BMJ Public Health

Female genital cutting (FGC) is identified within global health and human rights discourse as aligned with gender inequality and female disempowerment. The persistence of FGC in high-prevalence societies is assumed to reflect womens limited influence over decisions concerning their daughters. Yet anthropological research has questioned whether this interpretation adequately reflects how FGC is organized within practicing communities. Across two studies with 176,728 participants from 15 African and Asian countries, we examine whether mothers attitudes toward FGC predict daughters circumcision status and whether this relationship varies with regional FGC prevalence. Multilevel logistic regression models show that maternal attitudes strongly predict daughter circumcision status across both datasets. Contrary to expectations derived from disempowerment frameworks, the association between maternal attitudes and daughter outcomes is not weaker in high-prevalence contexts, it is stronger. These findings suggest that interpretations of FGC as reflecting female disempowerment may mischaracterize the social dynamics of societies in which FGC is common. Policy implications of the findings are discussed.

Background: Preterm births contribute to approximately 35% of neonatal deaths globally, with an estimated 13.4 million infants born prematurely each year. Despite this substantial burden, limited evidence exists on time to discharge and its determinants among preterm neonates admitted to Neonatal Intensive Care Units (NICUs), particularly in rural Ugandan settings. This study aimed to investigate time to discharge and associated factors among preterm neonates admitted to Kiwoko Hospital in Nakaseke District, Uganda. Methods: A retrospective cohort study was conducted using secondary data from Kiwoko Hospital on preterm neonates admitted to the Neonatal Intensive Care Unit (NICU) between 2020 and 2021 (n = 847). The cumulative incidence function was used to estimate the probability of discharge within 28 days of admission, accounting for competing events. A Fine and Gray sub-distribution hazard regression model was fitted to identify factors associated with time to discharge. Results: Of the 847 preterm admissions, 70.1% were discharged alive within 28 days. The median time to discharge was 14 days. The cumulative incidence of discharge by 28 days was 68%, accounting for competing events. During follow-up, 165 neonates did not complete the 28-day period, including 88 deaths. Factors significantly associated with time to discharge included place of delivery (SHR: 0.62; 95% CI: 0.53-0.73; p<0.001), maternal residence in other districts (SHR: 0.69; 95% CI: 0.48-0.99; p=0.044), extreme preterm (SHR: 0.05; 95% CI: 0.03-0.09; p<0.001), very preterm (SHR: 0.18; 95% CI: 0.14-0.25; p<0.001), moderate preterm (SHR: 0.59; 95% CI: 0.46-0.76; p<0.001), triplet births (SHR: 0.40; 95% CI: 0.23-0.68; p=0.001), 2-4 ANC visits (SHR: 0.70; 95% CI: 0.56-0.87; p=0.002), <=1 ANC visit (SHR: 0.64; 95% CI: 0.49-0.85; p=0.002), respiratory distress syndrome (SHR: 0.64; 95% CI: 0.48-0.74; p<0.001), and birth trauma (SHR: 2.62; 95% CI: 1.60-4.29; p<0.001). Conclusions: Respiratory distress syndrome, fewer antenatal care visits, out-of-district residence, and higher degrees of prematurity were associated with prolonged time to discharge among preterm neonates. Strengthening antenatal care utilization and improving access to quality neonatal care in underserved areas may enhance discharge outcomes.

Recognizing the challenges faced by primary caregivers regarding the health of children with congenital craniofacial anomalies (CCAs) contributes to strengthening healthcare programs according to patient[s] and families differential needs. This qualitative study presents the experiences of 25 caregivers of children with CCAs from Bogota and Cali, Colombia, identified from care registries and consultation statistics provideed from public high-complexity healthcare institutions. Grounded in Giorgis descriptive phenomenology and employing thematic analysis, this research utilized semi-structured interviews and focus groups to explore the diagnostic process and its impact, experiences with healthcare services, and the caregivers role and daily care activities. Data were analyzed using MAXQDA(R) qualitative software. Findings highlighted the emotional complexity of caring for childre[n]s health. Challenges included late diagnoses, pessimistic views of the children with CCAs condition by healthcare team members; lack of effective support, information, and guidance from health staff; absence of clear care and referral protocols, and limited access to specific adaptations and timely specialized care for children with CCAs. There were also reduced therapeutic services, and a pronounced gendered caregiving burden when responsibilities fall almost exclusively on mothers. System fragmentation, reflected in deficiencies in communication and a lack of clear, coordinated, and timely pathways of care, as well as the absence of adequate psychosocial support for families, emerged as common structural problems in healthcare services in both geographic settings where this research has been conducted. Gender-sensitive strategies focused on alleviating emotional concerns and the burden of caregiving from diagnosis onward within a patient and family-centered care model are decisive. Improving comprehensive CCAs training for healthcare personnel and making adjustments to care pathways are suggested to contribute to the implementation of inclusive health programs that address the diverse needs of children and their families.

BackgroundAccess to safe, equitable, and affordable surgical and anesthesia care is critical to reducing the burden of surgical diseases in Africa. To understand the state of access in South Sudan, we conducted a baseline assessment of surgical services in Central Equatoria State (CES) in May 2024. ObjectivesThis study aimed to survey public healthcare facilities in CES capable of providing essential surgical services. We used the capacity to perform cesarean section, laparotomy, and open fracture management--Bellwether procedures--as a proxy for assessing workforce, infrastructure, financing, information management, and service delivery. MethodsWe used a validated and contextualized Surgical Assessment Tool developed by the Harvard Program on Global Surgery and Social Change and the World Health Organization. Data were collected at the facility level and summarized descriptively using percentages, means (standard deviations), medians (minimum, maximum), and visualized in graphs, charts, and tables. ResultsAll three public health facilities assessed could perform Bellwether procedures for their catchment populations. However, workforce availability, financing, and surgical infrastructure were major constraints. The surgical workforce density was 2.27 surgical, anesthesia, and obstetric specialists per 100,000 population. Specialized procedures--such as repair of cleft lip and palate, clubfoot, and hydrocephalus shunt--were unavailable at all sites. None had magnetic resonance imaging (MRI) machines. The total average annual facility budget was $918,850, ranging from $3,960 to $800,000 at the teaching hospital--insufficient for proper operations. ConclusionWhile Bellwether procedures are routinely performed, access to quality and affordable care is compromised by deficits in workforce, financing, and infrastructure. We recommend that the Ministry of Health scale this survey nationally and develop a surgical policy and strategic plan focused on improving infrastructure, workforce, and financing for surgical and anesthesia care in South Sudan.

Abstract Importance Stigma and discrimination against transgender and gender-diverse people are prevalent across many settings and may contribute to substantial health disparities. Objective To synthesize global evidence on the prevalence of stigma, discrimination, and resilience among transgender (trans) and gender-diverse adults. Data Sources A systematic search was conducted in PubMed, Embase, CINAHL, Cochrane Central, LILACS, and PsycInfo for articles published between January 1, 2010 and January 2, 2023. This database search was supplemented by grey literature and secondary reference searches. Article Selection Studies were eligible if they presented primary quantitative data on prevalence of stigma, discrimination, and/or resilience among trans and gender-diverse adults (aged 18 and over), with no restrictions on study design, language, or geographic region. Data Extraction and Synthesis Two independent reviewers extracted data using standardized forms, with discrepancies resolved by consensus. The JBI Critical Appraisal Checklist for Prevalence Articles was used to assess risk of bias. Random effects meta-analysis was conducted for dichotomous prevalence measures using inverse variance weighting and logit transformation; non-dichotomous prevalence data were summarized descriptively. Main Outcomes and Measures Outcomes included prevalence estimates for various forms of stigma (anticipated, perceived, internalized, and experienced), discrimination in legal/institutional settings (housing, healthcare, employment, police/prison), and resilience. Results A total of 97 articles, with data from 72,158 unique trans and gender-diverse participants across 26 countries, met inclusion criteria. Studies showed moderate levels of anticipated stigma, perceived stigma, and internalized stigma. Meta-analyses of 36 studies provided pooled estimates of discrimination prevalence across multiple domains: 21.4% in housing (e.g., eviction, rental denial), 24.6% in healthcare (e.g., denial of care, mistreatment), 32.8% in employment (e.g., hiring bias, workplace harassment), and 39.1% in police/prison settings (e.g., profiling, mistreatment). High heterogeneity was observed across studies, reflecting regional and methodological differences. Resilience scores ranged from moderate to high, indicating variation within trans and gender-diverse communities. Conclusions and Relevance This systematic review and meta-analysis found that stigma and discrimination against trans and gender-diverse adults are pervasive globally. Variation in stigma and discrimination across settings and regions underscores the need for targeted interventions and policy reforms. Funding World Health Organization through a grant from the Elton John AIDS Foundation and the Bill and Melinda Gates Foundation.

Although the co-occurrence of diarrhea and malnutrition is well documented, research has largely focused on the acute management of diarrheal illness. Despite its importance, longitudinal evidence characterizing post-diarrheal recovery trajectories is sparse. We sought to characterize post-diarrheal nutritional recovery trajectories among children aged 6-35 months who were malnourished at enrollment using data from the Enterics for Global Health (EFGH) Shigella Surveillance study (2022-2024). EFGH enrolled children aged 6-35 months presenting with medically-attended diarrhea and followed them at 4 weeks and 3 months post-enrollment. This analysis included children with baseline wasting, stunting, or underweight (z-score < -2) and complete anthropometric follow-up. Latent class mixed-effects models were used to identify distinct post-diarrheal growth trajectories based on changes in anthropometric z-scores over time. Multinomial modified Poisson regression models examined associations between baseline factors and trajectory membership. Among 9,480 enrolled children, 16.5% (n=1,561) were wasted, 22.7% (n=2,155) stunted, and 21.0% (n=1,994) underweight at baseline. Wasting showed greater recovery potential (80.8%) compared with stunting (38.5%) and underweight (40.3%). Recovery was shaped by factors across multiple levels. Clinical severity markers ( prolonged diarrhea, dehydration, and hypoxemia) increased the risk of nutritional failure. Age also influenced outcomes: infants were more likely to worsen, whereas older toddlers more often experienced stagnation. Interventions including exclusive breastfeeding, oral rehydration therapy, appropriate antibiotics, and zinc supplementation, improved outcomes, while unimproved sanitation undermined recovery. These findings highlight the need for integrated strategies combining infection control, nutritional rehabilitation, and water, sanitation, and hygiene interventions tailored to the childrens developmental stage. Key MessagesO_LIPost-diarrheal nutritional recovery is highly heterogeneous, with wasting showing the greatest potential for improvement, while stunting and underweight often result in persistent growth stagnation. C_LIO_LIBaseline anthropometric deficits alone are insufficient to predict recovery, highlighting the need for dynamic monitoring and individualized management. C_LIO_LIInfants are particularly vulnerable to acute nutritional deterioration, while older toddlers frequently experience growth stagnation. C_LIO_LIModifiable protective factors including exclusive breastfeeding, ORS, zinc, and appropriate antibiotics, improved outcomes, whereas poor sanitation undermined recovery. C_LIO_LIIntegrated strategies, tailored to a childs developmental stage, combining clinical care, nutrition, and environmental interventions are critical to support sustained child growth and development. C_LI

Background: Many children under five die post hospital discharge in low-and middle-income countries (LMICs), particularly after treatment for severe infections. While some models exist, evidence on risk prediction for post-discharge mortality remains limited, with most relying solely on admission characteristics, overlooking in-hospital disease progression and discharge features. Methods: We used secondary data from prospective cohort studies in six Ugandan hospitals (2012-2021) to update models at discharge. Of 8,810 children included, 3,665 were aged <6 months and 5,145 were aged 6-60 months. Models were developed utilizing an elastic net regression approach, with admission variables selected a priori and discharge variables selected based on variable importance ranking. Performance was evaluated by applying 10-fold cross-validation, area under the receiver operating characteristic curve (AUROC), Brier score, and Net Reclassification Index (NRI). Results: Models augmented with discharge characteristics outperformed admission-only models. For children aged <6 months, the model AUROC improved by 5.1% (95% CI 3.0 - 7.3, P<0.001), achieving an AUROC of 0.81 and a Brier score of 0.06. In the 6-60m cohort, the model AUROC increased by 4.4% (95% CI 2.0 - 6.9, P<0.001), with an AUROC of 0.79 and a Brier score of 0.04. The NRI was 10.41% for children <6 months and 14.51% for those 6-60m and was achieved primarily through a reduction of false positive rates. Conclusion: Adding only three discharge characteristics to the post-discharge mortality model based on admission characteristics enhanced prediction accuracy, including model calibration, discrimination and risk stratification compared to admission-only models. Keywords: Post-discharge mortality, Risk prediction model, Elastic Net regression, Low-and middle-income countries, Child mortality, Critical illness.

OBJECTIVE This study investigates the long-term impacts of childhood exposure to voiding cystourethrogram (VCUG), a diagnostic procedure for vesicoureteral reflux. Primary outcomes include long-term health outcomes, mental health disorders, healthcare avoidance, and participation in risky behaviors compared to a control group. METHODS A 9-month retrospective cohort study was conducted with adults who received most of their medical care in the U.S. Respondents self-reported health metrics, behaviors, and outcomes via a 20-minute survey. Respondents were divided into two groups: those who remembered undergoing at least one VCUG in childhood (VCUG group), and those who did not (control group). RESULTS Of 334 respondents, 204 (61%) were in the VCUG group (mean age: 29, 70% female) and 130 (39%) were controls (mean age: 34, 70% female). Notable findings include: 47% of VCUG respondents were diagnosed with depression compared to 27% of controls. 15% of female-born VCUG respondents reported they would never visit a gynecologist compared to 2% of controls. 34% of VCUG respondents smoked regularly compared to 5% of controls, and 11% of VCUG respondents regularly missed work compared to 1% of controls. These findings highlight the need for further research and clinical consideration of VCUG's long-term consequences. CONCLUSIONS This study suggests that the effects of childhood VCUG extend into adulthood. Our findings underscore the need to reassess informed consent protocols and consider full-scale studies to minimize bias.

Purpose: Neurogenic dysphagia is prevalent in neurological inpatients and associated with adverse outcomes, yet its independent economic impact after adjustment for frailty and functional status remains poorly quantified. We aimed to estimate the independent effect of dysphagia on hospital length of stay (LOS) and costs, to test whether this effect differs between geriatric and non-geriatric patients, and to quantify the probability and magnitude of cost savings from improvements in swallowing function. Methods: We analysed 10,375 neurological inpatient cases (2021-2024) at a German university hospital. Dysphagia was defined by fiberoptic endoscopic evaluation of swallowing (FEES) or ICD-10 R13 coding (n = 1,382; 13.3%). Bayesian Gamma-log regression with informative priors from historical data and published literature was used to model LOS and total case costs (German DRG), adjusted for age, sex, Hospital Frailty Risk Score (HFRS, R13-adjusted), self-care index ("Selbstpflege-Index", SPI), stroke status, and emergency admission. A geriatric cohort was defined as age >=70 and adjusted HFRS >=5 (n = 2,053; 19.8%). Posterior predictive simulation estimated cost savings for hypothetical improvements of 1-3 points on the Functional Oral Intake Scale (FOIS). Results: After comprehensive adjustment, dysphagia was independently associated with 46.5% longer LOS (posterior ratio 1.465; 95% credible interval [CrI] 1.397-1.537) and 28.2% higher total case costs (ratio 1.282; CrI 1.213-1.354). The dysphagia x geriatric interaction was small but credible and ran in opposite directions: slightly attenuated for LOS (interaction ratio 0.908, CrI 0.837-0.986) but slightly amplified for costs (1.096, CrI 1.012-1.185), consistent with complexity-driven DRG grouping in geriatric patients. The absolute economic burden remained larger in the geriatric cohort due to higher baseline costs. In the geriatric cohort, a one-point FOIS improvement yielded a 74.3% posterior probability of LOS-based savings (mean EUR 555/case); at three points, this rose to 84.2% (mean EUR 1,115/case). The direct cost model confirmed high benefit probabilities from the payer's perspective (82.6% at dFOIS = 3). Conclusions: Neurogenic dysphagia is an independent and substantial driver of hospital LOS and costs in neurological inpatients, even after adjustment for frailty and functional status. The proportional effect on costs is slightly larger in geriatric patients, while the LOS effect is slightly smaller, consistent with the mechanics of the G-DRG system. Bayesian simulation indicates that improvements in swallowing function carry a high probability of generating cost savings, supporting the characterisation of dysphagia as a modifiable economic target with particular relevance to geriatric neurology.

Background Childhood sensory and intellectual disabilities represent significant yet under-recognized barriers to learning and human capital development. This study analyzes prevalence and severity of these conditions among 149.3 million children aged 5-19 years across 25 countries in Latin America and the Caribbean (LAC) using Global Burden of Disease 2023 data. Methods We extracted GBD 2023 estimates for vision loss, hearing loss, and intellectual disability across 25 LAC countries, stratified by age, sex, and severity. Regional estimates were calculated using population-weighted averages. Severity distributions were compared with OECD countries to contextualize regional patterns. Results: These conditions are estimated to affected 9,282,921 children (6.22%; 95% UI: 5.89-6.54%). Hearing loss was predominant, affecting an estimated 5.42 million (3.63%, 3.41-3.86), with 87.6% mild-to-moderate. Intellectual disability estimated to affected 2.56 million (1.71%, 1.58-1.85), with 61.7% borderline-to-mild. Vision loss estimated to affected 1.30 million (0.87%, 0.79-0.96), with 89% that can be effectively addressed with spectacles. Prevalence increased with age across all conditions. Male predominance was consistent for intellectual disability (2.00% vs 1.42%). Annual economic cost totaled US$19.3-29.0 billion, while comprehensive interventions would require US$9.45-14.23 billion with benefit-cost ratios of 2:1 to 15:1. Conclusions The distribution of children across milder levels of difficulty underscores the opportunity for education and public health systems to provide timely and accessible support. With approximately 88% of sensory impairments addressable through established technologies, investments in inclusive services can yield strong social and economic returns.

Estimates of the marginal cost per disability-adjusted life year (DALY) averted from government health expenditure (GHE) provide an empirical basis for allocating scarce health resources to maximise population health. Existing cross-country estimates have informed priority setting in several countries and international policy discussions but are based on data that are now more than a decade old. Since then, patterns of health expenditure, disease burden, and global health financing have changed substantially. This paper provides updated estimates of the marginal cost per DALY averted for 92 low- and middle-income countries (LMIC) by applying previously estimated elasticities of the effect of GHE on health outcomes from Ochalek et al. (2018) to recent data on mortality, morbidity, population structure, and GHE. Two policy options for improving health in LMIC are assessed: (1) the implications of countries allocating 15% of general government expenditure to health consistent with the Abuja Declaration; and (2) reallocating development assistance for health (DAH) to maximise health across countries. Scenario analyses use the estimated elasticities to reflect diminishing marginal returns to health expenditure when calculating the health gains associated with additional resources. Updated estimates of the marginal costs per DALY averted range from approximately $78 to $15,789 across countries. In most countries (72%), estimates are higher than in the previous analysis, largely reflecting increases in GHE. Increasing domestic expenditure to achieve the Abuja Declaration objective would avert 234 million DALYs but require $563 billion across countries. Reallocating $39.1 billion in existing DAH could avert 133.6 million DALYs. Updated estimates provide an empirical basis for informing both domestic priority setting and the allocation of international health financing. Aligning donor funding with country-specific opportunity costs could substantially increase the global health gains achieved with limited resources.

Abstract Objective: Frailty is an important concern in old age. Inflammation can cause frailty. Anti-inflammatory food supplements can play a role in slowing down frailty processes and consequences. This study explored the views of people (aged 50-89 years) on the need to develop a frailty supplement, preferences for its form and how older people could be encouraged to use such a supplement. Design: We conducted semi-structured qualitative interviews and used a framework method to analyse the data. Participants: 30 participants from a city in the UK. Setting: These participants were recruited from social housing, care homes, foodbanks and the wider population. Participants were from diverse ethnic, gender and age backgrounds. Results: Participants identified a strong need for the development of a food-based supplement for frailty. They expressed excitement for the supplement and viewed it as something which they would be happy to integrate in their daily food routine. In terms of preferences, our participants wanted to have multiple options, however, a biscuit-based supplement was preferred by most. The participants preferences were mainly based on taste of the supplement, its effectiveness, convenience in use and affordability. Muslim participants in the sample said they would be happy to use this supplement if it was developed using Halal ingredients. In terms of creating awareness and encouraging people to use the proposed supplement, participants suggested a variety of marketing methods. These included: word of mouth, face to face sessions with older adults, social media, especially YouTube and advertising on TV. Conclusion: The participants were generally open to the idea of a food-based supplement and felt that it could easily fit with their existing food practices and lifestyles. Keywords: older adults, frailty, food supplement, co-creation, healthy ageing

Objectives Concerns about COVID-19 were a key driver of infection-prevention behaviour during the pandemic. The aim of this study was to gain an in-depth longitudinal understanding of the type and frequency of concerns experienced throughout the first two years of the COVID-19 pandemic. Design Content analysis of qualitative descriptions provided in a prospective longitudinal online survey as part of the COVID-19 UK Public Experiences (COPE) Study. Method At baseline (March/April 2020), when the UK entered its first national lockdown, 11,113 adults completed the COPE survey. Follow-up surveys were conducted at 3, 12, 18 and 24 months. Participants were recruited via the HealthWise Wales research registry and social media. Baseline surveys collected demographic and health data, and all waves included an open-ended question about COVID-19 concerns. Content analysis was used to identify the type and frequency of concerns at each time point. Results A total of 41,564 open-text responses were coded into six categories: personal harm (n=16,353), harm to others (n=11,464), social/economic impact (n=6,433), preventing transmission (n=4,843), government/media (n=1,048), and general concerns (n=1,423). The proportion of respondents reporting any concern declined from 75.3% at baseline to 65.8% at 24 months. Over time, concerns about personal harm increased (baseline 41.8% vs. 24-months 52.7%) whereas concerns about harm to others decreased (baseline 48.5% vs. 24-months 28.6%). Concerns about harm were also expressed in relation to clinical vulnerability, lack of trust in government/media, and perceived lack of adherence by others. These were balanced against concerns about wider social and economic impacts of restrictions. Conclusions Public concerns about COVID-19 evolved substantially over the first two years of the pandemic, reflecting changing perceptions of risk and responsibility. Monitoring concerns longitudinally is vital to help guide effective communication and behavioural interventions during future pandemics.

BackgroundWomens autonomy in healthcare decision-making has become one of the most critical yet inequitably distributed determinants of health outcomes, gender equity, and sustainable development worldwide. In Northern Nigeria, the presence of ethnic and socio-cultural inequality is frequently concealed by the aggregated statistics of a region. MethodsThis cross-sectional secondary analysis utilized the 2024 Nigeria Demographic and Health Survey. The sample included 9,998 married women (15-49 years) identifying as Hausa, Fulani, or Kanuri in Northern Nigeria. Healthcare autonomy was categorized as husband/partner alone, respondent alone, or joint decision-making. Analysis included weighted descriptive statistics, Rao-Scott adjusted chi-square tests for residential associations, and complex sample multinomial logistic regression to identify multivariable correlates while adjusting for sampling weights, strata, and clusters. ResultsMean age was 30.38 years. Most participants lacked formal education (69.6%) and resided in rural areas (72.0%). Husband-only decision-making predominated (72.6%), while 22.5% reported joint and 4.9% independent autonomy. Joint decision-making was significantly higher in urban (33.3%) than rural areas (18.3%; Adjusted F=50.892, p<0.001). In adjusted models (Reference: Kanuri), Hausa and Fulani women had substantially lower odds of joint decision-making relative to husband-only outcomes. Rural residence correlated with lower odds of both independent and joint agency. Notably, wealth status was not a significant predictor after adjustment (p > 0.05). ConclusionsEthnicity and residence are robust determinants of healthcare autonomy among women in Northern Nigeria, persisting regardless of education or wealth. This "socio-cultural paradox" suggests that economic interventions alone are insufficient. Policies must complement socioeconomic approaches with culturally responsive strategies addressing household power dynamics and entrenched social norms.

IntroductionOn January 20, 2025, the U.S. government froze foreign assistance including for PEPFAR, though a limited waiver for "life-saving" interventions was subsequently granted. PEPFARs 2025 monitoring results, released April 17, 2026, covered only quarter 4 while an earlier inadvertent release included all four quarters. Combining both data sets, we systematically assess facility-level programmatic performance and reporting trends to quantify service disruptions accounting for reporting discrepancies. MethodsWe categorized facilities by reporting continuity across Q1 2024 and Q4 2025 (e.g. continuous, intermittent, dropped, or new) and assessed changes in service delivery by the category of health facility for key HIV treatment, testing, PMTCT, and prevention programming. We additionally analyze changes in employed human resources for health (HRH) reported by PEPFAR. ResultsPEPFAR data included 31,746 facilities and community service sites. 71.3% were classified as continuous reporters, 16.9% intermittent reporters, 2.5% community services, 3.9% dropped in 2025, and 3.1% new in 2025. Total number of people accessing HIV treatment declined modestly by -0.3%, but differed by facility category. Continuous facilities saw a 0.5% increase in people on treatment, while intermittent facilities saw a -1.7% decrease. HIV testing declined -17%. HIV diagnoses declined -13% in continuous facilities, -35% in community services, and -29% in intermittent facilities. PMTCT infant testing and diagnoses declined by -6% and -12% in continuous facilities, respectively, and -60% and -31% in intermittent facilities, respectively. PrEP initiations declined -33%. Total direct service delivery HCWs reduced -62,541 (-24%) ConclusionThese findings reveal substantial disruptions across PEPFAR service areas, with the steepest declines among intermittent and community-based delivery sites, alongside a 24% reduction in direct service delivery healthcare workers. As potentially the final data set PEPFAR will ever release, these findings represent a troubling inflection point. The dismantling of public data systems and accountability structures undermine progress and enable programmatic gaps to develop and go unnoticed that risk allowing HIV resurgence to occur over the coming years.

Background: Child acute malnutrition remains persistently above emergency thresholds in Chad's Sahelian drylands, with a predictable, but rarely recognized, dry season peak linked to declining pasture and livestock productivity, reduced milk availability and heightened exposure to zoonotic infections. Humanitarian responses remain largely reactive and treatment-focused, with limited evidence on preventive strategies that address drivers embedded in local livelihood systems. We evaluated the effectiveness and return on investment (ROI) of an integrated livestock management intervention designed to prevent the dry-season peak of child acute malnutrition in pastoral and agro-pastoral communities in Chad. Methods: We conducted a cluster-randomised controlled trial in Kanem and Barh-El-Gazel provinces, Chad. Seventy-six villages were randomised (1:1) to intervention or control. Eligible households had at least one child aged 6-59 months and access to milking livestock during the dry season. The intervention (December 2024-June 2025) combined livestock feed supplementation to sustain milk production near households during the dry season, household-level zoonotic risk mitigation, and nutrition counselling. Primary outcomes were the prevalence of global acute malnutrition (GAM) and severe acute malnutrition (SAM) at the dry-season peak (May 2025), assessed in a prespecified random subsample of 52 clusters. All 76 clusters were assessed post-peak (July 2025). Analyses followed an intention-to-treat approach using mixed-effects models. A societal ROI analysis was conducted over six months with projections to 24 months. Findings: At the dry-season peak, 821 children 6-59 months from 521 households were assessed across 52 villages. GAM prevalence was 22.2% in intervention villages versus 47.4% in controls (adjusted OR 0.29 [95% CI 0.18-0.49]; p<0.001), and SAM prevalence was 4.4% versus 19.4% (adjusted OR 0.17 [0.08-0.37]; p<0.001). Intervention households had higher daily milk availability (+588 mL per household; p<0.001), and children consumed more milk (+102 mL per day; p=0.008). Odds of self-reported diarrhoeal disease and acute respiratory infection were substantially lower among children in intervention villages (aOR 0.21 [0.10-0.44] and 0.22 [0.11-0.46], respectively). Post-peak, women's dietary diversity increased (aOR 3.68 [1.90-7.13]), alongside reduced workload, lower household food insecurity and distress livestock sales, improved livestock condition, and a benefit-cost ratio of 5.40 at six months, rising to 16.40 at 24 months. Interpretation: Protecting livestock productivity and sustaining children's access to milk while reducing zoonotic exposure during the pastoral lean season effectively prevents seasonal peaks of child acute malnutrition. This integrated anticipatory action and One Health livelihood-based approach offers a scalable, dignifying, high-return lifesaving preventive model for pastoral and agro-pastoral humanitarian settings.

ObjectiveStudies of nutritional status and host responses during severe and critical illness have focused predominantly on obesity; in contrast, the relationship between undernutrition, host responses, and clinical outcomes in adults hospitalized with severe infection remains poorly defined. We sought to determine whether severe undernutrition is associated with distinct host responses and clinical outcomes in adults hospitalized with severe infection. DesignProspective cohort study. SettingTwo public referral hospitals in Uganda. PatientsNon-pregnant adults ([&ge;]18 yr) hospitalized with severe, undifferentiated infection. InterventionsNone. Measurements and Main ResultsWe analyzed clinical data and serum Olink proteomic data from 432 participants (median age, 45 yr [IQR, 31-57 yr]; 44% male). Overall, 213 participants (49%) met prespecified criteria for undernutrition, including 52 (12%) with severe undernutrition. Clinically, severe undernutrition was associated with HIV coinfection, microbiologically diagnosed tuberculosis, greater physiological instability, and higher mortality. After adjustment for age, sex, illness duration, study site, and HIV, malaria, and tuberculosis coinfection, severe undernutrition was associated with higher expression of proteins involved in pro-inflammatory immune signaling, endothelial and vascular remodeling, hypoxia and oxidative stress responses, and extracellular matrix remodeling, together with lower expression of proteins linked to growth signaling, anticoagulant regulation, and lipid homeostasis. ConclusionsSevere undernutrition is associated with a distinct high-risk clinical phenotype and biologic signature in adults hospitalized with severe infection. These findings suggest that undernutrition may potentiate key domains of sepsis pathobiology, with implications for strengthening nutritional support and informing host-directed treatment strategies in low- and middle-income countries where malnutrition is common. Key PointsO_ST_ABSQuestionC_ST_ABSHow does undernutrition influence immune, metabolic, and endothelial responses to severe infection in adults? FindingsIn this multicenter cohort study of 432 adults hospitalized with severe infection in Uganda, severe undernutrition was associated with greater physiologic instability, higher mortality, and a distinct proteomic host-response profile. Adults with severe undernutrition exhibited a proteomic signature characterized by pro-inflammatory immune signaling, endothelial and extracellular matrix remodeling, and hypoxia and oxidative stress responses, together with lower expression of proteins involved in growth signaling, anticoagulant regulation, and lipid homeostasis. MeaningSevere undernutrition is associated with a distinct high-risk clinical and biologic phenotype during severe infection, with implications for nutritional support, risk stratification, and host-directed therapeutic strategies, particularly in low- and middle-income countries.

Background: Out-of-pocket healthcare expenditure (OOPHE) remains a major challenge to accessing adequate medical service, often discouraging individuals from seeking necessary medical services. The extent of OOPHE in Jigjiga city is unknown. This study aimed to assess the magnitude and associated factors of OOPHE among outpatients visiting public hospitals in Jigjiga city, Somali region, Eastern Ethiopia. Methods: A hospital-based cross-sectional study was conducted among 406 outpatients selected through systematic random sampling from three public hospitals in Jigjiga city. Data were collected through interviews-administered questionnaires and analysed by SPSS version 25.0. Binary and multivariable logistic regression analyses were performed to identify factors associated with OOPHE among outpatients (p < 0.05). Results: Overall, 89.5% of respondents incurred out-of-pocket healthcare payments at the point of service delivery. The mean OOPHE per outpatient was 485.6 {+/-} 349 birr ($3.12 {+/-} $2.24). Female [AOR = 3.38, 95% CI (1.54-7.42)], unmarried [AOR = 5.32, 95% CI (1.77-16.03)], and traveled [&ge;]5 km [AOR = 7.07, 95% CI (1.46-34.29)] and higher educational attainment (college and above) [AOR = 7.07, 95% CI (1.55-32.28)] were independently associated with higher odds of incurred OOPHE. Conclusion: The magnitude of out-of-pocket healthcare payments among outpatients was high. Sex, marital status, educational level, and distance to reach a public health facility were significant predictors of OOPHE. Policy action to reduce OOPHE in this setting should include strengthening and expanding the Community-Based Health Insurance scheme and promoting prepayment mechanisms, such as Social Health Insurance, for formal sector employees, specifically for government employees.

Background. Vietnam's disease burden has shifted from communicable, maternal, neonatal, and nutritional (CMNN) causes to non-communicable diseases (NCDs), but the tempo, drivers, and regional positioning of this transition have not been jointly quantified. We characterised Vietnam's epidemiological transition 1990-2023 against ten Southeast-Asian (SEA) peers. Methods. Using Global Burden of Disease 2023 data, we computed joinpoint-regression AAPC with 95% CI (BIC-penalised, up to three break-points) for age-standardised DALY rates and cause-composition shares. We applied Das Gupta three-factor decomposition to 1990-2023 absolute DALY change (population-size, age-structure, age-specific-rate effects) and benchmarked Vietnam's NCD share against an SDI-conditional peer trajectory via leave-one-out quadratic regression. Premature mortality was quantified as WHO 30q70 under both broad NCD and strict SDG 3.4.1 definitions, using Chiang II life-table adjustment identically across all eleven countries. Findings. The CMNN age-standardised DALY rate fell from 13,295.9 to 4,022.1 per 100,000 (AAPC -4.63%/year; 95% CI -4.80 to -4.46); the NCD rate fell only from 21,688.2 to 19,282.8 (AAPC -0.37; -0.45 to -0.30). NCD share of total DALYs rose from 52.99% to 70.67% (+17.67 pp; AAPC +1.09). Vietnam ranked fourth of eleven SEA countries in 2023 (up from sixth in 1990) and sat 5.3% above the SDI-expected trajectory. Das Gupta decomposition attributed the +10.63 million NCD DALY increase to population growth (+6.26 M) and ageing (+6.08 M); rate change removed only 1.71 M. Premature NCD mortality fell from 25.02% to 21.80% (broad, 12.9% reduction) and from 22.17% to 19.50% (SDG 3.4.1, 12.0%; Vietnam sixth of eleven) - far short of the SDG 3.4 one-third-reduction target. Interpretation. Vietnam has entered a disability- and ageing-dominated NCD phase. Meeting SDG 3.4 by 2030 requires population-scale primary prevention sized to demographic momentum.

Health visiting is England's universal home visiting programme for families with children under five and a key pillar of early intervention policy. Since the 2015 devolution of commissioning to Local Authorities (LAs), the service has faced sustained financial and workforce pressures, yet there is limited systematic evidence on whether resources and delivery have evolved differentially across areas and along the deprivation gradient. Using new Freedom of Information (FOI) data, we estimate how health visiting inputs (spending and workforce) and mandated contact delivery vary in levels and trajectories by baseline deprivation. FOI requests covered 147 English LAs (four pairs submitted joint returns), providing annual 2016-2021 Full-Time Equivalent (FTE) data on Health Visitors (HVs) and Clinical Skill Mix Staff (CSMS), which we link to DHSC Health Visitor Service Delivery Metrics reporting completion of the five mandated 0-5 reviews (New Birth Visits, 6-8 week reviews, 12-month reviews, 2-2.5 year reviews, and 2-2.5 year reviews completed with ASQ-3) and to LA revenue outturn expenditure on mandated and non-mandated 0-5 public health services (real-terms total and per child under five). Between 2016 and 2021, HV FTE fell by around one-fifth while CSMS expanded by roughly one-third, consistent with an overall contraction and a shift toward lower-band staff. To test whether these changes map onto underlying disadvantage, we stratify LAs into tertiles of baseline deprivation using the 2015 Income Deprivation Affecting Children Index (IDACI) and implement a three-part empirical strategy: (i) plotting tertile means over time, (ii) testing within-year cross-sectional differences using parametric and non-parametric methods with pairwise comparisons, and (iii) estimating LA fixed-effects regressions with Year x IDACI interactions under both a flexible year-by-year specification and a parsimonious linear-trend specification to assess differential trajectories. We find persistent cross-sectional gradients in per-child spending that are broadly progressive (more deprived LAs spend more per child on both mandated and non-mandated 0-5 services), while fixed-effects models show little evidence that spending trajectories differ systematically by deprivation. Workforce trends are more uneven: HV FTE declines more slowly and CSMS FTE grows more slowly in more deprived LAs in the linear-trend specification, while per-child HV trajectories show no differential trends. Despite these input differences, completion of mandated contacts is relatively stable across the deprivation gradient; the only consistent differential trend is faster improvement in the 6-8 week review in more deprived areas. Meanwhile, caseload pressure rises, increasing most sharply in the most deprived LAs in the pre-pandemic years, suggesting that completion-based performance measures may mask heterogeneities in service capacity and intensity. Finally, we quantify the resources required to restore recommended caseloads, implying the need for approximately 3,100 additional FTE staff and around 120 million GBP annually (plus training costs).