AIDS and Behavior

Background Community-led interventions for female sex workers (FSW) can improve HIV prevention and treatment outcomes by lowering self-stigma and strengthening social cohesion to improve service uptake. In Zimbabwe, the AMETHIST intervention trial integrated peer-led microplanning with self-help groups for FSW and demonstrated improved HIV treatment outcomes. We investigated the role of social cohesion and self-stigma in explaining these findings. Method We conducted a mixed-method analysis of data collected during AMETHIST. We re-analysed qualitative data from interviews and group discussions to identify narratives linking self-stigma, engagement with microplanners and/or self-help groups and HIV service use. We analysed quantitative data from endline respondent-driven sampling surveys for differences in self-reported measures of social cohesion and self-stigma between trial arms, and between those who did and did not participate in intervention activities or access services. Results In both arms, FSW self-reported engaging with peer supporters, participating in self-help groups and accessing HIV services. Qualitative narratives suggested peer support and group participation could reduce self-stigma and support service uptake. Lower levels of self-stigma were seen in the intervention arm (58.6% vs 63.2%; aOR 0.77; 95% CI 0.61-0.86). Social cohesion exceeded 50% across the whole sample, but was not associated with study arm, nor with engagement in intervention-related activities. Discussion Although qualitative data suggested some FSW felt their uptake of services was influenced by intervention components, quantitative analyses did not suggest either variable was on the causal pathway to the outcomes of the intervention. A limitation may have been the measurement of these complex constructs and the high levels of social cohesion across both study arms.

Background Men who have sex with men (MSM) in the Jakarta Metropolitan Area (JMA), Indonesia are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is a viable strategy for addressing enduring HIV disparities, yet remains underutilized among MSM in the JMA. Patterns and influences of PrEP use may inform future intervention targets but have not been extensively studied in this context. Methods Guided by the Andersen's Behavioral Model for Health Services Use, the present study investigated multidimensional correlates of varied PrEP use patterns among 183 JMA-based MSM aged 18-51 (median age=29) and at elevated risk of HIV infection. The multinomial regression model identified factors associated with current PrEP use and some use in the past, compared with never use (reference category). Results In the present study, 107 (58%) participants reported never use, 34 (19%) current use, and 42 (23%) some use of PrEP. Current PrEP use was negatively associated with HIV stigma and positively with perceived social support, online HIV information seeking, and sexualized drug use. Some PrEP use was negatively associated with HIV stigma and positively with online HIV information seeking. Conclusions The study findings provide support for the Andersen model's emphasis on predisposing characteristics, enabling resources, and need factors when tailoring PrEP implementation for higher-risk MSM in the JMA. Addressing stigma, reinforcing social support and HIV knowledge, and integrating PrEP care within multiple health care systems appear viable avenues for improving PrEP adoption in this key population.

Background. In the era of successful antiretroviral therapy (ART), mood disturbance remains highly prevalent in people with HIV (PWH). In the present study, we investigated the long-term legacy effects of long delay in ART initiation and low nadir CD4 count on mood symptoms in adults with HIV. The impacts of demographic and other HIV clinical factors were also examined. Methods. A total of 109 PWH (disease duration: 24.6{+/-}9.3 years) and 42 demographically matched healthy participants (people without HIV, or PWoH) participated in a cross-sectional study (41-70 years old (55.6{+/-}6.8), 62.9% African Americans, 27.2% female, 14.3{+/-}2.9 years of education). Mood symptoms were assessed with the Beck Depression Inventory-II (BDI-II) and the Profile of Mood States (POMS). A comprehensive neuropsychological test battery was administered to assess neurocognitive function. Results. Despite largely comparable neurocognitive performance between PWH and PWoH , PWH had worse mood symptoms than PWoH, including higher total BDI-II (p<.001) and total POMS scores (p=.002), as well as higher score in all POMS sub-scores (p<.007), except Vigor (p=.724). Within the PWH group, longer delays in ART initiation, lower nadir CD4 count, and lower educational attainment were associated with worse mood symptoms. By contrast, current plasma CD4+ cell count, plasma detectable viral load, and HIV disease duration were not associated with either BDI-II or POMS score. Conclusion. Mood disturbance is highly prevalent in PWH on ART. The long-term legacy effects of delay in ART initiation and low nadir CD4 count on mood management reinforce the necessity of early ART initiation in clinical practice.

Background: Internalized HIV stigma remains a major psychosocial challenge for women living with HIV (WLHIV) and may adversely affect antiretroviral therapy (ART) adherence and health-related quality of life (HRQoL). However, fewer studies in sub-Saharan Africa have examined how internalized stigma and ART adherence jointly relate to multidimensional HRQoL among WLHIV receiving routine HIV care. This study examined the associations of internalized HIV stigma and ART adherence with HRQoL among WLHIV in Lagos, Nigeria, and explored whether the relationship between stigma and HRQoL varied by ART adherence status. Methods: This was a baseline analytical study nested within a quasi-experimental study among WLHIV receiving care at the HIV Treatment Centre of the Nigerian Institute of Medical Research, Lagos, Nigeria. The analysis included 1,005 women with complete baseline data on internalized stigma, ART adherence, HRQoL, and selected covariates. Internalized stigma was assessed using the 10-item Internalized Stigma of HIV/AIDS Tool and categorized as low or high using the sample median. ART adherence was measured using pharmacy refill adherence and self-reported adherence, which were combined into a composite overall adherence variable. HRQoL was assessed using the WHOQOL-HIV BREF, and the primary outcome was the total domain-based quality-of-life score derived from the six WHOQOL-HIV domains. Linear regression was used to examine associations between stigma and adherence and the total domain-based QoL score, and an interaction term between internalized stigma and overall ART adherence was included to assess effect modification. Results: The mean age of participants was 47.8 years (SD 12.5), and 56.0% had high levels of internalized stigma. Overall, 73.3% were classified as adherent using the composite ART adherence measure. HRQoL was consistently poorer among women with high internalized stigma across all WHOQOL-HIV BREF domains. Women with high internalized stigma had a substantially lower total domain-based QoL score than those with low stigma (106.5; SD 11.0 vs 117.8; SD 10.6; p < 0.001). In the final multivariable model, high internalized stigma remained the strongest independent correlate of lower QoL ({beta} = -10.07, 95% CI: -11.41 to -8.73; p < 0.001), while overall ART non-adherence was also associated with lower QoL ({beta} = -2.78, 95% CI: -4.24 to -1.33; p < 0.001). Older age and living more than 5 km from the health facility were associated with lower QoL, whereas social support was associated with higher QoL. Interaction analyses showed that predicted QoL was highest among women with low stigma who were adherent and lowest among those with high stigma who were non-adherent. Conclusions: Internalized HIV stigma and ART non-adherence were independently associated with poorer HRQoL among WLHIV in Lagos, Nigeria. Internalized stigma emerged as the strongest correlate of poorer well-being, underscoring the need to move beyond narrowly biomedical models of HIV care. Interventions that integrate stigma reduction, adherence support, and psychosocial strengthening may be particularly valuable for improving patient-centered outcomes among WLHIV in routine HIV care settings.

Background Viral load suppression (VLS) remains suboptimal among adolescents and youth living with HIV (AYLWH) in Malawi. Depressive symptoms may affect treatment adherence and HIV outcomes, but evidence is limited. We assessed the association between depressive symptoms and VLS among AYLWH using Malawi Population-based HIV Impact Assessment (MPHIA) 2020-2021 data. Methods We conducted a cross-sectional secondary analysis of AYLWH aged 15-24 years. VLS was defined as HIV RNA less than 200 copies/mL and depressive symptoms as a Patient Health Questionnaire-2 score of 3 or higher. Survey-weighted logistic regression assessed associations with VLS, adjusting for sex, education, residence, household wealth, alcohol use, Teen Club participation, and awareness of HIV-positive status. Findings Among 201 participants, viral-load results were available for 200; 137 (68.5%) achieved VLS. Six (3.0%) participants had depressive symptoms. Depressive symptoms were not associated with VLS in univariable analysis (OR 0.8, 95% CI 0.1-4.6; p=0.80) or multivariable analysis (aOR 0.3, 95% CI 0.1-2.4; p=0.28). Urban residence (aOR 0.2, 95% CI 0.1-0.5; p=0.0020) and unawareness of HIV-positive status (aOR 0.1, 95% CI 0.02-0.1; p<0.001) were associated with lower odds of VLS. Interpretation Depressive symptoms were not significantly associated with VLS, although their low prevalence and PHQ-2 limitations reduced precision. The findings highlight the importance of strengthening HIV-status awareness and addressing context-specific barriers to care among AYLWH. Funding This secondary analysis received no specific funding.

Cash incentives are widely used in clinical research to support recruitment and retention, yet their ethical implications, particularly in high-risk settings such as HIV cure-related studies, remain inadequately understood. This study examined how key stakeholders perceive participant payment relative to other study characteristics when deciding whether to participate in HIV cure research. Using a choice-based conjoint (CBC) experiment, we assessed preferences among people living with HIV (PLWH), HIV researchers, and Institutional Review Board (IRB) members/bioethicists. Participants (N=88) completed eight choice tasks involving hypothetical HIV cure study scenarios varying across six attributes: incentive amount, invasiveness, requirement to pause HIV medications, time commitment, first-in-human status, and cost reimbursement. Across all participants, payment amount emerged as the most influential attribute (29.3%), followed by procedure invasiveness (22.3%) and the requirement to pause HIV medication (17.6%). The highest hypothetical payment level ($200 per visit) was significantly preferred. However, subgroup analyses revealed important differences: PLWH prioritized payment most strongly, whereas researchers and IRB members/bioethicists placed greater emphasis on minimizing invasiveness. The requirement to pause HIV medication was a salient concern across groups, though relatively more influential for IRB members/bioethicists than for PLWH. Time commitment and ancillary cost reimbursement had comparatively lower impact on decision-making. These findings highlight the central role of financial incentives in shaping willingness to participate in HIV cure research, raising ethical considerations regarding potential undue influence, especially in higher-risk studies. At the same time, stakeholders value minimizing procedural risks and disruptions to treatment. This study underscores the need for clearer guidance on appropriate payment practices and for balancing incentives with ethical safeguards, particularly in trials involving antiretroviral therapy interruption.

Introduction: Japan achieves high retention and viral suppression among people on antiretroviral therapy, yet treatment starts late. Most people obtain subsidised treatment through a physical disability certificate for HIV-related immune dysfunction, which requires two blood tests at least four weeks apart. We quantified the diagnosis-to-treatment cascade, identified who waits and tested whether the second test changes certification. Methods: Retrospective cohort of people newly diagnosed with HIV at 11 designated AIDS core hospitals in 2015 to 2024. We measured intervals from screening to hospital visit and to antiretroviral therapy, and emulated certification from the first test alone and from the two-test rule under every possible number of non-laboratory criteria (k = 0 to 8). Results: Of 1302 people (96% men; 68% with CD4 <350 cells/L or AIDS), 1036 (80%) followed the two-test pathway and 261 started treatment after one test, mostly because of AIDS or acute infection. People reached the hospital a median of 11 days after screening. Treatment then began a median of 70 days after the first visit in the two-test pathway and 11 days in the single-test pathway; 0.2% and 60.9% started within 14 days. Delay rose with CD4 count: 46 days when the mean count was [&le;]200 cells/L, 117 days when it was >500 with a laboratory criterion (16% of the two-test pathway) and 334 days when it was >500 without one (3%; adjusted hazard ratio 0.14, 95% confidence interval 0.09 to 0.23). Medians ranged from 35 to 96 days across facilities. The second test changed little: the first CD4 count agreed with the mean of two (intraclass correlation coefficient 0.959), HIV-RNA [&ge;]5000 copies/mL persisted in 97.6%, and certification status agreed in 99.0% for k [&ge;]1 (92.5% for k = 0), with discordance concentrated near 500 cells/L; the first test gave a milder grade in at most 2.9%. Conclusions: The statutory second test adds at least four weeks before antiretroviral therapy in Japan without changing who is certified, and delays most the people with the highest CD4 counts. Certification on a single test, with treatment separated from the subsidy procedure, would remove a delay that has no clinical or administrative justification.

Children living with HIV face significant challenges with adherence to daily oral antiretroviral (ARV) treatment due to poor palatability, complicated dosing, and caregiver burden. Long-acting delivery systems designed specifically for children may help overcome these barriers. Microarray patches, also known as microneedle patches, are a needle-free drug delivery technology that could simplify treatment administration and improve adherence. This study explored the acceptability and usability of a pediatric ARV microarray patch prototype among stakeholders in South Africa and Uganda, two countries with a high burden of pediatric HIV. A formative study was conducted in 2024 with 48 participants, including caregivers, community health workers, health care providers, and decision-makers. Data were collected through qualitative methods: interviews, simulated use sessions, and observations. Participants demonstrated high usability of the prototype, with 97% completing all application steps and nearly all reporting the prototype as easy to use and expressing confidence in successful administration. Most participants found the prototypes size, wear time, and temporary skin changes acceptable, and all preferred a weekly patch over daily oral treatment. Applying multiple patches at once to achieve a therapeutic dose was considered feasible. Decision-makers foresaw strong programmatic fit of a pediatric ARV microarray patch if caregivers apply the patch at home following initial facility-based guidance. Overall, the pediatric ARV microarray patch prototype was perceived as highly acceptable and usable across diverse end users, findings that generally align with studies of microarray patches for other use cases (e.g., contraception, HIV pre-exposure prophylaxis, vaccine delivery). The simplicity, comfort, and convenience of a pediatric ARV microarray patch could substantially improve treatment adherence and quality of life for children living with HIV. Further development and clinical evaluation are warranted to advance this promising technology toward real-world use.

Background Sustained retention in HIV care is essential for maintaining antiretroviral therapy (ART) and achieving viral suppression. We described national and regional retention in HIV care among paediatric and adolescent ART initiation cohorts in Uganda from 2020-2023. Methods We analyzed aggregated paediatric (aged 0-9 years) and adolescent (aged 10-19 years) ART cohort data reported through the District Health Information Software. We assessed 16 consecutive quarterly ART initiation cohorts per age group, from Quarter 1 2020 to Quarter 4 2023, at 6 (short-term), 12 (intermediate), and 24 (long-term) months after ART initiation. Each cohort comprised clients newly initiated on ART in a specific calendar quarter. Retention was defined as the proportion of clients alive and on ART within the net current cohort (original cohort plus transfer-ins minus transfer-outs). We described retention nationally and by region for each cohort and follow-up time point. We summarized the proportion of cohorts with retention [&ge;]95% by region as a descriptive measure of high retention. Results Among paediatric cohorts, median retention was 84% (IQR: 82-85%) at 6 months, 81% (IQR: 78-83%) at 12 months, and 78% (IQR: 75-80%) at 24 months. Only one national paediatric cohort achieved [&ge;]95% retention at 6 months and one at 12 months; none attained this target at 24 months. The proportion of paediatric cohorts with regional retention [&ge;]95% was highest in Karamoja at short-term follow-up (31%), in Kigezi at intermediate follow-up (31%), and in Lango at long-term follow-up (13%). Among adolescent cohorts, median retention was 82% (IQR: 80-85%) at 6 months, 82% (IQR: 81-85%) at 12 months, and 76% (IQR: 74-78%) at 24 months. No national adolescent cohort achieved [&ge;]95% retention. The proportion of adolescent cohorts with regional retention [&ge;]95% was highest in West Nile at 6 months (19%) and 12 months (31%), and in Karamoja at 24 months (25%). Conclusion Retention among paediatric and adolescent ART cohorts declined with longer follow-up and varied across regions. Strengthening age-appropriate support beyond the first year of ART and improving routine cohort-data quality could support more targeted programme responses.

Long-acting injectable human immunodeficiency virus (HIV) medicines expand treatment and prevention choices, but willingness to use them does not establish readiness to begin. We examined readiness to start these options, associated factors and conditions for acceptance among people living with HIV and pre-exposure prophylaxis (PrEP)-service clients in Uganda. This cross-sectional study analysed 225 participants at Mildmay Hospital and Kajjansi Health Centre IV in central Uganda. Readiness meant preferring initiation immediately or within three months. Modified Poisson regression estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), including age-by-service-group interaction. Separate models examined informational, perceptual and financial factors, adjusting for service group, age and sex. Logistic marginal standardisation checked demographic and expanded age comparisons. Overall, 108 participants (48.0%) were ready to start injectable HIV treatment or prevention, 111 (49.3%) wanted more information about these options, and six (2.7%) preferred initiation in six to twelve months. Readiness was 80.8% among people living with HIV aged 15-24 years and 34.4% among those aged 25 years or older (aPR 2.35, 95% CI 1.63-3.38). Corresponding proportions among PrEP-service clients were 39.2% and 41.4% (aPR 0.95, 95% CI 0.60-1.50; interaction p=0.002). In separate adjusted models, clinic-staff information (aPR 1.94, 95% CI 1.42-2.66), belief in greater effectiveness (2.00, 1.43-2.80) and a one-point increase in benefit score (3.27, 2.36-4.55) were associated with higher readiness. A one-point increase in concern score (0.70, 0.60-0.80) and financial difficulty sometimes or more often (0.68, 0.48-0.96) were associated with lower readiness. Fewer side effects was the leading condition for accepting injectable HIV treatment or prevention across service and readiness groups. Nearly half of participants were ready to start, while a similar proportion wanted further information about injectable options. Programmes should assess intended initiation timing alongside willingness and address safety, appointment flexibility, privacy and affordability through counselling and service planning.

Background. Despite relatively high coverage of interventions to prevent vertical transmission, HIV incidence among children born to women living with HIV (WLH) remains above elimination targets, partly because of substantial disengagement from antiretroviral therapy (ART) during the postpartum period. We evaluated the effectiveness of a data-driven continuous quality improvement (CQI) intervention in improving retention in care, virological suppression, and prevention of vertical transmission among pregnant and breastfeeding WLH receiving ART in maternal and child health (MCH) clinics. Methods and findings. This pragmatic cluster-randomized trial was conducted in 105 MCH clinics--three high-volume clinics in each of the 35 health zones (HZs) of Kinshasa Province, Democratic Republic of the Congo. During the pre-randomization phase (November 2016-December 2017), routine data collection using prevention of mother-to-child transmission registers was strengthened in all participating clinics. In January 2018, HZs were randomized 1:1 to implement CQI or continue the standard of care. In intervention HZs, quality improvement (QI) teams were established at the HZ and clinic levels. Indicators selected collaboratively with QI teams were calculated from routine program data and shared quarterly. Through July 2019, QI teams met quarterly to identify service-delivery challenges and develop strategies to improve outcomes, with an emphasis on retention. Thereafter, responsibility for producing indicators was transferred to QI teams, and meetings continued virtually through WhatsApp. Pregnant and breastfeeding WLH and their infants receiving care at participating clinics between November 2016 and July 2019 were enrolled and followed for at least 24 months. Primary outcomes were loss to follow-up (LTFU), viral suppression (<1,000 copies/mL), and a positive HIV test among live-born infants. Overall, 2,376 women were enrolled, including 1,217 (51.2%) before randomization. The analysis of CQI effectiveness included 1,900 participants who remained in care at randomization or enrolled thereafter: 1,103 (58.1%) in control HZs and 797 (41.9%) in intervention HZs. At 6, 12, and 24 months, LTFU was lower in the intervention group than in the control group: 18.6% versus 21.6% (adjusted risk difference [aRD], -5.2 percentage points; 95% CI, -9.6 to -0.8), 29.2% versus 31.0% (aRD, -3.9; 95% CI, -10.2 to 2.4), and 50.1% versus 55.5% (aRD, -7.1; 95% CI, -15.2 to 1.0), respectively. Estimated effects were larger in PEPFAR-supported and urban clinics, although interaction tests were not statistically significant. Viral-load results were available for 38.2%, 50.4%, and 73.5% of eligible participants at 6, 12, and 24 months, respectively. Neither viral-load-result availability nor viral suppression differed between groups. Infant HIV-test results were available for 8.1%, 32.7%, 34.2%, and 28.5% of eligible infants at 6 weeks and 6, 12, and 24 months, respectively. Conclusions. CQI implementation produced a modest improvement in retention, with the clearest evidence at 6 months and favorable but imprecise estimates through 24 months. Limited availability of maternal viral-load and infant HIV-test results precluded definitive conclusions about virological suppression and vertical transmission. Local quality-improvement interventions may strengthen processes within frontline teams control but cannot alone overcome failures across an interconnected care system. Future studies should align interventions operational reach with all health-system levels responsible for the intended outcomes.

Background The abrupt withdrawal and uneven restoration of United States PEPFAR support in 2025 disrupted HIV service delivery in aid-dependent countries worldwide. In Zambia, decreases in HIV service delivery have been documented at a national level, but variations by facility and by quarter have largely been masked by existing aggregate district- and province-level estimates. We examined facility-level variation in HIV service volumes delivered before and after the funding cuts. Methods We analysed monthly District Health Information System (DHIS2) data covering testing volumes, ART initiations, and numbers on ART for January 2024-December 2025) for two sets of facilities: 1) 24 selected SENTINEL network facilities across four provinces (Central, Copperbelt, Lusaka, and Southern); and 2) all facilities in two districts, Chongwe in Lusaka Province, which was supported by the U.S. CDC under PEPFAR, and Mpongwe in Copperbelt Province, which was supported by USAID under PEPFAR. For each facility, we calculated quarterly 2025:2024 ratios of service volumes and summarized quarterly and annual percentage changes in numbers of tests, treatment initiations, and clients on ART. Results Aggregate HIV testing volumes declined 18% in SENTINEL facilities from 2024 to 2025, with 17 of 24 facilities showing net annual decreases. Aggregate ART initiations declined 16%, with 23 of 24 facilities experiencing net decreases. For both indicators, variation between quarters and among individual facilities matched or exceeded aggregate changes. Numbers of clients currently on ART were comparatively stable, with only 6 facilities showing net declines exceeding 5%. District-level analyses showed divergent patterns. Net aggregate testing volumes increased by 7% in Chongwe District, but 28/39 facilities experienced quarterly declines exceeding 10% in at least one quarter and fell by 40% in Mpongwe District overall. Only 4 of 36 sites in Chongwe showed a net loss of clients over the course of 2025, with most experiencing gains, while Mpongwe experienced substantial variation by facility, with many having declines of >30% during some quarters and 14 of the 25 facilities suffering a net loss from 2024 to 2025. Conclusions Facility-level performance varied substantially within the same district following the 2025 PEPFAR funding disruptions, with some sites losing most of their service volumes while others remained stable or exceeded 2024 levels. These findings emphasize the need for facility-level monitoring to target recovery support where it is needed most.

The efficacy of current antiretroviral interventions for prevention of vertical HIV transmission is both a triumph and a challenge for future efficacy studies of novel agents, including long-acting antiretroviral agents. Given the effectiveness of current antiretroviral interventions, standard randomized controlled trials to assess novel interventions targeted towards further reducing vertical HIV transmission may be infeasible due to required sample sizes. To address this study design challenge, we propose a novel augmented clinical trial design, where a randomized trial with an active comparator is augmented with a concurrent observational cohort to supplement the standard-of-care arm. The proposed design and analysis can overcome sampling biases, and an associated diagnostic can evaluate potential biases from unmeasured covariates. The proposed trial design is illustrated with an example and studied further using a simulation study. In the illustrative example, an augmented trial with a 3:1 allocation ratio in the trial component yielded an unbiased treatment effect estimate, as compared to the trial component alone, and the standard error was reduced substantially. Although the total sample size of the augmented trial was larger than a similarly powered 1:1 standard trial, the sample size of the augmented trial's trial component was half the size of the standard trial and within the range of historically similar trials, thereby providing both feasibility and potential cost advantages. Although limitations with this design remain, many of these limitations can be mitigated by careful study planning and coordination. Augmented trials provide a potentially applicable solution to studying the efficacy of long-acting antiretrovirals for infant postnatal prophylaxis against HIV.

Sex workers remain disproportionately affected by HIV and mental health distress because their access to prevention and support services is shaped by stigma, criminalisation, violence, poverty, unequal client power, fear of disclosure and negative healthcare encounters. These pressures are particularly visible in district-level settings where sex workers must balance unstable income, personal safety and healthcare needs. A qualitative research design was used. Participants were recruited through purposive and snowball sampling. Twenty unique participants took part in the study: five participated in individual semi-structured interviews and 15 different participants attended two focus group discussions comprising seven and eight participants, respectively. No individual interview participant attended a focus group discussion. Participants were aged 18 years or older and lived or worked in the West Rand District. The interviews and focus group discussions were audio-recorded, transcribed verbatim and analysed through reflexive thematic analysis informed by Braun and Clarkes six-phase process, with data organisation supported by NVivo. Six themes were developed: sex work as economic survival rather than simple choice; HIV prevention under conditions of unequal client power; healthcare access shaped by stigma, fear and lack of confidentiality; mental health distress as part of everyday sex work; peer educators as trusted bridges to care; and the need for inclusive and differentiated support. HIV prevention and mental health support were interconnected through poverty, client negotiation, clinic mistrust, emotional distress and reliance on peer-led services. Economic insecurity, client power, stigma, weak confidentiality and psychological distress constrained access to HIV prevention and mental health support services. Peer educators facilitated access through information, referrals, emotional support and clinic navigation. Services should therefore be integrated, confidential, stigma-free and responsive to diverse gender identities, sexual orientations and sex-work settings.

Purpose Prescribing to lactating women is constrained by limited evidence. Published compatibility classifications provide clinical guidance and a discrete research comparator. How often prescribing diverges from that guidance, and what characteristics are associated with divergence, is unknown at national scale. Methods Retrospective analysis of prescriptions filled during lactation, identified in the 2012-2014 MarketScan Commercial Claims Database. Prescriptions were classified as concordant (Hale's lactation risk category L1-L3) or discordant (L4-L5). Multivariable logistic regression identified factors associated with concordance. Results Of 96,484 new prescriptions, 95,710 (99.2%) were concordant and 774 (0.8%) were discordant. Discordant prescriptions were filled later after delivery (median 59 vs 33 days) and had a day supply three times longer (30 vs 10 days). In multivariable analysis (N=28,732), concordant prescriptions were associated with maternal age under 35 (adjusted odds ratio (aOR)=1.34, 95% confidence interval (CI): 1.02-1.75) and chronic-condition medications (aOR=10.94, 95% CI: 6.47-18.50), and were less likely within 14 days of delivery (aOR=0.53, 95% CI: 0.38-0.73) and with each additional day of supply (aOR=0.96, 95% CI: 0.96-0.96). Compared with family practice, concordance did not differ for obstetric, internal medicine, or emergency medicine prescriptions, but prescriptions from other provider types had lower odds of concordance (aOR=0.57, 95% CI: 0.41-0.79). Conclusions Prescribing during lactation was overwhelmingly concordant with published compatibility guidance; the rare divergence was patterned by prescription and prescriber characteristics. Because the categories are an expert classification rather than consensus guidance, divergence should not be read as inappropriate prescribing.

Background Malaria and HIV remain major causes of illness in sub-Saharan Africa, accounting for 94% of the global malaria burden and over two-thirds of the global HIV burden. HIV-related immunosuppression increases susceptibility to malaria, with a higher malaria burden of up to 47% and severe malaria complications compared to HIV-negative individuals. Socio-demographic factors, individual knowledge, attitude, and perception are recognized determinants of malaria prevention behaviours, but no study has modelled their combined contribution, and there is scant research on these factors among people living with HIV. We assessed the level of knowledge, attitudes, and perceptions towards malaria, and identified the predictors of malaria prevention practice among HIV-positive individuals in Kampala, Uganda. Methods This cross-sectional study enrolled 620 HIV-positive patients attending the ART clinic of China-Uganda Friendship Hospital, Naguru, selected by systematic random sampling. Data collection was conducted from 21st July 2025 to 18th August 2025 using a structured, interviewer-administered questionnaire that measured socio-demographic characteristics, knowledge, attitude, perception, and the practice of malaria prevention. Associations were assessed using Mann-Whitney U, Kruskal-Wallis H, and Spearman correlation. The independent predictors of good malaria prevention practice were identified using binary logistic regression. Results Participants had a mean age of 34.8 years, were predominantly female (68.9%), Baganda (38.1%) by tribe, and the majority had a secondary level of education(46.0%). Most had good knowledge of malaria (97.3%) and a positive attitude (90.5%), while 57.3% held a positive perception of malaria risk and prevention; only 62.6% reported good malaria prevention practice, and most prevention methods used were sleeping under a mosquito net (71.1 3%) and closing windows early in the evening (70.3%). In regression analysis, knowledge (adjusted odds ratio [AOR] 1.198, 95% CI 1.03-1.40, p = 0.023) and attitude (AOR 1.101, 95% CI 1.04-1.17, p = 0.001) independently predicted good practice, while perception did not (AOR 1.00, 95% CI 0.96-1.04, p = 0.994). Scores of Attitude, perception, and malaria prevention practices varied significantly, though non-linearly, by education level, and were highest among non-educated participants. Conclusions Despite near-universal knowledge and predominantly positive attitudes in this study, more than a third of HIV-positive participants did not practice adequate malaria prevention, and perception did not independently predict malaria prevention practice once knowledge and attitude were accounted for. Programmes seeking to close this know-do gap should pair health education with structural support for prevention tools rather than education alone.

Purpose Older adults with HIV are at risk of psychiatric disorders and poor sleep quality, but evidence from sub-Saharan Africa is limited, particularly regarding sustained viral suppression. This study examined the prevalence of psychiatric disorders and poor sleep quality symptoms and their association with sustained viral suppression among older adults with HIV in Nigeria. Methods: A retrospective cohort study was conducted among older adults receiving care at a tertiary HIV clinic in Ibadan, Nigeria. Viral load data from 2019-2023 were abstracted from medical records to determine sustained viral load suppression, while psychiatric morbidity and sleep quality were assessed cross-sectionally in 2023. Psychiatric assessments included major depressive disorder, anxiety disorder, bipolar disorder and mania. Mixed-effects logistic regression assessed changes in viral suppression over time and associations with psychiatric morbidity and sleep quality. Results: Among 400 participants, 63.5% were female and mean age was 58.2 years (S.D 6.5). A total of 25.8% had major depressive disorder, 17.5% had anxiety disorder, 29.3% had poor sleep quality, 3.3%, bipolar disorder, and 1.0% mania. Viral suppression improved significantly over the retrospective period. Sustained viral suppression was significantly associated with higher odds of good sleep quality (OR = 1.69, 95% CI: 1.07 to 2.66, p = 0.025), but not psychiatric morbidity. Conclusion: Psychiatric disorders and poor sleep quality are common among older adults with HIV in Nigeria. Sustained viral suppression was associated with better sleep quality but not psychiatric morbidity highlighting the importance of integrating mental health and sleep assessment into comprehensive HIV care for older adults.

Retention in antiretroviral therapy (ART) programmes remains a major public health challenge in HIV care, with loss to follow-up (LTFU) and death threatening treatment success. Because these outcomes are competing events, conventional survival methods may yield biased estimates of their incidence and associated risk factors. To estimate the cumulative incidence of LTFU and mortality and identify factors associated with these outcomes among adults receiving ART in Northern Ghana using a competing-risks framework. We conducted a retrospective cohort study of 329 adults living with HIV who initiated ART at Nalerigu Baptist Medical Centre, Ghana, between January 2013 and December 2019. Fine--Gray subdistribution hazard models were used to evaluate predictors of LTFU and death while accounting for competing risks. Cause-specific Cox proportional hazards models were fitted as a sensitivity analysis. The incidence rates were 2.2 per 100 person-months (95% CI: 1.9--2.6) for LTFU and 0.74 per 100 person-months (95% CI: 0.57--0.98) for death. At 36 months, the cumulative incidence was 50.2% for LTFU and 16.0% for death. Patients residing closer to the clinic had a lower cumulative incidence of LTFU than those living farther away (SHR = 0.68, 95% CI: 0.49--0.93), whereas higher baseline weight was associated with increased LTFU (SHR = 1.02 per kg, 95% CI: 1.00--1.04). Mortality was lower among patients receiving efavirenz-based regimens (SHR = 0.27, 95% CI: 0.15--0.50), females (SHR = 0.39, 95% CI: 0.18--0.85), and those with higher baseline weight (SHR = 0.93 per kg, 95% CI: 0.90--0.96). Findings were broadly consistent in cause-specific Cox models. LTFU was substantially more frequent than mortality among adults receiving ART in Northern Ghana. Travel distance to the treatment facility was an important barrier to retention, while ART regimen, sex, and baseline weight were associated with mortality. Expanding access to ART services through decentralized and community-based models may improve retention and support efforts to achieve HIV control targets.

Background: Heavy menstrual bleeding (HMB) and menstrual pain (MP) are among the most common menstrual cycle related symptoms with substantial impacts on quality of life. Despite this, population-level evidence on their prevalence across the life course is scarce. Methods: We conducted descriptive analyses of six longitudinal population-based cohorts from the United Kingdom, United States, Norway, and Australia. We estimated cumulative prevalence (across all available timepoints) and age-specific point prevalence of HMB and MP. Cumulative prevalence estimates were stratified by sociodemographic factors, where data permitted. We also examined HMB and MP incidence in adolescent cohorts with repeated measurements. Findings: HMB and MP are commonly reported, with cumulative prevalence across all the cohorts and timepoints (i.e., ever reported) ranging from 36% to 89% for HMB and 46% to 72% for MP. In adolescence, MP (point-prevalence: 33% to 47%) is more commonly reported than HMB (16% to 24%), whereas in later ages (45 years and above), HMB (47% to 70%) is more prevalent than MP (24% to 40%). We found no consistent evidence that symptoms were more likely to co-occur than occur independently; patterns varied across life stages and cohorts. Symptoms were more common in those from lower socioeconomic backgrounds and minoritised ethnic groups. Incidence of both HMP and MP peaked in the years immediately following menarche. Interpretation: Most women experience heavy and/or painful periods at some point. MP is more common in adolescence and HMB in later reproductive life. Generating robust life-course evidence on menstrual symptom patterns is essential to inform clinical guidelines, reduce diagnostic delays, and address inequalities in menstrual health.

Purpose Lactation status is not recorded as a discrete data element in U.S. administrative claims databases, limiting research on lactation in health databases. We developed a claims-based phenotype to identify periods of probable lactation and used it to describe medications dispensed to lactating women enrolled in a national health plan. Methods This retrospective cohort study used data from the 2012-2014 Merative MarketScan Commercial Claims Database. Deliveries were identified by diagnosis-related group classification system. Lactation windows ran from the delivery date to the date of the last surrogate lactation indicator, such as breast pump and supply codes, the encounter code for supervision of a lactating mother, and mastitis. New prescriptions filled within a window were characterized by therapeutic group, prescriber type, lactation risk category, and availability of published lactation data. Results Of 566,284 women with a single delivery, 84,679 were determined to be lactating using the developed algorithm based on maternal phenotype. The median length of assignable lactation window was 17 days (IQR 5-47). Windows most often closed on a breast pump claim (53.2%) or a postpartum visit code (28.2%). Among 158,471 new prescriptions filled during lactation, central nervous system agents (54.5%), anti-infectives (17.5%), and hormonal products accounted for > 80%. Combined oral contraceptives represented 8.2% of hormonal prescriptions during lactation against 29.0% among women of unknown status. Obstetricians wrote approximately one third of prescriptions filled during lactation windows. Conclusions Lactation can be identified in administrative claims using codes already present in the data, making national description of dispensing during lactation possible.