Tropical Medicine and Infectious Disease

BackgroundEvidence emerging from Sub-Saharan Africa indicates that people living with HIV (PLHIV) on long-term antiretroviral therapy (ART) especially when the viral load is undetectable, may falsely test negative for HIV on rapid diagnostic tests. This study assessed the prevalence and factors associated with false negative rapid diagnostic HIV tests among Patients on antiretroviral therapy, with undetectable viral load levels at Kisenyi Health Center IV, Kampala, Uganda. MethodsBetween October 2023 and February 2024, a cross-sectional study was conducted among 1,248 PLHIV on ART with undetectable viral loads at Kisenyi Health Center IV. Participants were recruited consecutively, and HIV re-testing was conducted in accordance with the national serial rapid testing algorithm. The algorithm includes a screening test (Determine HIV-1/2), a confirmatory test (Stat-Pak(R)), and a tie-breaker test (SD Bioline(R)). Enzyme-linked immunosorbent assay (ELISA) was used as the final confirmatory method. Data on socio-demographics and clinical characteristics was collected using an electronic data abstraction tool. Logistic regression analysis was done to assess for factors associated with false negative results, using STATA version 14.0. ResultsThe median age of the participants was 34.0 (interquartile range 29.0-42.5 years). The prevalence of false-negative rapid test results was 3.2% (40/1248; CI:2.20-4.2). CD4 (aOR 1.001, CI:1.001-1.003) and duration on ART (aOR 0.884, CI:0.801-0.978) were significantly associated with false-negative HIV results. ConclusionFalse-negative results were observed in approximately 3 in every 100 PLHIV on ART with an undetectable viral load. Serial rapid testing alone may be suboptimal for detecting HIV infection in this population. Further confirmatory testing in individuals who test negative on rapid testing is recommended.

Because of its recent regulatory approval in southern and eastern Africa, CAB PrEP represents a scientific advancement with unknown implementation costs in most African countries. To our knowledge, this paper is the first study comparing PrEP costs in health facilities where clients had a choice between three PrEP methods. We collected and analyzed the direct service delivery costs for each method using the same costing approach and assumptions at three facilities in Lesotho and six facilities in Zimbabwe. On average, in Lesotho, the direct costs of providing CAB PrEP were $57.22 for an initiation visit and $54.20 for a refill visit (same PrEP product dose dispensed in both visit types), while the direct costs of oral PrEP were $22.47 (initiation visit with one month of PrEP dispensed) and $31.98 (refill visit dispensing a three-month dose of medication), and the direct costs of the dapivirine ring were $34.27 (initiation visit with one month of PrEP dispensed) and $50.70 (refill visit dispensing a three-month supply). In Zimbabwe, the average per-visit direct costs to provide CAB PrEP were $48.26 (initiation visit) and $47.40 (refill visit), to provide oral PrEP were $13.47 (initiation visit with one month of PrEP dispensed) and $21.78 (refill visit dispensing a three-month dose), and to provide the dapivirine ring were $42.56 (refill visit dispensing a three-month supply). Initiation visits for the dapivirine ring were not observed in Zimbabwe. At a time when national governments are creating budgets for the HIV response with decreased financial support from bilateral and multilateral partners, this paper will inform HIV prevention planning by providing critical client-level data from the healthcare provider perspective.

BackgroundHIV exposed infants (HEIs) are at a higher risk of infant mortality compared to their counterparts who are not HIV exposed. Early Infant Diagnosis (EID) is the critical first step in reducing HIV-related infant mortality through prompt identification of HIV-infected infants and subsequent initiation of antiretroviral therapy. However, there is limited information on Uptake of EID and factors associated with its timely completion among HIV exposed infants. Therefore, this study aimed at determining the uptake of EID and factors associated with its timely completion among HIV exposed infants at Lira Regional Referral Hospital (LRRH). MethodsThe study was a retrospective cohort of 252 HEIs born in the period of 1st January 2021 to 31st December 2021 chosen through consecutive sampling. Data abstraction tools were used to collect data on uptake of 1st, 2nd, 3rd DNA-PCR and final rapid test from mother-baby pair files and EID register. The main outcome was Uptake of EID and classified as timely and untimely according to the PMTCT guideline. Data was analyzed using descriptive statistics and generalized estimating equations (GEE) with poisson family, log link and unstructured correlation structure. ResultsThe timely uptake of EID among HIV exposed infants at 4-6 weeks, 9 months, 6 weeks after cessation of breastfeeding and 18 months were 80.1% (95% CI:74.5-84.7), 84.2% (95% CI:79.0-88.3), 3.7% (95% CI:2.0-7.0) and 78.8% (95% CI:73.2-83.6) respectively. Having cotrimoxazole given was associated with timely completion of EID [aRR=2.974, 95% CI (1.45-6.10)] ConclusionUptake of EID among HEIs was sub-optimal, below the Ministry of Healths 90% target. Timely cotrimoxazole administration was associated with EID completion,

CD4 testing is essential for identifying people with Advanced HIV Disease to enable provision of a diagnostic package (serum cryptococcal antigen testing and urine lipoarabinomannan testing) and prophylaxis. Lay providers (HIV diagnostic assistants) might be able to perform CD4 testing and advanced HIV diagnostics using lateral flow assays (LFAs). We conducted a prospective diagnostic accuracy study comparing LFA(Visitect) CD4 results performed by HIV diagnostic assistants and by laboratory technicians, using paired quantitative CD4 results from the PIMA device (performed by a nurse) as the reference standard. We also compared results of serum cryptococcal antigen (CrAg) and urine lipoarabinomannan (LAM) tests performed by HDAs to those performed by nurses. Implementation costs were estimated. We recruited 308 participants. Median CD4 was 248 cells/mm3; 115 (37.3%) patients had values below 200 cells/mm3. Sensitivity and specificity for determining CD4 below 200 cells/mm3 using the LFA operated by HIV diagnostic assistants was 94.8% (95%CI 89.1 - 97.6%) and 92.2% (95%CI 87.6 - 95.2%), respectively. Test performance of the LFA performed by laboratory technicians on batch after storage for up to eight hours was substantially worse. Subsequent serum-CrAg and urine-LAM test performed by HIV diagnostic assistants and nurses showed an agreement of 98.1% (kappa=0.74) and 98.1% (k=0.85), respectively. Incremental cost for CD4 test performed by on near patient device based quantitative test was $8.69 and for semi-quantitative LFA by HIV diagnostic assistants was $5.24 (in 2024 US dollars). Trained lay providers can accurately perform CD4, TB-LAM, and CrAg testing. Delaying CD4 testing by batching LFAs at the end of the day led to highly inaccurate results. Our findings support task sharing for decentralized advanced HIV disease testing.

BackgroundAdolescent girls and young women (AGYW) are disproportionately vulnerable to HIV. Despite expanded HIV testing services (HTS), the majority of AGYW remain unaware of their HIV status. This study aimed to assess determinants of HIV testing uptake among AGYW in mainland Tanzania before and after stratifying by age group (15-19 and 20-24 years) using data from three national surveys conducted over time. MethodologyA cross-sectional secondary data analysis was conducted using data from the Tanzania HIV Impact Surveys (2016/17 and 2022/23), obtained from the Population-based HIV Impact Assessment on 23/04/2025. Data analysis was performed using STATA version 17. Modified Poisson regression models were used to identify factors associated with HIV testing uptake before and after stratifying by age group (15-19 and 20-24 years). Results were presented using the adjusted prevalence ratio (APR) with a 95% confidence interval. ResultsHIV testing uptake among adolescents remained 40% in the years 2016/17 and 2022/23, while it increased from 86% to 90% among young women, respectively. Key factors consistently associated with higher prevalence of HIV testing uptake included being in a union, cohabiting, or formerly married; having secondary or higher education levels; and a history of sexually transmitted infections (STIs). ConclusionHIV testing uptake among AGYW in Tanzania has improved over time, with significant disparities between adolescents and young women. These findings highlight the need for age-specific strategies, intensifying adolescent-focused interventions while sustaining efforts among young women and reinforcing integrated reproductive health and HIV services.

BackgroundPyoderma gangrenosum (PG) is a rare neutrophilic ulcerative dermatosis with no FDA-approved therapies and limited validated outcome measures. Investigators Global Assessments (IGAs) are widely used in dermatology but often lack objective criteria, robust validation, and comparability across studies. There remains a critical need for a PG-specific, standardized, and validated severity instrument. MethodsWe developed and conducted initial validation of the Investigator Global Assessment for Pyoderma Gangrenosum (IGAPg(C)), a novel PG-specific IGA. An international multistakeholder panel guided development, with a core team designing the instrument based on prior research identifying key objective clinical features of PG severity. The IGAPg(C) incorporates ulcer depth, drainage, discoloration, and undermining, with ulcer location and extent used to resolve indeterminate cases. Standardized rater training materials were created. Construct validity was assessed in 36 patients evaluated by an expert PG clinician, with correlations to Patient Global Assessment (PGA), Skindex-Mini, and numeric rating scales (NRS) for 24-hour and 7-day pain. Inter-rater reliability was evaluated in a subset of 26 patients assessed independently by five raters using a two-way random-effects intraclass correlation coefficient (ICC [2,1]) within a linear mixed-effects model. ResultIGAPg(C) scores demonstrated strong correlation with PGA when assessed by an expert PG dermatologist (Pearsons r = 0.73) and when averaged across all raters (r = 0.69). Moderate correlations were observed with Skindex-Mini (r = 0.49), 24-hour pain NRS (r = 0.48), and 7-day pain NRS (r = 0.52), consistent with differing constructs measured. Inter-rater reliability was high (ICC = 0.76). Raters reported the instrument to be comprehensive, comprehensible, and efficient to administer. Reliability and construct validity metrics are summarized in Table 1. O_TBL View this table: org.highwire.dtl.DTLVardef@1e95777org.highwire.dtl.DTLVardef@6d6c90org.highwire.dtl.DTLVardef@1f28508org.highwire.dtl.DTLVardef@fc0795org.highwire.dtl.DTLVardef@560854_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 1.C_FLOATNO O_TABLECAPTIONConstruct validity and inter-rater reliability of the IGAPg morphological tool. Correlations between IGAPg scores and patient-reported outcomes (PGA, Skindex-Mini, and average pain) demonstrate moderate-to-strong construct validity. Values are shown for all raters, Rater 1 alone, and Raters 2-5. Inter-item PRO correlations confirm internal consistency. Pearson correlations between Rater 1 and Raters 2-5 are reported with shared patient counts and p-values (p < 0.05 was considered significant). ICC(2,1) indicated good inter-rater reliability with most score variability attributable to differences between patients with minimal variability due to rater differences and a moderate residual component. Inter-item patient reported outcomes correlations confirm difference in measured constructs. C_TABLECAPTION C_TBL ConclusionsDespite limitations including modest sample size and rater homogeneity, the IGAPg(C) demonstrated strong construct validity and high inter-rater reliability. Designed for dermatologists and trainees familiar with PG morphology, the IGAPg(C) represents a promising PG-specific outcome measure for clinical research and therapeutic trials. Future work will focus on refining training materials and expanding validation with structured patient-investigator engagement.

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

BackgroundCutaneous melanoma incidence is rising globally, yet epidemiological data from the high ultraviolet (UV) environment in the United Arab Emirates (UAE), with its diverse expatriate population, remain scarce. This study aims to characterize the epidemiological and histopathological features of cutaneous melanoma in a large, multi-ethnic cohort in the UAE. MethodsThis cross-sectional study analyzed histopathologically confirmed cases of cutaneous melanoma diagnosed at a tertiary referral center in the UAE from January 2017 to January 2025. Patient demographics, tumor location, histologic subtype, Clark level, and Breslow thickness were extracted and analyzed. Descriptive statistics, group comparisons, and multivariable logistic regression were performed using IBM SPSS version 29.0 to identify predictors of thick melanoma (Breslow thickness >1.0 mm). ResultsA total of 597 patients met the inclusion criteria (50.8% male; mean age 47.4{+/-}12.3 years). Individuals of European ancestry constituted 73.4% of cases. Superficial spreading melanoma was the predominant subtype (58.5%), and 46.9% of tumors were thin ([&le;]1.0 mm). Males presented with significantly thicker tumors than females (Breslow thickness of 0.72{+/-}1.32 vs. 0.50{+/-}0.58 mm; p < 0.01) and exhibited distinct anatomical distributions predominant to the back and torso as compared to females with leg and foot predominance. Multivariable analysis identified nodular melanoma (OR 18.40; 95% CI [7.08, 47.86]; p < 0.001) and increasing Clark level (OR 18.50; 95% CI [8.44, 40.58]; p < 0.001) as strong independent predictors of thick melanoma. ConclusionMelanoma in the UAE disproportionately affects fair-skinned expatriates and frequently presents with sex-specific clinical patterns. These findings highlight the need for targeted public awareness initiatives to reduce melanoma morbidity and mortality in the region.

COVID-19 disrupted global health service delivery, particularly among children and adolescents living with HIV (CALHIV), increasing the risk of poor treatment adherence. This study assessed the impact of the COVID-19 pandemic on WHO-recommended early warning indicators (EWIs) of HIV drug resistance (HIVDR) among CALHIV. We conducted a descriptive, longitudinal, retrospective study among children (0-9 years) and adolescents (10-19 years) receiving antiretroviral therapy (ART) in five health facilities in the Littoral region of Cameroon. Seven EWIs were monitored: ART attrition, viral load (VL) suppression, VL coverage, appropriate second VL, ARV medicine stock-outs, antiretroviral drug refills at the pharmacy, and appropriate switch to second-line ART. EWI were collected from January 2018 to December 2021 and classified as "poor," "fair," or "desirable" according to WHO criteria. Trend analyses were performed using Pearsons Chi-squared test with Yates correction in R (version 4.1.1). In 2021, 817 participants were included, comprising 214 children and 603 adolescents. Overall performance was poor for most EWIs in both age groups, except for ART attrition and VL coverage, which showed desirable performance across years. A slight improvement in most indicators was observed between 2018 and 2019, followed by a significant decline in 2020 (p<0.001), coinciding with strict COVID-19 restrictions, and a subsequent improvement in 2021 (p<0.01) as mitigation measures were eased. Despite this recovery, children consistently experienced worse outcomes, including higher ART attrition (9.4% vs 4.4%, p<0.05), lower VL suppression (75.3% vs 82.1%, p<0.05), and poorer access to confirmatory VL testing (15.1% vs 69.5%, p<0.001). Overall, the COVID-19 pandemic negatively affected HIV service delivery during its early phase, although the health system demonstrated adaptive capacity one year later. Targeted public health actions are therefore needed to prevent their long-term effects and improve treatment outcomes in this vulnerable population, especially among children.

BackgroundFemale sex workers (FSW) are a key population for HIV prevention and care. Increasing evidence suggests that social and structural barriers are key drivers of HIV transmission. This global systematic review assesses whether experiencing violence is associated with worse HIV outcomes among FSW. Methods and FindingsWe searched MEDLINE, Embase, and PsycINFO databases for studies published from January 1st, 2010 to February 10th, 2025 assessing the impact of violence on HIV outcomes among FSW, without restriction to language and study design. Some studies had multiple estimates due to reporting on multiple outcomes or exposures of interest. We pooled data from eligible studies using multi-level random-effects meta-analyses to quantify associations between recent (past year) or lifetime exposure to violence (physical, sexual, emotional/psychological and/or financial) and HIV outcomes (prevalent and incident HIV infection, HIV testing, ART use, ART adherence, and viral suppression) among FSW. We preferentially used adjusted estimates over unadjusted estimates if both were available. We included 91 studies with 221 estimates, comprising 179,727 FSWs in 37 countries. We found higher odds of prevalent HIV infection among FSWs with recent (pooled odds ratio (pOR):1.33; 95%CI:1.17-1.51; I2:64%; n=73 estimates) and lifetime (pOR:1.36; 95%CI:1.24-1.49; I2:38%; n=67) experiences of violence. Recently experiencing violence was associated with reduced odds of ART use (pOR:0.78; 95%CI:0.64-0.94; I2:8%; n=17). Lifetime exposure to violence was associated with reduced odds of viral suppression (pOR:0.88; 95%CI:0.79-0.98; I2:20%; n=6). There was no evidence of associations between violence and HIV incidence, HIV testing and ART adherence. ConclusionsExperiencing violence may increase HIV transmission risk and worsen HIV treatment outcomes among FSW. HIV interventions for FSWs must address violence as a structural determinant of HIV.

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

BackgroundHIV-related stigma among healthcare providers hinders service delivery and patient engagement, especially in low- and middle-income countries. The Intervensi Penghapusan Stigma dan Diskriminasi (IPSD) intervention employs a Community-Based Participatory Approach (CBPA) to reduce stigma among healthcare workers (HCWs) in Indonesia by involving people with HIV (PWH) and key populations (KP) as co-developers and co-implementers. MethodsThis cross-sectional study evaluated the implementation outcomes of adoption and fidelity, as defined by Proctor et al., using a validated 5-point Likert scale survey developed based on the Consolidated Framework for Implementation Research (CFIR) and Proctor et al. framework. A total of 120 physicians, nurses, midwives, and laboratory technicians from 31 primary health centres (PHCs) in Greater Jakarta participated in the survey. PHCs were categorised as either high- or average-performing based on triangulated data from PWH networks and evaluations by the Ministry of Health. Descriptive statistics and bivariate analyses, including chi-square and t-tests, were conducted at a significance level of p < 0.05. ResultsSignificant association was found between occupational role and PHC performance (p=0.012). High-performing PHCs reported stronger technical expertise (p=0.033) and better HIV/STI epidemiological knowledge (p=0.033). Organisational incentives influenced fidelity (p=0.032), with higher-performing PHCs reporting greater institutional support. ConclusionFindings underscore the need to reduce stigma through equitable services and supportive organisational climates. Agreement across PHCs showed shared recognition of involving PWH and KP as co-implementers and facilitated intervention adoption, aligning with evidence for contact-based stigma reduction. Differences between PHCs were shaped by capacity and knowledge, with higher-performing facilities showing stronger intervention fidelity. Organisational incentives facilitated sustained fidelity, while national mandates ensured adoption. By examining CFIR constructs and Proctor outcomes, this study informs scalable stigma reduction in primary healthcare. Limitations include small sample size, limited scope, self-reported data, and cross-sectional design, precluding multivariable modelling, making findings exploratory.

BackgroundChildren who are HIV-exposed uninfected (HEU) show greater morbidity and mortality than HIV-unexposed children (HUU). In this study we investigate sex differences in growth, infection rates and antibody response among HEU and HUU infants. MethodsThe study enrolled 107 pregnant women with HIV and 103 pregnant women without HIV with follow-up of their infants from birth to 12 months of age. Study measures assessed included growth parameters, the prevalence of children with overt disease symptoms as reported by the mother, PCR-based assessment of infections (cytomegalovirus (CMV), respiratory syncytial virus (RSV), rhinovirus, influenza A & B, rotavirus and malaria) as well as antibody profile to CMV, RSV and enterovirus infections. ResultsCompared to male HUU, male HEU infants had lower Height-for-age-z-scores ({beta} -0.75; P=0.047) in mixed-effect model accounting for age. Additionally, they showed transiently lower Weight-for-age-z-scores at 3 months (1.07 vs 0.05, P=0.04), with higher risk of rhinorrhea (RR=2.29, P=0.02) and lower enterovirus titers at birth (P=0.0066). Female HEU showed transiently higher stunting at 6 months (0% vs 21%; P=0.01) and lower CMV viremia at 6 months, with elevated CMV antibody titers at 3 months (P=0.04) compared to female HUU. With prevalence ranging from 25%-61%, CMV and Rhinovirus infections were dominant in all groups. HEU and HUU exhibited similar antibody decay and acquisition patterns for CMV, RSV, and Enterovirus across both sexes. ConclusionHEU infants show transient sex-based differences in growth, infection and immune profiles raising the relevance for considering sex as a key parameter to assess infant health.

HIV testing remains the primary entry point to HIV prevention, treatment, and care. Although Zambia has made substantial progress in its HIV response, men remain less consistently reached by HIV testing services. This study assessed trends and determinants of HIV testing uptake among men aged 15-59 years in Zambia using repeated nationally representative survey data. We pooled mens data from the Zambia Demographic and Health Surveys (ZDHS) conducted in 2007, 2013/14, 2018, and 2024. The outcome was HIV testing uptake, defined as ever tested for HIV and received results (DHS variable mv781). Analyses accounted for the complex survey design using sampling weights in Stata 14.2. Trends were examined using weighted proportions and design-adjusted chi-square tests. Determinants were assessed using multilevel logistic regression with men nested within clusters, reporting adjusted odds ratios (AORs) and 95% confidence intervals (CIs). HIV testing uptake increased markedly from 20.7% (2007) to 62.9% (2013/14) and peaked at 77.4% (2018), with a modest decline in 2024 (73.5%); differences across survey years were statistically significant (p<0.05). In the fully adjusted model, survey year remained a strong predictor of testing compared with 2007 (2013/14 AOR 6.91, 95% CI 5.62-8.49; 2018 AOR 13.85, 95% CI 11.21-17.12; 2024 AOR 7.24, 95% CI 5.86-8.95). Older age was associated with higher odds of testing (25-34 AOR 3.51; 35-49 AOR 3.08; 50-59 AOR 1.65 vs 15-24). Rural residence was associated with lower testing (AOR 0.82, 95% CI 0.72-0.93). Higher education showed a strong gradient (primary AOR 1.55; secondary/higher AOR 4.19 vs none). Married men (AOR 4.33, 95% CI 3.56-5.27) and employed men (AOR 1.32, 95% CI 1.17-1.49) had higher odds of testing. Significant regional differences persisted after adjustment. HIV testing uptake among men in Zambia rose substantially from 2007 to 2018 and remained high in 2024, though gaps persisted among younger men, rural residents, and selected provinces. Targeted, male-friendly strategies especially for younger and rural men and geographically tailored programming are needed to sustain gains and reduce inequities in HIV testing.

BackgroundSustained retention in HIV care is essential for achieving durable viral suppression and controlling the HIV epidemic. Loss to follow-up (LTFU) remains a persistent challenge in sub-Saharan Africa and shows substantial geographic variation. However, nationally representative analyses of routine monitoring data remain limited. Pharmacy refill data provide a scalable and objective approach for identifying individuals at risk of disengaging from care. We assessed the magnitude, spatial distribution, and predictors of LTFU among people living with HIV (PLHIV) receiving antiretroviral therapy (ART) across 26 mainland regions of Tanzania. MethodsWe conducted a retrospective cohort analysis using routinely collected program data from the National Care and Treatment Clinic (CTC-2) database of PLHIV receiving ART in Tanzania between 2017 and 2021. LTFU was defined as no recorded clinic visit for [&ge;]180 days after the last scheduled appointment, consistent with monitoring definitions used by the National AIDS and Sexually Transmitted Infections Control Programme (NASHCoP). Pharmacy refill adherence was calculated longitudinally and categorized as good ([&ge;]85%) or poor (<85%). Regional and district-level patterns were visualized using geospatial mapping. Multivariable logistic regression models were used to identify predictors of LTFU. ResultsA total of 52,828 PLHIV were included in the study, representing all 26 mainland regions of Tanzania. Overall, 26.6% were classified as LTFU during follow-up, with marked regional variation. The highest proportional LTFU was observed in Dar es Salaam (33.2%), followed by Njombe (32.9%) and Geita (32.7%), while the lowest was recorded in Mwanza (19.1%) and Iringa (20.3%). Good pharmacy refill adherence ([&ge;]85%) was strongly associated with lower odds of LTFU and remained the most robust independent predictor after adjustment (adjusted odds ratio [aOR] 0.34; 95% confidence interval [CI] 0.32-0.35). District-level analyses revealed substantial within-region heterogeneity, identifying localized clusters of elevated attrition not apparent in regional aggregates. ConclusionLTFU remains a major challenge to sustaining effective ART delivery in Tanzania. Pharmacy refill adherence may serve as a practical early indicator for identifying individuals at risk of disengagement from HIV care. Integrating refill-based monitoring with spatially informed analysis may support targeted retention strategies within routine HIV treatment programs.

BackgroundNigeria accounts for a significant share of global maternal mortality, and HIV remains a public health threat. Gombe State in northeastern Nigeria contends with profound barriers to healthcare access. This study evaluated the effectiveness of a community-based intervention using trained Community Health Workers (CHWs) to improve early identification of pregnancy and linkage to Antenatal Care (ANC) and HIV services. MethodsA quasi-experimental design was employed across six local government areas (LGAs) from January 2020 to June 2021. Three LGAs were randomly assigned to the intervention, where CHWs conducted home visits for pregnancy identification, health education, and referral facilitation. Three control LGAs received standard facility-based care. Data were collected via household surveys and facility records at baseline and endline. Analysis included Difference-in-Differences (DiD) estimation to determine the net intervention effect. ResultsThe intervention group showed significant improvements compared to the control. Early pregnancy identification (<20 weeks) increased from 45% to 78% (DiD: +29 pp, p<0.001). Attendance of at least one ANC visit rose from 58% to 85% (DiD: +22 pp, p<0.001), reducing the coverage gap by 89%. Subgroup analysis revealed the largest gains among adolescents (DiD: +31 pp) and rural residents (DiD: +27 pp). HIV testing uptake increased from 52% to 90% (DiD: +34 pp, p<0.001). Linkage to care for HIV-positive women improved from 65% to 92% (p=0.002). ConclusionA CHW-led, community-based strategy is highly effective in improving early engagement with ANC and HIV services in resource-limited settings. The intervention demonstrated a strong equity-promoting effect. Integration and scale-up of this model within primary healthcare systems is recommended.

IntroductionFor differentiated models of care (DMOCs) that support client-centred HIV treatment (ART) in South Africa, a key next step in achieving integration is aligning clinic visits and medication dispensing for HIV treatment with other health needs like family planning. We assessed alignment between ART medication and family planning supply collection visits among DMOCs in South Africa. MethodsWe analysed self-reported data collected between September-December 2024 from women living with HIV (18-49 years, on ART [&ge;]6 months) at 24 public healthcare facilities in four provinces (Gauteng, Mpumalanga, KwaZulu-Natal, and Eastern Cape). Participants were enrolled from four service delivery models: conventional care not eligible for DMOC (CN), conventional care eligible for DMOC but not enrolled (CE), facility pickup points (FAC-PuP), and external pickup points (EXT-PuP). Surveys assessed contraceptive use, visit alignment for injectable (Depo-Provera & Nur-Isterate) and oral contraceptive users, and how misaligned visits affected family planning adherence. ResultsAmong 843 eligible women, 57% (460/843) reported current contraception use, with Depo-Provera being the most common (44%). Contraceptives users were younger (median 35 vs 38 years) and had slightly less ART experience (median 7 vs 8 years) than non-users. Contraceptive use varied by DMOC: CN (52%), CE (60%), FAC-PuP (63%), and EXT-PuP (50%). Half (131/260) of women using oral contraceptives or injectables collected their contraceptive and ART products on different days, with EXT-PuP showing the lowest level of alignment. Primary reasons for non-use were personal choice and beliefs (38%), followed by pregnancy-related factors (26%). Analysis of unmet family planning need in a subsample of 299 women found 22% had unmet need. ConclusionThe findings reveal a high proportion of misalignment between ART and family planning services across models of care. Aligning ART and family-planning guidelines and services will promote ART and contraceptive adherence and reduce the burden on clients, maintaining the benefits of differentiated models and promoting integration of multi-condition service delivery.

BackgroundAchieving optimal adherence and retention in HIV care is essential for sustaining viral suppression. Pharmacy refill records offer an objective approach to assessing adherence in settings where routine viral load testing is limited. This study evaluated pharmacy refill adherence, loss to follow-up (LTFU), and their predictors among people living with HIV (PLHIV) in the Manyara region of Tanzania. MethodsWe conducted a retrospective cohort analysis of 22,650 PLHIV across five districts using the National CTC-2 database. LTFU was defined as no clinic visit for 180 days or more. We also analyzed a cross-sectional final status field updated by health trackers to distinguish research-defined LTFU from confirmed clinical outcomes. Predictors were evaluated using multivariable logistic regression, and spatial mapping identified geographic disparities. ResultsThe mean pharmacy refill adherence was 84.1%, with 57.9% achieving good adherence (>=85%). In the longitudinal analysis, 32.8% of patients met the research definition for LTFU (>=180-day absence) at some point during the study period. Cumulative LTFU was significantly higher in earlier initiation cohorts (2017-2019) compared to the 2021 cohort (aOR 1.89; 95% CI 1.76-2.02). However, cross-sectional system records, which health trackers update, showed that only 2.9% remained truly lost to care; 65.3% were active at their original clinic, 23.1% had eventually transferred to other facilities, and 6.7% were deceased. In multivariable regression, poor pharmacy adherence was the strongest behavioral predictor of disengagement (aOR 2.04; 95% CI 1.77-2.35). Significant geographic variation was observed, with residence in Simanjiro independently associated with the highest odds of LTFU (aOR 3.60; 95% CI 2.67-4.85). Spatial mapping confirmed a clustering of poor outcomes in districts characterized by nomadic pastoralist livelihoods. ConclusionPharmacy refill adherence is a potent predictor of disengagement and a practical early-warning indicator. The high rate of silent transfers and district-level disparities, particularly in nomadic hotspots, highlight the need for a national unique patient identifier and mobility-friendly retention strategies. Integrating automated refill alerts into the 90-day tracking window is essential to achieve 95-95-95 targets.

BackgroundSkin disease affects 4.7-4.9 billion individuals globally; however, little is known about access to dermatological care. MethodsWe conducted a multinational, cross-sectional survey of dermatological care across 194 WHO member states and three additional geographic areas in 2024-2025. Primary outcomes included dermatologist density per 100,000 population and number of dermatologists globally. Secondary outcomes included training programme density, workforce distribution, perceived access to care, and health system characteristics. Descriptive statistics and nonparametric tests compared outcomes across World Bank Income (WBI) levels and WHO regions. FindingsResponses were obtained from 158 countries. Mean dermatologist density was 2.66 per 100,000, ranging from 0.37 in low-income (LICs) to 5.05 in high-income countries (HICs). There are estimated 175,633 dermatologists globally (95% CI: 173,598-177,668). Forty-two percent of countries reported inadequate or extremely poor access to dermatological care. There was significant variation (p < 0.001) in access to all types of subspecialty care (paediatric, surgical, dermatopathology) across WBI levels, with consistently worse access in lower-income countries. Dermatologists are primarily based in urban centres (79%). Twenty-one percent of countries lack dermatology training programs, with training varying by WBI level (p < 0.001). Non-dermatologist healthcare workers bear a substantial responsibility for management of skin disease. InterpretationSignificant global disparities exist in access to dermatological care, particularly in lower resource settings. Achieving skin health equity will require global commitment to expanding/funding training programmes, incentivizing decentralization of dermatology practice, and optimizing alternative care delivery including upskilling front-line healthcare workers. FundingInternational League of Dermatological Societies and LOreal Dermatological Beauty.

BackgroundLoss to follow-up (LTFU) undermines the success of antiretroviral therapy (ART) programs, especially in high HIV prevalence regions like Njombe, Tanzania. Understanding factors influencing LTFU is critical to enhance patient retention. AimTo assess the prevalence and predictors of LTFU among people living with HIV (PLHIV) receiving ART in Njombe, Tanzania, from 2017 to 2021 MethodsWe conducted a retrospective cohort study using the National Care and Treatment Clinic (CTC2) database, defining LTFU as absence from care for 180 days or more. Logistic regression identified factors associated with LTFU. Data were cleaned using Microsoft Excel and analyzed using IBM SPSS Statistics version 26. Descriptive statistics were used to summarize demographic and clinical characteristics, and logistic regression was used to identify independent predictors of LTFU ResultsOf the 37,642 PLHIV initiated on ART, 13,411 (35.6%) were LTFU during the five-year study period. The highest annual incidence of LTFU occurred in 2020 (n = 4,069), coinciding with the onset of the COVID-19 pandemic. District-level disparities were substantial: Wangingombe recorded the highest disengagement prevalence (46.7%), while Makete recorded the lowest (23.7%). Multivariable analysis revealed that gender and age were not independent predictors of attrition (p > 0.05). However, significant associations with LTFU were observed for lower pharmacy refill adherence, marital status (single and divorced), and district of residence. Notably, patients in Wangingombe had more than double the odds of LTFU compared to those in Njombe (AOR 2.09; 95% CI: 1.95-2.24), whereas the 2021 initiation cohort demonstrated a significantly lower risk of disengagement (AOR 0.25; 95% CI: 0.22-0.28). ConclusionLTFU remains a critical challenge in the Njombe Region. Targeted interventions, including strengthened pharmacy refill monitoring, district-specific strategies, and psychosocial support for PLHIV, are essential to improve retention and sustain progress toward national HIV treatment goals.