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BackgroundHIV is the leading cause of mortality among youth in sub-Saharan Africa. Uganda hosts over 1.43 million refugees, and more than 83,000 live in Kampala, largely in informal settlements. There is limited information about HIV testing uptake and preferences among urban refugee and displaced youth. HIV self-testing is a promising method for increasing testing uptake. Further, mobile health (mHealth) interventions have been effective in increasing HIV testing uptake and could be particularly useful among youth. ObjectiveThis study aims to evaluate the feasibility and effectiveness of two HIV self-testing implementation strategies (HIV self-testing intervention alone and HIV self-testing combined with an mHealth intervention) in comparison with the HIV testing standard of care in terms of HIV testing outcomes among refugee/displaced youth aged 16 to 24 years in Kampala, Uganda. MethodsA three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomization will be performed with a 1:1:1 method. Approximately 450 adolescents (150 per cluster) will be enrolled and followed for 12 months. Data will be collected at the following three time points: baseline enrollment, 8 months after enrollment, and 12 months after enrollment. Primary outcomes (HIV testing frequency, HIV status knowledge, linkage to confirmatory testing, and linkage to HIV care) and secondary outcomes (depression, condom use efficacy, consistent condom use, sexual relationship power, HIV stigma, and adolescent sexual and reproductive health stigma) will be evaluated. ResultsThe study has been conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (June 14, 2019), Mildmay Uganda (November 11, 2019), and the Uganda National Council for Science and Technology (August 3, 2020). The Tushirikiane trial launched in February 2020, recruiting a total of 452 participants. Data collection was paused for 8 months due to COVID-19. Data collection for wave 2 resumed in November 2020, and as of December 10, 2020, a total of 295 participants have been followed-up. The third, and final, wave of data collection will be conducted between February and March 2021. ConclusionsThis study will contribute to the knowledge of differentiated HIV testing implementation strategies for urban refugee and displaced youth living in informal settlements. We will share the findings in peer-reviewed manuscripts and conference presentations. Trial RegistrationClinicalTrials.gov NCT04504097; https://clinicaltrials.gov/ct2/show/NCT04504097. International Registered Report Identifier (IRRID)DERR1-10.2196/26192

Background: The rapid global emergence of the COVID-19 pandemic in early 2020 created urgent demand for leading indicators to track the spread of the virus and assess the consequences of public health measures designed to limit transmission. Public transit mobility, which has been shown to be responsive to previous societal disruptions such as disease outbreaks and terrorist attacks, emerged as an early candidate. Methods: We conducted a longitudinal ecological study of the association between public transit mobility reductions and COVID-19 transmission using publicly available data from a public transit app in 40 global cities from March 16 to April 12, 2020. Multilevel linear regression models were used to estimate the association between COVID-19 transmission and the value of the mobility index 2 weeks prior using two different outcome measures: weekly case ratio and effective reproduction number. Results: Over the course of March 2020, median public transit mobility, measured by the volume of trips planned in the app, dropped from 100% (first quartile (Q1)–third quartile (Q3) = 94–108%) of typical usage to 10% (Q1–Q3 = 6–15%). Mobility was strongly associated with COVID-19 transmission 2 weeks later: a 10% decline in mobility was associated with a 12.3% decrease in the weekly case ratio (exp(β) = 0.877; 95% confidence interval (CI): [0.859–0.896]) and a decrease in the effective reproduction number (β = −0.058; 95% CI: [−0.068 to −0.048]). The mobility-only models explained nearly 60% of variance in the data for both outcomes. The adjustment for epidemic timing attenuated the associations between mobility and subsequent COVID-19 transmission but only slightly increased the variance explained by the models. Discussion: Our analysis demonstrated the value of public transit mobility as a leading indicator of COVID-19 transmission during the first wave of the pandemic in 40 global cities, at a time when few such indicators were available. Factors such as persistently depressed demand for public transit since the onset of the pandemic limit the ongoing utility of a mobility index based on public transit usage. This study illustrates an innovative use of "big data" from industry to inform the response to a global pandemic, providing support for future collaborations aimed at important public health challenges. [ABSTRACT FROM AUTHOR]

Background Tailored coronavirus disease 2019 (COVID-19) prevention strategies are needed for urban refugee youth in resource-constrained contexts. We developed an 8-wk interactive informational mobile health intervention focused on COVID-19 prevention practices informed by the Risk, Attitude, Norms, Ability, Self-regulation—or RANAS—approach. Methods We conducted a pre-post trial with a community-recruited sample of refugee youth aged 16–24 y in Kampala, Uganda. Data were collected before (T1) and immediately following (T2) the intervention, and at the 16-wk follow up (T3), to examine changes in primary (COVID-19 prevention self-efficacy) and secondary outcomes (COVID-19 risk awareness, attitudes, norms and self-regulation practices; depression; sexual and reproductive health [SRH] access; food/water security; COVID-19 vaccine acceptability). Results Participants (n=346; mean age: 21.2 [SD 2.6] y; cisgender women: 50.3%; cisgender men: 48.0%; transgender persons: 1.7%) were largely retained (T2: n=316, 91.3%; T3: n=302, 87.3%). In adjusted analyses, COVID-19 prevention self-efficacy, risk awareness, attitudes and vaccine acceptance increased significantly from T1 to T2, but were not sustained at T3. Between T1 and T3, COVID-19 norms and self-regulation significantly increased, while community violence, water insecurity and community SRH access decreased. Conclusions Digital approaches for behaviour change hold promise with urban refugee youth but may need booster messaging and complementary programming for sustained effects. [ABSTRACT FROM AUTHOR]

Introduction: Urban refugee youth remain underserved by current HIV prevention strategies, including HIV self‐testing (HIVST). Examining HIVST feasibility with refugees can inform tailored HIV testing strategies. We examined if HIVST and mobile health (mHealth) delivery approaches could increase HIV testing uptake and HIV status knowledge among refugee youth in Kampala, Uganda. Methods: We conducted a three‐arm pragmatic controlled trial across five informal settlements grouped into three sites in Kampala from 2020 to 2021 with peer‐recruited refugee youth aged 16–24 years. The intervention was HIVST and HIVST + mHealth (HIVST with bidirectional SMS), compared with standard of care (SOC). Primary outcomes were self‐reported HIV testing uptake and correct status knowledge verified by point‐of‐care testing. Some secondary outcomes included: depression, HIV‐related stigma, and adolescent sexual and reproductive health (SRH) stigma at three time points (baseline [T0], 8 months [T1] and 12 months [T2]). We used generalized estimating equation regression models to estimate crude and adjusted odds ratios comparing arms over time, adjusting for age, gender and baseline imbalances. We assessed study pragmatism across PRECIS‐2 dimensions. Results: We enrolled 450 participants (50.7% cisgender men, 48.7% cisgender women, 0.7% transgender women; mean age: 20.0, standard deviation: 2.4) across three sites. Self‐reported HIV testing uptake increased significantly from T0 to T1 in intervention arms: HIVST arm: (27.6% [n = 43] at T0 vs. 91.2% [n = 135] at T1; HIVST + mHealth: 30.9% [n = 47] at T0 vs. 94.2% [n = 113] at T1]) compared with SOC (35.5% [n = 50] at T0 vs. 24.8% [ = 27] at T1) and remained significantly higher than SOC at T2 (p<0.001). HIV status knowledge in intervention arms (HIVST arm: 100% [n = 121], HIVST + mHealth arm: 97.9% [n = 95]) was significantly higher than SOC (61.5% [n = 59]) at T2. There were modest changes in secondary outcomes in intervention arms, including decreased depression alongside increased HIV‐related stigma and adolescent SRH stigma. The trial employed both pragmatic (eligibility criteria, setting, organization, outcome, analysis) and explanatory approaches (recruitment path, flexibility of delivery flexibility, adherence flexibility, follow‐up). Conclusions: Offering HIVST is a promising approach to increase HIV testing uptake among urban refugee youth in Kampala. We share lessons learned to inform future youth‐focused HIVST trials in urban humanitarian settings. [ABSTRACT FROM AUTHOR]

We assessed mpox virus prevalence in blood, pharyngeal, and rectal specimens among persons without characteristic rash presenting for JYNNEOS vaccine. Our data indicate that the utility of risk-based screening for mpox in persons without skin lesions or rash via pharyngeal swabs, rectal swabs, and/or blood is likely limited. [ABSTRACT FROM AUTHOR]

Sexual and gender-based violence (SGBV) is a persistent concern in humanitarian contexts, yet there is a dearth of SGBV prevention and post-rape clinical care interventions tailored for refugee youth. Graphic medicine, the use of images and text such as in comic books, has been employed to depict lived experiences to promote health, wellbeing, and education. Comic books provide a low-cost, youth-friendly approach to health promotion that is accessible to varying literacy levels. Limited research, however, has described the process of developing graphic medicine approaches for SGBV prevention and sexual violence stigma reduction with and for refugee youth in humanitarian settings. To address this knowledge gap, this paper shares a Qualitative Comic Book Mapping approach, whereby qualitative data alongside theoretical and empirical SGBV literature informed the development of comic book scenarios with refugee youth aged 16-24 in Bidi Bidi refugee settlement, Uganda. Steps included conducting focus groups and in-depth individual interviews with 78 community members (youth, elders, service providers) in Bidi Bidi to explore SGBV lived experiences among refugee youth in Bidi Bidi and ideas for solutions to reduce SGBV and related stigma, in addition to improving post-rape care experiences and engagement. The Qualitative Comic Book Mapping approach involved: a) thematic analysis of qualitative data and identification of overarching themes; b) aligning qualitative themes with theories of change for SGBV prevention and stigma reduction; and c) co-developing comic book scenarios with refugee youth peer navigators and community experts to integrate SGBV prevention and stigma reduction theory with refugee youth lived experiences. The final comic book involved five youth-focused scenarios and was integrated in an intervention with refugee youth, including providing youth with a blank version of the comic book to complete themselves. We share how theoretically-informed comic books can be developed from qualitative data with refugee youth in a humanitarian setting. [ABSTRACT FROM AUTHOR]

Introduction: The COVID-19 pandemic has amplified pre-existing challenges to health promotion and care across the world, and particularly in low- and middle-income countries (LMICs). This qualitative study draws on data from a panel of immunisation experts and uses a novel framework of vaccine delivery domains to explore perspectives from those who live and work in these settings on the challenges to implementing COVID-19 vaccine programs in LMICs. Methods: We conducted a thematic content analysis of 96 participant free text replies to questions from Round I of a three-round Delphi consensus study amongst global experts on COVID-19 vaccine implementation. Results: Participant responses highlighted challenges to vaccine program implementation including issues related to equity; governance, decision-making, and financing; regulatory structures, planning, and coordination; prioritisation, demand generation, and communication; vaccine, cold chain, logistics, and infrastructure; service delivery, human resources, and supplies; and surveillance, monitoring, and evaluation. Conclusion: We reflect on our findings in light of global efforts to address vaccine inequity and emphasise three key areas salient to improving vaccination efforts during novel infectious disease outbreaks: 1) Ensuring safe and sustainable service delivery in communities and at points of care; 2) Strengthening systems for end-to-end delivery of vaccines, therapeutics, diagnostics, and essential supplies; 3) Transforming structural paradigms towards vaccine equity. [ABSTRACT FROM AUTHOR]

Scant studies have explored COVID-19 vaccine acceptability among refugees. However, contexts of forced migration may elevate COVID-19 vulnerabilities, and suboptimal refugee immunisation rates are reported for other vaccine-preventable diseases. We conducted a multi-methods study to describe COVID-19 vaccine acceptability among urban refugee youth in Kampala, Uganda. This study uses cross-sectional survey data from a cohort study with refugees aged 16–24 in Kampala to examine socio-demographic factors associated with vaccine acceptability. A purposively sampled cohort subset (n = 24) participated in semi-structured in-depth individual interviews, as did key informants (n = 6), to explore COVID-19 vaccine acceptance. Among 326 survey participants (mean age: 19.9; standard deviation 2.4; 50.0% cisgender women), vaccine acceptance was low (18.1% reported they were very likely to accept an effective COVID-19 vaccine). In multivariable models, vaccine acceptance likelihood was significantly associated with age and country of origin. Qualitative findings highlighted COVID-19 vaccine acceptability barriers and facilitators spanning social-ecological levels, including fear of side effects and mistrust (individual level), misinformed healthcare, community and family attitudes (community level), tailored COVID-19 services for refugees (organisational and practice setting), and political support for vaccines (policy environment). These data signal the urgent need to address social-ecological factors shaping COVID-19 vaccine acceptability among Kampala's young urban refugees. Trial registration: ClinicalTrials.gov identifier: NCT04631367. [ABSTRACT FROM AUTHOR]

There is a dearth of evidence-based post-rape clinical care interventions tailored for refugee adolescents and youth in low-income humanitarian settings. Comics, a low-cost, low-literacy and youth-friendly method, integrate visual images with text to spark emotion and share health-promoting information. We evaluated a participatory comic intervention to increase post-exposure prophylaxis (PEP) knowledge and acceptance, and prevent sexual and gender-based violence, in Bidi Bidi refugee settlement, Uganda. Following a formative qualitative phase, we conducted a pre-test post-test pilot study with refugee youth (aged 16–24 years) (n = 120). Surveys were conducted before (t0), after (t1), and two-months following (t2) workshops. Among participants (mean age: 19.7 years, standard deviation: 2.4; n = 60 men, n = 60 women), we found significant increases from t0 to t1, and from t0 to t2 in: (a) PEP knowledge and acceptance, (b) bystander efficacy, and (c) resilient coping. We also found significant decreases from t0 to t1, and from t0 to t2 in sexual violence stigma and depression. Qualitative feedback revealed knowledge and skills acquisition to engage with post-rape care and violence prevention, and increased empathy to support survivors. Survivor-informed participatory comic books are a promising approach to advance HIV prevention through increased PEP acceptance and reduced sexual violence stigma with refugee youth. Trial registration: ClinicalTrials.gov identifier: NCT04656522. [ABSTRACT FROM AUTHOR]

Background Water insecurity is linked to poor mental health through intrapersonal, relational and community-based stressors. We examined water insecurity and depression among refugee youth in Bidi Bidi, Uganda. Methods We conducted a cross-sectional survey and multivariable ordinal logistic regression to examine associations between water insecurity and depression severity, adjusting for gender, resilience, social support and food insecurity. Results Among participants (n=115; mean age: 19.7 y, SD 2.3), 80.0% reported water insecurity and 18.3% had moderate/severe depression symptoms. Water insecurity was independently associated with higher levels of depression severity (adjusted OR: 5.61; 95% CI 1.20 to 26.30; p=0.03). Conclusions Findings suggest water insecurity was commonplace and associated with depression. Water insecurity could be integrated in refugee mental health promotion by policymakers and community-based programmers. [ABSTRACT FROM AUTHOR]

With over 1.4 million refugees, Uganda is Sub-Saharan Africa's largest refugee-hosting nation. Bidi Bidi, Uganda's largest refugee settlement, hosts over 230,000 residents. There is a dearth of evidence-based sexual violence prevention and post-rape clinical care interventions in low- and middle-income humanitarian contexts tailored for refugee youth. Graphic medicine refers to juxtaposing images and narratives, often through using comics, to convey health promotion messaging. Comics can offer youth-friendly, low-cost, scalable approaches for sexual violence prevention and care. Yet there is limited empirical evaluation of comic interventions for sexual violence prevention and post-rape clinical care. This paper details the study design used to develop and pilot test a participatory comic intervention focused on sexual violence prevention through increasing bystander practices, reducing sexual violence stigma, and increasing post exposure prophylaxis (PEP) knowledge with youth aged 16–24 and healthcare providers in Bidi Bidi. Participants took part in a single-session peer-facilitated workshop that explored social, sexual, and psychological dimensions of sexual violence, bystander interventions, and post-rape clinical care. In the workshop, participants completed a participatory comic book based on narratives from qualitative data conducted with refugee youth sexual violence survivors. This pilot study employed a one-group pre-test/post-test design to assess feasibility outcomes and preliminary evidence of the intervention's efficacy. Challenges included community lockdowns due to COVID-19 which resulted in study implementation delays, political instability, and attrition of participants during follow-up surveys. Lessons learned included the important role of youth facilitation in youth-centred interventions and the promise of participatory comics for youth and healthcare provider engagement for developing solutions and reducing stigma regarding SGBV. The Ngutulu Kagwero (Agents of change) project produced a contextually and age-tailored comic intervention that can be implemented in future fully powered randomized controlled trials to determine effectiveness in advancing sexual violence prevention and care with youth in humanitarian contexts. [ABSTRACT FROM AUTHOR]

COVID-19 has highlighted the dynamic relationship between pandemic threats and global food systems. Despite important connections, research and policy-making on food systems and pandemics largely operate in silos. We propose a framework that integrates food systems and pandemic planning and response, exploring the role of the food system in shaping pandemics and, consequently, the role of pandemics in disrupting a now global food system. This framework highlights important connections between food production, distribution, and consumption at each stage of the pandemic cycle: prevention, response, and recovery. We use recent experiences with COVID-19 to illustrate vulnerabilities in systems interaction during the prevention and response phases. Over the long term, in the recovery phase, food systems must transform, adopting an enhanced level of functioning to improve resilience. To reduce population health risks and promote sustainable food systems, we call for implementation of surveillance systems for both emerging infections and food systems functioning in order to strengthen global food supply chains, create stakeholder resource coordination mechanisms, and address underlying socioeconomic vulnerabilities. Multidisciplinary global actors should draw on lessons from the COVID-19 pandemic to prevent the inevitable next one. [ABSTRACT FROM AUTHOR]

Background: Nonpharmaceutical interventions (NPIs) are the primary tools to mitigate early spread of the coronavirus disease 2019 (COVID-19) pandemic; however, such policies are implemented variably at the federal, provincial or territorial, and municipal levels without centralized documentation. We describe the development of the comprehensive open Canadian Non-Pharmaceutical Intervention (CAN-NPI) data set, which identifies and classifies all NPIs implemented in regions across Canada in response to COVID-19, and provides an accompanying description of geographic and temporal heterogeneity. Methods: We performed an environmental scan of government websites, news media and verified government social media accounts to identify NPIs implemented in Canada between Jan. 1 and Apr. 19, 2020. The CAN-NPI data set contains information about each intervention's timing, location, type, target population and alignment with a response stringency measure. We conducted descriptive analyses to characterize the temporal and geographic variation in early NPI implementation. Results: We recorded 2517 NPIs grouped in 63 distinct categories during this period. The median date of NPI implementation in Canada was Mar. 24, 2020. Most jurisdictions heightened the stringency of their response following the World Health Organization's global pandemic declaration on Mar. 11, 2020. However, there was variation among provinces or territories in the timing and stringency of NPI implementation, with 8 out of 13 provinces or territories declaring a state of emergency by Mar. 18, and all by Mar. 22, 2020. Interpretation: There was substantial geographic and temporal heterogeneity in NPI implementation across Canada, highlighting the importance of a subnational lens in evaluating the COVID-19 pandemic response. Our comprehensive open-access data set will enable researchers to conduct robust interjurisdictional analyses of NPI impact in curtailing COVID-19 transmission. [ABSTRACT FROM AUTHOR]

Introduction: Continuing education (CE) can help public health professionals maintain and further develop their knowledge and skills to adapt to the changing public health landscape. This scoping review aims to identify the preferred modalities for delivering CE to public health professionals and to determine how equity has been incorporated into public health training. Methods: Using the PRISMA extension for Scoping Reviews as a guide, we searched four databases for peer-reviewed primary research studies that evaluated public health workforce CE modalities. Results: The review included 33 studies published between 1 January 2000 and 6 August 2019 from over 11 countries. Most articles broadly described their training audience as public health professionals employed by government or non-governmental organizations. Delivery methods included online, in-person or blended learning (combining online and in-person instruction). Learners strongly preferred self-directed approaches. Organizational support, including protected time for professional development during work hours, was an important enabler of training completion. Commonly cited barriers included course duration and a high number of contact hours. Conclusion: Findings suggest that there is no single preferred training modality. We identified three elements that influence modality preference: design, delivery and organizational support. Modality should be determined by participants' location, needs and previous experiences to ensure the content is relevant and delivered in a way that equips learners to apply the knowledge gained. [ABSTRACT FROM AUTHOR]

Background: HIV is the leading cause of mortality among youth in sub-Saharan Africa. Uganda hosts over 1.43 million refugees, and more than 83,000 live in Kampala, largely in informal settlements. There is limited information about HIV testing uptake and preferences among urban refugee and displaced youth. HIV self-testing is a promising method for increasing testing uptake. Further, mobile health (mHealth) interventions have been effective in increasing HIV testing uptake and could be particularly useful among youth. Objective: This study aims to evaluate the feasibility and effectiveness of two HIV self-testing implementation strategies (HIV self-testing intervention alone and HIV self-testing combined with an mHealth intervention) in comparison with the HIV testing standard of care in terms of HIV testing outcomes among refugee/displaced youth aged 16 to 24 years in Kampala, Uganda. Methods: A three-arm cluster randomized controlled trial will be implemented across five informal settlements grouped into three sites, based on proximity, and randomization will be performed with a 1:1:1 method. Approximately 450 adolescents (150 per cluster) will be enrolled and followed for 12 months. Data will be collected at the following three time points: baseline enrollment, 8 months after enrollment, and 12 months after enrollment. Primary outcomes (HIV testing frequency, HIV status knowledge, linkage to confirmatory testing, and linkage to HIV care) and secondary outcomes (depression, condom use efficacy, consistent condom use, sexual relationship power, HIV stigma, and adolescent sexual and reproductive health stigma) will be evaluated. Results: The study has been conducted in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines. The study has received ethical approval from the University of Toronto (June 14, 2019), Mildmay Uganda (November 11, 2019), and the Uganda National Council for Science and Technology (August 3, 2020). The Tushirikiane trial launched in February 2020, recruiting a total of 452 participants. Data collection was paused for 8 months due to COVID-19. Data collection for wave 2 resumed in November 2020, and as of December 10, 2020, a total of 295 participants have been followed-up. The third, and final, wave of data collection will be conducted between February and March 2021. Conclusions: This study will contribute to the knowledge of differentiated HIV testing implementation strategies for urban refugee and displaced youth living in informal settlements. We will share the findings in peer-reviewed manuscripts and conference presentations. Trial Registration: ClinicalTrials.gov NCT04504097; https://clinicaltrials.gov/ct2/show/NCT04504097. International Registered Report Identifier (IRRID): DERR1-10.2196/26192 JMIR Res Protoc 2021;10(2):e26192 doi:10.2196/26192 [ABSTRACT FROM AUTHOR]

A recent publication in I CMAJ i [1] highlights the critical need for timely, accurate and accessible epidemiologic data for the ongoing coronavirus disease 2019 (COVID-19) outbreak to inform public health response efforts. Data sharing, standardization and visualization will continue to be crucial for supporting evidence-based control strategies and directing public health response efforts in Canada.[3] Footnotes 1 B Competing interests: b None declared. [Extracted from the article]

Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Eric J. Chow reports receipt of a travel grant from the Infectious Diseases Society of America to attend IDWeek 2022 and honoraria from Providence Health & Services for presentations on COVID-19. No other potential conflicts of interest were disclosed.

Meningococcal disease, caused by the bacterium Neisseria meningitidis, is a rare but life-threatening illness that requires prompt antibiotic treatment for patients and antibiotic prophylaxis for their close contacts. Historically, N. meningitidis isolates in the United States have been largely susceptible to the antibiotics recommended for prophylaxis, including ciprofloxacin. Since 2019, however, the number of meningococcal disease cases caused by ciprofloxacin-resistant strains has increased. Antibiotic prophylaxis with ciprofloxacin in areas with ciprofloxacin resistance might result in prophylaxis failure. Health departments should preferentially consider using antibiotics other than ciprofloxacin as prophylaxis for close contacts when both of the following criteria have been met in a local catchment area during a rolling 12-month period: 1) the reporting of two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains, and 2) ≥20% of all reported invasive meningococcal disease cases are caused by ciprofloxacin-resistant strains. Other than ciprofloxacin, alternative recommended antibiotic options include rifampin, ceftriaxone, or azithromycin. Ongoing monitoring for antibiotic resistance of meningococcal isolates through surveillance and health care providers' reporting of prophylaxis failures will guide future updates to prophylaxis considerations and recommendations., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Introduction: Refugees experience HIV vulnerabilities due to the confluence of displacement, violence and poverty. HIV self-testing, understudied with refugees, is a promising method to increase testing uptake, yet challenges remain with linkages to confirmatory testing following a positive HIV self-test. This study aims to evaluate the effectiveness of HIV self-testing kits and 'edutainment' comics in increasing HIV testing and HIV status knowledge among refugee youth aged 16-24 years in Bidi Bidi Refugee Settlement, Uganda., Methods and Analysis: This study will be conducted in Bidi Bidi. We conducted a qualitative formative phase with focus groups (n=40) to generate knowledge of barriers and facilitators of HIV prevention, testing and care among refugee youth (aged 16-24) in Bidi Bidi. These findings were used to create comic scenarios aligning with edutainment approaches to health promotion and inform a four-arm cluster randomised controlled trial in Bidi Bidi using a 2×2 factorial design: (1) HIV self-testing alongside edutainment comics, (2) HIV self-testing alone, (3) edutainment comic alone and (4) standard of care. The target sample size will be 120 youth (30 per arm), who will be enrolled in the trial and followed for 3 months. Data will be collected at baseline and 3 months after enrolment. The primary outcomes (HIV testing frequency, HIV status knowledge) and secondary outcomes (linkage to confirmatory HIV testing, HIV care linkage, HIV self-test kit use, HIV-related stigma, HIV knowledge, safer sex efficacy, condom use, adolescent sexual and reproductive health (SRH) stigma, sexual relationship power, access to SRH services) will be evaluated using descriptive statistics and regression analyses., Ethics and Dissemination: This study was approved by the University of Toronto Research Ethics Board, Mildmay Uganda Research Ethics Committee and the Uganda National Council for Science and Technology. Results will be shared in peer-reviewed publications and community knowledge sharing., Trial Registration Number: NCT05213689., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The rapid implementation of global COVID-19 vaccination programs has surfaced many challenges and inequities, particularly in low- and middle-income countries (LMICs). However, there continues to be a lack of consensus on which challenges are global priorities for action, and how to best respond to them. This study uses consensus-based methods to identify and rank the most important challenges and solutions for implementation of COVID-19 vaccination programs in LMICs., Methods: We conducted a three-round modified Delphi study with a global panel of vaccine delivery experts. In Round I, panelists identified broad topical challenges and solutions. Responses were collated and coded into distinct items. Through two further rounds of structured, iterative surveys panelists reviewed and ranked the identified items. Responses were analyzed qualitatively and quantitatively to achieve consensus on the most important COVID-19 vaccine delivery challenges and solutions., Results: Of the 426 invited panelists, 96 completed Round I, 56 completed Round II, and 39 completed Round III. Across all three rounds there was equal representation by gender, and panelists reported work experience in all World Bank regions and across a variety of content areas and organizations. Of the 64 initially identified items, the panel achieved consensus on three challenges and 10 solutions. Challenges fell under themes of structural factors and infrastructure and human and material resources, while solutions also included items within themes of communication, community engagement, and access and planning, processes, and operations., Conclusion: COVID-19 vaccine delivery is challenged by long-standing and structural inequities that disadvantage health service delivery in LMICs. These findings can, and should, be used by global health organizations to efficiently and optimally direct resources to respond to these key challenges and solutions., Competing Interests: Authors declare no competing interests., (Copyright: © 2022 Ariyarajah et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)