Sian Floyd

Common mental disorders (CMD) are increasing globally among young people. The DREAMS (Determined-Resilient-Empowered-AIDS-free-Mentored-Safe) multi-component intervention package, delivered during 2016–2023, aims to reduce HIV incidence among adolescent girls and young women (AGYW). We hypothesised that social, health and economic benefits of DREAMS would reduce CMD, though this was not the program’s goal. In each of two Kenyan settings (Gem and Nairobi) a randomly selected cohort of around 1000 AGYW aged 13–22 years was enrolled during 2017–2018 and followed up during 2019–2022. CMD was measured using the Shona-Symptom-Questionnaire; a score of ≥7 was classified as `experiencing CMD’. We used inverse-probability-of-treatment-weighting to control for confounding and compared 3 groups of AGYW: those invited to DREAMS by 2018 (early invitees), during 2020–2022 (later invitees), or not invited to DREAMS (non-invitees). In 2022, the proportion experiencing CMD was 45% (463/1023) in Gem, and 46% (410/889) in Nairobi. In Gem, the estimated proportions with CMD were 49%, 45%, and 38% for the counterfactual scenarios in which all AGYW were early invitees, all were later invitees, or all were non-invitees, respectively. There was evidence of an increase in CMD prevalence when comparing early invitees with non-invitees (11%; 95% CI:2%,21%). In Nairobi, the estimated proportions with CMD were 46%, 55%, and 32% for the scenarios in which all were early invitees, all were later invitees, or all were non-invitees, respectively. There was evidence of an increase in CMD prevalence when comparing early invitees to non-invitees (14.4; 95% CI:2.1%, 26.4%) and when comparing later invitees to non-invitees (23.3%; 95% CI:5.8%,41.2%). CMD was common among AGYW in both settings. The higher CMD prevalence among DREAMS invitees compared with non-invitees might be due to increased recognition of, and willingness to disclose, symptoms of mental ill-health. Specific interventions to address CMD among AGYW should be incorporated within health and HIV prevention programmes.

In Kenya, the DREAMS Partnership (“Determined, Resilient, Empowered, AIDS-free, Mentored and Safe”) aims to reduce new HIV cases among adolescent girls and young women (AGYW; aged 10–24) through a comprehensive programme of interventions. The impact of DREAMS varies across settings but reasons for this are not well understood. One potential reason is the differential implementation of DREAMS interventions due to on-the-ground adaptations made by implementers. We sought to understand if, how, and why DREAMS delivery was adapted in three Kenyan settings, so that complex interventions like DREAMS can be tailored to diverse contexts and challenges.We analysed 40 transcripts from individual and group discussions with DREAMS implementing teams. Data were collected between 2017–2019 in rural Gem and two Nairobi informal settlements. Using both FRAME and CFIR frameworks, we identified programming and contextual challenges that affected implementation, local adaptations made in response to these realities and challenges, and the goals and reasoning for adaptation. Reasons for adapting DREAMS were similar across settings yet the type of adaptation varied by context. Adaptations were made to: 1) improve programme attendance; 2) tailor content to better suit AGYW, encourage programme attendance and address community concerns; 3) support participants’ wellbeing, amidst poverty, hunger and violence; and 4) cope with insufficient programming resources. Given their close contact with participants and families, DREAMS mentors often developed unique context-specific strategies to make interventions more appealing and accessible to participants of different ages and circumstances. Understanding shared reasons for adaptation across settings can help anticipate challenges before implementation, and inform the co-design of interventions with communities. As context-specific issues inevitably arise during implementation, mentors can be instrumental in adapting DREAMS, serving as a bridge between programme implementers and beneficiaries. Supporting mentors’ ideas and ongoing commitment can ensure that those delivering programmes plan, learn, adapt and improve in partnership with communities.

Migrants have been identified as a population left behind by the AIDS (Acquired Immune Deficiency Syndrome) response, with evidence showing poorer HIV (Human Immunodeficiency Virus) outcomes and reduced intervention effectiveness in mobile populations. We used data from the HPTN 071 (PopART) trial (ClinicalTrials.gov number, NCT01900977) to investigate migration and HIV-related indicators, assessing whether community migration influenced PopART trial results and whether migration was associated with HIV status and position on the care continuum. The PopART trial, conducted in Zambia and South Africa (SA) from November 2013 to June 2018, evaluated a universal testing and treatment intervention using a three-arm design. A cohort of 18–44-year-olds was followed annually to estimate HIV incidence, with migration out of trial communities tracked using this cohort. migration into and within the community was tracked using intervention delivery data in community members aged 18 + . HIV-related indicators were HIV status, knowledge of HIV-positive status and ART use. Migration’s influence on the trial HIV incidence results was analysed using a two-stage approach for cluster-randomised trials, adjusting for community-level migration. Associations between HIV-related indicators and both out-migration (Poisson regression using cohort data) and in-migration (logistic regression using cross-sectional data) were also estimated. While migration differed between trial arms, there was no evidence that it confounded the intervention effect on HIV incidence. There was evidence out-migration was higher among HIV-positive individuals who did not know (or did not disclose) their HIV-positive status compared to those HIV-negative (adjusted rate ratio: Zambia 1.28, 95%CI 1.17-1.39; SA 1.27, 95%CI 1.17-1.38). Residents who had moved into the community within the previous year were less likely to be aware of their HIV-positive status than longer-term residents (adjusted odds ratio: Zambia 0.18, 95%CI 0.16-0.19; SA 0.23, 95%CI 0.20-0.28) and contributed to approximately one in four of the newly identified HIV infections. Following intervention delivery the gap in knowledge of HIV status and ART treatment coverage between recent in-migrants and longer-term residents closed. Countries with high HIV burden should aim to ensure a sustained delivery of HIV services in areas with high levels of population mobility and in areas with moderate to high HIV prevalence.

Background: Tuberculosis (TB) incidence is consistently higher in men than women globally. Whether this disparity arises from differential infection risk or sex-specific rates of progression from infection to disease remains unclear. We evaluated sex differences in the development of TB disease while accounting for baseline infection status.Methods: We conducted a pooled individual participant data analysis of 11 prospective cohort studies (n=22,424). TB infection was defined by a positive QuantiFERON-TB Gold In-Tube result, and incident TB was defined by bacteriologically confirmed or clinical diagnosis. We used mixed-effects logistic and Cox proportional hazards models, adjusted for age, to estimate odds ratios (OR) for infection and hazard ratios (HR) for incident TB by sex.Findings: Participants were followed for a median of 2.8 years, during which 411 individuals (1.8%) developed TB. Most participants were from Europe (52%) or South Africa/Zambia (34.4%). At baseline, males had a significantly higher likelihood of infection (OR 1.12; 95% CI 1.02–1.22). Among those with baseline infection, pooled incidence rates were 16.3 per 1,000 person-years (95% CI 10.9–24.4) in females and 15.6 (95% CI 9.8–24.8) in males. The risk of developing TB did not differ by sex among those with baseline infection (HR 0.86; 95% CI 0.65–1.14) or without baseline infection (HR 1.02; 95% CI 0.71–1.47).Interpretation: The higher TB incidence in men is likely driven by higher exposure and infection risk rather than increased biological susceptibility to progression following infection.

Comprehensive intervention packages are recommended to address multiple sources of HIV risk for adolescent girls and young women (AGYW). DREAMS is a multi-component HIV prevention program designed to reduce HIV incidence among AGYW. We conducted a prospective cohort study among AGYW aged 13–22 years, randomly selected in rural Gem and urban Nairobi informal settlements followed from 2017/2018–2019. AGYW were classified into three groups: (1) invited to DREAMS and received a “complete” package, (2) invited and received a “partial” package, or (3) not invited to DREAMS. We defined the “complete” package as 4–5 primary interventions in Gem and 5 in Nairobi: the “partial” package as 3 specific interventions in Gem and any 3–4 interventions in Nairobi. We used propensity score-adjusted logistic regression to estimate the causal effect of DREAMS on outcomes under three counterfactual scenarios: all AGYW accessed the complete package, all accessed a partial package, or none were invited. In Nairobi, 1081 AGYW were enrolled. By 2019, 26% accessed the complete package and 32% accessed the partial package. Among those receiving the complete package, there was increase in HIV status knowledge(24.8% [95%CI:16.4,32.6]),social support(13.9% [95%CI:3.3,23.6]) and self-efficacy(10.3% [95%CI:0.5,20.4]) and a decrease in the proportion with ≥2 lifetime partners(-8.0% [95%CI:-15.9,0.0]). In Gem, 1171 AGYW were enrolled. By 2019, 24% received the complete package and 21% received the partial package. We found evidence of an increase in HIV status knowledge(10.0% [95%CI:4.5,15.2]), social support(27.2% [95%CI:19.2,35.5]) and a decrease in condomless sex(-9.1% [95%CI:-13.6,-4.1]), and the proportion with ≥2 lifetime partners(-7.6% [95%CI:-12.4,-2.2]) for the complete package. Among those receiving the partial package, there was a decrease in condomless sex(-12.2% [95%CI: -17.0,-6.4]), and an increase in self-efficacy(8.0% [95%CI:0.0,17]). A package of 4–5 primary DREAMS interventions had positive impacts on multiple HIV-related outcomes in both settings. A partial package was effective in Gem, but not in Nairobi, suggesting the need for context-specific intervention strategies.

Background: Herpes simplex virus type 2 (HSV2) is an important cofactor for HIV acquisition and transmission. Associations between the infections are reexamined in longitudinal data from an HIV prevention trial. Methods: The HPTN 071 (PopART) trial evaluated a combination prevention intervention in 21 urban communities in Zambia and South Africa. HIV incidence was measured in a cohort of approximately 2000 adults (age, 18–44 years) selected randomly from each community and followed up for 36 months. Incidence of HSV2 infection was estimated, and the effects of risk factors were examined. The association between HIV incidence and HSV2 infection was examined at individual and community levels. Results: An overall 10 539 participants were HSV2 negative at baseline and retested after 36 months. Estimated HSV2 incidence was 5.4 per 100 person-years (95% CI, 5.0–5.7) for women and 2.9 per 100 person-years (95% CI, 2.6–3.2) for men. When compared with those remaining HSV2 negative, HIV incidence was higher in those who were HSV2 positive at baseline (women: adjusted rate ratio [aRR], 3.24 [95% CI, 2.50–4.20]; men: aRR, 2.57 [95% CI, 1.60–4.11]) and even higher in those who seroconverted to HSV2 during follow-up (women: aRR, 5.94 [95% CI, 4.42–7.98]; men: aRR, 8.37 [95% CI, 5.18–13.52]). At the community level, strong associations were seen between HIV incidence and HSV2 prevalence (R2 = 0.48, P < .001) and incidence (R2 = 0.36, P = .004). Conclusions: There were strong associations between HIV incidence and HSV2 prevalence and incidence at individual and community levels. HSV2 control could contribute to HIV prevention.

The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS’ effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15–22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017–18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017–18) and AGYW’s attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI: -5.3,+6.5; Gem: 44.3% vs 48.2%, -3.9; 95%CI: -11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.