Tropical Medicine and Infectious Disease

Background On the Zanzibar islands, Tanzania, mass drug administration (MDA) with praziquantel against Schistosoma haematobium infections has been implemented regularly since the early 2000s. Elimination of schistosomiasis as a public health problem has been achieved in most areas, with the goal of interruption of transmission. The RESIST project investigates the extent to which MDA-driven selection for praziquantel resistance is occurring and contributing to persistent transmission hotspots. Methodology As part of RESIST, the efficacy of praziquantel treatment was assessed in two schools on Pemba between October 2024 and March 2025. Longitudinal parasitological surveys were conducted before and two weeks after school-based MDA with praziquantel (40 mg/kg). Up to six urine samples per study participant were collected on different days pre- and post-MDA and examined for S. haematobium eggs by urine filtration microscopy. In a per-protocol analysis, drug efficacy was categorised as adequate, inconclusive, or reduced, based on hypothesis testing. A generalized linear mixed model was used to assess the association between pre-MDA infection intensity and drug efficacy at the individual level. Principal findings Pre-MDA, S. haematobium prevalence was 14.3% (62/434) in School 1 and 37.8% (233/617) in School 2. Post-MDA prevalence was 0.5% (2/434) and 9.6% (59/617), respectively. Egg reduction rates were 99.8% (90% confidence interval (CI): 99.2-100%) in School 1 and 94.8% (90% CI: 88.6-98.6%) in School 2, which were classified as adequate and inconclusive, respectively. In School 2, drug efficacy at the individual level was negatively associated with pre-MDA infection intensity. Conclusion/significance The efficacy of praziquantel on Pemba remains higher than the 90% threshold for optimal drug efficacy set by the World Health Organization. While the inconclusive efficacy results for School 2 can at least partially be explained by the variation in the participants pre-MDA infection intensities, further investigations are warranted to account for the disparity in praziquantel efficacy on Pemba. Trial registration: ISRCTN, ISRCTN59331501. Registered 24 October 2024, https://www.isrctn.com/ISRCTN59331501.

Introduction Miltefosine is the only approved oral antileishmanial agent, but its use in women of childbearing potential (WOCBP) is restricted due to preclinical teratogenicity. Current labeling recommends contraception during treatment and for at least five months thereafter, based solely on its long terminal elimination half-life. This study re-evaluated the required contraceptive duration using an exposure margin-based approach. Methods Virtual populations were generated from anthropometric data of 382 Indian, 4,462 Eastern African, and 4,019 Brazilian WOCBP with leishmaniasis. Published population pharmacokinetic models were used to simulate miltefosine exposure following 14-42-day regimens for visceral leishmaniasis (VL), post-kala-azar dermal leishmaniasis (PKDL), and cutaneous leishmaniasis (CL). A developmental safety exposure threshold was derived from the rat no-observed-adverse-effect level (0.6 mg/kg/day for 10 days) and adjusted using a 10-fold safety margin. Contraceptive durations resulting in median residual post-contraception exposure (AUCEOC-{infty}) below this threshold were considered supportive of contraceptive discontinuation. Results The developmental safety exposure threshold was estimated at 2.5 mg{middle dot}day/L. Despite pharmacokinetic differences across geographical regions and disease manifestations, required minimum contraceptive durations were consistent: three months from treatment initiation for the 14-day regimen, four months for 21- and 28-day regimens, and five months for the 42-day regimen. For the 14-day regimen, a single dose of a long-acting injectable contraceptive administered at treatment initiation would provide sufficient coverage. Conclusion An exposure margin-based approach supports shorter contraceptive durations than current recommendations. For the 14-day VL regimen, three months of contraception may provide a practical alternative to current labeling.

Background Madagascar has one of the highest burdens of schistosomiasis globally, yet epidemiological evidence from the South-east of the country remains limited. Existing surveillance estimates suggest relatively low prevalence in this region. This contrasts with the region's environmental suitability for transmission and its population's high occupational risk through rice farming. Methods A cross-sectional exploratory study was conducted across 13 villages around the Manombo Special Reserve, Farafangana District, between May and July 2025. Participants were surveyed for geographic, environmental and behavioural risk factors for schistosomiasis infection. Infection was diagnosed by Kato-Katz stool microscopy. Multivariable mixed-effects logistic and linear regression, with village as a random intercept, estimated associations with infection and intensity respectively, adjusting for the water catchment area of household water sources, sex, age group, recent praziquantel treatment and village-level open defecation rate. Results 227 participants were included. Overall S. mansoni prevalence was 53.3% (95% CI 46.8-59.8%); median infection intensity was 96 (IQR 48-288) eggs per gram of stool among those infected. Surface water contact was near-universal (97.3%). Prevalence varied markedly between neighbouring villages. No demographic, behavioural, or WASH variable was independently associated with infection. The water catchment area of household water sources was the primary predictor of infection. Conclusions Prevalence substantially exceeded current surveillance estimates, suggesting this population is underserved by existing control programmes. Water catchment area was the dominant determinant of transmission heterogeneity, possibly consistent with Biomphalaria habitat suitability. Water catchment area may represent a valuable and underutilised unit for targeting schistosomiasis surveillance and control in Madagascar.

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

Human Papillomavirus (HPV) infection among men who have sex with men (MSM) has become a significant public health concern, particularly in countries where male vaccination is unavailable. Given the high susceptibility of MSM to HPV and anal cancer, and the unavailability of HPV vaccination for males in low- and middle-income countries (LMICs), there is a need to identify alternative interventions for reducing disease transmission and burden in this population. The novel mathematical model presented in this article couples smoking behavior dynamics with HPV transmission and anal cancer progression among MSM. Smoking reduction is introduced as an intervention to assess its effects on disease transmission and burden. The basic reproduction number (R0) is derived using the next-generation matrix method, and a global sensitivity analysis is performed using partial rank correlation coefficients (PRCC) to identify the influence of model parameters on RR0. Further, the theoretical analysis of the model reveals a backward bifurcation, implying that RR0 < 1 is necessary but not sufficient to eradicate the disease. The study finds that smoking reduction among MSM reduces HPV infection and anal cancer burden relative to baseline projections without intervention. The joint effect of smoking reduction and vaccination shows that the critical vaccination coverage needed to achieve RR0 <1 decreases as the level of smoking reduction increases. A similar outcome is observed for contact reduction. These findings highlight the importance of concurrent interventions, which can significantly curtail the spread of HPV and reduce disease burden in both the high-risk group and the general population.

Introduction: Most people with tuberculosis (TB) reside in countries with limited resources for prompt TB diagnosis, resulting in diagnosis and treatment delays and ongoing community transmission. Current TB diagnostics rely on sputum, while some people with presumptive TB cannot produce adequate sample. A new generation near-point-of-care (NPOC) tests using sputum or tongue swabs may provide more accessible TB diagnosis. Methods: In this pragmatic cluster randomised controlled trial (cRCT) in Indonesia, a multi-component public health intervention will include: (a) introduction of NPOC MiniDock MTB test (Guangzhou Pluslife Biotech, China) on sputum, tongue swab, or both specimens, (b) optimisation of clinical algorithms incorporating the new test, (c) a promotional package to encourage patient attendance and test utilisation, and (d) TB household contact investigation, including the new test, by community health volunteers. We will randomly stratify 40 community health centre (CHC) areas into intervention and control arms (1:1) in Bandung District. The intervention will be administered in healthcare facilities (HCFs) and in the community of the intervention areas. The control areas will continue standard of care with no intervention, except TB notification refresher training, which will be delivered in both areas before intervention roll-out. The primary outcome is the number of TB cases diagnosed and notified by HCFs per population attending them. It will be measured by abstracting data on TB case notification and the number of HCF attendees over 12 months following completion of the intervention roll-out, compared to 12 months preceding any trial activities. Discussion: This trial will evaluate the effect of an intervention package incorporating the first-in-class NPOC on TB diagnosis and notification. The trial results will inform policy to improve TB diagnostic efforts in Indonesia and other high burden TB countries. Trial Registration: ClinicalTrials.Gov, NCT07293455.

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

BACKGROUND Diagnosis of Tuberculosis (TB) from stool specimen using the Xpert MTB/RIF Ultra assay (Xpert-Ultra assay) is important to confirm diagnosis for presumptive TB patients who are unable to produce sputum. We evaluated diagnostic performance of the Xpert-Ultra assay in stool specimen among adult migrant population living in generalized HIV epidemic situation. METHODS A prospective, cross-sectional study was conducted at outpatient and inpatient departments of the Shoklo Malaria Research Unit (SMRU) clinics and Mae Tao Clinic (MTC) located in Thailand-Myanmar border area. Presumptive TB patients of any age who were registered between November 14, 2022, and May 23, 2023, were eligible for inclusion based on reported signs and symptoms and/or radiological findings. Using liquid MTB culture in sputum as reference standard, evaluation of diagnostic performance of the Xpert-Ultra assay in stool was performed, and it was also compared with performance of smear microscopy and Xpert-Ultra assay in sputum specimen. RESULTS Total 113 participants were included in the analysis; 9 (7.96 %) had human immunodeficiency virus (HIV) infection, and 31 (27.43%) had confirmed TB on culture results. Among these culture-confirmed TB cases, the sensitivity of Xpert-Ultra assay in stool specimen was 90.32 % (95% confidence interval [CI], 74.25% to 97.96%). Although the absolute difference in sensitivity of Xpert-Ultra assay in stool was 3.23 % lower than sputum (95% CI: -9.46 % to 3.00 %), there was no statistically significant difference between the two sample types. The specificity of Xpert-Ultra assay in stool specimen was 98.78% (95% CI, 93.39% to 99.97%) against culture-negative TB cases, giving an absolute difference of 1.22 % (95% CI, -1.16% to 3.59%) compared to sputum Xpert-Ultra assay. This method demonstrated that diagnostic performance was consistent with World Health Organization (WHO) target product profiles on low-complexity assays for detecting Mycobacterium tuberculosis (MTB). CONCLUSIONS The Xpert-Ultra assay in stool specimen can be considered as a potential, alternative method in diagnosis of presumptive pulmonary TB in adults when respiratory sample is difficult to collect.

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

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

HIV/AIDS remains a major global public health challenge, and disparities in HIV testing persist. In 2024, an estimated 87% of people living with HIV were aware of their status, with lower testing coverage among children aged 0-14 years (63%), and among men (84%) compared with women (92%). Romania initiated its national AIDS program in 1995 and quickly progressed in addressing the epidemic; however, HIV testing remains largely concentrated in specialized services, with late diagnosis, missed testing opportunities, and stigma continuing to limit timely identification and linkage to care. This study aimed to understand better HIV testing/screening practices among clinicians in eastern Romania and to identify gaps that could be addressed through medical education. We conducted an analytical cross-sectional study among healthcare providers in the eastern region of Romania to assess whether HIV testing is routinely offered to patients, explore gaps in clinical judgment and perceived responsibility, and identify factors that facilitate HIV testing. A 17-question anonymous survey was distributed via WhatsApp to clinician groups between August 1 and September 30, 2023. Respondents included physicians (71.9%), nurses (28.1%), and other healthcare professionals, working in infectious diseases (36.0%), internal medicine (22.3%), primary care (13.7%), and other specialties, such as obstetrics-gynecology and pediatrics (18.0%). Only 38.1% of respondents reported routinely screening all patients aged 18 years and older for HIV, while 61.9% did not offer regular HIV testing. The most cited reasons for not screening were the perception that HIV testing was not their responsibility and that their department did not require testing (18.1% each). Clinicians working in settings with established policies on HIV confidentiality, non-discrimination, testing, and post-exposure prophylaxis were more likely to offer routine testing. Universal HIV screening remains uncommon among clinicians in eastern Romania. Supportive institutional policies appear to facilitate routine testing and may reduce missed opportunities for early diagnosis. Normalizing HIV testing as part of routine clinical care, in line with the Romanian National Health Strategy 2022-2030, is crucial for enhancing early detection and strengthening prevention efforts through coordinated action among clinicians, public institutions, and civil society.

Background: Doxycycline post-exposure prophylaxis (doxy-PEP) reduces the incidence of bacterial sexually transmitted infections (STIs) among men who have sex with men and transgender women (MSMTW), but it may select for antimicrobial resistance (AMR). AMR development will depend in part how doxy-PEP changes rates of antibiotic use. Methods: We conducted a retrospective electronic medical record review of antibiotic prescriptions received by patients at the Massachusetts General Hospital Sexual Health Clinic from January 1, 2023, to December 27, 2025. Using a Bayesian negative binomial regression, we assessed the direct, indirect, and combined effects of doxy-PEP implementation on antibiotic prescription rates among doxy-PEP-eligible MSMTW who were receiving HIV pre-exposure prophylaxis. Results: Controlling for direct effects, the cohort's total antibiotic prescription rate decreased by 10% (0.90, 95% CI 0.87 - 0.94) for every 100 doxy-PEP starts. Doxy-PEP users were prescribed antibiotics at double the rate predicted in the absence of doxy-PEP implementation, and, controlling for indirect effects, received 3.40 (95% CI 2.95 - 3.91) times the antibiotic prescriptions of patients not using doxy-PEP. Doxy-PEP non-users were prescribed antibiotics at less than half the rate predicted in the absence of doxy-PEP. The full cohort's overall antibiotic prescription rate increased by 1.4 times after doxy-PEP implementation. Conclusions: Individuals who are taking doxy-PEP have higher antibiotic prescription rates, increasing selection for antibiotic-resistant bacteria in these individuals. However, doxy-PEP-driven decreases in the overall incidence of bacterial STIs have the potential to decrease selective pressure for resistant organisms in those not using doxy-PEP.

Background: Drug-resistant tuberculosis (DR-TB) remains a major challenge to tuberculosis control in sub-Saharan Africa. Cameroon faces substantial challenges in managing DR-TB; however, national evidence on treatment outcomes remains unsynthesized. This systematic review and meta-analysis aimed to estimate pooled treatment outcomes, adverse drug events (ADEs), and predictors of unfavorable outcomes among patients with DR-TB in Cameroon. Methods: This systematic review and meta-analysis followed the PRISMA 2020 guidelines. PubMed, Scopus, Embase, Web of Science, the Cochrane Library, African Journals Online. Google Scholar and reference lists were also searched. Studies reporting World Health Organization-defined treatment outcomes among patients with DR-TB were included. Random-effects meta-analyses using generalized linear mixed models with logit transformation were performed. Heterogeneity was assessed using the I2 statistic, and publication bias and sensitivity analyses were conducted. Results: Fifteen studies conducted between 1998 and 2022 were included. The pooled mortality rate was 6.8% (95% CI: 4.7-9.7; 14 reports; n = 2,351 participants), loss to follow-up was 4.1% (95% CI: 2.8-6.1; 12 studies; n = 2,244 participants), and treatment failure was 5.0% (95% CI: 1.1-19.8; 12 studies; n = 2,050 participants). The pooled treatment success rate was 74.2% (95% CI: 60.4-84.4; 13 reports; n = 2,146 participants). Treatment success improved over time and was higher with modified regimens (87.2%; 95% CI: 83.8-89.9; 3 studies; n = 460 participants) than with standard regimens (68.8%; 95% CI: 52.2-81.6; 10 studies; n = 1,686 participants). Among patients with multidrug-resistant-TB, the pooled prevalence of adverse drug events was 70.8% (95% CI: 40.2-89.7; 3 studies; n = 251 participants), with ototoxicity (41.9%; 95% CI: 23.7-62.6; 3 studies; n = 251 participants) and gastrointestinal disorders (40.9%; 95% CI: 25.5-58.2; 2 studies; n = 172 participants) being the most common events. HIV co-infection was significantly associated with unfavorable treatment outcomes (pooled OR = 2.76; 95% CI: 1.95-3.93; 6 studies), and male gender was also associated with increased odds of unfavorable outcomes (OR = 1.73; 95% CI: 1.25-2.40; 5 studies). Conclusions: Approximately three-quarters of patients with DR-TB in Cameroon achieved successful treatment, although mortality, treatment failure, and adverse drug events remain important concerns. Strengthening pharmacovigilance, integrated TB/HIV care, and the implementation of effective all-oral regimens are essential to improve treatment outcomes. Systematic review registration number: CRD420261404490.

Background: Curable sexually transmitted infections (STIs) are associated with adverse birth outcomes, yet little cost-effectiveness evidence guides antenatal STI screening policy in high-burden settings. We conducted a cost-effectiveness and cost-utility analysis of the Philani Ndiphile trial in South Africa, comparing One-Time and Two-Time antenatal screening for C. trachomatis, N. gonorrhoeae, and T. vaginalis with standard syndromic management. Methods: A decision-analytic model from the provider perspective simulated costs and outcomes for pregnant women and infants. Costs included diagnostics, treatment, and neonatal hospitalisation for a primary composite outcome of preterm birth and/or low birthweight and its components (secondary trial outcomes). Modelled outcomes included incremental cost (US$) per composite (preterm birth and/or low birthweight) case, per component case and per disability-adjusted life year (DALY) averted. The analysis captured infant outcomes in the first year. Univariate and probabilistic sensitivity analyses were conducted to assess parameter uncertainty and robustness of results. Results: Screening for C. trachomatis, N. gonorrhoeae, and T. vaginalis twice during pregnancy was not cost-effective for preventing the primary composite outcome, nor for preventing low birthweight alone. However, two-time screening was cost-saving for preventing preterm birth alone, averting more DALYs and thereby yielding better health outcomes while reducing healthcare costs compared with syndromic management. One-time screening was not cost-effective for preventing any outcome. Conclusions: Repeat antenatal screening for C. trachomatis, N. gonorrhoeae, and T. vaginalis has the potential to prevent preterm births while reducing healthcare costs in high-burden settings. These findings support further research to confirm the clinical effectiveness of repeat screening and to evaluate longer-term health and economic impacts.

Background Urine tenofovir (uTFV) and dried blood spot (DBS) tenofovir diphosphate (TFV-DP) concentrations respectively estimate short- and medium-term adherence to tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART). We evaluated the accuracy of a point-of-care uTFV assay, and associations between uTFV/TFV-DP, and viral load (VL) and retention outcomes within a South African community ART programme. Methods We measured uTFV and DBS TFV-DP concentrations using liquid chromatography-tandem mass spectrometry (LC-MS/MS). We calculated sensitivity and specificity of the point-of-care uTFV assay at the manufacturer-recommended threshold of [&ge;]1,500 ng/mL compared to LC-MS/MS. We assessed associations of the point-of-care uTFV assay, and DBS TFV-DP concentrations with concurrent viraemia, and with retention-in-care by 16 weeks post-enrolment. Results Of 196 adults median age was 44 years, 127 (64.8%) were female, and 191 (97.4%) were receiving TDF. 185 (94.4%) had detectable point-of-care uTFV, which had high sensitivity (99.5%, 95% CI 96.5-100%) and moderate specificity (76.9%, 95% CI 46.0-93.8%) for detecting uTFV [&ge;]1,500 ng/mL. Two participants had concurrent viraemia [&ge;]1,000 copies/mL; of these 50.0% (95% CI 9.4-90.5) had undetectable point-of-care uTFV, and 100% (95% CI 19.7-100) had low TFV-DP <483 fmol/punch. Among participants without viraemia 97.4% (95% CI 93.6-99.0) had detectable uTFV, and 98.1% (95.3-99.6) had high TFV-DP [&ge;]483 fmol/punch. Point-of-care uTFV and DBS TFV-DP were not associated with retention-in-care. Conclusions The point-of-care uTFV assay demonstrated high sensitivity and moderate specificity to detect uTFV. Over 95% of people without viraemia had detectable point-of-care uTFV or high DBS TFV-DP levels respectively, but these were not associated with 16-week retention-in-care.

The 17th Ebola outbreak in the Democratic Republic of the Congo, announced on 15 May 2026, was attributed to Bundibugyo ebolavirus (BDBV). Although case isolation is the main control strategy, its effectiveness is compromised when patients escape isolation facilities before recovery. Between 14 May and 17 June 2026, 175 individuals reportedly left isolation facilities without formal discharge across Ituri Province. We assessed how this "isolation leakage" affects community transmission. We refined the SEIHFR framework to distinguish undetected community infections, detected but not-yet-isolated cases, isolated individuals, leakage, funeral-associated transmission, and removals. Using Bayesian inference, we fitted the model to daily Ituri surveillance data, escapee counts, and isolation census records. We estimated the leakage rate, reporting and detection probabilities, and the transmission rate, while fixing other parameters based on the BDBV literature. The model reproduced confirmed cases, deaths, discharges, and escapees. We estimated R_0=3.67 (95% HDI: 2.0-5.7), a leakage rate of {rho} {approx} 0.034 day^-1 (0.022-0.051), and high contact-tracing-driven detection (p_d {approx} 0.91-0.99). Leakage increased the detection-dependent reproduction number [R](p_d) from approximately 3.2 to above 5. Eliminating leakage reduced cumulative infections by about one-third, from 1,120 to 764, while the minimum detection level required for control increased from p_d [&ge;] 0.73 without leakage to p_d [&ge;] 0.87 at the fitted leakage rate. Shortening time to isolation prevented the most infections (73.4%; 59-84), followed by reducing leakage (29.7%; 14-52) and re-isolating escapees (12.6%; 6-24). Delaying leakage reduction until week 4 reduced its benefit from about 27% to below 2%. Isolation leakage represents a major transmission pathway that has until now gone largely unmeasured. While rapid initiation of isolation is highly beneficial, it cannot compensate for permeable isolation; therefore, early, community-driven efforts to control leakage, embedded within a multilayered response, are critical.

Introduction: HIV testing and pre-exposure prophylaxis (PrEP) are efficacious HIV prevention strategies, but uptake remains low among Sub-Saharan African men. Peer-delivered approaches may improve engagement. We developed an intervention combining peer-delivered oral HIV self-testing (HIVST) with incentivized peer referral to HIV services and an SMS-based HIV risk assessment among men in eastern Zimbabwe (IMPERATIVE Trial: NCT06370923). We co-adapted the intervention through iterative prototyping (IP) to enhance its acceptability, feasibility, and potential effectiveness. Methods: From November 2023 to June 2024, we implemented a novel IP framework to refine and test the intervention. Four primary distributors (PDs) were trained to deliver HIVSTs to three peers and refer them to clinic services. Peers could become secondary distributors (SDs), obtain HIVSTs from community hubs and distribute them further. Qualitative data were collected alongside intervention testing to adapt the intervention over two iterations. Activities included three forum theatre workshops, one community advisory board meeting, 25 in-depth interviews, four focus group discussions, and eight observational reports involving men, implementers, stakeholders, and advisory board members. Additionally, 20 men completed baseline and one-week follow-up surveys. Quantitative data were analysed descriptively; qualitative data were analysed using thematic analysis. Results: During testing, HIVST uptake was 100% among PDs, 90% among PD-recruited peers, and 63% among SD-recruited peers. Among self-testers, 50% sought confirmatory testing and about one-quarter initiated PrEP (PDs 25%, PD-recruited peers 30%, SD-recruited peers 25%). Participants viewed the intervention positively and anticipated increased HIV testing and PrEP initiation. Four areas for refinement were identified: recruitment, information dissemination, incentives, and socio-cultural factors. Participant recommendations were adopted before randomised controlled trial testing. Conclusion: Peer-delivered HIVST with referral to HIV services shows promise for engaging Zimbabwean men. The IP framework incorporating participant recommendations enhanced intervention design and delivery within the IMPERATIVE trial. This methodology may inform future intervention development in similar settings.

Background Uganda is among the African countries most affected by the ongoing clade Ib Mpox (monkeypox) outbreak, with sustained community transmission since 2024. Effective community-level prevention depends on understanding how risk and protective factors are distributed across the social ecology. We applied a socio-ecological framework to map the determinants of Mpox transmission risk and protective practice in affected districts. Methods We conducted a multi-district, community-based cross-sectional survey of 3,960 community members aged 15-65 years across high- and low-burden districts in Uganda between February and March 2025. Participants were selected by multistage sampling and interviewed using a structured tool administered on tablets. Individual-, household-, community- and structural-level characteristics were summarised descriptively. A modified Poisson regression model with district-clustered robust standard errors was used to estimate crude and adjusted prevalence ratios (cPR, aPR) for adequate Mpox prevention and control practice; the multivariable model included 3,916 participants with complete covariate data. Analyses were performed in R version 4.5.0. Results The mean age was 32.0 years (SD 10.7); 51.9% (2,056/3,960) were female and most had secondary education (54.2%). Comorbidity burden was substantial (sexually transmitted infections 28.3%, HIV 13.9%, tuberculosis 8.2%, malnutrition 6.2%). Four in five participants (80.2%) resided in high-burden districts and 60.9% perceived themselves at risk, yet only 18.7% had comprehensive knowledge of Mpox and 53.8% reported adequate prevention practice despite near-universal message exposure (93.2%). In adjusted analysis, comprehensive knowledge (aPR 1.32, 95% CI 1.15-1.52) and message exposure (aPR 1.88, 95% CI 1.31-2.71) were by far the strongest protective determinants; several occupational, income, education and religious categories were also independently associated with practice, whereas biological comorbidities were not. Conclusions Mpox transmission risk in Uganda is concentrated in high-burden districts and overlaps with a heavy comorbidity burden. Although some social and structural factors were independently associated with protective practice, it was driven primarily by the modifiable cognitive factors of knowledge and message exposure rather than by biological characteristics. Community-level interventions that convert near-universal message reach into accurate, actionable knowledge are likely to yield the greatest protective gains.

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

In primary healthcare centers lacking advanced imaging, community-based active tuberculosis (TB) case finding often relies on basic symptom screening. This approach often misses cases and leads to the inefficient allocation of rapid molecular testing (RMT). We aimed to develop and internally validate a simple clinical triage scorecard to improve TB detection and guide RMT use in resource-constrained settings. We conducted a retrospective cross-sectional study of 15,137 adults ([&ge;]18 years) evaluated within the Zero TB Yogyakarta program (2020-2025). Participants with complete clinical assessments and confirmatory GeneXpert results were included. Using multivariable logistic regression, we identified independent clinical predictors, which were subsequently transformed into an integer-based point scorecard. Model performance was evaluated via discrimination and calibration, utilizing bootstrap resampling (1,000 iterations) for internal validation. Among the 15,137 participants, 251 (1.7%) were GeneXpert-positive. The final multivariable model identified eight independent predictors: age, male sex, body mass index, prolonged cough, hemoptysis, unexplained weight loss, TB contact history, and diabetes mellitus. The model demonstrated strong predictive accuracy, with an optimism-adjusted AUROC of 0.836 and good calibration. When translated to the integer scorecard and compared directly to standard national symptom screening, the scorecard performed (AUROC 0.81 vs. 0.73; p<0.001). At a high sensitivity cut off score of [&ge;] 0, the tool achieved 93.63% sensitivity and 41.33% specificity. This point-of-care clinical scorecard provides higher diagnostic accuracy than standard symptom screening algorithms. By offering flexible operational thresholds, it empowers local health programs to dynamically balance the urgency of case detection with available diagnostic capacity, optimizing GeneXpert allocation where advanced radiological imaging is unavailable.