Tropical Medicine and Infectious Disease

Reproductive tract infections (RTI) are associated with adverse outcomes in pregnant African women. However, many diagnostic strategies are unaffordable or perform poorly. Here, we assess RTI prevalence and predictors of chlamydia/gonorrhea (CT/NG) in pregnant women reporting vaginal discharge and the performance of our previously published CT/NG risk algorithm in this population versus Rwandan National Guidelines (RNG). From 2017-2020, free sexually transmitted infections (STI) services were provided to residents in Kigali, Rwanda. Medical history and gynecologic examination were done. Laboratory assessments included HIV; syphilis; microscopy for trichomoniasis, bacterial vaginosis (BV), and candida; and PCR for CT/NG. Eighty-seven pregnant women received STI services. Prevalence was 28% for CT/NG, 15% for trichomoniasis, 24% for BV, 39% for candida, and 79% for any RTI. Predictors of CT/NG were age <=25 (adjusted prevalence odds ratio [aPOR]=4.92; 95% confidence interval [CI]: 1.52-15.90; p=0.008), inconsistent condom use (aPOR=4.86; 95%CI: 0.98-24.10; p=0.053), absence of candida (aPOR=4.23; 95%CI: 1.13-15.82; p=0.032), and endocervical inflammation/discharge (aPOR=4.91; 95%CI: 1.40-17.20; p=0.013). Our algorithm outperformed the 2019 and 2024 RNG (sensitivity: 92% versus 46% and 35% respectively). Pregnant women seeking STI services had high RTI prevalence. Our algorithm performed well. Algorithms tailored for pregnant women and including male partner risk factors should be explored.

Background: Sexual and gender minorities (SGM), including men who have sex with men (MSM) and transgender women, often face stigma, legal constraints, and limited access to sexual and reproductive health services. These conditions restrict prevention and care, increasing vulnerability to HIV and human papillomavirus (HPV) infections. While strong HIV-HPV interaction is documented in high-income settings, evidence from low- and middle-income countries remains limited. This study examines the burden, co-infection dynamics, and progression of HPV infection and anal dysplasia among MSM and transgender women in Pakistan. Methods: A cross-sectional study was conducted between September 2015 and October 2016 among men who have sex with men (MSM) and transgender women recruited from sexual health and antiretroviral therapy centers in Karachi. Eligible participants were aged [&ge;]18 years and self-reported anal sex within the past 6 months (N=298). Two anal specimens were collected for HPV DNA detection and genotyping using PCR, and anal squamous intraepithelial lesions (ASIL) were assessed cytologically using the Bethesda classification. Associations were estimated using Cox proportional hazards regression algorithms to derive prevalence ratios (PRs). Results: Among participants, 44% (n=133) were living with HIV. Overall HPV prevalence was 65.1%, rising to 87% among HIV-positive individuals compared to 48% among those without HIV ({chi}{superscript 2}p[&le;]0.001). Likewise 28.9% of participants living with HIV were infected with two or more than two types of HPV as compared with 18.8% participants without HIV ({chi}{superscript 2}p[&le;]0.001). HIV infection was strongly associated with HPV acquisition (adjusted PR 2.81, 95% CI 2.16-3.82). Among HPV-positive participants (n=194), 58.8% were co-infected with HIV. High-risk HPV was highly prevalent among those living with HIV (83.2% vs. 35.3% ({chi}{superscript 2}p[&le;]0.001)), with HPV16 as the dominant oncogenic type. Multiple HPV infections were more common among HIV-positive individuals ({chi}{superscript 2}p[&le;]0.001), and HIV seropositivity was 3.43 (95% CI: 2.55-3.51) times higher among those with high-risk HPV. Co-infected participants demonstrated prolonged smoking, longer duration of sex work, high-intensity sex work with limited condom negotiation, and higher prevalence of anal warts (all p<0.05). Anal dysplasia (ASIL) was present in 35% of participants and was higher among HIV-positive individuals (42.4% vs. 28.1%, p<0.001). HIV-HPV co-infection was independently associated with ASIL (adjusted PR 1.75, 95% CI 1.07-2.88), while high-risk HPV further amplified this risk (PR 3.04, 95% CI 1.75-5.26). Conclusion: These findings demonstrate a biological continuum in HIV-positive MSM and transgender women, where HIV increases HPV acquisition, persistence, and multiplicity, accelerating progression to anal dysplasia. This reflects a syndemic shaped by biological interaction and structural vulnerability. Integrating HPV screening and vaccination within HIV services is essential to interrupt progression to cancer in this high-risk population.

Crimean-Congo haemorrhagic fever virus (CCHFV) causes a viral zoonotic disease transmitted through tick bites and direct contact with infected blood or tissue of infected animals. Socio-ecological and behavioural risk factors for CCHFV exposure in Uganda remain poorly understood, which can lead to the omission of key risk factors in quantitative survey design and limit our wider understanding. In this study, we explored human-animal-tick interaction transmission risks in Uganda. We conducted 24 focus group discussions (FGDs) and 31 key-informant interviews (KIIs) across six environmentally and socio-ecologically diverse districts, between October 2023 and March 2024. Study sites were selected using K-prototype analysis, which combined environmental and socio-ecological variables to identify distinct clusters within Uganda. FGDs were conducted separately with groups of community leaders, men, women and teenagers with stratified purposive sampling. Medical doctors, veterinarians, traditional healers, district surveillance officers, and herdsmen were individually interviewed as key informants and purposively sampled. Data were transcribed and translated into English, and analysed thematically using iterative categorisation in NVivo 14. Most participants reported tick bites, some as frequently as every day. Close contact with animals was common, including sleeping next to them in the same building, largely due to concerns about animal theft. Less frequent but notable practices included slaughtering animals for consumption or sacrifice and interactions with wild animals during hunting. Slaughtering and butchering an animal which was sick or had died was reportedly performed by participants in most districts. Plucking and roasting engorged ticks was a practice described in the Kaabong and Arua districts of Northern Uganda. These practices and behaviours highlight potential key risks of CCHFV transmission and underscore the need for future studies to address specific behaviours, to quantify if, and to what extent, they present an exposure risk. Further work should include underlying reasons for the behaviours, which would help ensure that culturally appropriate interventions are targeted.

Abstract Introduction Onchocerciasis is targeted for elimination with community-directed treatment with ivermectin (CDTI). Alternative strategies are needed in areas where transmission persists despite long-term CDTI and/or are co-endemic with loiasis. This study assessed the efficacy of 35-day treatment with 100mg doxycycline on Wolbachia density at 6 months and microfilaridermia and palpable nodules at 30 months post-treatment. Methods A treatment follow-up study was conducted in 20 high-transmission onchocerciasis communities in a co-endemic loiasis area of South-West Cameroon. Community-based directly observed treatment with 100mg doxycycline was administered to community members aged [&ge;]9 years. Wolbachia clearance at 6-months and treatment efficacy on microfilaridermia and palpable nodules were assessed at 30-months post treatment. Factors associated with reductions in microfilaridermia post treatment, including adherence to doxycycline treatment were assessed with mixed-effects logistic regression. Results Over 92% (2835/3080) of eligible participants took 35 days of 100mg doxycycline over 5 or 6 weeks. This regimen achieved a 62.8% microfilaridermia reduction and 99% palpable nodule reduction in the 720 participants included at follow-up. Wolbachia depletion was observed in 92% of skin samples at 6 months post treatment. The most important factor associated with microfilaridermia after 30 months was having missed at least 7 doxycycline consecutive doses (OR 3.11, 95%CI: 1.17-8.26). Incomplete treatment to a lesser extent was not associated with reduced efficacy at follow-up. Conclusion This large-scale community intervention shows that a 5-week treatment with 100mg doxycycline is feasible and has high curative efficacy against adult O. volvulus as measured by the dramatic reduction in the proportion of palpable nodules at 30-months post treatment. The high efficacy shows the tremendous potential of anti-Wolbachia drugs as part of the arsenal for onchocerciasis elimination and paves the way for the next generation of anti-Wolbachia drugs with shorter treatment courses, which will facilitate the implementation of alternative strategies to accelerate onchocerciasis elimination.

Background: The lifespan of insecticide-treated nets (ITNs) varies widely across settings, reflecting both intrinsic product characteristics and external factors related to use, care, and environment. While the resistance to damage (RD) score captures intrinsic product durability, there is no standardized metric to quantify contextual risks. This study presents a proof of concept for the Risk Index (RI), a composite measure of site-level risk factors for ITN physical durability and survival. Methods: We conducted a secondary analysis of durability monitoring data from 44 sites across 15 countries in sub-Saharan Africa, covering 14 ITN products. The RI was calculated as a weighted composite of 12 indicators spanning net handling, net care attitudes, and use environment. Associations between RI and median ITN survival were assessed using weighted linear regression and multivariable mixed-effects models adjusting for RD score, with country included as a random effect. Results: RI scores ranged from 25.1 to 83.7 across study sites. In bivariable analysis, a 10-point decrease in RI was associated with a 4.0-month increase in median ITN survival (95% CI: 1.7-6.3; p=0.001). In multivariable analysis adjusting for RD, this association remained significant but attenuated to 2.2 months (95% CI: 0.1-4.2; p=0.037). Independently, a 10-point increase in RD score was associated with a 3.5-month increase in survival (95% CI: 1.3-5.7; p=0.001). No interaction was observed between RI and RD. Predicted survival differed by approximately one year between the lowest- and highest-risk settings. Conclusion: The RI provides a standardized measure of contextual risk factors affecting ITN lifespan, independent of ITN product type. When used alongside a product's RD score, the RI enables improved interpretation of expected site-level variation in net performance. This combined framework offers a practical basis for incorporating behavioural and environmental risk into vector control planning and for tailoring ITN strategies to local conditions.

Introduction: Hantavirus disease is an emerging and potentially severe zoonosis of global distribution. In Uruguay, it is transmitted by rodents inhabiting peridomestic, suburban, and rural areas. Global incidence is estimated at 150,000 to 200,000 cases per year, with up to 300 annual cases in the Americas. Since 1997, Uruguay's Ministry of Public Health (MPH) has monitored Hantavirus cardiopulmonary syndrome (HCPS), the most common clinical presentation in the region. By 2019, a total of 271 cases had been identified in the country, with an estimated mortality rate of nearly 50%. Objectives: To describe the clinical, epidemiological, and occupational characteristics of patients with Hantavirus disease in Uruguay during the pre-pandemic (2018-2019) and pandemic (2020-2021) periods. Methods: A descriptive, cross-sectional, observational study was conducted, including all serologically confirmed cases of Hantavirus infection reported to the MPH between 2018 and 2021. Clinical and demographic data were extracted from the mandatory reporting form for zoonotic diseases. Incidence and case fatality rates were calculated, and factors associated with fatal outcomes were analyzed. Results: A total of 58 confirmed cases were identified between 2018 and 2021. Most patients were male (62%), with a mean age of 36.5 years (SD 16). A decline in incidence was observed during 2020-2021, with no significant change in case fatality. Direct rodent exposure was the most frequently associated risk factor. Montevideo and Canelones were the most affected departments. Renal and pulmonary involvement were significantly associated with mortality. Conclusion: Hantavirus remains a relevant public health concern in Uruguay. Although a decrease in incidence was observed during the COVID-19 pandemic years, case fatality rates remained high. The findings underscore the need for sustained surveillance and early recognition, particularly in urbanizing regions.

Introduction: Dengue, chikungunya, and hand, foot, and mouth disease (HFMD) are priority notifiable infections in Thailand. Whether vector-borne and contact-mediated diseases responded differently to the coronavirus disease 2019 pandemic has not been quantified within a unified national surveillance framework over an extended period. Methods: We conducted an ecological interrupted time-series analysis using weekly province-level notifiable disease surveillance data from epidemiological week 1 of 2016 to week 53 of 2025 across all 77 Thai provinces. Incidence per 100,000 population was calculated using year-specific civil registration population denominators. Segmented quasi-Poisson regression with two Fourier harmonics for annual seasonality was fitted, with the primary pandemic onset defined as week 1 of 2020 and two alternative onset definitions prespecified for sensitivity analysis. Results: The analysis included 40,579 province-week observations across 527 epidemiological weeks, comprising 790,263 dengue, 32,265 chikungunya, and 713,822 HFMD cases nationally. Immediate incidence rate ratios at pandemic onset were 0.39, 0.54, and 0.51 for dengue, chikungunya, and HFMD, respectively. Sustained post-onset trends diverged across diseases, with declining trajectories for the two vector-borne infections and a positive post-onset slope for hand, foot, and mouth disease. Dengue rebounded above pre-pandemic levels by 2023, chikungunya remained quiescent through 2025, and HFMD exceeded its pre-pandemic baseline by approximately 26%. Conclusion: Vector-borne and contact-mediated diseases in Thailand followed sharply contrasting decadal trajectories that tracked the transmission ecologies of each pathogen. These findings support transmission-mode-specific pandemic-resilient surveillance, accelerated arboviral and enteroviral vaccine deployment, and integrated vector management.

Between 2015 and 2025, Cambodia reported a 99.9% decline in the number of cases of malaria. To aid acceleration of elimination, the National Center for Parasitology, Entomology and Malaria Control (CNM) implemented a package of interventions known as the Last Mile (LM) elimination program. The aim of this study was to determine the impact of the LM program on case numbers and evaluate the coverage of interventions. LM was rolled out between November 2020 and December 2023 in villages reporting a locally acquired case of Plasmodium falciparum or mixed infection with P. falciparum and P. vivax and included combinations of targeted drug administration (TDA), intermittent preventative treatment for forest goers (IPTf), active fever screening (AFS), the recruitment of a village or mobile malaria worker (VMW/MMW) and the top-up of insecticide-treated bed nets (ITN) depending on the vulnerability and receptivity of the village. A total of 103 full and 82 partial villages in seven provinces were included. Two rounds of TDA were administered, with a total of 10,678 individuals (67.6%) given during the first round and 9,678 (62.3%) during the second round. Coverage varied by province with none meeting the recommended threshold of 80%. IPTf was implemented each month among 35% (n=35) of full LM villages and 56% (n=42) of partial LM villages. A total of 11.7% (n=12) of full LM villages implemented AFS consistently on a weekly basis. Controlled interrupted time series showed no statistically significant difference in the number of malaria cases before and after the implementation of LM. Although we were unable to prove a statistically significant impact of LM, likely due to the small number of cases prior to LM, it is important to add to the limited evidence-based for Accelerator Strategies in countries approaching the elimination of malaria. Furthermore, findings from the feasibility and impact of individual interventions were used to change policy at the national level.

Methicillin-resistant Staphylococcus (MRS) infections are a significant public health concern. Anterior nares serve as a major reservoir and source of spread of MRS ssp. People living with HIV (PLWHIV) tend to be at higher risk of colonisation with MRS organisms due to frequent healthcare exposure. We assessed the prevalence of MRS nasal carriage and associated factors among PLWHIV at the HIV clinic of Kiruddu National Referral Hospital, Kampala, Uganda, from May to July 2024. Nasal swabs from 256 PLWHIV were cultured, and microbiological isolation was performed at MBN Clinical Laboratories. Prevalence was calculated as proportions, and logistic regression identified associations with clinical and socio-demographic factors (p < 0.05). Of 256 participants, 163 (63.7%) carried Staphylococcus, with 82 (32%) identified as MRS carriers (8.9% MRSA, 23% MRCoNS). Frequent hospital visits ([&ge;]3) (adjusted incidence risk ratio [A-IRR] = 1.18 x 107, p < 0.001), second-line antiretroviral therapy (ART) (A-IRR = 3.82, p = 0.041), and unsuppressed viral load (>1000 copies/mL) (adjusted odds ratio [AOR] = 11.3, 95% CI: 2.11-60.58, p = 0.005) were significantly associated with MRS carriage. Mask-wearing was protective against MRCoNS (A-IRR = 1.66, 95% CI: 1.06-2.58, p = 0.026). MRS isolates exhibited high resistance to erythromycin (81.7%) and trimethoprim-sulfamethoxazole (79.3%), but susceptibility to linezolid (93.9%). MRS nasal carriage is prevalent among PLWHIV. Individuals with frequent health care contact and those on second-line ART regimens are more susceptible to MRS colonization, while individuals who wear face masks and those with an undetectable HIV viral load are less susceptible. Antimicrobial Resistance (AMR) surveillance within HIV programs, enhanced infection control, ART adherence, and targeted screening for high-risk groups are critical to mitigate colonization.

Introduction: Viral load (VL) monitoring is the gold standard for antiretroviral therapy (ART) monitoring. Still, due to limited funds and infrastructure, many people living with HIV (PLHIV) in low- and middle-income countries do not receive timely VL testing. We evaluated the clinical performance and end-user acceptability of a prototype interferon gamma-induced protein 10 (IP-10) point-of-care (POC) test as a rule-out triage tool to identify individuals unlikely to have unsuppressed VL in PLHIV in Mozambique. Methods: A mixed-methods study was conducted between November 2023 and November 2024 at two primary healthcare facilities in Maputo Province. We enrolled 1,057 PLHIV on ART from stable and specialized risk clinics. Clinical performance of the IP-10 POC test (index test) was compared against plasma HIV VL (reference test; unsuppressed defined as >1000 copies/mL). Socio-demographic and clinical predictors of false-positive results were identified using multivariable logistic regression. Immediate acceptability was assessed through exit interviews on a subset of 43 PLHIV. Results: Among participants (71.7% female; median age 41.4 years), 12.0% had unsuppressed VL. The IP-10 POC test demonstrated high sensitivity (90.6%) and moderate specificity (35.6%). Specificity was higher in clinics treating stable patients (44.5% 95%CI: 39.7-49.3) compared to specialized risk clinics (26.5% 95%CI: 21.1-28.9). The proportion of false-positive results was also higher in patients attending specialized risk clinics. Independent predictors of false positivity included enrolment in a one-stop TB/HIV clinic (aOR=2.99 95%CI: 1.09-8.15), cotrimoxazole use (aOR=2.16, 95% CI: 1.13-4.13), and obesity (aOR=3.47 95%CI: 1.74-6.93). Acceptability was high: 70% of participants appreciated the test simplicity and rapid results, and 95.3% expressed interest in future testing. Most patients preferred finger-prick collection over venous draws. Conclusions: The IP-10 POC test is a highly sensitive triage tool, demonstrating superior performance among stable PLHIV enrolled in differentiated service delivery models like six-month multi-month dispensing. While factors associated with co-infections can reduce specificity, the test's high acceptability and potential to reduce confirmatory VL test demand suggests it could serve as a viable triage strategy for optimizing resources particularly in stable care pathways with a lower prevalence of inflammatory comorbidities. This could enable health systems to reallocate intensive monitoring toward higher-risk populations.

Background. Women living in leishmaniasis-endemic zones are regularly exposed to the sandfly vector in their environments. While case series and laboratory evidence consistently suggest transplacental transmission of Leishmania parasites with deleterious maternal-fetal effects, this issue has received insufficient attention, particularly in areas where the predominant Leishmania species is mainly associated with cutaneous disease (CL). Methodology/Principal Findings. We conducted an exploratory cross-sectional study in a highly endemic zone of Tabasco, Mexico, enrolling 53 women with singleton term deliveries between April 2018 and April 2020. Placental PCR was positive in 18 (34%) participants. Buccal swabs were positive in 11 (21.2%) of 52 newborns. Immunofluorescence confirmed intracellular amastigotes within macrophages near the vascular endothelium of PCR-positive placentas, with no surrounding inflammatory infiltration. Sequencing revealed homology to Leishmania mexicana or L. amazonensis. Birthweight percentile was modestly lower in the PCR-positive group (predicted mean 53.8% vs. 56.5%, p = 0.76), while small for gestational age showed a non-significant trend toward higher prevalence among PCR-positive cases (prevalence ratio = 2.06, 95% CI: 0.32-13.39, p = 0.45). Conclusions/Significance. Subclinical, dynamic transmission of Leishmania parasites typically associated with cutaneous disease was detected in this endemic zone. The presence of L. mexicana in human placentas was confirmed by immunofluorescence and sequencing, without an associated inflammatory response. These findings highlight the potential of CL-associated Leishmania species to reach the placenta and buccal mucosa of newborns, warranting further epidemiological investigation into the consequences of vertical transmission in regions with endemic CL.

Background In northern Thailand, scrub typhus primarily affects rural and hill tribe communities, yet awareness is low. In 2020 we trained community health volunteers (CHVs) to raise awareness in their communities using a train-the-trainer approach. CHV knowledge rose dramatically. However, we did not assess the effectiveness in community members and our strategy relied heavily on CHVs, who have limited availability. Methods In a second phase, object of this manuscript and conducted in 2022-2023, after training CHVs we measured the effectiveness in community members and compared in-person sessions carried out by CHVs with sessions using video or audio recordings only. All materials included key information about scrub typhus transmission, symptomatology, prevention, and management and had been developed following feedback from participants from the first round of activities in 2020. Effectiveness was evaluated using a questionnaire assessing scrub typhus knowledge. CHVs were also asked to rate the feasibility of suggested preventative measures. Results A total of 74 community members participated in six sessions. Knowledge of scrub typhus significantly improved post-training (median score increased from 2 to 6 out of 9, p<0.001) and audio and video recordings were as effective as in-person trainings. CHVs noted that some of the preventative measures recommended are difficult to put in practice such as wearing gloves, washing daily after work, avoiding kneeling and resting on the ground, and washing clothes daily. Conclusions Our findings support the use of locally adapted multimedia training for scrub typhus prevention, showing that scalable formats can be as effective as in-person ones. Further collaborative work with people at risk should refine preventative messages to improve feasibility and acceptance.

BackgroundControl of Aedes aegypti, the primary vector of dengue and other Aedes-borne viruses, is challenged by insecticide resistance, limited efficacy of existing tools and the large and widespread epidemics. Targeted Indoor Residual Spraying (TIRS), a modification of traditional indoor residual spraying focused on Ae. aegypti resting sites, has demonstrated promising results, yet its indirect community-wide effects remain underexplored. Methodology/Principal FindingsWe conducted an entomological cluster-randomized controlled trial in Iquitos, Peru, to evaluate the direct and indirect entomological impacts of TIRS using pirimiphos-methyl. Thirty clusters were randomized to receive either TIRS (15 clusters, 898 structures) or standard Ministry of Health vector control activities (15 clusters, 1,018 structures). Aedes aegypti indoor densities were assessed in the 45 days pre-intervention and at four time points up to 255 days post-intervention using Prokopack aspiration. Generalized linear mixed models with a negative binomial link were used to estimate incidence rate ratios (IRRs) and calculate efficacy (1-IRR) for houses that received TIRS (direct effect) and untreated houses in TIRS clusters (indirect effect). Direct efficacy reached 96% at 15 days post-spraying and remained significant (40%) at 255 days post-spraying. Indirect efficacy reached 69% at 15 days and declined to 7% by 255 days post-spraying. Despite only 57% household-level TIRS coverage, both direct and indirect impacts on Ae. aegypti were significant during early post-intervention surveys, and after 8 months in TIRS clusters. Conclusions/SignificanceTIRS provided substantial and sustained reductions in indoor Ae. aegypti density, including measurable indirect effects in untreated homes within intervention clusters. These findings demonstrate the entomological value of TIRS even at moderate coverage levels and highlight its potential for both preventive and reactive vector control programs and should be considered for implementation by Ministries of Health in dengue-endemic urban settings as well as by the U.S. military when deployed to tropical or subtropical locations.

Background: Advanced HIV disease (AHD) remains a major contributor to HIV-related morbidity and mortality despite widespread antiretroviral therapy (ART) access in sub-Saharan Africa. Although treatment-related adverse drug reactions (ADRs) may compromise treatment outcomes, evidence on the relationship between AHD and ADR occurrence remains limited. This study aimed to determine the prevalence and identify factors associated with AHD, characterize treatment-related ADR and assess the association between AHD and ADR occurrence among people living with HIV receiving ART in Dar es Salaam, Tanzania. Methods: We conducted a multicenter cross-sectional study among 1,513 people living with HIV receiving ART at selected HIV care and treatment clinics in Dar es Salaam, TanzaniaFor this adolescent/adult cohort, AHD was operationally defined as WHO clinical stage III/IV disease and/or baseline CD4 count <200 cells/mm3. Treatment-related ADRs were defined as participant-reported and/or clinically documented ART-related adverse events identified during routine HIV care, including both current and retrospectively reported events. Modified Poisson regression with robust standard errors was used to estimate crude and adjusted risk ratios (RRs) with 95% confidence intervals (CIs). Results: Among 1,508 participants with sufficient information for classification, 961 (63.7%) had AHD. Factors independently associated with AHD included age [&ge;]50 years (aRR 1.10, 95% CI 1.01-1.20), underweight nutritional status (aRR 1.17, 95% CI 1.00-1.35), and concomitant medication use (aRR 1.19, 95% CI 1.03-1.37), while DTG-based ART was associated with lower AHD prevalence (aRR 0.78, 95% CI 0.68-0.90). Overall, 569 participants (38.0%) reported at least one ADR. Composite AHD was not independently associated with ADR occurrence (aRR 0.95, 95% CI 0.82-1.11), but baseline CD4 <200 cells/mm3 was associated with increased ADR risk (aRR 1.20, 95% CI 1.02-1.41). Comorbidity (aRR 1.66, 95% CI 1.42-1.93) was the strongest correlate of ADR occurrence. Conclusion: AHD remains highly prevalent among people living with HIV receiving ART in Tanzania. While composite AHD was not independently associated with ADR occurrence, severe immunosuppression, comorbidity burden, and concomitant medication exposure were associated with increased ADR risk. These findings suggest that immunologic severity and broader clinical complexity may be more informative predictors of ART-related toxicity than composite syndromic AHD classification alone. Strengthened early diagnosis, differentiated advanced HIV care, integrated pharmacovigilance strategies, and routine medication risk assessment are needed.

Background: Persons with disabilities, particularly deaf individuals, remain a largely overlooked population in sexual and reproductive health (SRH) programming globally, with this gap especially pronounced in low- and middle-income countries. Deafness imposes substantial barriers to accessing information and services that are routinely available to hearing peers, further exacerbated in the post-COVID-19 era. This study assessed deaf adolescents' knowledge of and access to SRH education and services in Wakiso District, Uganda, and explored systemic, institutional, community, and adolescent-level factors shaping access. Methods: A mixed-methods cross-sectional study was conducted at Wakiso Secondary School for the Deaf from July 2022 to January 2023. Quantitative data were collected from 70 consecutively sampled deaf adolescents aged 13-19 years using a structured questionnaire. Qualitative data were gathered through key informant interviews (KIIs) with four purposively selected stakeholders and a focus group discussion (FGD) with deaf adolescent students. Qualitative data were analysed thematically. Results: The mean participant age was 17 years (SD {+/-}1.8); 65.7% were female. A large majority (88.6%) had heard of SRH components, and 98.6% perceived a need for SRH education or services. However, 84.3% reported challenges accessing these services at least 85% of the time. No participant had ever received SRH education or services through a formal health facility. The FGD revealed that adolescents' conceptualisation of SRH was narrow, centred on body hygiene and HIV prevention, while service-seeking was reactive and symptom-driven. Five cross-cutting themes emerged from the KIIs and were reinforced by FGD findings: communication barriers; inadequate and inaccessible services; family and community isolation; existing platforms and positive practices; and negative provider attitudes and limited capacity. The school nurse emerged as the sole functional SRH access point for most participants. Conclusion: Despite high awareness and near-universal perceived need, deaf adolescents in Uganda face profound multilevel barriers to SRH access. Structural, psychosocial, and knowledge-related barriers interact to exclude this population from formal health services. Findings call for disability-responsive SRH integration into health systems, training of health workers in accessible communication, community capacity building, and co-design of SRH programmes with deaf adolescents.

Background: Cambodia is a high-TB burden country where over a third of TB cases have gone undetected. The Community Mobilisation Initiatives to End TB (COMMIT) programme, implemented across four provinces and 27 operational districts (ODs) in Cambodia from October 2019 to September 2024, aimed to improve TB case finding, diagnosis, treatment, and prevention through community-driven approaches. This study evaluated the implementation, programme outcomes, and sustainability of COMMIT to inform future TB initiatives. Methods: This mixed-methods explanatory sequential study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Quantitative data were collected from the programme database and the national TB Management Information System (TB-MIS). In-depth interviews, guided by the Theoretical Domains Framework (TDF), explored contextual factors influencing programme implementation and complement quantitative findings. Quantitative data were analysed descriptively to estimate screening coverage, diagnostic yield, and construct care cascades. Qualitative data were transcribed and translated into English, coded, consolidated into a matrix structured using RE-AIM and TDF components, and analysed thematically. Results: COMMIT screened 695,970 people for TB. Key populations were reached, though sex and age disparities in screening participation reflected underlying social and structural barriers. Approximately 98% of those screened underwent diagnostic testing. Treatment initiation (>99%) and completion (>97%) rates were high. COMMIT operationalised contact investigation and evaluation for TB preventive treatment (TPT), screening over 90% of notified contacts. More than 20,000 people were TPT-eligible, of whom 68.7% enrolled in and 86.2% completed TPT. These programme outcomes were supported by strong community engagement, expansion of rapid molecular diagnostics, and programme adaptability during COVID-19. COMMIT was scaled from 10 to 27 ODs, during which it strengthened community capacity by training healthcare workers and expanding peer support groups. Stakeholders emphasised the need to reinforce local ownership and public-private sector collaboration, strengthen integrated services, and de-implement low-value practices such as symptom-based screening. Conclusions: COMMIT improved TB case detection, treatment support, and prevention in Cambodia through community-led strategies and sustained capacity building. Maintaining the programme impact will require continued investment in community systems, de-implementation of low-value practices, and the adoption of efficient, person-centred approaches that address evolving community needs.

Background: Despite rising enthusiasm for active case-finding for TB, there have been concerns about conducting simultaneous HIV screenings due to perceived stigma, although the evidence to support this concern is scarce. We assessed the acceptability of integrated HIV-TB community screening and characterised participants' motivations and prior testing history. Methods: The SLIM study was a non-interventional cross-sectional study conducted in Puducherry (February 2023 to January 2024). In two community health camp-style screening events (one urban and one peri-urban), adults 18 years and older were offered TB screening via portable chest X-ray with AI-assisted interpretation (qXR, Qure.ai), plus sputum testing (Truenat), alongside point-of-care HIV testing. Structured questionnaires captured sociodemographics, prior testing history, and motivations for participation. Acceptability was pre-specified as >50% uptake. Results: Of 273 eligible adults approached, 264 (96.7%) accepted integrated screening, nearly double our pre-specified threshold. Participants were predominantly low-income with limited formal employment. The dominant motivation was a desire to know one's health status (HIV: 74.8%; TB: 73.7%), followed by convenience (16 to 17%). Prior HIV and TB testing was rare (7 to 13% and 15 to 18%, respectively). Participation was uniformly high across demographic groups; however, the screened population skewed older and female (mean age 58 (standard deviation: 12.6) years; 67% female). Men under 45 comprised only 3.7% of participants, substantially below their 24.7% share in the Puducherry population per the most recent census. Conclusions: Integrated HIV-TB screening achieved near-universal uptake in a socioeconomically vulnerable population with little prior testing exposure, contradicting concerns that community HIV screening would be poorly accepted in India. Integrated community-based screening should be scaled up as a cornerstone of TB elimination in high-burden settings. Crucially, because TB incidence in India peaks in the 15 to 45 age group and disproportionately affects men, targeted strategies to bring younger men and women into community screenings are essential.

Introduction Reducing delays in leprosy case detection is essential for achieving global leprosy targets. Accurate measurement of these delays and their determinants relies largely on patient-reported data, as routine health records are often inadequate. The leprosy case detection delay (CDD) questionnaire, developed under the Post Exposure Prophylaxis for Leprosy (PEP4LEP) project, has been validated in Ethiopia, Mozambique, Tanzania, and Indonesia. However, it has not been adapted or validated for Nigeria or any major Nigerian indigenous language. This study aimed to culturally adapt and validate the CDD questionnaire for Igbo-speaking populations in Nigeria. Methodology/Principal Findings The CDD questionnaire underwent a standardized cross-cultural adaptation process. Content validity was assessed using item- and scale-level content validity indices, while construct validity was evaluated through hypothesis testing. Reproducibility was assessed using test-retest and inter-rater reliability; agreement using the Bland-Altman method and the Wilcoxon Signed-Rank test; reliability using Spearmans rank correlation coefficient and the Intraclass Correlation Coefficient (ICC); and internal consistency using Cronbachs alpha. Data were collected through face-to-face interviews with persons affected by leprosy at two time points separated by at least two weeks. Participants (n=100) had a mean age of 45.1 years (SD=18.7). Mean CDD was 77.2 months at baseline and 77.9 months at retest. The instrument demonstrated excellent content validity (I-CVI/S-CVI: 0.90-1.00), good internal consistency (Cronbachs =0.77), and excellent test-retest reliability (ICC=0.996, 95% CI: 0.994-0.997). Test and retest measurements were highly correlated ({rho}=0.985, p<0.001), with no evidence of systematic change over time (p=0.864). Seventy-two percent of participants reported identical CDD values across assessments. All items from the original English version were retained without modification. Conclusion/Significance The Igbo version of the CDD questionnaire demonstrated good validity and reliability and is suitable for assessing leprosy case detection delay among Igbo-speaking populations in Nigeria

BACKGROUND Erythema nodosum leprosum (ENL) is a severe inflammatory complication of leprosy associated with disability, morbidity and mortality. Impairment of health-related quality of life (HRQoL) in ENL has been reported using the Dermatology Life Quality Index (DLQI) and the 36-Item Short Form Health Survey (SF-36), the latter validated in people affected by leprosy. Understanding the correlation between these measures is important to determine whether the shorter dermatology-specific DLQI provides a valid and practical measure of HRQoL in ENL. OBJECTIVES To examine the relationship between DLQI and SF-36 scores in individuals with ENL using data from the Methotrexate and Prednisolone study in ENL (MaPs in ENL). METHODS A post-hoc analysis of prospectively collected HRQoL data from the trial sites in India, Indonesia, and Nepal of the MaPs in ENL multicentre randomised clinical trial was performed. HRQoL was assessed using the DLQI and SF-36 at enrolment and at weeks 24, 48 and 60. Associations between DLQI and SF-36 physical (PCS) and mental (MCS) component summary scores were evaluated using correlation analyses and multivariable linear regression at enrolment, and linear mixed-effects models during follow-up adjusted for age, sex, recruiting centre and enrolment SF-36 scores. RESULTS A total of 383 paired HRQoL assessments from 129 participants were analysed. At enrolment, HRQoL impairment was substantial (median DLQI 19, IQR 15-21; mean PCS 30.3 + - 7.3; mean MCS 33.3 + - 8.4). DLQI scores improved markedly during follow-up. Across all timepoints, DLQI was strongly inversely correlated with PCS and MCS (both p<0.001). In adjusted analyses, higher DLQI scores were consistently associated with lower PCS and MCS. At enrolment, each 1-point increase in DLQI was associated with a 0.66-point reduction in PCS and a 0.51-point reduction in MCS (both p<0.001). These associations remained strong during follow-up, with no evidence that they varied over time. CONCLUSIONS DLQI scores were strongly and consistently associated with SF-36 physical and mental health scores. These findings support the use of the DLQI as a practical patient reported outcome measure to assess the HRQoL associated with ENL and its change following treatment.

IntroductionWith rising tick-borne disease (TBD) cases and the geographical expansion of tick populations, the need for effective surveillance and public education regarding local risk is crucial. This study assessed the effectiveness of tick-check stations as a tool for tick surveillance, and their impact on community knowledge, attitude, and practices (KAP) related to ticks and TBD. MethodsTo assess the effectiveness of tick-check stations for surveillance, we evaluated station engagement and compared tick density estimates, species composition, and life-stage distributions with those obtained through concurrent active surveillance. In addition, we compared submission numbers and tick species and life stages to those collected through a mail-in submission system conducted by the Colorado Department of Public Health and Environment (CDPHE). To quantify feasibility, we estimated effort per tick and compared effort across simulated sampling scenarios. Finally, in-person surveys were conducted at trailheads to assess baseline tick KAP and to evaluate differences between sites with and without tick-check stations ResultsEngagement with tick-check stations was sustained throughout the study. Temporal tick densities estimated from tick-check station submissions were correlated with density estimates from active surveillance (R = 0.534), and species composition and life-stage distributions did not significantly differ between methods. Tick-check stations required less effort per tick than active surveillance when sampling sites were nearby or tick densities were low, whereas sites that were farther away or had higher tick densities required less effort per tick under a hybrid surveillance approach. When asked to list tick-borne pathogens in Colorado, 47% of survey participants who had read tick-check station signage identified Rocky Mountain spotted fever compared with 20% of participants in the control group (p = 0.007; odds ratio). Notably, a low proportion of survey participants (24%) reported performing tick-checks to prevent tick bites. ConclusionTick-check stations can provide tick density estimates comparable to active surveillance while requiring less effort in many scenarios, particularly in low-density settings. Our findings also highlight opportunities for targeted outreach to address gaps in TBD knowledge. As both a surveillance and educational tool, tick-check stations offer a sustainable approach for expanding tick monitoring in resource-limited settings.