Brief Report: Self-Reported HIV-Positive Status but Subsequent HIV-Negative Test Results in Population-Based HIV Impact Assessment Survey Participants-11 Sub-Saharan African Countries, 2015-2018.

BACKGROUND: HIV testing is a critical step to accessing antiretroviral therapy (ART) because early diagnosis can facilitate earlier initiation of ART. This study presents aggregated data of individuals who self-reported being HIV-positive but subsequently tested HIV-negative during nationally representative Population-Based HIV Impact Assessment surveys conducted in 11 countries from 2015 to 2018. METHOD: Survey participants aged 15 years or older were interviewed by trained personnel using a standard questionnaire to determine HIV testing history and self-reported HIV status. Home-based HIV testing and counseling using rapid diagnostic tests with return of results were performed by survey staff according to the respective national HIV testing services algorithms on venous blood samples. Laboratory-based confirmatory HIV testing for all participants identified as HIV-positives and self-reported positives, irrespective of HIV testing results, was conducted and included Geenius HIV-1/2 and DNA polymerase chain reaction if Geenius was negative or indeterminate. RESULTS: Of the 16,630 participants who self-reported as HIV-positive, 16,432 (98.6%) were confirmed as HIV-positive and 198 (1.4%) were HIV-negative by subsequent laboratory-based testing. Participants who self-reported as HIV-positive but tested HIV-negative were significantly younger than 30 years, less likely to have received ART, and less likely to have received a CD4 test compared with participants who self-reported as HIV-positive with laboratory-confirmed infection. CONCLUSIONS: A small proportion of self-reported HIV-positive individuals could not be confirmed as positive, which could be due to initial misdiagnosis, deliberate wrong self-report, or misunderstanding of the questionnaire. As universal ART access is expanding, it is increasingly important to ensure quality of HIV testing and confirmation of HIV diagnosis before ART initiation.

Building Research Capacity in Low- and Middle-Income Countries and Pandemic Preparedness: Lessons Learned and Future Directions.

Research capacity is a critical component of pandemic preparedness, as highlighted by the challenges faced during the Ebola outbreak in West Africa. Recent global initiatives, such as the Research & Development Task Force of the Global Health Security Agenda and the World Health Assembly's resolution on strengthening clinical trials, emphasize the need for robust research capabilities. This Perspective discusses the experiences of leaders in infectious disease research and capacity building in low- and middle-income countries, focusing on Colombia, Jamaica, and Pakistan. These case studies underscore the importance of collaborative efforts, interdisciplinary training, and global partnerships in pandemic response. The experiences highlight the necessity for rapid pathogen identification, capacity for genomic sequencing, and proactive engagement with policymakers. Challenges faced, including the shortage of trained staff and reliance on imported reagents, emphasize the ongoing need for building research capacity.

Global HIV control: is the glass half empty or half full?

The massive scale-up of HIV treatment and prevention over the past two decades has resulted in important reductions in new infections and mortality globally. Reduction in HIV incidence, however, has been unequal, with worsening epidemics in regions where the reach and scale of HIV control programmes have been insufficient, especially in eastern Europe, central Asia, the Middle East, north Africa, and Latin America where HIV epidemics are concentrated among key populations, including people who inject drugs, men who have sex with men, transgender people, and some minority racial and ethnic groups. The global state of the HIV pandemic highlights disparities in HIV control efforts and provides a roadmap for what should be done, including investment to better implement the effective HIV prevention and treatment tools that are available, but whose adoption and scale-up are not yet sufficient to get us close to an AIDS-free generation. To achieve the full potential of global HIV control, we call for urgent, evidence-informed implementation at scale of our existing and novel HIV prevention and treatment strategies in ways that are better, faster, more efficient, and cost-effective, especially in key populations and regions where the HIV pandemic continues to expand.

The epidemiology of HIV population viral load in twelve sub-Saharan African countries.

BACKGROUND: We examined the epidemiology and transmission potential of HIV population viral load (VL) in 12 sub-Saharan African countries. METHODS: We analyzed data from Population-based HIV Impact Assessments (PHIAs), large national household-based surveys conducted between 2015 and 2019 in Cameroon, Cote d'Ivoire, Eswatini, Kenya, Lesotho, Malawi, Namibia, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. Blood-based biomarkers included HIV serology, recency of HIV infection, and VL. We estimated the number of people living with HIV (PLHIV) with suppressed viral load (<1,000 HIV-1 RNA copies/mL) and with unsuppressed viral load (viremic), the prevalence of unsuppressed HIV (population viremia), sex-specific HIV transmission ratios (number female incident HIV-1 infections/number unsuppressed male PLHIV per 100 persons-years [PY] and vice versa) and examined correlations between a variety of VL metrics and incident HIV. Country sample sizes ranged from 10,016 (Eswatini) to 30,637 (Rwanda); estimates were weighted and restricted to participants 15 years and older. RESULTS: The proportion of female PLHIV with viral suppression was higher than that among males in all countries, however, the number of unsuppressed females outnumbered that of unsuppressed males in all countries due to higher overall female HIV prevalence, with ratios ranging from 1.08 to 2.10 (median: 1.43). The spatial distribution of HIV seroprevalence, viremia prevalence, and number of unsuppressed adults often differed substantially within the same countries. The 1% and 5% of PLHIV with the highest VL on average accounted for 34% and 66%, respectively, of countries' total VL. HIV transmission ratios varied widely across countries and were higher for male-to-female (range: 2.3-28.3/100 PY) than for female-to-male transmission (range: 1.5-10.6/100 PY). In all countries mean log10 VL among unsuppressed males was higher than that among females. Correlations between VL measures and incident HIV varied, were weaker for VL metrics among females compared to males and were strongest for the number of unsuppressed PLHIV per 100 HIV-negative adults (R2 = 0.92). CONCLUSIONS: Despite higher proportions of viral suppression, female unsuppressed PLHIV outnumbered males in all countries examined. Unsuppressed male PLHIV have consistently higher VL and a higher risk of transmitting HIV than females. Just 5% of PLHIV account for almost two-thirds of countries' total VL. Population-level VL metrics help monitor the epidemic and highlight key programmatic gaps in these African countries.

Increasing Effectiveness and Equity in Strengthening Health Research Capacity Using Data and Metrics: Recent Advances of the ESSENCE Mechanism.

Background: The ESSENCE on Health Research initiative established a Working Group on Review of Investments in 2018 to improve coordination and collaboration among funders of health research capacity strengthening. The Working Group comprises more than a dozen ESSENCE members, including diverse representation by geography, country income level, the public sector, and philanthropy. Objective: The overall goal of the Working Group is increased research on national health priorities as well as improved pandemic preparedness, and, ultimately, fewer countries with very limited research capacity. Methods: We developed a basic set of metrics for national health research capacity, assessed different models of coordination and collaboration, took a deeper dive into eight countries to characterize their national research capacity, and began to identify opportunities to better coordinate our investments. In this article, we summarize the presentations, discussions, and outcomes of our second annual (virtual) meeting, which had more than 100 participants representing funders, researchers, and other stakeholders from higher- and lower-income countries worldwide. Findings and conclusions: Presentations on the first day included the keynote speaker, Dr. Soumya Swaminathan, chief scientist of the World Health Organization (WHO), and updates on data and metrics for research capacity, which are critical to establish targets, road maps, and budgets. The second day focused on improving collaboration and coordination among funders and other stakeholders, the potential return on investment for health research, ongoing work to increase coordination at the country level, and examples of research capacity strengthening efforts in diverse health research areas from around the world. We concluded that an intentional data- and metric-driven approach to health research capacity strengthening, emphasizing coordination among funders, local leadership, and equitable partnerships and allocation of resources, will enhance the health systems of resource-poor countries as well as the world's pandemic preparedness.

Bibliometric Analysis of Authorship of Publications About Sub-Saharan Africa Published in the Journal Sexually Transmitted Diseases , 2011 to 2020.

BACKGROUND: As a potential indicator of equity in research partnerships, we conducted a bibliometric analysis of author affiliations and author order in publications about sub-Saharan Africa published in the journal Sexually Transmitted Diseases . METHODS: We identified articles in the journal Sexually Transmitted Diseases that were about sub-Saharan Africa and published from 2011 to 2020. Medical Subject Heading terms in PubMed were used to identity articles about sub-Saharan Africa. Authors with at least 1 affiliation in sub-Saharan Africa were characterized as sub-Saharan Africa-affiliated authors. RESULTS: Of the 1439 articles that were published in Sexually Transmitted Diseases from 2011 to 2020, 148 (10%) had a Medical Subject Heading term for a sub-Saharan African country. Of the 604 authors of these 148 articles, 53 (36%) of the first authors, 493 (53%) of the middle authors, and 58 (40%) of the last authors had a sub-Saharan African affiliation; 13 (8.8%) of the articles had no authors with a sub-Saharan African affiliation. The proportions of sub-Saharan African-affiliated authors in first and last authorship positions did not change significantly from 2011-2015 (77 articles) to 2016-2020 (71 articles). CONCLUSIONS: The underrepresentation of Africans in first and last authorship positions suggests power imbalances in global scientific partnerships. Funders, researchers, editors, publishers, and grant and manuscript reviewers each have roles in promoting equity in global health research. This study may serve as an example for journals to establish benchmarks and monitor progress toward a more equitable research environment.

Advancing Adolescent HIV Prevention and Care Through Implementation Science: An Agenda for Combating the Global AIDS Epidemic in Sub-Saharan Africa.

AIDS continues to be a major driver of adolescent mortality in Sub-Saharan Africa. Despite evidence of efficacy in this population, many efforts to address adolescent HIV have had limited impact across the region because of difficulty with implementation. The field of implementation science holds promise for addressing these challenges. The Fogarty-led Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) creates a platform for bidirectional learning between researchers and the users of research evidence that promotes the use of implementation science to strengthen adolescent HIV prevention and care across Africa. The unique contributions of AHISA are reflected in this supplement's articles which represent the collective learning of the Alliance; illustrate the value of implementation science in the context of adolescent HIV; and identify critical research gaps that should be addressed by implementation science in the future.

Advancing detection and response capacities for emerging and re-emerging pathogens in Africa.

Recurrent disease outbreaks caused by a range of emerging and resurging pathogens over the past decade reveal major gaps in public health preparedness, detection, and response systems in Africa. Underlying causes of recurrent disease outbreaks include inadequacies in the detection of new infectious disease outbreaks in the community, in rapid pathogen identification, and in proactive surveillance systems. In sub-Saharan Africa, where 70% of zoonotic outbreaks occur, there remains the perennial risk of outbreaks of new or re-emerging pathogens for which no vaccines or treatments are available. As the Ebola virus disease, COVID-19, and mpox (formerly known as monkeypox) outbreaks highlight, a major paradigm shift is required to establish an effective infrastructure and common frameworks for preparedness and to prompt national and regional public health responses to mitigate the effects of future pandemics in Africa.

What Do Global Health Practitioners Think about Decolonizing Global Health?

The growing awareness of colonialism's role in global health partnerships between HICs and LMICs and the associated calls for decolonization in global health has led to discussion for a paradigm shift that would lead to new ways of engagement and partnerships, as well as an acknowledgement that colonialism, racism, sexism, and capitalism contribute to inequity. While there is general agreement among those involved in global health partnerships that the current system needs to be made more equitable, suggestions for how to address the issue of decolonization vary greatly, and moving from rhetoric to reform is complicated. Based on a comprehensive (but not exhaustive) review of the literature, there are several recurring themes that should be addressed in order for the inequities in the current system to be changed. The degree to which decolonization of global health will be successful depends on how the global health community in both the HICs and LMICs move forward to discuss these issues. Specifically, as part of a paradigm shift, attention needs to be paid to creating a more equal and equitable representation of researchers in LMICs in decision-making, leadership roles, authorship, and funding allocations. There needs to be agreement in defining basic principles of best practices for global partnership, including a universal definition of 'decolonization of global health'; the extent to which current policies allow the perpetuation of power imbalance between HICs and LMICs; a set of principles, best practices, and models for equitable sharing of funds and institutional costs among partners; a mechanism to monitor progress prospectively the equitable sharing of credits (e.g., leadership, authorship), including a set of principles, best practices, and models; and, a mechanism to monitor progress prospectively the extent to which decolonialization will contribute to strengthening institutional capacity in the LMIC institutions.

Bibliometric analysis of sub-Saharan African and US authorship in publications about sub-Saharan Africa funded by the Fogarty International Center, 2008-2020.

BACKGROUND: Authorship and author order have been used as one measure to characterise equity in research partnerships. First and last (senior) authorships often denote scientific merit as well as potential for research career advancement. A previous analysis found that only about 20%-25% of publications about Africa with coauthors from top-ranking US universities had a first or last author from the topic country. In this bibliometric analysis, we evaluated authorship of publications about sub-Saharan Africa (SSA) funded by the Fogarty International Center (FIC) of the US National Institutes of Health, an institution with a mission of training and capacity building in low-income and middle-income countries. METHODS: We analysed publications from PubMed and Web of Science that were funded by FIC, about SSA, and published between 2008 and 2020. Relative citation ratio (RCR) data from iCite were used to compare group citation impact measures using the Wilcoxon rank sum test. RESULTS: A total of 3446 publications met the inclusion criteria, with annual number increasing from 114 in 2008 to 352 in 2020. SSA-affiliated first authors increased from 53 (47%) in 2008 to 224 (63%) in 2020. SSA-affiliated last authors increased from 32 (28%) to 166 (47%). For both first and last authorships, the median RCR value of publications with SSA-affiliated authors was lower than for US-affiliated authors (first authors: 0.84 vs 0.95, p=0.0021; last authors: 0.88 vs 0.91, p=0.010). CONCLUSION: The increase in first and last authorships by SSA-affiliated authors of publications about SSA suggests increasing equity in research activities funded by FIC. Further investigation and actions are needed to establish how authorship reflects other aspects of equity, the implication of the lower RCR in papers with SSA-affiliated first and last authors and what policies and practices are needed to further promote equity in global health research.

Opportunities and Challenges in North-South and South-South Global Health Collaborations During the COVID-19 Pandemic: The AFREhealth-CUGH Experience (as Reported at the CUGH 2021 Satellite Meeting).

Sustainable and equitable partnerships and collaborations between the Global North and Global South (as well as within the Global South) have been aspirations (if seldom achieved) of the "global health" endeavor over the past couple of decades. The COVID-19 pandemic led to global lockdowns that disrupted international travel and severely challenged these partnerships, providing a critical space for self-reflection on global health as a discipline. One major global north-south partnership is that between the African Forum for Research and Education in Health (AFREhealth) and the Consortium of Universities for Global Health (CUGH). This article reports on a recent Satellite meeting of the AFREhealth-CUGH Working Group (ACWG) at the CUGH 2021 virtual conference in March 2021 that provided insights on North-South and South-South global health partnerships, against the backdrop of the COVID-19 pandemic. The authors describe challenges and opportunities for research and education in these partnerships (as discussed at this ACWG Satellite meeting), and implications for the field of global health going forward as we emerge from the pandemic.

Building global health research capacity to address research imperatives following the COVID-19 pandemic.

Peter Kilmarx and Roger Glass discuss strengthening health research capabilities as a response to the COVID-19 pandemic.

A National Public Health Workforce to Control COVID-19 and Address Health Disparities in the United States.

A large, well-trained public health workforce is needed to control coronavirus disease 2019 (COVID-19) in the United States in the short term and to address other disease burdens and health disparities in the long run. As the public health workforce declined following the 2008 financial crisis, many US jurisdictions struggled to hire a sufficient number of staff for roles initially including testing and contact tracing and more recently for vaccination. Ultimately, COVID-19 control will require a combination of vaccination and rapid investigation, contact tracing, and quarantine to stop chains of transmission. New federal resources for a public health workforce have been made available. With appropriate attention to addressing administrative barriers and ensuring equity, a 21st-century US public health workforce will hasten the control of COVID-19, provide economic relief to individuals and communities, and reduce the burden of other infectious diseases, noncommunicable diseases, and other disease burdens. A long-term commitment to a robust public health workforce is vital to ensuring health security and preparedness for future health threats.

Return of Positive Test Results to Participants in Sexually Transmitted Infection Prevalence Studies: Research Ethics and Responsibilities.

BACKGROUND: In prevalence studies of sexually transmitted infections (STIs), investigators often provide syndromic management for symptomatic participants but may not provide specific treatment for asymptomatic individuals with positive laboratory test results because of the delays between sample collection and availability of results as well as logistical constraints in recontacting study participants. METHODS: To characterize the extent of this issue, 80 prevalence studies from the World Health Organization's Report on Global Sexually Transmitted Infection Surveillance, 2018, were reviewed. Studies were classified as to whether clinically relevant positive results were returned or if this was not specified. RESULTS: More than half (56%) of the cited studies did not specify if participants were notified of clinically relevant positive STI test results. The percentages were similar for low- and middle-income country populations (57%) and high-income country populations (53%). CONCLUSIONS: The absence of documentation of the provision of test results raises the possibility that in some instances, results may not have been communicated, with potential negative effects for participants, their sexual partners, and newborns. From an ethical perspective, clinically relevant results should be returned to study participants and treating clinicians in a timely fashion to ensure appropriate management of identified infections. Study authors should document if they returned test results to study participants and report on numbers lost to follow-up.

Contact Tracing and the COVID-19 Response in Africa: Best Practices, Key Challenges, and Lessons Learned from Nigeria, Rwanda, South Africa, and Uganda.

Most African countries have recorded relatively lower COVID-19 burdens than Western countries. This has been attributed to early and strong political commitment and robust implementation of public health measures, such as nationwide lockdowns, travel restrictions, face mask wearing, testing, contact tracing, and isolation, along with community education and engagement. Other factors include the younger population age strata and hypothesized but yet-to-be confirmed partially protective cross-immunity from parasitic diseases and/or other circulating coronaviruses. However, the true burden may also be underestimated due to operational and resource issues for COVID-19 case identification and reporting. In this perspective article, we discuss selected best practices and challenges with COVID-19 contact tracing in Nigeria, Rwanda, South Africa, and Uganda. Best practices from these country case studies include sustained, multi-platform public communications; leveraging of technology innovations; applied public health expertise; deployment of community health workers; and robust community engagement. Challenges include an overwhelming workload of contact tracing and case detection for healthcare workers, misinformation and stigma, and poorly sustained adherence to isolation and quarantine. Important lessons learned include the need for decentralization of contact tracing to the lowest geographic levels of surveillance, rigorous use of data and technology to improve decision-making, and sustainment of both community sensitization and political commitment. Further research is needed to understand the role and importance of contact tracing in controlling community transmission dynamics in African countries, including among children. Also, implementation science will be critically needed to evaluate innovative, accessible, and cost-effective digital solutions to accommodate the contact tracing workload.

A Mechanism for Reviewing Investments in Health Research Capacity Strengthening in Low- and Middle-Income Countries.

More than 40 agencies that fund health research capacity strengthening in low- and middle-income countries (LMICs) participate in the ESSENCE Health Research initiative, which has established a mechanism for reviewing and coordinating their funding. Taken together, the expected outcomes of implementation of the review mechanism are increases in the efficiency and equity in health research capacity strengthening activities with decreased duplication of efforts. The overall goal is increased support of research on national health priorities as well as improved pandemic preparedness in LMICs, and, eventually, fewer countries with very limited research capacity.

Evidence of behaviour change during an Ebola virus disease outbreak, Sierra Leone.

OBJECTIVE: To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015. METHODS: Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes. FINDINGS: Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9-9.1); and (ii) wait for a burial team following a relative's death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2-6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4-4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1-0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2-9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4-3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4-2.5) and aOR: 0.8 (95% CI: 0.6-1.2), respectively. CONCLUSION: Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks.

HIV-exposed uninfected infant morbidity and mortality within a nationally representative prospective cohort of mother-infant pairs in Zimbabwe.

OBJECTIVE: To examine morbidity and mortality risk among HIV-exposed uninfected (HEU) infants. DESIGN: Secondary data analysis of HEU infants in a prospective cohort study of mother-infant pairs. METHODS: Infants were recruited from immunization clinics (n = 151) in Zimbabwe from February to August 2013, enrolled at 4-12 weeks age, and followed every 3 months until incident HIV-infection, death, or 18-month follow-up. We estimated cumulative mortality probability and hazard ratios with 95% confidence intervals (CIs) using Kaplan-Meier curves and Cox regression, respectively. We also described reported reasons for infant hospitalization and symptoms preceding death. Median weight-for-age z-scores (WAZ) and median age were calculated and analyzed across study visits. RESULTS: Of 1188 HIV-exposed infants, 73 (6.1%) contracted HIV; we analyzed the remaining 1115 HEU infants. In total, 54 (4.8%) infants died, with median time to death of 5.5 months since birth (interquartile range: 3.6-9.8 months). Diarrhea, difficulty breathing, not eating, fever, and cough were commonly reported (range: 7.4-22.2%) as symptoms preceding infant death. Low birth weight was associated with higher mortality (adjusted hazard ratio 2.66, CI: 1.35-5.25), whereas maternal antiretroviral therapy predelivery (adjusted hazard ratio 0.34, CI: 0.18-0.64) and exclusive breastfeeding (adjusted hazard ratio 0.50, CI: 0.28-0.91) were associated with lower mortality. Overall, 9.6% of infants were hospitalized. Infant median WAZ declined after 3 months of age, reaching a minimum at 14.5 months of age, at which 50% of infants were underweight (WAZ below -2.0). CONCLUSION: Clinical interventions including maternal antiretroviral therapy; breastfeeding and infant feeding counseling and support; and early prevention, identification, and management of childhood illness; are needed to reduce HEU infant morbidity and mortality.