The Lancet Global Health

Background Childhood respiratory infectious deaths are partitioned across four Global Burden of Disease cause modules-26 etiological attributions within lower respiratory infections, tuberculosis, COVID-19, and whooping cough-never jointly reported. Whether the structure of this combined mortality spectrum has changed over time, and with what implications for intervention design, has not been quantified. We assembled and analyzed the integrated spectrum for children and adolescents aged 0-19 years, 1990-2023. Methods We integrated Global Burden of Disease Study 2023 (release v8352) estimates into a 29-node spectrum-26 lower respiratory infection etiologies plus tuberculosis, COVID-19, and pertussis-globally and across seven super-regions, with uncertainty propagated by summing bounds. We computed Shannon diversity, Herfindahl concentration, and effective cause counts; phenotyped pandemic-window collapse and rebound per cause; linked pathogen shares to WHO/UNICEF vaccine coverage; and mapped geographic concentration in sub-Saharan Africa and South Asia. Reporting follows GATHER. Results In 2023 the 29 causes jointly accounted for 965,330 deaths (95% uncertainty interval [UI] 680,096-1,342,437). Shannon diversity rose from 2.336 to 2.711 (+16.1%) between 1990 and 2023; the effective number of causes nearly doubled (5.57 to 9.94), inversely coupled to total deaths (Spearman rho = -0.997). Whooping cough ranked second (112,954 deaths; 95% UI 64,576-185,708; 11.7%) and showed the spectrum's only rebound above 100% (-57.4% collapse, +111.0% rebound). Tuberculosis ranked third (87,764; 57,779-124,912; 9.1%) with the highest concentration in sub-Saharan Africa and South Asia (87.1%). COVID-19 entered at rank five (52,899; 47,275-59,183; 5.5%). Nineteen of 29 causes exceeded the poverty-lock threshold (>80.59% of deaths in sub-Saharan Africa plus South Asia). Conclusions Childhood respiratory infectious mortality has become more diverse and more concentrated in poverty as it has declined. Single-pathogen interventions now address a shrinking share; the spectrum's structure argues for platform interventions-oxygen, antimicrobial access, referral-tailored jointly by age and geography, implying that pathogen-specific strategies alone cannot finish the remaining mortality agenda.

Background Lower respiratory infections (LRI) remain the leading infectious cause of death in children, and survival once ill is a direct tracer of health-system quality. Whether countries are converging toward the best survival performance achieved within their own region has never been tested at national level. We measured each country's distance to an empirical episode-fatality-ratio (EFR) frontier in 204 countries from 1990 to 2023. Methods For each country and year we computed EFR = LRI deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. Deaths span the full 1990-2023 series; episodes are observed for 1990, 2019 and 2023, with intermediate years linearly interpolated. The frontier was the 10th-percentile country EFR within each GBD super-region and year (sensitivity: 5th and 25th percentiles); the gap = EFR_country/EFR_frontier. We classified 33-year gap trajectories into catch-up phenotypes, ranked COVID-window (2019-2023) movers, cross-tabulated gap against avoidable deaths to build a priority list, and benchmarked upper respiratory infections (URI) at three time points as a near-zero-fatality contrast. Findings The median country's gap was 1.86 in 1990, 1.80 in 2019 and 1.86 in 2023; the share of countries more than twice their regional frontier was 44.6% in 1990 and 46.6% in 2023. Of 137 eligible countries, 67 narrowed and 69 widened their gap, with one unchanged. Nineteen countries achieved sustained catch-up, concentrated in North Africa and the Middle East (7) and Latin America (5), with China closing from 2.43 to 0.50, below its regional frontier; 28 countries regressed, led by Central Asia (Uzbekistan x3.5) and including the United States (x2.0). Over the COVID-19 window the median gap peaked at 2.00 in 2021 (+10.8% versus 2019, from unrounded medians) before returning to 1.86. Combining gap with avoidable deaths identifies two distinct policy problems: high-burden, moderate-gap giants (Nigeria 67,490 avoidable deaths, gap 2.4; India 54,109, gap 1.6) and extreme-gap outliers (Uzbekistan, gap 28.6). The Sub-Saharan Africa frontier fell further behind the High-income frontier (ratio 4.2 in 1990, 9.5 in 2023); the median Sub-Saharan African country sits 11.0 times the global 10th-percentile frontier but only 1.78 times its own regional frontier, so within-region benchmarking understates the region's true distance. URI gaps likewise did not converge (median 4.15 to 4.60). Interpretation Convergence toward the survival frontier is not the default national trajectory: over three decades the typical country made no net progress toward the best decile of its own region, and pandemic-era divergence was only partly reversed. National gap trajectories separate system-wide quality shortfalls from extreme outliers warranting audit, and expose a measurement trap in which regions whose frontiers stagnate appear closer to best practice than they are.

Human immunodeficiency virus (HIV) and hepatitis B virus (HBV) coinfection is associated with accelerated liver disease, but whether coinfection is associated with newly documented social determinants of health (SDoH) is unclear. We conducted a retrospective cohort study using TriNetX across 110 U.S. healthcare organizations (2010-2026). We propensity score matched adults with HIV/HBV to adults with HIV or HBV monoinfection. We organized newly documented SDoH indicators using a dynamic individual-level framework with four clinically recognized domains of social disadvantage: material vulnerability, healthcare access and engagement, interpersonal adversity, and psychosocial vulnerability. Matched cohorts included 10,071 HIV/HBV-HIV pairs and 9,659 HIV/HBV-HBV pairs (mean age, 47 years; 79% male; 66% non-White; median follow-up, 3.3 years). Over 178,900 person-years, HIV/HBV was associated with higher risk of the primary SDoH composite compared with HIV (11.5% vs 9.7%; incidence rate, 2.50 vs 1.97 per 100 person-years; hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.15-1.37) and HBV (11.0% vs 6.4%; incidence rate, 2.39 vs 1.67; HR, 1.50; 95% CI, 1.35-1.67). HIV/HBV was also associated with higher material vulnerability and healthcare access and engagement composites in both comparisons, including housing instability, food insecurity, financial insecurity, insurance instability, and care disengagement/nonadherence (HR range, 1.22-3.33 vs HIV; 1.31-1.94 vs HBV). In the HBV comparison, HIV/HBV was additionally associated with interpersonal adversity, primary support stressors, and violence or victimization (HR range, 1.36-2.16). Findings were robust across sensitivity analyses. HIV/HBV was associated with more newly documented SDoH than monoinfection, supporting dynamic SDoH assessment.

Background: Neonatal mortality remains a significant public health challenge in Sub Saharan Africa (SSA). The continuum of maternal care (COC), spanning antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC) represents an integrated pathway to improving neonatal survival. Multi-country evidence on how adherence to this full continuum affects neonatal outcomes across SSA is limited. Objectives: This study aimed to: (1) construct a composite COC indicator and describe its sociodemographic distribution; (2) estimate its association with neonatal mortality; (3) conduct a counterfactual analysis; and (4) examine cross country heterogeneity in the COC effect on neonatal mortality. Methods: Pooled Demographic and Health Survey (DHS) data from 35 SSA countries (2010 to 2026) were analyzed (N = 867,984 live births). A binary CoC indicator (coc1 = 1 if mother received [&ge;]4 ANC visits, skilled birth attendance, and PNC within 48 hours) was constructed. Survey-weighted logistic regression adjusted for wealth, education, residence, parity, maternal age, child sex, child age, and country. Counterfactual predictive margins and a COC and country interaction model were estimated in Stata 18. Results: Only 13.47% of mothers met the full COC threshold. COC completion was higher among wealthier, urban, more educated, and lower-parity women. After adjustment, CoC receipt was associated with significantly lower odds of neonatal death (aOR = 0.638, 95% CI: 0.577 - 0.706, p < 0.001). Counterfactual analysis showed the predicted neonatal mortality probability would fall from 3.15% (no CoC) to 2.04% (full CoC), an absolute risk reduction of 1.11 percentage points. Cross-country interaction terms were largely non-significant; only Namibia reached significance (p = 0.036). Conclusion: Completion of the full continuum of maternal care is independently associated with reduced neonatal mortality across SSA. Equity focused policies should prioritize integrated service delivery for rural, poor, and less educated women.

Introduction: Control of tuberculosis (TB) in children remains a major challenge globally. There is growing recognition that children with severe acute malnutrition (SAM) are a high-risk population for TB, but the global burden of TB in this group has never been comprehensively quantified. Methods: We conducted a systematic review and meta-analysis to estimate the prevalence of TB among children with SAM. Following PRISMA guidelines, we searched PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and WHO Global Index Medicus from database inception to June 15, 2026. We included studies reporting TB among systematically sampled cohorts of children <15 years with SAM as defined by the World Health Organization. Methodological study quality was assessed with adapted versions of the Newcastle-Ottawa Scale or the Joanna Briggs Institute critical appraisal checklist. Pooled TB prevalence was calculated using a random-effects model with predefined stratification of studies by geographic region, national TB incidence, and study quality. We also conducted subgroup analyses by age, sex, HIV status, SAM type, and TB exposure. Results: We included 73 studies comprising 33,869 children with SAM across 15 countries, predominantly from sub-Saharan Africa and South Asia, and predominantly reporting on hospitalized children. The pooled TB prevalence was 13% (95% CI: 11-16%), but there was substantial heterogeneity (I2=98%). Studies conducted in Southern Africa had the highest pooled TB prevalence (36%, 95% CI: 19-56%) compared to other regions (p<0.01). Pooled TB prevalence was higher in those with history of TB household exposure compared to those without (74% vs. 17%, p=0.01). Conclusions: Approximately one in eight children hospitalized with SAM have TB, greatest among children with history of TB exposure and those in Southern Africa. These findings highlight opportunities for improved early TB diagnosis and routine, integrated TB screening within hospital-based SAM care pathways.

Precision targeting is essential for maximising impact and cost-effectiveness of interventions at this stage of the HIV response in Malawi. We aimed to measure gaps in access to and use of condoms, HIV testing, pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision among HIV-negative individuals at public health facilities and social venues (bars, rest houses and liquor stores) in Blantyre, Malawi. We analysed cross-sectional data from 2,227 HIV-negative patients at government clinics and 1,634 patrons at social venues recruited in the Clinic vs Venue (CLOVE) study between January and March 2022. We estimated gaps in access to and use of condoms, HIV testing, PrEP and circumcision. Estimates were stratified by risk group, defined as reporting transactional sex, having multiple sex partners in the past 4 weeks, being female aged 15 to 24, or being male aged 30 and above. Access and use were based on self-reports. Overall, 30% of clinic and 60% of venue participants reported higher risk. Among men, we found a gap between access to condoms and condom use at last sex (76.7% vs 29.8% among clinic men; 75.4% vs 36.7% among venue men). Among women, the gap between access and use of condoms was 65.9% vs 18.0% at clinics and 79.9% vs 46.0% in the venues. Approximately 80-85% of participants reported knowing where to get an HIV test in Blantyre but less than half reported testing in the past 6 months. Use of PrEP was low (~2%). Comparable proportions of men who paid for sex and those with multiple partners (~77%) reported being circumcised, but this was lower among those aged 30 years or older (~57%). Despite expanded HIV prevention services in Blantyre, gaps remain in the uptake of prevention services among people reachable at public health facilities and social venues. Use of PrEP was particularly low across all groups. Condom and testing use remained suboptimal despite high reported access. Targeted efforts are needed to address barriers to uptake, particularly for PrEP among high-risk venue-based populations.

Objectives: Estimate fertility rate ratios (FRR) of HIV-positive relative to HIV-negative women in sub-Saharan Africa (SSA) by age group, CD4 stage, ART status, and country. Design: Analysis of nationally representative household surveys with HIV serological testing. Methods: We analysed current pregnancy and births in the past three years by HIV status from 72 nationally-representative household surveys in SSA between 2003 and 2017. Spectrum 2018 estimates for the distribution by CD4 stage and ART status were used to infer fertility of women on ART from changes in fertility of all HIV-positive women as ART coverage increased. We allowed regional differences in the age pattern of relative fertility and estimated country-specific random effects. Results: The ratio of fertility in untreated HIV-positive women with CD4 [&ge;]500 to HIV-negative women was 1.6 to 1.8 for age 15-19, relatively similar to 10% times lower for age 20-29, and 15-50% lower above age 30. Among age 15-19, each 15-point increase in percent sexually active reduced relative excess fertility by 24%. Fertility decreased with lower untreated CD4 count stages, consistent with previous estimates. Women on ART >6 months had fertility closer to that of HIV-negative women for ages 15-29, but still 25-40% lower above age 30. There was substantial variation across countries. Conclusions: Fertility differences for HIV-positive women compared to HIV-negative women are smaller than previous estimates, but vary substantially across countries. Recent data suggest fertility of women on ART is greater than that of untreated HIV-positive women, but remains lower than HIV-negative women. This conclusion should be reviewed as new evidence becomes available.

Background: In 2019, WHO recommended three consecutive reactive serological test results for HIV diagnosis to reduce false-positive diagnoses. Malawi changed from a two-test to a three-test strategy in 2022 as HIV test positivity declined. We assessed diagnostic performance, implementation fidelity, and costs. Methods: We analysed national HIV testing data from Nov 1, 2022, to Oct 31, 2025. Using observed three-test classifications as the reference standard, we reconstructed classifications under the two-test strategy. We estimated positive predictive value (PPV), implementation fidelity, potential false-positive diagnoses prevented, incremental costs, and time to offset testing costs through avoided antiretroviral therapy expenditure. Results: Among 9,885,599 encounters eligible for implementation-fidelity analysis, 99.98% followed a valid three-test pathway. The diagnostic-performance analysis included 9,862,908 encounters, of which 171,351 (1.7%) were classified HIV-positive and 9,138 (0.09%) were inconclusive. Under the two-test strategy, 1,209 inconclusive encounters with a T1+/T2+/T3- sequence would have been classified as HIV-positive. Retesting and reference-laboratory data indicated that 82.5% of these would subsequently be classified as HIV-negative, corresponding to 997 false-positive diagnoses prevented (10.3 per 100 000 three-test non-positive encounters; 95% CI 9.7-10.9). Retesting within 1-2 weeks was associated with the highest odds of potential false-positive classification (adjusted OR 39.37, 95% CrI 30.63-50.61). The incremental cost was US$471 per false-positive diagnosis averted and was offset within 7.30 years. Conclusions: Malawi's transition to a three-test HIV testing strategy prevented false-positive diagnoses and unnecessary antiretroviral therapy at modest cost, supporting broader adoption of WHO guidance in similar settings. Funding: Gates Foundation.

Background Respiratory infections remain the leading infectious cause of death among children and adolescents, yet the share of these deaths that could be averted with currently feasible care is not routinely quantified. Existing amenable-mortality frameworks rely on cause lists and population-level mortality benchmarks and do not exploit information on how many episodes occur. We propose an episode-fatality-ratio (EFR) frontier approach and apply it to lower respiratory infections (LRI), whooping cough (pertussis) and upper respiratory infections (URI) in 204 countries, 1990-2023. Methods For each cause, country and year we computed EFR = deaths/incident episodes using Global Burden of Disease (GBD) 2023 estimates for ages 0-19 years. The frontier was defined as the 10th-percentile country EFR within each GBD super-region, cause and year; avoidable deaths = max(0, deaths - episodes x frontier EFR). Primary estimates are deterministic; 95% uncertainty intervals (UIs) come from 2,000 Monte Carlo draws. Sensitivity analyses varied the frontier percentile, applied an aspirational global frontier, constructed pertussis counterfactuals, and recomputed all estimates within the single under-5 age band. Results In 2023, 333,803 childhood deaths from lower respiratory infections (95% UI 289,123-417,460; 46.9% of LRI deaths) were avoidable. Summing the three causes deterministically gives 391,034 avoidable deaths (46.5% of 840,444); the combined figure is a deterministic sum, and a UI is available for the LRI component only. The pertussis (43,958; 39.0%) and URI (13,273; 81.0%) estimates are secondary: their deterministic point values fall below their own Monte Carlo intervals and the underlying death estimates carry very wide uncertainty (global pertussis UI 12,545-321,874). Avoidable deaths fell from 1,050,468 (44.9%) in 1990, but between 2019 and 2023 the avoidable share for LRI+URI barely moved (48.7% to 47.7%) while absolute avoidable deaths fell 14.5%, a pattern consistent with stalled convergence to the frontier. Sub-Saharan Africa plus South Asia held 73.1% of avoidable deaths in 2023 versus 41.8% in 1990; ten countries accounted for 59.1%. Conclusion Nearly half of childhood respiratory-infection deaths remain avoidable relative to within-region best practice, and the residual burden is increasingly concentrated in low-income settings. In the pertussis counterfactual, most countries kept pace with their regional frontier, so further gains require advancing the frontier itself through quality-of-care improvements.

Background: Global HIV programmes are transitioning virally suppressed children and adolescents with HIV (CAWH) from prior regimens to dolutegravir-based antiretroviral therapy (ART). However, the supporting evidence largely stems from randomised trials in viraemic CAWH. The effect of transition for virally suppressed CAWH is unknown. Methods: We used observational, de-identified data from 724 clinics in KwaZulu-Natal, South Africa. We sequentially emulated three distinct target trials to estimate the effect of transitioning to dolutegravir-based ART in three paediatric populations: i) ages 8-17 years taking efavirenz-based ART, ii) 8-17 years taking ritonavir-boosted lopinavir (LPV/r)-based ART, and iii) 0-7 years taking LPV/r-based ART, all with a last viral load <1,000 copies/mL. The risk difference (RD) of death or viraemia >1,000 copies/mL through 12 and 24 months was estimated using an inverse probability weighting approach. Findings: From January 2020 to August 2024, 37,145 CAWH contributed 454,081 person-trials. In CAWH initially taking efavirenz, the standardised 12-month risk of death or viraemia was 11.9% with continued efavirenz and 6.7% with transition to dolutegravir (RD -5.2 [95% CI -5.8 to -4.6]). In older CAWH initially taking LPV/r, these risks were 17.8% and 9.5%, respectively (RD -8.3 [-10.0 to -6.8]). In younger children, the respective risks were 15.8% and 6.7% (RD -9.0% [-12.7 to -5.4]). Where available, 24-month endpoints showed slightly greater RDs. Interpretation: This large-scale, causal analysis highlights improvements in viral suppression and strongly supports ongoing transition to dolutegravir-based ART for virally suppressed CAWH. Funding: Gates Foundation, National Institute for Health and Care Research, Swiss National Science Foundation

Background Cardiovascular disease remains the leading cause of death worldwide, yet progress in reducing its burden has not been shared equally across regions. Sub-Saharan Africa has previously been identified as the only world region where age-standardized cardiovascular mortality failed to decline, but long-term, disease-specific trends in Western Sub-Saharan Africa (WSSA) remain poorly characterized. Methods We conducted an ecological trend analysis using Global Burden of Disease (GBD) 2023 data to evaluate age-standardized mortality and disability-adjusted life years (DALYs) for stroke and ischemic heart disease (IHD) in WSSA and globally from 1990 to 2023. Linear and segmented regression assessed long-term trends and breakpoints, risk factor attribution examined six major cardiovascular risk factors, and Pearson correlation evaluated associations between the Socio-demographic Index (SDI) and mortality. Results Global stroke and IHD mortality declined by 51.7% and 38.2%, respectively, between 1990 and 2023. In WSSA, stroke mortality declined by only 21.8%, while IHD mortality increased by 3.3%. Segmented regression identified a breakpoint in IHD mortality around 2007, after which the trend reversed from declining to increasing. High systolic blood pressure was the leading attributable risk factor for both diseases, while obesity, ambient air pollution, and elevated fasting glucose showed the largest relative increases. SDI rose 69.5% in WSSA but correlated strongly only with stroke mortality (r = 0.87), not IHD (r = 0.21). Conclusions WSSA is falling behind global cardiovascular progress, with IHD mortality reversing course despite substantial socioeconomic development. Targeted investment in hypertension control, cardiometabolic risk reduction, and cardiovascular care capacity is urgently needed to prevent this divergence from deepening.

While a causal link between urogenital schistosomiasis (Schistosoma haematobium) and anaemia is well established, quantitative associations between infection intensity and haemoglobin levels across endemic communities, at fine spatial scales, remain insufficiently characterized. As part of the broader Hybridisation in Urogenital Schistosomiasis (HUGS) investigation, we studied the micro-epidemiology of anaemia within two study communities in southern Malawi where S. haematobium remains endemic. Urine samples were examined by microscopy to quantify S. haematobium infection intensity, categorised as low (0-9 eggs/10 mL), moderate (10-49 eggs/10 mL), and heavy ([&ge;]50 eggs/10 mL). Individual haemoglobin concentrations were measured using a HemoCue photometer in 1,149 participants from Samama village (Mangochi District) and 977 participants from Mthawira village (Nsanje District). Linear geostatistical models incorporating individual-level characteristics and spatial covariates were used to estimate anaemia prevalence at fine geographical scales. Moderate anaemia (Hb 80-109 g/L) was most prevalent among children aged 6-12 years (45.30% in Samama and 39.54% in Mthawira), while severe anaemia was more frequent among adults aged [&ge;]19 years in both villages. Increasing S. haematobium infection intensity was associated with lower haemoglobin levels, with individuals harbouring heavy infections being at greater risk of moderate-to-severe anaemia. Spatial modelling revealed longer-range spatial correlation in Nsanje ({phi} = 66.7 km) than in Mangochi ({phi} = 25.5 km), indicating more spatially persistent risk in Nsanje and more localised heterogeneity in Mangochi. Predicted anaemia prevalence among female children aged 6-12 years with moderate infection intensity ranged from 25-65% in Mangochi and 64-76% in Nsanje. At the micro-epidemiological level, S. haematobium infection intensity was associated with the severity of anaemia, with substantial spatial heterogeneity within and between villages. Identification of high-risk clusters supports targeted interventions, including stepped-up preventive chemotherapy, improved water and sanitation, and iron supplementation.

Background Community health workers (CHWs) are central to universal health coverage strategies across sub-Saharan Africa. Yet whether CHW programs equitably reach women across socioeconomic and demographic groups remains poorly characterized at the multi-country level. Methods A cross-sectional secondary analysis of Standard DHS-8 data from Ghana (2022), Kenya (2022), Tanzania (2022), and Malawi (2024) was conducted (N = 68,019 women aged 15-49). The primary outcome was self-reported contact with a CHW or fieldworker in the prior 12 months. Survey-weighted logistic regression was performed using Taylor series linearization to account for complex survey design, both individually per country and pooled. The RE-AIM framework guided the evaluation of program reach. Results National CHW coverage varied 7-fold, from 3.1% in Tanzania to 22.8% in Malawi. The most consistent cross-country equity finding was by age: women aged 15-19 had approximately half the adjusted odds of CHW contact compared to women aged 25-29 in every country (pooled aOR = 0.47, 95% CI [0.42, 0.52], p < .001). Pro-poor wealth gradients were significant in Kenya and Malawi, whereas Ghana achieved equitable reach across all wealth quintiles (p = .685). Rural residence was independently associated with higher CHW contact in Kenya (aOR = 1.48) and Malawi (aOR = 1.91). Conclusions Adolescent women aged 15-19 are systematically underserved by CHW programs across sub-Saharan Africa, a finding consistent across four countries with widely different program scales. This adolescent gap is the most consistent equity finding across the dataset, persisting across all four countries regardless of program scale, wealth distribution, or governance structure. Ghana's Community-based Health Planning and Services (CHPS) program demonstrates that equitable CHW reach across wealth quintiles is achievable at scale. Kenya's extreme within-county variation indicates that sub-national governance quality is a dominant driver of equity. Targeted strategies, including CHW protocol redesign and school-based outreach, are urgently needed to close the adolescent reach gap.

Background: Neonatal mortality remains disproportionately high in sub-Saharan Africa (SSA), accounting for nearly half of all deaths in children under five. Although antenatal care, skilled birth attendance, and postnatal care are individually associated with improved newborn survival, few studies have examined whether their integrated receipt as a continuum of care (CoC) confers additional protection against neonatal death, particularly after accounting for sociodemographic confounding and heterogeneity across country contexts. Methods: A pooled cross-sectional analysis was conducted using DHS-8 Births Recode files from five countries: Nigeria (2024), Mali (2023-2024), Congo DRC (2023-2024), Kenya (2022), and Lesotho (2023-2024). The analytical sample comprised 37,351 births within the 36-month postnatal care reference window. Complete CoC was defined as receipt of adequate antenatal care ([&ge;]4 visits with first-trimester initiation), skilled birth attendance, and postnatal care within 48 hours for the mother or newborn. Neonatal mortality was defined as death within 27 days of birth. Survey-weighted logistic and log-Poisson regression models estimated adjusted odds ratios (aOR) and adjusted prevalence ratios (aPR). G-computation quantified the population attributable fraction (PAF). Country-specific heterogeneity was examined through random-effects meta-analysis (DerSimonian-Laird method) and a two-level multilevel logistic regression model. Results: The overall neonatal mortality rate was 29.3 per 1,000 live births (95% CI: 27.6-31.0). Complete CoC prevalence was 19.2% (95% CI: 18.5-19.9%), ranging from 7.8% in Congo DRC to 47.8% in Lesotho. In unadjusted analysis, complete CoC was associated with a 24% reduction in neonatal death odds (cOR: 0.764, 95% CI: 0.583-1.000, p = 0.050). After adjustment for wealth, education, residence, parity, maternal age, child sex, and country, the association was substantially attenuated and non-significant (aOR: 0.961, 95% CI: 0.717-1.289; aPR: 0.962, 95% CI: 0.722-1.282). The PAF under universal complete CoC was 3.2%. The pooled meta-analytic estimate was aOR 0.718 (95% CI: 0.447-1.152), with moderate heterogeneity (I{superscript 2} = 38.9%; {tau}{superscript 2} = 0.089). Country-specific estimates ranged from aOR 0.455 (95% CI: 0.256-0.810) in Kenya to 1.447 (95% CI: 0.496-4.220) in Lesotho. Conclusion: Complete continuity of maternal healthcare was not independently associated with reduced neonatal mortality after full adjustment, suggesting that the unadjusted benefit was attributable to sociodemographic selection rather than a direct causal pathway. These findings underscore the insufficiency of service utilisation metrics in isolation and highlight the need to address the structural and contextual determinants that simultaneously constrain both care access and neonatal survival. Country-level heterogeneity in the CoC-mortality relationship points to the importance of tailored, context-specific interventions.

Background: The Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (HIV/AIDS) remain a major public health concern in Ghana. Despite sustained progress in treatment and prevention, regional prevalence variations persist, driven by healthcare access, urbanization, and socio-economic factors. This study identifies trends and hotspots to guide effective HIV surveillance and control strategies in Ghana. Methods: A retrospective ecological study was conducted using secondary HIV data confirmed by laboratory testing, from the Ghana District Health Information Management System (DHIMS2) for the period 2020 to 2024. HIV prevalence was calculated as the number of confirmed cases per 100,000 population, using denominators from the Ghana Statistical Service 2021 Population and Housing Census. Spatiotemporal variation in prevalence was visualized using choropleth maps. Global Morans Index examined whether overall spatial dependency existed, followed by local indicators of spatial association (LISA), comprising local Morans I and the Getis-Ord Gi* statistic, to identify local clusters, outliers, and hotspots or coldspots. Results: National HIV prevalence per 100,000 population rose from 0.68 in 2020 to 0.84 in 2024. The highest burden was in the southern and middle belt regions: Western North (2.16), Bono East (1.71), Eastern (1.30), Volta (1.06), and Ahafo (1.01). Northern regions remained consistently low throughout the study period, with Northern (0.32), Upper East (0.26), and Savannah (0.30) recording averages below 0.50 per 100,000. Global Morans Index indicated a dispersed pattern in 2020 (I = -0.43), spatially random pattern between 2021 and 2023, and weak positive spatial association in 2024 (I = 0.22). Conclusions: Regional disparity in HIV prevalence in Ghana is widening, with greater burden concentrated in the more urbanized southern regions. Interventions guided by surveillance data and tailored to specific regions, including strengthened testing infrastructure and a more equitable distribution of health resources, are needed to curb transmission and support HIV in Ghana and the AIDS control programme. Keywords: HIV, AIDS, spatiotemporal analysis, Morans I, Getis-Ord Gi*, Ghana

Abstract Preventable neonatal deaths remain a major public health problem in Zimbabwe, where near-universal antenatal and facility-delivery coverage coexist with a rising neonatal mortality rate. This study evaluated whether institutionalising three core "vital signs" of the community health system (a trained village health worker (VHW) workforce, functional community governance structures, and modified women's and men's participatory learning and action groups) reduces preventable neonatal deaths in Mashonaland West Province. An embedded QUAN (qual) mixed-methods design was used, with a two-arm, parallel-group cluster-randomised controlled trial as the dominant strand. Fifty-two ward-level clusters were randomised 1:1 to the institutionalised community health system package or to standard Ministry of Health and Child Care community services, and 984 pregnant women were enrolled between 1 September 2020 and 31 October 2021, with each mother-infant pair followed to 28 days after delivery, yielding 973 mother-infant pairs for intention-to-treat analysis. The primary outcome was neonatal death within 28 days of life, expressed per 1,000 live births. The primary analysis used a three-level mixed-effects log-binomial regression model with cluster and community-health-worker random intercepts, adjusted for pre-specified covariates. Supervised machine-learning classifiers with leave-one-cluster-out cross-validation, Cox proportional-hazards regression, and multilevel logistic models were fitted as supplementary analyses. An embedded longitudinal process evaluation used key informant interviews and focus group discussions, which were analysed thematically and integrated with the quantitative findings. The neonatal mortality rate was 44.8 per 1,000 live births in the intervention arm versus 110.1 per 1,000 in the control arm. The adjusted risk ratio for neonatal death was 0.43 (95% CI 0.26-0.70; p < 0.001), a 57% relative reduction, with a number needed to treat of 16 mother-infant pairs (95% CI 11-29). Low birthweight (<2,500 g), birth interval under two years, and low community women's literacy were the strongest risk factors, while trained VHWs, functional community governance, early antenatal care, and sustained participatory group attendance were independently protective. The women's and men's groups were protective in a dose-dependent manner, becoming significant at four or more cycles (about 14 meetings) (adjusted odds ratio 0.71; 95% CI 0.60-0.85; p = 0.001). A random forest classifier discriminated against neonatal deaths with a cross-validated area under the curve of 0.842 and a sensitivity of 0.912. Qualitative findings converged with the trial results, identifying male engagement, earlier care-seeking, danger-sign literacy, social-network activation, and community death audits as the behavioural and structural mechanisms of change. Institutionalising the community health system package (trained VHWs, functional governance, early antenatal engagement, and sustained participatory groups) was associated with a substantial reduction in preventable neonatal deaths. The findings suggest that in high-coverage, high-mortality settings, the binding constraint is structural rather than clinical, and that scaling functional community governance and workforce infrastructure in the most disadvantaged communities may accelerate progress toward neonatal survival targets. The principal limitations are a one-year follow-up period, the rarity of neonatal death, and concurrent national programming that only partially reached the control clusters. Trial registration: Pan African Clinical Trials Registry, PACTR202607591142118 (https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=PACTR202607591142118); registered retrospectively on 7 July 2026.

Background: HIV/HBV coinfection is associated with substantial liver-related morbidity and mortality, yet the impact of social vulnerability (SV) on clinical outcomes has not been systematically assessed. We evaluated associations of multidimensional SV with mortality, hepatic, virologic, and extrahepatic organ outcomes among adults with HIV/HBV. Methods: We conducted a retrospective cohort study using TriNetX data from 110 U.S. healthcare organizations (2010-2026). We propensity score matched adults with HIV/HBV with and without documented SV 1:1 (2,024 per group). SV was defined using a four-domain framework encompassing material, healthcare access and engagement, interpersonal, and psychosocial vulnerability. Results: Over 15,900 person-years, SV was associated with higher mortality (hazard ratio [HR], 2.06; 95% confidence interval [CI], 1.72-2.47), liver composite events (HR, 1.37; 95% CI, 1.07-1.76), hepatic decompensation (HR, 1.94; 95% CI, 1.39-2.70), hepatic failure (HR, 2.39; 95% CI, 1.53-3.73), HBV viremia (HR, 1.69; 95% CI, 1.32-2.16), and HIV viremia (HR, 2.05; 95% CI, 1.71-2.46). SV was also associated with major adverse cardiovascular events (HR, 1.47), chronic kidney disease (HR, 1.49), and diabetes (HR, 1.25). Multidomain SV generally showed stronger associations than single-domain SV for most hepatic and virologic outcomes, with HR ranges of 1.76-2.62 versus 1.35-1.76 for single-domain SV. Healthcare access and engagement vulnerability was most consistently associated with mortality and hepatic outcomes. Conclusions: SV was associated with mortality, hepatic disease, impaired HIV/HBV control, extrahepatic organ morbidity, and acute care utilization in adults with HIV/HBV. SV assessment may improve risk stratification and identify actionable intervention targets during HIV/HBV care.

Background & objectives: India's fifth National Family Health Survey measured anaemia in all 707 districts, whereas the sixth survey did not. Anaemia is now assessed through a venous blood survey covering 183 districts and reported only at the national level. Using the most recent district-level measurements, we examined whether the remaining survey indicators could predict district anaemia, whether omitting district anaemia altered programme prioritisation, and the value of repeating district-level measurement. Methods: We estimated district anaemia prevalence and uncertainty for children aged 6-59 months and non-pregnant women aged 15-49 years using small-area estimation with design-based variances. We evaluated prediction from the retained survey indicators using both district-level and leave-one-State-out validation, compared district prioritisation under three information scenarios using matched preference draws, and estimated the value of repeating measurement of the same underlying prevalence. Results: Median standard errors of district estimates were 3.57 percentage points for children and 2.22 percentage points for women. The best predictive surrogate had a root mean squared error of 10.14 percentage points for children, of which 9.44 percentage points reflected structural error, representing approximately 2.5 times the root mean squared measurement error. In leave-one-State-out validation, predictions performed worse than the training-set mean. Among the 71 districts prioritised using current estimates, 19.1% were not among the latent top 71 districts. Measuring 183 districts recovered 46.3% of this prioritisation gap when districts were selected according to decision value, compared with 9.6% under equal allocation across States. Interpretation & conclusions: Available survey indicators did not adequately substitute for direct measurement of district anaemia. When measurement resources are limited, the choice of districts to be measured has a greater influence on programme prioritisation than the total number of districts measured, provided differences between measurement platforms are addressed before comparison.

Introduction: Nutritional challenges are a global public health concern, especially among children under five in sub-Saharan African countries. The coexistence of an overweight/obese mother and an underweight child in the same household is recognized as a dual burden of malnutrition (DBM). Our study aimed to examine the prevalence and associated factors of DBM among mother-child dyads in Mozambique. Methods: We used nationally representative, cross-sectional data from the Mozambique Demographic and Health Survey 2022-2023 (n=3,605 mother-child dyads). The children's undernutrition condition and maternal BMI status were calculated using the WHO standard reference guidelines. The outcome variable, dual burden of malnutrition, was then created if the children had any undernutrition condition (stunting, wasting, or undernutrition) and the corresponding mother was overweight/obese. Multivariable binary logistic regression, Erreygers's concentration index, and concentration curve were analyzed to determine associated factors and social inequalities. Results: The prevalence of the dual burden of malnutrition was about 5.51%. Mothers aged [&ge;]34 years [aOR (95% CI): 4.01(1.44, 11.14); p<0.05] and mothers with four or more children [aOR (95% CI): 2.68(1.29, 5.57); p<0.05] had higher odds of DBM. Rural residence and using unimproved toilet facilities (latter an indicator) were also significantly associated with experiencing DBM. Additionally, maternal age modified the association between women's empowerment and mother-child DBM. Women aged 15-19 years at the lowest and highest empowerment levels were more likely to experience DBM compared to women 20 years or older. A positive and statistically significant concentration index indicates that wealth-related inequalities exist, with DBM more concentrated among wealthier mother-child dyads. Conclusion: Our study highlights the persistence of household-level DBM in Mozambique. These findings emphasize the need for targeted interventions addressing social and economic inequalities, including poor sanitation marker of broader household deprivation. Prioritizing integrated maternal-child nutrition interventions within national strategies is essential to improving equity in nutrition and health outcomes.

Abstract Background: HIV self-testing (HIVST) has been promoted as a strategy to reach individuals who do not access facility-based testing. However, evidence on whether HIVST leads to more frequent testing among women of reproductive age in Uganda remains limited. This study evaluated the impact of HIV self-testing on recent HIV testing among women using nationally representative data. Methods: Data were drawn from the 2022 Uganda Demographic and Health Survey (UDHS), including 6,438 women aged 15-49 years. The primary outcome was recent HIV testing, defined as having tested for HIV within the 12 months preceding the survey. The treatment variable was ever having used HIV self-testing. Propensity score matching (PSM) with 1:1 nearest neighbour matching (caliper = 0.05) was used to balance observed covariates including parity, media exposure, education, residence, wealth quintile, health insurance, and age group. The average treatment effect on the treated (ATT) was estimated. Results: Among 6,438 women, 23.87% (1,537) reported ever using HIV self-testing. Recent HIV testing was observed in 67.4% of HIVST users compared to 47.4% of non-users (unmatched difference = 20%). After matching, HIVST use increased the likelihood of recent testing by 15.6 percent (ATT = 15.6%; SE = 0.052; t = 2.99). Covariate balance was achieved post-matching, with mean bias reduced from 20.5% to 0.7%, and the B statistic falling from 50.4% to 2.5% (below the 25% threshold). All standardized differences were substantially reduced, with education showing perfect balance (100% reduction) and wealth showing 97.6% reduction. Conclusion: HIV self-testing significantly increases recent HIV testing among women of reproductive age in Uganda. Expanding access to HIVST, particularly for women with lower education, those in poorer wealth quintiles, and those without media exposure, could improve testing frequency and support progress toward the UNAIDS 95-95-95 targets.