into digital and community-based MH approaches that empower women to navigate stigma and access care independently is also needed.

BACKGROUND:Although depression is common in people with HIV, mental health interventions are not available to the vast majority of people with HIV in Africa. We aimed to test the effectiveness of the HIV+D collaborative stepped care depression intervention in adult HIV care in Uganda. METHODS:A cluster-randomised controlled trial was done at 40 randomly selected primary HIV care centres (clusters) at public health-care facilities in three districts in Uganda. The 40 clusters were randomly allocated (1:1) to enhanced usual care only (EUC arm) or to HIV+D intervention plus EUC, with the randomisation stratified by level of health facility. We recruited adults (aged 18 years or older) with HIV with depression, defined by the locally validated version of the Patient Health Questionnaire 9 (PHQ-9). Participants were consecutively recruited into the study clinics until there was a maximum of 30 participants per cluster. HIV+D was coordinated by a lay counsellor and involved four sequential steps of psychoeducation, behavioural activation, antidepressant medication, and referral. EUC comprised sharing screening results with the HIV clinic physician and training on the WHO guidelines for depression management in routine care. The primary outcome was PHQ-9 scores at 3 months. The trial is registered with the ISRCTN registry (ISRCTN86760765) and is completed. FINDINGS:8441 people with HIV were referred to the trial, and 1115 (13%) were enrolled between May 3 and Dec 31, 2021. The mean age was 38 years, 859 (77%) were female, 535 were enrolled in the EUC group, and 580 were enrolled in the HIV+D plus EUC group. Primary outcome data were available for 1097 (98%) participants. We observed high levels of fidelity, with 290 (92%) of 316 participants in the HIV+D plus EUC intervention group receiving the recommended 4-10 sessions of behavioural activation. At 3 months, the mean PHQ-9 scores were lower in the HIV+D plus EUC group, at 3·0 (SD 3·2) compared with the EUC group, at 7·6 (SD 4·2; adjusted mean difference 4·4; 95% CI 3·4-5·5; p<0·0001; effect size [d]=1·34). This effect was sustained, although attenuated, at 12 months (adjusted mean difference 1·9; 95% CI 1·0-2·8; p<0·0001; d=0·81). Baseline depression severity scores moderated the HIV+D plus EUC intervention effect, with the intervention having stronger effects for those with baseline scores in the severe range (≥20) than for those whose scores were in the moderate range (10-19) both at 3 and 12 months (p values for effect modification were <0·001 and 0·005, respectively). There was no evidence of effect modification by sex nor baseline HIV viral load. One participant in the HIV+D plus EUC group was hospitalised because of severe depression. INTERPRETATION:The HIV+D plus EUC intervention had a significant and sustained effect on depression compared with EUC. This intervention offers a scalable approach to integrate mental health care for adult HIV care settings. FUNDING:Wellcome Trust Senior Research Fellowship in Public Health and Tropical Medicine.

Abstract Background WHO recommend that children and adolescents attend scheduled well-care visits for health promotion, prevention, early detection, identification and management of disability and disease. Children born to adolescent mothers experience a disproportionate burden of poor health outcomes, but their well-care attendance is under-researched. Methods Cross-sectional data were used from a cohort of adolescent and young mothers (10–24 years; n = 1040) and their children (n = 1145) recruited through purposive, convenience-based sampling across healthcare facilities and community-based settings in Eastern Cape, South Africa (2017–2019). Quantitative data on visit attendance up to 18 months were analysed using descriptive statistics for children of adolescent mothers (10–19 years) aged ≥ 19 months at data collection, to allow complete observation of visits. In 2022, semi-structured interviews (n = 16) were conducted until saturation, to explore factors influencing attendance. Themes were developed and matched to the capability, opportunity and motivation model of behaviour (COM-B) and Theoretical Domains Framework using a realist thematic template analysis approach. Results Records were available for 415/482 eligible children. Attendance declined from 85.1% (95%CI: 81.3–88.4) at 6 weeks to 49.7% (95%CI: 46.6–56.5%) at 18 months, with higher attendance during visits coinciding with the childhood immunisation schedule. Attendance and qualitative findings were similar by maternal HIV status. Themes were matched to the COM-B. Capability: mothers’ organisational and financial acumen facilitated their child’s attendance; mothers persisted in attending despite harsh attitudes from healthcare workers. Opportunity: financial and kinship support and information in the child health booklet facilitated visit attendance; lack of childcare support, poor weather, cost and distance to clinic interfered with attendance. Motivation: mothers were motivated to attend visits to gain knowledge and fulfil their parental role. Conclusion This study identified missed opportunities for promoting life-course health and well-being among children and their adolescent mothers, and theory-informed opportunities to support well-care visit attendance. Findings challenge deficit-based narratives highlighting mothers’ motivations and strategies for ensuring attendance. Enhancing the quality of nurse-adolescent mother interactions may increase the perceived and actual value of visits and support attendance. Further research is needed on interventions to promote consistent attendance, address barriers to access and identify opportunities to strengthen integration of well-care and HIV-related services.

PROBLEM:Female genital mutilation/cutting (FGM/C) is harmful to physical, mental, and reproductive health, though the effect of this practice on a woman's HIV susceptibility is poorly understood. Despite the known associations of FGM/C with short-term vaginal epithelial damage, neither genital inflammation nor the genital microbiome have been explored in women who have undergone FGM/C. In this study we compare the genital immune milieu and microbiome among female sex workers (FSWs) by FGM/C status, hypothesizing that these biological factors are dysregulated in women who have undergone FGM/C, heightening their risk of HIV acquisition. METHOD OF STUDY:1003 FSWs in Nairobi, Kenya, were enrolled in the Maisha Fiti study and visited a study clinic up to three times from June 2019 to March 2021. Participants self-reported any previous exposure to FGM/C as well as other relevant sociodemographic factors. Levels of proinflammatory cytokines and soluble E-cadherin (sE-cad), a biomarker of epithelial barrier disruption, were measured by multiplex immunoassay using self-collected cervicovaginal secretion samples provided by HIV-uninfected participants. Genital inflammation was defined using a composite score of inflammatory cytokines previously associated with HIV acquisition. The presence of inflammation was compared longitudinally between groups using mixed models to control for potential confounders including age, bacterial vaginosis (BV) status as defined by Nugent score, and others. Vaginal bacterial abundance, Shannon diversity, and total levels of key vaginal bacteria were measured by qPCR and compared by FGM/C status in an exploratory analysis. RESULTS:44 of 1003 (4%) participants had undergone Type I or II FGM/C. These participants were older (p < 0.001) and more likely to test positive for herpes simplex virus-2 (HSV-2; p = 0.04), and less likely to have completed primary education (p = 0.03). Among HIV-uninfected participants, there was no evidence that genital inflammation was associated with FGM/C status after controlling for potential confounders (aOR = 0.70; 95% CI: 0.31-1.59; p = 0.40). There was no evidence of a difference in BV prevalence (p > 0.99), total bacterial abundance (p = 0.96), or Shannon diversity (p = 0.15) by FGM/C status. CONCLUSIONS:Type I or II FGM/C was not associated with genital inflammation or microbial dysregulation in the long-term among HIV-negative FSWs in this cohort. This may be due to the duration elapsed since FGM/C occurred or the lowered mucosal immune activation previously observed in FSWs.

Study Objectives:There is little research on sleep health interventions in Africa. We assessed the feasibility and acceptability of a tiered sleep health intervention among Ugandan adolescents. The intervention, delivered in two secondary schools, comprised universal components (sleep education sessions, structural changes to light, temperature and school-timings) plus targeted psychologist-delivered group cognitive behaviour therapy for insomnia (CBT-I) for students with moderate/severe insomnia (Insomnia Severity Index ≥15). Methods:Feasibility and acceptability were assessed through semi-structured interviews immediately after the intervention (T1) and 3 months later (T2) among students with baseline (T0) insomnia, teachers and dormitory matrons, along with structured implementation trackers. We conducted a quantitative survey at baseline to assess prevalence of dimensions of sleep and mental health, and for those with insomnia only, repeated this at T1 and T2. Results:The intervention was feasible and acceptable. High fidelity, dose and reach were achieved through integration of sleep education to the school schedule, structural changes to light, temperature and wake-up time for boarding students, effective small group delivery of CBT-I sessions and good retention despite fatigue due to extended sessions. Acceptability was reflected in high student engagement and positive feedback on the relevance of both universal and targeted components. Among 36 students with baseline insomnia, prevalence of moderate/severe insomnia decreased to 19.4% (7/36) post-intervention and further to 3.6% (1/28) at three months, indicating strong potential for impact. Conclusions:Multi-level, school-based sleep interventions can be successful in low-income settings. Large-scale cluster-randomized controlled trials are needed to estimate impact and cost-effectiveness.

Young people have low uptake of mental health. We compared two task-shifted mental health care models, i.e., adult Friendship Bench (FB) delivered by community health workers and Youth Friendship Bench (YouFB) delivered by trained university students in Harare, Zimbabwe. We hypothesised that the peer-delivered YouFB would have greater uptake and effectiveness in managing common mental disorders (CMDs) in 16–19-year-olds compared to the standard FB model. We also aimed to evaluate the reach, fidelity, acceptability and cost of the YouFB compared to standard FB. We conducted an open-label cluster-randomised, hybrid type-2 implementation trial with cost analysis in 26 primary care clinics and their surrounding communities. Facilities were randomised 1:1 to FB or YouFB. The primary implementation outcome was uptake, defined as the proportion of adolescents aged 16–19 offered FB sessions for treatment of CMD who completed at least one FB session. Secondary implementation outcomes included reach, fidelity, and acceptability. The main clinical outcome was the clinical effectiveness of YouFB vs. FB at six months, assessed by changes in Shona Symptom Questionnaire (SSQ-14) scores. We also carried out a cost analysis from a societal perspective. Acceptability was evaluated qualitatively using in-depth interviews. Reach was calculated as the number of adolescents receiving FB sessions per clinic day. Uptake in the FB and YouFB arms was 86.6

Background The likelihood of HIV acquisition is increased following forced vaginal sex. This relates in part to epidemiological and behavioural factors; however, the biological effects of forced vaginal sex, including impacts on immune parameters linked to HIV susceptibility, are poorly understood. Here, we examine biological mediators of HIV susceptibility among female sex workers (FSWs) in Nairobi, Kenya, who recently experienced forced vaginal sex. Methods The Maisha Fiti study was a longitudinal cohort study of FSWs from Nairobi, Kenya. At up to three visits, HIV-uninfected participants completed a detailed sociodemographic survey in which they were asked if they had experienced forced vaginal sex in the past 7 days. Proinflammatory cytokines and soluble E-cadherin (sE-cad), a biomarker of epithelial barrier disruption, were quantified in cervico-vaginal secretions by multiplex immunoassay. Associations between recent forced sex and genital inflammation were assessed longitudinally in a mixed-effects regression model adjusted for potential confounders and within-participant correlation. Results Of the 746 participants, 44 (6%) reported forced vaginal sex in the past 7 days at baseline, with strong evidence of associations with adverse childhood experiences (p<0.001), mental health issues (p<0.001) and poverty (p=0.02). Recent forced sex was associated with increased genital inflammation (adjusted OR (aOR)=2.74; 95% CI 1.33 to 5.68; p<0.01) independent of previously defined confounders but was not associated with altered levels of sE-cad (p=0.56). Neither recent consensual sex (aOR=0.94, 95% CI 0.63 to 1.40, p=0.76) nor forced sex within the past 6 months, excluding the past 7 days (aOR=0.93, 95% CI 1.21 to 5.42, p=0.70), was associated with genital inflammation. Conclusions Cervicovaginal inflammation is increased in FSWs for at least a week after forced vaginal sex. This has important implications for HIV prevention programmes that provide care to women experiencing gender-based violence. Further studies are needed to understand the specific timing of proinflammatory cytokine release following forced vaginal sex.

Objectives Few studies have assessed sleep among African adolescents. We aim to understand factors associated with subjective sleep quality among female Ugandan adolescents and the association of poor sleep quality with subsequent menstrual- and mental health, and educational performance. Methods We analyzed data from a cluster-randomized controlled trial that evaluated a menstrual health intervention in 60 Ugandan secondary schools. Data were collected through cross-sectional surveys at baseline (March-June 2022) and endline (July-August 2023), and prospective daily diaries (April-August 2023). We used logistic regression to analyze associations with poor sleep at baseline, and linear regression to analyze associations of poor sleep with subsequent menstrual and mental health, and education performance, adjusting for clustering. Results Of 3841 female participants (mean age=15.6years), 580 (15.1%) reported poor sleep quality and 829 (21.6%) reported feeling tired at baseline. Poor sleep was associated with socio-economic factors including smaller household size, lower socioeconomic status, and fewer meals consumed the previous day. There was strong evidence that poor sleep at baseline was associated with multiple dimensions of poor menstrual health including menstrual pain (adjusted odds ratio=1.74, 95%CI 1.29-2.33), more unmet menstrual practice needs (adjusted odds ratio=2.68, 95%CI 1.99-3.60), and with mental health problems (adjusted odds ratio=2.40, 95%CI 1.80-3.19). Results were similar for baseline tiredness. Prospectively reported poor sleep quality was associated with subsequent poor menstrual and mental health, and subsequent poor educational performance. Conclusions Poor sleep is prevalent among in-school female Ugandan adolescents and is associated with subsequent poorer menstrual health, mental health, and educational performance. Improving sleep in this population could benefit menstrual health, mental health and education outcomes.