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Background Parenting programmes, including those delivered in the Global South, are effective strategies to reduce violence against children (VAC). However, there is limited evidence of their impact when implemented at scale within routine delivery systems. This study aimed to address this gap by evaluating the real-world delivery of Parenting for Lifelong Health for Teens in Tanzania.Methods Participating parents/caregivers and their adolescent girls were recruited by local implementing partners in 2020–2021 as part of a community-based HIV prevention initiative focused on addressing drivers of female adolescent HIV-vulnerability such as VAC, caregiver–adolescent relationships and sexual reproductive health communication. The 14-session, group-based parenting programme was delivered by trained teachers and community facilitators. Quantitative surveys administered by providers measured a variety of outcomes including child maltreatment (primary outcome) and multiple secondary outcomes linked to increased risk of VAC. Multilevel models examined pre–post effects as well as variation by attendance and baseline demographic variables.Results Pre–post data from 27 319 parent/caregiver–child dyads were analysed, of which 34.4% of parents/caregivers were male. Analyses showed large reductions in child maltreatment (parents/caregivers: IRR=0.55, (95% CI 0.54, 0.56); adolescents: IRR=0.57, (95% CI 0.56, 0.58)), reduced intimate partner violence experience, reduced school-based violence, increased communication about sexual health, reduced poor supervision, reduced financial insecurity, reduced parenting stress, reduced parent and adolescent depression, and reduced adolescent conduct problems. In contrast to these positive outcomes, parents/caregivers and adolescents also reported reduced parental positive involvement and support of education, with those experiencing greater adversity reporting less change than those with less adversity.Conclusions This study is the first to examine the large-scale implementation of an evidence-based parenting programme in the Global South. Although additional research is necessary to examine potential negative effects on positive parenting and parent support of education, findings suggest that Furaha Teens can sustain its impact on key outcomes associated with VAC when delivered at scale.

Abstract Background Globally, violence against children poses substantial health and economic challenges, with estimated costs nearing USD 7 trillion. This prompts the urgent call for effective evidence-based interventions in preventing and mitigating violence against children. ParentApp is a mobile, open-source application designed to offer a remote version of the Parenting for Lifelong Health (PLH) programme. ParentApp is the first digital parenting intervention for caregivers of adolescents aged 10–17 years to be tested in low- and middle-income settings. Methods This study is a pragmatic, two-arm, cluster-randomised trial in Mwanza, Tanzania’s urban and peri-urban areas. Assessments are set for baseline, 1 month post-intervention, and 12 months post-intervention. We randomised 80 clusters, each with about 30 caregiver-adolescent dyads, with a 1:1 ratio stratified by urban or peri-urban location. Both arms receive an entry-level smartphone preloaded with Kiswahili apps—ParentApp for intervention and WashApp control. The primary method of analysis will be generalised linear mixed-effects models with adjustment for person-level characteristics and multiple imputation. In three-level models, measurement waves are nested within a person, nested within a sub-ward. Regressions will constrain groups to be equal at baseline and include covariates for stratification, percentage of male caregivers, and individual-level characteristics. Discussions Preparations for the trial began in December 2022, including community mobilisation and sensitisation. Rolling recruitment, baseline data collection, and implementation onboarding took place between April and September 2023. One-month post-test data collection began in August 2023 and thus far achieved 97% and 94% retention rates for caregivers and adolescents respectively. Final post-test data collection will begin in September 2024, anticipated to run until April 2025. This SAP was submitted to the journal before the interim analysis to preserve scientific integrity under a superiority hypothesis testing framework. Trial registration The trial was registered on the Open Science Framework on 14 March 2023: https://doi.org/10.17605/OSF.IO/T9FXZ . The trial protocol was published in Trials 25, 119 (2024): Baerecke, L., Ornellas, A., Wamoyi, J. et al. A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: study protocol for a pragmatic cluster-randomised controlled trial. Trials 25, 119 (2024). https://doi.org/10.1186/s13063-023-07893-x .

Abstract Background Evidence-based parenting programmes have strong evidence in preventing and mitigating violence, but in-person programmes are challenging to deliver at scale. ParentApp is an open-source, offline-first app-based adaptation of the Parenting for Lifelong Health for Parents and Teens programme to promote playful and positive parenting, reduce risks for sexual violence victimisation, and prevent violence against adolescents. This study aims to evaluate the effectiveness and cost-effectiveness of ParentApp compared to an attention-control group. Methods This study is a two-arm pragmatic cluster-randomised controlled trial to test whether ParentApp reduces adolescent physical abuse, emotional abuse, and sexual violence risks and victimisation at 1 month and 12 months post-intervention. Caregivers of adolescents aged 10–17 years and their adolescent children (N = 2400 caregiver-adolescent dyads) will be recruited in urban and peri-urban communities in the Mwanza region of Tanzania. A total of 80 study clusters will be stratified and randomised (1:1) to the intervention group, who will receive ParentApp with support through a WhatsApp group, or to an attention-control group, who will receive a water, sanitation, and hygiene app. Quantitative data will be collected through outcomes questionnaires with caregivers and adolescents, administered at baseline, 4 months post-baseline, and 16 months post-baseline, as well as through routine implementation data and ParentApp engagement data. Qualitative data will be collected through individual interviews and focus groups with caregivers, adolescents, and implementing partner staff. Discussion App-based interventions have the potential to expand access to evidence-based parenting support, but currently lack rigorous evidence in low- and middle-income countries. This is the first known randomised control trial of a hybrid digital parenting programme to prevent the abuse of adolescents in low- and middle-income settings. Trial registration The trial was registered on the Open Science Framework on 14 March 2023, registration: OSF.IO/T9FXZ .

Abstract Background Violence against adolescents is a universal reality, with severe individual and societal costs. There is a critical need for scalable and effective violence prevention strategies such as parenting programmes, particularly in low- and middle-income countries where rates of maltreatment are highest. Digital interventions may be a scalable and cost-effective alternative to in-person delivery, yet maximising caregiver engagement is a substantial challenge. This trial employs a cluster randomised factorial experiment and a novel mixed-methods analytic approach to assess the effectiveness, cost-effectiveness, and feasibility of intervention components designed to optimise engagement in an open-source parenting app, ParentApp for Teens. The app is based on the evidence-based Parenting for Lifelong Health for Teens programme, developed collaboratively by academic institutions in the Global South and North, the WHO, and UNICEF. Methods/design Sixteen neighbourhoods, i.e., clusters, will be randomised to one of eight experimental conditions which consist of any combination of three components (Support: self-guided/moderated WhatsApp groups; App Design: sequential workshops/non-sequential modules; Digital Literacy Training: on/off). The study will be conducted in low-income communities in Tanzania, targeting socioeconomically vulnerable caregivers of adolescents aged 10 to 17 years (16 clusters, 8 conditions, 640 caregivers, 80 per condition). The primary objective of this trial is to estimate the main effects of the three components on engagement. Secondary objectives are to explore the interactions between components, the effects of the components on caregiver behavioural outcomes, moderators and mediators of programme engagement and impact, and the cost-effectiveness of components. The study will also assess enablers and barriers to engagement qualitatively via interviews with a subset of low, medium, and high engaging participants. We will combine quantitative and qualitative data to develop an optimised ParentApp for Teens delivery package. Discussion This is the first known cluster randomised factorial trial for the optimisation of engagement in a digital parenting intervention in a low- and middle-income country. Findings will be used to inform the evaluation of the optimised app in a subsequent randomised controlled trial. Trial registration Pan African Clinical Trial Registry, PACTR202210657553944. Registered 11 October 2022, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24051 .

Abstract Background Routine adolescent health screening aiming at the detection of unnoticed medical problems may increase awareness among policy makers and contribute to improved health in this population. Research is needed to inform the World Health Organization (WHO) and national health programs to provide evidence-based guidance on whether public health systems should offer comprehensive adolescent health screening, what should be included in different contexts, and how it should be delivered. We conducted formative research to define the content and delivery strategies for health check-ups to be performed in young (10–14 years) and older (15–19 years) adolescents, and to assess whether such services are likely to be acceptable and feasible in Tanzania. Methods As part of a collaborative research program coordinated by WHO in Chitungwiza, Zimbabwe; Mwanza City, Tanzania; and Cape Coast, Ghana a series of key informant interviews were conducted from April to July 2020, using a semi-structured guide with purposively selected stakeholders from government departments, non-governmental and community-based organisations, schools and health facilities. Data transcripts were coded using NVivo 12 software and thematic analysis was performed. Results We report results from 31 key informant interviews to address four main domains: proposed health conditions for routine health check-ups, health interventions to be combined with such check-ups, preferable venues, and the mode for delivering such screening activities. Stakeholders were supportive of introducing routine health check-ups among adolescents. They recommended focusing on non-communicable diseases, physical disabilities, common mental health problems, reproductive health problems, specific communicable diseases, and hygiene-related problems. They also recommended combining counselling and family planning information with these check-ups. Three venues were proposed: schools, community settings (to reach out-of-school adolescents), and youth-friendly health facilities (for conditions requiring a high level of confidentiality). Conclusions Stakeholders were supportive of the proposed routine health check-ups for adolescents, recommending specific health conditions to be screened for in both community and school settings. Based on the above, we plan to conduct implementation research to determine the number of new treatable conditions detected, and the costs of offering such services. In the longer term, evaluation of their health impact and cost-effectiveness will be required to guide policy.

BackgroundPoverty and social inequality exacerbate HIV risk among adolescent girls and young women (AGYW) in sub-Saharan Africa. Cash transfers can influence the structural determinants of health, thereby reducing HIV risk. ObjectiveThis study assessed the effectiveness of cash transfer delivered along with combination HIV prevention (CHP) interventions in reducing the risky sexual behavior of AGYW in Tanzania. The incidence of herpes simplex virus type 2 (HSV-2) infection was used as a proxy for sexual risk behavior. MethodsA cluster randomized controlled trial was conducted in 15 matched pairs of communities (1:1 intervention to control) across 3 strata (urban, rural high-risk, and rural low-risk populations) of the Shinyanga Region, Tanzania. The target population was out-of-school AGYW aged 15-23 years who had completed 10-hour sessions of social and behavior change communication. Eligible communities were randomly assigned to receive CHP along with cash transfer quarterly (intervention group) or solely CHP interventions (control group) with no masking. Study recruitment and baseline survey were conducted between October 30, 2017 and December 1, 2017. Participants completed an audio computer-assisted self-interview, HIV counselling and testing, and HSV-2 testing at baseline and during follow-up visits at 6, 12, and 18 months after the baseline survey. A Cox proportional hazards model with random effects specified at the level of clusters (shared frailty) adjusted for matching pairs and other baseline imbalances was fitted to assess the effects of cash transfer on the incidence of HSV-2 infection (primary outcome). Secondary outcomes included HIV prevalence at follow-up, self-reported intergenerational sex, and self-reported compensated sex. All secondary outcomes were measured at each study visit. ResultsOf the 3026 AGYW enrolled in the trial (1482 in the intervention and 1544 in the control), 2720 AGYW (1373 in the intervention and 1347 in the control) were included in the final analysis. Overall, HSV-2 incidence was not significantly different at all follow-up points between the study arms in the adjusted analysis (hazard ratio 0.96, 95% CI 0.67-1.38; P=.83). However, HSV-2 incidence was significantly lower in the rural low-risk populations who received the cash transfer intervention (hazard ratio 0.45, 95% CI 0.29-0.71; P=.001), adjusted for potential confounders. ConclusionsAlthough this trial showed no significant impact of the cash transfer intervention on HSV-2 incidence among AGYW overall, the intervention significantly reduced HSV-2 incidence among AGYW in rural low-risk communities. Factors such as lesser poverty and more asset ownership in urban and rural high-risk communities may have undermined the impact of cash transfer. Trial RegistrationClinicalTrials.gov NCT03597243; https://clinicaltrials.gov/show/NCT03597243

Abstract Background Despite the rapid dissemination of parenting programs aiming to reduce and prevent violence against children (VAC) worldwide, there is limited knowledge about and evidence of the implementation of these programs at scale. This study addresses this gap by assessing the quality of delivery and impact of an evidence-based parenting program for parents/caregivers and their adolescent girls aged 9 to 14—Parenting for Lifelong Health Teens (PLH-Teens), known locally as Furaha Teens—on reducing VAC at scale in Tanzania. The study will explore participating family and staff perspectives on program implementation and examine factors associated with implementation and how implementation quality is associated with intervention outcomes when the program is delivered to approximately 50,000 parent-child dyads (N = 100,000) in schools and community centers across eight districts of Tanzania. Methods This mixed-methods study will answer the following research questions: (1) what is the implementation quality and fidelity of PLH-Teens at scale in Tanzania; (2) what factors are associated with the quality of delivery and implementation fidelity of PLH-Teens; (3) how are implementation quality and fidelity associated with intervention outcomes; (4) what are participant and implementing staff perspectives on the acceptability, appropriateness, feasibility, benefits, and challenges of delivering PLH-Teens in their schools and communities; (5) what is the impact of PLH-Teens on VAC and participant well-being; and (6) how much does it cost to deliver PLH-Teens at scale? Qualitative and quantitative data will be collected directly from implementers, parents/caregivers, and adolescents using pre-post questionnaires, observational assessments, cost surveys, focus groups, and interviews. Qualitative data will be analyzed thematically with the aid of NVIVO software. Quantitative data will be cleaned and analyzed using methods such as correlation, regression, and structural equation models using Stata and R. COREQ and TREND guidelines will be used, where appropriate. Discussion Findings will provide vital insights into some of the factors related to quality implementation at scale. Lessons learned regarding the implementation of PLH-Teens at scale will be applied in Tanzania, and also in the delivery of PLH parenting programs globally.

Abstract Background Literature suggests that most mental disorders have their onset in childhood and adolescence, but go undiagnosed until adulthood. Shorter versions of the screening tools such as the Patient Health Questionnaire with four items (PHQ-4) may help to improve screening coverage. This study assessed the psychometric properties of the PHQ-4 in screening for core symptoms of depression and anxiety among out of school adolescent girls and young women (AGYW). Methods This is a cross-sectional analysis of data from a cluster randomized controlled trial conducted among AGYW between June and July 2018 in North-West Tanzania. Two thousand four hundred twenty-six out-of-school AGYW aged 15 to 23 years were included. Data were collected on tablets using audio computer-assisted self-interviews (ACASI). Cronbach’s α was used to measure the reliability of the PHQ-4 while confirmatory factor analysis (CFA) and principal components analysis (PCA) were used for construct validity assessment. In CFA, three criteria were used to assess how well the model fits the data: Standardized Root Mean Square Residual (SRMR), the Comparative Fit Index (CFI), the Root Mean Square Error of Approximation (RMSEA) and 90% confidence interval for RMSEA. Results Of the 2426 participants, 33.8 and 35.5% screened positive for core symptoms of anxiety (GAD-2 ≥ 3) and depression (PHQ-2 ≥ 3), respectively. Cronbach’s α of the PHQ-4 was 0.81. Both items-correlation and corrected items-correlation of the PHQ-4 had total correlations above 0.5 (p

Abstract Background HIV testing is a gateway to HIV care and treatment for people diagnosed with HIV and can link those with negative results to HIV preventive services. Despite the importance of HIV testing services (HTS) in HIV control, uptake of HTS among female sex workers (FSWs) across sub-Saharan Africa (SSA) remains sub-optimal. Concerns about stigma associated with sex work and fear of loss of livelihood if HIV status becomes known, are some of the restrictions for FSWs to utilize HTS offered through health care facilities. Introduction of HIV self-testing (HIVST) may mitigate some of the barriers for the uptake of HTS. This study explored the acceptability of FSWs towards the introduction of HIVST in Tanzania. Methods We conducted an exploratory study employing in-depth interviews (IDI) and participatory group discussions (PGD) with FSWs in selected regions of Tanzania. Study participants were recruited through snowball sampling. Data were thematically analysed by two analysts using NVivo software. The analysis was informed by the social-ecological model and focused on factors associated with the acceptability of HIVST. Results We conducted 21 PGD sessions involving 227 FSWs. Twenty three IDIs were conducted to complement data collected through PGD. Our study has demonstrated that FSWs are enthusiastic toward HIVST. Convenience (time and cost saved), and belief that HIVST will increase privacy and confidentiality motivated participants’ support for the self-testing approach. Participants did express concerns about their ability to interpret and trust the results of the test. Participants also expressed concern that HIVST could cause personal harm, including severe distress and self-harm for individuals with a reactive test. Very likely, concern about adverse effects of HIVST was linked to the study participants’ lay perception that HIVST would be provided only through unassisted modality. Conclusions FSWs demonstrated high enthusiasm to use the HIVST once it becomes available. Expectations for increased confidentiality, autonomy, and reduced opportunity costs were among the leading factors that attracted FSWs to HIVST. The major obstacles to the acceptability of HIVST included fear of HIV reactive test and not trusting self-diagnoses. Our findings underscore the importance of providing adequate access to counselling and referral services in conjunction with HIVST.

Abstract Background Complex health interventions must incorporate user preferences to maximize their potential effectiveness. Discrete choice experiments (DCEs) quantify the strength of user preferences and identify preference heterogeneity across users. We present the process of using a DCE to supplement conventional qualitative formative research in the design of a demand creation intervention for voluntary medical male circumcision (VMMC) to prevent HIV in Tanzania. Methods The VMMC intervention was designed within a 3-month formative phase. In-depth interviews (n = 30) and participatory group discussions (n = 20) sought to identify broad setting-specific barriers to and facilitators of VMMC among adult men. Qualitative results informed the DCE development, identifying the role of female partners, service providers’ attitudes and social stigma. A DCE among 325 men in Njombe and Tabora, Tanzania, subsequently measured preferences for modifiable VMMC service characteristics. The final VMMC demand creation intervention design drew jointly on the qualitative and DCE findings. Results While the qualitative research informed the community mobilization intervention, the DCE guided the specific VMMC service configuration. The significant positive utilities (u) for availability of partner counselling (u = 0.43, p

Abstract Background HIV testing and counselling (HTC) is an essential component for HIV prevention and a critical entry point into the HIV continuum of care and treatment. Despite the importance of HTC for HIV control, access to HTC services among female sex workers (FSWs) in sub-Saharan Africa (SSA) remains suboptimal and little is known about factors influencing FSWs’ access to HTC. Guided by the client-centred conceptual framework, we conducted a systematic review to understand the facilitators and barriers influencing FSWs in SSA to access HTC services. Methods A systematic search was conducted in MEDLINE, POPLINE and Web of Science databases for literature published between January 2000 and July 2017. References of relevant articles were also searched. We included primary studies of any design, conducted in SSA and published in the English language. Studies conducted in multi-sites inclusive of SSA were included only if data from sites in SSA were separately analysed and reported. Similarly, studies that included other subpopulations were only eligible if a separate analysis was done for FSWs. This review excluded papers published as systematic reviews, editorial comments and mathematical modelling. The protocol for this review is registered in the Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42017062203. Results This review shows that factors related to approachability, acceptability, availability, affordability and appropriateness of the services are crucial in influencing access to HTC services among FSWs in SSA. These factors were mediated by individual attributes such as HIV risk perceptions, awareness of the availability of HTC, and perceptions of the importance and quality of HTC services. The decision to utilise HTC was predominantly hampered by discriminatory social norms such as HIV stigma and criminalisation of sex work. Conclusions FSWs’ access to HTC is facilitated by multiple factors, including individual awareness of the availability of HTC services, and perceived quality of HTC especially with regard to assured confidentiality. Concerns about HIV stigma and fear about discrimination due to community intolerance of sex work acted as major barriers for FSWs to seek HTC services from the facilities offering health services to the general population.

Abstract Background Across sub-Saharan Africa (SSA), HIV disproportionately affects men-who-have-sex-with-men (MSM) compared with other men of the same age group in the general population. Access to HIV services remains low among this group although several effective interventions have been documented. It is therefore important to identify what has worked well to increase the reach of HIV services among MSM. Methods We searched MEDLINE, POPLINE and the Web of Science databases to collect published articles reporting HIV interventions among MSM across sub-Saharan Africa. Covidence was used to review the articles. The review protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) - CRD42017060808. Results The search identified 2627 citations, and following removal of duplicates and inclusion and exclusion criteria, only 15 papers were eligible for inclusion in the review. The articles reported various accrual strategies, namely: respondent driven sampling, known peers identified through hotspot or baseline surveys, engagement with existing community-based organizations, and through peer educators contacting MSM in virtual sites. Some programs, however, combined some of these accrual strategies. Peer-led outreach services were indicated to reach and deliver services to more MSM. A combination of peer outreach and mobile clinics increased uptake of health information and services. Health facilities, especially MSM-friendly facilities attract access and use of services by MSM and retention into care. Conclusions There are various strategies for accrual and delivering services to MSM across SSA. However, each of these strategies have specific strengths and weaknesses necessitating combinations of interventions and integration of the specific context to inform implementation. If the best of intervention content and implementation are used to inform these services, sufficient coverage and impact of HIV prevention and treatment programs for MSM across SSA can be optimized.

INTRODUCTION:A programmatic mapping and size estimation study was conducted in 24 districts in 5 regions of Tanzania to estimate the size and locations of female sex workers (FSW) and men who have sex with men (MSM) to inform the HIV programming for Key Populations. METHODOLOGY:Data were collected at two levels: first, interviews were conducted with informants to identify venues where FSWs and MSM frequent. Secondly, the size of MSM and FSWs were estimated through interviews with FSWs, MSM and other informants at the venue. The venue estimates were aggregated to generate the ward level estimates. Correction factors were then applied to adjust for MSM/FSW counted twice or more, absent from the venues on the mapping day or remain online and hidden. The ward size estimates for mapped wards were extrapolated to non-mapped wards and aggregated to generate district and regional level estimates. RESULTS:A total of 4,557 level I interviews were conducted. Further, 3,098 FSWs and 1,074 other informants at the FSWs venues and 558 MSM and 210 other informants at the MSM venues were interviewed during level II. The mapping survey identified 6,658 FSW, 1,099 FSW and MSM and 50 MSM venues in 75 wards. A total of 118,057 (range: 108,269 to 127,845) FSWs and 23,771 (range: 22,087 to 25,454) MSM were estimated in the study regions after extrapolation and accounting for correction factors. It was estimated that 5.6% and 1.3% of the female and male population of reproductive age (15-49 years old) could be FSWs and MSM in the study regions, respectively. CONCLUSION:This study provides the baseline figures for planning, target setting and monitoring of the HIV intervention services in the study areas and geographic prioritisation of the response by allocating more resources to areas with a large number of FSWs and MSM.

BackgroundLittle has been documented about partner violence among adolescent girls and young women (AGYW) who are out of school, a factor associated with HIV acquisition. To understand areas for prioritising HIV prevention intervention efforts, we explored the prevalence and correlates of partner violence among out of school AGYW in Shinyanga, Tanzania.MethodsA cross-sectional analysis of data from AGYW aged 15-23 years recruited in a cluster randomised trial conducted between October and December 2017 was used to examine correlates of partner violence. Data were collected through an Audio Computer-Assisted Self-interview. Multivariate logistic regression analysis was used to evaluate the association.Results2276 (75.5%) AGYW were sexually active. Of these, 816 (35.9%) reported having experienced violence from partners in the last six months. After adjusting for other covariates, being formerly married (AOR = 1.55, 95% CI:1.02, 2.37), having children (AOR = 1.79, 95% CI:1.47, 2.16), anxiety and depression symptoms (AOR = 3.27, 95%CI: 2.15, 4.96), having engaged in sex work in the past six months (AOR = 1.92, 95% CI: 1.45, 2.53) and economic deprivation (AOR = 1.61, 95% CI: 1.34,1.92) were significantly associated with partner violence.ConclusionsAlmost one in three sexually active AGYW had experienced partner violence in the 6 months preceding the survey. The findings underscore the need for future research to focus on understanding the reasons and dynamics underlying high level of partner violence among AGYW. Furthermore, there is a need for implementing intervention programs that aim to reduce economic deprivation among AGYWs and address social norms and structures perpetuating violence against AGYW.Trial registrationClinicalTrials.gov-ID NCT03597243.

BACKGROUND:HIV-infected female sex workers (FSWs) have poor linkage to HIV care in sub-Sahara Africa. METHODS:We conducted 21 participatory group discussions (PGDs) to explore factors influencing linkage to HIV care among FSWs tested for HIV through a comprehensive community-based HIV prevention project in Tanzania. RESULTS:Influences on linkage to care were present at the system, societal and individual levels. System-level factors included unfriendly service delivery environment, including lengthy pre-enrolment sessions, concerns about confidentiality, stigmatising attitudes of health providers. Societal-level factors included myths and misconceptions about ART and stigma. On the individual level, most notable was fear of not being able to continue to have a livelihood if one's status were to be known. Facilitators were noted, including the availability of transport to services, friendly health care providers and peer-support referral and networks. CONCLUSION:Findings of this study underscore the importance of peer-supported linkages to HIV care and the need for respectful, high-quality care.

BackgroundIn sub-Saharan Africa, adolescent girls and young women (AGYW) who are out of school are at higher risk of depressive and anxiety disorders compared to their school attending peers. However, little is known about the prevalence and risk factors for these conditions among out-of-school AGYW. This study examines the prevalence of depression and anxiety and associated factors in a community sample of out-of-school AGYW in Tanzania.MethodsA cross-sectional analysis of baseline data from an on-going cluster randomized controlled trial in North-West Tanzania was conducted. A total of 3013 out-of-school AGYW aged 15 to 23 years from 30 clusters were included. Anxiety and depression were assessed using the Patient Health Questionnaire (PHQ-4), a tool comprising of PHQ-2 and Generalized Anxiety Disorders (GAD-2) screeners. Data were collected using Audio Computer-Assisted Self-Interview (ACASI). A random-effects logistic regression was fitted for binary outcomes and an ordinal logistic regression model with robust variance was used to adjust for clustering at the village level. Logistic regression and ordinal logistic regression were used to explore the associations between mental disorders symptoms and other factors.ResultsThe prevalence of depressive (PHQ-2 ≥ 3) and anxiety (GAD-2 ≥ 3) symptoms among out-of-school AGYW were 36% (95% CI 33.8%-37.3%) and 31% (95% CI 29.0%-32.3%) respectively. Further, using the PHQ-4 tool, 33% (95% CI 30.8%-34.2%) had mild, 20% (95% CI 18.3%-21.1%) moderate and 6% (95% CI 5.5%-7.2%) had severe symptoms of anxiety and depression. After adjusting for other covariates, two factors most strongly associated with having anxiety symptoms were violence experience from sexual partners (AOR = 1.63, 95% CI: 1.36-1.96) and HIV positive status (AOR = 1.54, 95% CI: 1.03-2.31). Likewise, living alone, with younger siblings or others (AOR = 2.51, 95% CI: 1.47-4.29) and violence experience from sexual partners (AOR = 1.90, 95% CI: 1.59-2.27) were strongly associated with depression symptoms. Having savings (AOR = 0.81, 95% CI: 0.70-0.95) and emotional support (AOR = 0.82, 95% CI: 0.67-0.99) were protective against depression and anxiety, respectively.ConclusionDepressive and anxiety symptoms are prevalent among out-of-school AGYW in Tanzania. The findings emphasize the need to strengthen preventive interventions and scale-up mental health disorder screening, referral for diagnosis and management.

Voluntary Medical Male Circumcision (VMMC) for HIV prevention in Tanzania was introduced by the Ministry of Health and Social Welfare in 2010 as part of the national HIV prevention strategy. A qualitative study was conducted prior to a cluster randomized trial which tested effective strategies to increase VMMC up take among men aged ≥20 years. During the formative qualitative study, we conducted in-depth interviews with circumcised males (n = 14), uncircumcised males (n = 16), and participatory group discussions (n = 20) with men and women aged 20-49 years in Njombe and Tabora regions of Tanzania. Participants reported that mothers and female partners have an important influence on men's decisions to seek VMMC both directly by denying sex, and indirectly through discussion, advice and providing information on VMMC to uncircumcised partners and sons. Our findings suggest that in Tanzania and potentially other settings, an expanded role for women in VMMC communication strategies could increase adult male uptake of VMMC services.

Assessing the readiness of health facilities to deliver safe male circumcision services is more important in sub-Saharan Africa because of the inadequacy state of health facilities in many ways. The World Health Organization recommends that only facilities equipped with available trained staff, capable to perform at least minor surgery, able to offer minimum MC package and appropriate equipment for resuscitation, and compliant with requirements for sterilization and infection control should be allowed to deliver safe circumcision services. A cross-sectional study using quantitative data collection technique was conducted to assess the readiness of the health facilities to deliver safe circumcision services in selected districts of Tanzania. All hospitals, health centres and 30% of all dispensaries in these districts were selected to participate in the study. Face-toface questionnaires were administered to the heads of the health facilities and to health practitioners. Overall, 49/69 (59%) of the facilities visited provided circumcision services and only 46/203 (24%) of the health practitioners performed circumcision procedures. These were mainly assistant medical officers and clinical officers. The vast majority – 190/203 (95%) – of the health practitioners require additional training prior to providing circumcision services. Most facilities – 63/69 (91%) – had all basic supplies (gloves, basin, chlorine and waste disposal) necessary for infection prevention, 44/69 (65%) provided condoms, HIV counselling and testing, and sexuallytransmitted infections services, while 62/69 (90%) had the capability to perform at least minor surgery. However, only 25/69 (36%) and 15/69 (22%) of the facilities had functioning sterilization equipment and appropriate resuscitation equipment, respectively. There is readiness for roll out of circumcision services; however, more practitioners need to be trained on circumcision procedures, demand forecasting. Sterilization equipment for infection prevention and resuscitation equipment should also be made available.

Background HIV surveillance of generalised epidemics in Africa primarily relies on prevalence at antenatal clinics, but estimates of incidence in the general population would be more useful. Repeated cross-sectional measures of HIV prevalence are now becoming available for general populations in many countries, and we aim to develop and validate methods that use these data to estimate HIV incidence. Methods and Findings Two methods were developed that decompose observed changes in prevalence between two serosurveys into the contributions of new infections and mortality. Method 1 uses cohort mortality rates, and method 2 uses information on survival after infection. The performance of these two methods was assessed using simulated data from a mathematical model and actual data from three community-based cohort studies in Africa. Comparison with simulated data indicated that these methods can accurately estimates incidence rates and changes in incidence in a variety of epidemic conditions. Method 1 is simple to implement but relies on locally appropriate mortality data, whilst method 2 can make use of the same survival distribution in a wide range of scenarios. The estimates from both methods are within the 95% confidence intervals of almost all actual measurements of HIV incidence in adults and young people, and the patterns of incidence over age are correctly captured. Conclusions It is possible to estimate incidence from cross-sectional prevalence data with sufficient accuracy to monitor the HIV epidemic. Although these methods will theoretically work in any context, we have able to test them only in southern and eastern Africa, where HIV epidemics are mature and generalised. The choice of method will depend on the local availability of HIV mortality data., Introduction Monitoring the continuing spread of the HIV epidemic is essential for determining public health priorities, assessing the impact of interventions, and making estimates of current and future health care [...]