An HIV-1 risk assessment tool for women aged 15-49 in African countries: A pooled analysis across 15 nationally representative surveys.

BACKGROUND: Women in Africa disproportionately acquire HIV-1. Understanding which women are most likely to acquire HIV-1 can guide focused prevention with pre-exposure prophylaxis (PrEP). Our objective is to identify women at highest risk of HIV-1 and estimate PrEP efficiency at different sensitivity levels. METHODS: Nationally representative data were collected from 2015-2019 from 15 population-based household surveys. This analysis included women aged 15-49 who tested HIV-1 sero-negative or had recent HIV-1. Least absolute shrinkage and selection operator regression models were fit with 28 variables to predict recent HIV-1. Models were trained on the full population and internally cross-validated. Performance was evaluated using area under the receiver-operating-characteristic curve (AUC), sensitivity, and number needed to treat (NNT) with PrEP to avert one infection. RESULTS: Among 209,012 participants 248 had recent HIV-1 infection, representing 118 million women and 402,000 (95% CI: 309,000-495,000) new annual infections. Two variables were retained in the model: living in a subnational area with high HIV-1 viremia and having a sexual partner living outside the home. Full-population AUC was 0.80 (95% CI: 0.76-0.84); cross-validated AUC was 0.79 (95% CI: 0.75-0.84). At a sensitivity of 33%, up to 130,000 cases could be averted if 7.9 million women were perfectly adherent to PrEP; NNT would be 61. At a sensitivity of 67%, up to 260,000 cases could be averted if 25.1 million women were perfectly adherent to PrEP; the NNT would be 96. CONCLUSIONS: This risk assessment tool was generalizable, predictive, and parsimonious with tradeoffs between reach and efficiency.

ART history prior to conception: trends and association with postpartum disengagement from HIV care in Khayelitsha, South Africa (2013-2019): a retrospective cohort study.

INTRODUCTION: In recent years, the expansion of HIV treatment eligibility has resulted in an increase in people with antiretroviral therapy (ART) experience prior to pregnancy but little is known about postpartum engagement in care in this population. We examined differences in disengagement from HIV care after delivery by maternal ART history before conception. METHODS: We analysed data from people living with HIV (aged 15-49) in Khayelitsha, South Africa, with ≥1 live birth between April 2013 and March 2019. We described trends over time in ART history prior to estimated conception, classifying ART history groups as: (A) on ART with no disengagement (>270 days with no evidence of HIV care); (B) returned before pregnancy following disengagement; (C) restarted ART in pregnancy after disengagement; and (D) ART new start in pregnancy. We used Kaplan-Meier curves and proportional-hazards models (adjusted for maternal age, number of pregnancy records and year of delivery) to examine the time to disengagement from delivery to 2 years postpartum. RESULTS: Among 7309 pregnancies (in 6680 individuals), the proportion on ART (A) increased from 19% in 2013 to 41% in 2019. The proportions of those who returned (B) and restarted (C) increased from 2% to 13% and from 2% to 10%, respectively. There was a corresponding decline in the proportion of new starts (D) from 77% in 2013 to 36% in 2019. In the first recorded pregnancy per person in the study period, 26% (95% CI 25-27%) had disengaged from care by 1 year and 34% (95% CI 33-36%) by 2 years postpartum. Individuals who returned (B: aHR 2.10, 95% CI 1.70-2.60), restarted (C: aHR 3.32, 95% CI 2.70-4.09) and newly started ART (D: aHR 2.41, 95% CI 2.12-2.74) had increased hazards of postpartum disengagement compared to those on ART (A). CONCLUSIONS: There is a growing population of people with ART experience prior to conception and postpartum disengagement varies substantially by ART history. Antenatal care presents an important opportunity to understand prior ART experiences and an entry into interventions for strengthened engagement in HIV care.

Prevalence of persistent hypertension following pregnancy complicated by hypertensive disorders in low- and middle-income countries: a systematic review.

Background: Hypertensive disorders of pregnancy can lead to persistent hypertension (pHTN) in the months and even years following delivery. However, its prevalence in low- and middle-income countries (LMICs) is not well characterized. Objective: To synthesize available evidence on the pHTN prevalence following a pregnancy complicated by hypertensive disorders of pregnancy in LMICs. Search strategy: PubMed, CINAHL Plus, Global Health (EBSCOhost), and Scopus from inception through a search date of July 12, 2022, and updated on January 2, 2024. Selection criteria: Cross-sectional studies and cohort studies reporting pHTN prevalence were eligible. Data collection and analysis: We conducted a narrative synthesis of data and categorized reported prevalence time points into several broader categories. We used the Newcastle-Ottawa checklist to assess the risk of bias. The protocol is registered in PROSPERO (CRD42022345739). Results: We reviewed 1,584 abstracts and identified 22 studies that reported pHTN between 2000 and 2023 from 14 LMICs. The overall prevalence of pHTN ranged between 6.9% and 62.2%, with the highest prevalence noted within African studies and the lowest in South American studies. Estimates at different follow-up periods postpartum were 6.9%-42.9% at six weeks, 34.0%-62.2% at three months, 14.8%-62.2% at six months, 12.7%-61.2% at 12 months, and 7.5%-31.8% at more than 12 months. The quality score of the selected studies ranged from 50% to 100%. Conclusions: The extant literature reports a high prevalence of pHTN in LMICs following a pregnancy complicated by hypertensive disorders. To reduce long-term complications of pHTN, programs should emphasize early screening and linkages to long-term care for at-risk women. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=345739, PROSPERO (CRD42022345739).

A Patient-Centered, Combination Intervention to Support Adherence to HIV Pre-exposure Prophylaxis During Pregnancy and Breastfeeding: A Randomized Pilot Study in Malawi.

BACKGROUND: Daily oral pre-exposure prophylaxis (PrEP) can reduce HIV incidence in pregnant and breastfeeding women, but adherence is essential. METHODS: We conducted a pilot randomized trial to evaluate an intervention package to enhance antenatal and postnatal PrEP use in Lilongwe, Malawi. The intervention was based on patient-centered counseling adapted from previous PrEP studies, with the option of a participant-selected adherence supporter. Participants were locally eligible for PrEP and randomized 1:1 to intervention or standard counseling (ie, control) and followed for 6 months. Participants received the intervention package or standard counseling at enrollment, 1, 3, and 6 months. Adherence was measured through plasma and intracellular tenofovir concentrations and scored using a published algorithm. Our primary outcome was retention in care with concentrations consistent with 4-7 doses/week. RESULTS: From June to November 2020, we enrolled 200 pregnant women with the median gestational age of 26 (interquartile range: 19-33) weeks. Study retention was high at 3 months (89.5%) and 6 months (85.5%). By contrast, across the 2 time points, 32.8% of participants retained in the study had adherence scores consistent with 2-5 doses/week while 10.3% had scores consistent with daily dosing. For the composite primary end point, no substantial differences were observed between the intervention and control groups at 3 months (28.3% vs. 29.0%, probability difference: -0.7%, 95% confidence interval: -13.3%, 11.8%) or at 6 months (22.0% vs. 26.3%, probability difference: -4.3%, 95% confidence interval: -16.1%, 7.6%). CONCLUSIONS: In this randomized trial of PrEP adherence support, retention was high, but less than one-third of participants had pharmacologically confirmed adherence of ≥4 doses/week. Future research should focus on antenatal and postnatal HIV prevention needs and their alignment across the PrEP continuum, including uptake, persistence, and adherence.

Impact of a Multi-Institutional Initiative to Engage Students and Early-Stage Scholars From Underrepresented Racial and Ethnic Minority Groups in HIV Research: The Centers for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative.

BACKGROUND: The Centers for AIDS Research Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI) aims to establish programs to develop pathways for successful careers in HIV science among scholars from underrepresented racial and ethnic populations. This article describes cross-site evaluation outcomes during the first 18 months (July 2021-December 2022) across 15 programs. METHODS: The aims of the evaluation were to characterize participants, describe feasibility, challenges, and successes of the programs and provide a basis for the generalizability of best practices to Diversity, Equity, and Inclusion (DEI) programs in the United States. Two primary data collection methods were used: a quarterly programmatic monitoring process and a centrally managed, individual-level, participant quantitative and qualitative survey. RESULTS: During the first year of evaluation data collection, 1085 racially and ethnically diverse scholars ranging from the high school to postdoctoral levels applied for CDEIPI programs throughout the United States. Of these, 257 (23.7%) were selected to participate based on program capacity and applicant qualifications. Participants were trained by 149 mentors, teachers, and staff. Of the N = 95 participants responding to the individual-level survey, 95.7% agreed or strongly agreed with statements of satisfaction with the program, 96.8% planned to pursue further education, and 73.7% attributed increased interest in a variety of HIV science topics to the program. Qualitative findings suggest strong associations between mentorship, exposure to scientific content, and positive outcomes. CONCLUSIONS: These data provide evidence to support the feasibility and impact of novel DEI programs in HIV research to engage and encourage racially and ethnically diverse scholars to pursue careers in HIV science.

Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI): Developing Career Pathways for Early-Stage Scholars From Racial and Ethnic Groups Underrepresented in HIV Science and Medicine.

BACKGROUND: There is an urgent need to increase diversity among scientific investigators in the HIV research field to be more reflective of communities highly affected by the HIV epidemic. Thus, it is critical to promote the inclusion and advancement of early-stage scholars from racial and ethnic groups underrepresented in HIV science and medicine. METHODS: To widen the HIV research career pathway for early-stage scholars from underrepresented minority groups, the National Institutes of Health supported the development of the Centers for AIDS Research (CFAR) Diversity, Equity, and Inclusion Pathway Initiative (CDEIPI). This program was created through partnerships between CFARs and Historically Black Colleges and Universities and other Minority Serving Institutions throughout the United States. RESULTS: Seventeen CFARs and more than 20 Historically Black Colleges and Universities and Minority Serving Institutions have participated in this initiative to date. Programs were designed for the high school (8), undergraduate (13), post baccalaureate (2), graduate (12), and postdoctoral (4) levels. Various pedagogical approaches were used including didactic seminar series, intensive multiday workshops, summer residential programs, and mentored research internship opportunities. During the first 18 months of the initiative, 257 student scholars participated in CDEIPI programs including 150 high school, 73 undergraduate, 3 post baccalaureate, 27 graduate, and 4 postdoctoral students. CONCLUSION: Numerous student scholars from a wide range of educational levels, geographic backgrounds, and racial and ethnic minority groups have engaged in CDEIPI programs. Timely and comprehensive program evaluation data will be critical to support a long-term commitment to this unique training initiative.

An Internship Approach to Strengthen the Pathway for Historically Underrepresented Groups in Health Sciences Research: The North Carolina Diversity and Inclusion Pathway Program.

BACKGROUND: To increase engagement of historically underrepresented groups in health sciences research, we created the North Carolina Diversity and Inclusion Pathway Program (NC-DIPP). This year-long, paid internship provides undergraduate and graduate students from 2 historically Black colleges and universities an opportunity to gain real-world experience under the mentorship of expert faculty. METHODS: To evaluate the early experiences with the NC-DIPP program, we conducted semi-structured interviews with interns and program leaders. Faculty mentors completed an online questionnaire to describe their experiences to date. A thematic approach was used to analyze the findings. RESULTS: In March-April 2023, 7 of 8 interns (88%), 6 of 11 mentors (54%), and 4 of 4 program leaders (100%) participated in various evaluation components. Overall, respondents agreed about the importance of programs like NC-DIPP, which further engage historically underrepresented groups in the health sciences. Interns had positive feedback about the internship, including real-world work experience, connections to experienced mentors, and early career planning. On a scale of 1 (poor) to 10 (excellent), interns rated their experience as a median of 8.3 (range: 4.5-10.0). Mentors had favorable but slightly lower scores (median: 7.0, range: 5.0-8.0). Areas for improvement were noted, including clearer expectations, improved logistical support, and central engagement of interns across projects. CONCLUSIONS: This early evaluation of NC-DIPP was generally favorable across all stakeholder groups. By providing a long-term experience in health science research, such programs can contribute to work experience, career planning, and professional networking.

Money, chores and emotional support: Kenyan and Zambian fathers' perceptions of male partner involvement in maternal and infant health within the context of HIV.

In sub-Saharan Africa, involving male partners in the prevention of mother-to-child transmission of HIV improves maternal and infant outcomes. Male involvement is typically conceptualised as male partners attending antenatal care, which is difficult for many men. Little is known about how men view their involvement in family health within the context of HIV, particularly outside of clinic attendance. Through interviews with 35 male partners of pregnant or postpartum women living with HIV in Kenya and Zambia, this study elicited perceptions of male involvement in maternal and infant health in families affected by HIV. Men supported the importance of clinic attendance but reported conflicts with the need to work and fulfil their role as the family's financial provider. Providing money for necessities was deemed more critical for their family's health than clinic attendance. Men's involvement was conveyed through various other supportive actions, including helping with household chores and providing emotional support (showing love and reducing women's stress). Future strategies to promote male partner involvement in the prevention of mother-to-child transmission of HIV and maternal and child health should build upon the actions men view as most meaningful to promote their family's health within their real-world life circumstances and cultural context, particularly their role as financial providers.

Male partners' support and influence on pregnant women's oral PrEP use and adherence in Malawi.

Introduction: Daily oral pre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention method for pregnant and postpartum women, but adherence barriers exist. Understanding the role of male partners in supporting PrEP use may inform strategies to support PrEP adherence among pregnant and breastfeeding women. Methods: To understand male partners' involvement in women's use of PrEP, we conducted in-depth interviews with pregnant women in Lilongwe, Malawi who had recently decided to use PrEP (n = 30) and their male partners (n = 20) in the context of a PrEP adherence trial. Women were purposively recruited to ensure variation in their partners' HIV status. Interviews were conducted in Chichewa using a semistructured guide. We followed a thematic approach to analyze the interview data. Results: Most male partners were receptive to women using PrEP during pregnancy because it eased their fears of the woman and baby acquiring HIV. Men often played a key role in women's PrEP adherence by providing daily reminders and encouragement to adhere to their medication. The majority of women appreciated this support from the men as it lessened the burden of remembering to take their medications daily on their own and aided their adherence. However, several women who lacked male partner support spoke of wanting their partners to be more involved. Many men living with HIV found the mutual support beneficial for their antiretroviral therapy adherence, while men without HIV or with status unknown appreciated knowing that the family was protected. While most men were open to women continuing PrEP beyond the current study, some would only support it if women were still at risk for acquiring HIV. Conclusion: In this study, male partners were strongly motivated to support the PrEP adherence of their female partners as a way of ensuring that the pregnant women and unborn babies were protected against HIV. Promoting disclosure and tangible support that arises organically among men may be helpful, but programs to enhance this support and identify ways to support women who do not receive support from their partners or do not wish to disclose their PrEP use to partners may be needed.

Perspectives and experiences of Zambian pregnant and postpartum women receiving two intervention models to increase uptake of male partner HIV testing.

This study explored the experiences of pregnant women who received two intervention models for increasing uptake of male partner HIV testing in antenatal settings. As part of a randomised trial, we interviewed twenty participants who received partner notification services only while 22 received the partner notification plus HIV self-testing. Thematic analysis was used to analyse the data. Partner notification services helped to initiate discussions of HIV testing with partners, influence partners to undergo testing, and encouraged disclosure of HIV status. Some women experienced difficulties engaging partners due to fear of their partner's reaction. Some partners were unable to test due to time constraints. The partner notification plus HIV self-testing intervention, stimulated discussion about HIV testing; facilitated testing for men at their convenience; addressed privacy/confidentiality, and stigma concerns; and provided the opportunity to disclose HIV status. Some women feared disclosure and retribution in case of discordance results. There were also challenges with men making follow-ups for confirmatory HIV tests. The addition of HIV self-test kits to partner notification services can expand HIV testing services to male partners, including those of HIV-negative women. Additional efforts are needed to link men to appropriate HIV prevention, care, and treatment services.

Acceptability of a Combination Adherence Strategy to Support HIV Antiretroviral Therapy and Pre-exposure Prophylaxis Adherence During Pregnancy and Breastfeeding in Malawi.

In two parallel pilot studies, we implemented a combination adherence intervention of patient-centered counselling and adherence supporter training, tailored to support HIV treatment (i.e., antiretroviral therapy) or prevention (i.e., pre-exposure prophylaxis, or PrEP) during pregnancy and breastfeeding. Using a mixed-methods approach, we evaluated the intervention's acceptability. We investigated engagement, satisfaction, and discussion content via survey to all 151 participants assigned to the intervention arm (51 women living with HIV, 100 PrEP-eligible women without HIV). We also conducted serial in-depth interviews with a subgroup (n = 40) at enrollment, three months, and six months. In the quantitative analysis, the vast majority reported high satisfaction with intervention components and expressed desire to receive it in the future, if made available. These findings were supported in the qualitative analysis, with favorable comments about counselor engagement, intervention content and types of support received from adherence supporters. Overall, these results demonstrate high acceptability and provide support for HIV status-neutral interventions for antiretroviral adherence.

Combination HIV prevention during pregnancy and the post-partum period in Malawi and Zambia: a mathematical modelling analysis.

INTRODUCTION: Despite widespread success in reducing vertical HIV transmission, most antenatal care (ANC) programmes in eastern and southern Africa have not emphasized primary prevention of maternal HIV acquisition during pregnancy and lactation/breastfeeding. We hypothesized that combination HIV prevention interventions initiated alongside ANC could substantially reduce maternal HIV incidence. METHODS: We constructed a multi-state model describing male-to-female HIV transmission in steady heterosexual partnerships during pregnancy and lactation/breastfeeding, with initial conditions based on population distribution estimates for Malawi and Zambia in 2020. We modelled individual and joint increases in three HIV prevention strategies at or soon after ANC initiation: (1) HIV testing of male partners, resulting in HIV diagnosis and less condomless sex among those with previously undiagnosed HIV; (2) initiation (or re-initiation) of suppressive antiretroviral therapy (ART) for male partners with diagnosed but unsuppressed HIV; and (3) adherent pre-exposure prophylaxis (PrEP) for HIV-negative female ANC patients with HIV-diagnosed or unknown-status male partners. We estimated the percentage of within-couple, male-to-female HIV transmissions that could be averted during pregnancy and lactation/breastfeeding with these strategies, relative to base-case conditions in which 45% of undiagnosed male partners become newly HIV diagnosed via testing, 75% of male partners with diagnosed but unsuppressed HIV initiate/re-initiate ART and 0% of female ANC patients start PrEP. RESULTS: Increasing uptake of any single strategy by 20 percentage points above base-case levels averted 10%-11% of maternal HIV acquisitions during pregnancy and lactation/breastfeeding in the model. Joint uptake increases of 20 percentage points in two interventions averted an estimated 19%-23% of transmissions, and with a 20-percentage-point increase in uptake of all three interventions, 29% were averted. Strategies achieving 95% male testing, 90% male ART initiation/re-initiation and 40% female PrEP use reduced incident infections by 45%. CONCLUSIONS: Combination HIV prevention strategies provided alongside ANC and sustained through the post-partum period could substantially reduce maternal HIV incidence during pregnancy and lactation/breastfeeding in eastern and southern Africa.

Elevating Mentorship Competency for Sustained Impact via the University of Zambia Mentor Training Program.

The University of Zambia (UNZA) Mentor Training Program is conducted annually to strengthen the mentorship capacity of postgraduate programs for the health professions. This intensive five-session course trains faculty members in the mentorship of students. Established by senior UNZA leaders and US-based collaborators, this program was designed to address gaps in mentorship identified at the institutional level. Faculty facilitators developed the course curriculum and used a train-the-trainer model to ensure program sustainability. Participants were faculty members who mentor PhD and Master of Medicine students. To assess the program's impact, mentors and their mentees completed questionnaires on the mentor's mentoring competencies at the end of the course and 1 year later. Competency scores were compared longitudinally to quantify potential changes in mentoring behaviors. Mentors and mentees alike noted mentor growth in all competency domains from postcourse to 1 year later, providing evidence of a trend toward improvement in mentorship and that the program may have sustainable and positive effects on mentoring behaviors over time. Salient areas of growth corresponded to emphasized topics and discussions, including addressing diversity, aligning expectations, assessing capacities, motivating mentees, and fostering independence. These findings suggest that mentors internalized this content and transferred it to behavior change. The behavior changes may reveal a larger change in the institutional environment around the mentoring of students. The UNZA Mentor Training Program appears to have sustained impact after a year and should bode well for future benefits to students, faculty, and the institution.

Two strategies for partner notification and partner HIV self-testing reveal no evident predictors of male partner HIV testing in antenatal settings: A secondary analysis.

BACKGROUND: To meet global targets for the elimination of mother-to-child HIV transmission, tailored approaches to HIV testing strategies need prioritizing. Herein, we sought to identify individual-level factors associated with male partner HIV testing. METHODS: We conducted a secondary analysis of data from two parallel randomized trials of pregnant women living with HIV and those HIV-negative in Lusaka, Zambia. Across both trials, control groups received partner notification services only, while intervention groups received partner notification services plus HIV self-test kits for their partners. Associations between baseline factors and male partner testing were estimated using a probability difference. The outcome of interest was uptake of male partner HIV testing of any kind within 30 days of randomization. RESULTS: The parent study enrolled 326 participants. Among the 151 women in the control groups, no clear associations were noted between maternal or male partner characteristics and reported uptake of male partner HIV testing. There were positive trends favouring partner testing among women who completed primary school education, had larger households (>2 members), and whose partners were circumcised. Likewise, no clear predictors of male partner testing were identified among the 149 women in the intervention groups. However, negative trends favouring no testing were noted among older, multiparous women from larger households. CONCLUSION: No consistent predictors for male partner HIV testing across two compared strategies were observed. Our findings suggest that differentiated strategies for male partner HIV testing may not be necessary. Instead, consideration should be given to universal approaches when bringing such services to scale.

"PrEP protects us": Behavioural, normative, and control beliefs influencing pre-exposure prophylaxis uptake among pregnant and breastfeeding women in Zambia.

Background: Although pre-exposure prophylaxis (PrEP) is recommended for pregnant and breastfeeding women at elevated HIV risk, uptake has been low in Zambia. Methods: In in-depth interviews, we explored beliefs about PrEP among 24 HIV-negative pregnant and breastfeeding Zambian women. Thematic analysis was used to identify behavioural, normative and control beliefs likely to influence PrEP uptake. Results: Most women viewed PrEP as a good method of protecting themselves and their babies from HIV infection. Partners were cited as key referents in decision making about PrEP use. Many women felt that PrEP use was not entirely in their control. Most reported that they would not use PrEP if their partners did not approve. Health care providers with negative attitudes, long distance to clinics, and extended waiting times were cited as barriers to PrEP uptake. Conclusion: HIV-negative pregnant and breastfeeding women had a positive attitude towards PrEP but barriers to uptake are multifaceted.

Salient beliefs and intention to use pre-exposure prophylaxis among pregnant and breastfeeding women in Zambia: Application of the Theory of Planned Behaviour.

Primary HIV prevention is a priority for pregnant and breastfeeding women in sub-Saharan Africa; however, such services should be designed to optimise uptake and continuation. Between September and December 2021, we enrolled 389 women who were not living with HIV into a cross-sectional study from antenatal/postnatal settings at Chipata Level 1 Hospital. We used the Theory of Planned Behaviour to study the relationship between salient beliefs and intention to use pre-exposure prophylaxis (PrEP) among eligible pregnant and breastfeeding women. On a seven-point scale, participants had positive attitudes towards PrEP (mean = 6.65, SD = 0.71), anticipated approval of PrEP use from significant others (mean = 6.09, SD = 1.51), felt confident that they could take PrEP if they desired (mean = 6.52, SD = 1.09) and had favourable intentions to use PrEP (mean = 6.01, SD = 1.36). Attitude, subjective norms, and perceived behavioural control significantly predicted intention to use PrEP respectively (ß = 0.24; ß = 0.55; ß = 0.22, all p < 0.01). Social cognitive interventions are needed to promote social norms supportive of PrEP use during pregnancy and breastfeeding.

Strategies to increase couples HIV testing and counselling in sub-Saharan Africa: a systematic review.

INTRODUCTION: Couple HIV testing and counselling (CHTC) is associated with measurable benefits for HIV prevention and treatment. However, the uptake remains limited in much of sub-Saharan Africa, despite an expanded range of strategies designed to promote access. METHODS: Following PRIMSA guidelines, we conducted a systematic review to characterize CHTC uptake strategies. Five databases were searched. Full-text articles were included if they were: conducted in sub-Saharan Africa during the study period (1980-2019), targeted heterosexual couples, reported at least one strategy to promote CHTC and provided a quantifiable measure of CHTC uptake. After the initial and full-text screening, key features of the studies were abstracted and synthesized. RESULTS: Of the 6188 unique records found in our search, 365 underwent full-text review with 29 distinct studies included and synthesized. Most studies recruited couples through antenatal care (n = 11) or community venues (n = 8) and used provider-based HIV testing (n = 25). The primary demand creation strategies included home-based CHTC (n = 7); integration of CHTC into clinical settings (n = 4); distribution of HIV self-testing kits (n = 4); verbal or written invitations (n = 4); community recruiters (n = 3); partner tracing (n = 2); relationship counselling (n = 2); financial incentives (n = 1); group education with CHTC coupons (n = 1); and HIV testing at other community venues (n = 1). CHTC uptake ranged from negligible to nearly universal. DISCUSSION: We thematically categorized a diverse range of strategies with varying levels of intensity and resources used across sub-Saharan Africa to promote CHTC. Offering CHTC within couples' homes was the most common approach, followed by the integration of CHTC into clinical settings. Due to heterogeneity in study characteristics, we were unable to compare the effectiveness across studies, but several trends were observed, including the high prevalence of CHTC promotion strategies in antenatal settings and the promising effects of home-based CHTC, distribution of HIV self-tests and integration of CHTC into routine health services. Since 2019, an updated literature search found that combining partner notification and secondary distribution of HIV self-test kits may be an additionally effective CHTC strategy. CONCLUSIONS: There are many effective, feasible and scalable approaches to promote CHTC that should be considered by national programmes according to local needs, cultural context and available resources.

Decolonizing Global Health Research: Perspectives from US and International Global Health Trainees.

Background: "Decolonizing global health" (DGH) may help global health trainees understand and remediate the effects of historical colonialism on global health, but little is known regarding how trainees perceive DGH. Understanding their perspectives is critical for designing educational interventions tailored to their needs. Objectives: To understand how trainees perceive DGH research and to determine if perspectives differ between trainees from high- (HICs) versus low- and middle-income countries (LMICs). Methods: An online survey of all 2017-2022 pre-doctoral and post-doctoral trainees (n = 111) and mentors (n = 91) within a multi-university program that supports US and international investigators in one-year mentored global health research. The survey evaluated individuals' self-reported knowledge and attitudes toward DGH and their perceptions of historical colonialism's impact on eight aspects of global health. Findings: The response rate to trainee surveys was 56%. Trainees from LMICs were less aware of the concept of DGH; 5/25 (20%) had never heard of DGH and 16/25 (64%) reported that they "know a little," whereas all HIC trainees had heard of DGH and 29/36 (81%) reported that they "know a little" (p = 0.019). For three aspects of global health (i.e., which research questions get asked; development of collaborative relationships; and data/statistical analyses), trainees from LMICs were more likely to report positive effects of colonialism. However, in open-ended responses, no thematic differences existed between how LMIC and HIC trainees defined DGH (i.e., actively eliminating power imbalances; prioritizing local needs; promoting local leadership; providing equitable opportunities; and ensuring programs are culturally appropriate). Conclusions: Different perspectives surrounding what DGH means suggest a shared understanding may be needed and is arguably prerequisite to designing educational interventions to help global health trainees recognize, understand, and act in global health. Future research is needed to understand perspectives on decolonization across diverse contexts with attention to constructs such as race, ethnicity, and gender.