Abstract Background In 2016, the World Health Organization revised its antenatal care (ANC) recommendation from four to eight visits. For low- and middle-income countries like Uganda, where achieving even four visits remains a challenge, this transition has significant cost implications for both the health system and households. This study estimated the incremental costs of adopting the eight-visit model from a societal perspective. Methods The study was conducted in six government health facilities in southwestern Uganda. A micro-costing approach estimated health facility costs (personnel, equipment, consumables, and overhead). Costs incurred at patients’ end (transport, ultrasound, medical expenses, and time) were collected from 785 women using a questionnaire, with all costs in 2025 USD. Results For an average of 4.3 visits, total cost per woman was $100.1: facility costs $43.7 (43.7%), and patient costs $56.4 (56.3%). Transitioning to eight visits would increase total cost by $57.8 (57.8%), of which $36.4 (63.0%) would fall on households, equivalent to 68.8% of average monthly household income. Total costs would rise by 55.4% ($115.5 to $179.5) at Health Center IVs and 64.3% ($102.3 to $168.1) at Health Center IIIs, with facility costs up 43.4% and 62.9% and patient costs up 61.2% and 65.7%, respectively. Conclusion Transitioning to eight ANC visits would impose a large financial burden on households, with the incremental patient cost equivalent to more than two-thirds of average monthly household income. Equitable implementation requires improving availability of medicines and diagnostics, subsidizing transport, exploring telemedicine or community-based models, and improving efficiency at lower-tier health centers. Highlights Evidence on the incremental costs of scaling up antenatal care services in low-income countries, especially from a societal perspective that captures household costs, remains limited. Transitioning to WHO-recommended eight antenatal care visits in Uganda would increase total cost per woman by 57.8% to $157.9, with 63% of the incremental cost ($36.4) falling on households, equivalent to more than two-thirds of average monthly household income, and 37% ($21.4) on health facilities. To ensure equitable scale-up, policy interventions should improve availability of medicines and diagnostics at public facilities, subsidize transport costs, and explore telemedicine or community-based models to reduce household financial burden.

Background Retention in HIV care is associated with higher rates of antiretroviral treatment adherence and viral suppression, as well as lower risk of AIDS-related morbidity and mortality. However, the multidimensional nature of retention complicates measurement standardisation, limiting comparability and global evaluation. Objectives This study explored how HIV stakeholders define and assess retention, aiming to develop a patient-centred and conceptually robust understanding to inform research and practice. Methods We conducted a qualitative study using interpretive description methodology, an applied qualitative approach designed to generate practice-relevant knowledge in health research. We purposively sampled 20 stakeholders representing diverse areas of expertise and geographic regions across World Bank country income classifications. We conducted and video-recorded in-depth semistructured interviews and subsequently transcribed them. Using constant comparative analysis, we identified recurring, convergent and contradictory patterns. Results The analysis identified five overarching themes. The first two, exploratory themes, included Patient-Centred Understanding of Retention in HIV Care, which captured how stakeholders conceptualised retention in their respective contexts and Operationalisation of Retention Measures, which explored the key components used to measure retention. The next two explanatory themes, included Purpose-Driven Definitions of Retention, which described how retention measures were selected based on their intended use, and Building Capacity through Shared Understanding and Integrated Action, which emphasised retention as a cyclical, interconnected process dependent on collaboration between patients and health systems. The final, prescriptive theme, Advancements Shaping Retention, reflected stakeholders’ shared vision of improving retention through innovations in HIV treatment and technology. Conclusions The findings suggest that stakeholders operationalise retention measures in line with specific objectives and individual health goals, while remaining attentive to contextual realities. Retention measures should remain flexible and patient-centred, rather than relying on a single rigid standard.

Introduction Africa faces a substantial health burden characterised by a dual burden of communicable and non-communicable diseases compounded by persistent health system and infrastructure constraints. Digital health interventions offer scalable opportunities to strengthen healthcare delivery. Interactive voice response (IVR), an automated telephone-based technology, shows promise across African health settings; however, existing evidence is dispersed across isolated studies and demonstrates variability in outcomes and implementation approaches. This scoping review maps existing evidence on the use of IVR in healthcare in Africa, focusing on applications, outcomes and implementation experiences.Methods and analysis Eligible studies will include all designs that evaluate IVR-based health interventions in African healthcare settings, while non-voice digital interventions and non-empirical publications will be excluded. We will conduct a scoping review guided by the Arksey and O'Malley framework and the Joanna Briggs Institute and report findings using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. We will systematically search bibliographic databases and grey literature from 2000 to the end of 2025. Two independent reviewers will screen studies, extract data and chart evidence on IVR characteristics, implementation strategies, barriers and facilitators and outcomes. A third reviewer will resolve disagreements. We will synthesise findings descriptively and thematically, presenting results in tables, visual maps and an equity-focused analysis guided by PROGRESS-Plus.Ethics and dissemination Ethical approval is not required because this scoping review synthesises previously published, publicly available literature and does not involve human participants or primary data collection. We will share the findings through a peer-reviewed publication and conference presentations, and we will discuss the results with digital health stakeholders, clinicians and policymakers to inform future IVR work in Africa.

Background:Ugandan women and their children suffer from high maternal and perinatal mortality, often due to low antenatal care (ANC) and skilled birth usage. We partnered with community members, women and the Ugandan Ministry of Health to formatively develop an intervention (Support-Moms app) to improve health education, engage social support networks, and augment access to ANC and delivery by a formal health care provider (HCP) for pregnant women in rural Uganda. Methods:We conducted a type 1 hybrid effectiveness-implementation trial to test the effectiveness of the Support-Moms intervention. We enrolled 824 pregnant women (<20 weeks gestation) living in Southwestern Uganda and randomized them (1:1) to standard of care or Support-Moms intervention. The primary effectiveness outcome was completion of a HCP-led skilled birth (discharge card) and was analyzed as intention-to-treat. Secondary outcomes included number of ANC visits, institution-based delivery, social support, quality-of-life, mode of infant delivery, pre-term birth, birth weight, obstetric complications and deaths (maternal, fetal, newborn). Results:A total of 1,216 women were screened, and 824 pregnant women enrolled (mean age ~28 years; gestation at enrolment ~13 weeks). Complete outcomes were available for 818 (99%). The Support-Moms intervention increased HCP-led skilled births compared to standard of care (93% vs 84%; OR 2.51, 95% CI 1.57-4.03, p<0.001). Women in the intervention group were more likely to achieve ≥4 ANC visits (84.1% vs 75.1%; OR 1.76, 95% CI 1.24-2.50, p=0.001) and less likely experience postpartum hemorrhage (9.1% vs 22.7%, OR 0.34, 95% CI 0.22-0.52, p<0.001) or for their neonates to require resuscitation (9.8% vs 13.7%, OR 0.69, 95% CI 0.45-0.99, p=0.001). Initiation of breastfeeding within an hour was higher (97.1% vs 71.7%, OR 1.76, 95% CI 1.15-3.44, p=0.001) and postnatal depression decreased (20.1% vs 27.1%, OR 0.68, 95% CI 0.49-0.94, p=0.019). More intervention participants reported adequate support, were birth-prepared and had a birth companion. There were no maternal deaths or differences in term births, birthweight, mode of delivery, perinatal mortality or other obstetric complications. Conclusions:In rural Uganda, the Support-Moms mHealth-based, social-support intervention significantly increased HCP-led skilled births compared with routine care, while also improving ANC attendance, early breastfeeding initiation, birth preparedness, perceived social support and higher presence of companion at birth. Less women experienced PPH, neonatal resuscitation, and postnatal depression. Further evaluation should focus on the cost effectiveness and sustainability of this program. Trial registration:Clinicaltrials.gov NCT05940831.

Background:Latent tuberculosis (TB) infection care often requires engagement with multiple teams in several locations throughout the diagnostic and treatment steps of the TB infection care cascade. The intersecting effects of geographic proximity and social drivers on care cascade retention have not been well examined. Methods:We conducted a retrospective cohort study of patients with a positive TB infection test between 2018-2019 within a health system in Boston, Massachusetts. The primary outcome was attendance at a TB clinic after a referral was placed. The primary exposure was geographic proximity, as measured by travel time by car. We assessed effect modification of proximity by Social Vulnerability Index (SVI), a composite measure of census tract social drivers. Results:We identified 1677 patients with positive TB infection tests; 1208 (72%) were referred to a TB clinic, of whom 748 (62%) completed referral. Longer travel times were associated with lower odds of referral completion (furthest vs nearest quartiles: adjusted odds ratio, 0.76 [95% confidence interval, .71-.82]). SVI significantly modified the effects of proximity: Increasing travel time was associated with decreasing probability of clinic attendance for patients in lower-vulnerability census tracts but had minimal effect on clinic attendance among patients in higher vulnerability census tracts. Conclusions:Additional support is needed for individuals referred to TB clinics that require long travel times to attend. Support should also account for other social drivers affecting care access for those living near TB clinics.

Background:The global incidence of syphilis has increased in recent years. Understanding syphilis epidemiology will inform screening and treatment programs. However, such data are lacking in many communities. We outline a population-based syphilis screening program in a rural community in southwestern Uganda to describe the population prevalence of syphilis. Methods:In June 2019 we conducted a cross-sectional, population-based study of adults >18 years of age. Two-stage syphilis testing was completed with Treponema pallidum hemagglutination (TPHA) rapid immunochromatographic testing, confirmed by rapid plasma reagin (RPR) in those with positive TPHA (syphilis seroprevalence). We calculate inverse probability of treatment (IPT) weights using logistic regression to estimate the population prevalence of positive TPHA. We included covariates with a univariable α = .10 in multivariable logistic regression models, stratified by sex, to estimate correlates of syphilis seroprevalence. Results:Among 749 participants who participated in this population-based study, 724 (97%) completed syphilis screening. The median age was 42.9 years (standard deviation, 15.6 years) and 456 of 724 (63%) were women. Based on the IPT-weighted adjusted model, the syphilis population seroprevalence was 10.6% (95% confidence interval, 8.4%-13.4%). Among the 62 of 79 (78%) participants who completed RPR testing, all had titers ≤1:4. Syphilis seroprevalence was associated with less education, human immunodeficiency virus (HIV) infection, and ≥2 sexual partners in the prior month among women and with HIV among men. Conclusions:We describe a high prevalence of current or former syphilis (10.6%) in a population-based study in rural Uganda. Syphilis screening and surveillance programs in this region require expansion to capture populations not routinely in care.

Objective:We developed Healthy Families-PrEP to support perinatal women to use HIV prevention strategies.Design:Single-arm study to evaluate PrEP use among pregnant women exposed to the intervention.Methods:We offered safer conception counselling, including TDF/FTC as PrEP with adherence support (Healthy Families-PrEP) for women planning for pregnancy in South Africa with a partner with HIV or unknown serostatus. Women completed pregnancy and HIV testing quarterly and were followed for 1 year or until pregnancy end. For those initiating PrEP, electronic pillcap data and plasma were collected. We described PrEP adherence by proportion of days with pillcap openings and proportion of women with detected (>= 10ng/ml) plasma tenofovir.Results:From November 2017 to January 2020, 326 women with median age 24 years [interquartile range (IQR) 22-27] enrolled. Partner HIV-serostatus was unknown by 316 (97%). Over 3204 person-months of follow-up, 56 women became pregnant. Twenty-six women used PrEP during pregnancy and opened pillcaps on a mean of 53.1% [95% confidence interval (CI) 46.9-59.3%] of days. Plasma tenofovir was detected among 25, 15.4, and 12.5% of women providing samples during months 0-3, 4-6, and 7-9. No HIV seroconversions were observed.Conclusion:We observed low-pregnancy incidence. Counselling may have encouraged delayed pregnancy plans; some women may have exaggerated pregnancy plans to enroll. About half of pregnant women used PrEP and took over half of doses by pillcap. Fewer than 25% had tenofovir detected, likely reflecting pregnancy-related pharmacokinetics and adherence challenges. High interest in pregnancy PrEP use highlights the need to optimize adherence support and prevention choice.

Background:Pregnant women are vulnerable to HIV acquisition. Oral HIV pre-exposure prophylaxis (PrEP) is safe and effective for use during pregnancy. We describe PrEP adherence among pregnant women using multiple measures.Methods:We conducted a secondary data analysis among women enrolled in a study evaluating an adherence intervention for PrEP among those planning for and with pregnancy in South Africa. Our analysis included women who used PrEP and became pregnant. Longitudinal PrEP use was assessed using concentrations of tenofovir (TFV) in plasma, tenofovir diphosphate (TFV-DP) in dried blood spots, and electronic pillcap data from quarterly visits. Plasma TFV <= 10 ng/mL and TFV-DP <= 16.6 fmol/punch were below quantifiable limits. Data were analyzed during prepregnancy (quarter before pregnancy) and pregnancy trimesters.Results:Among 35 women, 69% were 18-24 years old, 40% were nulliparous, and 94% did not know their partner's HIV serostatus. Median pillcap adherence was 55%-80% and was highest during prepregnancy (72%, interquartile range: 54%-86%) and third trimester (80%, interquartile range: 30%-94%). The proportion of women with quantifiable TFV was 47% (n = 8/17) prepregnancy and 33% (n = 9/27), 19% (n = 4/21), and 14% (n = 2/14) for trimesters 1-3, respectively. TFV-DP was detected in 75% of samples (n = 12/16) prepregnancy, and 50% (n = 13/26), 29% (n = 6/21), and 27% (n = 4/15) for trimesters 1-3, respectively. No women acquired HIV during pregnancy.Conclusions:PrEP use declined during pregnancy by all measures. Discrepancies between pillcap measurements and drug concentrations could be due to physiologic changes during pregnancy or under- or overuse of the pillcaps. Determining what drug metabolite concentrations are needed to confer protection during pregnancy is important for optimizing counseling and prevention support.

Mentorship plays a critical role in promoting career development and generating impactful research and programs, yet it is typically considered an altruistic endeavor and a luxury. Mentorship programs are largely unfunded and unsupported, particularly in the Global South. However, they are important in global health given the high need for mentors in many settings as well as the cross-cultural complexities and power dynamics inherent in the field. Mentor training programs are becoming increasingly available and have been shown to increase traditional metrics of impact-namely, manuscripts, grants, and program milestones. However, the current focus on these metrics without supporting mentorship can detract from their impact, leading to quantity over quality and programs disconnected from the communities they are meant to serve. In this article, we argue that making mentorship itself a metric will facilitate the true impact we seek in global health, while simultaneously promoting equity in opportunity. We describe mechanisms to ensure quality in mentorship and highlight the importance of governmental and non-governmental agencies and philanthropy in enabling institutions to implement mentorship programs. We further describe increasing access to mentorship at scale through digital platforms like The Village, which enables and supports mentor-mentee matches. Elevating mentorship to a core performance indicator will have profound downstream effects for the practice and products of global health.

INTRODUCTION:Data to guide tuberculosis (TB) preventive treatment (TPT) of close contacts of people with multidrug-resistant tuberculosis (MDR-TB) are limited. While levofloxacin-based TPT has been shown safe and efficacious, alternatives are needed for those exposed to fluoroquinolone-resistant Mycobacterium tuberculosis (M. tb). The PHOENIx trial evaluates whether using a novel nitroimidazole, delamanid, in high-risk household contacts (HHCs) of patients with MDR-TB reduces their risk of developing active TB. METHODS/DESIGN:PHOENIx is a phase 3, open-label, multicenter clinical trial with a cluster-randomized superiority design (households form the clusters). The study objectives are to compare efficacy and safety of 26 weeks of delamanid versus isoniazid for preventing confirmed or probable TB during 96 weeks of follow-up among HHCs of adults with pulmonary MDR-TB. HHCs are defined as young children <5 years, people living with HIV or non-HIV immunosuppression, or people with evidence of M. tb infection. The study was originally designed to enroll 3452 HHCs to provide 90 % power to detect a 50 % reduction in the cumulative proportion of HHCs developing confirmed or probable TB during 96 weeks of follow-up from 5 % in the isoniazid arm to 2.5 % in the delamanid arm. The design included a sample size re-evaluation to address uncertainty in study design assumptions. DISCUSSION:Preventing MDR-TB is a global priority. Alternatives to levofloxacin-based TPT are needed since fluoroquinolone resistance is growing. PHOENIx, a phase 3 trial evaluating delamanid, is poised to inform WHO guidelines.

BackgroundComprehensive STI care requires not only patient treatment but STI partner notification (PN) and evaluation to prevent ongoing STI transmission and reinfection. In rural, southwestern Uganda, we explored healthcare practitioners’ views on three STI PN models that focused on task-shifting to non-physician practitioners to inform the development of a novel STI PN services delivery system.MethodsFrom September to November 2023, we conducted individual in-depth interviews with 32 participants from 4 categories (8 participants from each category): patients with a self-reported history of having an STI in Uganda, healthcare workers (physicians, nurses, and community health workers), pharmacists, and healthcare administrators (Ministry of Health officials and regional referral hospital administrators). Interviews explored participants’ views on a nursing-based, pharmacy-based, and community-based STI PN models as well as healthcare system tools and needs to facilitate PN. We used inductive and deductive approaches to generate a codebook guided by the Consolidated Framework for Implementation Research in a thematic analysis.ResultsTen female and twenty-two male participants participated in individual in-depth interviews. The median age of the patient and healthcare practitioner participants was 32 and 34 years, respectively. We found that (1) the nursing model was overall supported as nurses (though with one participant noting dissatisfaction with nurses), (2) pharmacies are well-positioned to engage in STI PN as they are early points of contact for patients, incentivized monetarily by PN and patient-delivered partner medication, and have the potential to physically restructure to create private spaces and increase counseling training, (3) the community-based model should center on village health teams and focus on advocacy and education.ConclusionGiven the high STI incidence globally and in sub-Saharan Africa, exploring innovative STI care models that resonate with patients and healthcare practitioners will be important. Future work includes a Delphi method to refine these models for testing.

Pregnant and postpartum people (PPPs) face heightened risk for HIV acquisition, yet depression and trauma-related symptoms can undermine adherence to pre-exposure prophylaxis (PrEP). To inform the development of a brief mental health-focused adherence intervention, we explored the impacts of depression and posttraumatic stress disorder (PTSD) symptoms on PrEP use among PPPs in Cape Town, South Africa. Twenty-eight PPPs with elevated symptoms of depression and/or PTSD and recent PrEP adherence challenges completed qualitative interviews. Six antenatal providers were also interviewed. Thematic analysis revealed three key findings with subthemes that deepen exploration of each theme: (1) depression and PTSD symptoms contributed to missed PrEP doses or late pickups by increasing doubt about PrEP efficacy, amplifying pill burden, intensifying avoidance and withdrawal (e.g., hypersomnia and disengagement from providers), and disrupting memory through rumination and emotional overload; (2) most PPPs preferred support from professional counselors, while a minority preferred informal support; and (3) intervention design considerations included aligning patient and provider goals, selecting between individual or group formats, and addressing integration barriers such as staffing and space constraints. Providers affirmed the need for embedded mental health support. Intervention strategies that increase PrEP knowledge and motivation while targeting emotional withdrawal, fatigue, and cognitive overload may improve adherence and reduce HIV risk in this population.

Non-communicable diseases (NCDs) represent a growing health burden in sub-Saharan Africa, especially in Uganda. The COVID-19 pandemic presented significant challenges for the Ugandan healthcare system, though changes in hospital admissions and outcomes for adults with NCDs and without COVID-19 infection remain unknown. We evaluated trends of NCD-related in-hospital mortality among patients without COVID-19 in a large regional referral hospital in Uganda from March 2019 through August 2021. Between March 1, 2019, and August 31, 2021, we conducted a chart review of Ugandan adults who carried a history of or were admitted for an NCD to Mbarara Regional Referral Hospital. Based on mortality trends, we broke admissions into three periods: Pre-Pandemic (March 1, 2019, to May 31, 2020), Early Pandemic (June 1, 2020, to March 31, 2021), and Late Pandemic (April 1, 2021, to August 31, 2021), and calculated admission and mortality rates for the most common NCD diagnoses. A multivariable logistic regression model was fitted for a primary outcome of in-hospital mortality. Of 3777 total individuals, 1655 were admitted Pre-Pandemic, 1423 in the Early Pandemic, and 699 in the Late Pandemic. We found a five-fold increase in mortality in the Early Pandemic period compared to the Pre-Pandemic and Late Pandemic periods (15.4 vs 2.9 vs 2.4, p < 0.001). Factors associated with increased odds for in-hospital mortality included admission during the Early Pandemic period (odds ratio [OR] 5.59; 95

Background Lenacapavir, a novel HIV-1 capsid inhibitor, shows promise for treating MDR HIV-1, as well as for pre-exposure prophylaxis (PrEP) in prevention of HIV infection. Its unique mechanism and lack of cross-resistance with other antiretroviral classes make lenacapavir a significant addition to HIV therapy. The clinical trials CALIBRATE and CAPELLA have demonstrated high viral suppression rates in both ART-naive individuals and individuals with MDR HIV-1. Lenacapavir-associated resistance mutations, such as M66I and Q67H, rarely seen as natural polymorphisms in lenacapavir-naive populations, are predominantly studied in subtype B HIV-1.Objectives Our study aimed to investigate the prevalence of lenacapavir resistance-associated mutations in HIV-1 subtypes A1 and D in a cohort of individuals living with HIV-1 from southwestern Uganda.Methods Utilizing plasma samples from ART-naive adults living in Uganda, HIV-1 Gag p24 (capsid) sequences were analysed for lenacapavir resistance mutations.Results Among 546 lenacapavir-naive participants, no major lenacapavir resistance-associated mutations were found. Minor mutations were present in 1.6% of participants, with T107A being the most common. Longitudinal data indicated the persistence of T107A for at least 3 years post-ART initiation in one participant. Phylogenetic analysis indicated individuals carrying T107A were found independently in distinct locations within the tree, suggesting that T107A might have arisen from multiple distinct base substitution events. Shannon entropy analysis showed high variability in certain capsid sites, but none overlapped with known lenacapavir resistance sites.Conclusions These findings suggest a low prevalence of naturally occurring lenacapavir resistance mutations in Uganda, supporting lenacapavir's potential efficacy in this region.

BackgroundMobile health (mHealth) interventions that leverage social support (SS) can improve partner involvement and pregnancy experiences and promote antenatal care (ANC) attendance and skilled births. In our previous studies, we used behavioral frameworks to develop a user-centered mHealth-based, audio SMS text messaging app to support pregnant individuals to use maternity care services in rural Uganda (Support-Moms app). In our pilot study, we observed high intervention uptake, acceptability, and feasibility, as well as increased ANC attendance and skilled births. ObjectiveWith the promising pilot data, we propose a type 1 hybrid implementation-effectiveness trial to test if this novel patient-centered automated and customized mHealth-based SS intervention is effective and cost-effective enough to warrant future large-scale implementation into Uganda’s routine maternity care. MethodsWe will physically recruit 824 pregnant women at <20 weeks of gestation living in Mbarara and Mitooma districts, southwestern Uganda, and randomize them (1:1) to receive standard of care or the Support-Moms app, with at least 2 of their identified social supporters. Our primary outcome will be the proportion of skilled births. Secondary outcomes will include number of ANC visits, institution-based delivery, mode of infant delivery, preterm birth, birth weight, SS, obstetric complications, and deaths (maternal, fetal, and newborn). We will assess other implementation, service, and client outcomes through study records, the mHealth platform, and questionnaires with all women in the intervention, their social supporters, health care providers (HCPs), and managers from participating facilities. We will conduct face-to-face in-depth exit interviews with 30 purposively selected intervention participants and 15 facility HCPs and managers to explore implementation strategies for scale-up. Annual maternity resource allocations, costs, number of ANC visits, and deliveries will be assessed from facility records up to 36 months after implementation. We will estimate incremental cost-effectiveness ratios concerning cost per additional HCP-led delivery, per death averted, and per quality-adjusted life year gained as cost-effectiveness measures. ResultsThis study was funded in September 2023. Ethics approval was obtained in February 2024, and actual data collection started in March 2024. As of January 2025, 75% (618/824) of all projected study participants provided consent and were recruited into the study. Participants are expected to be followed up until delivery, and 15% (124/824) have so far exited. Data analysis for the trial is expected to start as soon as the last participant exits from the study. The qualitative interviews will start in April 2025, and data will be analyzed and published as soon as data collection is done, which is expected in March 2027. ConclusionsWe are testing the feasibility, acceptability, and cost-effectiveness of implementing Support-Moms into routine maternity care from individual and facility perspectives. We hypothesize that Support-Moms will be an effective and cost-effective strategy to improve maternity service use for women in rural Uganda and similar settings. Trial RegistrationClinicalTrials.gov NCT05940831; https://clinicaltrials.gov/study/NCT05940831 International Registered Report Identifier (IRRID)DERR1-10.2196/67049

Real-time electronic adherence monitoring involves "smart" pill boxes that record and monitor openings as a proxy for pill taking and may be useful in understanding and supporting PrEP use; however, acceptability and/or feasibility for PrEP users is uncertain. We sought to understand the experiences of using a real-time electronic adherence monitor for PrEP delivery among young women in Kisumu and Thika, Kenya. We used the Wisepill device to monitor PrEP use among 18-24-year-old women for two years. Half of the participants were randomized to also receive SMS adherence reminders (daily or as needed for missed doses). We assessed acceptability quantitatively and qualitatively according to the four constructs of Unified Theory of Acceptance and Use of Technology (UTAUT): performance expectancy, effort expectancy, social influence, and facilitating conditions. We assessed feasibility by monitor functionality during periods of PrEP use. We analyzed quantitative data descriptively and compared by site and over time; qualitative data were analyzed inductively and deductively. The median age was 21 years (IQR 19-22), median education was 12 years (IQR 10-13), 182 (53%) had disclosed PrEP use, and 55 (16%) reported recent intimate partner violence. Most participants reported high levels of usefulness and high interest in using the monitor with few problems or worries reported throughout follow-up. Feasibility was high overall with some differences by site (96% functional monitor days in Kisumu vs 88% in Thika). Few monitors were reported lost (N = 29; 8%) or dysfunctional (N = 11; 3%). In qualitative interviews, electronic monitoring was perceived as useful because it supported privacy, confidentiality, easy storage, and PrEP adherence. Effort was generally considered low. Participants expressed some concern for stigma from monitor and/or PrEP use. Facilitating conditions involved the monitor size, color, and battery life. Overall, real-time electronic adherence monitoring was a highly acceptable and feasible approach to understand PrEP adherence among young women in a sub-Saharan African setting.

BACKGROUND A total of 700 000 US children and adolescents are estimated to have latent tuberculosis (TB) infection. Identifying facilitators and barriers to engaging in TB infection care is critical to preventing pediatric TB disease. We explored families’ and clinicians’ perspectives on pediatric TB infection diagnosis and care. METHODS We conducted individual interviews and small group discussions with primary care and subspecialty clinicians, and individual interviews with caregivers of children diagnosed with TB infection. We sought to elicit facilitators and barriers to TB infection care engagement. We used applied thematic analysis to elucidate themes relating to care engagement, and organized themes using a cascade-grounded pediatric TB infection care engagement framework. RESULTS We enrolled 19 caregivers and 24 clinicians. Key themes pertaining to facilitators and barriers to care emerged that variably affected engagement at different steps of care. Clinic and health system themes included the application of risk identification strategies and communication of risk; care ecosystem accessibility; programs to reduce cost-related barriers; and medication adherence support. Patient- and family-level themes included TB knowledge and beliefs; trust in clinicians, tests, and medical institutions; behavioral skills; child development and parenting; and family resources. CONCLUSIONS Risk identification, education techniques, trust, family resources, TB stigma, and care ecosystem accessibility enabled or impeded care cascade engagement. Our results delineate an integrated pediatric TB infection care engagement framework that can inform multilevel interventions to improve retention in the pediatric TB infection care cascade.

IntroductionAdherence counselling with point-of-care (POC) drug-level feedback using a novel tenofovir assay may support pre-exposure prophylaxis (PrEP) adherence; however, perceptions of urine testing and its impact on adherence are not well studied. We qualitatively examined how POC tenofovir testing was experienced by transgender women (TGW) in Uganda.MethodsWithin a cluster randomized trial of peer-delivered HIV self-testing, self-sampling for sexually transmitted infections and PrEP among HIV-negative TGW showing overall low PrEP prevention-effective adherence (NCT04328025), we conducted a nested qualitative sub-study of the urine POC assay among a random sample of 30 TGW (August 2021-February 2022). TGW interviews explored: (1) experiences with POC urine tenofovir testing and (2) perceptions of PrEP adherence counselling with drug-level feedback. We used an inductive content analytic approach for analysis.ResultsMedian age was 21 years (interquartile range 20-24), and 70% engaged in sex work. Four content categories describe how TGW experienced POC urine tenofovir testing: (1) Urine tenofovir testing was initially met with scepticism: Testing urine to detect PrEP initially induced anxiety, with some perceptions of being intrusive and unwarranted. With counselling, however, participants found POC testing acceptable and beneficial. (2) Alignment of urine test results and adherence behaviours: Drug-level feedback aligned with what TGW knew about their adherence. Concurrence between pill taking and tenofovir detection in urine reinforced confidence in test accuracy. (3) Interpretation of urine tenofovir results: TGW familiar with the interpretation of oral-fluid HIV self-tests knew that two lines on the test device signified positivity (presence of HIV). However, two lines on the urine test strip indicated a positive result for non-adherence (absence of tenofovir), causing confusion. Research nurses explained the difference in test interpretation to participants' satisfaction. (4) White coat dosing: Some TGW deliberately chose not to attend scheduled clinic appointments to avoid detecting their PrEP non-adherence during urine testing. They restarted PrEP before returning to clinic, a behaviour called "white coat dosing."ConclusionsIncorporating POC urine testing into routine PrEP adherence counselling was acceptable and potentially beneficial for TGW but required attention to context. Additional research is needed to identify effective strategies for optimizing adherence monitoring and counselling for this population.

Timely initiation of and adherence to antiretroviral therapy (ART) is critical for improving HIV outcomes and reducing HIV transmissibility. Social networks, or the social relationships individuals have with each other, have been linked with positive health outcomes, but less is known about the extent to which social network composition and structure are associated with improved ART adherence among people living with HIV (PLWH). We conducted an ego -centric network study among 828 previously ART -naive PLWH presenting for ART initiation at 11 clinics in Mbarara, Uganda (rural population) and Gugulethu, South Africa (peri-urban population). We collected social network data using name generator and name interpreter questions. ART adherence was monitored over 12 months using wireless monitors (Wisepill). Our primary outcome of interest was ART adherence during the 12 -month follow-up period. We used generalized linear models to estimate the associations between network measures and ART adherence. PLWH at the Uganda site (compared with the South Africa site) were less isolated, had larger social networks, and had more social ties providing sufficient social support; they were also more likely to bridge different social groups whereby not all social ties were connected to each other. In Uganda, social isolation was associated with a 5.5 percentage point reduction in ART adherence (95% confidence interval [CI] -9.95 to -1.13; p = 0.014), while having more same gender social ties was associated with higher ART adherence (b = 0.13, 95% CI 0.02-0.25, p = 0.025). In South Africa, there was no association between social isolation and ART adherence, and having more friendship ties (vs. family ties) was associated with lower ART adherence (b = -2.20, 95% CI -3.56 to -0.84; p = 0.002). Identifying and supporting PLWH who are isolated may facilitate optimal adherence, but understanding how networks differentially affect ART adherence by country context is important.