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Objectives To describe the experiences of oral HIV pre-exposure prophylaxis (PrEP) use, preferences comparing oral PrEP to future long-acting PrEP products (the dapivirine vaginal ring (PrEP ring) and injectable cabotegravir (CAB PrEP)), and service provision preferences among female sex workers (FSWs) and their managers.Methods Qualitative formative focus group discussions were conducted in two urban (Copperbelt, Lusaka) and two rural (Central, Luapula) provinces in Zambia. Consenting participants included 43 FSWs and 36 sex work managers. Eligible participants self-identified as FSWs or sex work managers, were 18 years or older and spoke English, Nyanja or Bemba.Results FSWs had a median age of 28 years and 60% reported ever using oral PrEP. Among potential future HIV prevention options, most FSWs preferred longer acting PrEP methods, mainly CAB PrEP over the PrEP ring. This preference was consistent across provinces. Many FSWs had personal oral PrEP experience and appreciated the high effectiveness but conveyed that the realities of daily use, including pill visibility, and attributed side effects did not meet their needs. FSWs and managers also identified frequent stigma and misinformation-related barriers to PrEP access and use at community and facility levels. Most FSWs and managers agreed that informing non-paying or long-term partners of PrEP use was acceptable. Participants offered recommendations for greater sensitisation and peer-led services or service extension through trusted figures in the community.Conclusions Zambian FSWs and their managers preferred longer acting PrEP methods, particularly CAB PrEP, as part of comprehensive HIV prevention method choice, with little difference between provinces. PrEP programming led by FSW peers, managers or other trusted figures was recommended to address misinformation, sensitise partners and potentially deliver services to circumvent perceived stigma at health facilities.

Evidence suggests that bi-annual mass drug administration (MDA) of single-dose azithromycin to 1-11 month-old children reduces child mortality in high child-mortality settings. Several countries conduct annual MDAs to distribute azithromycin to individuals ages 6 months and older to prevent trachoma infection. This study examined the feasibility and acceptability of reaching 1-11 months-old children during a trachoma MDA in Côte d'Ivoire by extending azithromycin distribution to infants 1-5 months old during the campaign. In November 2020, the study piloted single-dose azithromycin for 1-5 month-olds during a trachoma MDA in one health district. Monitoring data included the number of children reached and occurrences of adverse drug reactions. Feasibility, the extent to which the target population received the intervention (coverage), was assessed through a population-based, household survey with parents/caregivers of eligible children conducted after the MDA. Acceptability was explored through in-depth interviews (IDIs) with parents/caregivers of eligible children, focus group discussions (FGDs) with community drug distributors (CDDs), and IDIs with their supervisors. CDD FGDs and supervisor IDIs also documented implementation challenges and recommendations for scale-up. 1,735 1-5 month-olds received azithromycin during the pilot activity (estimated population coverage of 90.2%). Adverse drug reactions were reported for 1% (n = 18) infants; all were mild and self-limited. The post-MDA coverage survey interviewed 267 parents/caregivers; survey-based intervention coverage was 95.4% of 1-5 month-olds. Qualitative data revealed high intervention acceptability among parents, CDDs, and supervisors. Implementation challenges included the need to weigh babies to calculate dosage for 1-5 month-olds and the need to obtain written informed consent from parents to provide the drug to 1-5 month-olds. CDDs also indicated the need for more information on azithromycin and possible side effects during training. Delivering azithromycin to younger infants appears acceptable to parents and implementers; >90% coverage indicates feasibility to integrate into a trachoma MDA. (Clinicaltrials.gov ID number: NCT04617626).

# Background The COVID-19 pandemic imposed challenges to HIV service provision in Africa. The Ending AIDS in West Africa project (#EAWA), implemented in Burkina Faso and Togo, took measures to mitigate service provision disruptions due to COVID-19. We document the project’s strategies for ensuring an uninterrupted service provision to people living with HIV (PLHIV) during the COVID-19 pandemic. # Methods Using reports from project staff, we summarized #EAWA’s service provision strategies during the pandemic. This finding was complemented by a descriptive analysis of routine program data collected from December 2019 to April 2021 to evaluate how well these measures performed. # Results COVID-19-related travel restrictions, lockdowns, logistical challenges, and fear of health facilities restricted access to HIV care. Building on shifting policy environments in both countries, #EAWA adopted a contingency plan to accelerate the multi-month dispensing of ARVs (MMD) and differentiated drug delivery (DDD). Quantitative results show that the pandemic briefly disrupted ARV refills and MMD dispensation. The implementation of EAWA’s contingency plan corresponded to a rapid increase in drug refills and MMD in both countries. # Conclusions Examination of programmatic data from this HIV program shows that COVID-19 provided the impetus to embrace MMD to ensure continuity of care. Despite an extremely challenging and shifting environment, the #EAWA project was able to respond nimbly to ensure clients stayed on treatment.

On March 30, 2020, the Government of Nigeria implemented its first COVID-19 related lockdown. We worked with two humanitarian projects in Nigeria, the Integrated Humanitarian Assistance to Northeast Nigeria (IHANN II) in Borno State and the United Nations High Commissioner for Refugees South-South Health and Nutrition Intervention (UNHCR-SS-HNIR) for Cameroon Refugees and vulnerable populations in Cross River State, to document the programmatic adaptations to Family Planning/Reproductive Health (FP/RH) services in response to COVID-19 and identify successes and challenges of those adaptations. A mixed methods approach including quantitative analysis of data from routine programmatic activities, qualitative data from in-depth interviews (IDIs) with project staff and process documentation of programmatic activities and modifications was used to 1) identify modifications in FP/RH services due to COVID-19, 2) understand staff perception of their utility and impact, and 3) gauge trends in key FP/RH in-service delivery indicators to assess changes prior to and after the March 2020 lockdown. Monitoring data shows notable declines in service utilization after lockdowns in antenatal care, postnatal care, and outreach campaigns, followed by a return to pre-lockdown levels by July 2020. Results show projects introduced numerous COVID-19 precaution strategies including: community sensitization; triage stations and modification of service flow in facilities; and appointment scheduling for essential services. Findings from IDIs speak to a well-coordinated and implemented COVID-19 response with project staff noting improvements in their time management and interpersonal communication skills. Lessons learned included the need to better sensitize and educate communities, maintain FP commodities and increase support provided to health workers. Deliberate adaptations in IHANN II and UNHCR-SS-HNIR projects turned challenges to opportunities, ensuring continuity of services to the most vulnerable populations.

Use of reproductive health (RH), maternal, newborn and child health (MNCH) services in Uganda is suboptimal. Reasons for this are complex; however, service-delivery factors such as availability, quality, staffing, and supplies, contribute substantially to low uptake. The COVID-19 pandemic threatened to exacerbate existing challenges to delivery and use of high-quality RH and MNCH services. We conducted a mixed methods study, combining secondary analysis of routine electronic health management information system (eHMIS) data with exploratory key informant interviews (KII) to examine changes in health service uptake over the course of the pandemic and to understand service delivery adaptations implemented in response. We analyzed eHMIS data for four services (family planning, facility-based deliveries, antenatal visits, and immunization for children by one year), comparing them across four time periods: pre-COVID-19, partial lockdown, total lockdown and post lockdown. Additionally, KIIs were used to document adaptations made for continuity of health services. Use of services declined substantially during total lockdown; however, rebounded quickly to earlier observed levels, during the post lockdown for all four services, especially for immunization for children by one year. KIIs identified several health services delivery adaptations. At the community level, these included: community outreaches, training some mothers as community liaisons to encourage others to seek health services, and support from local leaders to create call centers to facilitate clients transport during travel restrictions. Health facilities creatively used space to accommodate social distancing and shifted providers' roles. District leadership reassigned health workers to facilities closest to their homes, provided vehicle passes to staff, and ambulances to transport pregnant women in critical need. WhatsApp groups facilitated communication at district level and enabled redistribution of supplies. Ministry of Health produced critical guidelines for continuity of health services. Implementing partners provided and redistributed commodities and personal protective equipment, and provided technical support, training and transport.

Use of reproductive health (RH), maternal, newborn and child health (MNCH) services in Uganda is suboptimal. Reasons for this are complex; however, service-delivery factors such as availability, quality, staffing, and supplies, contribute substantially to low uptake. The COVID-19 pandemic threatened to exacerbate existing challenges to delivery and use of high-quality RH and MNCH services. We conducted a mixed methods study, combining secondary analysis of routine electronic health management information system (eHMIS) data with exploratory key informant interviews (KII) to examine changes in health service uptake over the course of the pandemic and to understand service delivery adaptations implemented in response. We analyzed eHMIS data for four services (family planning, facility-based deliveries, antenatal visits, and immunization for children by one year), comparing them across four time periods: pre-COVID-19, partial lockdown, total lockdown and post lockdown. Additionally, KIIs were used to document adaptations made for continuity of health services. Use of services declined substantially during total lockdown; however, rebounded quickly to earlier observed levels, during the post lockdown for all four services, especially for immunization for children by one year. KIIs identified several health services delivery adaptations. At the community level, these included: community outreaches, training some mothers as community liaisons to encourage others to seek health services, and support from local leaders to create call centers to facilitate clients transport during travel restrictions. Health facilities creatively used space to accommodate social distancing and shifted providers’ roles. District leadership reassigned health workers to facilities closest to their homes, provided vehicle passes to staff, and ambulances to transport pregnant women in critical need. WhatsApp groups facilitated communication at district level and enabled redistribution of supplies. Ministry of Health produced critical guidelines for continuity of health services. Implementing partners provided and redistributed commodities and personal protective equipment, and provided technical support, training and transport.

# Background Viral load (VL) testing of patients on antiretroviral therapy (ART) is critical to suppressing HIV. Timely transport of VL samples from health facilities to the laboratory for testing is often problematic in Turkana County, Kenya, and transportation barriers cause delays that can negatively impact the health of ART patients. Unmanned Aerial Vehicles (UAVs), or drones, are being promoted as a potential, novel way to reduce transportation times for laboratory samples and medical commodities. Our study models the use of UAVs in a remote area of Kenya to estimate costs and feasibility of their application for the Afya Nyota ya Bonde project, a large HIV service delivery program. # Methods We gathered data from 12 Afya-supported facilities on VL sample transportation and turnaround time, ART drug transportation, and transportation practices and costs. The annual cost and average turnaround time for the transportation of VL samples and ART drugs was calculated using baseline data from the program to establish a comparison for scenarios that use a UAV. We then designed and costed four transportation scenarios that used UAVs to pick up VL samples and deliver ART drugs through a logistics company that will be adding UAV services. # Results The modeled scenarios demonstrate that UAVs could transport nearly 100% of VL samples to the lab within the three-day goal compared to the 3% that are transported under the current system. Additionally, using UAVs could reduce the burden on health workers who must personally transport the samples, reducing opportunity costs resulting from facility closures due to provider absence. However, the UAV scenario cost more than three times the current costs (US$ 56,350/Kenyan Shillings (KSh) 5,635,000 per year compared to between US$ 172,878/Ksh 17,287,800 and US$ 200,208/Ksh 20,020,800), and the consolidation of VL testing days required to accommodate the UAV may be problematic for ART patients. # Conclusions As the cost of UAV transport declines, this technology could be an important tool for optimizing the transport of lab samples and medications.

Abstract Background Female sex workers, MSM, and transgender women—collectively referred to as key populations (KPs)—are disproportionately affected by gender-based violence (GBV) and HIV, yet little is known about the violence they face, its gender-based origins, and responses to GBV. The purpose of this study was to understand the nature and consequences of GBV experienced, to inform HIV policies and programming and to help protect KPs’ human rights. Methods Using a participatory approach, FSWs, MSM, and transgender women in Barbados, El Salvador, Trinidad and Tobago, and Haiti conducted 278 structured interviews with peers to understand their experiences of and responses to GBV. Responses to open-ended questions were coded in NVivo and analyzed using an applied thematic analysis. Results Nearly all participants experienced some form of GBV. Emotional and economic GBV were the most commonly reported but approximately three-quarters of participants reported sexual and physical GBV and other human rights violations. The most common settings for GBV were at home, locations where sex work took place such as brothels, bars and on the street; public spaces such as parks, streets and public transport, health care centers, police stations and—for transgender women and MSM—religious settings and schools. The most common perpetrators of violence included: family, friends, peers and neighbors, strangers, intimate partners, sex work clients and other sex workers, health care workers, police, religious leaders and teachers. Consequences included emotional, physical, and sexual trauma; lack of access to legal, health, and other social services; and loss of income, employment, housing, and educational opportunities. Though many participants disclosed experiences of GBV to friends, colleagues and family, they rarely sought services following violence. Furthermore, less than a quarter of participants believed that GBV put them at risk of HIV. Conclusions Our study found that across the four study countries, FSWs, MSM, and transgender women experienced GBV from state and non-state actors throughout their lives, and much of this violence was directly connected to rigid and harmful gender norms. Through coordinated interventions that address both HIV and GBV, this region has the opportunity to reduce the national burden of HIV while also promoting key populations’ human rights.

# Background Community engagement and empowerment are critical components of HIV programming, especially for key population communities affected by HIV, and are increasingly considered determinants of readiness for a locally financed and managed response to the epidemic. # Methods To better understand how the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) project engaged with civil society organizations (CSOs), we conducted an online survey to document their perspectives on LINKAGES’ engagement of key population communities, the benefits and challenges of receiving U.S. government funding, and perceptions of sustainability among CSOs supported by LINKAGES. We conducted descriptive analyses for closed-ended items and an inductive thematic analysis for open-ended questions. # Results Seventy-one CSOs across 18 countries participated. They described having been meaningfully involved, indicating they took part in the process of planning and designing the program and found LINKAGES to be very helpful in their work to engage members of key populations in HIV treatment, care, and prevention, but desired greater involvement in programmatic decision-making and evaluation of HIV programming. CSOs highly valued capacity strengthening provided by LINKAGES, specifically related to monitoring and evaluation, financial management, and HIV service quality and delivery, and the vast majority believed the project contributed to increased organizational sustainability. Primary challenges in implementing LINKAGES programming identified by the survey included: difficulty meeting HIV testing and treatment targets, constraints on funding, and excessive reporting requirements, as well as limited program resources to address structural barriers to engaging key populations in services. # Conclusions Effective HIV programming for key populations requires engaging their communities in every aspect of project planning, implementation, and assessment, and strengthening investments to address the many structural barriers that exist for them. Community engagement and empowerment are critical for a sustained, locally led response to the HIV epidemic.

BACKGROUND: Uptake of VMMC among adult men has been lower than desired in Nyanza, Kenya. Previous research has identified several barriers to uptake but qualitative exploration of barriers is limited and evidence-informed interventions have not been fully developed. This study was conducted in 2012 to 1) increase understanding of barriers to VMMC and 2) to inform VMMC rollout through the identification of evidence-informed interventions among adult men at high risk of HIV in Nyanza Province, Kenya. METHODS: Focus groups (n = 8) and interviews were conducted with circumcised (n = 8) and uncircumcised men (n = 14) from the two districts in Nyanza, Kenya. Additional interviews were conducted with female partners (n = 20), health providers (n = 12), community leaders (n = 12) and employers (n = 12). Interview and focus group guides included questions about individual, interpersonal and societal barriers to VMMC uptake and ways to overcome them. Inductive thematic coding and analysis were conducted through a standard iterative process. RESULTS: Two primary concerns with VMMC emerged 1) financial issues including missing work, losing income during the procedure and healing and family survival during the recovery period and 2) fear of pain during and after the procedure. Key interventions to address financial concerns included: a food or cash transfer, education on saving and employer-based benefits. Interventions to address concerns about pain included refining the content of demand creation and counseling messages about pain and improving the ways these messages are delivered. CONCLUSIONS: Men need accurate and detailed information on what to expect during and after VMMC regarding both pain and time away from work. This information should be incorporated into demand creation activities for men considering circumcision. Media content should frankly and correctly address these concerns. Study findings support scale up and/or further improvement of these ongoing educational programs and specifically targeting the demand creation period.