Global health

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A multi-methods implementation research evaluation of a program scale cluster randomized trial to improve integration of HIV prevention and treatment services in family planning clinics in Kenya
(2026-04-20) Wanje, George Horace; McClelland, R. Scott
Funding cuts to the US President’s Emergency Plan for AIDS Relief (PEPFAR) undermine the global HIV response and threaten harm reduction efforts across low-and middle-income countries (LMICs). In the current geopolitical and funding landscape, the urgency of integrating HIV services within broader health systems is greater than ever to sustain hard-won gains. Integrating HIV prevention and treatment services into family planning (FP) clinics offers a promising strategy to address HIV and unwanted pregnancy simultaneously while supporting the UNAIDS 95-95-95 targets for testing, treatment, and prevention. However, evidence on how best to integrate these two services in LMICs remains limited. The FP HIV SCALE study is a hybrid type II effectiveness-implementation trial that evaluates the effectiveness of the Systems Analysis and Improvement Approach (SAIA) as an implementation strategy to increase the integration of HIV prevention and treatment services at program scale in FP clinics when implemented by the Mombasa County public health workforce in Kenya. The work described in this dissertation is nested within the FP HIV SCALE study. We applied a combination of multi-method analytical approaches, including linear regression models, mixed-methods studies, and a rigorous configurational comparative method called coincidence analysis (CNA) to conduct an implementation evaluation for the FP HIV SCALE study. The primary aims were to: 1) evaluate associations between organizational readiness for change, organizational climate, and successful integration of HIV counseling, HIV testing, screening and linkage for PrEP, and linkage to HIV care in FP clinics; 2) evaluate implementation outcomes of acceptability, appropriateness, and feasibility from healthcare workers’ perspectives of using a modified national register (research record) to document programmatic integrated FP/HIV performance data; and 3) define the difference-makers of SAIA micro-interventions that are necessary or sufficient for the successful integration of HIV counseling and testing in FP clinics. In the first aim, we did not observe associations between organizational readiness, organizational climate metrics, and clinical outcomes for integrated HIV services. We identified organizational climate metrics that are important predictors of readiness for change. For both FP clinic staff and clinic managers, upward communication and innovation/flexibility metrics were predictive of organizational readiness. Furthermore, clinic managers’ perceptions of management support and commitment to the facility were strongly associated with organizational readiness. The second aim used a convergent mixed-methods approach to evaluate the research record, applying the Consolidated Framework for Implementation Research (CFIR) to assess outcomes of acceptability, appropriateness, and feasibility from Proctor’s Implementation Outcomes Framework. Family planning clinic staff and managers in intervention and control clinics found the research record highly acceptable, appropriate, and feasible for documenting integrated outcomes in a single place. Finally, the third aim on CNA identified difference-makers of SAIA micro-intervention categories that resulted in achieving success of integrated HIV counseling and testing in FP clinics. For HIV counseling, three candidate models each with three pathways were identified. A sufficiency model with three pathways was identified as the best because of its high coverage scores compared to the other two models. The patient education category of micro-interventions was a sufficient condition for achieving the outcome. The other two pathways represented the data quality category bundled with either the training category or the external support category of micro-interventions. For HIV testing, we identified a single model consisting of two pathways. The training category of micro-interventions alone was sufficient for producing the outcome, and a second pathway was a conjunct of patient education and data quality micro-interventions. This dissertation offers novel insights that are broadly relevant in the field of implementation research, as well as a roadmap for integrating HIV prevention and treatment services into FP clinics. By applying implementation science to real-world scale-up efforts, this work helps bridge the “know-do gap” in integrating health services. These findings deepen our understanding of how we and others have hypothesized the relationship between readiness and clinical outcomes while also highlighting potential gaps in measurement, the practical tools essential for integration, and the optimal combination of factors that drive success of integrated outcomes. Collectively, these findings offer important lessons for LMICs and provide actionable insights for researchers and policymakers working to advance the integration of HIV and FP services globally.
Implementation Outcomes and Impacts of Ciudad Medio Ambiente y Salud: An Environmental Initiative Promoting One Health in Iquitos, Peru
(2026-04-20) Alarcon, Jorge Antonio; Zunt, Joseph
Colonialism, extractivism, and rapid urbanization in Iquitos—the largest city in the Peruvian Amazon—have disrupted core urban systems, limiting access to green space, health services, and environmental infrastructure, and contributing to interconnected human, ecological, and environmental crises. With only 1 m² of green space per capita, Iquitos is one of the most green-deficient cities in Peru. Addressing this deficit may mitigate multiple dimensions of One Health.Ciudad Medio Ambiente y Salud (Ciudad MAS) is a residential garden program designed to promote the adoption of residential green spaces to address mental health, vector-related risks, and environmental quality. This dissertation first specifies Ciudad MAS using implementation science frameworks, including Proctor’s recommendations for reporting implementation strategies and the Implementation Research Logic Model. It then evaluates findings from a pilot cluster randomized trial assessing implementation outcomes, environmental quality, and mental health. The specification process demonstrates that participatory environmental design initiatives can be systematically adapted for scale through implementation science. Strategies derived from prior design experience aligned with Expert Recommendations for Implementing Change (ERIC). The pilot achieved high adoption of functional gardens. Although green space per capita did not increase, residential environmental quality improved through increased tree planting, maintenance, and accessibility. Acceptability, appropriateness, and feasibility were high at baseline and remained high, suggesting strong implementation readiness. No significant short-term effects were observed on anxiety or depression scores. However, residential satisfaction improved, and exploratory analyses suggest a plausible pathway linking built-environment improvements to mental health outcomes. Overall, this work demonstrates that residential gardens can function as scalable, implementation science–informed One Health interventions in land-constrained and resource-limited cities.
Tailoring community antiretroviral therapy delivery to the needs and preferences of people living with HIV in refugee settlements in Uganda
(2026-04-20) Klabbers, Robin Elise; Wagner, Anjuli D
Ending the HIV epidemic as a public health threat by 2030 will require equitable progress across all subpopulations and contexts, including those affected by displacement and humanitarian instability. In refugee settlements in Uganda, engagement in care among people with HIV (PWH) remains below global targets, despite the availability of free HIV services, including antiretroviral therapy (ART). This shortfall reflects the numerous structural and social barriers that humanitarian populations must overcome to access care, including stigma, limited social support, long distances to clinics, inclement weather, underdeveloped road infrastructure, constrained livelihood opportunities to offset transportation costs, and competing survival needs. Community ART delivery, a differentiated service delivery model (DSDM) offered in Uganda, including in refugee settlements, moves HIV treatment out of health facilities and into the community with the goal of improving care engagement while reducing the burden on health systems. While community ART delivery has demonstrated effectiveness in improving retention and viral suppression in other settings across sub-Saharan Africa, refugee settlements represent a fundamentally different service environment. Evidence is lacking on how community ART delivery uptake and implementation are shaped by the unique context and what adaptations may be necessary to ensure its impact. The objective of this dissertation was to generate actionable evidence on what enables and motivates participation in community ART delivery among PWH in refugee settlements, and on the contextual factors shaping implementation feasibility for providers. The long-term goal of this research is to generate findings that will ultimately inform the design of effective, person-centered DSDMs for HIV in humanitarian settings. This work was carried out through three interconnected studies. In the first study, 34 in-depth interviews (IDIs) with PWH and seven focus group discussions (FGDs) with 51 HIV care providers were conducted across five refugee settlements in midwestern and southwestern Uganda (October 2024 – May 2025). Barriers to participation in and implementation of community ART delivery were explored within IDIs and FGDs, as well as strategies to address these barriers, and perspectives on ideal model design, guided by the Consolidated Framework for Implementation Research (CFIR) 2.0. Using rapid qualitative methods, barriers were mapped to CFIR constructs and proposed strategies to Expert Recommendations for Implementing Change (ERIC) strategy clusters, with findings synthesized into causal pathway diagrams. Barriers to community ART delivery participation and implementation were closely intertwined. PWH and providers described barriers related to both motivation and opportunity that were shaped by local conditions, local attitudes surrounding HIV, model characteristics, weak relational connections within ART groups, poor teaming, limited resources, lack of incentives, inadequate work infrastructure, and communication challenges. Key strategies to address these barriers that were proposed by participants included changing infrastructure, utilizing financial strategies, adapting and tailoring community ART delivery to the context, developing stakeholder interrelationships, and engaging consumers. Rather than endorsing a single model, participants highlighted the need for a flexible mix of community ART delivery options. Confidentiality, flexibility, and reliability were identified as hallmarks of ideal community ART delivery. In the second study, IDIs and FGD participants prioritized the barriers to community ART delivery participation and implementation that they had identified through structured ranking exercises. In IDIs, participants were asked to rank their first, second, and third most important barriers to community ART delivery participation. In FGDs, implementation barriers were prioritized using the nominal group technique, which consisted of individual rating of perceived barrier importance, frequency, duration, impact on equity, and addressability using Likert scales—followed by structured group discussion and voting. Participation and implementation barriers were prioritized using mean ranking and frequency of mention, and multi-dimensional priority was examined using go-zone analysis. Stigma and structural health system constraints were the highest-priority barriers to community ART delivery. Stigma-related concerns—including involuntary disclosure, anticipated stigma, and internalized stigma—were consistently ranked among the most important barriers to participation and were also identified as major challenges to implementation. Structural barriers included lack of suitable community ART delivery sites, geographic distance, transport limitations, and human resource shortages. Barriers related to community ART delivery site infrastructure were perceived as highly impactful and relatively addressable, whereas stigma and human resource constraints were considered less readily addressable. Transport and staffing limitations were described as more recent challenges in the context of funding and service delivery transitions. In the third study, 250 PWH receiving ART from 12 health centers in refugee settlements in midwestern and southwestern Uganda were offered participation in a discrete choice experiment (DCE) to quantify community ART delivery preferences that was designed using Sawtooth Lighthouse Studio and was informed by prior qualitative findings. Participants completed 8 choice tasks, each consisting of two hypothetical community ART delivery model alternatives and an opt-out option. Alternatives were defined by delivery location, delivery structure (group versus individual), provider type, dispensing interval, delivery timing, and service duration. Preferences were estimated using hierarchical Bayesian multinomial logit models. Additional non-DCE questions assessed willingness to pay and willingness to participate by group size. Findings revealed participant preferences were driven by delivery structure (relative importance 27.5%; 95% credible interval [CrI] 24.0%, 31.1%), delivery location (24.9%; 95% CrI 21.2%, 28.5%), provider type (22.0%; 95% CrI 17.5%, 26.3%), and the amount of ART dispensed at each refill (15.9%; 95% CrI 14.0%, 17.8%). Participants preferred group delivery with social support and income-generating activities (0.67; 95% CrI 0.48, 0.87), home delivery (0.41; 95% CrI 0.24, 0.60), delivery by health workers in uniform (0.32; 95% CrI 0.11, 0.53) and expert clients (0.22; 95% CrI 0.02, 0.42), and six-month dispensing (0.54; 95% CrI 0.43, 0.65). Individual delivery, delivery at non-healthcare community locations, and delivery by Village Health Team members were disliked. The opt-out alternative had strongly negative utility (−3.94; 95% CrI −4.52, −3.42) suggesting strong preference for community ART delivery. Limited evidence was found for clearly defined subgroups with distinct preference patterns. Willingness to participate was higher for community ART delivery models with small groups (82%) than large groups (46%), and 55% of participants reported willingness to pay for home delivery. Together, these three studies advance understanding of how community ART delivery functions in an understudied humanitarian context at a time when global displacement is rising and DSDMs are being scaled up across sub-Saharan Africa. By integrating qualitative inquiry, structured prioritization, and quantitative preference elicitation, this dissertation moves beyond cataloguing barriers to elucidate how structural, social, and organizational factors converge to shape the capacity of community ART delivery to reduce time and transport burdens for PWH in refugee settlements in Uganda. It distills priority targets for implementation optimization and identifies the model features most valued by participants. By centering the perspectives of PWH and applying rigorous implementation science methods, this research offers a stakeholder-informed framework for tailoring differentiated service delivery in resource-constrained humanitarian settings. In doing so, it provides actionable guidance to strengthen DSDM scale-up among displaced populations and advances equitable, person-centered HIV service delivery toward ending the HIV epidemic as a public health threat.
Humanized Mouse with a Diverse Polyclonal B Cell Repertoire as a Model for Neutralizing Antibody Responses against EBV and HIV
(2026-02-05) Chhan, Crystal Belle; McGuire, Andrew T
Epstein-Barr virus (EBV) and human immunodeficiency virus (HIV) cause diseases of global health importance. However, it has been historically difficult to model human neutralizing B cell responses to these two viruses using small animals. I leveraged a transgenic mouse model that encodes a genetically human antibody repertoire to generate neutralizing monoclonal antibodies (mAbs) against the EBV gp350 and gp42 glycoproteins, which have been technically difficult to isolate from natural infection. gp42 and gp350 are involved in attachment and fusion into B cells respectively. Thus, these mAbs have great potential as therapeutic agents against EBV-associated malignancies. In a second project, I investigated the utility of these humanized mice as a surrogate to model VRC01-class B cell responses, a rare class of HIV broadly neutralizing antibodies that target the CD4 binding site on HIV envelope. I utilized high-throughput sequencing to identify the presence of these rare potentially protective B cells in humanized mice and evaluated if an anti-idiotypic immunogen, designed to target genetically encoded features of VRC01-class B cells, could selectively target and expand these cells in vivo.
Measurement of Fertility Intentions to Improve Person-Centered Reproductive Health Counseling among Kenyan Women
(2026-02-05) Seth, Aparna; Drake, Alison
Despite growing recognition that fertility intentions exist along a continuum and encompass ambivalence, most measurement approaches rely on binary categorizations that classify pregnancies as "intended" or "unintended." This framework obscures reproductive decision-making complexity and may contribute to high rates of misclassification of fertility intentions. Accurate measurement of fertility intentions is essential for delivering person-centered reproductive health counseling aligned with women's actual desires and needs. This dissertation addresses measurement gaps through three integrated studies examining fertility intention measurement among Kenyan women, including women living with HIV (WLWH).First, I conducted a systematic review, which identified 26 measures of fertility intentions and pregnancy ambivalence. Less than one-third of measures originated from low- and middle-income countries (LMICs), and domains assessed in those measures varied systematically by geography: LMIC measures emphasized cognitive orientations while high-income country measures emphasized emotional responses and pregnancy planning behaviors. Pregnancy ambivalence was operationalized inconsistently across measures, limiting understanding of its prevalence and meaning. These findings challenge assumptions about universal applicability of fertility intention measures and underscore the need for context-specific measure development and validation. Next, I conducted an evaluation of the Desire to Avoid Pregnancy (DAP) scale among 2,504 Kenyan WLWH, providing novel evidence about this measure's performance in sub-Saharan Africa. Unlike the original unidimensional US validation, the scale exhibited a two-factor structure distinguishing “wanting” pregnancy from “worrying” about consequences, with moderate inter-factor correlation suggesting these dimensions can coexist. Both subscales demonstrated excellent reliability. This bidimensional structure can capture pregnancy ambivalence among women who can simultaneously desire pregnancy and worry about its consequences (e.g. HIV transmission), with implications for how clinicians interpret and respond to DAP scores. In the last study, I developed and validated the HerChoice scale by evaluating the scale among 496 Kenyan women. The final scale resulted in a 5-item measure of fertility intentions including three domains: cognitive orientation, emotional responses, and life course consequences. The scale demonstrated excellent reliability and construct validity evidenced by associations with contraceptive use and sexual activity in the last month. Measurement invariance was observed across age, education, parity, and relationship status, indicating the scale functions equivalently across diverse Kenyan women. Together, these studies demonstrate that more nuanced measurement of fertility intentions is both possible and necessary in LMIC settings. Findings provide evidence about measurement gaps and tools that could address them, including a locally derived brief scale (HerChoice) and cross-cultural validation evidence for an existing multi-domain measure (DAP). However, better measurement tools alone are insufficient without implementation. Tools that accurately capture the complexity of fertility intentions can enable person-centered reproductive health counseling, but only when health systems invest in provider training to interpret and respond to measured intentions, establish counseling protocols that move beyond binary contraceptive decisions, and create service delivery models where women's expressed intentions guide care.
Mapping Disparities in Medication Access, Utilization, and Spending across the United States
(2025-10-02) Sahu, Maitreyi; Dieleman, Joseph L
Achieving equitable access to medicines requires measuring disparities in pharmaceutical utilization and spending and understanding the mechanisms that drive them. Yet in the United States, disparities in medication access, use, and spending—by race, geography, and disease—remain inadequately measured and insufficiently addressed. This dissertation develops new tools and applies them at scale to quantify these inequities, leveraging large-scale spending, prevalence, and geospatial data to examine underlying mechanisms and support targeted health policy action. Chapter 2 introduces a novel probabilistic framework to map prescription drugs to likely health conditions in retail pharmaceutical claims data, addressing a major limitation of existing administrative datasets. Unlike approaches based on US Food and Drug Administration–approved indications or clinical guidelines, it captures real-world prescribing practices, enabling measurement of both on- and off-label use. The resulting drug-condition map supports national, state, and county-level estimates of condition-specific utilization and spending across the US. Chapter 3 applies this drug-condition map to generate state-level estimates of pharmaceutical utilization and spending by race and ethnicity, producing the most comprehensive geographic mapping of medication inequities to date, covering 143 conditions, four payer types, and all 50 states and DC. Findings reveal persistent underutilization among Black populations relative to need, and substantial variation across states and conditions. Decomposition analyses highlight the relative contributions of disease prevalence, prescribing intensity, spending per prescription. Chapter 4 evaluates the role of physical access to community pharmacies in shaping these disparities over a ten-year period across the US. Using over a decade of geolocated pharmacy data, I develop a metric incorporating both driving and walking proximity to assess access across urban and rural census block groups nationwide. I then examine how access relates to medication use, using a disparity index building on findings from Chapter 3. I find that inadequate pharmacy access is associated with wider racial disparities in medication use across health conditions. Together, these chapters offer a data-rich framework for understanding and addressing inequities in access, use, and spending on prescribed medicines across the United States.
Optimizing STI/HIV care for safety net patients in South King County, Washington: Implementation science methods for planning efficient and equitable service provision
(2025-10-02) Morozoff, Chloe; Rubin Means, Arianna
Sexually transmitted infections (STIs) are associated with significant health and financial burden in the United States, affecting an estimated 20% of the population per year. Bacterial STIs and HIV disproportionately impact low-income, immigrant, racial, and ethnic minority populations nationally and in King County (Washington). While health surveillance data reveal obvious STI disparities, it is unclear how to address care gaps in ways that are locally feasible and acceptable to both providers and care recipients. The objective of this project was to leverage implementation science methods to identify optimal strategies for improving STI/HIV testing and treatment services in South King County, the cities and neighborhoods located south of Seattle which experience the highest regional bacterial STI rates and high and growing HIV rates. Given South King County hosts a high proportion of clients living below the poverty line, this study specifically focused on opportunities to improve safety net services, which provide medical care to clients irrespective of their ability to pay, often accepting Medicaid as an insurance and providing sliding scale services to medically uninsured clients. This project includes three studies which, together, identify priorities and potential actions for improving STI/HIV care in South King County from the perspective of providers and clients. In the first study we conducted a landscape analysis of STI/HIV service delivery, using an exploratory sequential mixed-method design (qual -> QUAN). We first conducted 12 key-informant interviews with local service providers and applied rapid thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR 2.0) to identify barriers and facilitators to care. Insights from these interviews informed the development of a quantitative prioritization survey, which was administered to 31 STI subject matter experts to rank the importance of noted barriers and the feasibility and effectiveness of proposed implementation strategies to address them. We identified key challenges related to limited healthcare accessibility, misconceptions about STIs among safety net clients, healthcare workforce shortages, and provider knowledge gaps relating to a shifting STI landscape. Prioritized implementation strategies included mass media campaigns to improve STI knowledge among the public, increased funding for safety net providers to implement operational changes that improve accessibility of care, and use of technology to expand and streamline STI testing. Notably, no feasible strategies were identified for addressing the barrier of high client out-of-pocket costs. In the second study, we conducted a discrete choice experiment (DCE) with potential safety net clients in South King County, to identify preferences for service delivery attributes that could promote client accessibility and utilization of STI/HIV services. Clients completed 12 choice questions, exploring their preferences related to five STI/HIV service and facility-level attributes including: cost, travel time, type of clinical location, appointment hours, and appointment scheduling method. We fit an effects-coded Hierarchical Bayes model to estimate average attribute-level preference weights and overall attribute relative importance scores. We also conducted subgroup analyses to examine differences in preferences by survey language of choice and type of health insurance. A total of 250 clients completed interviews, 190 of whom completed surveys in English and 60 in Spanish. Most clients were either enrolled in Medicaid (42%) or held no insurance at the time of the survey (33%). Cost was the most important attribute overall to clients, accounting for 42% of the impact on choice in where to access services and remaining the top priority across all subgroups. The next most important factors were travel time, with a preference for shorter commutes, followed by type of facility location. Participants demonstrated strong preferences for traditional clinical settings such as general health clinics and sexual and reproductive health clinics, over services offered at community locations such as libraries or through health fairs. Our findings also suggest that, to a lesser degree, shifting hours of operation to allow for evening or weekend appointments and improving online scheduling can further align services with client preferences. In our third study, we use an optimization modeling technique to explore ideal safety net locations to bolster STI/HIV services within South King County. We used a Maximum Covering Location Problem (MCLP), which aims to maximize demand coverage within a distance or time threshold that is hypothesized to be geographically accessible. We expanded traditional MCLP models to also account for facility-level attributes, such as clinic hours, when defining accessibility and estimating utilization. Our objective function maximized the number of STI positive cases within South King County who have access to STI services. We used simulations based on data from our discrete choice experiment to estimate utilization rates for different facility-models. We also ran a series of one-way sensitivity analyses to test variability in model inputs. Our model identified three key locations for expanding service delivery, resulting in an overall coverage rate of 83%, meaning that the three selected locations were estimated to be accessible to 83% of clients diagnosed with STIs. Sensitivity analyses explored the impact of using different data inputs and model constraints, resulting in similar solutions. Prioritized locations were primary care clinics with expanded hours of operation. Results from our model could be incorporated into healthcare priority setting processes, to aid stakeholders in their decision-making processes about strategic locations for driving health outcomes under resource constraints. This dissertation contributes to the literature by providing a use case for the practical application of implementation science frameworks and methods for local health departments. Study findings specify useful information about determinants of STI/HIV safety net service delivery, alongside feasible and effective implementation strategies for addressing key challenges. Additionally, we generate information about relative preferences of clients when accessing STI services, allowing safety net providers and public health practitioners to tailor care to clients. Lastly, we demonstrate a practical use case for applying DCE results to identifying locations for bolstering care that maximize client preferences and estimated utilization of care. Learnings from this work were grounded in participant ideas and feedback and provided an opportunity to explore alignment between client and providers in terms of priorities.
Mycobacterium tuberculosis ESX-5 Paralogs Modulate Macrophage Responses and Bacterial Metal Homeostasis
(2025-10-02) Haynes, Austin Michael; Hawn, Thomas R
University of Washington Abstract Mycobacterium tuberculosis ESX-5 Paralogs Modulate Macrophage Responses and Bacterial Metal Homeostasis Austin Michael Haynes Chair of the Supervisory Committee:Thomas R. Hawn Department of Medicine, Division of Allergy and Infectious Diseases and Department of Global Health Extended co-evolutionary history of humans and Mycobacterium tuberculosis (Mtb), the causative agent of TB disease, has led to an evolutionary arms race between host and pathogen. The processes by which the immune system recognizes and destroys invading pathogens has been extensively co-opted and subverted by Mtb via the evolution of specially adapted virulence effectors. Through a tightly orchestrated bacterial response, Mtb moves these effectors out of the bacterium and into the host cell interface. Traditional bacterial transport systems such as the generalized secretion (SEC) and twin arginine transport (TAT) systems move many effectors, however in Mtb, Type-7 or "ESX" systems play an essential role in virulence processes. Of the five ESX systems in Mtb, some have experimentally defined roles in virulence. ESX-1 is essential for phagosome antagonism while ESX-3 sequesters iron from the host, an essential micronutrient. ESX-5 in contrast is poorly resolved despite secreting a large number of effectors (5-10% of Mtb coding capacity). Based on prior clinical, genetic, and lab-based studies, we hypothesize ESX-5 may play roles in virulence and nutrient acquisition. To date, limited functional work has been performed to fully elucidate functional roles for many ESX-5 secreted putative virulence factors. In complement, the human immune system is persistently evolving in the face of extensive pathogen pressure. The historic and current burden of Mtb infection across modern hominids has pushed human populations to evolve strategies countering pathogens such as Mtb. While humans evolve substantially slower than their mycobacterial counterparts, there is evidence to suggest human populations are actively evolving mechanisms to counter Mtb infection resulting in resistance. Clinically, populations who resist TB infection via persistently negative testing (RSTRs) are being extensively studied to understand the complex genetic interplay resulting in presumed enhanced control of Mtb during early exposure. However, given the complexity of human genetics, the interplay of multiple genes and cell types, and the heterogeneity of Mtb infection itself, we still don't mechanistically understand how RSTRs are able to remain Mtb negative compared to their susceptible counterparts (LTBI). As such we aimed to understand how the genetics of Mtb resistant populations (RSTRs) differ from susceptible individuals (LTBI), affording possible functional insight into resistance processes. Ultimately, we aim to gain functional insight into both human and bacterial genetics to more clearly resolve early Mtb-Host interactions during early infection. Initially, we performed a brief transcriptomic screen of RSTR and LTBI alveolar macrophages to explore the role of human genetics in altering transcriptional responses to early Mtb infection. We demonstrated that alveolar macrophages from these populations display similar but distinct responses. These transcriptional responses in RSTRs are marked by an increased inflammatory response to interferons relative to LTBI counterparts, which could possibly lead to enhanced control of Mtb. Subsequently we investigated the function of specific Mtb gene clusters during early primary macrophage infection. We independently deleted ESX-5a, ESX-5b, and ESX-5c, each containing a PE/PPE heterodimer and Esx heterodimer from the H37Rv strain of Mtb. We then examined the functional consequences of these deletions in macrophages, mice, and axenic bacterial culture. We initially observed that deletion of these gene clusters significantly alters cytokine levels of TNF, IL-6, and IL-1β in primary macrophages. Further analysis revealed this may be due to differential post-transcriptional or translational regulation of target cytokines, resulting in divergent cytokine profiles within infected macrophages. We next examined if this impact observed in human macrophages would impact the fitness of these strains in vivo where we observed early time point growth defects of our mutant strains tested in C57BL/6 mice. Subsequent transcriptome analysis revealed these gene clusters likely play a role in heavy metal response or homeostasis. Indeed, we demonstrated these gene clusters are metal responsive and that their level of expression is correlated to cytokine response levels in primary human macrophages. Together, these observations indicate that both human and bacterial genetics play a role in the outcome of early disease. Not only are these ESX-5 gene clusters involved in stimulating a cellular response in vitro and in vivo, but that these paralogs likely also play a dual role in heavy metal response. These suggest novel function for these previously undefined paralogs and highlight the importance of studying both bacteria and host concurrently to gain novel insight into host-pathogen interactions.
Prevalence and correlates of neurocognitive disorders and the impact on quality of life in women aging with HIV in Nairobi, Kenya.
(2025-10-02) Mwangi, Caroline Wachu; Masyuko, Sarah
Introduction As antiretroviral therapy (ART) coverage expands, people living with HIV (PLHIV) are surviving into older age. In sub-Saharan Africa, women constitute the majority of PLHIV, and emerging evidence suggests that women living with HIV (WLHIV) face a disproportionate burden of neurocognitive impairment as compared to women living without HIV. Despite its clinical importance, neurocognitive impairment among older WLHIV in African settings remains under-recognized and poorly understood.Objective To estimate the prevalence and correlates of neurocognitive impairment and assess its association with health-related quality of life (HRQoL) in WLHIV aged ≥50 years in Kenya. Methods: We conducted a cross-sectional secondary analysis of 200 women aged ≥50 years enrolled at the Comprehensive Care Centre at Kenyatta National Hospital between September 2024 and March 2025. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) and the score was classified as normal (26-30), mild (18-26), moderate (10-17) and severe (>10). The quality of life was measured using the WHOQOL-BREF-HIV instrument and domains assessed were Physical, Psychological, Independence, Social Relationships, Environment and Spirituality/Religion. Depression and Post Traumatic Stress Disorder (PTSD) were evaluated using PHQ-9 and PCL-5, respectively. Logistic and linear regression models were used to identify correlates of cognitive impairment and its association with Health Related Quality of Life (HRQoL) domains. Results: Most participants (62%) were aged 50-59 years, and the majority had completed at least primary school. The prevalence of any form of cognitive impairment was 86%, with mild impairment (66%) being the most common. Being between age 60-69 years was significantly associated with higher odds of moderate to severe impairment compared to aged 50-59 years. Attaining secondary education or higher was strongly protective against moderate to severe impairment after adjustment. Overall HRQoL scores did not differ significantly by cognitive status, but participants with normal or mild cognitive impairment had higher psychological QoL scores compared to those with moderate or severe impairment. Conclusion: Cognitive impairment was prevalent in our study population, with mild impairment being the most common. Advancing age and lower educational attainment are key risk factors for cognitive impairment. Routine cognitive screening, integrated psychosocial support, and interventions to build cognitive reserve, especially through improved education and mental health services, are urgently needed to promote healthy aging and preserve quality of life in this population.
Acceptability of same-day HIV pre-exposure prophylaxis initiation among individuals with depression symptoms during emergency care in Nairobi, Kenya.
(2025-10-02) Sankei, Pirirei; Farquhar, Carey
University of WashingtonAbstract Acceptability of same-day HIV pre-exposure prophylaxis initiation among individuals with depression symptoms during emergency care in Nairobi, Kenya. IntroductionHIV pre-exposure prophylaxis (PrEP) is an important prevention strategy, but its integration into routine care faces challenges, especially in low- and middle-income countries. Emergency departments (EDs) present a unique, yet underutilized, opportunity for PrEP delivery, particularly for people with less access to care or who are marginalized and face challenges accessing care, such as those from key populations. Emergency care utilization is high among people with depression and may influence health decision-making, including PrEP uptake. This study aimed to determine the acceptability of same-day PrEP initiation among ED patients with varying depression severities and identify associated patient-level factors. The hypothesis was that patients screening positive for moderate to severe depression would be less likely to accept same-day PrEP than those with screening scores consistent with a lower risk of depression due to the potential impact of depression-related cognitive impairment on health decision-making. Methods This cross-sectional study utilized secondary data from the ED-PrEP study, conducted from July 5, 2024, to August 18, 2024, at the ED of Kenyatta National Hospital in Nairobi, Kenya. 1 The study population included 295 adult ED patients (aged ≥18) who were not critically ill or pregnant and had a Patient Health Questionnaire 9 (PHQ-9) scores of 1 or higher. The primary outcome was the acceptability of same-day PrEP initiation, defined as willingness to start PrEP if eligible. Depression severity was the primary exposure, categorized by PHQ-9 scores: minimal to mild (scores 1-8), moderate (scores 9-14), and moderately severe to severe (scores 15-27). Statistical analysis was conducted using chi-square tests, simple, univariate, and multivariate logistic regression to calculate unadjusted and adjusted odds ratios (aOR) with 95% confidence intervals (CI), adjusting for sociodemographic and behavioral confounders. Results Of the 295 participants analyzed, 46% had minimal to mild depression, 39% moderate, and 15% moderately severe to severe depressive symptoms. Willingness to initiate same-day ED-PrEP was high across all groups: 76.3% (minimal to mild), 76.5% (moderate), and 84.4% (moderately severe to severe). There was no statistically significant association between depression severity and PrEP acceptability. However, being unmarried (aOR=2.93, 95% CI: 1.42-6.06), reporting consistent condom use (aOR=3.72, 95% CI: 1.22-11.34), knowing a partner's HIV status (aOR=2.07, 95% CI: 1.18-3.64), and experiencing intimate partner violence (IPV) (aOR=2.34, 95% CI: 1.15-4.76) were significantly associated with higher PrEP acceptability. Conclusions Depressive symptom severity did not influence the acceptability of same-day PrEP initiation among ED patients in Nairobi. The high overall PrEP acceptability highlights the feasibility of integrating PrEP services into the emergency departments. Factors such as marital status, condom use, awareness of partner HIV status, and history of IPV were strong predictors of PrEP acceptability. These results underscore the importance of comprehensive, person-centered approaches in EDs that address both HIV risk and co-occurring vulnerabilities like IPV, to effectively improve PrEP uptake in high-burden settings
Prevalence and cofactors of developmental delay among preschool aged children who are HIV exposed and uninfected in Kenya
(2025-10-02) King'e, Maureen Mumbi; Njuguna, Irene N
Background: HIV-exposed uninfected children (CHEU) represent a growing population in sub-Saharan Africa following scale-up of maternal antiretroviral therapy (ART). Emerging evidence suggests increased risk for developmental delays, particularly in expressive language and motor domains. However, data from preschool-aged CHEU in low-resource settings remain limited. Methods: We conducted a cross-sectional analysis of 706 children aged 3–5 years (634 CHEU, 72 children not exposed to HIV [CHU]) enrolled at 11 sites in three counties in Kenya. Development was assessed using the Ages and Stages Questionnaire (ASQ-3), which screens for delays in gross and fine motor, communication, problem-solving and personal social domains. We compared the prevalence of domain-specific and global delays among CHEU and CHU and identified correlates of delay among CHEU. Results: Overall, 42% of CHEU and 35% of CHU children had a delay in at least one developmental domain (p = 0.30). Fine motor delays were significantly more prevalent among CHEU (15% vs. 2.8%, adjusted prevalence ratio 4.16 (95% CI: 1.05–16.53). Gross motor delays were only observed in CHEU (10% vs 0% p = 0.002). There were no differences among CHEU and CHU in the other domains. Among CHEU, developmental delays were associated with stunting, reduced head circumference, previous neurological conditions, and delayed milestone attainment in early childhood. Longer breastfeeding duration and access to multiple play materials were protective. No significant associations were found with maternal ART regimen or timing. Conclusion: Preschool-aged children in Kenya face a high burden of developmental delays, and CHEU are more vulnerable. Findings highlight the importance of integrating early developmental screening and interventions into child care. Targeted services addressing modifiable risk factors can improve outcomes and school readiness in this vulnerable group.
Multimodal Implementation Research on Primary Health Care Services in sub-Saharan Africa: Implementation Outcomes, Service Readiness and Costs
(2025-10-02) Birru, Ermyas M; Sherr, Kenneth
Primary health Care (PHC) serves as the cornerstone for achieving universal health coverage (UHC), one of the health-related targets in the 2030 Sustainable Development Goals (SDGs). PHC facility managers play a key role in ensuring quality of care by overseeing daily operations, managing human resources, and effectively implementing national PHC guidelines. This dissertation reports findings on implementation outcomes, service readiness, and costs through multimodal implementation research on strategies to improve PHC services in sub-Saharan Africa (sSA). Two of the three research Aims (Aims 2 and 3) are embedded within a district-based implementation and dissemination program in central Mozambique's PHC settings, called the Integrated District Evidence-to-Action (IDEAs) program for neonatal mortality reduction, implemented from 2016 to 2020. IDEAs applied a system-level Audit and Feedback (A&F) strategy that included three core components: routine facility and district readiness assessments, district-level biannual health facility performance review meetings, and targeted facility support through supportive supervision to help health facilities implement their micro-interventions developed during the biannual meetings. There were nine cycles of IDEAs. For Aim 1, this study synthesized implementation strategies and outcomes of evidence-based management interventions for PHC managers in sSA through a systematic review. Nine case studies from six countries—Ethiopia (3 studies), South Africa (2), and one each from Botswana, Kenya, Tanzania, and Zambia—were identified. The interventions included evidence-based training programs, peer-to-peer learning, electronic systems for monitoring management practices, and supportive supervision. Common implementation strategies included training and education, coaching and mentoring, knowledge sharing through learning collaboratives, interactive and continuous learning, and A&F using routine data. Interventions were implemented using more than one strategy. Acceptability was a consistent positive implementation outcome reported, with management effectiveness improving in areas such as financial and resource management, organizational climate, and human resource management. For Aim 2, we assessed effectiveness of management training and IDEAs intervention on improving basic obstetric and neonatal service readiness in PHC facilities. We found that IDEAs intervention's effectiveness in enhancing service availability was highest when health facility managers in the intervention sites had received management training, with an average increase of 11.1 points out of 100 per year (95% CI: 0.7 to 21.5, p=0.037), after adjusting for potential confounders. Hence, capacitated PHC managers were better able to optimize a system-level A&F strategy to improve PHC services, bundling management training with A&F strategies could enhance effectiveness. For Aim 3, a mixed costing approach (gross and microcosting) was used to estimate the cost of implementing IDEAs. We found the total cost of the program across 12 districts over five years (2016-2020), discounted to 2020 US dollars was USD $2,197,971 with $495,323 (23.8%) allocated to capital costs and $1,702,648 (77%) to recurrent costs. The average cost of IDEAs activities annually per district was $36,693; A&F meetings made up $10,893 (29.7%) of costs, with per diem as the main cost driver; Capital cost were $8,255 (22.5%), with vehicle purchase as the main cost driver; Targeted support were divided into two parts, district focused and facility supervision. The performance review meetings occurred biannually, each lasting five days, resulting in a total of 10 days per year per district. The average hours spent per year attending A&F meetings for the seven key positions from health facilities, district and province was 2320 hours (80 hours per person annually per district), while five district staff conducting supervision spent a total of 240 hours per year (60 hours per person annually per district). We were not able to estimate staff hours for routine data collection since it was contracted to local agencies. This study provides new insights into the cost of implementing iterative system-level A&F strategies in low-income settings. As demonstrated in this dissertation, we applied a multimodal implementation research approach — using evidence synthesis to improve health system coordination and management, strengthen management capacity, and incorporate economic evaluation — helped identify pathways for the systematic integration of national PHC guidelines, offering insights for improving PHC services. The key takeaway is that while implementation research is valuable for improving healthcare systems, there is a significant knowledge gap regarding what works for PHC management in sub-Saharan Africa and the costs associated with implementing a system-level A&F strategy. This dissertation aims to spread knowledge about strengthening health systems to improve primary healthcare and achieve universal health coverage.
Incremental Cost of Hepatitis C Screening, Diagnosis and Treatment among People Who Inject Drugs in Kenya
(2025-10-02) Machuka, Judy Wanjiru; Masyuko, Sarah SM
Hepatitis C virus infection is a global public health threat, and has potential to progress to chronic liver disease, liver cancer and preventable deaths, if left untreated. Among people who use injecting drugs, the prevalence of HCV is 52% globally and 13-40% in Kenya, which is higher than in the general population, where the prevalence is 0.7% globally and 0.9% in Kenya. Injectable drug use accounts for 1 in 3 HCV related deaths globally. While Direct Acting Antiviral treatment has been known to eradicate the virus by 95%,15 only 23% people were diagnosed with the virus and 5% initiated treatment globally, by 2020. In Africa, of 10% diagnosed with the virus, 0.4% initiated treatment. In Kenya, there is limited data of the proportion of people diagnosed with the virus and initiated on treatment. Additionally, there is a dearth of cost data for screening, diagnosis and treatment among people who inject drugs in Kenya. This was the first cost study with the largest cohort of people who inject drugs treated in Kenya. The two aims of the study were: 1. To estimate the annual incremental costs, using a micro-costing approach and payer (Ministry of Health) perspective over 5-year time horizon and 2. To determine human and other resources use by analyzing monitoring and evaluation data from time and motion surveys and health care provider interviews. The study analyzed secondary data collected from 123 clients who underwent screening, diagnosis and treatment in 8 needle syringe program and methadone treatment centers in Kenya. The total annual incremental costs were $48,996. Total annual incremental costs per client were $398 and the biggest cost drivers were personnel, $285 (73%) and lab, stationery and supplies accounting for $83 (21%). The overall time taken for screening, diagnosis and treatment was 55 min (IQR 40, 103), out of which screening took the longest time, 20 min (18, 42). With an understanding of these costs, there is need for scale up these services to increase access to this priority population. Provision of treatment by the Ministry of Health and focus on this population, provides a valuable opportunity for Hepatitis C virus micro-elimination.
Quantifying averted burden from infectious disease control policies
(2025-08-01) Carter, Austin; Smith, David L
This dissertation explores methods for calculating averted burden from infectious disease control policies and applies those methods in the contexts of pediatric HIV in sub-Saharan Africa and malaria in Uganda. In my first aim, I describe the Shapley value estimate as the preferred approach to decomposition and then introduce an innovation to the application of Shapley value estimation in the context of interventions implemented at different times with overlapping effects. I call this innovation sequential Shapley value estimation and detail the algorithm for its application. In my second aim, I apply sequential Shapley value estimation to calibrated estimates of pediatric HIV burden in sub-Saharan Africa. I present intervention coverage level for three biomedical interventions and highlight variable impact made through these interventions in preventing new HIV infections and mortality among children under-15. I also estimate avertable burden in 2023 and discuss the implications for future policy. In my third aim, I propose a framework for evaluating outbreak detection approaches using averted burden and apply it to malaria outbreak detection in Uganda.
Health perspectives: Exploring differential reporting across sex and generations
(2025-08-01) Arrieta, Alejandra; Gakidou, Emmanuela
In health metrics, health surveys are an important source of information, particularly for the estimation of health risk exposures and outcomes. This dissertation studies how the same survey questions are answered differently depending on whether the respondent is a mother of a child in the 90s, the child as a young adult, or whether the respondent is female or male. Topics explored were chosen as those in which sex and social norms around sex and across generations can influence how we experience health, the risk factors we are exposed to, and our relationship with morbidity. In the first chapter, Differences in reporting of child abuse by mothers and young adults, we used a longitudinal study to compare mothers’ prospective accounts of their child experiencing different forms of violence against children (VAC), and young adults’ retrospective self-reports of experiencing VAC. We then studied the socioeconomic factors associated with mothers reporting abuse of their child among children that were classified as having experienced abuse. For this end, we used the Avon Longitudinal Study of Parents and Children (ALSPAC), a 30-year prospective birth cohort study in England. This chapter addresses a well discussed issue in the field, the underreporting of VAC depending on the survey respondent. We used longitudinal data, unlike previous work where mostly cross-sectional data was used. We found that when questions are asked in the same way, there was no evidence of mothers underreporting physical or psychological abuse in comparison to children, even though there was little reliability across respondents. Among the pairs of mothers and children in which at least one of them reported abuse, we found that the sex of the child and other mother characteristics are associated with mothers’ reporting of physical or psychological abuse. Finally, the first chapter reflects on the social norms around discipline, as both mothers and the young adults described physical cruelty to be related to acts of severe physical violence, in which case acts such as pushing, smacking or kicking, would not be classified as abuse if mothers were the only respondents. Chapters two and three focus on a fundamental topic in the measurement of the burden of disease, the measurement of morbidity through disability weights. In chapter two, Differential health loss valuation by sex of the respondent in the Global Burden of Disease (GBD) study we analyzed differences by sex of the respondents in the disability weights used for the GBD study. Similar to literature focused on paired comparison questions from Martens de Noordout et al. in 2018, Liu et al. in 2020, and Haagsma et al. in 2024, we found high correlation of health preferences by sex. This translated into anorexia nervosa being the only health state for which there a was a significant difference between disability weights estimated with female only and male only paired comparison data. In contrast, the sex stratification of the population health equivalence questions resulted in significantly different disability weights for females and males in almost all health states measured. In other words, we found that in the disability weights used in the GBD study, preferences for health states do not differ by sex, but females are less willing to accept disability as health program evaluations in comparison to males. Finally, in chapter three, Differential health loss valuation by sex on population health equivalence questions (PHE), we further explored the sex differences found in chapter two and analyzed willingness to accept disability using the disability weights data from the GBD study. Through a marginal logistic model using generalized estimating equation, we found that even when we take age and education into account, females are more likely to choose programs that avoid deteriorating health over preventing death for the relative few. Before this study there was no empirical evidence on the differences in PHE valuation by sex of the respondent, mainly due to the use of PHE data as a methodological step. These questions are not used to rank health states but to anchor the preferences revealed through paired comparison questions in values that are useful for the estimation of Years Lived with Disability (0 to 1 ranges). It is in these questions, that we found females are more likely to choose the program that averts lifelong consequences of disease over programs that avert death as creating the greater population health benefit. Consequently, we estimated that if all disability weights input data were stratified by sex, female disability weights would be larger for every heath state. Notably, because 70 percent of the respondents of population health equivalence questions are female, the current set of disability weights in the GBD study reflect more the preferences of disability weights of females than males.
Malnutrition Among People Who Inject Drugs (PWID) Living with HIV in Kenya: A Cross-sectional Analysis
(2025-08-01) Dale, Edith; Farquhar, Carey
Background: People who inject drugs (PWID) living with HIV face heightened vulnerability to malnutrition and food insecurity, both of which can compromise immune function and antiretroviral therapy (ART) adherence. Although these issues are well documented globally, there is limited research in sub-Saharan Africa, particularly in Kenya, where HIV prevalence among PWID is over four times the national average. This study aimed to examine the prevalence and predictors of abnormal weight status among PWID living with HIV in Kenya to inform targeted, integrated interventions. Methods: This cross-sectional study analyzed secondary data from PWID living with HIV in Nairobi and Kenya’s coastal region. Abnormal weight was defined as either underweight (BMI <18.5) or overweight/obese (BMI ≥25), with normal weight as the reference category. Univariate and multivariate logistic regression analyses were used to identify sociodemographic, behavioral, and clinical factors associated with abnormal weight status. Results: Among 223 participants, 34.1% were underweight and 10.3% overweight/obese. In multivariate analysis, male sex was significantly associated with underweight status. While marital status and alcohol use were not independently significant in the multivariate analysis, they were both positively associated with BMI in univariate analyses. Conclusion: Findings highlight the coexistence of undernutrition and emerging trends of overnutrition among PWID living with HIV in Kenya, two distinct but important challenges. Nutritional vulnerability in this population is shaped by multiple factors, including substance use patterns, gender, and lack of social support. Integrating tailored nutrition interventions into HIV care and harm reduction services are critical to address these intersecting needs.
Evaluating School-Based Deworming Coverage of Soil-Transmitted Helminths Programs for Children Living in Benin, India, and Malawi
(2025-08-01) Neutz, Hana; Means, Arianna R
Soil Transmitted Helminths (STH) are a group of intestinal parasitic worms infecting over 1.5 billion people, disproportionately affecting the health outcomes of women and children in marginalized communities. Most countries reduce STH-associated morbidities in children through school-based deworming (SBD) programs. Our objective was to calculate school-based STH deworming coverage and identify school-level correlates of coverage across areas participating in a cluster randomized trial in Benin, Malawi, and India. We conducted a secondary analysis of DeWorm3’s repeat cross-sectional longitudinal school survey over three years, including 308 observations of school-level deworming in Benin, 1,713 in India, and 164 in Malawi. SBD coverage was calculated and compared across time and sites using Kruskal-Wallis tests. A multivariate analysis using generalized linear mixed effects models with clustering by school and time determined correlates of coverage at the 0.05 significance level. SBD coverage was 100% in India (95% confidence interval [CI]: 97.2%, 140%), 87% in Benin (CI: 72.5%, 97.4%), and 46% in Malawi (CI: 33.6%, 62.7%). High attendance rates were significantly associated with increased (Benin) and decreased (Malawi) coverage. High student-to-faculty ratios (Benin, India) and a higher percentage of female teachers (India), were associated with reduced coverage. Exploring these correlates of coverage could assist in identifying schools unable to meet the WHO thresholds for preventing STH-associated morbidities in children.
A Qualitative Study Identifying Factors and Solutions to Increase Gender Equity in Soil-Transmitted Helminth Treatment for Children in India, Benin, and Malawi
(2025-08-01) Zha, Cindy; Means, Arianna R
Background: Approximately 24% of the world’s population is infected with a soil-transmitted helminth (STH), a neglected tropical disease (NTD) where a parasitic worm lives in human intestine (1). STH infection disproportionally affects marginalized populations in low-and-middle income countries (LMIC) (2). Children are the most vulnerable population to STH infection and experience a disproportionate amount of STH morbidities causing cognitive delay, stunting, malnutrition, and increased school-absenteeism (3). Few studies have identified factors contributing to gender inequity in deworming treatment of children. We aim to identify factors and solutions to gender equitable deworming treatment of children in Benin, India, and Malawi. Methods: The Health Equity Implementation Framework (HEIF) was utilized to inform this study and develop our codebook. We conducted a secondary analysis of 40 focus group discussions from the DeWorm3 Project. A thematic analysis based on the HEIF and valence scoring of the HEIF domains were used to analyze the data. Results: Seven themes were developed according to the HEIF in regard to factors and solutions that contribute to gender equitable deworming treatment of children. The themes are as follows: cMDA reaches out of school children, who are disproportionately female , parental engagement during cMDA contributes to gender equitable treatment in children, household gender norms can perpetuate both equities and inequities in children, CDD’s influence equitable treatment uptake, community fear can lead to treatment refusal and sensitization is imperative to overcome this barrier, migration outside of the community inhibits deworming treatment through cMDA, and providing children food during MDA can increase treatment uptake for all genders (4,5). Through scoring the HEIF domains, we found the Clinical Encounter domain of the HEIF had the strongest, positive influence on gender equitable treatment . Conclusion: To achieve global benchmarks of reducing STH-associated morbidities in children, it is necessary to implement strategies to reach all children. To engage gender equitable treatment of children in deworming campaigns, we recommend implementing these three strategies: cMDA as the standard of care for deworming, tailoring sensitization of deworming to children to overcome their specific fears and providing food to children during deworming to promote gender equitable treatment of children.
Understanding Risk Perceptions Regarding Cardiovascular Disease Among Young Adults in Gilgit, Pakistan
(2025-08-01) Aman, Naznain; Pfeiffer, James
Background: Cardiovascular disease (CVD) remains the leading cause of death worldwide, disproportionately impacting low- and middle-income countries (LMICs) such as Pakistan, where mortality rates associated with CVD exceed the global average. Recent epidemiological shifts show increasing CVD incidence among younger populations. In the province of Gilgit-Baltistan (GB), where health infrastructure remains limited, CVD-related morbidity and mortality among young adults has been rising in recent years. Contributing factors among this demographic include widespread behavioral risks such as tobacco use, unhealthy dietary habits, and low levels of physical activity, along with a high prevalence of undetected and unmanaged hypertension. Objective: The study explores risk perceptions regarding CVD among young adults in Gilgit who have a baseline knowledge of CVD and its risk factors. It examines whether this knowledge translates into action and identifies perceived benefits and barriers to adopting CVD-preventive behaviors. Methods: The study employed a qualitative design using the Health Belief Model (HBM) as a theoretical framework. Semi-structured interviews were conducted in Urdu with 31 undergraduate students aged 19–25, enrolled at Karakoram International University (KIU), Gilgit. Participants were recruited via snowball sampling. Data was analyzed through thematic analysis, combining deductive and inductive approaches, using ATLAS.ti software. Results: Participants recognized CVD as a serious condition and expressed concern over its increasing incidence among young adults. However, most perceived their own risk as low, except those with a family history of CVD or personal health issues. Perceptions of CVD as a distant threat led to a low prioritization of preventive behaviors. Even among participants who acknowledged a higher personal risk, adopting healthy behaviors remained challenging. Barriers included academic stress, digital distractions, and religious beliefs. Social and familial influences served as both key motivators for behavior change and barriers in contexts where participants had limited control, such as shared family meals. Individual willpower emerged as an important internal driver, shaped by these external dynamics. Conclusion: Our findings highlight the need to develop culturally relevant, youth-centered interventions that promote CVD prevention by addressing both individual perceptions and broader social determinants of behavior.
Age of initiation of gender affirming hormone therapy and mental health outcomes among transgender, non-binary, and gender diverse adults living in the U.S.
(2025-08-01) Vega, Agus; Ronen, Keshet
Introduction: Gender-affirming hormone therapy (GAHT) has been associated with improved psychosocial well-being among transgender, non-binary, and gender-diverse (TGD) individuals. However, limited evidence exists on how the timing of initiation influences mental health in adulthood. This study examines the associations between GAHT initiation (age and desire) with depression and gender congruence indicators, in a national sample of TGD adults who identify as transfeminine in the United States. Methods: We conducted a secondary analysis of data from the 2022–2024 Transgender Women’s Internet Survey and Testing (TWIST) study. Participants were grouped by GAHT experience: (1) initiated before 18, (2) initiated at ≥18, (3) never initiated but desired, and (4) never initiated nor desired. Depression was measured using the PHQ-9 (cutoff ≥10). Gender identity–appearance alignment and comfort with how others perceive their gender were measured via self-report. Modified Poisson regression with robust standard errors was used to estimate prevalence ratios (PRs), adjusting for sociodemographic covariates. Results: Among 5,178 adult respondents, 286 (5.5%) initiated GAHT in adolescence, 3,844 (74.2%) in adulthood, 841 (16.2%) desired but never accessed GAHT, and 207 (4.1%) neither initiated nor desired GAHT. The prevalence of moderate to severe depression among the four groups was 47.5%, 48.9%, 62.1%, and 56.0%, respectively. Alignment between gender identity and appearance, as well as comfort with how others perceive their gender, were highly prevalent among individuals who initiated GAHT during adolescence (69.9% and 57.9%, respectively), but less prevalent among those who desired but never accessed GAHT (22.3% and 15.7%). In adjusted models, all three comparison groups had significantly higher prevalence of depression and lower prevalence of gender congruence indicators than adolescent initiators (p < 0.05 for all comparisons). Notably, participants who desired but did not access GAHT demonstrated the greatest disparities in depression (adjusted PR = 1.45, 95% CI = 1.24, 1.69), appearance–identity alignment (adjusted PR = 0.32, 95% CI = 0.27, 0.38) and comfort with how others perceive their gender (adjusted PR = 0.28, 95% CI = 0.23, 0.34) when compared to those who initiated GAHT in adolescence. Discussion: Initiation of GAHT at any age was linked to more favorable outcomes; however, starting during adolescence appeared to confer additional mental health and gender congruence benefits. In comparison to early initiators, individuals who desired but never initiated it experienced the most pronounced psychosocial challenges. These findings highlight the importance of supporting timely access to GAHT—particularly for youth—and advancing affirming clinical and policy strategies to promote the well-being of TGD individuals.

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