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An increasing number of threats, both natural (e.g. fires, drought) and anthropogenic (e.g. agriculture, infrastructure development), are likely to affect both availability and quality of plants that grouse rely on for cover and food. As such, there is an increasing need to monitor plants and their use by grouse over space and time to better predict how changes in habitat quality influence the behavior of grouse. We use the greater sage-grouse Centrocercus urophasianus to showcase how new technology can be used to advance our understanding of the ecology, behavior and conservation of grouse. We demonstrate how laser, spectral and chemical detectors and unmanned aerial systems can be used to measure structural and phytochemical predictors of habitat quality at several spatial scales. We also demonstrate how advanced biotelemetry systems and robotic animals can be used to measure how habitat quality influences fine-scale habitat use, movement and reproductive effort of grouse. Integrating these technologies will allow researchers to better assess and manage the links among habitat quality (safety and food), resource acquisition (foraging behavior) and reproductive behaviors of grouse.

Weather is a significant factor influencing forest health, productivity, and the carbon cycle. However, our understanding of these effects is limited for many regions and ecosystems. Assessing the impact of weather variability on harvester productivity from plantation forests may assist in forest planning through the use of data modeling. We investigated whether weather data combined with timber harvesting attributes could be used to create a high-performance model that could accurately predict harvester productivity in Eucalyptus plantations using machine learning. Furthermore, we aimed to provide an online application to assist forest managers in applying the model. For the modeling, we considered 15 weather and timber harvesting attributes. We considered productivity as the target attribute. We subjected the database to 24 common algorithms in default mode and compared them according to error metrics and accuracy. From the timber harvesting features combined with weather features, the Catboost model can predict the productivity of harvesters in a tuned mode, with a coefficient of determination of 0.70. The use of weather data combined with timber harvesting attributes in the model is an accurate approach for predicting harvester productivity in Eucalyptus plantations, allowing for the creation of an online, free application to assist forest managers.

Tactical planning in timber harvesting involves aspects related to forest macro-planning and, particularly, the allocation of resources and sequencing of activities, all of which affect the allocation of timber in forest yards and roads and the productivity of forest machines. Data-driven approaches encourage the use of information obtained from data to enhance decision-making efficiency and support the development of short-term strategies. Therefore, our investigation was intended to determine whether a data-driven approach can generate sufficient input for modeling forwarder productivity in timber forwarding in Pinus and Eucalyptus planted forests, to support tactical planning. We utilized 3812 instances of raw data that were generated over a 36-month period. The data were collected from 23 loggers who operated in Pinus and Eucalyptus planted forests. We applied 22 regression algorithms that applied a supervised learning method from an experimental machine learning approach to the data instances. We evaluated the fitted models using three performance metrics. Out of the tested algorithms, the default mode of light gradient boosting produced a root mean squared error of 14.80 m3 h−1, a mean absolute error of 2.70, and a coefficient of determination of 0.77. Therefore, data-driven methods adequately support forwarder productivity modeling in timber forwarding in planted forests and help forest managers with tactical planning.

Seedling species with different architectures, e.g., mean leaf angles, are often subjected to the same irrigation management in forest nurseries, resulting in wasted water and fertilizer and reduced seedling quality. We aimed to evaluate whether irrigation volumes applied to tree seedling species with different leaf angles affect the physiological quality in forest nurseries and, consequently, performance after potting. We submitted nine seedling species with different mean leaf angles to four daily water regimes (8, 10, 12, and 14 mm). In the nursery, the following physiological attributes were considered to assess seedling quality: leaf water potential, daily transpiration rate, SPAD value, chlorophyll a and b, anthocyanins, carotenoids, and total nutrient content. After potting, we evaluated height and stem diameter over 120 days. Leaf angle can be used as a criterion for optimizing irrigation in forest nurseries, avoiding water and fertilizer wastage, and increasing physiological seedling quality. Leaf angle measurements combined with concurrent assessments of leaf traits are helpful in further understanding the effects of leaf angle variation and water regime on seedling quality. For positive leaf angles, an irrigation volume of 8 mm is sufficient to increase physiological seedling quality. Conversely, seedlings with negative leaf angles show the opposite response, requiring the largest irrigation volume (14 mm) to increase physiological seedling quality, except when the mean leaf area is small and concentrated in the upper half of the stem, which facilitates the access of irrigation water to the substrate and thus satisfies seedling water requirements. For all species, up to 120 days after planting in pots, the effect of the irrigation volume that provides greater growth and physiological quality at the end of the nursery phase is not overcome by other irrigation volumes applied.

The correct capture of forest operations information carried out in forest plantations can help in the management of mechanized harvesting timber. Proper management must be able to dimension resources and tools necessary for the fulfillment of operations and helping in strategic, tactical, and operational planning. In order to facilitate the decision making of forest managers, this work aimed to analyze the performance of machine learning algorithms in estimating the productivity of timber harvesters. As predictors of productivity, we used the availability of hours of machine use, individual mean volumes of trees, and terrain slopes. The dataset was composed of 144,973 records, carried out over a period of 28 months. We tested the predictive performance of 24 machine learning algorithms in default mode. In addition, we tested the performance of blending and stacking joint learning methods. We evaluated the model’s fit using the root mean squared error, mean absolute error, mean absolute percentage error, and determination coefficient. After cleaning the initial database, we used only 1.12% to build the model. Learning by blending ensemble stood out with a determination coefficient of 0.71 and a mean absolute percentage error of 15%. From the use of data from machine learning algorithms, it became possible to predict the productivity of timber harvesters. Testing a variety of machine learning algorithms with different dynamics contributed to the machine learning technique that helped us reach our goal: maximizing the model’s performance by conducting experimentation.

In forest nurseries, irrigation management becomes more complex as different seedlings of tropical species, with different architectures, are grown close to each other. In this context, there are gaps in knowledge about the physiological responses of species with different mean leaf angles when subjected to different irrigation depths. Thus, this work aimed to analyze whether mean leaf angles affect irrigation efficiency and, consequently, physiological responses of tree seedlings. Six species with different mean leaf angles were submitted to three irrigation depths (6, 9, and 12 mm) applied daily by micro-sprinklers in a completely randomized design in a split plot scheme. The following variables were evaluated: leaf water potential, stomatal conductance, relative water content in the leaf, daily transpiration, leaching fraction, and total dry mass. In tree species seedlings with positive mean leaf angles, smaller irrigation depths are already able to increase leaf water potential, stomatal conductance, leaf relative water content, and transpiration efficiency. In contrast, when the mean leaf angles are negative, it is necessary to apply larger irrigation depths so that seedling physiological responses do not reduce the production of total dry mass.

Choosing the ideal number of rotations of planted forests under a silvicultural management regime results in uncertainties in the cash flows of forest investment projects. We verified if there is parity in the Eucalyptus wood price modeling through fractional Brownian motion and geometric Brownian motion to incorporate managerial flexibilities into investment projects in planted forests. We use empirical data from three production cycles of forests planted with Eucalyptus grandis × E. urophylla in the projection of discounted cash flows. The Eucalyptus wood price, assumed as uncertainty, was modeled using fractional and geometric Brownian motion. The discrete-time pricing of European options was obtained using the Monte Carlo method. The root mean square error of fractional and geometric Brownian motions was USD 1.4 and USD 2.2, respectively. The real options approach gave the investment projects, with fractional and geometric Brownian motion, an expanded present value of USD 8,157,706 and USD 9,162,202, respectively. Furthermore, in both models, the optimal harvest ages execution was three rotations. Thus, with an indication of overvaluation of 4.9% when assimilating the geometric Brownian motion, there is no parity between stochastic processes, and three production cycles of Eucalyptus planted forests are economically viable.

Background: The commonly used methods for the financial evaluation of plantation forest investment projects do not incorporate uncertainties and ignore the value related to flexibility. The real options analysis makes it possible to capture these values in investment projects, increasing their value and return. Despite this, studies involving real options in forest investment projects are scarce, specifically those related to Pinus spp. Therefore, this study aimed to: (a) analyze whether the real options analysis adds value to investment projects of Pinus elliottii Engelm. plantations; and (b) make the real options analysis more accessible to forest managers and potentially increase its use in the investment projects of Pinus spp. plantations. Methods: We evaluated two investment projects in P. elliottii plantations in southern Brazil, which differed in the way of obtaining the land for planting: with lease or purchase of land on a planning horizon of 21 years. In the real options analysis, we used deferral, expansion, and abandonment. Results: Individually, the deferral, expansion, and abandonment options add value to investment projects in Pinus elliottii plantations. The option to expand the forested area is one that adds the most value to the investment project with land lease. In the investment project with land purchase, it is abandonment. Conclusions: Investment projects in Pinus elliotti plantations that contemplate the land purchase analyzed through the real options analysis present higher financial returns than those that consider land lease, inverting the result provided by the traditional analysis.

Background: Experts in ecological restoration have discussed the cost reduction to make forest restoration financially feasible. This is very important in developing countries, such as Brazil, and for smallholder farmers; however, economic studies do not usually consider the uncertainties in their analysis. Therefore, this study aimed to analyze, under conditions of uncertainty, how tropical tree seedlings produced in polyethylene bags, polyethylene tubes, and biodegradable containers (Ellepot®) interfere with the costs of implementation and post-planting maintenance investment projects in a deforested tropical seasonal forest area in southern Brazil. Methods: We evaluated total costs, production costs, and equivalent annual uniform costs, and the probability distributions and estimated ranges of stochastic values were adjusted through Monte Carlo method simulation. Furthermore, the seedling survival rate was recorded over 12 months post-planting. Results: The costs with tree seedling acquisition and direct labor were the components that most impacted total costs in the three investment projects. The forest restoration investment project with tree seedlings produced in polyethylene bags was economically unfeasible in relation to other projects. Conclusions: The best economic alternative was observed in the investment project with tree seedlings produced in Ellepot®, which showed a survival rate >80% after one year and the lowest total cost, production cost, and equivalent uniform annual cost.

As prevention of mother-to-child HIV-1 transmission (PMTCT) programs decrease the numbers of HIV-1-infected infants, it remains important to improve growth in HIV-1-exposed, uninfected (EU) infants. To determine the growth rate and predictors of growth faltering in breast-fed and formula-fed EU infants, growth analyses [weight-for-age (WAZ), weight-for-length (WLZ), and length-for-age (LAZ) Z-scores] were conducted by using data from a randomized feeding trial in HIV-1-infected women in Kenya. Growth faltering in EU infants was compared based on randomization to breastfeeding (BF) or formula feeding (FF) using Cox proportional hazards regression models. Linear mixed-effects models determined rate and cofactors of length growth. Among 338 EU infants, 164 (49%) were breast-fed and 174 (51%) formula-fed. In both arms, growth declined steadily during follow-up. By 2 y, 29% of children were underweight (WAZ < -2), 18% were wasted (WLZ < -2), and 58% were stunted (LAZ < -2), with no differences by feeding arm. Higher maternal education (y) and taller stature (cm) were associated with a decreased risk of underweight and stunting [underweight: adjusted HR (aHR) = 0.90 (95% CI: 0.83, 0.99), P = 0.03, and aHR = 0.92 (95% CI: 0.87, 0.97), P = 0.002; and stunting: aHR = 0.91 (95% CI: 0.85, 0.97), P = 0.003, and aHR = 0.96 (95% CI: 0.92, 0.99), P = 0.02, respectively]. Diarrhea was associated with an increased risk of wasting [aHR = 2.26 (95% CI: 1.11, 4.62), P = 0.03]. In multivariate analyses, FF was associated with slower declines in length velocity [0.24 LAZ/y (95% CI: 0.06, 0.43), P = 0.009]. Despite being uninfected, HIV-1-exposed infants showed frequent growth faltering, suggesting the need for vigilance in recognizing stunting within PMTCT programs. The slower rate of decline in length growth with FF may reflect benefits of micronutrients. Because BF is the best option for HIV-1-infected mothers in resource-limited settings, nutritional interventions should be examined for their impact on growth in EU breast-fed infants. [ABSTRACT FROM AUTHOR]

Background: Although evidence supports a relationship between human immunodeficiency virus (HIV)-1 exposure and HIV-1-specific CD8(+) T cell responses, studies have not demonstrated a direct association between the quantity of HIV-1 to which a person is exposed and the presence or absence of a response.Methods: From 1999 to 2005, maternal HIV-1 RNA levels were measured in blood, cervical secretions, and breast milk at delivery and 1 month after delivery. HIV-1-specific interferon (IFN)-γ Elispot assays were conducted to determine infant CD8(+) T-cell responses at 3 months of age.Results: Among 161 infants tested with Elispot assays, 23 (14%) had positive results. Mothers whose infants had a positive assay had higher breast milk HIV-1 RNA levels at month 1 compared with mothers whose infants had negative Elispot assays (3.1 vs 2.5 log(10) copies/mL; P = .017). Female infants were also more likely to have positive Elispot assays than male infants (P = .046), and in multivariate analyses, both female sex and high breast milk HIV-1 levels remained important predictors of a positive response (P = .022 and P = .015, respectively).Conclusions: Exposure to breast milk HIV-1 and sex were associated with development of HIV-1-specific CD8(+) T-cell responses in infants. These data support a role for mucosal exposure via the oral route in induction of systemic HIV-1-specific cellular immunity. [ABSTRACT FROM AUTHOR]

Background: Bacterial vaginosis (BV) is common and has been associated with increased HIV-1 susceptibility. The objective of this study was to identify risk factors for BV in African women at high risk for acquiring HIV-1.Methods: We conducted a prospective study among 151 HIV-1-seronegative Kenyan female sex workers. Nonpregnant women were eligible if they did not have symptoms of abnormal vaginal itching or discharge at the time of enrollment. At monthly follow-up, a vaginal examination and laboratory testing for genital tract infections were performed. Multivariate Andersen-Gill proportional hazards analysis was used to identify correlates of BV.Results: Participants completed a median of 378 (interquartile range 350-412) days of follow-up. Compared with women reporting no vaginal washing, those who reported vaginal washing 1 to 14 [adjusted hazard ratio (aHR) 1.29, 95% confidence interval (CI) 0.88-1.89], 15 to 28 (aHR 1.60, 95% CI 0.98-2.61), and >28 times/wk (aHR 2.39, 95% CI 1.35-4.23) were at increased risk of BV. Higher BV incidence was also associated with the use of cloth for intravaginal cleansing (aHR 1.48, 95% CI 1.06-2.08) and with recent unprotected intercourse (aHR 1.75, 95% CI 1.47-2.08). Women using depot medroxyprogesterone acetate contraception were at lower risk for BV (aHR 0.59, 95% CI 0.48-0.73).Conclusions: Vaginal washing and unprotected intercourse were associated with increased risk of BV. These findings could help to inform the development of novel vaginal health approaches for HIV-1 risk reduction in women. [ABSTRACT FROM AUTHOR]

Understanding how the level of human immunodeficiency virus type 1 (HIV-1)-infected breast milk cells (BMCs) affects HIV transmission via breast-feeding can shed light on the mechanism of infection and aid in establishing effective interventions. The proportion of infected cells to total cells was measured in serial breast milk samples collected from 291 HIV-1-infected women in Nairobi, Kenya, by use of real-time DNA polymerase chain reaction amplification of BMCs. The number of infected BMCs per million cells was associated with levels of cell-free viral RNA in breast milk (R=.144; P=.032), levels of cell-free virus in blood plasma (R=.365; P<.001), and the detection of proviral DNA in cervical and vaginal secretions (P<.001 and P = .030, respectively). The number of infected BMCs per million cells was lower in colostrum or early milk than in mature milk (P<.001). Previous studies demonstrated that the concentration of BMCs varies throughout lactation, and we used these data to transform infected BMCs per million cells to infected BMCs per milliliter. The estimated concentration of infected BMCs per milliliter was higher in colostrum or early milk than in mature milk (P<.001). Each log10 increase in infected BMCs per milliliter was associated with a 3.19-fold-increased risk of transmission (P=.002), after adjustment for cell-free virus in plasma (hazard ratio [HR], 2.09; P=.03) and breast milk (HR, 1.01; P=1.00). This suggests that infected BMCs may play a more important role in transmission of HIV via breast-feeding than does cell-free virus. [ABSTRACT FROM AUTHOR]

Polymerase chain reaction was used to determine the prevalence and correlates of human herpesvirus 8 (HHV8) in saliva, mouth, cervical, vaginal, plasma, and peripheral-blood mononuclear cell (PBMC) samples from 174 HHV8-seropositive female prostitutes in Mombasa, Kenya. The prevalence of detection of HHV8 was 32% in saliva samples, 28% in mouth swabs, 4% in cervical swabs, 2.3% in vaginal swabs, 9% in plasma samples, and 18% in PBMC samples. Human immunodeficiency virus type 1 (HIV-1) seropositivity was associated with detection of HHV8 from any mucosal surface (odds ratio, 2.1 [95% confidence interval, 1.1-4.0]). In HIV-1-seropositive women, there was no association between detection of HHV8 and either CD4 count or HIV-1 viral load. [ABSTRACT FROM AUTHOR]

Cross-sectional analyses have associated vitamin A deficiency with genital shedding of herpes simplex virus (HSV) among human immunodeficiency virus type 1 (HIV-1)-infected women. A randomized clinical trial of vitamin A supplementation given daily for 6 weeks was conducted among 376 women in Mombasa, Kenya, who were coinfected with HSV-2 and HIV-1. At follow-up, there was no significant difference in the detection of genital HSV DNA between women receiving vitamin A supplementation and women receiving placebo (40% vs. 44%, respectively; P = .5) Among women shedding HSV, there was no significant difference in the mean HSV DNA quantity between the group that received vitamin A supplementation and the group that received placebo (4.51 vs. 4.67 log10 copies/swab; P = .6). HSV shedding was associated with significantly higher vaginal and cervical HIV-1 shedding, even after controlling for the plasma HIV-1 load and the CD4 count. Vitamin A supplementation is unlikely to decrease HSV shedding and infectivity. Copyright © 2004 Infectious Diseases Society of America [ABSTRACT FROM AUTHOR]

To determine the effects of plasma, genital, and breast milk human immunodeficiency virus type 1 (HIV-1) and breast infections on perinatal HIV-1 transmission, a nested case-control study was conducted within a randomized clinical trial of breast-feeding and formula feeding among HIV-1-seropositive mothers in Nairobi, Kenya. In analyses comparing 92 infected infants with 187 infants who were uninfected at 2 years, maternal viral RNA levels >43,000 copies/mL (cohort median) were associated with a 4-fold increase in risk of transmission (95% confidence interval [CI], 2.2-7.2). Maternal cervical HIV-1 DNA (odds ratio [OR], 2.4; 95% CI, 1.3-4.4), vaginal HIV-1 DNA (OR, 2.3; 95% CI, 1.1-4.7), and cervical or vaginal ulcers (OR, 2.7; 95% CI, 1.2-5.8) were significantly associated with infant infection, independent of plasma virus load. Breast-feeding (OR, 1.7; 95% CI, 1.0-2.9) and mastitis (relative risk [RR], 3.9; 95% CI, 1.2-12.7) were associated with increased transmission overall, and mastitis (RR, 21.8; 95% CI, 2.3-211.0) and breast abscess (RR, 51.6; 95% CI, 4.7-571.0) were associated with late transmission (occurring >2 months postpartum). Use of methods that decrease infant exposure to HIV-1 in maternal genital secretions or breast milk may enhance currently recommended perinatal HIV-1 interventions. [ABSTRACT FROM AUTHOR]

Research Highlights: The mean leaf angle and crown projection area can be used as criteria for grouping tree seedling species in different irrigation zones in tree nurseries with overhead microsprinkler systems, preventing water and fertilizer waste, and increasing growth. Background and Objectives: There are important gaps in current functional knowledge about how plant architecture, especially the mean leaf angles of tree seedlings, affect water and nutrient solution capture in overhead microsprinkler systems. These gaps contribute to water and fertilizer waste in tree nurseries. This research aimed to ascertain how mean leaf angles affect irrigation water capture, leaching, and the growth of tree seedlings given different volumes of irrigation. Materials and Methods: Nine species of tree seedlings with different mean leaf angles were submitted to four irrigation volumes (8, 10, 12, and 14 mm) applied daily by overhead microsprinklers in a split-plot design completely randomized. The variables leaching fraction, height, stem diameter, shoot, root, and total dry mass, Dickson quality index, crown projection area, root system quality, and leachate electrical conductivity were evaluated. Results: For species with mean leaf angles of −54, 31, 38, 42, 55, 57, and 58°, the 8 mm irrigation volume was sufficient to produce greater growth and less leaching. For species with angles of −56 and −14°, the 14 mm irrigation volume was required to produce greater growth. Conclusions: The tree seedling species with positive mean leaf angles facilitate irrigation water and nutrient solution capture, allowing the application of lower irrigation volume. On the other hand, some tree seedling species with negative mean leaf angles hinder irrigation water and nutrient solution capture, requiring the application of higher irrigation volume. When the tree seedling species have a negative mean leaf angle, but the crown projection area is small, the difficulty of water and nutrient solution reaches directly the substrate is attenuated.

To examine associations between method of contraception, sexually transmitted diseases (STDs), and incident human immunodeficiency virus type 1 (HIV-1) infection, a prospective observational cohort study was done among female sex workers attending a municipal STD clinic in Mombasa, Kenya. Demographic and behavioral factors significantly associated with HIV-1 infection included type of workplace, condom use, and parity. In multivariate models, vulvitis, genital ulcer disease, vaginal discharge, and Candida vaginitis were significantly associated with HIV-1 seroconversion. Women who used depo medroxyprogesterone acetate (DMPA) had an increased incidence of HIV-1 infection (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.4-3.4). In a multivariate model controlling for demographic and exposure variables and biologic covariates, the adjusted HR for HIV-1 infection among DMPA users was 2.0 (CI, 1.3-3.1). There was a trend for an association between use of high-dose oral contraceptive pills and HIV-1 acquisition (HR, 2.6; CI, 0.8-8.5). [ABSTRACT FROM AUTHOR]

Breast-feeding may be an important route of human immunodeficiency virus type 1 (HIV-1) vertical transmission in settings where it is routinely practiced. To define the prevalence and quantity of HIV-1 in cell-free breast milk, samples from HIV-1-seropositive women were analyzed by quantitative competitive reverse transcription-polymerase chain reaction (QC-RT-PCR). HIV-1 RNA was detected in 29 (39%) of 75 specimens tested. Of these 29 specimens, 16 (55%) had levels that were near the detection limit of the assay (240 copies/mL), while 6 (21%) had >900 copies/mL. The maximum concentration of HIV-1 RNA detected was 8100 copies/mL. The prevalence of cell-free HIV-1 was higher in mature milk (47%) than in colostrum (27%, P = 0.1). Because mature milk is consumed in large quantities, these data suggest that cell-free HIV-1 in breast milk may contribute to vertical transmission of HIV-1. [ABSTRACT FROM AUTHOR]

Breast milk samples from human immunodeficiency virus type 1 (HIV-1)-seropositive women were analyzed by polymerase chain reaction to determine the prevalence and determinants of HIV-1-infected cells in breast milk. Breast milk samples (212) were collected from 107 women, and 58% of the samples had detectable HIV-1 DNA. The proportion of HIV-1-infected cells in the milk samples ranged from 1 to 3255/10(4) cells. Breast milk samples with detectable HIV-1 DNA were more likely to be from women with absolute CD4 cell counts of < 400 (odds ratio, 3.1; 95% confidence interval [CI], 1.5-7.0). Severe vitamin A deficiency (< 20 micrograms/dL) was associated with a 20-fold increased risk of having HIV-1 DNA in breast milk among women with < 400 CD4 cells/mm3 (95% CI, 2.1-188.5). Women with CD4 cell depletion, especially those with vitamin A deficiency, may be at increased risk of transmitting HIV-1 to their infants through breast milk. [ABSTRACT FROM AUTHOR]

http://dx.doi.org/10.5902/198050985082Os componentes utilizados na produção de substratos influem diretamente no ciclo vegetativo, na qualidade e consequentemente nos custos de produção das mudas. Nesse experimento estudou-se o desenvolvimento, qualidade e custos de produção de mudas de Eucalyptus grandis Hill ex Maiden × Eucalyptus urophylla S. T. Blake, por meio de propagação sexuada, utilizando 12 composições de substrato. A análise dos resultados evidenciou que os substratos puros, a exceção da fibra de coco, não apresentaram características físicas adequadas para a produção de mudas, via sexuada, de Eucalyptus grandis Hill ex Maiden × Eucalyptus urophylla S. T. Blake em tubetes. Os melhores resultados foram obtidos nos substratos com mistura 1:1 de casca de arroz carbonizada e fibra de coco e na mistura 1:1 de vermiculita e fibra de coco, devido às melhores características morfológicas apresentadas e da possibilidade de redução do tempo de produção, levando à redução no custo final das mudas.

The popular cram schools are voluntary initiatives aimed at people who are not able to afford the cost of private cram schools. The FCA popular cram school integrates a large project from UNESP, which has 30 cram school distributed throughout Sao Paulo State and located in different University units. Among the problems found in popular cram schools, school evasion, characterized when the student quits the course and is very common in this context. Thus, the aim of this work was to identify the profile of the drop out student from the FCA cram school as well as to know the reasons that led them to leave. The survey was conducted in two phases: 1) students´ profile when entering the cram school, through a structured questionnaire, 2) semi-structured interviews by telephone with all the drop out students, trying to identify the reasons that led them to abandon the course. The statistical analysis used was descriptive. Among the reasons that led them to leave, it was found that 65% of the students attributed this attitude to external factors as opposed to 35% who put the internal factors as the decisive reason of their departure. Some of the factors that could be attest for the FCA cram school evasion are: primarily, the heterogeneity of students and their need to work in order to support themselves and their family; students lack of motivation about a long-term success; lack of family encouragement; the difficulty of the student to establish significant personal links with cram school staff and the fact that the professors are mostly undergraduate students from different courses in different areas, with little didactic-pedagogic preparation and inability to work with students' heterogeneity.

Introdução: Por dia, o Brasil produz cerca de 250.000 toneladas de lixo. Desse total, 60% corresponde a resíduos orgânicos passíveis de serem compostados, ou seja, transformados em adubo orgânico e utilizados, principalmente, nas hortas e na produção de mudas. Com esta prática sustentável, alguns benefícios podem ser verificados, como: redução considerável do volume de lixo encaminhado aos aterros sanitários e lixões e aumento da capacidade de infiltração de água no solo, reduzindo a erosão. No entanto, verifica-se atualmente que, infelizmente, a compostagem é um processo ainda pouco praticado no país, fazendo-se necessária a criação de novos mecanismos de difusão e popularização desse conhecimento na sociedade. Objetivos: Nesse sentido, buscou-se elaborar um vídeo instrucional para orientar profissionais da educação infantil no ensino interdisciplinar do processo de compostagem. Métodos: Para elaboração do vídeo didático, todo material áudio-visual utilizado foi obtido concomitantemente à execução do projeto de extensão intitulado “Educação ambiental com crianças até 6 anos: compostagem de resíduos de cozinha e sua utilização”, realizado em 2008 no Centro de Convivência Infantil (CCI) - Lageado da UNESP de Botucatu por estudantes de graduação da unidade. A elaboração do vídeo foi dividida em 3 fases: 1) filmagem de cada atividade do projeto, com uma câmera digital, constituindo um banco de vídeos, áudios e imagens, 2) elaboração do roteiro do vídeo didático, 3) edição do material áudio-visual obtido, por meio do software Windows® Movie Maker versão 2.1. Resultados: O trabalho resultou num vídeo no formato DVD com o título “Educação ambiental com crianças até 6 anos: compostagem de resíduos de cozinha e sua utilização”, tendo 45 minutos de duração, onde o conteúdo foi dividido em 10 capítulos, sendo eles: gincana com materiais recicláveis, coleta e separação do lixo, visita ao aterro sanitário de Botucatu-SP, introdução ao processo de compostagem, atividades lúdicas e artísticas sobre compostagem, picagem do material para compostagem, ação dos microorganismos na matéria orgânica, principais fatores que afetam a compostagem, semeadura e utilização do composto e encerramento com a participação dos pais das crianças. Após a gravação dos discos, efetuou-se sua divulgação junto aos CCI da UNESP e escolas infantis públicas e privadas da cidade de Botucatu. Desse modo, devido à crescente demanda por novos materiais didáticos na área educacional, o vídeo produzido caracteriza-se como uma ferramenta importante na orientação de profissionais da educação infantil que almejam ensinar o processo da compostagem, facilitando, dessa maneira, o processo de internalização e aceitação das temáticas por parte da criança.

Abstract Background Trichomonas vaginalis has been associated with increased vaginal HIV-1 RNA shedding in antiretroviral therapy (ART)-naïve women. The effect of trichomoniasis on vaginal HIV-1 shedding in ART-treated women has not been characterized. We tested the hypothesis that T. vaginalis infection would increase vaginal HIV-1 RNA shedding in women on ART, and that successful treatment would reduce vaginal HIV-1 RNA levels. Methods We conducted a prospective cohort study including monthly follow-up of 147 women receiving ART in Mombasa, Kenya. Those with T. vaginalis infection, defined by the presence of motile trichomonads on vaginal saline wet mount, received treatment with single dose metronidazole (2 g). Test of cure was performed at the next monthly visit. Using the pre-infection visit as the reference category, we compared detection of vaginal HIV-1 RNA before versus during and after infection using generalized estimating equations. A cut-off of 100 HIV-1 RNA copies/swab was used as the lower limit for linear quantitation. Results Among 31 women treated for trichomoniasis, the concentration of vaginal HIV-1 RNA was above the limit for quantitation before, during, and after T. vaginalis infection in 4 (13% [95% CI 4% - 30%]), 4 (13% [95% CI 4% - 30%]), and 5 (16% [95% confidence interval {CI} 5% - 34%]) women respectively. After adjusting for potential confounding factors, we could detect no difference in the likelihood of detecting vaginal HIV-1 RNA before versus during infection (odds ratio [OR] 1.41, 95% CI 0.23 - 8.79, p = 0.7). In addition, detection of HIV-1 RNA was similar before infection versus after successful treatment (OR 0.68, 95% CI (0.13 - 3.45), p = 0.6). Conclusion Detection of vaginal HIV-1 RNA during ART was uncommon at visits before, during and after T. vaginalis infection.

Abstract Background Prompt use of an effective anti-malarial drug is essential for controlling malaria and its adverse effects in pregnancy. The World Health Organization recommends an artemisinin-based combination therapy as the first-line treatment of uncomplicated malaria in the second and third trimesters of pregnancy. The study objective was to determine the degree to which presumed episodes of uncomplicated symptomatic malaria in pregnancy were treated with a recommended anti-malarial regimen in a region of Uganda. Methods Utilizing a population-based random sample, we interviewed women living in Jinja, Uganda who had been pregnant in the past year. Results Self-reported malaria during the index pregnancy was reported among 67% (n = 334) of the 500 participants. Among the 637 self-reported episodes of malaria, an anti-malarial drug was used for treatment in 85% of the episodes. Use of a currently recommended treatment in the first trimester was uncommon (5.6%). A contraindicated anti-malarial drug (sulphadoxine-pyrimethamine and/or artemether-lumefantrine) was involved in 70% of first trimester episodes. Recommended anti-malarials were used according to the guidelines in only 30.1% of all second and third trimester episodes. Conclusions Self-reported malaria was extremely common in this population and adherence to treatment guidelines for the management of malaria in pregnancy was poor. Use of artemether-lumefantrine combined with non-recommended anti-malarials was common practice. Overuse of anti-malarial drugs, especially ones that are no longer recommended, undermines malaria control efforts by fueling the spread of drug resistance and delaying appropriate treatment of non-malarial febrile illnesses. Improved diagnostic capacity is essential to ultimately improving the management of malaria-like symptoms during pregnancy and appropriate use of currently available anti-malarials.

Abstract Background Among children, early mortality following highly active antiretroviral therapy (HAART) remains high. It is important to define correlates of mortality in order to improve outcome. Methods HIV-1-infected children aged 18 months-12 years were followed up at Kenyatta National Hospital, Nairobi after initiating NNRTI-based HAART. Cofactors for mortality were determined using multivariate Cox regression models. Results Between August 2004 and November 2008, 149 children were initiated on HAART of whom 135 were followed for a total of 238 child-years (median 21 months) after HAART initiation. Baseline median CD4% was 6.8% and median HIV-1-RNA was 5.98-log10 copies/ml. Twenty children (13.4%) died at a median of 35 days post-HAART initiation. Mortality during the entire follow-up period was 8.4 deaths per 100 child-years (46 deaths/100 child-years in first 4 months and 1.0 deaths/100 child-years after 4 months post-HAART initiation). On univariate Cox regression, baseline hemoglobin (Hb) Conclusion High early mortality was observed in this cohort of Kenyan children receiving HAART, and low baseline hemoglobin was an independent risk factor for death.

Abstract Background Low vitamin E levels are often found in HIV-1 infection, and studies have suggested that higher levels may decrease the risk of disease progression. However, vitamin E supplementation has also been reported to increase CCR5 expression, which could increase HIV-1 replication. We hypothesized that vitamin E levels at HIV-1 acquisition may influence disease progression. Methods Vitamin E status was measured in stored samples from the last pre-infection visit for 67 Kenyan women with reliably estimated dates of HIV-1 acquisition. Regression analyses were used to estimate associations between pre-infection vitamin E and plasma viral load, time to CD4 count Results After controlling for potential confounding factors, each 1 mg/L increase in pre-infection vitamin E was associated with 0.08 log10 copies/mL (95% CI -0.01 to +0.17) higher set point viral load and 1.58-fold higher risk of mortality (95% CI 1.15–2.16). The association between higher pre-infection vitamin E and mortality persisted after adjustment for set point viral load (HR 1.55, 95% CI 1.13–2.13). Conclusion Higher pre-infection vitamin E levels were associated with increased mortality. Further research is needed to elucidate the role vitamin E plays in HIV-1 pathogenesis.

Background: Provision of essential newborn care at home, rapid identification of illness, and care-seeking by caregivers can prevent neonatal mortality. Mobile technology can connect caregivers with information and healthcare worker advice more rapidly and frequently than healthcare visits. Community health workers (CHWs) are well-suited to deliver such interventions. We developed an interactive short message service (SMS) intervention for neonatal health in Kenya, named CHV-NEO. CHV-NEO sends automated, theory-based, actionable, messages throughout the peripartum period that guide mothers to evaluate maternal and neonatal danger signs and facilitate real-time dialogue with a CHW via SMS. We integrated this intervention into Kenya's national electronic community health information system (eCHIS), which is currently used at scale to support CHW workflow., Methods: The effect of CHV-NEO on clinical and implementation outcomes will be evaluated through a non-blinded cluster randomized controlled trial. Twenty sites across Kisumu County in Western Kenya were randomized 1:1 to provide either the national eCHIS with integrated CHV-NEO messaging (intervention) or standard of care using eCHIS without CHV-NEO (control). We will compare neonatal mortality between arms based on abstracted eCHIS data from 7200 pregnant women. Secondary outcomes include self-reported provision of essential newborn care (appropriate cord care, thermal care, and timely initiation of breastfeeding), knowledge of neonatal danger signs, and care-seeking for neonatal illness, compared between arms based on questionnaires with a subgroup of 2000 women attending study visits at enrollment in pregnancy and 6 weeks postpartum. We will also determine CHV-NEO's effect on CHW workflows and evaluate determinants of intervention acceptability, adoption, and fidelity of use through questionnaires, individual interviews, and messaging data., Discussion: We hypothesize that the CHV-NEO direct-to-client communication strategy can be successfully integrated within existing CHW workflows and infrastructure, improve the provision of at-home essential newborn care, increase timely referral of neonatal illness to facilities, and reduce neonatal mortality. The intervention's integration into the national eCHIS tool will facilitate rapid scale-up if it is clinically effective and successfully implemented., Trial Registration: ClinicalTrials.gov, NCT05187897 . The CHV-NEO study was registered on January 12, 2022., (© 2024. The Author(s).)

Premise: Intraspecific variation in drought resistance traits, such as drought escape, appear to be frequent within wild, ruderal forb species. Understanding how these traits are arrayed across the landscape, particularly in association with climate, is critical to developing forbs for wildland restoration programs. Use of forbs is requisite for maintaining biological diversity and ecological services., Methods: Using 6074 greenhouse-grown Chaenactis douglasii seedlings from 95 wild, seed-sourced populations across the western United States, we recorded bolting phenology and estimated genome size using flow cytometry. Mixed-effects regression models were used to assess whether climate of seed origin was predictive for bolting phenology and genome size., Results: Variation in bolting, reflecting an annual vs. perennial lifespan in this species, was observed in 8.7% of the plants, with bolting plants disproportionately occurring in locations with warm, arid climates. Populations with increasing heat and aridity were positively correlated with observed bolting (r = 0.61, p < 0.0001). About one-third (22%) of the total (61%) lifespan variation was attributed to seed source climate and annual heat moisture index, a measure of aridity. Genome size had no significant effect on bolting. Projected climate modeling for mid-century (2041-2070) supports an increasing occurrence of annual lifespan., Conclusions: Our analyses support a drought escape, bet-hedging strategy in C. douglasii. Populations exposed to greater aridity exhibited a higher proportion of individuals with an annual lifespan. Drought escape leading to an annual lifespan can affect how seeds are propagated and deployed for climate-informed restoration., (Published 2024. This article is a U.S. Government work and is in the public domain in the USA.)

Objective: To compare preferences, uptake, and cofactors for unassisted home-based oral self-testing (HB-HIVST) versus clinic-based rapid diagnostic blood tests (CB-RDT) for maternal HIV retesting., Design: Prospective cohort., Methods: Between November 2017 and June 2019, HIV-negative pregnant Kenyan women receiving antenatal care were enrolled and given a choice to retest with HB-HIVST or CB-RDT. Women were asked to retest between 36 weeks gestation and 1-week post-delivery if the last HIV test was <24 weeks gestation or at 6 weeks postpartum if ≥24 weeks gestation, and self-report on retesting at a 14-week postpartum., Results: Overall, 994 women enrolled and 33% (n = 330) selected HB-HIVST. HB-HIVST was selected because it was private (n = 224, 68%), convenient (n = 211, 63%), and offered flexibility in the timing of retesting (n = 207, 63%), whereas CB-RDT was selected due to the trust of providers to administer the test (n = 510, 77%) and convenience of clinic testing (n = 423, 64%). Among 905 women who reported retesting at follow-up, 135 (15%) used HB-HIVST. Most (n = 595, 94%) who selected CB-RDT retested with this strategy, compared to 39% (n = 120) who selected HB-HIVST retesting with HB-HIVST. HB-HIVST retesting was more common among women with higher household income and those who may have been unable to test during pregnancy (both retested postpartum and delivered <37 weeks gestation) and less common among women who were depressed. Most women said they would retest in the future using the test selected at enrollment (99% [n = 133] HB-HIVST; 93% [n = 715] CB-RDT-RDT)., Conclusions: While most women preferred CB-RDT for maternal retesting, HB-HIVST was acceptable and feasible and could be used to expand HIV retesting options., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Drake 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.)

Introduction: Children with moderate or severe wasting are at particularly high risk of recurrent or persistent diarrhoea, nutritional deterioration and death following a diarrhoeal episode. Lactoferrin and lysozyme are nutritional supplements that may reduce the risk of recurrent diarrhoeal episodes and accelerate nutritional recovery by treating or preventing underlying enteric infections and/or improving enteric function., Methods and Analysis: In this factorial, blinded, placebo-controlled randomised trial, we aim to determine the efficacy of lactoferrin and lysozyme supplementation in decreasing diarrhoea incidence and improving nutritional recovery in Kenyan children convalescing from comorbid diarrhoea and wasting. Six hundred children aged 6-24 months with mid-upper arm circumference <12.5 cm who are returning home after an outpatient visit or inpatient hospital stay for diarrhoea will be enrolled. Children will be randomised to 16 weeks of lactoferrin, lysozyme, a combination of the two, or placebo and followed for 24 weeks, with biweekly home visits by community health workers and clinic visits at 4, 10, 16 and 24 weeks. The primary analysis will compare the incidence of moderate-to-severe diarrhoea and time to nutritional recovery between each intervention arm and placebo. The trial will also test whether these interventions reduce enteric pathogen carriage, decrease enteric permeability and/or increase haemoglobin concentration in enrolled children. Finally, we will evaluate the acceptability, adherence and cost-effectiveness of lactoferrin and/or lysozyme., Ethics and Dissemination: The trial has been approved by the institutional review boards of the Kenya Medical Research Institute, the University of Washington, the Kenyan Pharmacy and Poisons Board, and the Kenyan National Commission on Science, Technology and Innovation. The results of this trial will be shared with local and international stakeholders and published in peer-reviewed journals, and the key findings will be presented at relevant conferences., Trial Registration Number: NCT05519254, PACTR202108480098476., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Women who engage in sex work in sub-Saharan Africa have a high risk of acquiring HIV infection. HIV incidence has declined among all women in sub-Saharan Africa, but trends among women who engage in sex work are poorly characterised. We synthesised data on HIV incidence among women who engage in sex work in sub-Saharan Africa and compared these with the total female population to understand relative incidence and trends over time., Methods: We searched MEDLINE, Embase, Global Health, and Google Scholar from Jan 1, 1990, to Feb 28, 2024, and grey literature for studies that reported empirical estimates of HIV incidence among women who engage in sex work in any sub-Saharan Africa country. We calculated incidence rate ratios (IRRs) compared with total female population incidence estimates matched for age, district, and year, did a meta-analysis of IRRs, and used a continuous mixed-effects model to estimate changes in IRR over time., Findings: From 32 studies done between 1985 and 2020, 2194 new HIV infections were observed among women who engage in sex work over 51 490 person-years. Median HIV incidence was 4·3 per 100 person years (IQR 2·8-7·0 per 100 person-years). Incidence among women who engage in sex work was eight times higher than matched total population women (IRR 7·8 [95% CI 5·1-11·8]), with larger relative difference in western and central Africa (19·9 [9·6-41·0]) than in eastern and southern Africa (4·9 [3·4-7·1]). There was no evidence that IRRs changed over time (IRR per 5 years: 0·9 [0·7-1·2])., Interpretation: Across sub-Saharan Africa, HIV incidence among women who engage in sex work remains disproportionately high compared with the total female population. However, constant relative incidence over time indicates HIV incidence among women who engage in sex work has declined at a similar rate. Location-specific data for women who engage in sex work incidence are sparse, but improved surveillance and standardisation of incidence measurement approaches could fill these gaps. Sustained and enhanced HIV prevention for women who engage in sex work is crucial to address continuing inequalities and ensure declines in new HIV infections., Funding: Bill & Melinda Gates Foundation, UK Research and Innovation, National Institutes of Health., Translation: For the French translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Clinical risk score tools require validation in diverse settings and populations before they are widely implemented. We aimed to externally validate an HIV risk assessment tool for predicting HIV acquisition among pregnant and postpartum women. In the context of prevention of mother-to-child transmission programs, risk score tools could be used to prioritize retesting efforts and delivery of pre-exposure prophylaxis (PrEP) to pregnant and postpartum women most at risk for HIV acquisition while minimizing unnecessary perinatal exposure., Methods: Data from women enrolled in a cross-sectional study of programmatic HIV retesting and/or receiving maternal and child health care services at five facilities in Western Kenya were used to validate the predictive ability of a simplified risk score previously developed for pregnant/postpartum women. Incident HIV infections were defined as new HIV diagnoses following confirmed negative or unknown status during pregnancy. Predictive performance was assessed using the area under the receiver operating characteristic curve (AUC) and Brier score., Results: Among 1266 women with 35 incident HIV infections, we found an AUC for predicting HIV acquisition of 0.60 (95% CI, 0.51, 0.69), with a Brier score of 0.27. A risk score >6 was associated with a 2.9-fold increase in the odds of HIV acquisition (95% CI, 1.48, 5.70; p = 0.002) vs scores ≤6. Women with risk scores >6 were 27% (346/1266) of the population but accounted for 52% of HIV acquisitions. Syphilis, age at sexual debut, and unknown partner HIV status were significantly associated with increased risk of HIV in this cohort., Conclusion: The simplified risk score performed moderately at predicting risk of HIV acquisition in this population of pregnant and postpartum women and may be useful to guide PrEP use or counseling., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Chhun 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.)

Introduction: The Data-informed Stepped Care (DiSC) study is a cluster-randomized trial implemented in 24 HIV care clinics in Kenya, aimed at improving retention in care for adolescents and youth living with HIV (AYLHIV). DiSC is a multi-component intervention that assigns AYLHIV to different intensity (steps) of services according to risk. We used the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to characterize provider-identified adaptations to the implementation of DiSC to optimize uptake and delivery, and determine the influence on implementation outcomes., Methods: Between May and December 2022, we conducted continuous quality improvement (CQI) meetings with providers to optimize DiSC implementation at 12 intervention sites. The meetings were guided by plan-do-study-act processes to identify challenges during early phase implementation and propose targeted adaptations. Meetings were audio-recorded and analysed using FRAME to categorize the level, context and content of planned adaptations and determine if adaptations were fidelity consistent. Providers completed surveys to quantify perceptions of DiSC acceptability, appropriateness and feasibility. Mixed effects linear regression models were used to evaluate these implementation outcomes over time., Results: Providers participated in eight CQI meetings per facility over a 6-month period. A total of 65 adaptations were included in the analysis. The majority focused on optimizing the integration of DiSC within the clinic (83%, n = 54), and consisted of improving documentation, addressing scheduling challenges and improving clinic workflow. Primary reasons for adaptation were to align delivery with AYLHIV needs and preferences and to increase reach among AYLHIV: with reminder calls to AYLHIV, collaborating with schools to ensure AYLHIV attended clinic appointments and addressing transportation challenges. All adaptations to optimize DiSC implementation were fidelity-consistent. Provider perceptions of implementation were consistently high throughout the process, and on average, slightly improved each month for intervention acceptability (β = 0.011, 95% CI: 0.002, 0.020, p = 0.016), appropriateness (β = 0.012, 95% CI: 0.007, 0.027, p<0.001) and feasibility (β = 0.013, 95% CI: 0.004, 0.022, p = 0.005)., Conclusions: Provider-identified adaptations targeted improved integration into routine clinic practices and aimed to reduce barriers to service access unique to AYLHIV. Characterizing types of adaptations and adaptation rationale may enrich our understanding of the implementation context and improve abilities to tailor implementation strategies when scaling to new settings., (© 2024 The Author(s). Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of International AIDS Society.)

Background: Vaginal rings formulated to deliver two drugs simultaneously have potential as user-controlled, long-acting methods for dual prevention of HIV and pregnancy., Methods: Two phase 1 randomized trials (MTN-030/IPM 041 and MTN-044/IPM 053/CCN019) respectively enrolled 24 and 25 healthy, HIV-negative participants to evaluate safety, pharmacokinetics, and vaginal bleeding associated with use of a vaginal ring containing 200mg dapivirine (DPV) and 320mg levonorgestrel (LNG) designed for 90-day use. MTN-030/IPM 041 compared the DPV/LNG ring to a DPV-only ring (200mg) over 14 days of use. MTN-044/IPM 053/CCN019 compared continuous or cyclic use of the DPV/LNG ring over 90 days of use. Safety was assessed by recording adverse events (AEs). DPV and LNG concentrations were quantified in plasma, cervicovaginal fluid, and cervical tissue. Vaginal bleeding was self-reported., Results: There were no differences in the proportion of participants with grade ≥2 genitourinary AEs or grade ≥3 AEs with DPV/LNG ring vs. DPV ring use (p = .22), or with DPV/LNG ring continuous vs. cyclic use (p = .67). Higher plasma DPV concentrations were observed in users of DPV/LNG compared to DPV-only rings (Cmax p = 0.049; AUC p = 0.091). Plasma DPV and LNG concentrations were comparable with continuous and cyclic use (Cmax p = 0.74; AUC p = 0.25). With cyclic use, median nadir plasma DPV concentration was approximately 300 pg/mL two days after removal and median t1/2 for cervicovaginal fluid DPV concentration was 5.76 hours (n = 3). Overall bleeding experiences did not differ between continuous and cyclic users (p = 0.12)., Conclusions: The extended duration DPV/ LNG rings were well tolerated and the observed DPV concentrations in plasma and cervicovaginal fluid when used continuously exceeded concentrations observed in previous DPV ring efficacy studies. LNG concentrations in plasma were comparable with other efficacious LNG-based contraceptives. Genital DPV concentrations had a short half-life and were thus not well sustained following ring removal., Competing Interests: The following authors have read the journal’s policy and have competing interests: Sharon L. Achilles has received consulting fees from Mayne Pharma and Merck and has received research funding from The National Institutes of Health, the US Food and Drug Administration, the Pennsylvania Department of Health, Society of Family Planning Research Fund, Estetra SRL (an affiliate company of Mithra Pharmaceuticals), EvoFem, and Merck, all of which were managed by Magee-Womens Research Institute. Barbra A. Richardson has received payment from Gilead Sciences for DSMB membership. Brid Devlin and John Steytler were full-time salaried employees of the International Partnership for Microbicides (IPM), a non-profit company registered in the United States of America, at the time the work was performed. Craig W. Hendrix is an Inventor on patent relating to vaginal microbicides and the founder of a microbicide development company, both unrelated to this study product and both managed by Johns Hopkins University. Beatrice A. Chen has served on a Merck & Co. advisory board and has received research grants from Sebela, Mylan, and Medicines360, all of which were managed by Magee-Womens Research Institute. NIH employees (Diana L. Blithe, Jill Brown, and Jeanna M. Piper) contributed to the study design, manuscript development and the decision to publish as well as providing safety oversight during study conduct but had no role in data collection and analysis. All other authors have declared that no competing interests exist. This does not alter our adherence to PLOS One policies on sharing data and materials., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: Women living with HIV (WLWH) face unique reproductive health (RH) barriers which increase their risks of unmet need for contraception, contraceptive failure, unintended pregnancy, and pregnancy-related morbidity and mortality and may prevent them from achieving their reproductive goals. Patient-centered counseling interventions that support health care workers (HCWs) in providing high-quality RH counseling, tailored to the needs of WLWH, may improve reproductive health outcomes., Methods and Design: We are conducting a non-blinded cluster randomized controlled trial (cRCT) of a digital health intervention for WLWH (clinicaltrials.gov #NCT05285670). We will enroll 3,300 WLWH seeking care in 10 HIV care and treatment centers in Nairobi and Western Kenya. WLWH at intervention sites receive the Mobile WACh Empower intervention, a tablet-based RH decision-support counseling tool administered at baseline and SMS support during two years of follow-up. WLWH at control sites receive the standard of care FP counseling. The decision-support tool is a logic-based tool for family planning (FP) counseling that uses branching logic to guide RH questions based on participants' reproductive life plans, tailoring counseling based on the responses. Follow-up SMSs are based in the Information-Motivation-Behavioral (IMB) Skills model of behavioral change and are tailored to participant characteristics and reproductive needs through separate SMS "tracks". Follow-up visits are scheduled quarterly for 2 years to assess plans for pregnancy, pregnancy prevention, and contraceptive use. The primary outcome, FP discontinuation, will be compared using an intent-to-treat analysis. We will also assess the unmet need for FP, dual method use, viral load suppression at conception and unintended pregnancy., Discussion: The Mobile WACh Empower intervention is innovative as it combines a patient-centered counseling tool to support initial reproductive life decisions with longitudinal SMS for continued RH support and may help provide RH care within the context of provision of HIV care., Competing Interests: The authors have declared that no competing interest exists., (Copyright: © 2024 Ngumbau 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.)