The Lancet Global Health

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 (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.

BackgroundLong-acting injectable HIV pre-exposure prophylaxis (PrEP), including Lenacapavir, has the potential to accelerate HIV incidence declines in eastern and southern Africa (ESA). However, high product and delivery costs and constrained budgets necessitate efficient prioritization strategies to maximize impact and achieve cost-effectiveness. MethodsWe used district-level HIV incidence estimates published by UNAIDS to estimate the direct health and economic impact of prioritizing Lenacapavir delivery according to geography, age, and sex across 837 districts in 11 high-burden ESA countries. Infections and disability-adjusted life years (DALY) averted, number needed to treat (NNT), cost per DALY averted, and price thresholds to achieve cost-effectiveness were estimated across geographic prioritization scenarios. Cost-effectiveness was assessed against a $500 per DALY averted threshold, assuming $5,000 discounted lifetime HIV treatment costs and 10 DALYs per HIV infection. Sensitivity analyses varied Lenacapavir costs (commodities + delivery) per person per year (pppy) ($125 versus $55), DALYs per HIV infection (7.5), and the risk differentiation among those who uptake long-acting PrEP. ResultsHIV incidence varied substantially across ESA, with 50% of new infections in districts containing less than 20% of at-risk adults. Lenacapavir cost-effectiveness varied accordingly, with high-incidence districts exhibiting substantially lower NNT and higher price thresholds for cost-effective delivery. In high-incidence districts, [>5/1,000 person-years (py)], of South Africa, Mozambique, Lesotho, and eSwatini, Lenacapavir would be cost-effective at $50-100 pppy. In South Africa, at annual cost $55 pppy, Lenacapavir was cost-effective in all 52 districts when provided to women aged 15-24 years with incidence exceeding twice the district average and could reach approximately 18-20% of new infections while covering 4% of the full HIV-negative adult population aged 15-49 years. Geographically optimized prioritization in South Africa with minimal age and risk-group stratification achieved efficiency comparable to country-level prioritization to high-risk groups and key populations ([~]20% incidence reduction with 3-5% coverage). Impact and cost-effectiveness were sensitive to assumptions about risk heterogeneity. ConclusionsLenacapavir impact and cost-effectiveness varies substantially across geographic settings, driven primarily by variation in HIV incidence. Simple incidence-based models can identify where universal provision to certain demographic groups is both impactful and cost-effective, particularly in high-incidence districts and age groups.

BackgroundTuberculosis (TB) remains a leading cause of morbidity and mortality among people living with HIV (PLHIV), who face a 12-fold higher risk of active TB reactivation than HIV-negative individuals. TB preventive therapy (TPT) is an effective intervention, yet TB/HIV co-infection persists at 40-45%, raising questions about the durability of a single course of TPT. This study assessed the time from TPT completion to TB diagnosis and predictors of early TB reactivation. MethodsWe conducted a retrospective case-only cohort study using routine data from Ugandas electronic medical record system, TB registers, and patient files at three TASO Centres of Excellence (Soroti, Mbale, Tororo). PLHIV on antiretroviral therapy (ART) diagnosed with TB after completing TPT between 2022-2024 were included. Participant characteristics and time to TB diagnosis were summarised descriptively; predictors of early TB were identified using logistic regression. ResultsAmong 670 participants, most were female (464, 69.3%) with mean age 51.6 years (SD 14.5). Newly diagnosed TB accounted for 638 (95.2%), including bacteriologically confirmed pulmonary TB (535, 79.9%), clinically diagnosed TB (123, 18.4%), and extrapulmonary TB (12, 1.8%). Overall, 548 (82.8%) participants were virally suppressed, with most on Dolutegravir-based regimens (641, 95.7%). Early TB occurred in 144 (21.5%), with average time to diagnosis 2.6 years. Multivariable analysis showed care at TASO Soroti was protective (aOR = 0.104, p < 0.001), while clinically diagnosed TB (aOR = 1.91, p = 0.007), shorter ART duration (<5 years: aOR = 3.07, p = 0.001; 5-10 years: aOR = 1.74, p = 0.018), and viral suppression (aOR = 1.87, p = 0.014) increased odds of early TB. ConclusionsTB can occur soon after TPT completion, with one in five PLHIV developing early disease particularly those with shorter ART duration despite viral suppression. Strengthening TB screening, continuous monitoring, and repeat TPT for high-risk groups may improve prevention.

Low participation in public health testing can lead to biased estimates of disease prevalence and inefficient allocation of public health resources. We evaluated the impact of monetary incentives and revisits on participation in door-to-door COVID testing in rural western Kenya. We conducted a cross-sectional study of all residents in 12 villages in rural western Kenya. We offered an incentive of KSh 200 (1.85 USD), KSh 350 (3.23 USD), or KSh 700 (6.47 USD), randomized at the household level, for each household member >3 months old who participated in COVID testing. Among 7,049 individuals, 5,659 individuals consented to testing. Overall, after revisits, 78.2% consented in the KSh 200 group, 80.6% in the KSh 350 group, and 81.9% in the KSh 700 group. Among individuals offered KSh 200, revisiting increased the consent rate from 68.1% to 78.2%, or 7.3 percentage points higher than the first visit consent rate in the KSh 700 group. Participation was very high (96.9%) among available individuals, but 17.2% of individuals were never available. Offering KSh 200 minimized the cost per consenting individual in our sample, even with revisits, compared to higher amounts. However, individuals in the KSh 700 group were slightly more likely to test positive, which suggests these individuals are missed at lower incentive amounts. Overall 0.3% (95% CI: 0.2, 0.5) tested positive for current infection by qPCR on nasal swabs, and 8.6% (7.7, 9.6) tested positive for SARS-CoV-2-specific antibodies by ELISA on dried blood spots. Accounting for nonresponse bias suggests this COVID population burden may be an underestimate. Our findings suggest incentives can increase participation in household door-to-door public health surveillance testing and may improve disease prevalence estimates by reducing nonresponse bias. However, high incentives may not be cost effective when low incentives motivate very high levels of participation. Significance StatementAchieving high levels of participation in testing can inform public health strategies for reducing the spread of infectious diseases. Cash incentives are one tool for increasing participation, but there is little evidence on the effectiveness of this approach in low-resource settings. We find that cash incentives increase participation in free COVID-19 testing in rural Kenya and may reduce nonresponse bias.

BackgroundTyphoid fever incidence estimates are central to policy decisions on vaccine introduction and investments in non-vaccine prevention and control but are often unavailable. We explored whether prevalence metrics from sentinel studies of community-onset bloodstream infections could accurately predict local Salmonella Typhi (S. Typhi) incidence. MethodsUsing a previous systematic review (January 2018-December 2024), we identified studies reporting both typhoid incidence and prevalence of community-onset bloodstream infections from sentinel sites. From authors, we requested data on blood culture isolates and analysed four metrics: (i) S. Typhi prevalence among probable pathogens, (ii) S. Typhi rank order, (iii) S. Typhi to Escherichia coli ratio, and (iv) S. Typhi to stably endemic organisms ratio. Typhoid incidence was categorized as low (<10), medium (10-100) or high (>100) per 100,000 person-years. We used univariate ordinal regression to assess the association between each metric and typhoid incidence level. The model performance was evaluated by the c-statistic, sensitivity, and specificity. FindingsAnalysis of 29 study sites (20 Africa, 9 Asia) yielded 4,625 probable pathogens. The median (IQR) typhoid incidence was 140 (28-319) per 100,000 person-years. All metrics were associated with increased typhoid incidence level: for each 1% increase in S. Typhi prevalence OR 1.07 (95%CI 1.02-1.15); rank order OR 0.25 (95%CI 0.06-0.64); log S. Typhi to E. coli ratio OR 2.91 (95%CI 1.45-7.42); log S. Typhi to stably endemic organisms ratio OR 3.69 (95%CI 1.69-11.3). A parsimonious model using S. Typhi prevalence alone achieved c-statistics of 0.87 (0.58-0.97), 0.76 (0.51-0.91), and 0.88 (0.69-0.96) for low, medium, and high incidence, respectively. InterpretationSentinel prevalence metrics from bloodstream infections, particularly S. Typhi prevalence among probable pathogens, could be useful for inferring local typhoid fever incidence where direct data are unavailable. FundingGates foundation Research in contextO_ST_ABSEvidence before this studyC_ST_ABSGlobally, annual deaths from typhoid fever were estimated at 71,954 (95% uncertainty interval 38,051 to 118,560) in 2023. Typhoid conjugate vaccines (TCV) are recommended for regions with high typhoid incidence. Implementation, however, can be challenging due to a lack of local incidence data. Generating community incidence estimates requires expensive and time-consuming large prospective or hybrid surveillance studies, or novel techniques such as serology or environmental surveillance. Our previous study proposed that metrics from sentinel healthcare facilities such as the prevalence of Salmonella Typhi (S. Typhi) among all bloodstream pathogens or its rank order relative to other pathogens could serve as proxy for community incidence. However, contemporaneous incidence and prevalence data from the same time and location were limited in our previous study. To explore typhoid incidence estimation strategies, we searched PubMed and MEDLINE on January 8, 2026 with search terms including keywords of "typhoid fever", "incidence", and "prediction" without restrictions to language or publication date. Previous studies estimated incidence based on complex country-level covariates and disease modelling that lack ease of applicability for policy decisions. Recognising the need for pragmatic tools, we explored whether prevalence metrics from sentinel studies of community-onset bloodstream infections could accurately predict local S. Typhi incidence. Added value of this studyOur study was based on typhoid incidence studies that had available data for isolates of bloodstream infections. Of 29 sites across Africa and Asia with 4,625 probable pathogens, we found that all four sentinel metrics were significantly associated with typhoid incidence level. We demonstrated that a parsimonious model using S. Typhi prevalence alone achieved good discriminative performance in identifying high incidence settings. Implications of all the available evidenceWhen typhoid incidence estimates are unavailable, prevalence metrics from sentinel studies of community-onset bloodstream infections could help policymakers infer typhoid incidence and optimise resource allocation in water, sanitation, and hygiene, and TCV introduction.

BackgroundAbrupt cessation of USAID and CDC resources to KwaZulu Natal province in South Africa, threatens the progress over decades to address HIV. MethodsWe used a previously developed validated HIV transmission model with input from the KZN Department of Health and local stakeholders to estimate impact of funding cuts on HIV incidence and mortality at 12-months and through 2030. We applied the model to estimate the impact of restoring funds on HIV incidence and mortality. ResultsHIV incidence increased at 12 months and through 2030 by 3.4% and 22.8%, leading to 35,300 and 116,100 additional infections, and 12,800 and 42,300 additional deaths, respectively. Restoring funding after a 12-month pause, reallocated to focus on long-acting PrEP, would avert 12,600 new infections. ConclusionThis model application demonstrates that the sudden cessation of USAID and CDC commitments in the largest HIV epidemic in the world leads to increased incidence and mortality and threatens decades of progress in KZN, South Africa. Restoring funding within 12 months and increasing efficiency of HIV interventions can reestablish KwaZulu Natal province, South Africas trajectory toward EHE goals.

BackgroundStage at time of diagnosis and survival after diagnosis are critical parameters regarding control of any cancer in any geographical setting. In earlier research focusing on the initial years of the "Treat All" era (2016-2019), we found that HIV-associated Kaposi sarcoma (KS) in East Africa continued to be diagnosed at advanced stage of disease and conferred high mortality. Given the potential for broader implementation of "Treat All" as well as the announcement of National Comprehensive Cancer Network guidelines for cancer treatment in Africa since 2020 -- but also the countervailing influence of the COVID-19 pandemic -- we sought to provide an update on KS stage at diagnosis and survival after KS diagnosis among people living with HIV (PLWH) in East Africa. MethodsWe evaluated adult PLWH in Kenya, Tanzania and Uganda with a new diagnosis of KS identified at ambulatory and inpatient settings in four regions between September 2021 and April 2024. At time of biopsy, participants were examined to document the extent of KS. In a prospective cohort study, we followed participants to monitor vital status. ResultsAmong 493 PLWH with a new diagnosis of KS, the median (IQR) number of anatomic sites with KS lesions was 9 (4-12), and 91% had ACTG stage T1 (advanced KS). Over a median follow-up of 11 (IQR: 2.2-20) months, a total of 209 participants died, and three were lost to follow-up. Cumulative incidence of death (95% confidence interval) at months, 3, 6, 12 and 18 following KS diagnosis was 26% (22% to 30%), 32% (28%-36%), 39% (34%-43%) and 45% (40%-51%), respectively. Cumulative incidence of death was similar between countries and year of KS diagnosis. ConclusionsAmong PLWH with newly diagnosed KS in East Africa during the post-initial phase of the "Treat All" era (2021-2024), the majority had advanced disease at KS diagnosis and survival was very poor. These parameters are unchanged from the five prior years. Our findings emphasize the need for better KS control strategies in the region, including primary prevention, novel approaches for earlier detection, more timely linkage to care, and more accessible and potent anti-KS therapy.

BackgroundIn trials, three-month weekly rifapentine and isoniazid (3HP) showed higher adherence and completion than the six-month daily isoniazid (6H) regimen for TB preventive treatment (TPT). However, programmatic outcome data remain limited. MethodologyWe evaluated the TPT cascade among people with HIV (PWH) aged >15 years newly enrolled in HIV care in western Kenya. Initiation and completion of 6H (Jan to Sept 2022) were compared to 3HP (Oct 2022-Sept 2023) using Chi-square tests. Correlates of non-initiation and non-completion were assessed using Poisson regression with generalized linear models. Mortality within 24 months was evaluated using Cox proportional hazards regression. ResultsOf 1,930 PWH (median age 33 years [IQR=27-41]), 65.8% were female, and 19.5% had AHD at enrolment. Overall, 1,922 (99.6%) were screened for active TB, of whom 1,790 (97.5%) were TPT-eligible; 1577 (88.1%) of these initiated TPT. TPT initiation was higher with 3HP than 6H (89.8% vs. 84.2%; p<0.001). TPT completion was similar for 3HP and 6H (89.2% vs. 88.8% p=0.77). TB incidence (per 1,000 person-months) was lower among TPT-completers (0.22; 95% CI 0.15-0.35) than those who neither initiated (4.25; 95% CI 1.77-10.23) nor completed TPT (3.75; 95% CI 2.49-5.64). AHD was associated with higher risk of TPT non-initiation (aRR=2.14; 95% CI 1.59-2.87) and non-completion of both 6H (aRR=2.56; 95% CI: 1.55-4.23) and 3HP (aRR=1.68; 95% CI 1.07-2.63). Conclusions3HP increased TPT initiation but did not improve completion rates compared to 6H. Targeted interventions are needed to support 3HP completion, particularly in PWH with AHD Key pointsWe compared 3HP and 6H for TB prevention in people with HIV in western Kenya. 3HP led to better initiation and both had high completion rates. Advanced HIV disease affected participation and non-completers faced significant mortality.

IntroductionHIV testing for children of women living with HIV (WLHIV) is an efficient method of diagnosing HIV in children. We analyzed pooled data from 13 Population-based HIV Impact Assessments (PHIA) conducted from 2015 through 2019 to determine the gap in diagnosing HIV in children of WLHIV. MethodsIn each PHIA, children younger than 15 years in a subset of households were sampled for HIV testing. Mother-reported responses on childs status were linked to maternal interviews and biomarker data. Analysis was restricted to children whose mothers were alive, older than 15 years and aware of their HIV-positive status prior to the survey. We calculated weighted proportions of children who were never previously tested and proportion of children living with HIV (CLHIV) with no evidence of antiretroviral treatment (ART) use (categorized as newly diagnosed). Survey weights were pooled across all PHIAs to account for survey design and nonresponse. ResultsOf 4,234 WLHIV, 3,436 were aware of their HIV status and had at least one child (n=6,173) for whom responses were obtained. Of the 6,173 children, 43.5% (n=2,371) were reported as never been tested. Overall, 5,500 children provided blood for HIV testing during the survey. Newly diagnosed test positivity was 1.7% (90/5,191); 2.9% (61/2,120) among those with reported unknown HIV status and 0.9% (29/3,071) among those with reported HIV negative status. Among children with reported HIV positive status, 94.5% were confirmed by survey testing and of these, 91% had antiretrovirals (ARVs) detected. ConclusionsOver 40% of children of WLHIV who were aware of their HIV positive status had never been tested for HIV. HIV positivity ranged between 0.9% to 2.9% while 9.0% of children known to be HIV positive were not on ART. The study calls for renewed efforts to enhance testing of children and treatment linkage for those diagnosed with HIV.

BackgroundInsecticides remain the cornerstone of mosquito vector control for malaria, dengue, and other mosquito-borne diseases, yet global patterns of deployment and their socioeconomic and environmental drivers are poorly characterized. Understanding where and why insecticides are used is essential for better targeting control efforts and ensuring they are effective, equitable, and efficient. MethodsWe analyzed annual country-level insecticide-use data from 122 countries (1990-2019), reported as standard spray coverage for insecticide-treated nets (ITNs), residual spraying (RS), spatial spraying (SS), and larviciding (LA). Generalized linear mixed models and hurdle models quantified associations between deployment and disease incidence, human development index (HDI), human population density, temperature, and precipitation. Models were evaluated using repeated cross-validation and applied to generate downscaled predictions of insecticide use at subnational administrative region level 2 (ADM2) globally. FindingsInsecticide deployment increased with malaria and dengue incidence, but this response was substantially stronger in higher-HDI countries, indicating that deployment depends on socioeconomic capacity as well as disease burden that leads to weaker scaling in lower-resource settings. Intervention types exhibited distinct patterns; ITN use tracked malaria burden, whereas infrastructure-intensive approaches (e.g., RS and SS) were concentrated in higher-HDI settings and increased with Aedes-borne disease incidence. Downscaled ADM2-level maps uncovered substantial within-country heterogeneity that is obscured at the national scale, highlighting regions where predicted deployment remains low relative to disease risk across sub-Saharan Africa, South Asia, and parts of Latin America. InterpretationGlobal insecticide deployment reflects not only epidemiological need but also economic and logistical capacity, creating mismatches between risk and control. High-resolution mapping can support more equitable allocation of interventions, guide insecticide resistance stewardship, and improve strategic planning as climate and urbanization reshape mosquito-borne disease risk.

BackgroundRotavirus remains a leading cause of childhood diarrhoeal hospitalisation globally. Malawi introduced the monovalent G1P8 rotavirus vaccine (Rotarix(R)) in October 2012 and in April 2016 switched from trivalent to bivalent oral poliovirus vaccine (tOPV to bOPV). More than a decade after Rotarix(R) introduction, evidence on sustained vaccine effectiveness and population-level impact in high-transmission, low-income settings remains limited, and it is uncertain whether programme changes such as the OPV formulation switch have influenced Rotarix(R) performance over time. MethodsWe estimated the long-term impact and effectiveness of Rotarix(R) on diarrhoea hospitalisation in Malawi and explored whether OPV type changes Rotarix(R) effectiveness. We used interrupted time-series and test-negative case-control analyses to assess the impact and effectiveness of Rotarix(R), respectively, over seven years post vaccine introduction using data from diarrhoeal surveillance studies in children under five years hospitalised with acute gastroenteritis at Queen Elizabeth Central Hospital, in Blantyre, Malawi, between 1997 and 2019. Stool samples from these children were collected and tested for rotavirus A antigen using enzyme immunoassay (EIA). To assess the effect of concurrent vaccination with OPV, we used a test-negative case-control study to estimate the interaction between the two vaccines. FindingsThe interrupted time-series was based on 7,952 hospitalisations and showed a 23% (95% confidence interval (CI): 10 - 34%) reduction in rotavirus hospitalisations rates among children under five years in the post-vaccine introduction period (January 2013 - December 2019) compared with the pre-vaccine period (July 1997 - December 2012). There was a stronger effect among infants under one year (37%; 95% CI: 25 - 47%). Protection declined with age, with little measurable impact beyond infancy. The test-negative analysis enrolled 1,909 children and Rotarix(R) effectiveness for two doses was 52% (95% CI: 18 - 71%) overall, 67% (95% CI: 36 - 82%) among infants and 29% (95% CI: -136 - 74%) in those older than one year. Analyses of the tOPV to bOPV switch (n = 1,622) showed no measurable interaction with Rotarix(R) performance (aOR 1.07; 95% CI: 0.85 - 1.34). InterpretationRotarix(R) provides moderate protection for Malawian infants, and the transition from tOPV to bOPV did not influence vaccine effectiveness. The lower effectiveness of rotavirus vaccination with increasing child age highlights the need to evaluate alternative vaccination strategies alongside strengthened WASH interventions to sustain vaccine impact in LMICs. FundingMRC Discovery Medicine North (DiMeN) Doctoral Training Partnership (UKRI) and National Institute for Health and Care Research (NIHR) Research in contextO_ST_ABSEvidence before this studyC_ST_ABSMultiple reviews have evidenced variable vaccine effectiveness by setting and age. A recent global review and meta-regression of efficacy and effectiveness data by the authors (https://doi.org/10.1016/j.eclinm.2025.103122), updated to October 2024, highlighted lower rotavirus vaccine effectiveness and impact in high-burden, low- and middle-income countries (LMICs) compared with high-income settings. Studies in LMICs including those in sub-Saharan Africa (SSA) consistently indicate that protection is strongest in infants, with impact and effectiveness declining in older children. Multiple factors have been implicated for this variability in effectiveness, including interference from co-administration of oral polio vaccines. We also conducted a systematic review of post-licensure rotavirus vaccine impact and effectiveness studies from sub-Saharan Africa (CRD42023436851). We also assessed the principal study designs used and the extent to which they adjusted for concurrent public health and social measures (PHSMs). We searched PubMed, EMBASE, MEDLINE, CINAHL, and Google Scholar for studies of vaccine impact or effectiveness in children under five years and screened reference lists of included studies. Across all eligible studies, none measured or adjusted for concurrent public health or social measures. To date, most SSA evaluations have focused on the early post-introduction period, with limited evidence on longer-term vaccine performance and no epidemiological evaluation of the potential effect of co-administration of oral polio vaccines on rotavirus vaccine effectiveness. Added value of this studyWe provide a long-term evaluation of the monovalent rotavirus vaccine (Rotarix(R)) in Malawi using a single hospital-based surveillance platform spanning the pre-vaccine and post-vaccine periods. We combine interrupted time-series analyses of population-level impact with test-negative estimates of individual-level effectiveness using consistent age strata. We also examine whether the national switch from trivalent to bivalent oral poliovirus vaccine modified rotavirus vaccine effectiveness, addressing a programme change that has rarely been assessed in rotavirus vaccine evaluations. Implications of all the available evidenceThe available evidence indicates modest rotavirus vaccine benefit in sub-Saharan Africa, with protection concentrated in infancy and little measurable effect in older children. Our findings highlight the need to interpret long-term vaccine impact estimates alongside changes in other PHSMs that influence rotavirus disease burden, including water and sanitation and access to care. The absence of an effect associated with OPV formulation change suggests that modifying OPV valency alone is unlikely to improve rotavirus vaccine performance. Extending protection beyond infancy may require alternative vaccine schedules alongside sustained improvements in broader public health conditions.

BackgroundThe burden of new HIV infections and HIV-related deaths have declined dramatically in sub-Saharan Africa (SSA). However, current HIV surveillance systems are primarily donor-funded and rely on data from population-based surveys and routine health services. These need to evolve so that they can reliably monitor future HIV trajectory, in the context of declining burden of HIV and limited donor funding. We qualitatively assessed stakeholder perceptions of the current status and future needs for HIV surveillance. MethodsFrom September 2024 to February 2025, we conducted a grounded-theory qualitative study whose participants were representatives of international HIV agencies, policy makers and health sector development partners and HIV programme managers from Malawi, Lesotho, Zimbabwe, Ghana and Kenya, and HIV programme implementers from Malawi. We conducted 28 online and in-person key informant interviews and three focus group discussions with 34 Malawi-based participants working at sub-national level. These were audio-recorded for transcription. We conducted sequential deductive and inductive content analyses. ResultsWe found that HIV programs in SSA are familiar with and have successfully used routine health system data, population-based surveys, and mathematical modeling for HIV surveillance and monitoring and evaluation (M&E). However, most respondents could not distinguish the differences between M&E and surveillance and were unaware of the key inputs for mathematical models used to estimate key impact indicators. They expressed concern over the parallel HIV data systems, lack of integration with the broader health surveillance systems, sub-optimal quality of routine facility-based data, and the huge cost and limited precision of population-based surveys. They recommended investment in several areas including data quality improvement, adoption of digital technology and artificial intelligence to improve the efficiency of the surveillance system, expanded stakeholder sensitization in mathematical modeling, implementation of targeted surveys focusing on high-risk populations, and prioritization of HIV morbidity and mortality indicators. ConclusionsFuture HIV surveillance strategies need to invest in institutionalizing local capacity for using multiple HIV data streams to inform key surveillance indicators through modeling and analytic tools, establishing management systems to enhance routine data quality, streamlining HIV surveillance and M&E indicators, and fostering disease surveillance integration. Targeted surveys will be required to complement routine facility-based surveillance.

BackgroundCervical cancer remains a significant global public health challenge, with the overwhelming majority of its burden borne by low- and middle-income countries. Globally, an estimated 660,000 new cases and 350,000 deaths occur each year, with more than 90% of cervical cancer-related mortality concentrated in resource-limited settings. In Africa, limited access to organized screening programs and early detection services continues to contribute to persistently high incidence and mortality rates, despite the preventable nature of the disease. MethodsWe conducted a cross-sectional analysis of WHO STEPwise (STEPS) survey data collected between 2014 and 2019 from 11 African countries. The analysis included 25,471 women aged 15 years and older. Weighted prevalence estimates were calculated, and multivariable logistic regression models were fitted to identify factors associated with ever having been screened for cervical cancer. Predicted probabilities were estimated and stratified by age and residence. ResultsThe pooled prevalence of cervical cancer screening uptake was approximately 10.0%. Uptake was consistently higher among urban women than rural women across all age groups. In adjusted analyses, screening uptake increased strongly with age, peaking at 50-54 years (AOR = 8.21; 95% CI: 5.55-12.14). Higher education showed a clear positive gradient, with tertiary education associated with more than threefold higher odds compared with no education (AOR = 3.20; 95% CI: 2.65-3.86). Urban residence was associated with higher uptake (AOR = 1.22; 95% CI: 1.11-1.34). Substantial cross-country variation was observed, with higher odds in Botswana (AOR = 6.58; 95% CI: 5.51-7.86) and markedly lower odds in Benin (AOR = 0.08; 95% CI: 0.05-0.14). Hypertension was positively associated with screening uptake, while low fruit and vegetable intake were inversely associated. ConclusionsCervical cancer screening uptake in Africa remains critically low and unevenly distributed. Addressing age, educational, urban-rural, and country-level disparities is essential to achieving WHO elimination targets.

Despite substantial progress in preventing mother-to-child transmission (PMTCT) of HIV in Zambia, HIV infection among children whose mothers test HIV-negative represents an understudied phenomenon that may reflect non-vertical transmission pathways. This cross-sectional secondary analysis of the 2024 Zambia Demographic and Health Survey (ZDHS) examined the prevalence and correlates of HIV among children aged 2-14 years whose mothers tested HIV-negative. Children with valid HIV blood test results were linked to their co-resident mothers HIV test results using household-level identifiers. HIV prevalence with 95% confidence intervals was estimated by age group, sex, residence, province, and wealth quintile. Bivariate associations were assessed using chi-square tests and odds ratios. Among 13,960 children of HIV-negative mothers, 69 (0.49%; 95% CI: 0.39%-0.63%; weighted: 0.58%) tested HIV-positive. Prevalence varied substantially by province (p < 0.001), with Copperbelt Province exhibiting the highest burden at 2.97%. Urban children had significantly higher prevalence than rural children (1.10% vs. 0.26%; OR = 3.68, 95% CI: 2.25-6.03, p < 0.001). A paradoxical wealth gradient was observed, with children in richer households showing higher prevalence than those in the poorest households (OR = 4.93, 95% CI: 2.19-11.10, p < 0.001). Maternal education was marginally associated with child HIV status (p = 0.04). Neither child sex (p = 0.10) nor age group (p = 0.29) was significantly associated with HIV positivity. A substantial proportion of HIV-positive children in Zambia have HIV-negative mothers, highlighting important gaps in the current PMTCT-focused paradigm and calling for expanded prevention strategies that address transmission risks beyond vertical transmission.

BackgroundTo promote sustainability and strengthen national ownership of Advanced HIV Disease (AHD) services, a transition was implemented across 22 health facilities in Central Malawi. This transition involved shifting responsibility for key AHD program elements, including clinical service delivery, diagnostics, provider mentorship, and reporting systems, from implementing partner-led implementation to full Ministry of Health (MoH) leadership. This evaluation assessed the impact of this transition on diagnostic coverage, TB preventive therapy (TPT) uptake, and 12-month survival outcomes. MethodsA retrospective cohort study was conducted involving all children and adults enrolled in AHD care during the pre-MoH transition (January 2020-December 2021) and post-MoH transition (January 2023-December 2024) periods. Eligibility followed national AHD criteria: CD4 count <200 cells/mm3, WHO stage 3 or 4 illness, or age <5 years. AHD clients data were abstracted from clinical records and linked across routine facility registers to assess diagnostic and treatment indicators. Kaplan-Meier survival curves, Cox proportional hazards, and Fine and Gray competing risk models were used to evaluate 6 and 12-month mortality and retention as primary outcomes. ResultsA total of 1,044 AHD clients were included (553 pre-transition; 491 post-transition) in the evaluation. Median age increased post-transition (35.9 to 38.5 years, p<0.001). CD4 testing declined (80.7% to 46.0%, p<0.001) testing uptake, while WHO staging and TB diagnostic coverage improved. TB diagnoses decreased (44.5% to 31.2%, p=0.002). TPT uptake dropped from 46.4% to 31.6% (p<0.001). Twelve-month mortality significantly declined from 9.4% to 5.5% (adjusted hazard ratio [aHR]=0.59, 95% CI: 0.37-0.94, p=0.026). Retention in care remained stable (HR=0.86, 95% CI: 0.62- 1.20, p=0.384). ConclusionsTransitioning AHD services to MoH leadership sustained key program outcomes and significantly reduced mortality. Continued mentorship and government ownership were key drivers of success. However, declines in CD4 testing and TPT coverage highlight the need for strengthened diagnostics and preventive care integration. These findings support scaling nationally-led AHD models in high-burden HIV settings.

BackgroundArtemisinin-based combination therapies (ACTs) are the most widely used treatment for Plasmodium falciparum malaria. Kelch 13 mutations associated with artemisinin partial resistance (ART-R) have emerged in Sub-Saharan Africa (SSA) and are now reported in an increasing number of countries. ACT treatment failure rates are at risk of unprecedented increase. To summarise existing surveillance data and guide future surveillance, we produce modelled estimates of the spatiotemporal distributions of Kelch 13 and partner drug marker prevalence in SSA. MethodsWe develop and validate spatiotemporal statistical models, fitted within a Bayesian framework, given molecular surveillance data. We estimate the prevalence of Kelch 13 mutations that are validated or candidate markers of ART-R and the prevalence of the mutations Pfcrt-K76T, Pfmdr1-N84Y, Pfmdr1-Y186F, and Pfmdr1-D1246Y, associated with selection by pressure from the ACT partner drugs amodiaquine and lumefantrine. FindingsOur models reflect all existing clusters of ART-R-associated Kelch 13 mutations. We estimate the prevalence of these Kelch 13 mutations to be greater than 10% in 23% of the area of endemic malaria transmission in SSA in 2026. We also estimate that 5.8% of malaria cases in 2026 will be affected by a validated or a candidate ART-R marker. Our estimates of the prevalence of Pfcrt-K76T and other partner drug markers reflect sustained pressure from artemether-lumefantrine: we estimate the median prevalence of Pfcrt-76T across SSA to be 19% in 2026. InterpretationOur models allow readers to visualise variation in observed mutation prevalences and to extrapolate prevalence to regions in space and time that are not represented in surveillance data. To monitor the changing distribution of antimalarial resistance markers within the constraints of the current global health funding climate it is critical that validated, statistical frameworks are incorporated into decision-making workflows to make the best use of molecular surveillance data. FundingThis research was funded by the European Union under the Global Health EDCTP3 Joint Undertaking (grant agreement 101103076) and the Australian National Health and Medical Research Council (APP2019093). Research in contextO_ST_ABSEvidence before this studyC_ST_ABSOngoing systematic reviews of molecular surveillance of antimalarial resistance markers collate evidence of changing prevalences of Kelch 13 mutations associated with artemisinin partial resistance. However, there is a high degree of sampling bias in this data, and there are regions where limited surveillance has been carried out. We searched PubMed with the search terms: (((spatial OR spatiotemporal) AND (artemisinin OR Kelch)) AND (Africa)) AND (model* OR map OR mapping) which returned 30 results. We identified one recent pre-print describing spatiotemporal models of molecular markers of ART-R and partner drug resistance, however these models were not formally validated and model uncertainty may have been under-estimated. Added value of this studyWe use spatiotemporal statistical models to estimate resistance marker prevalence in regions where there has been no molecular surveillance. Our models predictions are contextualised by estimates of model uncertainty, and we validate our modelling framework through posterior predictive checks and by evaluating its predictive performance on held-out data. Implications of all available evidenceKelch 13 mutation prevalences are rising in all existing clusters where mutations have been identified, including in southern Africa. We estimate elevated prevalences in regions that neighbour existing clusters that are not well-represented in our surveillance dataset.

ObjectiveTo evaluate whether new tuberculosis (TB) tools in the electronic health record (EHR) can support latent TB infection (LTBI) screening, testing and treatment among children and adolescents in a primary care setting. Study DesignThis retrospective cohort study included children and adolescents between the ages 1-25 years who had a well-child or well-adolescent visit at a Federally Qualified Health Center in Oakland, California, from December 2021 to December 2022. Four new EHR tools were introduced for the completion and documentation of TB risk factor screening, testing and treatment. Data were extracted from the EHR to identify gaps in these steps, and logistic regression was used to examine factors associated with completion of TB infection screening and testing. Acceptability was evaluated using provider satisfaction surveys before and after the implementation of TB EHR tools. ResultsOf 5,879 individuals (median age of 9 years at first visit, interquartile range (IQR) 4-13 years), 94% completed TB risk factor screening. Among those with a new risk factor, 59% had a TB infection test ordered and 96% completed testing. Ten participants (3%) tested positive, all initiated LTBI treatment, and most (n=7, 70%) completed treatment. Overall, 5,162 (88%) individuals completed their LTBI care cascade. Younger children ages 1-4 years were more likely to be screened for TB risk factors, but were less likely to be tested. Provider satisfaction increased from 40% to 71% for risk factor screening, and 36% to 77% for test ordering. ConclusionEHR tools supported completion of the pediatric LTBI care cascade, while also increasing provider satisfaction. EHR-based solutions show promise as part of multi-component strategies to address gaps in LTBI care for children and adolescents.

Background Nigeria has experienced its largest recorded diphtheria outbreak since late 2022, centred on Kano State, where facility-based surveillance documented over 25,000 confirmed cases. The true community burden remains unknown. We conducted a population-based household survey to estimate community attack rates, mortality, vaccination coverage, and determinants of infection and death. Methods We performed a retrospective household survey (September-October 2024) using spatially randomised cluster sampling (65 clusters, ~15 households each; recall period January 2023 to interview). Survey-weighted analyses, multivariable logistic regression, and sensitivity analyses were used. Findings We enrolled 7,998 individuals from 1,068 households. The community attack rate was 1.1% (95% CI 0.7-1.4), 4.2 times (2.7-5.3) higher than facility-based estimates. The case fatality ratio was 8.8% (1.9-15.6) overall and 21.3% among children under five; two thirds of deaths occurred at home. Delayed care-seeking of four or more days was associated with markedly higher mortality (risk ratio 32.6, 95% CI 2.4-450.0). Vaccination was strongly protective against death (vaccine effectiveness 57%, 95% CI 34- 72%; E-value 4.07). Among campaign-eligible children, routine EPI coverage was 56.6%; the reactive campaign reached few previously unvaccinated children (99.7% overlap with prior recipients), leaving 11.6% of eligible children unvaccinated. Interpretation Community diphtheria burden substantially exceeded facility surveillance estimates, with most deaths occurring outside the health system. Delayed care-seeking and low vaccination coverage were the main drivers of mortality, highlighting the need for improved community surveillance, decentralised care, and better-targeted vaccination.