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Gender role ideology, i.e. beliefs about how genders should behave, is shaped by social learning. Accordingly, if perceptions about the beliefs of others are inaccurate this may impact trajectories of cultural change. Consistent with this premise, recent studies report evidence of a tendency to overestimate peer support for inequitable gender norms, especially among men, and that correcting apparent norm misperception promotes transitions to relatively egalitarian beliefs. However, supporting evidence largely relies on self-report measures vulnerable to social desirability bias. Consequently, observed patterns may reflect researcher measurement error rather than participant misperception. Addressing this shortcoming, we examine mens gender role ideology using both conventional self-reported and a novel wife-reported measure of mens beliefs in an urbanising community in Tanzania. We confirm that participants overestimate peer support for gender inequity. However, the latter measure, which we argue more accurately captures mens true beliefs, implies that this tendency is relatively modest in magnitude and scope. Overestimation was most pronounced among men holding relatively inequitable beliefs, consistent with misperception of peer beliefs reinforcing inequitable norms. Furthermore, older and poorly educated men overestimated peer support for gender inequity the most, suggesting that outdated and limited social information contribute to norm misperception in this context.

Global health interventions increasingly target the abolishment of child marriage (marriage under 18 years, hereafter referred to as early marriage). Guided by human behavioural ecology theory, and drawing on focus groups and in-depth interviews in an urbanising Tanzanian community where female early marriage is normative, we examine the common assumption that it is driven by the interests and coercive actions of parents and/or men. We find limited support for parent-offspring conflict. Parents often encouraged early marriages, but were motivated by the promise of social and economic security for daughters, rather than bridewealth transfers alone. Moreover, forced marriage appears rare, and adolescent girls and young women (AGYW) were active agents in the transition to marriage, sometimes marrying against parental wishes. Support for gendered conflict was stronger. AGYW were described as being lured into unstable relationships by men misrepresenting their long-term intentions. Community members voiced concerns over these marriages. Overall, early marriage appears rooted in limited options, encouraging strategic, but risky choices on the marriage market. Our results highlight plurality and context dependency in drivers of early marriage, even within a single community. We conclude that engaging with the importance of context is fundamental in forging culturally sensitive policies and programs on early marriage.

Achieving gender equality fundamentally requires a transfer of power from men to women. Yet data on mens support for womens empowerment (WE) remains scant and limited by reliance on self-report methodologies. Here, we examine mens support for WE as a sexual conflict trait, both via direct surveys (n = 590) and indirectly by asking mens wives (n = 317) to speculate on their husbands views. Data come from a semi-urban community in Mwanza, Tanzania. Consistent with reduced resource competition and increased exposure to relatively egalitarian gender norms, higher socioeconomic status predicted greater support for WE. However, potential demographic indicators of sexual conflict (high fertility, polygyny, large spousal age gap) were largely unrelated to mens support for WE. Contrasting self- and wife-reported measures suggests that men frequently exaggerate their support for women in self-reported attitudes. Discrepancies were especially pronounced among men claiming the highest support for WE, but smallest among men who held a professional occupation and whose wife participated in wage labour, indicating that these factors predict genuine support for WE. We discuss the implications of these results for our understanding of both individual variation and patriarchal gender norms, emphasising the benefits of greater exchange between the evolutionary human sciences and global health research on these themes.

BackgroundThe concept of 'child marriage' in global health distinguishes ostensibly harmful from healthy ages to marry at a universally-applied threshold of 18-years. With intensifying efforts to end child marriage, targeted communities are increasingly asked to change their perception of such marriages from relatively benign to profoundly problematic. The objective of this study is to understand how this shift in perception is navigated by adolescent girls and young women (AGYW).MethodsUsing qualitative data collected in 2019 from a semi-urban community in Tanzania where marriage under 18-years is common and campaigns to end child marriage ongoing, we contrast reports of lived experiences of marriage under 18-years among AGYW to views of child marriage as an abstract concept. Thirteen in-depth interviews with AGYW, as part of a wider qualitative study, were recorded, transcribed, and analyzed using a framework analysis approach.ResultsWhile many AGYW had heard of child marriage, the concept was routinely conflated with forced marriage, which is rare in the community, and non-marital teenage sex and pregnancy, which are common. As a likely consequence, participants disagreed on whether or not child marriage occurs locally. Furthermore, accounts of real-life marriages under 18 sometimes aligned with, but often departed from, common narratives about the purported causes and harmful consequences inherent to the global health concept of child marriage.ConclusionsWe argue that engaging with diverse local views and experiences of marrying young is essential to producing culturally-sensitive, effective initiatives addressing the vulnerabilities of female adolescence.

A global campaign to end "child marriage" has emerged over the last decade as part of growing international commitments to address gender inequities and improve female wellbeing. Campaigns typically assert that young brides have negligible autonomy in the marriage process and that marrying under 18 years has resolutely negative impacts on wellbeing. Yet, surprisingly few studies explore local attitudes towards marriage and its timing within contexts where early marriage is most common. As such our understanding of motivations and potential conflicts of interest leading female adolescents into marriage remain poorly informed by viewpoints of people purportedly at risk. We present an exploratory study of attitudes to early marriage in northwestern Tanzania where marriage before or shortly after 18 years is normative. We use focus group discussions, complimented by a survey of 993 women, to investigate local views on marriage. We explore (i) why people marry, (ii) when marriage is deemed appropriate, and (iii) who guides the marriage process. Contrary to dominant narratives in the end child marriage movement, we find that women are frequently active rather than passive in the selection of when and who to marry. Furthermore, marriage is widely viewed as instrumental in acquiring social status within one's local community. Our conclusions illuminate why rates of early marriage remain high despite potential negative wellbeing consequences and increasingly restrictive laws. We discuss our results in relation to related qualitative studies in other cultural contexts and consider the policy implications for current efforts to limit early marriage in Tanzania and beyond.

: Introduction: Interruptions in treatment pose risks for people with HIV (PWH) and threaten progress in ending the HIV epidemic; however, the COVID‐19 pandemic's impact on HIV service delivery across diverse settings is not broadly documented. Methods: From September 2020 to March 2021, the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium surveyed 238 HIV care sites across seven geographic regions to document constraints in HIV service delivery during the first year of the pandemic and strategies for ensuring care continuity for PWH. Descriptive statistics were stratified by national HIV prevalence ( Results: Questions about pandemic‐related consequences for HIV care were completed by 225 (95%) sites in 42 countries with low (n = 82), medium (n = 86) and high (n = 57) HIV prevalence, including low‐ (n = 57), lower‐middle (n = 79), upper‐middle (n = 39) and high‐ (n = 50) income countries. Most sites reported being subject to pandemic‐related restrictions on travel, service provision or other operations (75%), and experiencing negative impacts (76%) on clinic operations, including decreased hours/days, reduced provider availability, clinic reconfiguration for COVID‐19 services, record‐keeping interruptions and suspension of partner support. Almost all sites in low‐prevalence and high‐income countries reported increased use of telemedicine (85% and 100%, respectively), compared with less than half of sites in high‐prevalence and lower‐income settings. Few sites in high‐prevalence settings (2%) reported suspending antiretroviral therapy (ART) clinic services, and many reported adopting mitigation strategies to support adherence, including multi‐month dispensing of ART (95%) and designating community ART pick‐up points (44%). While few sites (5%) reported stockouts of first‐line ART regimens, 10–11% reported stockouts of second‐ and third‐line regimens, respectively, primarily in high‐prevalence and lower‐income settings. Interruptions in HIV viral load (VL) testing included suspension of testing (22%), longer turnaround times (41%) and supply/reagent stockouts (22%), but did not differ across settings. Conclusions: While many sites in high HIV prevalence settings and lower‐income countries reported introducing or expanding measures to support treatment adherence and continuity of care, the COVID‐19 pandemic resulted in disruptions to VL testing and ART supply chains that may negatively affect the quality of HIV care in these settings., INTRODUCTION The COVID‐19 pandemic has had major direct and indirect impacts on population health globally, through disruptions in the accessibility and quality of basic health services [1], in supply chains [...]

Objective To assess adoption of World Health Organization (WHO) guidance into national policies for prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV) and to monitor implementation of guidelines at facility level in rural Malawi, South Africa and the United Republic of Tanzania. Methods We summarized national PMTCT policies and WHO guidance for 15 indicators across the cascades of maternal and infant care over 2013-2016. Two survey rounds were conducted (2013-2015 and 2015-2016) in 46 health facilities serving five health and demographic surveillance system populations. We administered structured questionnaires to facility managers to describe service delivery. We report the proportions of facilities implementing each indicator and the frequency and durations of stock-outs of supplies, by site and survey round. Findings In all countries, national policies influencing the maternal and infant PMTCT cascade of care aligned with WHO guidelines by 2016; most inter-country policy variations concerned linkage to routine HIV care. The proportion of facilities delivering post-test counselling, same-day antiretroviral therapy (ART) initiation, antenatal care and ART provision in the same building, and Option B+ increased or remained at 100% in all sites. Progress in implementing policies on infant diagnosis and treatment varied across sites. Stock- outs of HIV test kits or antiretroviral drugs in the past year declined overall, but were reported by at least one facility per site in both rounds. Conclusion Progress has been made in implementing PMTCT policy in these settings. However, persistent gaps across the infant cascade of care and supply-chain challenges, risk undermining infant HIV elimination goals. Objectif Evaluer la transposition des recommandations de l'Organisation mondiale de la Sante (OMS) dans les politiques nationales de prevention de la transmission mere-enfant (PTME) du virus de l'immunodeficience humaine (VIH) et controler l'application de ces politiques dans les centres de sante de zones rurales d'Afrique du Sud, du Malawi et de Republique-Unie de Tanzanie. Methodes Nous avons repertorie les politiques nationales de PTME et les recommandations de l'OMS pour 15 indicateurs, sur toute la chaine de soins de sante de la mere et du nourrisson, sur la periode comprise entre 2013 et 2016. Deux series d'enquetes ont ete realisees (2013-2015 et 2015-2016) dans 46 centres de sante au service des populations de cinq systemes de surveillance demographique et de sante. Nous avons interroge les responsables de ces centres a l'aide de questionnaires directifs afin d'obtenir une description de la prestation des soins. Nous avons calcule la proportion de centres ayant applique chaque indicateur ainsi que la frequence et la duree des ruptures de stock de fournitures, pour chaque zone etudiee et chaque serie d'enquetes. Resultats En 2016, dans tous les pays etudies, les lignes directrices de l'OMS avaient ete prises en compte dans les politiques nationales relatives a la chaine des soins de PTME du VIH; la plupart des differences constatees entre les politiques de ces differents pays concernaient la liaison avec les soins de routine contre le VIH. La proportion des centres offrant des conseils apres depistage, proposant de debuter une therapie antiretrovirale (TAR) le jour meme, fournissant dans un meme endroit des soins prenataux et des TAR et appliquant l'Option B+ a augmente ou est restee a 100% dans toutes les zones etudiees. Les progres dans l'application des politiques en matiere de diagnostic et de traitement du nourrisson ont ete variables d'une zone a une autre. Les ruptures de stock de kits de depistage du VIH ou de medicaments antiretroviraux au cours de l'annee precedente ont generalement diminue, mais dans chaque zone, sur les deux periodes etudiees, au moins une structure a ete confrontee a ce probleme. Conclusion Des progres ont ete faits dans l'application des politiques de PTME dans ces regions. Neanmoins, des manquements persistants dans la chaine de soins de sante du nourrisson et les problemes des chaines d'approvisionnement risquent de compromettre l'atteinte des objectifs d'elimination du VIH chez le nourrisson. Objetivo Evaluar la adopcion de las directrices de la Organizacion Mundial de la Salud (OMS) en las politicas nacionales de prevencion de la transmision del virus de la inmunodeficiencia humana (VIH) de madre a hijo y supervisar la aplicacion de las directrices a nivel de las instalaciones sanitarias en las zonas rurales de Malawi, la Republica Unida de Tanzania y Sudafrica. Metodos Resumimos las politicas nacionales de PTMI y las directrices de la OMS para 15 indicadores en toda la serie de servicios de atencion maternoinfantil durante el periodo 2013-2016. Se realizaron dos rondas de encuestas (2013-2015 y 2015-2016) en 46 instalaciones sanitarias que atienden a cinco poblaciones del sistema de vigilancia sanitaria y demografica. Se administraron cuestionarios estructurados a los gestores de las instalaciones para describir la prestacion de servicios. Informamos las proporciones de las instalaciones que aplican cada indicador y la frecuencia y duracion de la falta de existencias de suministros, por emplazamiento y ronda de encuestas. Resultados En todos los paises, las politicas nacionales que influyen en la serie de servicios de atencion maternoinfantil de la PTMI se ajustaron a las directrices de la OMS para 2016; la mayoria de las variaciones de las politicas entre paises se referian a la vinculacion con la atencion habitual de la infeccion por el VIH. La proporcion de instalaciones que ofrecen asesoramiento posterior a la prueba, iniciacion de la terapia antirretrovirica en el mismo dia, atencion prenatal y suministro de terapia antirretrovirica en el mismo edificio, y la Opcion B+ aumentaron o se mantuvieron en el 100 % en todos los emplazamientos. El progreso en la aplicacion de las politicas de diagnostico y tratamiento del lactante vario de un emplazamiento a otro. Las existencias de kits de pruebas del VIH o de medicamentos antirretrovirales se redujeron en general en el ultimo ano, pero en ambas rondas se informo de la existencia de al menos una instalacion por emplazamiento. Conclusion Se ha progresado en la aplicacion de la politica de PTMI en estos ambitos. Sin embargo, las persistentes brechas en la serie de servicios de atencion infantil y los desafios de la cadena de suministro pueden socavar los objetivos de eliminacion del VIH infantil., [phrase omitted] Introduction In recent years, ambitious global commitments have been made to improve programmes for the prevention of motherto-child transmission (PMTCT) of human immunodeficiency virus (HIV). In 2011, the [...]

: Introduction: Extrapulmonary tuberculosis (EPTB) is difficult to confirm bacteriologically and requires specific diagnostic capacities. Diagnosis can be especially challenging in under‐resourced settings. We studied diagnostic modalities and clinical outcomes of EPTB compared to pulmonary tuberculosis (PTB) among HIV‐positive adults in antiretroviral therapy (ART) programmes in low‐ and middle‐income countries (LMIC). Methods: We collected data from HIV‐positive TB patients (≥16 years) in 22 ART programmes participating in the International Epidemiology Databases to Evaluate AIDS (IeDEA) consortium in sub‐Saharan Africa, Asia‐Pacific, and Caribbean, Central and South America regions between 2012 and 2014. We categorized TB as PTB or EPTB (EPTB included mixed PTB/EPTB). We used multivariable logistic regression to assess associations with clinical outcomes. Results and Discussion: We analysed 2695 HIV‐positive TB patients. Median age was 36 years (interquartile range (IQR) 30 to 43), 1102 were female (41%), and the median CD4 count at TB treatment start was 114 cells/μL (IQR 40 to 248). Overall, 1930 had PTB (72%), and 765 EPTB (28%). Among EPTB patients, the most frequently involved sites were the lymph nodes (24%), pleura (15%), abdomen (11%) and meninges (6%). The majority of PTB (1123 of 1930, 58%) and EPTB (582 of 765, 76%) patients were diagnosed based on clinical criteria. Bacteriological confirmation (using positive smear microscopy, culture, Xpert MTB/RIF, or other nucleic acid amplification tests result) was obtained in 897 of 1557 PTB (52%) and 183 of 438 EPTB (42%) patients. EPTB was not associated with higher mortality compared to PTB (adjusted odd ratio (aOR) 1.0, 95% CI 0.8 to 1.3), but TB meningitis was (aOR 1.9, 95% CI 1.0 to 3.1). Bacteriological confirmation was associated with reduced mortality among PTB patients (aOR 0.7, 95% CI 0.6 to 0.8) and EPTB patients (aOR 0.3 95% CI 0.1 to 0.8) compared to TB patients with a negative test result. Conclusions: Diagnosis of EPTB and PTB at ART programmes in LMIC was mainly based on clinical criteria. Greater availability and usage of TB diagnostic tests would improve the diagnosis and clinical outcomes of both EPTB and PTB., Introduction In low‐ and middle‐income countries (LMIC), tuberculosis (TB) accounts for approximately 40% of HIV/AIDS‐related deaths among adults, and half of those TB cases are undiagnosed at the time of [...]

: Introduction: Since 2015, the World Health Organization (WHO) has recommended that all people living with HIV (PLHIV) initiate antiretroviral treatment (ART), irrespective of CD4+ count or clinical stage. National adoption of universal treatment has accelerated since WHO's 2015 “Treat All” recommendation; however, little is known about the translation of this guidance into practice. This study aimed to assess the status of Treat All implementation across regions, countries, and levels of the health care delivery system. Methods: Between June and December 2017, 201/221 (91%) adult HIV treatment sites that participate in the global IeDEA research consortium completed a survey on capacity and practices related to HIV care. Located in 41 countries across seven geographic regions, sites provided information on the status and timing of site‐level introduction of Treat All, as well as site‐level practices related to ART initiation. Results: Almost all sites (93%) reported that they had begun implementing Treat All, and there were no statistically significant differences in site‐level Treat All introduction by health facility type, urban/rural location, sector (public/private) or country income level. The median time between national policy adoption and site‐level introduction was one month. In countries where Treat All was not yet adopted in national guidelines, 69% of sites reported initiating all patients on ART, regardless of clinical criteria, and these sites had been implementing Treat All for a median period of seven months at the time of the survey. The majority of sites (77%) reported typically initiating patients on ART within 14 days of confirming diagnosis, with 60% to 62% of sites implementing Treat All in East, Southern and West Africa reporting same‐day ART initiation for most patients. Conclusions: By mid‐ to late‐2017, the Treat All strategy was the standard of care at almost all IeDEA sites, including rural, primary‐level health facilities in low‐resource settings. While further assessments of site‐level capacity to provide high‐quality HIV care under Treat All and to support sustained viral suppression after ART initiation are needed, the widespread introduction of Treat All at the service delivery level is a critical step towards global targets for ending the HIV epidemic as a public health threat., Introduction WHO's 2015 recommendation for immediate treatment of all PLHIV, regardless of CD4+ cell count, represented a paradigm shift in HIV care and treatment. By preventing morbidity and mortality among [...]

Background Most countries have formally adopted the World Health Organization's 2015 recommendation of universal HIV treatment ('treat all'). However, there are few rigorous assessments of the real-world impact of treat all policies on antiretroviral treatment (ART) uptake across different contexts. Methods and findings We used longitudinal data for 814,603 patients enrolling in HIV care between 1 January 2004 and 10 July 2018 in 6 countries participating in the global International epidemiology Databases to Evaluate AIDS (IeDEA) consortium: Burundi (N = 11,176), Kenya (N = 179,941), Malawi (N = 84,558), Rwanda (N = 17,396), Uganda (N = 96,286), and Zambia (N = 425,246). Using a quasi-experimental regression discontinuity design, we assessed the change in the proportion initiating ART within 30 days of enrollment in HIV care (rapid ART initiation) after country-level adoption of the treat all policy. A modified Poisson model was used to identify factors associated with failure to initiate ART rapidly under treat all. In each of the 6 countries, over 60% of included patients were female, and median age at enrollment ranged from 32 to 36 years. In all countries studied, national adoption of treat all was associated with large increases in rapid ART initiation. Significant increases in rapid ART initiation immediately after treat all policy adoption were observed in Rwanda, from 44.4% to 78.9% of patients (34.5 percentage points [pp], 95% CI 27.2 to 41.7; p < 0.001), Kenya (25.7 pp, 95% CI 21.8 to 29.5; p < 0.001), Burundi (17.7 pp, 95% CI 6.5 to 28.9; p = 0.002), and Malawi (12.5 pp, 95% CI 7.5 to 17.5; p < 0.001), while no immediate increase was observed in Zambia (0.4 pp, 95% CI -2.9 to 3.8; p = 0.804) and Uganda (-4.2 pp, 95% CI -9.0 to 0.7; p = 0.090). The rate of rapid ART initiation accelerated sharply following treat all policy adoption in Malawi, Uganda, and Zambia; slowed in Kenya; and did not change in Rwanda and Burundi. In post hoc analyses restricted to patients enrolling under treat all, young adults (16-24 years) and men were at increased risk of not rapidly initiating ART (compared to older patients and women, respectively). However, rapid ART initiation following enrollment increased for all groups as more time elapsed since treat all policy adoption. Study limitations include incomplete data on potential ART eligibility criteria, such as clinical status, pregnancy, and enrollment CD4 count, which precluded the assessment of rapid ART initiation specifically among patients known to be eligible for ART before treat all. Conclusions Our analysis indicates that adoption of treat all policies had a strong effect on increasing rates of rapid ART initiation, and that these increases followed different trajectories across the 6 countries. Young adults and men still require additional attention to further improve rapid ART initiation., Author(s): Olga Tymejczyk 1,2,*, Ellen Brazier 1,2, Constantin T. Yiannoutsos 3, Michael Vinikoor 4,5, Monique van Lettow 6,7, Fred Nalugoda 8, Mark Urassa 9, Jean d'Amour Sinayobye 10, Peter F. [...]

: Introduction: Eighty percent of adolescents living with perinatally and behaviourally acquired HIV live in sub‐Saharan Africa (SSA), a continent with marked economic inequality. As part of our global project describing adolescents living with perinatally acquired HIV (APH), we aimed to assess whether inequality in outcomes exists by country income group (CIG) for APH within SSA. Methods: Through the CIPHER cohort collaboration, individual retrospective data from 7 networks and 25 countries in SSA were included. APH were included if they entered care at age 10 years. World Bank CIG classification for median year of first visit was used. Cumulative incidence of mortality, transfer‐out and loss‐to‐follow‐up was calculated by competing risks analysis. Mortality was compared across CIG by Cox proportional hazards models. Results: A total of 30,296 APH were included; 50.9% were female and 75.7% were resident in low‐income countries (LIC). Median [interquartile range (IQR)] age at antiretroviral therapy (ART) start was 8.1 [6.3; 9.5], 7.8 [6.2; 9.3] and 7.3 [5.2; 8.9] years in LIC, lower‐middle income countries (LMIC) and upper‐middle income countries (UMIC) respectively. Median age at last follow‐up was 12.1 [10.9; 13.8] years, with no difference between CIG. Cumulative incidence (95% CI) for mortality between age 10 and 15 years was lowest in UMIC (1.1% (0.8; 1.4)) compared to LIC (3.5% (3.1; 3.8)) and LMIC (3.9% (2.7; 5.4)). Loss‐to‐follow‐up was highest in UMIC (14.0% (12.9; 15.3)) compared to LIC (13.1% (12.4; 13.8)) and LMIC (8.3% (6.3; 10.6)). Adjusted mortality hazard ratios (95% CI) for APH in LIC and LMIC in reference to UMIC were 2.50 (1.85; 3.37) and 2.96 (1.90; 4.61) respectively, with little difference when restricted only to APH who ever received ART. In adjusted analyses mortality was similar for male and female APH. Conclusions: Results highlight probable inequality in mortality according to CIG in SSA even when ART was received. These findings highlight that without attention towards SDG 10 (to reduce inequality within and among countries), progress towards ensuring healthy lives and promoting wellbeing for all at all ages (SDG 3) will be hampered for APH in LIC and LMIC., Introduction Sub‐Saharan Africa (SSA) is a complex region marked by diversity and inequality. Across the continent gross national income per capita varies almost thirty fold from 160/1000. Sub‐Saharan Africa is [...]