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Objective: Most people with epilepsy (PWE) could live seizure‐free if treated with one or more antiseizure medications (ASMs). The World Health Organization (WHO) estimates that 75% of PWE in low‐resource settings lack adequate antiseizure treatment. Limited education surrounding epilepsy and the out‐of‐pocket costs of ASMs in particular pose barriers to managing epilepsy in resource‐poor, low‐income settings. The aim of this study is to implement and test a novel strategy to improve outcomes across the epilepsy care cascade marked by (1) retention in epilepsy care, (2) adherence to ASMs, and (3) seizure reduction, with the measured goal of seizure freedom. Methods: A randomized, double‐blinded clinical trial will be performed, centered at the Ignace Deen Hospital in Conakry, Republic of Guinea, in Western Sub‐Saharan Africa. Two hundred people with clinically diagnosed epilepsy, ages 18 years and above, will receive education on epilepsy and then be randomized to (i) free ASMs versus (ii) conditional cash, conditioned upon return to the epilepsy clinic. Participants will be followed for 360 days with study visits every 90 days following enrollment. Significance: We design a randomized trial for PWE in Guinea, a low‐resource setting with a high proportion of untreated PWE and a nearly completely privatized healthcare system. The trial includes a conditional cash transfer intervention, which has yet to be tested as a targeted means to improve outcomes for people with a chronic neurological disorder. The trial aims to provide an evidence base for the treatment of epilepsy in such settings. Plain Language Summary: We present a clinical trial protocol for a randomized, blinded study of 200 people with epilepsy in the low‐resource African Republic of Guinea, providing an educational intervention (E), and then randomizing in a 1:1 allocation to either free antiseizure medication (m) or conditional cash (c2) for 360 days. Measured outcomes include (1) returning to outpatient epilepsy care, (2) adherence to antiseizure medications (ASMs), and (3) reducing the number of seizures. This study is an initial look at giving small amounts of cash for desired results (or "nudges") for improving epilepsy outcomes in the sub‐Saharan African and brain disorder contexts. [ABSTRACT FROM AUTHOR]

We combine data from 84 Demographic and Health Surveys from 46 countries to analyze trends and socioeconomic differences in adult mortality, calculating mortality based on the sibling mortality reports collected from female respondents aged 15-49. The analysis yields four main findings. First, adult mortality is different from child mortality: while under-5 mortality shows a definite improving trend over time, adult mortality does not, especially in sub-Saharan Africa. The second main finding is the increase in adult mortality in sub-Saharan African countries. The increase is dramatic among those most affected by the HIV/AIDS pandemic. Mortality rates in the highest HIV-prevalence countries of southern Africa exceed those in countries that experienced episodes of armed conflict. Third, even in sub-Saharan countries where HIV prevalence is not as high, mortality rates appear to be at best stagnating, and even increasing in several cases. Finally, the main dimension along which mortality appears to differ in the aggregate is by sex. Adult mortality rates in sub-Saharan Africa have risen substantially higher for men than for women-especially so in the high HIV-prevalence countries. On the whole, the data do not show large gaps by urban/rural residence or by school attainment. [ABSTRACT FROM AUTHOR]

Separated, divorced, and widowed individuals in Africa are at significantly increased risk for HIV infection. Using nationally representative data from 13 sub-Saharan African countries, this study confirms that finding and goes further by examining those who have experienced a marital dissolution and are now remarried. Results show that remarried individuals form a large portion of the population and have a higher-than-average HIV prevalence. HIV-positive remarried individuals are at risk of transmitting the infection to their spouse, because many of the couples are serodiscordant. The large number of high-risk remarried individuals is a source of vulnerability and further infection, and should be acknowledged and taken into account by prevention strategies that rarely address this population. [ABSTRACT FROM AUTHOR]

Using nationally representative data from 13 sub-Saharan African countries, we reinforce and expand upon previous findings that men report using condoms more frequently than women do and that unmarried respondents report that they use condoms with casual partners more frequently than married individuals report using them with their spouses. Based on descriptive, bivariate, and multivariate analyses, we also demonstrate to a degree not previously shown in the current literature that married men from most countries report using condoms with extramarital partners about as frequently as unmarried men report using them with casual partners. Married women from most of the countries included in the study reported using condoms with extramarital partners less frequently than unmarried women reported using them with casual partners. This result is especially troubling because marriage usually ensures regular sexual intercourse, thereby providing more opportunities for a person to pass HIV infection from an extramarital partner to his or her spouse. These findings about high-risk behaviors can be used to better target future HIV-transmission-prevention efforts. [ABSTRACT FROM AUTHOR]

Summary: Background: Most couples affected by HIV/AIDS in sub-Saharan Africa live in discordant relationships. Men are thought to be the index case in most relationships, and most social marketing and awareness campaigns are focused on men. We investigated serodiscordance in stable relationships to establish the gender balance of index-case infections. Methods: We did a systematic review, random-effects meta-analysis, and meta-regression of published and unpublished studies enrolling discordant couples and assessed the proportion of men and women that were index cases. We repeated the analysis with data from demographic and health surveys (DHS) from the 14 countries that have documented the HIV status of couples. Our primary outcome was the total number of HIV discordant couples, including the proportion of HIV-positive women. Findings: We included data from 27 cohorts of 13 061 couples and DHS data from 14 countries of 1145 couples. The proportion of HIV-positive women in stable heterosexual serodiscordant relationships was 47% (95% CI 43–52), which shows that women are as likely as men to be the index partner in a discordant couple. DHS data (46%, 41–51) and our sensitivity analysis (47%, 43–52) showed similar findings. Meta-regression showed that urban versus rural residence (odds ratio 0·31, 95% CI 0·22–0·39), latitude (β coefficient 0·02, 0·023–0·034), gender equality (β coefficient −0·42, −0·56 to −0·27), HIV prevalence (β coefficient −0·037, −0·04 to −0·030), and older age (β coefficient 0·20, 0·08–0·32) were associated with the proportion of female index cases. Interpretation: Our study shows the need to focus on both sexes in HIV prevention strategies, such as promotion of condom use and mitigation of risk behaviours. Funding: None. [ABSTRACT FROM AUTHOR]

Transactional sex is an important risk-coping mechanism and a leading contributor to the HIV/AIDS epidemic in sub-Saharan Africa. We use data from a conditional cash transfer (CCT) experiment in rural Tanzania designed to incentivize safer sexual behavior by conditioning transfers on testing negative for sexually transmitted infections (STIs). For women, we find that negative shocks measured by food insecurity lead to a 36% increase in STIs and increases in self-reported risky sexual behavior. We find no significant effects of negative shocks on either STIs or self-reported sexual behavior for men. This CCT design did not appear to mitigate the behavioral response to shocks that we document in women. We propose that this finding can be explained by binding credit constraints and the relatively infrequent timing of the CCTs. When women experience a negative shock, cash needs are immediate, while transfers linked to a CCT are paid out in a specific point in time. If women are unable to access credit during a shock, they may resort to transactional sex even if they face monetary incentives to do otherwise. [ABSTRACT FROM AUTHOR]