Cholera Outbreak - Haiti, September 2022-January 2023.

On September 30, 2022, after >3 years with no confirmed cholera cases (1), the Directorate of Epidemiology, Laboratories and Research (DELR) of the Haitian Ministry of Public Health and Population (Ministère de la Santé Publique et de la Population [MSPP]) was notified of two patients with acute, watery diarrhea in the metropolitan area of Port-au-Prince. Within 2 days, Haiti's National Public Health Laboratory confirmed the bacterium Vibrio cholerae O1 in specimens from the two patients with suspected cholera infection, and an outbreak investigation began immediately. As of January 3, 2023, >20,000 suspected cholera cases had been reported throughout the country, and 79% of patients have been hospitalized. The moving 14-day case fatality ratio (CFR) was 3.0%. Cholera, which is transmitted through ingestion of water or food contaminated with fecal matter, can cause acute, severe, watery diarrhea that can rapidly lead to dehydration, shock, and death if not treated promptly (2). Haiti is currently facing ongoing worsening of gang violence, population displacement, social unrest, and insecurity, particularly in the metropolitan area of Port-au-Prince, including Belair, Bas-Delmas, Centre-Ville, Martissant, Cité Soleil, Croix-des Bouquets, and Tabarre, creating an environment that has facilitated the current resurgence of cholera (3). This report describes the initial investigation, ongoing outbreak, and public health response to cholera in Haiti. Cholera outbreak responses require a multipronged, multisectoral approach including surveillance; case management; access to safe water, sanitation, and hygiene (WASH) services; targeted oral cholera vaccine (OCV) campaigns; risk communication; and community engagement. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.

Contribution of whole genome sequencing in the molecular diagnosis of mosaic partial deletion of the NF1 gene in neurofibromatosis type 1.

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease with complete penetrance but highly variable expressivity. In most patients, Next Generation Sequencing (NGS) technologies allow the identification of a loss-of-function pathogenic variant in the NF1 gene, a negative regulator of the RAS-MAPK pathway. We describe the 5-year diagnosis wandering of a patient with a clear NF1 clinical diagnosis, but no molecular diagnosis using standard molecular technologies. The patient presented with a typical NF1 phenotype but NF1 targeted NGS, NF1 transcript analysis, MLPA, and array comparative genomic hybridization failed to reveal a genetic aberration. After 5 years of unsuccessful investigations, trio WGS finally identified a de novo mosaic (VAF ~ 14%) 24.6 kb germline deletion encompassing the promoter and first exon of NF1. This case report illustrates the relevance of WGS to detect structural variants including copy number variants that would be missed by alternative approaches. The identification of the causal pathogenic variant allowed a tailored genetic counseling with a targeted non-invasive prenatal diagnosis by detecting the deletion in plasmatic cell-free DNA from the proband's pregnant partner. This report clearly highlights the need to make WGS a clinically accessible test, offering a tremendous opportunity to identify a molecular diagnosis for otherwise unsolved cases.

Contribution of Whole-Genome Sequencing and Transcript Analysis to Decipher Retinal Diseases Associated with MFSD8 Variants.

Biallelic gene defects in MFSD8 are not only a cause of the late-infantile form of neuronal ceroid lipofuscinosis, but also of rare isolated retinal degeneration. We report clinical and genetic data of seven patients compound heterozygous or homozygous for variants in MFSD8, issued from a French cohort with inherited retinal degeneration, and two additional patients retrieved from a Swiss cohort. Next-generation sequencing of large panels combined with whole-genome sequencing allowed for the identification of twelve variants from which seven were novel. Among them were one deep intronic variant c.998+1669A>G, one large deletion encompassing exon 9 and 10, and a silent change c.750A>G. Transcript analysis performed on patients' lymphoblastoid cell lines revealed the creation of a donor splice site by c.998+1669A>G, resulting in a 140 bp pseudoexon insertion in intron 10. Variant c.750A>G produced exon 8 skipping. In silico and in cellulo studies of these variants allowed us to assign the pathogenic effect, and showed that the combination of at least one severe variant with a moderate one leads to isolated retinal dystrophy, whereas the combination in trans of two severe variants is responsible for early onset severe retinal dystrophy in the context of late-infantile neuronal ceroid lipofuscinosis.

Description of Oromurcia magadanensis sp. nov. (Acari, Oribatida, Ceratozetidae) from Russia, with remarks on biogeography of the genus Oromurcia Thor, 1930.

Species of the genus Oromurcia Thor, 1930 (Oribatida, Ceratozetidae) mainly have an arctic or alpine distribution in the Western Palaearctic region and Greenland. We describe a new species of Oromurcia from Northeast Asia (Magadan Region, Russia) based on adult and juvenile instars. Numerous populations of Oromurcia magadanensis sp. nov. were found under arctic-alpine plants in a narrow stream gully with large snow accumulation on the Ola Plateau (1023 m a.s.l.). Adults of Oromurcia magadanensis sp. nov. differ from those of Oromurcia bicuspidata and O. sudetica by their smaller size, the presence of clavate, distally broadly rounded bothridial seta, tutorium with several teeth distally, and the absence of striations on the lamella. Juvenile instars of the new species differ from those of O. bicuspidata and O. sudetica by the presence of medium-sized gastronotic setae in the larva, and long lateral and posterior gastronotic setae in nymphs. We compare adult and juveniles of Oromurcia magadanensis sp. nov. with those of other members of the ceratozetid subfamily Trichoribatinae Shaldybina, 1966 from arctic or alpine regions, for which ontogeny is known, and provide revised diagnoses for adult and juvenile members of Trichoribatinae. All Oromurcia species are associated with cold wet places (periglacial habitats, bogs and fens, alpine meadows, snowbeds, and, less frequently, montane coniferous forests) in Eastern and Western Palaearctic, but they are absent from High Arctic and Siberian regions that are ultra-cold in winter. This spatial disjunction argues for a former Trans-Palaearctic range that was possibly subdivided by reсurrent cryo-arid Pleistocene episodes.

Novel TTLL5 Variants Associated with Cone-Rod Dystrophy and Early-Onset Severe Retinal Dystrophy.

Variants of the TTLL5 gene, which encodes tubulin tyrosine ligase-like family member five, are a rare cause of cone dystrophy (COD) or cone-rod dystrophy (CORD). To date, only a few TTLL5 patients have been clinically and genetically described. In this study, we report five patients harbouring biallelic variants of TTLL5. Four adult patients presented either COD or CORD with onset in the late teenage years. The youngest patient had a phenotype of early onset severe retinal dystrophy (EOSRD). Genetic analysis was performed by targeted next generation sequencing of gene panels and assessment of copy number variants (CNV). We identified eight variants, of which six were novel, including two large multiexon deletions in patients with COD or CORD, while the EOSRD patient harboured the novel homozygous p.(Trp640*) variant and three distinct USH2A variants, which might explain the observed rod involvement. Our study highlights the role of TTLL5 in COD/CORD and the importance of large deletions. These findings suggest that COD or CORD patients lacking variants in known genes may harbour CNVs to be discovered in TTLL5, previously undetected by classical sequencing methods. In addition, variable phenotypes in TTLL5-associated patients might be due to the presence of additional gene defects.

Hogsbackia africaensis/ gen. nov., sp. nov. (Acari, Oribatida, Ceratozetoidea, Punctoribatidae), from Afromontane forest of South Africa.

A new oribatid mite genus, Hogsbackia gen. nov. (Oribatida, Punctoribatidae), with type species Hogsbackia africaensis sp. nov., is proposed and described from the indigenous Afromontane forest of South Africa. The new genus is closely related to Scotiazetes, from which it is most easily distinguished by body size ratio, number of notogastral and genital setae, type of humeral porose area Ah, position of dorsophragmata, and leg setation. The redescription of Scotiazetes bidens Wallwork, 1966 is presented, based on material from South Georgia (Antarctic region). The generic diagnosis of Scotiazetes is revised, and the genus is transferred from Ceratozetidae to Punctoribatidae. Relationships between the genera Hogsbackia gen. nov., Scotiazetes and other punctoribatid genera are discussed.

Sculpteremaeus olszanowskii gen. nov., sp. nov. (Acari, Oribatida, Cymbaeremaeidae) from chaparral in California, USA, with a reassessment of Cymbaeremaeidae.

A new oribatid mite genus, Sculpteremaeus gen. nov. (Oribatida, Cymbaeremaeidae), with Sculpteremaeus olszanowskii sp. nov. as type species, is proposed and described based on adults. It is from sandy soil-litter in chaparral of California, USA, an environment from which no oribatid mites have been recorded previously. Based on an analysis of adults of all genera of Cymbaeremaeidae, the new genus is closely related to Ametroproctus, from which it is most easily distinguished by the morphology of lamellae, size of lamellar cusps, and shape of the tutorium. We expand the Cymbaeremaeidae family diagnosis, and question the inclusion of Scapheremaeus based on extensive molecular evidence showing its closer relationship with Ameronothroidea and Licneremaeoidea.

Atypical Retinal Phenotype in a Patient With Alström Syndrome and Biallelic Novel Pathogenic Variants in ALMS1, Including a de novo Variation.

Alström syndrome (ALMS) is a rare autosomal recessive multi-organ syndrome considered to date as a ciliopathy and caused by variations in ALMS1. Phenotypic variability is well-documented, particularly for the systemic disease manifestations; however, early-onset progressive retinal degeneration affecting both cones and rods (cone-rod type) is universal, leading to blindness by the teenage years. Other features include cardiomyopathy, kidney dysfunction, sensorineural deafness, and childhood obesity associated with hyperinsulinemia and type 2 diabetes mellitus. Here, we present an unusual and delayed retinal dystrophy phenotype associated with ALMS in a 14-year-old female, with affected cone function and surprising complete preservation of rod function on serial electroretinograms (ERGs). High-throughput sequencing of the affected proband revealed compound heterozygosity with two novel nonsense variations in the ALMS1 gene, including one variant of de novo inheritance, an unusual finding in autosomal recessive diseases. To confirm the diagnosis in the context of an unusually mild phenotype and identification of novel variations, we demonstrated the biallelic status of the compound heterozygous variations (c.[286C > T];[1211C > G], p.[(Gln96*)];[(Ser404*)]). This unique case extends our knowledge of the phenotypic variability and the pathogenic variation spectrum in ALMS patients.

Proteasome subunit PSMC3 variants cause neurosensory syndrome combining deafness and cataract due to proteotoxic stress.

The ubiquitin-proteasome system degrades ubiquitin-modified proteins to maintain protein homeostasis and to control signalling. Whole-genome sequencing of patients with severe deafness and early-onset cataracts as part of a neurological, sensorial and cutaneous novel syndrome identified a unique deep intronic homozygous variant in the PSMC3 gene, encoding the proteasome ATPase subunit Rpt5, which lead to the transcription of a cryptic exon. The proteasome content and activity in patient's fibroblasts was however unaffected. Nevertheless, patient's cells exhibited impaired protein homeostasis characterized by accumulation of ubiquitinated proteins suggesting severe proteotoxic stress. Indeed, the TCF11/Nrf1 transcriptional pathway allowing proteasome recovery after proteasome inhibition is permanently activated in the patient's fibroblasts. Upon chemical proteasome inhibition, this pathway was however impaired in patient's cells, which were unable to compensate for proteotoxic stress although a higher proteasome content and activity. Zebrafish modelling for knockout in PSMC3 remarkably reproduced the human phenotype with inner ear development anomalies as well as cataracts, suggesting that Rpt5 plays a major role in inner ear, lens and central nervous system development.

Checklist of oribatid mites (Acari: Oribatida) of Canada and Alaska.

This checklist of the oribatid fauna of Canada and Alaska (excluding Astigmata) includes 580 identified species in 249 genera and 96 families. The known fauna of Canada includes 556 identified species in 247 genera, and that of Alaska includes 182 species in 95 genera; 39 of the 42 oribatid superfamilies are represented. We further list ~ 300 species that are currently unidentified, and possibly undescribed. In addition, we list 42 genera that are represented only by unidentified and probably undescribed species. For each species we give combinations and synonymies, specific locations in Alaska and the Provinces and Territories of Canada, habitats, and biogeography.                There are 182 identified species known for Alaska, 152 for Yukon, 122 for Northwest Territories, 58 for Nunavut; 210 for British Columbia, 213 for Alberta, 15 for Saskatchewan, 84 for Manitoba, 167 for Ontario, 210 for Québec, 110 for Nova Scotia, 77 for New Brunswick, 84 for Newfoundland and 6 for Prince Edward Island. The known fauna of Canada is smaller than that of Austria, and is approximately equivalent to that of the Czech Republic. As these countries are much smaller in size than Canada and less ecologically diverse, we consider the Canadian and Alaskan fauna are at most 25% known. The paucity of these data reflects the absence of taxonomic and faunistic studies on Oribatida in State, Provinces or Territories, and especially in the Canadian and Alaskan National Park systems and the hundreds of Provincial Parks.                Despite the almost 90% increase in described species since the catalogue of Marshall et al. (1987), there is a need for focussed, coordinated research on Oribatida in the natural regions throughout Canada and Alaska, and for monographs on families and genera with large numbers of undescribed species, such as Brachychthoniidae, Damaeidae, Cepheidae, Liacaridae, Oppiidae, Suctobelbidae, Hydrozetidae, Phenopelopidae, Scheloribatidae, Haplozetidae and Galumnidae.

Trichoribates sidorchukae sp. nov. (Acari, Oribatida, Ceratozetidae) from tropical montane Ecuador, with revised generic diagnosis.

Species of the oribatid mite genus Trichoribates (Oribatida, Ceratozetidae) are primarily north temperate in distribution, with only two species known from the Neotropics. We describe Trichoribates sidorchukae sp. nov. from the tropical montane of Ecuador, based on adult morphology, the first species in the genus from Ecuador. We provide a revised generic diagnosis to include character states overlooked in previous diagnoses. An identification key to known species of Trichoribates in the Neotropical region is provided.

Mutations in KARS cause a severe neurological and neurosensory disease with optic neuropathy.

Mutations in genes encoding aminoacyl-tRNA synthetases have been reported in several neurological disorders. KARS is a dual localized lysyl-tRNA synthetase and its cytosolic isoform belongs to the multiple aminoacyl-tRNA synthetase complex (MSC). Biallelic mutations in the KARS gene were described in a wide phenotypic spectrum ranging from nonsyndromic deafness to complex impairments. Here, we report on a patient with severe neurological and neurosensory disease investigated by whole-exome sequencing and found to carry biallelic mutations c.683C>T (p.Pro228Leu) and c.871T>G (p.Phe291Val), the second one being novel, in the KARS gene. The patient presented with an atypical clinical presentation with an optic neuropathy not previously reported. At the cellular level, we show that cytoplasmic KARS was expressed at a lower level in patient cells and displayed decreased interaction with MSC. In vitro, these two KARS variants have a decreased aminoacylation activity compared with wild-type KARS, the p.Pro228Leu being the most affected. Our data suggest that dysfunction of cytoplasmic KARS resulted in a decreased level of translation of the nuclear-encoded lysine-rich proteins belonging to the respiratory chain complex, thus impairing mitochondria functions.

Where are the missing gene defects in inherited retinal disorders? Intronic and synonymous variants contribute at least to 4% of CACNA1F-mediated inherited retinal disorders.

Inherited retinal disorders (IRD) represent clinically and genetically heterogeneous diseases. To date, pathogenic variants have been identified in ~260 genes. Albeit that many genes are implicated in IRD, for 30-50% of the cases, the gene defect is unknown. These cases may be explained by novel gene defects, by overlooked structural variants, by variants in intronic, promoter or more distant regulatory regions, and represent synonymous variants of known genes contributing to the dysfunction of the respective proteins. Patients with one subgroup of IRD, namely incomplete congenital stationary night blindness (icCSNB), show a very specific phenotype. The major cause of this condition is the presence of a hemizygous pathogenic variant in CACNA1F. A comprehensive study applying direct Sanger sequencing of the gene-coding regions, exome and genome sequencing applied to a large cohort of patients with a clinical diagnosis of icCSNB revealed indeed that seven of the 189 CACNA1F-related cases have intronic and synonymous disease-causing variants leading to missplicing as validated by minigene approaches. These findings highlight that gene-locus sequencing may be a very efficient method in detecting disease-causing variants in clinically well-characterized patients with a diagnosis of IRD, like icCSNB.

Acari of Canada.

Summaries of taxonomic knowledge are provided for all acarine groups in Canada, accompanied by references to relevant publications, changes in classification at the family level since 1979, and notes on biology relevant to estimating their diversity. Nearly 3000 described species from 269 families are recorded in the country, representing a 56% increase from the 1917 species reported by Lindquist et al. (1979). An additional 42 families are known from Canada only from material identified to family- or genus-level. Of the total 311 families known in Canada, 69 are newly recorded since 1979, excluding apparent new records due solely to classification changes. This substantial progress is most evident in Oribatida and Hydrachnidia, for which many regional checklists and family-level revisions have been published. Except for recent taxonomic leaps in a few other groups, particularly of symbiotic mites (Astigmata: feather mites; Mesostigmata: Rhinonyssidae), knowledge remains limited for most other taxa, for which most species records are unpublished and may require verification. Taxonomic revisions are greatly needed for a large majority of families in Canada. Based in part on species recorded in adjacent areas of the USA and on hosts known to be present here, we conservatively estimate that nearly 10,000 species of mites occur in Canada, but the actual number could be 15,000 or more. This means that at least 70% of Canada's mite fauna is yet unrecorded. Much work also remains to match existing molecular data with species names, as less than 10% of the ~7500 Barcode Index Numbers for Canadian mites in the Barcode of Life Database are associated with named species. Understudied hosts and terrestrial and aquatic habitats require investigation across Canada to uncover new species and to clarify geographic and ecological distributions of known species.

Virologic outcome among patients receiving antiretroviral therapy at five hospitals in Haiti.

INTRODUCTION: Viral load (VL) assessment is the preferred method for diagnosing and confirming virologic failure for patients on antiretroviral therapy (ART). We conducted a retrospective cross-sectional study to evaluate the virologic suppression rate among patients on ART for ≥6 months in five hospitals around Port-au-Prince, Haiti. METHODS: Plasma VL was measured and patients with VL <1,000 copies/mL were defined as virologically suppressed. A second VL test was performed within at least six months of the first test. Factors associated with virologic suppression were analyzed using logistic regression models accounting for site-level clustering using complex survey procedures. RESULTS: Data were analyzed for 2,313 patients on ART for six months or longer between July 2013 and February 2015. Among them, 1,563 (67.6%) achieved virologic suppression at the first VL test. A second VL test was performed within at least six months for 718 (31.0%) of the patients. Of the 459 patients with an initial HIV-1 RNA <1,000 copies/mL who had a second VL performed, 394 (85.8%) maintained virologic suppression. Virologic suppression was negatively associated with male gender (adjusted odds ratio [aOR]: 0.80, 95% CI: 0.74-0.0.86), 23 to 35 months on ART (aOR:0.72[0.54-0.96]), baseline CD4 counts of 201-500 cells/mm3 and 200 cells/mm3 or lower (aORs: 0.77 [0.62-0.95] and 0.80 [0.66-0.98], respectively), poor adherence (aOR: 0.69 [0.59-0.81]), and TB co-infection (aOR: 0.73 [0.55-0.97]). CONCLUSIONS: This study showed that over two-thirds of the patients in this evaluation achieved virologic suppression after ≥ six months on ART and the majority of them remained suppressed. These results reinforce the importance of expanding access to HIV-1 viral load testing in Haiti for monitoring ART outcomes.

Tegoribatidae of North America, with proposal of Protectoribates gen. nov., and new species (Acari, Oribatida, Tegoribatidae).

The oribatid mite family Tegoribatidae has been represented in continental North America by the genera Tegoribates and Tectoribates. Herein, I describe a new genus of Tegoribatidae from North America, Protectoribates, and two new species: Protectoribates occidentalis sp. nov., from forest habitats in western North American, and Tegoribates walteri sp. nov., from forest habitats in California, based on adults and immatures. The descriptions of adults of the type species of Tegoribates, T. subniger Ewing, and other North American species, T. americanus Hammer and T. bryophilus Woolley, are expanded and immatures of T. americanus are described for the first time. Immatures of Protectoribates are apheredermous whereas those of Tegoribates are eupheredermous, though retaining centrodorsal setae. Scutozetes Hammer 1952 is transferred from Tegoribatidae to Ceratozetidae after re-examination of type material. I provide a revised diagnosis for Tegoribates and a key to tegoribatid genera and species for North America. Finally, I provide a revised diagnosis for Tegoribatidae based on world genera.

Contribution to the knowledge of the oribatid mite family Nesozetidae (Acari, Oribatida).

A new oribatid mite species of the genus Nesozetes (Oribatida, Nesozetidae) is described from moss (Sphagnum sp.) on the seepage area below a permanent spring in South Africa. Nesozetes membranus sp. nov. differs from its only congener, Nesozetes rostropterus, described from Fiji, by the presence of a second pair of membranes located in the podosomal region, setiform bothridial setae and striate subcapitular mentum. A revised diagnosis of Nesozetidae, discussion on its taxonomic status, and information on distribution and ecology of Nesozetes species are given.

Trends in Prevalence of Advanced HIV Disease at Antiretroviral Therapy Enrollment - 10 Countries, 2004-2015.

Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/µL) among persons starting antiretroviral therapy (ART) is important to understand ART program outcomes, inform HIV prevention strategy, and forecast need for adjunctive therapies.*,†,§ To assess trends in prevalence of advanced disease at ART initiation in 10 high-burden countries during 2004-2015, records of 694,138 ART enrollees aged ≥15 years from 797 ART facilities were analyzed. Availability of national electronic medical record systems allowed up-to-date evaluation of trends in Haiti (2004-2015), Mozambique (2004-2014), and Namibia (2004-2012), where prevalence of advanced disease at ART initiation declined from 75% to 34% (p<0.001), 73% to 37% (p<0.001), and 80% to 41% (p<0.001), respectively. Significant declines in prevalence of advanced disease during 2004-2011 were observed in Nigeria, Swaziland, Uganda, Vietnam, and Zimbabwe. The encouraging declines in prevalence of advanced disease at ART enrollment are likely due to scale-up of testing and treatment services and ART-eligibility guidelines encouraging earlier ART initiation. However, in 2015, approximately a third of new ART patients still initiated ART with advanced HIV disease. To reduce prevalence of advanced disease at ART initiation, adoption of World Health Organization (WHO)-recommended "treat-all" guidelines and strategies to facilitate earlier HIV testing and treatment are needed to reduce HIV-related mortality and HIV incidence.

Comparison of electromagnetic neuronavigation system and free-hand method for ventricular catheter placement in internal shunt.

OBJECTIVE: Optimal ventricular catheter positioning is able to reduce the risk of catheter dysfunction, and subsequently the risk of multiple revision surgery. The objective of our study was to compare the proportion of optimal ventricular catheter placements in a cohort of patients operated for ventriculoperitoneal (VP) shunt between a free-hand group and a neuronavigated group. PATIENTS AND METHODS: Twenty patients with hydrocephalus requiring VP shunt were prospectively included in this study. Patients were divided into two groups; the ventricular catheter was positioned using free-hand method (n=10) or magnetic navigation system (n=10). For the two groups, clinical baseline characteristics, etiology of hydrocephaly and initial ventricular size were assessed. The main judgment criterion was the proportion of optimal catheter placements defined by the presence of all catheter holes in the ventricle, evaluated on post-operative CT scan. RESULTS: There was no initial difference between the two groups in terms of hydrocephalus etiology or initial ventricular size. The number of optimal catheter placements was 6/10 in the neuronavigated group versus 1/10 in the free-hand group (p<0.05). There were no complications during post-operative period in either cohort. CONCLUSION: In patients suffering from hydrocephaly, the use of an electromagnetic neuronavigation system for ventricular catheter placement significantly improved the proportion of optimal catheter placements. Long-term follow-up is necessary to evaluate the number of revision surgeries and the cost in each group.

"This Method, I Think, Can Shed New Light": Haitian-American Women's Reflections on Risk, Culture, and Family Planning Decisions From a Short-Term Trial of a Cervical Barrier (Femcap™).

Improving the reproductive health of immigrant populations requires understanding the specific context of risk and need. As part of a field trial of the FemCap™, a woman-initiated cervical barrier contraceptive, we conducted postintervention focus group discussions (FGDs) with 20 women (five FGDs) of Haitian background, the majority of whom were born in Haiti and spoke Haitian Créole at home, at a community health center in south Florida. Participants discussed the role of religion and inequitable gender norms in Haitian traditions about family planning decisions and provided important insights into the gender-power nuances of their partnership dynamics vis à vis the use of female barrier methods. Encouraged by more equitable gender norms in the United States, participants were eager to serve as health education agents, with strong altruistic sentiments toward other Haitian girls and women who they felt could be encouraged to negotiate for greater reproductive decision-making power.