Tropical Medicine and Infectious Disease

Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment-seeking in low-resource settings is scarce. This study aims to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among adults with STI-related symptoms in rural Uganda. The STI prevalence study (STIPS) conducted a population-based survey and STI testing among all consenting adults aged 18-49 in two communities in rural south-central Uganda. Of 1,825 participants, 962 individuals self-reported STI symptoms in the past six months; we present descriptive data on treatment-seeking and STI prevalence among these individuals. We used multivariable Poisson regressions with robust variance to determine the sociodemographic and symptom-related factors independently associated with seeking STI treatment at a clinic and assessed the association with previous clinic treatment-seeking and current STI diagnosis. Forty-three percent of adults who reported STI-related symptoms in the past six months said they did not seek any treatment. Among those who did, 58% sought treatment at a private clinic, 28% at a government clinic, 9% at a pharmacy/drug store, 3% at a traditional healer, 2% at a market/shop, and 5% at another location. Among both men and women, having multiple STI related symptoms was positively associated with clinic treatment seeking (men=PRR: 1.73, 95%CI: 1.36-2.21; women=PR: 1.41, 95%CI: 1.12-1.78). Approximately one-third of men and women who reported previously seeking clinic treatment for their symptoms were diagnosed with a curable STI at the time of the survey. In this setting, nearly half of adults with STI-related symptoms are not seeking clinical care and many who report having sought treatment recent STI symptoms have curable STIs. Future studies should explore barriers to care-seeking and strategies to improve STI services.

BackgroundMpox (formerly Monkeypox) virus has affected the lives of thousands of individuals both in endemic and non-endemic countries. Before the May 2022 outbreak, Mpox infections were sporadically endemic in Central and Western Africa, still research into Mpox has been limited and lacking epidemiological data. Thus, identification of potential risk factors to better understand who is at risk of being infected is critical for future prevention and control. ObjectiveTo synthesize comprehensive evidence on risk factors associated with human Mpox transmission both in endemic and non-endemic countries from inception to March 31, 2024. MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in conducting the systematic review. Electronic databases were searched. Two reviewers sifted the articles that were included in the review: firstly, by title and abstract, and secondly, by full text. We used the Newcastle-Ottawa Scale (NOS) to assess the risk of bias for included articles. Fixed or random effects meta-analysis were conducted when at least two studies reported odds ratios (OR), relative risks (RR), with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic and sensitivity analysis was also done. The study protocol has been registered under PROSPERO with ID: CRD42023459895. Results947 articles were identified from the database search and 31 articles were eligible to be included in the systematic review. The findings of the meta-analysis showed that interaction with infected animals (OR = 5.61, 95% CI = 2.83, 11.13), HIV (OR = 4.46, 95% CI = 3.27, 6.08), other STIs (OR = 1.76, 95% CI = 1.42, 2.91), sexual contact/activities (OR = 1.53, 95% CI = 1.13, 4.82), contact with an infected person (OR = 2.39, 95%CI = 1.87, 3.05), being identified as men who have sex with men (MSM) (OR = 2.18, 95%CI = 1.88, 2.51), and having multiple sexual partners Mpox (OR = 1.61, 95%CI = 1.24, 2.09), were associated with an increased risk of contracting Mpox. However, patients who were vaccinated against smallpox had a lower risk of Mpox infection (OR = 0.24, 95%CI = 0.11, 0.55). ConclusionThis study is the first meta-analysis on reported risk factors for Mpox. Our analysis demonstrated that certain factors were associated with increased risk of Mpox, whereas smallpox vaccination had a protective role against contracting Mpox. The study findings could facilitate future strategic public health planning and targeted intervention. Key messages of this articleO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIMpox (monkeypox) is a zoonotic infectious disease of notable global public health importance due to recent outbreaks in non-endemic countries. C_LIO_LIPrior outbreaks of Mpox have been associated with travel to endemic areas in Western and Central Africa, contact with infected animals, and close contact with infectious lesions, particularly among household members. C_LI What this study addsO_LIThis study is the first meta-analysis on reported risk factors for Mpox. Our study findings add to the body of evidence on Mpox research efforts and could assist in future Mpox global strategic intervention and control. C_LIO_LIOur meta-analysis revealed a strong correlation between increased risk of Mpox infection, HVI, other STIs, physical and sexual contacts, and being identified as MSM. C_LIO_LIWhile HIV infection may be a risk factor for Mpox, Mpox lesions could also facilitate the transmission of HIV and other STIs. C_LI How this study might affect research, practice or policyO_LIThe results of this systematic review and meta-analysis provide evidence to support policymakers in future Mpox intervention and prevention in both endemic and non-endemic countries based on identified risk factors. C_LI

ObjectivesDoxycycline prophylaxis shows promise for sexually transmitted infection (STI) prevention, but data primarily come from high-income countries. This study assessed awareness, willingness and factors associated with willingness to use doxycycline for STI prevention among men who have sex with men (MSM) using HIV-PrEP in Vietnam. MethodsBetween January 25 and February 4, 2024, a cross-sectional study recruited males aged [≥]18 years who reported sex with men in the past 12 months from 11 PrEP clinics in Hanoi and Ho Chi Minh City. Self -administered surveys were conducted, and multivariable logistic regression was applied to identify factors associated with willingness to use doxyPEP/PrEP. ResultsAmong 350 participants (45.7% Hanoi, 54.3% Ho Chi Minh City), the median age was 25 (interquartile range [IQR]: 21-30), and 10.6% self-reported an STI diagnosis in the past 12 months. In the previous 6 months, the median number of sex partners was 2 (IQR: 1-4), 53.1% reported condomless anal sex. Awareness of doxycycline was low (20.2%; 65/322), however, 75.4% (264/350) expressed willingness to use it, with 63.6% (168/264) preferring doxyPrEP. Participants who disclosed HIV-PrEP use to all sex partners (adjusted odds ratio [aOR]: 4.17; 95% confidence interval [95%CI] 1.84, 9.46), and those with higher perceived STI risk (aOR: 1.12; 95% CI 1.03, 1.22) were more likely to report willingness to use doxycycline prophylaxis. Concerns about daily medication (aOR: 0.43; 95% CI 0.24, 0.81) and fear of judgement from peers (aOR: 0.41; 95% CI: 0.21, 0.81) were associated with lower willingness. ConclusionsKnowledge of doxyPEP/PrEP among MSM on HIV-PrEP in Vietnam was low. However, most expressed willingness to use doxycycline prophylaxis, with two-thirds preferring doxyPrEP. Findings highlight the need to disseminate information on doxyPEP/PrEP for STI prevention strategy, evaluating the usage and comparative effectiveness of doxyPEP and doxyPrEP to guide implementation efforts in Vietnam. 1. What is already known on this topicMen who have sex with men (MSM) experience a disproportionate burden of HIV and bacterial sexually transmitted infections (STIs) worldwide, including in Vietnam. Despite the successful expansion of HIV Pre-Exposure Prophylaxis (PrEP) programs in Vietnam, bacterial STI rates remain persistently high among PrEP users, highlighting gaps in prevention efforts. Evidence from high-income countries (HICs) suggests that doxycycline prophylaxis can significantly reduce the incidence of bacterial STIs such as syphilis and chlamydia. However, little is known about the awareness, acceptability, and feasibility of doxycycline prophylaxis in Vietnam and other low-and middle-income countries (LMICs). 2. What this study addsThis study is the first to assess awareness, attitudes, and willingness to use doxycycline prophylaxis for STI prevention among MSM in Vietnam, a LMIC setting. Despite low prior awareness, the study found high willingness (75.4%) to use doxycycline, with most participants preferring daily doxyPrEP over doxyPEP. It also identified critical facilitators, such as perceived high STI risk and disclosure of HIV-PrEP use to sex partners, as well as barriers, including stigma, cost, and concerns about daily medication. These findings provide insights into the feasibility of introducing doxycycline prophylaxis in Vietnam, distinguishing it from contexts in HICs where different preferences and barriers may exist. 3. How this study might affect research, practice, or policyThis study provides a foundation for further research on doxycycline prophylaxis in LMICs, emphasizing the need to evaluate its real-world effectiveness and implementation in settings with high AMR prevalence. Policymakers can use these findings to develop tailored guidelines and subsidies for doxycycline prophylaxis in Vietnam, ensuring affordability and accessibility.

BackgroundHistorically, the Democratic Republic of the Congo (DRC) has faced the greatest public health burden from mpox, including more than 70,000 probable cases from 01 January 2024 to 02 February 2025. However, there has been a relative paucity of investigation focused on mpox community engagement in DRC, including assessments of disease knowledge and risk perception. MethodsGiven the ongoing Clade I mpox public health emergency of international concern, and the linkage between sustained human-to-human transmission and dense sexual networks, we sought to investigate mpox knowledge and sexual behaviours among key populations. Between March 20, 2024, and August 25, 2024, we recruited 2794 participants distributed across Kinshasa, Kwango and North Kivu provinces, with a focus in urban centers where mpox risk was considered high. ResultsMost participants were considered other at-risk populations (1035; 37.0%), followed by men who have sex with men (MSM, 831; 29.7%) and sex workers (810; 29.0%). Mpox knowledge, including transmission routes, as well as sexual and health-seeking behaviours were evaluated through questionnaires led by peer educators. Overall, only 6.1% of all participants reported prior mpox knowledge. Among this participant subset, zoonosis ("direct contact with infected animals") and "people living in high-risk areas" were the most frequently selected options in regard to mpox transmission and populations at risk, respectively. When considering at-risk behaviors for mpox, those that identified as sex workers reported significantly higher risk sexual activities including multiple sexual partners (80.3% of sex work participants), engaging in transactional sex (84.7.0%), and anonymous sex (80.8%) compared to MSM. However, both sex workers (44.8%) and MSM (56.7%) reported the highest health seeking behaviors for a suspected sexually transmitted infection. ConclusionOur results highlight that community engagement which incorporates both mpox knowledge and risk perception activities and is inclusive of at-risk populations are needed for ongoing mpox containment and mitigation efforts.

The 2022 mpox outbreak disproportionately affected men who have sex with men (MSM) and individuals with history of HIV. This study investigated the prevalence of HIV infection and associated factors among mpox cases in Colombia. A cross-sectional analysis of 4,046 confirmed mpox cases reported to the Public Health Surveillance System between June 25 and December 31, 2022, was conducted. The prevalence of a history of HIV infection in mpox cases was determined, and associated factors were assessed using bivariate and multivariate logistic regression. Most mpox patients were male (97%), with a median age of 31 years (IQR = 27, 37). The most affected age group was 25 to 34 years (52%), and 83.7% were MSM. The prevalence of HIV history was 60%, with the highest rates in Manizales, Medellin, and Itagui. Common symptoms included genital lesions (59.6%) and fever (67.6%). Factors associated with HIV history in mpox patients were male sex [OR = 9.6, 95% CI = 4.35, 21.31], having sexually transmitted infections: hepatitis B [OR = 2.9, 95% CI = 1.91, 4.40], hepatitis C [OR = 7.0, 95% CI = 3.50, 13.97], syphilis [OR = 2.1, 95% CI = 1.46-3.12], hospitalization [OR = 2.2, 95% CI = 1.65, 2.93], Colombian nationality [OR = 2.5, 95% CI = 1.86, 3.48] and being homosexual [OR = 2.5, 95% CI = 2.09, 3.06]. A high prevalence of HIV infection (60%) was found among mpox patients in Colombia, predominantly among MSM. This highlights the need for targeted interventions, such as priority care for people with HIV, active surveillance, and education for timely diagnosis and prevention of complications.

ContextPrompt administration of post exposure prophylaxis (PEP) is one of the key strategies for ending human deaths from rabies. Delay in seeking first dose of rabies PEP or failure to complete the recommended PEP dosage may result in clinical rabies and death. ObjectivesTo assess the efficacy of short message system (SMS) phone texts on adherence to scheduled PEP doses among bite patients in rural eastern Kenya. Trial design and methodsWe conducted a single arm before-after field trial that compared adherence among bite patients presenting at Makueni Referral Hospital in October - December 2018 (control group) and January - March 2019 (intervention group that received an SMS reminder one day prior to their scheduled PEP doses). Data on demographics, socio-economic status, circumstances surrounding the bite, expenditures related to the bite were collected for all patients. ResultsA total of 186 bite patients were enrolled in the study, with 82 (44%) being in the intervention and 104 (56%) in the control group. The odds of PEP completion was three times (OR 3.37, 95% CI 1.28, 10.20) among patients that received the SMS reminder compared to those that did not. The intervention group had better compliance on the scheduled doses 2 to 5 with a mean deviation of 0.18 days compared to 0.79 days for the control group (p = 0.004). The main reasons for non-compliance included lack of funds (30%), forgetfulness (23%) on days for follow-up treatment, among others. Although the majority of bite patients (94%) were under the Makueni medical insurance cover and did not pay for PEP, nearly all (96%, n=179) the bite patients incurred indirect costs of transport at an average of 4 USD (0 - 45 USD) per visit. ConclusionThis study suggests integrating SMS reminders in healthcare service delivery increases compliance to PEP and may strengthen rabies control and elimination strategies. Trial registrationThe study trial is registered at US National Institute of Health (clinicalTrial.gov) identifier number NCT05350735. https://clinicaltrials.gov/ct2/show/NCT05350735

Campaigns to scale up Voluntary Medical Male Circumcision (VMMC) for the prevention of HIV transmission has been going on for years in selected Southern African countries, following recommendations from the World Health Organisations. Despite significant strides made in the initiative and its proven benefits, controversies surrounding the strategy have never ceased, and its future remains uncertain especially as some countries near their initial targets. Over the years, as the campaigns unfolded, a lot of insights have been generated in favour of continuing the VMMC campaigns, while some insights portray the impression that the strategy is not worthy the risks and effort required, or enough has been done, as the targets have been achieved. This article proposes a scoping review that aims at synthesizing and consolidating that evidence into a baseline for a further systematic review aimed at developing sound recommendations for the future of the VMMC strategy for HIV prevention. The scoping review will target all scientific literature published on the Web of Science, Cochrane Library, Scopus, Science Direct, PubMed as well as WHO Institutional Repository for Information Sharing (IRIS) since 2011. The review shall be guided by Arksey and OMalleys (2005) framework for scoping reviews, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist shall be followed. Discussion of the findings is envisioned to yield evidence that can be further analysed to give insights about risk/cost-benefits ratios of the strategy at this point in time as well best clinical practices for the VMMC procedure, to inform the future of the strategy.

ObjectivesMycoplasma genitalium (MG) disproportionately affects men who have sex with men (MSM). We determined the cost-effectiveness of testing strategies for MG using a healthcare provider perspective. MethodsWe used inputs from a dynamic transmission model of MG among MSM living in Australia in a decision tree model to evaluate the impact of four testing scenarios on MG incidence: 1) no one tested; 2) symptomatic MSM; 3) symptomatic and high-risk asymptomatic MSM; 4) all MSM. We calculated the incremental cost-effectiveness ratios (ICERs) using a willingness to pay threshold of $30,000 AUD per QALY gained. We explored the impact of adding an AMR tax (i.e. additional cost per antibiotic consumed) to identify the threshold whereby any testing for MG is no longer cost-effective. ResultsTesting only symptomatic MSM is the most cost-effective (ICER $3,677 per QALY gained) approach. Offering testing to all men is dominated (i.e. not recommended because of higher costs and lower QALYs gained compared to other strategies). When the AMR tax was above $150, any testing for MG was no longer cost-effective. ConclusionTesting only symptomatic MSM is the most cost-effective option even when the potential costs associated with AMR are accounted for (up to $150 additional cost per antibiotic consumed). For pathogens like MG where there are anticipated future costs related to AMR, we recommend models to test the impact of incorporating these costs as they can change the conclusions of cost-effectiveness studies. KEY MESSAGESO_LIWhat is already known on this topic - Mycoplasma genitalium (MG) is a sexually transmitted pathogen with rising antimicrobial resistance. C_LIO_LIWhat this study adds - This economic evaluation found that testing only symptomatic men who have sex with men (MSM) is the most cost-effective option. When the costs per antibiotic consumed is greater than $150, any testing for MG is no longer cost-effective. C_LIO_LIHow this study might affect research, practice or policy - Among testing strategies for MSM, testing for MG should be restricted to symptomatic men only. C_LI

Despite availability of highly effective oral HIV pre-exposure prophylaxis (PrEP) for close to a decade, uptake and adherence among at-risk young men who have sex with men (YMSM) in Kenya, remain significantly low. This study investigated levels of PrEP knowledge, motivations, facilitators and barriers influencing PrEP initiation, persistence and adherence among YMSM, in efforts to optimise use and reduce risk of new HIV infections. In September 2021, 22 YMSM purposively selected from 248 YMSM who had previously participated in an integrated bio-behavioural sexual health survey, took part in semi-structured in-depth interviews. Interview guides were developed based on the Information-Motivation-Behavioural skills (IMB) model. Questions focused on each of the three IMB model constructs: information about PrEP, motivational factors influencing decision to use or not to use PrEP, and ability to initiate and adhere to PrEP. Data analysis generated three key themes: knowledge, motivation, and barriers to using oral and on-demand PrEP. Participants expressed its awareness and effectiveness in HIV prevention, but were concerned about PrEP- and HIV-related stigma, with the fear that family, friends, and potential romantic partners might perceive them as being promiscuous, or as living with HIV. Participants reported being capable of seeking PrEP services provided in MSM-friendly facilities, with public health facilities perceived as hostile considering the criminalization of, and societal stigma toward same-sex practices. These findings highlight the crucial need to re-strategize PrEP promotion not only as an effective but also a safe HIV-prevention option for at-risk populations. This study recommends expediting the integration of long acting lenacapavir and cabotegravir in the Kenyan health system as a means to diversify PrEP modalities and potentially reduce the stigma experienced in oral PrEP use.

IntroductionOver the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men. MethodsWe conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men. ResultsOverall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors. ConclusionsAcross eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.

BackgroundFemale sex workers (FSWs) in sub Saharan Africa bear a disproportionate burden of HIV infection. While pre exposure prophylaxis (PrEP) is increasingly accessible in the region, limited data exist on FSWs awareness of and willingness to use PrEP. This study aimed to assess PrEP awareness and willingness to use it, along with associated factors, among FSWs in Kigali, Rwanda. MethodsThis cross sectional study, conducted from April to September 2024, evaluated PrEP awareness and willingness to use it among 333 FSWs recruited through community based FSW associations. Data were analyzed using SPSS, with logistic regression employed to explore associations between participant characteristics and PrEP awareness and willingness. Ethical approval was obtained from the Rwanda National Ethics Committee. ResultsThe mean age of participants was 30 years (SD: 7.26), with 47% aged between 25 and 34. Most were single (67%) and unemployed (66%), with nearly half (49.5%) reporting only primary education. A significant proportion (81%) had undergone HIV testing in the past six months, and 50% had been involved in sex work for 2 to 5 years. The median number of sexual partners in the past week was 7. Awareness of PrEP was high (81%), however, consistent condom users were less likely to be aware of PrEP (adjusted odds ratio (aOR): 0.40, 95% confidence interval (CI): 0.19, 0.83), as were those not screened for sexually transmitted infections (STIs) compared to those who were screened (aOR: 0.43, 95% CI: 0.22, 0.85). Willingness to use PrEP was reported by 80% of participants. Those with a primary education were more willing to use PrEP compared to those with no formal education (aOR: 4.09, 95% CI: 1.62, 10.33). Conversely, participants screened for STIs were less likely to report willingness compared to those not screened (aOR: 0.28, 95% CI: 0.12, 0.62). ConclusionThis study demonstrates high awareness and willingness to use PrEP among FSWs in Kigali. However, consistent condom users and those unscreened for STIs were less aware of PrEP, and willingness to use it varied based on education and STI screening status. These findings underscore the need for targeted health education and STI screening initiatives to enhance PrEP uptake and strengthen HIV prevention efforts in this vulnerable population.

RationaleRetention of Female sex workers at one month of PrEP is critical as low retention may lead to sub-optimal protection and increased HIV incidence rates in this sub-population. We determined factors associated with retention at one month among Female Sex workers on Pre-Exposure Prophylaxis for HIV prevention in selected health facilities in Kampala Capital City Authority, Uganda. MethodsIn this retrospective cohort study we followed 350 FSWs from September to December 2021; and 30 women underwent in-depth interviews. Retention was categorically defined as the number of FSWs who adhered to their clinic appointments got refills over the total number of FSWs expected to come for a refill. Poisson regression was used for multivariate analysis and thematic data analysis was conducted for the quantitative and qualitative data respectively. ResultsThe median age of the FSWs was 25 years. 40.9% of the FSWs had attended primary level, 43.7% secondary level, 3.4% tertiary level education respectively, and 12% had no education. The mean duration of sex work was 3 years.On average, the FSWs had 14 sex partners in the past week. 59.4% reported lubricant use on the last sexual encounter compared to 40.6% who did not use lubricants. Factors associated with retention to PrEP at bivariate level were religion, place of work, lubricant use, use of drugs, received PrEP counselling at initiation, the color of PrEP tablet, pill size and attitude of health care workers. The Poisson regression showed that Retention to PrEP was 7% higher among sex workers that use lubricants compared to those that dont use holding other factors constant (adjusted 0.02 [1.01, 1.14] IRR 1.07) and retention to PrEP among sex workers that think the health care workers had a good attitude was 23% higher than those that think HCW had fair attitude holding other factors constant (adjusted 0.012 [1.05, 1.44] IRR 1.23). FSWs who had no stigma had 90% higher retention than those who had stigma) (adjusted 0.04 [0.814, 0.996] IRR 0.90).No drugs at the facility affected PrEP retention by about 76% among FSWs (adjusted 0.003 [0.67, 0.922] IRR 0.76). FSWs were retained to PrEP because they felt at risk when they experienced condom breaks during intercourse or they failed to use condoms with a client. Barriers to PrEP retention included drug side effects, lack of financial resources, food insecurity, stigma, and doubts about PrEP efficacy, travel and health system factors. ConclusionA high proportion of FSWs were retained on PrEP. FSWs considered PrEP as a reliable method of protection against HIV in cases of condom breaks or if they had sex without a condom. A number of barriers to PrEP retention at both personal and systems-level need to be addressed for successful PrEP implementation.

PurposeMany adolescents under 18 years old who sell sex are at elevated risk for sexually transmitted infection (STI) acquisition, which may persist into adulthood. There has been limited study of the burden of the risks and vulnerabilities among women who started selling sex as adolescents across Sub-Saharan Africa. MethodsAdult female sex workers (FSW) recruited through respondent-driven sampling in five cities in Cameroon from December 2015 to October 2016 completed a questionnaire and human immunodeficiency virus (HIV) and syphilis testing. Multivariable logistic regression analysis controlling for age was used to identify factors associated with reporting selling sex before age 18. ResultsSelling sex before age 18 was reported by 11.5% (256/2,220) of FSW. Initiation of selling sex as an adolescent was positively associated with experiencing dysuria (adjusted odds ratio [aOR]:1.50, 95% confidence interval [CI]:1.08-2.10) or genital warts (aOR:1.78, 95% CI:1.08-2.94) and negatively associated with prior recent testing for HIV (aOR:0.71, 95% CI:0.53-0.96) or STIs (aOR:0.65, 95% CI:0.44-0.96). Consistent condom use with clients was negatively associated with early initiation of selling sex (aOR:0.58, 95% CI:0.42-0.80), while experience of recent sexual violence was positively associated with early initiation (aOR:1.74, 95% CI:1.15-2.63). There were no independent significant differences in HIV (24.5%) or syphilis (8.4%) prevalence. ConclusionsGiven the limited use of HIV and STI testing services by women who sold sex as adolescents, the prevalence of forced sex, condomless sex, and STI symptoms were high. Programs serving FSW should more vigorously aim to serve adolescents and adults who began selling sex early.

In 2007, the World Health Organization recommended voluntary medical male circumcision (VMMC) as an effective HIV prevention strategy in countries with a high HIV burden and low prevalence of male circumcision. While there is some evidence that VMMC lowers the risk of other sexually transmitted infections (STIs), its population-level impact beyond HIV remains uncertain. This study aimed to examine population and individual level associations between male circumcision (scale-up) and self-reported STIs (defined as a self-reported STI diagnosis or symptoms of a genital soar, ulcer, or discharge, in the past 12 months) among sexually active adolescent boys and men aged 15-49. We analysed nationally representative data from Demographic and Health Surveys conducted before (2004-2006) and after (2015-2020) VMMC scale-up in Malawi, Rwanda, Zambia, and Zimbabwe using a multilevel logistic regression approach adjusted for potential confounders. Our analysis included 41,094 respondents; circumcision coverage increased over time in all countries except Zimbabwe (11.9% before vs. 12.8% after VMMC scale-up; p=0.821). STI prevalence also increased, from 5.3% (95% CI 4.8-5.8) before to 8.2% (95% CI 7.7-8.7; p<0.001) after VMMC scale-up, with variations in the relative increase across countries. At population level, we found a higher odds of self-reported STIs after compared to before VMMC scale-up (aOR 1.52; 95% CI 1.33-1.74; p<0.001). We found no association between circumcision status and self-reported STIs at individual-level (aOR 1.03; 95% CI 0.92-1.17; p=0.55). These findings suggest that while VMMC protects against HIV and some STIs, its impact on reducing the STI burden at population level in Eastern and Southern Africa is limited. As STI rates remain high, especially among young men, our results underscore the need for comprehensive, male-oriented sexual health strategies. Reducing service delivery barriers, combined with integrating VMMC into person-centred sexual health services for men, may help address persistent gaps in STI prevention.

BackgroundThe WHO-recommended prevalence thresholds for deciding schistosomiasis mass drug administration (MDA) are based on anecdotal evidence and may mislead. This study systematically synthesized evidence to generate a single optimal global prevalence threshold that should guide schistosomiasis MDA programmes worldwide. MethodsWe searched several databases from 1978 to 31st October 2021 without language restriction. Two reviewers selected studies, extracted data, and assessed risk of bias using relevant risk of bias tools, and resolved disagreements through discussion. The review followed best practices protocols and guidelines. Data were analysed and presented as prevalence reduction (PR) and relative risk (RR) for dichotomous outcomes or mean difference for continuous outcomes, each presented with their 95% confidence intervals (CI). Meta-regression of observations on prevalence rates and intensity of infection were performed to assess the effect of repeat MDA over time. Sensitivity analysis was performed to test the robustness of the results to the risk of bias components. The overall level of evidence was graded using GRADE. FindingsOf the 1,232 studies retrieved, 38 met our inclusion criteria and 34 were included in the meta-analysis. No direct relation was observed between prevalence and intensity of infection. Praziquantel reduced prevalence of S. mansoni in school age children (SAC) at 12 months (RR 0.56, 95% CI 0.46 to 0.69; 14 studies, n=86,073); 24 months (RR 0.46; 95% CI 0.32 to 0.66; 14 studies; n=83,721); 36 months (RR 0.44, 95% CI 0.33 to 0.58; 7 studies, n=70,933) and 48 months (RR 0.25, 95% CI 0.11 to 0.59; 5 studies; n=27,483). Similarly for S. haematobium, there were reductions in prevalence in school age children (SAC) at 12 months (RR 0.38, 95% CI 0.28 to 0.52; 8 studies, n=37,868); at 24 months (RR 0.30; 95% CI 0.30[boxh]0.52; 7 studies; n=37,107); and 36 months (RR 0.39, 95% CI 0.21 to 0.71; 5 studies, n=28,146). There was no significant reduction in prevalence at 48 months (2 studies, n=10,954). Further analyses were performed from a series of prevalence thresholds created from the data at 5%, 10%, 15%, 20%, 30% and [&ge;]40% and the results showed differences in the effect of MDA when each threshold was applied in the regression model. For annual MDA involving SAC, school-based treatment (SBT) appeared to perform better than community-wide treatment (CWT) in terms of prevalence reduction; but this could be subject to the frequency of treatment and retreatment applied in SAC compared to CWT. Using the optimal prevalence threshold of 10%, the model suggested it will take over 10 years to bring the prevalence of schistosomiasis to 1% for S. haematobium and up to 15 years for S. mansoni with repeated annual MDA. InterpretationThis systematic review and meta-analysis provides evidence that 10% prevalence is the optimum that should be used as the standard global threshold for implementing MDA in endemic countries. FundingThis work was commissioned and supported by the World Health Organization, Geneva, Switzerland as part of evidence-based schistosomiasis guideline development. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSCurrently, the prevalence thresholds used in implementing mass drug administration within the preventive chemotherapy strategy for schistosomiasis control are based on anecdotal evidence and unreliable. We identified relevant studies regardless of language or publication status (published, unpublished, in press, and ongoing). We searched PubMed, CINAHL and LILACS from 1978 to 31st October 2021 without language restriction. We also searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2021), mRCT, Hinari, the WHO Library Database, Africa Journals Online and Google Scholar. Experts in the field of schistosomiasis were contacted, preprint repositories were searched and the reference lists of articles were reviewed for additional or unpublished data. This study was commissioned by the WHO to provide systematically synthesized evidence to inform on a single global prevalence threshold that should be applied by endemic countries when deciding MDA campaigns for the prevention and control of schistosomiasis. Added value of this studyThis is the first systematic review and meta-analysis commissioned by the WHO to determine a single prevalence threshold that should be employed by endemic countries for the implementation of global schistosomiasis mass drug administration. This study pooled data involving thousands of participants across thousands of villages from all endemic settings, making it unique in terms of statistical power and generalizability of the main findings and conclusions. The study used PICOS (P-population, I-intervention, C-comparator, O-outcomes and S-study) to formulate an appropriate review question, clear objectives, stringent inclusion and exclusion criteria as well as rigorous quality assessment and data synthesis, following strictly best practices for preparing and reporting systematic reviews. The search has been very comprehensive including all relevant electronic databases and non-electronic sources, done in close collaboration with experienced information specialist. The review process ensured meticulous attention to details, making the necessary effort to minimize bias, carrying out aspects of the review independently by the reviewers and addressing disagreements through discussions between the reviewers. Given the geographical variations, and differences in the levels of baseline endemicities, diagnostic criteria, age groups treated and follow-up times across studies, this necessitated robust sub-group analyses to detect any sub-group effects. We ran meta-regression analyses to identify any potentially useful trends, and tested the robustness of effect estimates from sensitivity analyses. We have assembled world-class experts from diverse backgrounds and geographical locations, including epidemiologists, evidence synthesis specialists, economists, allied health professionals, statisticians, biomedical scientists, clinicians and non-medical experts to produce this innovative, demand-driven, policy- and context-relevant systematic review and meta-analysis that will help guide policy and practice in the global control of schistosomiasis. Implications of all the available evidenceOur review provides evidence that 10% baseline prevalence is the minimum optimal threshold that should be used to decide the implementation of MDA programmes in schistosomiasis endemic countries. Praziquantel is effective in reducing the prevalence of schistosomiasis at 12 months, but incremental benefit of repeated annual treatment appears to be minimal after 12 months. Effectiveness depends on several factors, which are difficult to disentangle, however, the rate at which prevalence decreases does not appear to be influenced by baseline intensity of infection and treatment approach (whether whole community or school-based). From exploratory analysis, intensity of infection appears to be more stable than prevalence for assessing outcome of MDA. Therefore, further research is needed to determine an optimal intensity threshold and compare it with prevalence threshold. In terms of policy, the difficulty in achieving elimination with mass drug administration alone means that integration of non-pharmacological interventions such access to clean water, improved sanitation, hygiene education (WASH) and snail control to complement MDA if elimination is to be achieved. This systematic review was registered in PROSPERO CRD422020221548.

BackgroundTests for diagnosing schistosomiasis in areas where prevalence is low due to control programme of the disease should be suffiently sensitive to detect the residual disease. If they had sufficient diagnostic accuracy they could replace conventional microscopy as they provide a quicker answer and are easier to use. ObjectivesTo compare sensitivity and specificity of new tests, especially rapid diagnostic tests (RDTs), with regard to a certain reference test. MethodsWe searched the electronic databases Pubmed, EMBASE, the Cochrane Library and LILACS up to February 2021. Furthermore we searched results from the previous meta-analyses. We included studies that used microscopy as the reference standard: for S. haematobium, microscopy of urine prepared by filtration, centrifugation, or sedimentation methods; and for S. mansoni, microscopy of stool by Kato-Katz thick smear. Two review authors independently extracted data, assessed quality of the data using QUADAS-2, and performed meta-analysis where appropriate. Grading of evidence was done with the GRADE methodology by using GradePro. Using the variability of test thresholds, we used a bayesian bivariate random-effects summary receiver operating characteristic model for all eligible tests. We investigated heterogeneity, and carried out sensitivity analyses where possible. Results for sensitivity and specificity are presented as percentages with 95% confidence intervals (CI). ResultsThe review gathered 203 articles stating a diagnostic test for the diagnosis of S. haematobium and S. mansoni out of which 114 entered the analyses. Microscopy of Urine filtration or Kato-Katz smears were used as the reference standard. Compared with Kato-Katz smears, AWE-SEA ELISA (Se=94%; Sp=64%) is comparable to CCA1 (Se=87%; Sp=60%). IgG ELISA (Se=93%; Sp=68%) has also a very good ability to detect true positive as well as CAA cassette (Se=73%; Sp=68%). For S. haematobium, proteinuria (Se=59%; Sp=83%) and haematuria (Se=74%; Sp=87%) reagent strips showed reasonably high specificities with a considerably better sensitivity for the haematuria test. There are interesting promising new diagnostic tests that were tested in field studies. However prevalences of the locations where these studies took place are variable and there are no specific study with a high number of patients in areas with low level of schistosomiasis infection.

IntroductionLymphatic filariasis (LF) is a neglected tropical disease caused by infection with parasitic worms, spread by mosquitoes. In countries where LF is validated as eliminated as a public health problem by the World Health Organization (WHO), post-validation surveillance (PVS) is required to ensure recrudescence has not occurred and verify the sustained elimination of transmission. However, it is unclear what PVS strategies should be applied, how PVS strategies should be tailored to meet country capacity and need, and whether currently used approaches align with upcoming WHO guidelines. ObjectivesThis study will aim to review available evidence on PVS implementation in countries previously endemic for LF; examine barriers and facilitators to PVS implementation; critique alignment in PVS activities with international guidelines; and identify knowledge gaps in PVS implementation that may be addressed through further research. MethodsWe will search four databases (PubMed, Scopus, Embase and Web of Science) for peer-reviewed literature and the WHO Institutional Repository for Information Sharing (IRIS) database for grey literature. Documents published between January 1, 2007 and November 5, 2024 will be included. Two reviewers will independently screen studies based on a priori inclusion and exclusion criteria. The quality of included studies will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist, and deductive content analysis will be conducted to synthesise data. The study will also examine alignment with upcoming WHO PVS guidelines. ConclusionThis review will systematically collate and analyse available literature on PVS of LF, which, to our knowledge, has not yet been conducted. Our study will synthesise knowledge in this field and provide an evidence base which may be used to guide the design of future PVS strategies. This protocol has been registered in PROSPERO (registration ID: CRD42024618436).

BackgroundMore than 70% of new, emerging, and reemerging infectious diseases are from animal origin. Human interaction with bats has been associated as a driver for various fetal zoonoses, including numerous viral diseases of bat-origin. A lot of serological evidence has been gathered around human-bat interaction, yet very little is known regarding the underlying risk factors at community level. This study was aimed at understanding the human-bat interactions and associated factors among communities in Bundibugyo District in Uganda. MethodsA cross-sectional study was conducted using both qualitative and quantitative data collection methods in Harugale, Burondo and Ntandi Subcounties in Bundibugyo District between November 2022 and March 2023. A total of 344 participants were interviewed using a semi structured questionnaire installed on the Kobo Collect Software. Key Informant interviews were also conducted among purposively selected individuals who have vast knowledge on human-bat interaction. Proportional piling and focus group discussions were conducted among groups of men, women, and youths to get their insights into human-bat interaction. Quantitative data was cleaned using Microsoft Excel and exported to Stata 15 for analysis. Qualitative data was analyzed using Atlas. ti (version 8.0). Our study was limited by response and recall bias during data collection. ResultsThe study revealed that 54.1% of the respondents were males, 42.1% were aged above 40 years. Households headed by males (APR=1.31, 95% CI:1.07-1.62, Batwa communities (APR=3.03, 95% CI:1.87-3.94), residing in urban areas (APR=1.72, 95 CI%:1.35-2.20), trading of food and animal products (APR=0.6, 95 CI%:0.36-0.99), no occupation (APR=0.27, 95 CI%:0.12-0.57) and residing in incomplete houses (APR=1.57, 95 CI%:1.25-1.98) were significantly associated with exposure of humans to bats. There was high exposure of humans to bats in Ntandi compared to Burondo and Harugale. Women groups highlighted use of bat repellants and killing of bats using sticks as the measures to reduce human bat interaction during the Focus Group Discussions. ConclusionGenerally, there is high exposure to bats among human communities in Bundibugyo district which increases the risk of zoonotic disease transmission at human-bat interface. Findings from this study aim to enable the one health interventions to reduce bat-human interaction potential risks in both urban and rural areas and support design of feasible interventions for Bundibugyo district and Uganda at large.

Withdrawal Statement"This manuscript has been withdrawn by the authors as they did not obtain the necessary ethical clearance for the study. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author."

BackgroundOnchocerciasis remain to be an important public health problem targeted for elimination in Tanzania. Ulanga District was known for its high endemicity since 1960s and has been implementing MDA through Community Directed Treatment with Ivermectin (CDTI) strategy since 1998. However, current reports indicate high prevalence of Onchocerciasis in both human and vector species probably because of poor treatment coverage indicating limited evidence for transmission. This study was conducted to assess treatment coverage and explore determinants of drug uptake during MDA program. MethodsA cross-sectional community-based study using multistage cluster sampling was carried out in Ulanga District, Morogoro Tanzania from April-June 2019. Study participants were randomly selected from households and interviewed using a structured questionnaire. Modified Poisson regression was performed to determine independent factors associated with MDA uptake. ResultsA total of 502 participants were recruited during the study period with a response rate of 96%. The majority (67%) were females, and the mean age of the study participants was 37.8 {+/-}15 years with an age range of 25-34 (25.5 %). MDA coverage for the studied villages was as follows; Mawasiliano (68%) Uponera (83%), Isongo (84%) and Togo (79%). The drug uptake for all villages was below the optimal coverage recommended by WHO (85%) for successful transmission interruption. Having an age of [&le;] 24 years [Adjusted Prevalence Ration (APR) = 3.9(95% CI:1.9-8.3), p < 0.05)], Living in the village for at least a year [APR = 3.4 (95% CI:2.4-4.8), p <0.05)] and believing IVM prevent Onchocerciasis [APR = 13.4(95% CI:2.9-60.9)], p<0.05) were associated with increased chances of Ivermectin uptake during MDA. In addition, decreased drug uptake [APR = 12(95% CI: 2.4-60.9), p<0.05)] was attributable to fear of restriction to drinking alcohol after taking drugs. ConclusionLow coverage below the WHO optimal recommended coverage has been demonstrated in the studied villages. This implies low drug uptake, delayed interruption of transmission and Onchocerciasis elimination. These findings, therefore, emphasize the need to intensify the MDA awareness campaigns targeting less compliant groups in the community to reinforce the benefits of ivermectin in Onchocerciasis control and address the community misconceptions about MDA.