Linda Campbell

In 2023, an estimated 39.9 million people globally were living with HIV, including 7.7 million in South Africa. Adherence to antiretroviral therapy (ART) is crucial for health outcomes, yet remains challenging. Households may shape health behaviours, including ART adherence. This study evaluated a household-level intervention to improve ART adherence in Cape Town, South Africa, which aimed to promote HIV competency for participants and their households. Baseline data were collected from 316 participants in 12 clinics (May 2021 - May 2022), with endline data from 198 participants (December 2021 - July 2022). Cluster-level analysis and mixed-effects models, with multiple imputation and complete case approaches, were utilised. At endline, there was evidence of a difference between control and intervention arms for following the ART schedule (aOR: 3.88, t = 2.62, p = 0.009), and taking ART on time (aOR: 2.28, t = 2.54, p = 0.01). Household-based interventions may have an impact on ART adherence, and should be considered in future adherence research, programming, and interventions. CLINICAL TRIAL REGISTRATION: Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

The COVID-19 crisis gave rise to measures such as physical distancing, sheltering in place, and social bubbles that impacted sexual lives profoundly. One group particularly badly impacted by COVID-19 containment, and at risk of sexual and mental health consequences as a result, comprised gay, bisexual and other men who have sex with men -- many of whom were more likely to live alone, to have had multiple partners before the epidemic, and some of whom were lacking in peer support for their mental health. This study investigated how members of this group living in Flanders (Belgium) experienced sex and sexuality during the COVID-19 epidemic. We conducted 29 in-depth interviews with gay, bisexual and other men who have sex with men who practised consensual nonmonogamy and/or sociosexuality, and used reflexive thematic analysis to analyse the data. Interviewees provided a nuanced and emotionally resonant account of sex as a pathway to intimacy, rather than just a physical act. In their descriptions, Intimacy was framed as a protective factor against the mental health challenges exacerbated by pandemic isolation.

HIV remains a major global health challenge. Worldwide, the virus has taken the lives of an estimated 44.1 million people (UNAIDS, 2025). In 2022, approximately 39.9 million people were living with...

Widening health inequities in Belgium highlight the need for proactive, outreach-oriented primary care models. Large-scale community health worker programm

Summary: Background: In sub-Saharan Africa (sSA), invasive antimicrobial-resistant infections often originate from community-level acquisition. We assessed whether a behavioural intervention bundle targeting sub-optimal antibiotic use and hygiene practices reduced household-level acquisition of extended-spectrum beta-lactamase–producing E. coli (ESBL-E). Methods: We conducted a cluster-randomised controlled trial in 22 village clusters in Nanoro district, Burkina Faso. We enrolled 12 randomly selected households per cluster to assess intervention impact on ESBL-E household-transmission. The intervention comprised three rounds at three-month intervals and combined WHO AWaRe–based educational feedback for formal and informal medicine providers with a community-wide WASH and antibiotic-use behaviour change campaign. Consenting household members provided stool samples before, during, and after intervention rollout, alongside a pre–post household WASH survey. We estimated intervention effects on ESBL-E acquisition using Bayesian Markov models. Cox frailty models assessed associations between WASH exposures and acquisition. ClinicalTrials.gov, NCT05378880 . Findings: Between Oct 11, 2022, and Feb 19, 2024, 1203 individuals were enrolled. At baseline, 57·3% (346/604) of control and 48·6% (291/599) of intervention household members were colonised. Pre-intervention acquisition incidence was 3·8 per 100 person-days (95% credible interval [CrI] 2·0–9·9) in the intervention group and 3·5 (95% CrI 1·8–9·6) in the control group. The intervention did not change the risk of ESBL-E acquisition in months 1–6 (hazard ratio [HR] 1·02, 95% CrI 0·78–1·31), while we estimated a reduction in ESBL-E acquisition from months 6–9 (HR 0·82, 95% CrI 0·56–1·14). Acquisition risk was higher in the rainy season (peak HR 1·73, 95% CI 1·49–2·00), while improved sanitation was associated with lower risk (HR 0·77, 95% CI 0·59–1·00). Interpretation: Findings, though inconclusive, were consistent with a modest intervention-related reduction in ESBL-E incidence. Higher acquisition rates associated with the rainy season and poor sanitation highlight the need to tackle environmental drivers of AMR transmission in addition to antibiotic use in rural sSA. Funding: JPI-AMR CABU EICO grant number: JPIAMR2021-053 Research in context: Evidence before this study: A systematic review of antimicrobial stewardship interventions in both community and hospital-settings published in 2019 found that only 23% (190/825) reported microbiological outcomes, underscoring a lack of evidence on how stewardship interventions affect antimicrobial resistance (AMR). Since then, this gap remains, and particularly for sub-Saharan Africa (sSA). Here, invasive AMR infections are frequently community-associated, with household transmission considered a dominant pathway for community-level AMR acquisition. Two systematic reviews on community-level transmission of AMR bacteria, including one published in 2025, reported ESBL-E acquisition rates of 0·17–0·29 per 100 person-days, with half of individuals clearing their colonisation within 3–4 months. However, all of the included 11 studies were from high-income contexts. The Drivers of Resistance in Uganda and Malawi (DRUM) study provided important One Health insights into human, animal, and environmental reservoirs of ESBL-E and Klebsiella pneumoniae, and found high ESBL-E prevalences up to 60%. This study however, was observational and did not evaluate interventions, and to date, has not quantified community-level transmission. The published community-level interventions in sSA have largely focused on formal healthcare providers or prescribers to reduce sub-optimal antibiotic use. A recent scoping review identified only seven intervention studies targeting general communities in sSA, highlighting a lack of rigorous evaluations of community-centred stewardship and AMR mitigation efforts more broadly and outside formal healthcare settings. None of these studies measured microbiological outcomes or effects on community transmission of resistant bacteria. Added value of this study: The CABU-EICO trial is, to our knowledge, the first cluster-randomised AMR intervention in a rural, low-income setting to quantify the effects of an intervention targeting both providers and communities on community-level ESBL-E transmission-dynamics. Using repeated stool sampling from household members and a continuous-time multi-state modelling framework, we estimated household-level ESBL-E acquisition and duration of colonisation, and found evidence for a reduction in ESBL-E transmission following the intervention. Additionally, we quantified seasonal patterns in the risk of ESBL-E acquisition in our West African setting, showing a peak during the rainy season, despite reportedly lower antibiotic use during this time of year. By moving beyond prevalence-based outcomes and antibiotic-use metrics alone, our intervention evaluation provides a statistically more efficient and mechanistically informative framework for evaluating AMR interventions. Implications of all the available evidence: This study shows that household-level transmission of ESBL-E is substantial in rural sSA and markedly higher than estimates from high-income settings, with clear seasonal peaks during the rainy season and increased risk associated with poor sanitation. Together with recent One Health genomic evidence demonstrating frequent transmission between humans, animals and the environment in Eastern Africa, these findings suggest that community-level AMR dynamics are driven by both antibiotic selection pressure and environmental exposure pathways. Effective AMR control in similar settings will therefore require, similar to our approach, integrated One Health strategies that combine antibiotic stewardship, with structural and environmental interventions, and that incorporate transmission as well as acquisition outcomes to fully capture intervention impact.

Adherence to antiretroviral therapy (ART) remains central to HIV management, yet is shaped not only by individual behaviour but by the social and structural realities within which people live. This research examines the household as a key environment influencing treatment adherence, exploring how the quality, type, and quantity of household support contribute to inequalities in health outcomes and how strengthening household dynamics can improve adherence and resilience. Across a mixed-methods design, the research identifies the household as both a site of vulnerability and a resource for care. A systematic review of studies from low- and middle-income countries revealed that gender norms, socioeconomic inequality, health system barriers, and stigma intersect to shape the level of support people living with HIV (PLHIV) receive at home. These intersecting factors create uneven opportunities for adherence, underscoring the need for interventions that address broader social and structural contexts. Quantitative analyses from the SINAKO cluster randomised controlled trial in Cape Town, South Africa, further demonstrated how household and community environments influence adherence. During the COVID-19 lockdown, households with stronger functioning, communication, and solidarity maintained better adherence despite economic strain. Violence, depression, food insecurity, and stigma undermined adherence, whereas well-being and supportive household relationships enhanced it. At ART initiation, greater household support and higher HIV knowledge were associated with better adherence, while male gender, reinitiating treatment, and psychological violence predicted poorer outcomes. Finally, analyses indicated evidence that the SINAKO household-based intervention delivered by community health workers improved ART adherence and strengthened household-HIV competency. Household-HIV competency was furthermore associated with household functioning, violence, and ART adherence itself. Together, the findings show that ART adherence is co-produced within household systems shaped by social and structural determinants. Building HIV-competent households—through inclusive, supportive, and resilient home environments—offers a promising pathway toward more equitable and sustainable HIV care. Overall, the findings indicate the importance of taking the household into consideration when evaluating and intervening in HIV care.

Background: Obtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men Web-based respondent-driven sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research, it remains unclear whether WEB RDS is suitable for sampling hidden populations such as men who have sex with men. Objective: This study aims to evaluate how viable the WEB RDS methodology is for obtaining a nationwide sample of men who have sex with men, suitable for population inference of sexual health characteristics, in Belgium. Methods: We adapted the Medical Resource Council process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing “WEB RDS” as a complex intervention with respondent-driven recruitment as the aim, we evaluated indicators of context, implementation, mechanisms of impact, and performance. We analyzed the data using a mixed methods approach that integrated findings from quantitative analysis, such as RDS diagnostics, and qualitative thematic analysis. Results: Sampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). A visual examination of the convergence and bottleneck plots indicates that many more waves of recruitment would be needed for population estimates to become independent of the seeds. However, producing further waves was impeded by challenges inherent to the research context and process. Men who have sex with men and their community organization representatives indicated that, in Belgium, men who have sex with men are overresearched, with low motivation for the topic of sexual health and digital etiquette dictating not sharing survey links. A moderate reward of €10-€30 (US $11.2-$33.6) with a dual incentive structure was insufficient to overcome these barriers. Conclusions: This study indicates that WEB RDS, even with a moderate incentive, is not a viable sampling strategy for obtaining valid population estimates of sexual health traits of men who have sex with men in Belgium. The study emphasizes the need to understand men who have sex with men research motivation and topic saliency. Additionally, the study highlights the importance of digital etiquette. Finally, the study showcases the use of the adapted Medical Research Council framework for evaluating WEB RDS methodology.

Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z = − 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z = − 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z = − 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z = − 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z = − 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support. Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.

BACKGROUND Obtaining a representative sample is a substantial challenge when undertaking health research among hidden and hard-to-reach populations such as men who have sex with men Web-based respondent-driven sampling (WEB RDS) was developed to overcome such sampling challenges and to create population estimates based on network and sampling characteristics. Despite a decade of research, it remains unclear whether WEB RDS is suitable for sampling hidden populations such as men who have sex with men. OBJECTIVE This study aims to evaluate how viable the WEB RDS methodology is for obtaining a nationwide sample of men who have sex with men, suitable for population inference of sexual health characteristics, in Belgium. METHODS We adapted the Medical Resource Council process evaluation framework for interventions, to evaluate an empirical WEB RDS. Viewing “WEB RDS” as a complex intervention with respondent-driven recruitment as the aim, we evaluated indicators of context, implementation, mechanisms of impact, and performance. We analyzed the data using a mixed methods approach that integrated findings from quantitative analysis, such as RDS diagnostics, and qualitative thematic analysis. RESULTS Sampling did not reach a sufficient sample size (n=193) to compensate for an RDS design effect of 3 and the number of recruitment waves was low (waves=7). A visual examination of the convergence and bottleneck plots indicates that many more waves of recruitment would be needed for population estimates to become independent of the seeds. However, producing further waves was impeded by challenges inherent to the research context and process. Men who have sex with men and their community organization representatives indicated that, in Belgium, men who have sex with men are overresearched, with low motivation for the topic of sexual health and digital etiquette dictating not sharing survey links. A moderate reward of €10-€30 (US $11.2-$33.6) with a dual incentive structure was insufficient to overcome these barriers. CONCLUSIONS This study indicates that WEB RDS, even with a moderate incentive, is not a viable sampling strategy for obtaining valid population estimates of sexual health traits of men who have sex with men in Belgium. The study emphasizes the need to understand men who have sex with men research motivation and topic saliency. Additionally, the study highlights the importance of digital etiquette. Finally, the study showcases the use of the adapted Medical Research Council framework for evaluating WEB RDS methodology.

In March 2020, the South African government imposed a lockdown to control COVID-19 transmission. Lockdown may affect people living with HIV’s (PLWH) antiretroviral therapy (ART) adherence. Data from a cluster randomised control trial was collected from 152 PLWH in Cape Town sub-districts from October 2019–March 2020 when the lockdown halted collection. Subsequently, 83 PLWH were followed-up in June–July 2020. Random effects models were used to analyse: (1) changes between baseline and follow-up and (2) correlates of adherence during lockdown. At follow-up, there was an increase in the odds of being below the poverty line and the odds of experiencing violence decreased. Measures for well-being, household functioning, stigma and HIV competency improved. Violence, depression, food insecurity, and stigma were associated with poorer ART adherence; higher well-being scores were associated with better adherence. During lockdown, governments need to ensure financial support, access to (mental) health services, and services for those experiencing violence. Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.