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Unmanned aerial vehicles (UAVs) or drones are increasingly explored as a solution to transport challenges for medical goods, including emergency blood supplies, vaccines, medicines, diagnostic samples, and even organs, particularly for “last mile” delivery.1,2 Proof-of-concept tests have demonstrated the technological viability of UAVs to safely transport medical supplies3–6 and keep them within the required parameters for clinical viability.7–9 A few research studies have determined the cost-effectiveness of adding UAVs to specific medical supply chains1,10 or the optimal placement for UAV stations.11–13 Yet very few cases of successful scale-up of UAVs for medical transport exist. Recent work has focused on proving a UAV can successfully complete a flight but has neglected to address health-system integration and long-term sustainability. As a result, decision makers lack information on how to explore the potential utility of UAVs in addressing medical transport challenges and, if determined useful, how to add UAVs to health systems or achieve use at scale. Successful implementation of any health system change relies on a complex set of factors.14 In the case of UAVs, not only will the selected technology need to be appropriate for the distance, weight, and size requirements of the transported items, but (1) it will need to operate within regulations, (2) the concept must be embraced by stakeholders, (3) financial resources need to be available, (4) human resources must be in place, and (5) operational procedures must be developed to effectively work within existing structures. When these aspects are not considered, operations can be delayed, inefficient, or fail entirely. In short, as with any intervention, the impact of UAVs on the broader health system should be considered before implementation.15 Using the framework of the World Health Organization health system building blocks,16 this commentary describes challenges for integrating UAVs into complex health systems and presents a tool for considering whether UAVs could help address medical transport challenges and how they can be integrated into health systems. Under the assumption that readers may be unfamiliar with UAVs, we begin with some general information (Box). BOX What Is an Unmanned Aerial Vehicle (UAV)?1,4

Background Viral load (VL) testing of patients on antiretroviral therapy (ART) is critical to suppressing HIV. Timely transport of VL samples from health facilities to the laboratory for testing is often problematic in Turkana County, Kenya, and transportation barriers cause delays that can negatively impact the health of ART patients. Unmanned Aerial Vehicles (UAVs), or drones, are being promoted as a potential, novel way to reduce transportation times for laboratory samples and medical commodities. Our study models the use of UAVs in a remote area of Kenya to estimate costs and feasibility of their application for the Afya Nyota ya Bonde project, a large HIV service delivery program. Methods We gathered data from 12 Afya-supported facilities on VL sample transportation and turnaround time, ART drug transportation, and transportation practices and costs. The annual cost and average turnaround time for the transportation of VL samples and ART drugs was calculated using baseline data from the program to establish a comparison for scenarios that use a UAV. We then designed and costed four transportation scenarios that used UAVs to pick up VL samples and deliver ART drugs through a logistics company that will be adding UAV services. Results The modeled scenarios demonstrate that UAVs could transport nearly 100% of VL samples to the lab within the three-day goal compared to the 3% that are transported under the current system. Additionally, using UAVs could reduce the burden on health workers who must personally transport the samples, reducing opportunity costs resulting from facility closures due to provider absence. However, the UAV scenario cost more than three times the current costs (US$ 56,350/Kenyan Shillings (KSh) 5,635,000 per year compared to between US$ 172,878/Ksh 17,287,800 and US$ 200,208/Ksh 20,020,800), and the consolidation of VL testing days required to accommodate the UAV may be problematic for ART patients. Conclusions As the cost of UAV transport declines, this technology could be an important tool for optimizing the transport of lab samples and medications.

Gay, bisexual and other men who have sex with men face both high levels of violence and a disproportionate burden of poor health outcomes. We explored violence perpetrated against Salvadoran gay, bisexual and other men who have sex with men by public security forces; perceived motivations of violence; and impacts on health. We conducted structured qualitative interviews with 20 participants and used systematic coding and narrative analysis to identify emergent themes. Nearly all participants described the physical, emotional, sexual and/or economic violence by public security forces. Most attributed being targeted to their gender expression and/or perceived sexual orientation. The most common impact was emotional distress, including humiliation, fear and depression; lasting physical injuries were also widely reported. Study participants felt unable to report these incidents for fear of retribution or inaction. Men reported feelings of helplessness and distrust, avoidance of authorities and altering when, where or how often they appeared in public spaces. Programmes and interventions should focus on providing mental health services for LGBTI (lesbian, gay, bisexual, transgender and intersex) victims of violence, educating public security forces on the legal rights of Salvadorans and expanding current LGBTI-inclusive policies to all public security forces.

Transgender (trans) women experience gender-based violence (GBV) throughout their lives, which impedes their access to services and contributes to poor health outcomes and quality of life. To inform policies and health programs, trans women worked with the United States Agency for International Development (USAID)- and President's Emergency Plan for AIDS Relief (PEPFAR)-supported LINKAGES project, the United Nations Development Programme, The University of the West Indies, and local organizations to document experiences of GBV and transphobia in healthcare, education, and police encounters. Trans women conducted 74 structured interviews with other trans women in El Salvador, Trinidad and Tobago, Barbados, and Haiti in 2016. We conducted qualitative applied thematic analysis to understand the nature and consequences of GBV and transphobia and descriptive quantitative analysis to identify the proportion who experienced GBV in each context. A high proportion experienced GBV in education (85.1%), healthcare (82.9%), from police (80.0%), and other state institutions (66.1%). Emotional abuse was the most common in all contexts and included gossiping, insults, and refusal to use their chosen name. Participants also experienced economic, physical, and sexual violence, and other human rights violations based on their gender identity and expression. At school, participants were physically threatened and assaulted, harassed in bathrooms, and denied education. In healthcare, participants were given lower priority and received substandard care. Healthcare workers and police blamed participants for their health and legal problems, and denied them services. From police, participants also experienced physical and sexual assault, theft, extortion for sex or money, and arbitrary arrest and detention. Participants had difficulty obtaining identification documents that matched their gender identity, sometimes being forced to alter their appearance or being denied an identification card. Service providers not only failed to meet the specific needs of trans women but also discriminated against them when they sought services, exacerbating their economic, health, and social vulnerability. Although international and regional resolutions call for the legal protection of transgender people, states do not meet these obligations. To respect, promote, and fulfill trans women's human rights, governments should enact and enforce antidiscrimination and gender-affirming laws and policies. Governments should also sensitize providers to deliver gender-affirming services.

Background: In 2015, the WHO issued guidelines recommending oral pre-exposure prophylaxis (PrEP) for individuals at substantial risk of HIV. Given their role in health service delivery, ministries of health are assuming major responsibility for PrEP services in sub-Saharan Africa. However, these are often strained and under-resourced. We measured the delivery of selected integrated services and identified the factors that impede effective delivery of integrated services to prepare for the integration of PrEP into health services for women. Methods: Three services were examined: 1) HIV testing within family planning, 2) HIV testing within general outpatient services, and 3) care and prevention services for HIV-positive clients not eligible for antiretrovirals (“Pre-ART”). Descriptive, mixed-methods research was conducted in three Kenyan counties using: service delivery observations (n = 3246) and client exit interviews (n = 3257) in public facilities, and semi-structured interviews with providers, managers and officials (n = 112). Results: Integrated services were not consistently implemented. HIV testing was not systematically offered or received; most clients were not aware testing was available, and tests were largely unavailable. Pre-ART services did not systematically deliver mandated services. Rates of cervical cancer and tuberculosis screening were especially low; a concerning gap given the elevated risk for HIV-positive women. Supply-side challenges of staffing, infrastructure and commodity shortages were common. Conclusions: In an era of significant demands on treatment resources and decreasing funding for prevention, the identification of the technical, material, and human resources required for successful and sustainable delivery of integrated services must be addressed to support successful PrEP implementation. Key words: Pre-exposure prophylaxis, Kenya, Integrated health, HIV

OBJECTIVES: We conducted a process evaluation to examine the perceptions of program implementers, community leaders, and beneficiaries to assess the intervention's acceptability and to document how multisectoral agricultural livelihood interventions were implemented. METHODS: Interventions were implemented from March 2019 to March 2020 in 30 unions of three Bangladeshi districts. Delivered by community partners, interventions aimed to improve health and nutrition service utilization, social and behavior change regarding infant and young child feeding (IYCF), and homestead food production (through community farmers or private sector agro-input retailers) among poor mothers of under-two children. Leveraging the RE-AIM framework, we evaluated implementation through in-depth interviews with service providers (n = 13), focus group discussions with beneficiaries (8 sessions), and process documentation (12 events). RESULTS: Most service providers, community leaders, and beneficiaries expressed satisfaction with interventions and a desire to continue participation. Beneficiaries especially appreciated the health and nutrition education provided through different formats, including mothers' group meetings, voice messages, home visits, counseling at health facilities, and education on food production by community farmers or retailers. Additionally, beneficiaries described increased health knowledge and highly valued material benefits offered through vegetable seeds and poultry rearing inputs. Beneficiaries appreciated retailers' support to grow vegetables and raise chickens and awareness efforts on the importance of good nutrition and IYCF practices. However, findings suggested community farmers offered more interpersonal support than retailers. Service providers noted the importance of sustained community engagement. CONCLUSIONS: Findings suggest that tested interventions combining food production with health and nutrition education are a viable, acceptable approach to promoting improved IYCF practices. Existing community-based organizations can reach vulnerable households with multisectoral nutrition approaches. FUNDING SOURCES: United States Agency for International Development (USAID).

Background Female sex workers, MSM, and transgender women—collectively referred to as key populations (KPs)—are disproportionately affected by gender-based violence (GBV) and HIV, yet little is known about the violence they face, its gender-based origins, and responses to GBV. The purpose of this study was to understand the nature and consequences of GBV experienced, to inform HIV policies and programming and to help protect KPs’ human rights. Methods Using a participatory approach, FSWs, MSM, and transgender women in Barbados, El Salvador, Trinidad and Tobago, and Haiti conducted 278 structured interviews with peers to understand their experiences of and responses to GBV. Responses to open-ended questions were coded in NVivo and analyzed using an applied thematic analysis. Results Nearly all participants experienced some form of GBV. Emotional and economic GBV were the most commonly reported but approximately three-quarters of participants reported sexual and physical GBV and other human rights violations. The most common settings for GBV were at home, locations where sex work took place such as brothels, bars and on the street; public spaces such as parks, streets and public transport, health care centers, police stations and—for transgender women and MSM—religious settings and schools. The most common perpetrators of violence included: family, friends, peers and neighbors, strangers, intimate partners, sex work clients and other sex workers, health care workers, police, religious leaders and teachers. Consequences included emotional, physical, and sexual trauma; lack of access to legal, health, and other social services; and loss of income, employment, housing, and educational opportunities. Though many participants disclosed experiences of GBV to friends, colleagues and family, they rarely sought services following violence. Furthermore, less than a quarter of participants believed that GBV put them at risk of HIV. Conclusions Our study found that across the four study countries, FSWs, MSM, and transgender women experienced GBV from state and non-state actors throughout their lives, and much of this violence was directly connected to rigid and harmful gender norms. Through coordinated interventions that address both HIV and GBV, this region has the opportunity to reduce the national burden of HIV while also promoting key populations’ human rights.

This article describes the UNC-CH MCH Leadership Consortium, a collaboration among five MCHB-funded training programs, and delineates the evo- lution of the leadership curriculum developed by the Consortium to cultivate interdisciplinary MCH leaders. In response to a suggestion by the MCHB, five MCHB-funded training programs—nutrition, pediatric dentistry, social work, LEND, and public health—created a consortium with four goals shared by these diverse MCH disciplines: (1) train MCH professionals for field leadership; (2) address the special health and social needs of women, infants, children and adolescents, with emphasis on a public health population-based approach; (3) foster inter- disciplinary practice; and (4) assure competencies, such as family-centered and culturally competent practice, needed to serve effectively the MCH population. The consortium meets monthly. Its primary task to date has been to create a leadership curriculum for 20-30 master's, doctoral, and post-doctoral trainees to understand how to leverage per- sonal leadership styles to make groups more effective, develop conflict/facilitation skills, and identify and enhance family-centered and culturally competent organi- zations. What began as an effort merely to understand shared interests around leadership development has evolved into an elaborate curriculum to address many MCH leadership competencies. The collaboration has also stimulated creative interdisciplinary research and practice opportunities for MCH trainees and faculty. MCHB-funded training programs should make a commitment to collabo- rate around developing leadership competencies that are shared across disciplines in order to enhance interdisci- plinary leadership.

Importance Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy. Objective To determine whether small economic incentives could increase circumcision prevalence by addressing reported economic barriers to VMMC and behavioral factors such as present-biased decision making. Design, Setting, and Participants Randomized clinical trial conducted between June 22, 2013, and February 4, 2014, among 1504 uncircumcised men aged 25 to 49 years in Nyanza region, Kenya. VMMC services were provided free of charge and participants were randomized to 1 of 3 intervention groups or a control group. Interventions Participants in the 3 intervention groups received varying amounts of compensation conditional on undergoing circumcision at 1 of 9 study clinics within 2 months of enrollment. Compensation took the form of food vouchers worth 200 Kenya shillings (≈US $2.50), 700 Kenya shillings (≈US $8.75), or 1200 Kenya shillings (≈US $15.00), which reflected a portion of transportation costs and lost wages associated with getting circumcised. The control group received no compensation. Main Outcomes and Measures VMMC uptake within 2 months. Results Analysis of data for 1502 participants with complete data showed that VMMC uptake within 2 months was higher in the US $8.75 group (6.6%; 95% CI, 4.3%-9.5% [25 of 381]) and the US $15.00 group (9.0%; 95% CI, 6.3%-12.4% [34 of 377]) than in the US $2.50 group (1.9%; 95% CI, 0.8%-3.8% [7 of 374]) and the control group (1.6%; 95% CI, 0.6%-3.5% [6 of 370]). In logistic regression analysis, the US $8.75 group had significantly higher VMMC uptake than the control group (adjusted odds ratio [AOR] 4.3; 95% CI, 1.7-10.7), as did the US $15.00 group (AOR 6.2; 95% CI, 2.6-15.0). Effect sizes for the US $8.75 and US $15.00 groups did not differ significantly ( P = .20). Conclusions and Relevance Among uncircumcised men in Kenya, compensation in the form of food vouchers worth approximately US $8.75 or US $15.00, compared with lesser or no compensation, resulted in a modest increase in the prevalence of circumcision after 2 months. The effects of more intense promotion or longer implementation require further investigation. Trial Registration clinicaltrials.gov Identifier:NCT01857700

Introduction: Stakeholders continue to discuss the appropriateness of antiretroviral-based pre-exposure prophylaxis (PrEP) for HIV prevention among sub-Saharan African and other women. In particular, women need formulations they can adhere to given that effectiveness has been found to correlate with adherence. Evidence from family planning shows that contraceptive use, continuation and adherence may be increased by expanding choices. To explore the potential role of choice in women's use of HIV prevention methods, we conducted a secondary analysis of research with female sex workers (FSWs) and men and women in serodiscordant couples (SDCs) in Kenya, and adolescent and young women in South Africa. Our objective here is to present their interest in and preferences for PrEP formulations pills, gel and injectable. Methods: In this qualitative study, in Kenya we conducted three focus groups with FSWs, and three with SDCs. In South Africa, we conducted two focus groups with adolescent girls, and two with young women. All focus groups were audio-recorded, transcribed and translated into English as needed. We structurally and thematically coded transcripts using a codebook and QSR NVivo 9.0; generated code reports; and conducted inductive thematic analysis to identify major trends and themes. Results: All groups expressed strong interest in PrEP products. In Kenya, FSWs said the products might help them earn more money, because they would feel safer accepting more clients or having sex without condoms for a higher price. SDCs said the products might replace condoms and reanimate couples' sex lives. Most sex workers and SDCs preferred an injectable because it would last longer, required little intervention and was private. In South Africa, adolescent girls believed it would be possible to obtain the products more privately than condoms. Young women were excited about PrEP but concerned about interactions with alcohol and drug use, which often precede sex. Adolescents did not prefer a particular formulation but noted benefits and limitations of each; young women's preferences also varied. Conclusions: The circumstances and preferences of sub-Saharan African women are likely to vary within and across groups and to change over time, highlighting the importance of choice in HIV prevention methods.

SummaryUnsafe abortion accounts for 35% of maternal mortality in Kenya. Post-abortion care (PAC) reduces maternal death and provides an opportunity to prevent unwanted pregnancies. Few studies have documented how the receipt of PAC services varies by client age. In this study, descriptive data were collected from clients, providers and eight health facilities in Kenya's Central and Nairobi provinces to examine receipt of PAC services by client age, client satisfaction and provider attitudes. Delivery of PAC treatment, pain management, HIV and STI services and violence screening did not vary by age. However, fewer youth between the ages of 15 and 24 received a contraceptive method compared with adult clients (35% versus 48%; p=0.02). Forty-nine per cent of youth reported not using a family planning method due to fears of infertility, side-effects or lack of knowledge compared with 22% of adults. Additional efforts are needed in Kenya to bolster the family planning services that young PAC clients receive and increase the uptake of contraception.

Background Uptake of VMMC among adult men has been lower than desired in Nyanza, Kenya. Previous research has identified several barriers to uptake but qualitative exploration of barriers is limited and evidence-informed interventions have not been fully developed. This study was conducted in 2012 to 1) increase understanding of barriers to VMMC and 2) to inform VMMC rollout through the identification of evidence-informed interventions among adult men at high risk of HIV in Nyanza Province, Kenya. Methods Focus groups (n = 8) and interviews were conducted with circumcised (n = 8) and uncircumcised men (n = 14) from the two districts in Nyanza, Kenya. Additional interviews were conducted with female partners (n = 20), health providers (n = 12), community leaders (n = 12) and employers (n = 12). Interview and focus group guides included questions about individual, interpersonal and societal barriers to VMMC uptake and ways to overcome them. Inductive thematic coding and analysis were conducted through a standard iterative process. Results Two primary concerns with VMMC emerged 1) financial issues including missing work, losing income during the procedure and healing and family survival during the recovery period and 2) fear of pain during and after the procedure. Key interventions to address financial concerns included: a food or cash transfer, education on saving and employer-based benefits. Interventions to address concerns about pain included refining the content of demand creation and counseling messages about pain and improving the ways these messages are delivered. Conclusions Men need accurate and detailed information on what to expect during and after VMMC regarding both pain and time away from work. This information should be incorporated into demand creation activities for men considering circumcision. Media content should frankly and correctly address these concerns. Study findings support scale up and/or further improvement of these ongoing educational programs and specifically targeting the demand creation period.