The Lancet Global Health

BackgroundMarked declines in pediatric HIV have been achieved across sub-Saharan Africa, yet progress among adolescents remains uneven and strongly patterned by place. Drawing on place-based perspectives in health geography, we conceptualize Eastern and Southern Africa (ESA) and West and Central Africa (WCA) not merely as epidemiological regions, but as dis-tinct assemblages of health systems, gender norms, and historical investment trajectories shaping HIV risk and care. Using UNICEF-harmonized indica-tors from 2000 to 2024, we examined how place structures progress toward the 2030 Sustainable Development Goal (SDG 3.3) target. MethodsWe pooled country-level estimates using inverse-variance random-effects meta-analysis (restricted maximum likelihood for{tau} 2 with Hartung-Knapp adjustment). HIV incidence and AIDS-related mortality were analysed on the log scale, and mother-to-child transmission (MTCT) on the logit scale. Outcomes were pooled by region, age group (0-14; 15-19), sex, and year. We quantified percentage change from 2010 to 2024, the achieved annualized rate of change (ARC), and the required ARC from 2024 to 2030 to achieve a 90% reduction from 2010 levels. Robustness was assessed using prespecified sensitivity analyses. FindingsBetween 2010 and 2024, child HIV incidence declined by 72% in ESA and 66% in WCA, while adolescent incidence declined by 54% and 62%, respectively. In 2024, MTCT remained above elimination thresholds in both regions (9.9% in ESA; 17.6% in WCA). Adolescent girls experienced substantially higher HIV incidence than boys, with pooled female-to-male incidence rate ratios of 4.13 (95% CI: 3.32-5.13) in ESA and 4.92 (4.04-5.99) in WCA. Despite progress, achieved declines among adolescents (ARC: -5.4%/year in ESA; -6.6%/year in WCA) fall well short of the acceleration required to meet 2030 targets. ConclusionHIV progress among children and adolescents in sub-Saharan Africa is deeply place-dependent. While ESA reflects the benefits of earlier and sustained health system investments, persistent structural and gendered vulnerabilities continue to constrain adolescent outcomes, particularly in WCA. Achieving SDG 3.3 will require place-responsive strategies that integrate gender-sensitive adolescent prevention, differentiated care, and strengthened PMTCT within the specific social, political, and health system contexts shaping risk and access. HighlightsO_LIHIV declines among children and adolescents show strong place-based patterning. C_LIO_LIChild HIV incidence declined faster in ESA than in WCA, 2010-2024. C_LIO_LIAdolescent girls had four- to five-fold higher HIV incidence than boys. C_LIO_LIMTCT remains above elimination thresholds, especially in West and Central Africa. C_LIO_LIMeeting 2030 targets requires accelerated, place-responsive strategies. C_LI

BackgroundGlobal investments to combat HIV, tuberculosis, and malaria (HTM) have delivered substantial health gains, and may have reduced the burden placed by these diseases on the routine health system. We estimated the reduction in primary health care (PHC) utilization resulting from the scale-up of HTM services over 2000-2023 in 108 low- and middle-income countries. MethodsFor each disease, we applied established mathematical models to quantify PHC utilization (outpatient visits and inpatient bed-days provided outside of HTM programs) by individuals with symptomatic HIV, tuberculosis, or malaria unable to access HTM-specific services. For each country, we estimated averted PHC utilization by comparing a scenario describing the actual scale-up of HTM services to a counterfactual scenario holding HTM service coverage constant at year 2000 levels. We applied published unit costs to estimate the averted costs resulting from reduced PHC utilization. FindingsOver 2000-2023, scale-up of HTM services averted an estimated 6{middle dot}9 (95% interval: 4{middle dot}4-10{middle dot}4) billion outpatient PHC visits and 3{middle dot}9 (2{middle dot}5-6{middle dot}1) billion inpatient bed-days, representing US$135 (70-248) billion in averted costs. These reductions were greatest in Sub-Saharan Africa and East Asia and Pacific regions. Across study countries, these reductions represented a median of 4{middle dot}4% of hospital bed capacity and 1{middle dot}6% of government health spending in 2023. These percentages were 22{middle dot}9% and 5{middle dot}1% respectively for low-income countries. InterpretationOver recent decades, sustained investments in HTM services in high-burden settings have averted substantial PHC utilization and associated costs. These benefits should be considered when assessing investment impact. FundingThe Global Fund.

BackgroundIn sub-Saharan Africa (sSA), invasive antimicrobial-resistant infections often originate from community-level acquisition. We assessed whether a behavioural intervention bundle targeting sub-optimal antibiotic use and hygiene practices reduced household-level acquisition of extended-spectrum beta-lactamase-producing E. coli (ESBL-E). MethodsWe conducted a cluster-randomised controlled trial in 22 village clusters in Nanoro district, Burkina Faso. We enrolled 12 randomly selected households per cluster to assess intervention impact on ESBL-E household-transmission. The intervention comprised three rounds at three-month intervals and combined WHO AWaRe-based educational feedback for formal and informal medicine providers with a community-wide WASH and antibiotic-use behaviour change campaign. Consenting household members provided stool samples before, during, and after intervention rollout, alongside a pre-post household WASH survey. We estimated intervention effects on ESBL-E acquisition using Bayesian Markov models. Cox frailty models assessed associations between WASH exposures and acquisition. ClinicalTrials.gov, NCT05378880. FindingsBetween Oct 11, 2022, and Feb 19, 2024, 1203 individuals were enrolled. At baseline, 57{middle dot}3% (346/604) of control and 48{middle dot}6% (291/599) of intervention household members were colonised. Pre-intervention acquisition incidence was 3{middle dot}8 per 100 person-days (95% credible interval [CrI] 2{middle dot}0-9{middle dot}9) in the intervention group and 3{middle dot}5 (95% CrI 1{middle dot}8-9{middle dot}6) in the control group. The intervention did not change the risk of ESBL-E acquisition in months 1-6 (hazard ratio [HR] 1{middle dot}02, 95% CrI 0{middle dot}78-1{middle dot}31), while we estimated a reduction in ESBL-E acquisition from months 6-9 (HR 0{middle dot}82, 95% CrI 0{middle dot}56-1{middle dot}14). Acquisition risk was higher in the rainy season (peak HR 1{middle dot}73, 95% CI 1{middle dot}49-2{middle dot}00), while improved sanitation was associated with lower risk (HR 0{middle dot}77, 95% CI 0{middle dot}59-1{middle dot}00). InterpretationFindings, though inconclusive, were consistent with a modest intervention-related reduction in ESBL-E incidence. Higher acquisition rates associated with the rainy season and poor sanitation highlight the need to tackle environmental drivers of AMR transmission in addition to antibiotic use in rural sSA. FundingJPI-AMR CABU EICO grant number: JPIAMR2021-053 Research in contextO_ST_ABSEvidence before this studyC_ST_ABSA systematic review of antimicrobial stewardship interventions in both community and hospital-settings published in 2019 found that only 23% (190/825) reported microbiological outcomes, underscoring a lack of evidence on how stewardship interventions affect antimicrobial resistance (AMR). Since then, this gap remains, and particularly for sub-Saharan Africa (sSA). Here, invasive AMR infections are frequently community-associated, with household transmission considered a dominant pathway for community-level AMR acquisition. Two systematic reviews on community level transmission of AMR bacteria, including one published in 2025, reported ESBL-E acquisition rates of 0{middle dot}17-0{middle dot}29 per 100 person-days, with half of individuals clearing their colonisation within 3-4 months. However, all of the included 11 studies were from high-income contexts. The Drivers of Resistance in Uganda and Malawi (DRUM) study provided important One Health insights into human, animal, and environmental reservoirs of ESBL-E and Klebsiella pneumoniae, and found high ESBL-E prevalences up to 60%. This study however, was observational and did not evaluate interventions, and to date, has not quantified community-level transmission. The published community-level interventions in sSA have largely focused on formal healthcare providers or prescribers to reduce sub optimal antibiotic use. A recent scoping review identified only seven intervention studies targeting general communities in sSA, highlighting a lack of rigorous evaluations of community-centred stewardship and AMR mitigation efforts more broadly and outside formal healthcare settings. None of these studies measured microbiological outcomes or effects on community transmission of resistant bacteria. Added value of this studyThe CABU-EICO trial is, to our knowledge, the first cluster-randomised AMR intervention in a rural, low-income setting to quantify the effects of an intervention targeting both providers and communities on community-level ESBL-E transmission-dynamics. Using repeated stool sampling from household members and a continuous-time multi-state modelling framework, we estimated household-level ESBL-E acquisition and duration of colonisation, and found evidence for a reduction in ESBL-E transmission following the intervention. Additionally, we quantified seasonal patterns in the risk of ESBL-E acquisition in our West African setting, showing a peak during the rainy season, despite reportedly lower antibiotic use during this time of year. By moving beyond prevalence-based outcomes and antibiotic-use metrics alone, our intervention evaluation provides a statistically more efficient and mechanistically informative framework for evaluating AMR interventions. Implications of all the available evidenceThis study shows that household-level transmission of ESBL-E is substantial in rural sSA and markedly higher than estimates from high-income settings, with clear seasonal peaks during the rainy season and increased risk associated with poor sanitation. Together with recent One Health genomic evidence demonstrating frequent transmission between humans, animals and the environment in Eastern Africa, these findings suggest that community-level AMR dynamics are driven by both antibiotic selection pressure and environmental exposure pathways. Effective AMR control in similar settings will therefore require, similar to our approach, integrated One Health strategies that combine antibiotic stewardship, with structural and environmental interventions, and that incorporate transmission as well as acquisition outcomes to fully capture intervention impact.

BackgroundPhysical distancing measures that reduce social contacts have formed a key part of national COVID-19 containment and mitigation strategies. Many Sub-Saharan African nations are now facing increasing numbers of cases of COVID-19 and there is a need to understand what levels of measures may be required to successfully reduce transmission. MethodsWe collated epidemiological data along with information on key COVID-19 specific response policies and health system capacity estimates for services needed to treat COVID-19 patients in Senegal. We calibrated an age-structured SEIR model to these data to capture transmission dynamics accounting for demography, contact patterns, hospital capacity and disease severity. We simulated the impact of mitigation and suppression strategies focussed on reducing social contact rates. ResultsSenegal acted promptly to contain the spread of SARS-CoV-2 and as a result has reduced the reproduction number from 1.9 (95% CI 1.7-2.2) to 1.3 (95% CI 1.2-1.5), which has slowed but not fully interrupted transmission. We estimate that continued spread is likely to peak in October, and to overwhelm the healthcare system with an estimated 77,400 deaths (95% CI 55,270-100,700). Further reductions in contact rates to suppress transmission (Rt<1) could significantly reduce this burden on healthcare services and improve overall health outcomes. ConclusionsOur results demonstrate that Senegal has already significantly reduced transmission. Enhanced physical distancing measures and rapid scale up of hospital capacity is likely to be needed to reduce mortality and protect healthcare infrastructure from high levels of demand.

IntroductionChildren experience elevated risks of developing and dying from tuberculosis (TB). We estimated the additional pediatric TB cases and deaths that could occur over 2025-2034 if programmes supported by United States bilateral health aid and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) are discontinued. MethodsWe collated data on funding sources for TB and HIV programs in low- and middle-income countries and constructed scenarios representing reductions in health aid from 2025. Using calibrated transmission-dynamic models for 130 countries, we projected the discontinuation of TB and HIV treatment services under several funding reduction scenarios, and how this would affect pediatric TB exposure and treatment access. We projected pediatric TB incidence and mortality over 2025-2034 to calculate the impact of funding reductions. ResultsCompared to maintenance of pre-2025 service levels, withdrawal of services currently supported by US bilateral health aid was projected to result in an additional 2.5 million (95% uncertainty interval: 1.8-3.3) pediatric TB cases and 340,000 (240,000-460,000) deaths over 2025-2034. Withdrawal of US support to the Global Fund and reduction in non-US contributions was projected to result in an additional million 8.9 (6.9-11.5) pediatric TB cases and 1.5 million (1.1-2.0) deaths, more than double the number expected with continued service levels. Impacts were greatest in Sub-Saharan Africa and South-East Asia. Restoration of services in 2026 led to a substantially smaller number of additional deaths. FindingsWithout actions to restore discontinued services, cuts to health aid for TB and HIV programs could result in large numbers of childhood TB deaths over the next decade.

BackgroundRecent shifts in the global health funding landscape--most notably the dismantling of the United States Agency for International Development (USAID) and possible reduced contributions to the Global Fund to Fight AIDS, TB and Malaria (Global Fund)-- threaten essential tuberculosis (TB) services in low- and middle-income countries (LMICs). We quantified the potential impact on the household economic burden of TB. MethodsWe used linked epidemiological and economic models, calibrated to 79 LMICs, to estimate future TB patient costs under four scenarios: continuation of 2024 funding levels (baseline), termination of USAID, termination of USAID plus announced reductions in Global Fund contributions, and full elimination of external funding for TB. Outcomes included total TB-attributable household costs and numbers of households experiencing catastrophic costs (disease-related costs >20% of annual income). FindingsUSAID termination was projected to produce US$7.5 (95% uncertainty interval: $6.1-8.9) billion in additional patient-incurred costs and 3.9 (3.1-4.6) million additional households experiencing catastrophic costs over 2025-2050. The worst-case scenario (elimination of all external funding) resulted in $79.7 ($60.0-99.2) billion in additional patient-incurred costs and 40.5 (30.9-50.7) million additional households experiencing catastrophic costs--a 32% increase over baseline. Impacts were greatest for poorer households, with over 50% of additional catastrophic costs occurring in the poorest 20% of households. InterpretationAbrupt reductions in international donor funding for TB may reverse recent progress toward financial risk protection and health equity in LMICs. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSSeveral prior studies have examined the potential impact of cuts in international health funding from the United States of America. We searched PubMed and medRxiv for studies quantifying the effects of reductions in international donor funding on the economic burden of tuberculosis, published between January 1 and August 7, 2025, using search terms related to funding ("funding", "donor", "aid", "assistance"), tuberculosis ("tuberculosis", "TB"), patients or households (patient*, household*), and economic burden (cost*, econ*). The identified studies described a range of potential health consequences that could result from funding cuts. To our knowledge, no studies have considered the impact of funding cuts on the household economic burden of disease. Added value of this studyOur modelling suggested that termination of United States Agency for International Development (USAID) funding could lead to US$7.5 (95% uncertainty interval: $6.1-8.9) billion in additional patient-incurred costs and 3.9 (3.1-4.6) million additional households experiencing catastrophic costs over 2025-2050. Further reductions in funding to the Global Fund to Fight AIDS, TB and Malaria (Global Fund) in line with current announcements from donor countries could lead to a further $21.2 ($16.6-25.6) billion in patient-incurred costs and 10.7 (8.4-13.0) million households experiencing catastrophic costs. If all external TB funding were terminated, a projected $72.2 ($53.9-90.4) billion in patient-incurred costs could accrue and 36.6 (27.7-46.1) million households could experience catastrophic costs, compared with the impact of the funding cuts to USAID alone. Implications of all the available evidenceDisruptions to TB services resulting from reductions in international donor funding could result in increased tuberculosis-associated morbidity and mortality, which in turn could result in increased economic burden on resource-constrained households in the worlds poorest countries. Strategies to reduce the disruption caused by funding cuts and protect vulnerable populations are urgently needed.

BackgroundThe epidemiology of COVID-19 remains speculative in Africa. To the best of our knowledge, no study, using robust methodology provides its trajectory for the region or accounts for local context. This paper is the first systematic attempt to provide prevalence, incidence, and mortality estimates across Africa. MethodsCaseloads and incidence forecasts are from a co-variate-based instrumental variable regression model. Fatality rates from Italy and China were applied to generate mortality estimates after making relevant health system and population-level characteristics related adjustments between each of the African countries. ResultsBy June 30 2020, around 16.3 million people in Africa will contract COVID-19 (95% CI 718,403 to 98,358,799). Northern and Eastern Africa will be the most and least affected areas. Cumulative cases by June 30 are expected to reach around 2.9 million (95% CI 465,028 to 18,286,358) in Southern Africa, 2.8 million (95% CI 517,489 to 15,056,314) in Western Africa, and 1.2 million (95% CI 229,111 to 6,138,692) in Central Africa. Incidence for the month of April 2020 is expected to be highest in Djibouti, 32.8 per 1000 (95% CI 6.25 to 171.77), while Morocco will experience among the highest fatalities (1,045 deaths, 95% CI 167 to 6,547). ConclusionLess urbanized countries with low levels of socio-economic development (hence least connected to the world), are likely to register lower and slower transmissions at the early stages of an epidemic. However, the same enabling factors that worked for their benefit can hinder interventions that have lessened the impact of COVID-19 elsewhere.

Liver cirrhosis and chronic liver diseases impose a substantial and growing health burden globally, with sub-Saharan Africa (SSA) disproportionately affected. Leveraging Global Burden of Disease 2021 data and Bayesian hierarchical models, we quantified mortality and disability trends in SSA from 1990 to 2021 and projected disease burden through 2035, incorporating scenarios for hepatitis B vaccination scale-up. In 2021, liver cirrhosis accounted for an estimated 181,311 deaths in SSA, despite a 29% decline in age-standardized death rates (ASDR) since 1990. Absolute deaths increased by 65%, predominantly driven by hepatitis B (37%), hepatitis C (28%), and alcohol-related cirrhosis (17%). Disability-adjusted life years (DALYs) surged by 76%, from approximately 1.05 million in 1990 to 1.85 million in 2021, highlighting rising absolute disability alongside a 29% reduction in age-standardized DALYs. Mortality and disability burdens were highest in Somalia, Central African Republic, and Guinea-Bissau. Males bore nearly twice the burden of females. While death rates declined across all socio-demographic strata, absolute deaths rose by 55-86%. Projections to 2035 suggest further potential reductions in mortality from hepatitis B (up to 21.5%), hepatitis C (up to 18.7%), and alcohol-related cirrhosis, while the burden of non-alcoholic fatty liver disease is expected to remain stable or increase slightly. Scaling up hepatitis B vaccination could further avert 27% of related deaths by 2035. These findings reveal persistent and widening disparities in cirrhosis burden across SSA, underscoring the urgent need for integrated, context-specific interventions combining viral hepatitis control with metabolic liver disease management to improve equitable liver health outcomes.

BackgroundReductions in United States (US) funding for tuberculosis (TB) and HIV programmes have raised concerns and challenges for TB care and management in South Africa and globally. We used mathematical modelling to illustrate the potential impact of unmitigated funding disruptions, estimating long-term effects on TB incidence and mortality over 2025-2035. MethodsStakeholder-informed scenarios were modelled, assuming both minimal and maximal disruptions to key TB and HIV services, including preventive therapy for people living with HIV (PLHIV), TB testing, TB treatment initiation, and antiretroviral therapy (ART) coverage. Results and discussionBetween 2025 and 2035, reduced ART coverage was projected to result in 235,000-1,000,000 additional HIV infections; and a 12-41% increase in TB episodes, and 21-72% rise in TB deaths among people living with HIV. Overall, 220,000-730,000 additional TB episodes and 67,000-225,000 TB deaths are anticipated, potentially reversing years of progress. Although mitigation efforts were not included in the model, early responses in South Africa have involved increased diagnostic testing and additional domestic funding. To maintain progress in TB and HIV control, rapid and sustained programmatic responses and funding are essential to prevent substantial setbacks and avert avoidable illness and death.

BackgroundHIV incidence in sub-Saharan Africa has declined substantially since 2000 according to epidemic estimates published by UNAIDS. These estimates, derived by fitting mathematical models to national surveillance data, guide HIV programmes and epidemic response strategies. We assessed whether the level and age distribution of HIV incidence from modelled estimates were consistent with empirical HIV incidence observations, and whether incidence levels and trends were systematically different between study types, populations, and age groups. MethodsWe conducted an updated systematic review of adult HIV incidence data from sub-Saharan Africa published July 2019-February 2024 by searching Scopus, PubMed, Embase, and OVID databases, and combined with earlier systematic review data. We matched empirical incidence measurements between 1990-2023 to UNAIDS HIV incidence estimates by study area, sex, age group, and year. We used Bayesian mixed-effect Poisson regression to estimate (1) incidence rate ratios (IRR) between empirical observations and matched modelled incidence estimates adjusted for sex, year and study type/population; and (2) time trends in age-specific incidence from population-based cohort studies and household surveys. Results3560 HIV empirical incidence measurements were included from 179 studies conducted in 21 countries, comprising 23,000 new infections and 3.1 million person-years. Incidence observations from nationally-representative household surveys (IRR 1.07 95%CI 0.68, 1.67) and population-representative study populations (IRR 0.98 95%CI 0.51, 1.89) were not significantly different from matched modelled estimates, and declined at the same rate as modelled estimates (annual aRR 0.99 95%CI 0.98, 1.01). Studies among pregnant women (IRR 2.60 95%CI 1.58, 4.28), control arms of clinical trials (IRR 3.01 95%CI 1.90, 4.77) and key populations (FSW IRR: 6.46 95%CI 4.18, 10.00; MSM 44.02 95%CI 27.35, 70.87) had significantly higher incidence than modelled total population incidence estimates. Across population cohorts in Eastern and Southern Africa, HIV incidence among adults aged 15-49 declined by 75-90% between 2010-2023, and declined 7% (95%CI 4-10%) faster per year among young adults 15-24 compared to age 25+ years. Modelled incidence declined similarly to cohort data, but did not reflect the aging of the epidemic. ConclusionObserved incidence in population-representative studies in sub-Saharan Africa has declined steeply. Mathematical models that infer incidence from cross-sectional HIV surveillance data estimated the same incidence level and decline over time as population-representative studies. Studies with non-representative inclusion criteria had significantly higher incidence, including those among pregnant women and most HIV prevention/vaccine efficacy trials. The age pattern of incidence in modelled estimates should be reconsidered to capture the aging of the epidemic indicated by cohort studies.

BackgroundTuberculosis services in many settings rely heavily on international donor funding. In 2025, the United States Agency for International Development (USAID) was dismantled, and other countries also announced cuts to overseas development assistance. We quantified potential epidemiological impacts attributable to these reductions in international donor funding. MethodsWe calibrated a deterministic tuberculosis model to epidemiological indicators in low- and middle-income countries. We projected three future scenarios assuming: a) levels of funding in 2024 continue through 2035, b) termination of USAID funding from 2025, and c) additional reductions in funding through The Global Fund in line with current donor announcements from 2025. We assumed a reduction in tuberculosis treatment initiation rates proportional to budget reductions for each scenario, estimating cumulative excess incident episodes of symptomatic tuberculosis and tuberculosis deaths. FindingsWe modelled 79 countries, representing 91% of global tuberculosis incidence and 90% of global tuberculosis mortality in 2023. Our modelling suggested that the termination of USAID funding may lead to 420 500 excess tuberculosis deaths by 2035. Further reductions in funding in line with current announcements by the United States, France, the United Kingdom, and Germany may lead to an additional 699 200, 63 100, 50 500, and 30 500 TB deaths, respectively. Impacts would be greatest in low-income countries. InterpretationWe estimate substantial potential impacts on tuberculosis morbidity and mortality due to reductions in international donor funding. Expanded support from domestic and international donors is essential to address immediate gaps in prevention, diagnosis, and treatment. FundingThis work was unfunded.

BackgroundTuberculosis (TB) and human immunodeficiency virus (HIV) are leading causes of infectious disease deaths, with disproportionate impact in low- and middle-income countries (LMICs). Despite well-established biological relationships between these diseases, there is limited information on how TB prevalence differs between people living with and without HIV. MethodsWe conducted a systematic review and meta-analysis of TB prevalence surveys conducted in LMICs and published during January 1st 1993-October 13th 2025 (PROSPERO CRD42024503853). We extracted bacteriologically-confirmed TB prevalence estimates stratified by participant HIV status. Surveys that offered HIV testing to all, sputum-collection-eligible, or TB-positive participants were included in the primary analysis. We applied Bayesian meta-regression to estimate pooled risk ratios (RR) of bacteriologically-confirmed TB prevalence among participants living with versus without HIV. Additionally, we estimated country-level and overall TB notification-to-prevalence (N:P) ratios by HIV status. FindingsOf 10,211 potentially relevant publications, 12 TB prevalence surveys--representing 264,530 participants within nine countries in Southern and Eastern Africa--were used in the primary analysis. Reported TB prevalence was higher among participants living with versus without HIV in 11/12 surveys, with an overall pooled RR of 3{middle dot}86 (95% credible interval: 2{middle dot}41-5{middle dot}53). N:P ratios were higher among participants living with HIV in all examined countries. The overall pooled N:P ratios were 1{middle dot}74 (0{middle dot}59-4{middle dot}56) and 0{middle dot}48 (0{middle dot}17-1{middle dot}20) among participants living with versus without HIV, respectively. InterpretationIn Southern and Eastern Africa, bacteriologically-confirmed TB prevalence is three- to six-times higher among people living with HIV. Comparison of prevalence and notification data suggest higher rates of TB diagnosis for people living with versus without HIV, but also indicates substantial delays in the detection of untreated TB cases for both populations. FundingWellcome Trust, UK National Institute for Health and Care Research, UK Foreign, Commonwealth and Development Office, NIH. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSThere is limited systematic evidence on how the prevalence of TB disease differs between people living with HIV and without HIV. Multiple observational cohorts have described substantially elevated TB incidence among populations with HIV, but disease prevalence will also be affected by differences in mortality and treatment uptake rates. We searched PubMed from inception through January 21, 2026 using the search string ((HIV AND TB) OR HIV/TB) AND (prevalence AND (systematic review OR meta-analysis)) without any restrictions on language. We also reviewed investigators personal libraries. This search yielded 506 publications; however few of these included prevalence data. An analysis conducted in 2020 synthesized HIV status-stratified data from seven national TB prevalence surveys in Africa and found that HIV prevalence was lower among prevalent TB cases than among notified cases. This study did not include subnational surveys and did not distinguish between survey participants with self-reported or test-confirmed HIV status. Added value of this studyThis study synthesized TB prevalence data, stratified by participant HIV status, from national and subnational surveys conducted in LMICs and published between January 1st 1993 and October 13th, 2025. Collated data represented 681,402 survey participants across ten countries. All but one study were conducted in Southern and Eastern Africa. We limited our primary analysis to surveys that systematically tested participants for HIV and bacteriologically-confirmed TB. The prevalence of bacteriologically-confirmed TB was estimated to be three to six times higher than among people living with versus without HIV. Ratios of TB notifications to TB prevalence were higher for people living with HIV compared to people without HIV, suggesting higher rates of TB case detection (and likely shorter duration of disease) for people living with HIV and untreated TB than those without HIV. Implications of all available evidenceFew estimates of community-representative TB prevalence stratified by participant HIV status exist. These surveys have been concentrated in Southern and Eastern Africa, despite TB-HIV burden being distributed globally. Our findings highlight the elevated burden of TB among people living with HIV in these settings, as well as the limited data on the intersection of TB and HIV epidemiology in other world regions. Furthermore, our comparison of notification and prevalence data demonstrate substantial shortfalls in TB case detection, regardless of an individuals HIV status.

BackgroundThe effect of HIV co-infection on COVID-19 outcomes in sub-Saharan Africa is unknown. MethodsWe conducted a population cohort study using linked data from adults attending public sector health facilities in the Western Cape, South Africa. We used Cox-proportional hazards models adjusted for age, sex, location and comorbidities to examine the association between HIV and COVID-19 death among (i) public sector "active patients" ([&ge;]1 health visit in the 3 years before March 2020), (ii) laboratory-diagnosed COVID-19 cases and (iii) hospitalized COVID-19 cases. COVID-19 was diagnosed with SARS-CoV-2 PCR tests. We calculated the standardized mortality ratio (SMR) for COVID-19 comparing HIV positive vs. negative adults using modelled population estimates. ResultsAmong 3,460,932 public sector patients (16% HIV positive), 22,308 were diagnosed with COVID-19, of whom 625 died. In adjusted analysis, HIV increased risk of COVID-19 mortality (adjusted hazard ratio [aHR]:2.14; 95% confidence interval [CI]:1.70; 2.70), with similar risks across strata of viral load and immunosuppression. increased HIV-associated risk of COVID-19 death remained when restricting to COVID-19 cases (aHR:1.70; 95%CI:132; 2.18) or hospitalized cases (aHR:1.45; 95%CI:1.14; 1.84). Current and previous tuberculosis also increased COVID-19 mortality risk (aHR [95%CI]:2.70 [1.81; 4.04] and 1.51 [1.18; 1.93] respectively). The SMR for COVID-19 death associated with HIV was 2.39 (95% CI:1.96; 2.86); population attributable fraction 8.5% (95%CI:6.1; 11.1). ConclusionHIV was associated with a doubling of COVID-19 mortality risk. While our findings may over-estimate the HIV-associated risk COVID-19 death due to residual confounding, people with HIV should be considered a high-risk group for COVID-19 management.

BackgroundUntreated pulmonary tuberculosis (TB) causes ongoing lung damage, which may persist after treatment. Conventional approaches for assessing TB health effects may not fully capture these mechanisms. We evaluated how TB-associated lung damage and post-TB sequalae affect the lifetime health consequences of TB in high HIV prevalence settings. MethodsWe developed a microsimulation model representing dynamic changes in lung function for individuals evaluated for TB in routine clinical settings. We parameterized the model with data for Uganda, Kenya, and South Africa, and estimated lifetime health outcomes under prompt, delayed, and no TB treatment scenarios. We compared results to earlier modelling approaches that omit progressive lung damage and post-TB sequelae. FindingsWe estimated 4.6 (95% uncertainty interval 3.4-5.8), 7.2 (5.1-9.6), and 18.0 (15.1-20.0) year reductions in life expectancy due to TB under prompt, delayed, and no treatment scenarios, respectively. Disability-adjusted life years (DALYs) from TB were estimated as 8.3 (6.2-10.6), 12.6 (9.0-17.0), and 27.8 (24.1-30.6) under prompt, delayed, and no treatment scenarios, respectively. Post-TB DALYs represented 9-53% of total DALYs. Modelling approaches that omit progressive lung damage and post-TB sequelae underestimated lifetime health losses of TB by 48-57%, and underestimated the benefits of prompt treatment by 45-64%. InterpretationDelayed initiation of TB treatment causes greater lung damage and higher mortality risks during and after the disease episode. In settings with co-prevalent TB and HIV, accounting for these factors substantially increased estimates of the lifetime disease burden and life expectancy loss caused by TB. FundingNIH. Research in context Evidence before this studyResearch on long-term sequalae among tuberculosis (TB) survivors has focused on describing the prevalence and nature of these post-TB sequalae, and quantifying their contribution to the overall burden of TB disease. There is limited evidence describing how improvements in TB diagnosis and prompt treatment initiation could affect the overall health losses associated with TB, inclusive of post-TB sequelae. We searched PubMed from database inception until July 19, 2024, with no language restrictions for studies reporting how TB diagnosis and treatment affect post-TB sequelae and lifetime health losses, using the search terms "(tuberculosis OR TB) AND (post-TB OR post-tuberculosis) AND (diagnos*) AND (treat*) AND (model*)". We retrieved 21 publications based on this search. Of these, one study reported a mathematical modeling approach for estimating lifetime health outcomes and costs by considering the delay in diagnosis, post-TB sequelae, and treatment discontinuation among TB patients in Brazil, but did not simulate changes in lung function during the TB episode. Added value of this studyTo our knowledge, this is the first study to investigate the effects of timeliness of TB diagnosis on progressive lung damage and lifetime health outcomes for individuals with TB. To do so, we constructed a mathematical model simulating changes in lung function before, during, and after TB treatment, and simulated multiple counterfactual scenarios for a cohort of individuals presenting to primary health services with undiagnosed TB disease in Uganda, Kenya, and South Africa. We compared the results of this analysis to the estimates produced by earlier modelling approaches that do not represent TB-associated lung damage or post-TB sequelae. Implications of all the available evidenceThe results of this analysis showed that post-TB sequelae represent a substantial share of the overall health losses associated with TB, and that better post-TB lung function (resulting from a shorter duration of untreated TB disease) is a major contributor to the overall health benefits of prompt TB diagnosis and treatment. These results are not accurately captured by earlier modelling approaches that did not consider TB-associated lung damage or post-TB sequelae. The findings of this analysis contribute to the evidence base describing how TB interventions can influence lung function dynamics during and after TB disease, and the resulting changes in disability and mortality due to TB.

BackgroundMen in sub-Saharan Africa (SSA) continue to have worse health outcomes across HIV, STI, and TB-HIV co-infections as compared to women. Improving service coverage is critical for population health and HIV epidemic control. In HIV, for example, recent models show that improving mens HIV testing and treatment coverage could reduce HIV incidence among women in the region by half. There is potential to combine and optimize services across HIV, STI and TB-HIV co-infections, yet little is known about effective interventions to improve mens outcomes across health services. MethodsWe conducted a scoping review of interventions to understand what interventions work for men, and any synergies in interventions that work across health services. We specifically focused on interventions aimed to improve service utilization in the following service domains: condom use; pre-exposure prophylaxis (PrEP); STI testing and treatment; HIV testing, initiation, and retention; and TB testing and treatment among those living with HIV (co-infected). Articles and abstracts had to include sex-disaggregated data or solely focus on mens health service outcomes. We searched PubMed, Medline, Cochrane Central Register of Controlled Trials, the CABI Global Health databases, and major international conference abstracts. We included studies from SSA, published between January 1, 2009 to Dec 31, 2022, quantitative data on at least one of the selected service domains, disaggregated data for the general male population (not solely key populations), an intervention study (report outcomes for at least one non-standard service delivery strategy) with a comparison group, and available in English. We describe the type of interventions evaluated and synthesize overarching themes of "what works" for reaching men. FindingsWe identified 15,595 intervention articles and included 71 in the scoping review, representing 111 unique interventions. Over a quarter of interventions targeted male partners and only 7 exclusively targeted men. Nearly half of the interventions had HIV testing as their primary outcome. Only a handful of interventions included outcomes related to condom use, STI, or TB co-infection services. No interventions examined the effect of PrEP use among general male populations. Community services was the most common intervention type (n=40, 36%), followed by community outreach (n=19; 17%), incentives (n=16; 14%) and facility services (n=16, 14%). Counseling and peer support had the least number of interventions evaluated (n=8, 7%). We were unable to identify cross-cutting strategies to reach men across HIV and related health services in sub-Saharan Africa, largely because there is little evidence outside HIV testing interventions. The limited evidence available points to the fact that men need convenient, active outreach, and improved experiences with health services. The same principles may apply to all services intended to reach men, including sexual health and TB co-infection services, although the evidence is limited. ConclusionThis review highlights the need for additional research on cross-cutting strategies to improve mens engagement in HIV and related health services. The limited evidence available suggests that convenient services, actively engaging men, and providing positive experiences with health services largely improve service utilization. Additional evidence is needed for PrEP use and non-HIV services (such as STI and TB co-infection).

BackgroundMalawi is rapidly closing the gap in achieving the UNAIDS 95-95-95 targets, with 90% of people living with HIV in Malawi aware of their status. As we approach epidemic control, interventions to improve coverage will become more costly. There is therefore an urgent need to identify innovative and low-cost strategies to maintain and increase testing coverage without diverting resources from other HIV services. MethodsA data-driven individual-based model was parameterized with data from a community-representative survey (sociodemographic, health service utilization, HIV testing history) of men and youth in Malawi (data collected 08/2019). 79 different strategies for the implementation of HIV self-testing (HIVST) and provider-initiated-testing-and-counselling at the outpatient department (OPD) were evaluated. Outcomes included percent of men/youth tested for HIV in a 12-month period, cost-effectiveness, and human resource requirements. Testing yield was assumed to be constant across the scenarios. FindingsFacility-based HIVST offered year-round resulted in the greatest increase in proportion of men and youth tested in the OPD (from 45% to 72%-83%), was considered cost-saving for HIVST kit priced at $1.00, and generally reduced required personnel as compared to the status quo. At higher HIVST kit prices, and more relaxed eligibility criteria, all scenarios that considered year-round HIVST in the OPD remained on the cost-effectiveness frontier. InterpretationFacility-based HIVST is a cost-effective strategy to increase the proportion of men/youth tested for HIV and decreases the human resource requirements for HIV testing in the OPD-providing additional health care worker time for other priority health care activities. FundingFCDO; USAID

BackgroundThe World Health Organization declared a global cholera emergency in 2023 due to an increase in cholera outbreaks, with most cholera-associated deaths reported in Africa. Characterizing large-scale burden patterns can help with monitoring progress in cholera control and targeting interventions. MethodsWe modeled the mean annual incidence of suspected cholera for 2011-2015 and 2016-2020 on a 20 km by 20 km grid across Africa using a global cholera database and spatial statistical models. We then examined how 2011-2020 incidence is associated with post-2020 cholera occurrence and investigated the potential reach of prospective interventions when prioritized by past incidence. FindingsAcross 43 African countries mean annual incidence rates remained steady at 11 cases per 100,000 population through both periods. Cholera incidence shifted from Western to Eastern Africa, and we estimated 125,701 cases annually (95% CrI: 124,737-126,717) in 2016-2020. There were 296 million (95% CrI: 282-312 million) people living in high-incidence second-level administrative (ADM2) units ([&ge;] 10 cases per 100,000 per year) in 2020, of which 135 million experienced low incidence (<1 per 100,000) in 2011-2015. ADM2 units with sustained high incidence in Central and Eastern Africa from 2011-2020 were more likely to report cholera in 2022-2023, but cases were also reported in sustained low ADM2 units. Targeting the 100 million highest burden populations had potential to reach up to 63% of 2016-2020 mean annual cases but only 37% when targeting according to past 2011-2015 incidence. InterpretationBy revealing the changing spatial epidemiology of cholera in Africa, these 10-year subnational estimates may be used to project OCV demand, characterize the potential of targeting interventions based on past burden, and track progress towards disease control goals.

BackgroundIn sub-Saharan Africa (SSA), institutional births have risen rapidly but mortality has remained high. We examined whether there have been increasing births at hospitals, with skilled attendance, and emergency capacity as indicators of comprehensive, higher-quality childbirth services in 21 SSA countries over the last two decades. MethodsWe analysed national household surveys between 2001 and 2022 to examine population trends in birth place (hospital or lower-level), attendant, and Caesarean Section (CS) rates by wealth quintile, and routine health facility data for 2022 on volumes of live births and CS by facility level. Countries were classified based on recent institutional delivery coverage (<65%, 65-85%, >85%), to assess patterns of change and future directions in line with a maternal and neonatal mortality transition model. ResultsInstitutional delivery increases were primarily driven by lower-level facilities, which had low birth volumes and limited CS capacity. Yet countries that reached high delivery coverage saw greater gains in hospital births, attendance by doctors, and CS rates among the poorest. As national coverage rose, more deliveries were conducted at higher-volume CS-capable hospitals. Low population CS rates among the poorest persisted everywhere. ConclusionMajor increases in institutional deliveries have not sufficiently translated into equitable access to comprehensive, life-saving childbirth care in 21 countries of SSA. Shifts towards hospital deliveries in countries that reached high coverage, consistent with the transition model, can provide guidance to those with lower coverage (<85%). Contextualizing strategies to equitably provide high-quality childbirth care will be transformative for womens and newborns health in SSA.

BackgroundUrban and rural settings differ in key determinants of tuberculosis (TB) burden, including transmission dynamics, social and structural determinants, and healthcare access. However, understanding of urban and rural TB burden is limited, hindering implementation of public health interventions to end TB. Methods and FindingsWe conducted a systematic review and meta-analysis of urban and rural differences in adult pulmonary TB prevalence in low- and middle-income countries between 1993 and 2024. Bayesian multilevel meta-regression was used to estimate pooled urban-to-rural prevalence ratios (PR) for bacteriologically-confirmed and smear-positive TB overall, and by World Health Organization (WHO) region. We also stratified analysis by survey-level risk of bias and TB screening algorithm, investigated time trends, and evaluated associations with country-level TB incidence and population proportion living in urban areas. To estimate the number of people with prevalent TB in urban and rural areas in study countries, and how these have changed between 2000 and 2023, we fitted a Bayesian multivariate model to WHO incidence and case detection ratio data and combined these estimates with assumptions about the duration of treated and untreated TB and the distribution of urban and rural populations. We included 46 surveys conducted between 2000 and 2019, encompassing 2,331,775 participants. The pooled urban-to-rural prevalence ratio of bacteriologically-confirmed TB was 1.08 (95% credible interval [CrI]: 0.87-1.33) and was 1.21 (95% CrI: 0.92-1.57) for smear-positive TB. However, there were substantial differences between WHO regions: the African Region had higher urban bacteriologically-confirmed prevalence (PR: 1.29, CrI: 1.01-1.61), while the Western Pacific Region had higher rural prevalence (PR: 0.64, CrI: 0.45-0.89), and burden was broadly similar in the South-East Asia Region (PR: 0.86, 95% CrI: 0.64-1.10). Time trends indicated a small increase in the overall bacteriologically-confirmed urban-to-rural prevalence ratio between 2000 and 2019, with a mean PR increase of 2.2% (95% CrI: -2.5 to 8.0%) per year. We estimated that, for 2023 in the 26 represented study countries (combined population: 2.2 billion urban, 2.4 billion rural), 47% (95% CrI: 34-62%; 6.5 million, 95% CrI: 3.6-11.8 million) of prevalent TB was in urban areas, and 53% (95% CrI: 38-66%; 7.3 million, 95% CrI: 4.2-12.8 million) in rural areas. Within countries, there were striking changes in the urban and rural distribution between 2000 and 2023, with the share of urban cases increasing in nearly all countries. ConclusionBetween 2000 and 2023, TB epidemics have become increasingly urbanised, both in proportional and absolute terms, although with considerable variation across countries and regions. Public health approaches tailored to urban and rural TB epidemiology and demography will be required to end TB.

BackgroundThe impact of COVID-19 on all-cause mortality in sub-Saharan Africa remains unknown. MethodsWe monitored mortality among 306,000 residents of Kilifi Health and Demographic Surveillance System, Kenya, through four COVID-19 waves from April 2020-September 2021. We calculated expected deaths using negative binomial regression fitted to baseline mortality data (2010-2019) and calculated excess mortality as observed-minus-expected deaths. We excluded deaths in infancy because of under-ascertainment of births during lockdown. In February 2021, after two waves of wild-type COVID-19, adult seroprevalence of anti-SARS-CoV-2 was 25.1%. We predicted COVID-19-attributable deaths as the product of age-specific seroprevalence, population size and global infection fatality ratios (IFR). We examined changes in cause of death by Verbal Autopsy (VA). ResultsBetween April 2020 and February 2021, we observed 1,000 deaths against 1,012 expected deaths (excess mortality -1.2%, 95% PI -6.6%, 5.8%). Based on SARS-CoV-2 seroprevalence, we predicted 306 COVID-19-attributable deaths (a predicted excess mortality of 30.6%) within this period. Monthly mortality analyses showed a significant excess among adults aged [&ge;]45 years in only two months, July-August 2021, coinciding with the fourth (Delta) wave of COVID-19. By September 2021, overall excess mortality was 3.2% (95% PI -0.6%, 8.1%) and cumulative excess mortality risk was 18.7/100,000. By VA, there was a transient reduction in deaths attributable to acute respiratory infections in 2020. ConclusionsNormal mortality rates during extensive transmission of wild-type SARS-CoV-2 through February 2021 suggests that the IFR for this variant is lower in Kenya than elsewhere. We found excess mortality associated with the Delta variant but the cumulative excess mortality risk remains low in coastal Kenya compared to global estimates.