Sexually Transmitted Infections

Background Chemsex, drug use before/during sex to facilitate and enhance the experience, is undertaken by a minority of gay, bisexual and other men who have sex with men (GBMSM), but evidence of chemsex prevalence in England is limited. This study describes trends in chemsex prevalence between 2022-2025 and identifies factors associated with chemsex amongst GBMSM in England. Methods Data from the RiiSH study (2022-2025), an annual online cross-sectional survey of GBMSM recruited through social networking/dating apps and community partners, were analysed. Trends in chemsex prevalence and adjusted prevalence were estimated using log-binomial regression models. The following seven variables were candidate factors associated with chemsex and were assessed through logistic regression: age, sexual orientation, education, employment, HIV status, HIV PrEP use, and sexual health service (SHS) use. Results 5728 GBMSM were included in this study. Adjusted chemsex prevalence varied from 6.1% in 2022 to 4.2% in 2023, 5.1% in 2024 and 6.8% in 2025. Chemsex was more likely in GBMSM who were: gay (aOR=1.57 versus other sexual orientations; 95%CI 1.11-2.29, p=0.01), unemployed (aOR=3.08 versus employed full-time; 95%CI 2.19-4.26, p<0.001); aged 35-59 versus 16-34 years (p<0.001), with recent HIV PrEP use (aOR=3.79 versus no recent use; 95%CI 2.63-5.56, p<0.001), SHS use (aOR=2.23 versus no recent use; 95%CI 1.76-2.83, p<0.001), and living with HIV (aOR=3.16 versus negative/unknown HIV status; 95%CI 2.43-4.09, p<0.001). Conclusions Chemsex prevalence was low and stable between 2022-2025. PrEP and SHS use were associated with chemsex, supporting integration of specialist support services within SHS.

Background: European Association of Urology (EAU) Guidelines identify urogenital infections as a possible treatable cause of infertility, yet the current recommendation for antibiotic treatment remains weak due to a lack of high-quality evidence. We evaluated the effect of antibiotic treatment of asymptomatic urogenital infections on both conventional and apoptosis-related (flow cytometry sperm apoptosis test, FACS-APO) sperm parameters, as well as on pregnancy outcomes, in infertile couples. Methods: In this retrospective, single-centre study, we analysed 265 couples with an asymptomatic urogenital infection (Ureaplasma urealyticum, Mycoplasma hominis, Mycoplasma genitalium, and Chlamydia trachomatis) confirmed in at least one partner by first-void urine testing, who received simultaneous antibiotic treatment. Paired conventional semen analysis and FACS-APO were performed before and 0-9 months after treatment completion. Partner infection concordance, the effect of follow-up timing on treatment response, and pregnancy outcomes within 12 months were also assessed. Results: Sperm concentration, total sperm count, total and progressive motility, and the proportion of viable sperm increased significantly after treatment, while the proportion of late apoptotic / necrotic sperm and calculated sperm DNA fragmentation decreased significantly (all p<0.05); the proportion of early apoptotic sperm remained unchanged, and semen volume did not change. Among 244 couples with complete bilateral microbiological testing, Ureaplasma urealyticum was by far the most prevalent pathogen (57.8% of men, 87.7% of women), and female partner positivity given male positivity was 83.0%. The improvement in sperm concentration and total sperm count was most pronounced within 3 months after treatment and diminished, or reversed, beyond 6 months. Pregnancy was achieved in 127 of 265 couples (47.9%; per-protocol rate 53.4%) within 12 months, most commonly following in vitro fertilization (72/127) or spontaneously (21/127). Conclusions: Antibiotic treatment of asymptomatic urogenital infections in infertile couples was associated with significant improvement in conventional semen parameters and a reduction in sperm apoptosis and calculated DNA fragmentation. Given the retrospective, uncontrolled design, these findings should be regarded as hypothesis-generating rather than definitive proof of a causal, fertility-enhancing effect, and warrant confirmation in prospective controlled studies.

Background: Treponema pallidum quantitative polymerase chain reaction (qPCR) positivity and cycle threshold (Ct) by rapid plasma reagin (RPR), disease stage, and other characteristics are poorly characterized in routine-care specimens, leaving it unclear when qPCR of such specimens is informative for diagnosis. Methods: This Japanese multicenter cross-sectional study explored qPCR positivity and Ct by these characteristics. Nonblood specimens collected during routine care underwent qPCR at a central laboratory for this study. Bayesian logistic and normal regressions modeled positivity and mean Ct of TP0574 and polA with stage-specific continuous automated RPR terms, patient characteristics, collection site, and facility random intercepts. Estimates were standardized over the analyzed specimens. Population-group predictions were instead averaged within each group. Results: Among 154 nonblood specimens from 145 patients (71.7% non-MSM men and women) at 14 facilities, 109 (70.8%) were qPCR positive. At RPR 1, adjusted positivity was 72.2% (95% credible interval, 60.9%--82.9%) in primary and 43.8% (16.7%--69.9%) in secondary syphilis. Positivity showed a modest downward trend with RPR in primary but increased in secondary syphilis, reflecting a stage-by-RPR interaction (secondary-to-primary ratio of odds ratios, 1.78; 1.25--2.65). Predicted positivity showed an upward trend with RPR values among MSM; adjusted positivity was relatively high for genital/urethral/urinary and anal/perianal/rectal specimens. Adjusted mean Ct increased with RPR in primary and followed an inverted-U pattern in secondary syphilis. Conclusions: In primary syphilis, nonblood qPCR positivity was high even at low RPR. When serologic findings remain inconclusive in this stage, qPCR is highly recommended for securing an early diagnosis.

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.

ObjectiveTo assess the knowledge, willingness and barriers to human papillomavirus (HPV) vaccination among caregivers of adolescent girls living with HIV in Sierra Leone. MethodsThis cross-sectional study examined HPV vaccine knowledge, willingness, and barriers among 249 caregivers of adolescent girls living with HIV in Sierra Leone. Data were collected through structured questionnaires at public tertiary hospitals and high-volume HIV clinics, and associations were assessed using chi-square tests, logistic regression, and Kruskal-Wallis analyses. ResultsOnly 32.1% (80/249) of caregivers had heard of HPV, with even fewer aware of its link to cervical cancer (24.4%, 60/246) or prevention methods of cervical cancer (31.9%, 79/248). Misconceptions were prevalent; 16.3% (36/221) erroneously linked oral contraceptives to cervical cancer, and 61.1% (44/72) of caregivers unwilling to vaccinate cited distrust in vaccine efficacy. While tertiary-educated caregivers exhibited the highest level of knowledge (45.5%, p < 0.001), their willingness to vaccinate (50%, 33/66) was comparable to that of less-educated groups, highlighting a knowledge-action gap. Structural barriers dominated, with 66.1% (154/233) citing unawareness of the vaccine and 10.3% (24/233) missing school-based vaccination days. Relationship dynamics significantly influenced willingness: extended family members showed the highest willingness (69.4%, p = 0.029), whereas grandparents were least willing (31%, 9/29). Although systemic gaps such as disrupted vaccination services, vaccine supplies and cold chain limited uptake, healthcare workers emerged as the most effective information source (rank sum = 889.5, p = 0.039). ConclusionThe study highlights the need for culturally tailored education to dispel myths and community-driven strategies engaging trusted actors like healthcare workers and extended families. This study justifies the need for integration of HPV vaccination and cervical cancer screening into HIV care services.

Aim: Brucellosis remains endemic throughout the Mediterranean basin, the Middle East and Central Asia. Genitourinary involvement is an uncommon but clinically consequential focal complication that closely mimics urological emergencies and may precipitate unnecessary surgery. Contemporary data describing its frequency, laboratory signature and treatment outcomes in endemic settings remain limited. Material-Methods: We retrospectively screened all adults ([&ge;]18 years) with confirmed brucellosis managed at a tertiary infectious diseases unit between January 2008 and December 2020. Genitourinary involvement was defined as epididymo-orchitis, orchitis, epididymitis and/or brucellar pyelonephritis. Clinical, laboratory, ultrasonographic, therapeutic and outcome variables were abstracted using a standardised form. Proportions are reported with Wilson score 95% confidence intervals (CI). Reporting followed the STROBE statement. Result: Genitourinary involvement was identified in 18 of 125 patients with brucellosis (14.4%; 95% CI 9.3-21.6); 16 (88.9%) were men and the mean age was 35.2 years (range 22-62). Scrotal disease dominated the male presentation: epididymo-orchitis in 10 of 16 men (62.5%; 95% CI 38.6-81.5), orchitis in 4 (25.0%) and epididymitis in 2 (12.5%). Both women presented with pyelonephritis, one of whom developed a tubo-ovarian abscess requiring drainage. Constitutional features were near-universal (fatigue 100%, night sweats 88.9%, fever 77.8%). Leukocyte counts remained within the reference interval in every patient (mean 5,680/mm3), whereas erythrocyte sedimentation rate (mean 32 mm/h) and C-reactive protein (mean 24.2 mg/L) were only mildly to moderately raised. The Coombs anti-Brucella test was positive in 18 of 18 patients (100%) and the standard agglutination test in 17 of 18 (94.4%), whereas blood culture yielded Brucella melitensis in only 1 of 18 (5.6%). Concomitant extragenitourinary focal disease was present in 8 patients. All patients received doxycycline plus rifampicin; none required modification of the regimen or orchiectomy, and no treatment failure occurred (0 of 18; 95% CI 0-17.6). Median follow-up was 12 weeks (range 6-52) and no relapse was documented within this interval. Conclusions: In endemic regions, genitourinary brucellosis should be suspected in any patient with acute scrotal or flank symptoms accompanied by constitutional complaints, even when the leukocyte count is normal and acute-phase reactants are only marginally elevated. Coombs anti-Brucella serology rather than blood culture is the diagnostic cornerstone, and prompt doxycycline-rifampicin therapy averts surgical intervention.

Background: In England, a national school-based human papillomavirus (HPV) vaccination programme was introduced in September 2008. Routine vaccination against HPV16/18 is offered to girls aged 12-13 and a 'catch-up' offer ran for girls aged 14-18 during the programme's first two years. Methods: Data from 19,407 women aged 25-29yrs attending cervical screening across England 2016-2025 were collected and residual samples from 4,837 high-risk (HR) HPV-screening-positive women were genotyped to monitor type-specific HR-HPV prevalence and evaluate vaccination impact. Results: Type-specific HR-HPV results were available for 3,683 HR-HPV-screen-positive samples. Estimated age-adjusted prevalence of HPV16 and HPV18 was 91% (95% confidence interval [CI]: 87-94%) and 84% (95%CI: 65-93%) lower respectively among routine-eligible women than vaccination-ineligible women. Large declines were also observed for HPV31 (85% [95%CI: 72-92%]) and HPV45 (84% [95%CI: 73-90%]) but not for other HR-HPV types. Among 618 women with cytological abnormalities, HPV16/18 was present in samples from 53.9% (95%CI: 34.8-73.1%) of vaccination-ineligible, 18.1% (95%CI: 13.5-22.7%) of catch-up-eligible, and 6.5% (95%CI: 3.6-9.3%) of routine-eligible women. Conclusions: The early years of the HPV vaccination programme in England conferred strong protection against HPV16, 18, 31 and 45, and dramatically changed the target remaining for screening strategies to detect and reduce cervical disease.

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.

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.

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 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.

Routine facility-based testing for hepatitis C virus (HCV) remains underutilised in India despite national screening policy. WHO has recommended HCV self-testing (HCVST) since 2021 to increase access to testing services. This study evaluated the HCVST by assessing its reach and uptake in urban-slum communities within Haridwar, Uttarakhand, India. The implementation study (CTRI/2023/07/054590) took place between 12th July 2023 and 31st August 2024. Three Primary Healthcare Centre (PHC) catchment areas were assigned to deliver either (1) facility-based HCVST, (2) home-based HCVST, or (3) standard of care (SoC). Facility-based delivery involved trained users offering kits to patients visiting the PHC (Site 1: Jwalapur 1), whereas home-based delivery (Site 2: Jwalapur 2) involved trained users and ASHAs approaching community households selected via a KISH grid. Primary outcomes were OPD-footfall standardized operational reach; the proportion offered testing out of the PHC catchement areas footfall, and uptake (acceptance among those offered). Secondary analysis explored demographic and behavioural predictors of those that refused to test. Of 7,091 outpatient department (OPD) footfall, 724 (10.2%) individuals were offered HCVST at intervention sites, of which 465 (64.2%) agreed to self-test. Operational reach was 17.8% (393/2,212; 95% CI: 16.2 to 19.5%) through the facility-based intervention and 14.4% (331/2,296; 95% CI: 13.0 to 15.9%) in the home-based intervention.HCVST uptake was higher through the home-based model (71.9%, 238/331, 95% CI: 66.7 to 76.7%) than in the facility (57.8%, 227/393, 95% CI: 52.7 to 62.7%). At the SoC site, only 11 individuals received standard of care HCV testing. The study HCV positivity was 1.1% (5/465; 95% CI: 0.35% to 2.49%): with four testing positive at the facility site (4/227), one at the community site (1/238), and none at the SoC site (0/11). Men were more likely to refuse HCVST than women (OR 0.54, 95% CI 0.37 to 0.78, p=0.001).Participants in the facility-based model had 1.87 times higher odds of refusal compared to those in the home-based delivery model. There is minimal routine HCV testing in the OPD setting of Urban PHCs despite national screening policy. HCVST improved testing coverage and uptake in urban slums compared to SoC. However, HCV positivity was low overall, suggesting that untargeted screening - whether facility-based or home-based - may identify few infections without additional strategies to reach higher-risk populations.

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.

Mosquito-borne orthoflaviviruses pose a significant threat to human and animal health worldwide. In Europe, West Nile (WNV), Usutu (USUV) and Bagaza (BAGV) viruses have expanded their geographic distribution and are detected with increasing frequency. Following the emergence of BAGV in 2021, we investigated the circulation dynamics and genomic diversity of orthoflaviviruses in southern Portugal, where their epidemiology remains poorly understood. Active Orthoflavivirus surveillance was conducted in birds and mosquitoes during 2021-2023 using serological and molecular assays, complemented by viral genome sequencing and phylogenomic analyses. Viral RNA was detected in 3.5% (41/1,171) of birds, while seroneutralization assays identified an overall seroprevalence of 55.3% (503/910). WNV RNA (lineage-1, strains WMed-1.2 and WMed-1.3) was detected annually in resident birds, including Alectoris rufa, Cyanopica cooki and Garrulus glandarius (1.5%, 18/1,171), and in Culex univittatus mosquitoes (0.8%, 2/255). Together with a WNV-specific seroprevalence of 28.5% (259/910) in birds, these findings support sustained local circulation. USUV RNA (Africa 3.1 sub-lineage) was detected in A. rufa in 2021 and 2023 (0.2%, 2/1,171), but seroprevalence was low (1.3%, 8/623), consistent with intermittent circulation. BAGV RNA (genotype-2) was detected only during the 2021 outbreak in A. rufa and Emberiza calandra (1.8%, 21/1,171), although BAGV-specific antibodies (6.6%, 60/910) were detected for up to two years after the outbreak, suggesting continued exposure or low-level circulation. Overall, our findings reveal contrasting circulation dynamics of orthoflaviviruses in southern Portugal. Sustained WNV circulation implies the need to strengthen avian and human surveillance in Portugal to better assess its public health risk, while the sporadic detection of USUV and BAGV underscores the value of long-term, integrated One Health surveillance for improving early warning and preparedness for emerging mosquito-borne diseases.

Introduction Vaccination against human papillomavirus (HPV) is the most effective strategy for preventing cervical cancer. We evaluated HPV Vaccine Integrated Service Implementation (HPV-VISION), a program aimed at integrating HPV vaccination with adolescent health (AH) services and the Expanded Program on Immunization (EPI) to improve vaccine uptake among girls aged 9 to 14 years in rural Ethiopia. Methods This mixed-methods implementation study was implemented in four woredas testing two models of integrating HPV vaccination into routine health services: integration with EPI and with an AH service package. We used program monitoring data; exit interviews, in-depth interviews, and focus group discussions with adolescent girls and caregivers; key informant interviews; and costing data. We analyzed effectiveness using negative binomial generalized estimating equation models with facility-level monthly HPV vaccinations as the primary outcome. We analyzed exit interview data descriptively across models. We analyzed qualitative data thematically and conducted a costing analysis. Results The HPV-VISION program delivered 25,821 HPV vaccinations from March to August 2025. Adjusting for baseline differences, facilities in the AH model delivered, on average, 34% fewer HPV vaccinations per month compared to those in the EPI model (adjusted IRR: 0.66; 95% CI: 0.51-0.87). Nearly all girls said they would be happy to receive services again at the place they were interviewed (EPI: 94%, AH: 98%). Experience of care was positive overall with individual measures varying across models. The incremental delivery cost (excluding vaccine cost) per vaccinated girl was USD $7.54 in the EPI model and USD $14.28 in the AH model. Conclusion We recommend that HPV vaccine delivery incorporates integration with AH services and routine vaccination to most efficiently reach underserved girls. An optimal mix of integration with the EPI program and AH services should be based on regional HPV vaccination indicators, other AH needs, population demographics, and costs of the models.

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.

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.

ABSTRACT Background: Trachoma remains the leading infectious cause of blindness. Over 100M people are at risk, and 1.9M already live with visual impairment or blindness. Ethiopia bears the greatest burden of disease with ~61M or 59% of the known affected global population. Although Chlamydia trachomatis (Ct) infection initiates disease, infection alone fails to explain why inflammation resolves in some but progresses to irreversible scarring and vision loss in others. Previous studies have largely examined gene expression or limited protein panels, leaving the conjunctival immune protein environment poorly characterized. We hypothesized that distinct conjunctival immune states capture these pathogenic processes and could reveal biomarkers for selecting treatment and surveillance strategies. Methods and Findings: We conducted a cross-sectional study of 667 participants residing in the hyperendemic Amhara region of Ethiopia at least one year after the most recent azithromycin mass drug administration to treat Ct. The upper tarsal conjunctivae was graded for TF and TI, trachomatous inflammation-follicular or intense, respectively; I-TS/TT, inflammation with scarring with or without trichiasis, defined as one or more eyelashes touching the globe of the eye; and TS and TT, scarring with or without trichiasis but no inflammation. T0 represented no trachoma. The protein concentrations of 41 immune mediators were quantified using Meso Scale Discovery electrochemiluminescence immunoassays. Associations with infection and grade were evaluated using covariate-adjusted models with false discovery rate correction. Bernoulli mixture modeling (BMM) revealed four distinct Immune State Types (ISTs). Both approaches supported a shared biological framework characterized by selective immune activation in Ct infection, broad inflammation in TF/TI, and chemokine remodeling versus immune quiescence in the scarred conjunctiva. Ct infection was associated with a focused IFN-{gamma}-centered response. IST1 captured this immune response where 51.9% of the participants had Ct; we therefore termed IST1 Quiescent Infection. In contrast, TF/TI was associated with higher concentrations of proinflammatory, Th1/Th17, chemokine, regulatory, and remodeling pathways mediators. This profile fit well within IST2, termed Broad Inflammation, where 72.4% of the participants had TF/TI. TS/TT retained considerable chemokine activity, whereas I-TS/TT showed a narrower, IL-17A-dominant inflammatory profile. BMM separated scarring into two states characterized by distinct profiles: IST3, Conjunctival Remodeling, with significantly stronger chemokine and T-cell maintenance signals; and IST4, Quiescent Scarring, with the majority of chemokines being significantly downregulated. This suggests that scarred conjunctiva can retain substantial immune activity or shift toward a more attenuated state. Conclusions: This study establishes the first IST framework for trachoma, revealing biologically distinct immune states with different potential clinical implications. IST1 indicates the need for antibiotic treatment, whereas IST2 suggests that novel immunotherapeutics might be effective in thwarting disease progression. The upregulated chemokines in IST3 may indicate risk of progression to TT necessitating prospective studies and potential novel antifibrotic interventions. Together, our findings provide a strong biological foundation for stratifying patients by immune state and matching them to preventive and therapeutic care. Prospective validation and streamlined biomarker panels will support the translation of this framework into field settings to help avert disease progression and blindness.

Background HPV-vaccination prevents HPV-related cancers, but uptake remains suboptimal. In the Netherlands, a catch-up campaign invited 18-27-year-olds for an additional cost-free opportunity to initiate or complete their HPV-vaccination in 2023-2024, which led to 24% of this invited population getting vaccinated. As young adults increasingly seek health information online, understanding online questions, concerns and misinformation in response to the campaign may help improve future vaccination efforts. Supplemental to overall evaluation of the vaccination campaign, we piloted online social listening processes to generate an insight report for Public Health Service (PHS) Amsterdam. Objective This study piloted online social listening processes at the PHS Amsterdam to identify actionable insights into questions, concerns and misinformation surrounding the HPV-vaccination catch-up campaign among young adults. Methods Upon inventory of potential platforms and data sources, a retrospective online social listening analysis was conducted across the platforms Instagram, Facebook, and X, collecting data from PHS, the National Public Health Institute for Public Health and the Environment (RIVM), the Dutch public broadcasting foundation (NOS), and LINDA.meiden sources from January 1, 2023, to June 1, 2024. Publicly available posts, comments, and engagement concerning HPV-vaccination were manually collected, and inductively coded. Themes were assessed for risk, based on expected potential harm and observed reach, and used to develop recommendations. Results A total of 821 posts and 5157 comments were collected and analysed. Ten recurring themes were identified across varying levels of risk. Two themes were classified as high risk: an information gap regarding the effectiveness of HPV-vaccination and concerns about the transparency on HPV-vaccine side effects. Three themes were classified as medium risk: questioning HPV-vaccine effectiveness under certain circumstances, reduced general vaccine trust following COVID-19, and accessibility issues related to vaccination locations and service times. Two themes were classified as neutral risk: questions regarding eligibility criteria for the campaign and calls for broader HIPV-prevention measures. Finally, three low risk themes concerned questions regarding HPV-vaccine brand specifics, campaign choices, and questions about scheduling or rescheduling HPV-appointments. Comments also referred to subsequent information sources, including reliable sources (public health institutes), false narratives and misinformation. Recommendations focused on addressing questions and information gaps (i.e. improving HPV risk perception and providing more detailed HPV-vaccine information), improving communication about HPV-vaccination, and reducing practical barriers to vaccination. Conclusions Manual social listening across selected online sources provided actionable insights into the public discourse during the HPV-vaccination catch-up campaign. Results mostly reflected questions, concerns and information gaps. Although some themes were critical of HPV-vaccination, false narratives and misinformation did not dominate the discourse. Recommendations aim to reduce practical barriers and address information needs. This pilot showed that online social listening can be effectively implemented even with limited resources.

Purpose: Videourodynamics (VUDS) are used to assess bladder dysfunction and risk of upper urinary tract deterioration in patients with spina bifida (SB), but interpretation is subject to interrater variability. Machine learning models have previously classified bladder dysfunction severity and predicted incident hydronephrosis using VUDS data. This study evaluated the performance of adapted versions of these models in an independent external cohort. Materials and Methods: VUDS data were collected from SB patients who underwent VUDS at a single institution between 2016 and 2025. Previously developed machine learning frameworks were adapted for implementation in the independent dataset. Three models were utilized: a deep learning convolutional neural network model using pressure-volume data, a deep learning imaging model using fluoroscopic imaging data, and an ensemble model that averaged the risk data from the pressure-volume and fluoroscopic data. The models were evaluated for prediction of incident hydronephrosis and classification of bladder dysfunction severity compared to expert pediatric urologist reviewers. Results: 70 patients were included in the hydronephrosis cohort, of whom 13 (18%) developed incident hydronephrosis. The ensemble model outperformed individual modalities, with a concordance index of 0.77 (pressure-volume only: 0.70, imaging only: 0.72) and an overall AUROC of 0.75 (pressure-volume: 0.67, imaging: 0.74). For bladder dysfunction classification in 95 VUDS studies, the ensemble model achieved 71% accuracy compared to 60% for pressure-volume data alone and 66% for imaging alone, with no substantial disagreements with expert reviewers. Conclusions: The machine learning models that were developed to predict incident hydronephrosis and classify the severity of bladder dysfunction using VUDS data were able to be adapted to an external, independent dataset and perform with similar discrimination and accuracy as previously reported.