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Abstract Background Africa is the global region where modern-slavery is most prevalent, especially among women and girls. Despite the severe health consequences of human trafficking, evidence on the risks and experiences of trafficked adolescents and young women is scarce for the region. This paper addresses this gap by exploring the intersections between violence, migration and exploitation among girls and young women identified as trafficking survivors in Nigeria and Uganda. Methods We conducted secondary analysis of the largest routine dataset on human trafficking survivors. We used descriptive statistics to report the experiences of female survivors younger than 25 years-old from Nigeria and Uganda. We also conducted 16 semi-structured interviews with adolescents identified as trafficked in both countries. We used thematic analysis to explore participants’ perceptions and experiences before, during and after the trafficking situation. Results Young female survivors of human trafficking in Nigeria and Uganda are exposed to a range of experiences of violence before migration, during transit and at destination. The qualitative data revealed that children and adolescents migrated to escape family poverty, violence and neglect. They had very low levels of education and most had their studies interrupted before migrating. Family members and close social contacts were the most common intermediaries for their migration. During transit, sexual violence and hunger were common, especially among Nigerians. Participants in both the quantitative and qualitative studies reported high levels of violence, deception, coercion, withheld wages and poor working conditions at destination. The adolescents interviewed in the qualitative study reported severe mental suffering, including suicide attempts. Only one reported the prosecution of perpetrators. Conclusions Our findings suggest that interventions to prevent or mitigate the negative impact of adverse childhood experiences can contribute to preventing the trafficking of adolescents in Nigeria and Uganda. These interventions include social protection mechanisms, universal access to education, social service referrals and education of parents and carers. Importantly, effective prevention also needs to address the systemic conditions that makes trafficking of female adolescents invisible, profitable and inconsequential for perpetrators.

Introduction: Africa has one of the highest burdens of cervical cancer in the world. The unacceptably high incidence and mortality rates could be reduced through implementing a comprehensive approach to its prevention and control that includes screening, which however, is low in most low-and-middle-income countries. Hence, this systematic review aims at exploring factors that prevent women from utilising cervical cancer screening services in the region. Methods: A mixed method systematic review was conducted. A search was performed on PubMed (Medline), EMBASE, CINAHL (EBSCOHOST) and Scopus databases for articles published until May 2019 without time, language or study design limits. Two reviewers critically appraised the included studies independently using the standard quality assessment criteria for evaluating primary research papers. Results of the quantitative and mixed methods studies were transformed into qualitative data and synthesised using thematic analysis. Results: From a potential 2 365 studies, 24 from 11 countries met the eligibility criteria and were selected; eight qualitative, 13 quantitative, and three that used the mixed-method approach. The primary barriers were identified as poor access to screening services, lack of awareness and knowledge on cervical cancer and screening, and socio-cultural influences. Service providers perceived lack of skills, screening equipment and supplies, and staff shortages as the major barriers to the provision of screening services. Conclusion: Barriers to cervical cancer screening in Africa are multifaceted and require a holistic approach that will address them concurrently at the health system, individual, interpersonal, community and structural levels. Political will complimented by stakeholder involvement is required in the development and implementation of strategies that will ensure acceptability, availability, accessibility, and affordability of screening to minimise barriers in accessing the service. [ABSTRACT FROM AUTHOR]

Objective: The objective of this research was to assess physical and sexual violence experienced by sexual and gender minorities in nine African countries, and to examine factors associated with violence.Methods: We conducted an exploratory multi-country cross-sectional study among self-identifying sexual and gender minorities, using a survey tool available in paper and online. Participants were sampled through venue-based and web-based convenience sampling. We analysed data using descriptive statistics and logistic regression, with Stata15.Findings: Of 3798 participants, 23% were gender minorities, 20% were living with HIV, and 18% had been coerced into marriage. Fifty-six per cent of all participants had experienced physical or sexual violence in their lifetime, and 29% in the past year. Gender minorities had experienced significantly higher levels of violence compared to cisgender (sexual minority) participants. The variable most strongly associated with having experienced violence was being coerced into marriage (AOR, 3.02), followed by people living nearby knowing about one's sexual orientation and/or gender identity (AOR, 1.90) and living with HIV (AOR, 1.47).Conclusion: Sexual and gender minorities in Eastern and Southern Africa experience high levels of violence. Sexual orientation and gender identity need to be recognised as risk factors for violence in national and regional law and policy frameworks. States should follow the African Commission Resolution 275 and provide protection against violence based on real or perceived sexual orientation or gender identity. [ABSTRACT FROM AUTHOR]

Background: We sought to describe linkage to care, ART continuity, and factors associated with linkage to care among people with HIV following release from incarceration in South Africa.Methods: We conducted a study of South African correctional service community reentrants who were receiving ART at the time of release. The study was implemented in three of 46 correctional service management areas. Participants were enrolled prior to corrections release and followed up to 90 days post-release to obtain self-reported linkage to care status and number of days of ART provided at corrections release. Clinic electronic and paper charts were sought and abstracted to verify self-reported linkage to care. Log-binomial regression, adjusted for facility, was used to identify associations with post-release linkage to care (self-reported and verified). We sought to specifically assess for associations with HIV diagnosis during index incarceration, ART initiation during index incarceration, and duration of incarceration.Results: From May 2014 to December 2016, 554 inmates met eligibility and 516 (93%) consented to participate; 391 were released on ART, 40 of whom were excluded from analysis post-release. Of the remaining 351, 301 (86%) were men and the median age was 35 years (interquartile range 30, 40). Linkage to care was self-reported by 227 (64%) and linkage to care could be verified for 121 (34%). At most, 47% of participants had no lapse in ART supply. Initiating ART during the index incarceration showed a trend toward increased self-reported post-release linkage to care. Age > 35 years was associated with increased verified linkage to care while HIV diagnosis outside of a correctional setting and ART initiation during the index incarceration showed trends toward association with increased verified linkage to care.Discussion: The results of our study are the first description of retention in care following correctional facility release from an African setting and indicate high levels of attrition during the transition from correctional facility to community care. Initiating ART within a correctional facility did not impair post-release linkage to care. [ABSTRACT FROM AUTHOR]

Background: More than 40% of adults in Sub-Saharan Africa are unaware of their HIV status. HIV self-testing (HIVST) is a novel approach with a potential to increase uptake of HIV testing and linkage to care for people who test HIV positive. We explored HIV stakeholder's perceptions about factors that enable or deter the uptake of HIV self-testing and experiences of self-testing of adult users in Africa.Methods: This systematic review of qualitative evidence included articles on qualitative studies published or made available between January 1998 to February 2018 on perspectives of key stakeholders, including HIV policymakers, HIV experts, health care providers, and adult men and women (18 years and above) about factors that enable or deter the uptake of HIV self-testing and experiences of self-testing among adult users. We searched CINAHL, MEDLINE in Pubmed, EMBASE, AJOL, PsycINFO, Social Science Citation Index (SSCI), and Web of Science for articles in English on HIVST with qualitative data from different African countries.Results: In total, 258 papers were retrieved, and only nine (9) studies conducted in 5 African countries were eligible and included in this synthesis. Perceived facilitators of the uptake of HIVST were autonomy and self-empowerment, privacy, confidentiality, convenience, opportunity to test, including couples HIV testing, and ease of use. The perceived barriers included the cost of buying self-test kits, perceived unreliability of test results, low literacy, fear and anxiety of a positive test result, and potential psychological and social harms. HIV stakeholder's concerns about HIVST included human right issues, lack of linkage to care, lack of face-to-face counseling, lack of regulatory and quality assurance systems, and quality of self-test kits. Actual HIVST users expressed preference of oral-fluid self-testing because of ease of use, and that it is less invasive and painless compared to finger-stick/whole blood-based HIV tests. Lack of clear instructions on how to use self-test kits, and existing different products of HIVST increases rates of user errors.Conclusions: Overcoming factors that may deter HIV testing, and HIVST, in particular, is complex and challenging, but it has important implications for HIV stakeholders, HIVST users, and public health in general. Research is warranted to explore the actual practices related to HIVST among different populations in Africa. [ABSTRACT FROM AUTHOR]

Background: Filicide, the act of a parent or parental figure killing their child, has been reported in various African countries. However, there is a lack of comprehensive reviews on the prevalence and associated factors of filicide across the African continent, which is characterized by diverse cultural beliefs and practices. This review aims to examine the prevalence and risk factors of filicide in Africa. Methods: This review included studies on filicide in Africa, identified through searches in various databases (PubMed, Scopus, Africa Journal Online, and Google Scholar) using relevant keywords. The Mendeley reference manager was used to organize all identified articles and remove duplicate entries. A two-round screening process was conducted by two independent reviewers, with the final set of articles selected through mutual agreement. The quality of the studies was then assessed. Results: Out of the 107 retrieved articles, only 15 were included in the review. These studies revealed diverse prevalence rates: 3.7% of total homicides, 1.38% of deaths from family violence, and 13.02% for autopsied children. Various potential risk factors for filicide were identified, including unwanted pregnancies, marital conflicts, family disputes and violence, low socio-economic status, mental health issues in perpetrators, and mental, physical, or neurological vulnerabilities in victims. Cultural beliefs were also recognized as contributing factors to filicide. Conclusion: Filicide is a complex and multi-dimensional issue influenced by various individual, familial, and societal factors. The review highlighted a high prevalence of filicide in Africa, shaped by these diverse factors. [ABSTRACT FROM AUTHOR]

Background: Diarrheal diseases substantially affect public health impact in low- and middle-income countries (LMIC), particularly in Africa, where previous studies have indicated a lack of comprehensive data. With a growing number of primary studies on enteric infections in Africa, this study aimed to estimate the incidence and mortality of diarrheal pathogens across all ages in Africa in the year 2020. We also explored different methodological assumptions to allow comparison with other approaches. Methods: Through a systematic review and meta-analysis of data from African LMICs, we estimated the etiology proportions for diarrheal diseases and deaths. We combined the etiology proportions with incidence data collected from a population survey in Africa from 2020 and mortality data from the Global Health Observatory of WHO. Results: We estimated 1,008 billion diarrhea cases (95% UI 447 million-1,4 billion) and 515,031 diarrhea deaths (95% UI 248,983-1,007,641) in the African region in 2020. In children under five, enteroaggregative E. coli (EAEC) (44,073 cases per 100,000 people, 95% UI 18,818 − 60,922) and G. lamblia (36,116 cases per 100,000 people, 95% UI 15,245 − 49,961) were the leading causes of illness. Enteroinvasive E. coli (EIEC) (155 deaths per 100,000 people, 95% UI 106.5-252.9) and rotavirus (61.5 deaths per 100,000 people, 95% UI 42.3-100.3) were the primary causes of deaths. For children over five and adults, Salmonella spp. caused the largest number of diarrheal cases in the population of children ≥ 5 and adults (122,090 cases per 100,000 people, 95% UI 51,833 − 168,822), while rotavirus (16.4 deaths per 100,000 people, 95% UI 4.2–36.7) and enteroaggregative E. coli (EAEC) (14.6 deaths per 100,000 people, 95% UI 3.9–32.9) causing the most deaths. Geographically, the highest incidence of diarrhea was in Eastern Africa for children under five (114,389 cases per 100,000 people, 95% UI 34,771 − 172,884) and Central Africa for children over five and adults (117,820 cases per 100,000 people, 95% UI 75,111–157,584). Diarrheal mortality was highest in Western Africa for both children below five and above (children < 5: 194.5 deaths per 100,000 people, 95% UI 120-325.4; children ≥ 5 and above: 33.5 deaths per 100,000 people, 95% UI 12.9–75.1). Conclusion: These findings provide new information on the incidence and mortality of sixteen pathogens and highlight the need for surveillance and control of diarrheal infectious diseases in Africa. The cause-specific estimates are crucial for prioritizing diarrheal disease prevention in the region. [ABSTRACT FROM AUTHOR]

Background: The implementation of digital disease surveillance systems at national levels in Africa have been challenged by many factors. These include user applicability, utility of IT features but also stable financial support. Funding closely intertwines with implementations in terms of geographical reach, disease focus, and sustainability. However, the practice of evidence sharing on geographical and disease coverage, costs, and funding sources for improving the implementation of these systems on the continent is unclear. Objectives: To analyse the key characteristics and availability of evidence for implementing digital infectious disease surveillance systems in Africa namely their disease focus, geographical reach, cost reporting, and external funding support. Methods: We conducted a systematic review of peer-reviewed and grey literature for the period 2003 to 2022 (PROSPERO registration number: CRD42022300849). We searched five databases (PubMed, MEDLINE over Ovid, EMBASE, Web of Science, and Google Scholar) and websites of WHO, Africa CDC, and public health institutes of African countries. We mapped the distribution of projects by country; identified reported implementation cost components; categorised the availability of data on cost components; and identified supporting funding institutions outside Africa. Results: A total of 29 reports from 2,033 search results were eligible for analysis. We identified 27 projects implemented in 13 countries, across 32 sites. Of these, 24 (75%) were pilot projects with a median duration of 16 months, (IQR: 5–40). Of the 27 projects, 5 (19%) were implemented for HIV/AIDs and tuberculosis, 4 (15%) for malaria, 4 (15%) for all notifiable diseases, and 4 (15%) for One Health. We identified 17 cost components across the 29 reports. Of these, 11 (38%) reported quantified costs for start-up capital, 10 (34%) for health personnel compensation, 9 (31%) for training and capacity building, 8 (28%) for software maintenance, and 7(24%) for surveillance data transmission. Of 65 counts of external funding sources, 35 (54%) were governmental agencies, 15 (23%) foundations, and 7 (11%) UN agencies. Conclusions: The evidence on costing data for the digitalisation of surveillance and outbreak response in the published literature is sparse in quantity, limited in detail, and without a standardised reporting format. Most initial direct project costs are substantially donor dependent, short lived, and thus unsustainable. [ABSTRACT FROM AUTHOR]

Background: Half of the estimated annual 28 million non-communicable diseases (NCDs) deaths in low- and middle-income countries (LMICs) are attributed to weak health systems. Current health policy responses to NCDs are fragmented and vertical particularly in the African region. The World Health Organization (WHO) led NCDs Global action plan 2013-2020 has been recommended for reducing the NCD burden but it is unclear whether Africa is on track in its implementation. This paper synthesizes Africa's progress towards WHO policy recommendations for reducing the NCD burden.Methods: Data from the WHO 2011, 2014 and 2015 NCD reports were used for this analysis. We synthesized results by targets descriptions in the three reports and included indicators for which we could trace progress in at least two of the three reports.Results: More than half of the African countries did not achieve the set targets for 2015 and slow progress had been made towards the 2016 targets as of December 2013. Some gains were made in implementing national public awareness programmes on diet and/or physical activity, however limited progress was made on guidelines for management of NCD and drug therapy and counselling. While all regions in Africa show waning trends in fully achieving the NCD indicators in general, the Southern African region appears to have made the least progress while the Northern African region appears to be the most progressive.Conclusion: Our findings suggest that Africa is off track in achieving the NCDs indicators by the set deadlines. To make sustained public health gains, more effort and commitment is urgently needed from governments, partners and societies to implement these recommendations in a broader strategy. While donors need to suit NCD advocacy with funding, African institutions such as The African Union (AU) and other sub-regional bodies such as West African Health Organization (WAHO) and various country offices could potentially play stronger roles in advocating for more NCD policy efforts in Africa. [ABSTRACT FROM AUTHOR]

Abstract Introduction Africa has one of the highest burdens of cervical cancer in the world. The unacceptably high incidence and mortality rates could be reduced through implementing a comprehensive approach to its prevention and control that includes screening, which however, is low in most low-and-middle-income countries. Hence, this systematic review aims at exploring factors that prevent women from utilising cervical cancer screening services in the region. Methods A mixed method systematic review was conducted. A search was performed on PubMed (Medline), EMBASE, CINAHL (EBSCOHOST) and Scopus databases for articles published until May 2019 without time, language or study design limits. Two reviewers critically appraised the included studies independently using the standard quality assessment criteria for evaluating primary research papers. Results of the quantitative and mixed methods studies were transformed into qualitative data and synthesised using thematic analysis. Results From a potential 2 365 studies, 24 from 11 countries met the eligibility criteria and were selected; eight qualitative, 13 quantitative, and three that used the mixed-method approach. The primary barriers were identified as poor access to screening services, lack of awareness and knowledge on cervical cancer and screening, and socio-cultural influences. Service providers perceived lack of skills, screening equipment and supplies, and staff shortages as the major barriers to the provision of screening services. Conclusion Barriers to cervical cancer screening in Africa are multifaceted and require a holistic approach that will address them concurrently at the health system, individual, interpersonal, community and structural levels. Political will complimented by stakeholder involvement is required in the development and implementation of strategies that will ensure acceptability, availability, accessibility, and affordability of screening to minimise barriers in accessing the service.

Background: A fundamental ethical issue in African genomics research is how socio-cultural factors impact perspectives, acceptance, and utility of genomic information, especially in stigmatizing conditions like orofacial clefts (OFCs). Previous research has shown that gatekeepers (e.g., religious, political, family or community leaders) wield considerable influence on the decision-making capabilities of their members, including health issues. Thus, their perspectives can inform the design of engagement strategies and increase exposure to the benefits of genomics testing/research. This is especially important for Africans underrepresented in genomic research. Our study aims to investigate the perspectives of gatekeepers concerning genomic risk information (GRI) in the presence of OFCs in a sub-Saharan African cohort. Methods: Twenty-five focus group discussions (FGDs) consisting of 214 gatekeepers (religious, community, ethnic leaders, and traditional birth attendants) in Lagos, Nigeria, explored the opinions of participants on genomic risk information (GRI), OFC experience, and the possibility of involvement in collaborative decision-making in Lagos, Nigeria. Transcripts generated from audio recordings were coded and analyzed in NVivo using thematic analysis. Results: Three main themes—knowledge, beliefs, and willingness to act—emerged from exploring the perspective of gatekeepers about GRI in this group. We observed mixed opinions regarding the acceptance of GRI. Many participants believed their role is to guide and support members when they receive results; this is based on the level of trust their members have in them. However, participants felt they would need to be trained by medical experts to do this. Also, religious and cultural beliefs were crucial to determining participants' understanding of OFCs and the acceptance and utilization of GRI. Conclusions: Incorporating cultural sensitivity into public engagement could help develop appropriate strategies to manage conflicting ideologies surrounding genomic information in African communities. This will allow for more widespread access to the advances in genomics research in underrepresented populations. We also recommend a synergistic relationship between community health specialists/scientists, and community leaders, including spiritual providers to better understand and utilize GRI. [ABSTRACT FROM AUTHOR]

Background: Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men's health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men's participation in and utilisation of HIV services in Uganda. Methods: Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked. Results: Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men's participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men's risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a 'sick role'; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men's involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability. Conclusion: To improve men's involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes. [ABSTRACT FROM AUTHOR]

Background: The high under-five mortality rate (U5MR) in Africa is a significant public health concern. Previous studies have found that satellite retrieved light at night (LAN) data with long-term and global coverage can be used as a proxy for socio-economic development and urbanization. Currently, few studies on the effects of LAN on child mortality have been conducted in Africa, a region with varying levels of urbanization between countries. Objective: To quantify the correlation between risk of child mortality and LAN as an indicator of urbanization and economic development in Africa. Methods: Using data from the Demographic and Health Survey (DHS) database conducted in 15 African countries out of 46 countries from 2005 to 2013, this study estimated LAN levels for children based on their year of birth and residential addresses. This study used Cox proportional hazards models to assess the association between LAN and the risk of child mortality in Africa. Results: The mean U5MR was 95 per 1,000 livebirths among the 15 African countries during 2005–2013. After adjusting for covariates, each 10-unit increment in LAN was associated with a 5.3% reduction in the risk of U5MR. The effect estimates were more pronounced in areas with lower LAN. Conclusion: In Africa, the risk of U5MR decreased with increasing LAN, especially in areas with lower LAN. The results suggest that the development of urbanization and socio-economic conditions may be beneficial to child health, especially in regions with low LAN. The use of LAN as a proxy may offer an intriguing approach for identifying areas requiring targeted development in urbanization and socio-economic conditions. [ABSTRACT FROM AUTHOR]

Background: Currently, Africa is the region of the world where the highest number of new cases of HIV infection are registered. In 2022, Equatorial Guinea was the Central African country with the highest HIV prevalence (6.9%) and incidence (3.80 per 1,000 amongst the population of all ages). The main objective of this study was to determine the perceptions of HIV and the meanings given to it among the population of Equatorial Guinea in order to assess to what extent they represent a barrier to the prevention strategies implemented hitherto. Methods: A total of 30 semi-structured interviews and nine focal groups were carried out. Findings: The interviewees' testimonies revealed a combination of differing perceptions and meanings around HIV. In some cases, HIV was perceived as "a non-existent illness", and in others as "a disease of others", or as "a disease of bad luck". Other majority perceptions of HIV classed it as "a deadly disease" or "a sexual illness". Conclusions: All these perceptions of HIV and the social representations constructed around it can represent a barrier to adopting preventive practices. Hence, in order to improve efficacy, efficiency, and effectiveness, it is recommended that HIV prevention policies take into account the heterogeneity of meanings linked to the different social groups that have contracted the virus. [ABSTRACT FROM AUTHOR]

Background: COVID-19 resulted in enormous disruption to life around the world. To quell disease spread, governments implemented lockdowns that likely created hardships for households. To improve knowledge of consequences, we examine how the pandemic period was associated with household hardships and assess factors associated with these hardships. Methods: We conducted a cross-sectional study using quasi-Poisson regression to examine factors associated with household hardships. Data were collected between August and September of 2021 from a random sample of 880 households living within a Health and Demographic Surveillance System (HDSS) located in the Harari Region and the District of Kersa, both in Eastern Ethiopia. Results: Having a head of household with no education, residing in a rural area, larger household size, lower income and/or wealth, and community responses to COVID-19, including lockdowns and travel restrictions, were independently associated with experiencing household hardships. Conclusions: Our results identify characteristics of groups at-risk for household hardships during the pandemic; these findings may inform efforts to mitigate the consequences of COVID-19 and future disease outbreaks. [ABSTRACT FROM AUTHOR]

Background: Scale-up and sustainability are often studied separately, with few studies examining the interdependencies between these two processes and the implementation contexts of innovations towards malaria prevention and control. Researchers and implementers offer much more attention to the content of innovations, as they focus on the technological dimensions and the conditions for expansion. Researchers have often considered innovation a linear sequence in which scaling up and sustainability represented the last stages. Using systems thinking in this manuscript, we analyze complex scaling and sustainability processes through adopting and implementing seasonal malaria chemoprevention (SMC) in Burkina Faso from 2014 to 2018. Methods: We conducted a qualitative case study involving 141 retrospective secondary data (administrative, press, scientific, tools and registries, and verbatim) spanning from 2012 to 2018. We complemented these data with primary data collected between February and March 2018 in the form of 15 personal semi-structured interviews with SMC stakeholders and non-participant observations. Processual analysis permitted us to conceptualize scale-up and sustainability processes over time according to different vertical and horizontal levels of analysis and their interconnections. Results: Our results indicated six internal and external determinants of SMC that may negatively or positively influence its scale-up and sustainability. These determinants are effectiveness, monitoring and evaluation systems, resources (financial, material, and human), leadership and governance, adaptation to the local context, and other external elements. Our results revealed that donors and implementing actors prioritized financial resources over other determinants. In contrast, our study clearly showed that the sustainability of the innovation, as well as its scaling up, depends significantly on the consideration of the interconnectedness of the determinants. Each determinant can concurrently constitute an opportunity and a challenge for the success of the innovation. Conclusion: Our findings highlight the usefulness of the systemic perspective to consider all contexts (international, national, subnational, and local) to achieve large-scale improvements in the quality, equity, and effectiveness of global health interventions. Thus, complex and systems thinking have made it possible to observe emergent and dynamic innovation behaviors and the dynamics particular to sustainability and scaling up processes. [ABSTRACT FROM AUTHOR]

Abstract Background Population-level research evaluating HIV-related stigma among countries with varied national HIV prevalence is scarce. To better understand HIV-related stigma and mitigate its potential negative effects, it is necessary to evaluate its relationship with HIV prevalence, as well as the mechanisms that influence it. This study aimed to analyze how HIV-related stigma correlates with subnational HIV prevalence in three African countries with varied HIV epidemics. Methods This paper used data from the nationally representative Population-based HIV Impact Assessment (PHIA) surveys conducted from 2015–2017 in Malawi, Zambia, and Tanzania. Each country's sub-national geographic divisions were used to categorize them as low (0–5.4%), middle (5.5–11.2%), and high (11.3–17.1%) HIV prevalence regions in the main analysis. Questions from the survey stigma module were used to measure HIV-related stigma. Logistic regression and multilevel models were performed to assess the associations between the level of sub-national HIV prevalence and HIV-related stigma measures among persons living with, and without, HIV. Results The results show that the odds of people living without HIV expressing stigmatizing behavior towards PLWH was significantly lower in regions of middle (OR = 0.80, 90%CI = (0.68–0.96)) and high (OR = 0.65, 90%CI = (0.53–0.80)) HIV prevalence when compared to low prevalence regions. The odds of reporting discriminatory attitudes were also lower for those in middle (OR = 0.87, 90%CI = (0.78–0.98)) and high (OR = 0.64, 90%CI = (0.56–0.73)) HIV prevalence regions compared to others. Living in middle and high HIV prevalence regions was associated with lower odds of expressing prejudice toward PLWH (OR = 0.84, 90%CI = (0.71–0.99) and OR = 0.60, 90%CI = (0.45–0.80), respectively) among people living without HIV. Notably, PLWH living in high prevalence regions had higher odds of reporting internalized stigma (OR = 1.48, 90%CI = (1.02–2.14)) compared to those living in low prevalence regions. Conclusions The results indicate that among people not living with HIV, subnational HIV prevalence was negatively associated with discriminatory attitudes and prejudice towards PLWH, but HIV prevalence was positively associated with self-reported internalized stigma among PLWH. These results provide insight on how resources could be invested to reduce HIV related stigma among both PLWH and those not living with HIV.

Background: Effective interventions among female sex workers require a thorough knowledge of the context of local sex industries. We explore the organisation of female sex work in a low socio-economic setting in Kampala, Uganda. Methods: We conducted a qualitative study with 101 participants selected from an epidemiological cohort of 1027 women at high risk of HIV in Kampala. Repeat in-depth life history and work practice interviews were conducted from March 2010 to June 2011. Context specific factors of female sex workers' day-to-day lives were captured. Reported themes were identified and categorised inductively. Results: Of the 101 women, 58 were active self-identified sex workers operating in different locations within the area of study and nine had quit sex work. This paper focuses on these 67 women who gave information about their involvement in sex work. The majority had not gone beyond primary level of education and all had at least one child. Thirty one voluntarily disclosed that they were HIV-positive. Common sex work locations were streets/roadsides, bars and night clubs. Typically sex occurred in lodges near bars/night clubs, dark alleyways or car parking lots. Overall, women experienced sex work-related challenges at their work locations but these were more apparent in outdoor settings. These settings exposed women to violence, visibility to police, a stigmatising public as well as competition for clients, while bars provided some protection from these challenges. Older sex workers tended to prefer bars while the younger ones were mostly based on the streets. Alcohol consumption was a feature in all locations and women said it gave them courage and helped them to withstand the night chill. Condom use was determined by clients' willingness, a woman's level of sobriety or price offered. Conclusions: Sex work operates across a variety of locations in the study area in Kampala, with each presenting different strategies and challenges for those operating there. Risky practices are present in all locations although they are higher on the streets compared to other locations. Location specific interventions are required to address the complex challenges in sex work environments. [ABSTRACT FROM AUTHOR]

Background: The child support grant (CSG) is the largest unconditional cash transfer program in Africa and aims to alleviate poverty and improve child health and nutrition in low-income families in South Africa. Among informal working women, the CSG is an important source of income after childbirth when informal workers are unable to work, but reports suggest that women experience delays in accessing the CSG. We explore experiences and challenges of accessing the CSG among informal workers in Durban, South Africa. Methods: We undertook a longitudinal mixed-methods cohort study. Women informal workers were recruited during pregnancy and followed-up for up to one year after the baby was born. Quantitative questionnaires and semi-structured in-depth interviews were used to collect data about women's plans for applying for the CSG, the application process, use of the CSG in the household, and household food insecurity. Interviews were conducted in IsiZulu by experienced researchers. Descriptive analysis of quantitative data used SPSS v26, and framework analysis using NVIVO v12.3 was used for qualitative analysis. Results: Twenty-four informal working women were enrolled. The CSG received for older children was reported as an important and reliable source of income for mothers after childbirth. However, delays receiving the CSG for the new baby meant this support was unavailable to first-time mothers. The complex application process for the CSG required mothers to travel to various government departments to complete the required documentation, often taking the baby with them. This was costly and time-consuming for mothers who were already vulnerable, and led to delays in obtaining CSG funds. Many women experienced moderate or severe food insecurity before and after the baby was born. As a result, some mothers had to return to work earlier than planned, disrupting childcare and breastfeeding. Conclusions: Cash transfer programmes can effectively support low income households and improve outcomes for mothers and children. In South Africa there is a need for innovative approaches to streamline CSG applications, so women can access the funds immediately post-delivery to fill a resource gap and provide support at a vulnerable time for mothers and their children. [ABSTRACT FROM AUTHOR]

Background: Studies have investigated dietary attributes associated with cardiovascular disease (CVD) risk in Africa. However, there has been no effort to critically assess the existing evidence. This systematic review examined available evidence on the association between plant-based dietary exposures and CVD risk profile in Africa. PROSPERO registration number: CRD42020159862. Methods: We conducted a literature search for observational studies reporting on plant-based dietary exposures in relation to CVD risk profile in African populations. PubMed-Medline, Scopus, EBSCOhost, and African Journals Online platforms were searched up to 19 March 2021. Titles and abstracts of the identified records were screened independently by two investigators. The quality of the studies was also assessed independently. Results: Of 458 entries identified, 15 studies published between 2002 and 2020 were included in this review. These studies originated from 12 sub-Saharan Africa (SSA) countries. Sample sizes ranged from 110 to 2362, age from 18 to 80 years; and majority of participants were females (66.0%). In all, four plant-based dietary exposures were identified across SSA. Sixty percent of the studies reported a significant association between a plant-based dietary exposure with at least one CVD risk factor such as hypertension, diabetes mellitus, dyslipidaemia, overweight/obesity, and metabolic syndrome. Conclusions: The few available studies suggest that there may be a protective effect of plant-based dietary exposures on CVD risk profile in the African setting. Nonetheless, more elaborated studies are still needed to address plant-based diet (PBD) adherence in relation with CVD risk in African populations. [ABSTRACT FROM AUTHOR]