Introduction Female and male sex workers experience heightened vulnerability to HIV and other health harms that are compounded by substance use, physical and sexual violence, and limited access to health services. In Kisumu, Kenya, where sex work is widespread and substance use is a growing public health concern, offering pre‐exposure prophylaxis (Pr EP ) for HIV prevention could help curtail the HIV epidemic. Our study examines “syndemics,” or mutually reinforcing epidemics of substance use, violence and HIV , in relation to Pr EP acceptability and feasibility among female and male sex workers in Kenya, one of the first African countries to approve Pr EP for HIV prevention. Methods From 2016 to 2017, sex workers in Kisumu reporting recent alcohol or drug use and experiences of violence participated in qualitative interviews on HIV risk and perspectives on health service needs, including Pr EP programming. Content analysis identified themes relating to Pr EP knowledge, acceptability, access challenges and delivery preferences. Results Among 45 female and 28 male sex workers, median age was 28 and 25 respectively. All participants reported past‐month alcohol use and 91% of women and 82% of men reported past‐month drug use. Violence was pervasive, with most women and men reporting past‐year physical (96% women, 86% men) and sexual (93% women, 79% men) violence. Concerning Pr EP , interviews revealed: (1) low Pr EP knowledge, especially among women; (2) high Pr EP acceptability and perceived need, particularly within syndemic contexts of substance use and violence; and (3) preferences for accessible, non‐stigmatizing Pr EP delivery initiatives designed with input from sex workers. Conclusions Through a syndemic lens, substance use and violence interact to increase HIV vulnerability and perceived need for Pr EP among female and male sex workers in Kisumu. Although interest in Pr EP was high, most sex workers in our sample, particularly women, were not benefiting from it. Syndemic substance use and violence experienced by sex workers posed important barriers to Pr EP access for sex workers. Increasing Pr EP access for sex workers will require addressing substance use and violence through integrated programming.

There is a clear need for effective strategies to address the factors that affect retention, or Lost-to-follow-up (LTFU) and adherence to HIV care and treatment. Depression in particular may play an important role in the high rates of LTFU along the prevention of mother-to-child HIV transmission (PMTCT) cascade in sub-Saharan Africa. This study assessed the association between prenatal depression and 1) LTFU or 2) Uptake of PMTCT services. As part of a randomized control trial to evaluate the effect of conditional cash transfers on retention in and uptake of PMTCT services, newly-diagnosed HIV-infected women, ≤32 weeks pregnant, registering for antenatal care (ANC), in 85 clinics in Kinshasa, Democratic Republic of Congo (DRC), were recruited and followed-up until LTFU, death, transfer out, or six-weeks postpartum. Participants were interviewed at enrollment using a questionnaire which included the Patient Health Questionnaire (PHQ-9). Depression was defined as a PHQ-9 score of ≥15. Among 433 women enrolled, 51 (11.8%) had a PHQ-9 score ≥15 including 15 (3.5%) with a score ≥20. At six weeks postpartum, 67 (15.5%) were LFTU and 331 (76.4%) were in care and had accepted all available PTMCT services. Of participants with depression at enrollment, 17.7% (9/51) were LTFU at six weeks postpartum compared to 15.2% (58/382) among those without, but the association was not statistically significant. On the other hand, 78.4% (40/51) of participants with prenatal depression were in care at six weeks postpartum and had attended all their scheduled visits and accepted available services compared to 76.2% (291/382) among those without depression. In this cohort of newly-diagnosed HIV-infected pregnant women, prenatal depression assessed with a PHQ-9 score ≥15 was not a strong predictor of LTFU among newly-diagnosed HIV-infected women in Kinshasa, DRC.

Women who use alcohol and drugs are often in their childbearing years, creating a need for integrated substance abuse and reproductive health services. However, our understanding of the social context and drivers of substance use during pregnancy, particularly in developing countries, is limited and largely unaddressed in clinical care. Our qualitative research explored the reproductive health of women of childbearing age who inject drugs and its implications for healthcare in Kisumu, Kenya. We used in-depth, semi-structured qualitative interviews with 17 women who inject drugs to explore reproductive health topics including knowledge, practices, and clinical interactions related to substance use during pregnancy. All but one woman had a prior pregnancy and two were pregnant during our study. Alcohol and drug use was prevalent throughout pregnancy, often described as a coping mechanism for stress. Women received mixed advice from family and social contacts regarding alcohol use during pregnancy, leading to differing perceptions of its health effects. Healthcare providers infrequently screened women for alcohol or drug use. Our analysis highlights the need for culturally appropriate alcohol and drug screening and counseling to be included in integrated reproductive health services in western Kenya.

Due to heightened vulnerability to HIV from frequent engagement in sex work and overlapping drug-using and sexual networks, women who inject drugs should be a high priority population for pre-exposure prophylaxis (PrEP) and other biomedical HIV prevention tools. Kenya is one of the first African countries to approve oral PrEP for HIV prevention among "key populations," including people who inject drugs and sex workers. The objective of this study was to explore preferences and perceived challenges to PrEP adoption among women who inject drugs in Kisumu, Kenya. We conducted qualitative interviews with nine HIV-uninfected women who inject drugs to assess their perceptions of biomedical HIV interventions, including oral PrEP, microbicide gels, and intravaginal rings. Despite their high risk and multiple biomedical studies in the region, only two women had ever heard of any of these methods. All women were interested in trying at least one biomedical prevention method, primarily to protect themselves from partners who were believed to have multiple other sexual partners. Although women shared concerns about side effects and product efficacy, they did not perceive drug use as a significant deterrent to adopting or adhering to biomedical prevention methods. Beginning immediately and continuing throughout Kenya's planned PrEP rollout, efforts are urgently needed to include the perspectives of high risk women who use drugs in biomedical HIV prevention research and programing.

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Background Theoretical and methodological research on risk-taking practices often frames risk as an individual choice. While risk does occur at individual level, it is determined by aspirations which are connected to others and society. For many displaced women globally, these aspirations are often linked to the well-being of their children and other household members. This article explores the links between aspirations for the future, gendered household dynamics, and health risk-taking behavior among the Rwandan urban refugee community. Methods This analysis drew from participant observation, focus group discussions, and in-depth interviews with 49 male and 42 female household members from 36 Rwandan refugee households in Yaoundé, Cameroon. The fieldwork was conducted over 12 months between May–August 2016, May–August 2017, and February–August 2018. Results We observed that while there was considerable convergence among household members in aspirations, there was considerable difference in risk-taking practices engaged to achieve them with women often assuming the greatest risks. These gendered realities of risk were not only related to structural concerns including access to different forms of capital, but also to socio-cultural gendered expectations of women, how risks were defined and justified, and household dynamics that drove the gendered reality of observed risk-behavior. Conclusions Humanitarian programs and policies are distinctly finite in nature; focused on the short-term needs of persons affected by conflict. However, many humanitarian situations in the world are protracted. In the midst of these challenges, themes of future-orientation, possibilities, and shared aspirations for a better future emerge. These aspirations and the practices, including risk-taking practices that stem from them are central to understand if we are to ensure a just peace and stability in displaced communities throughout the developing world. Our analysis highlights the need to examine sociocultural dimensions related to hopes for the future, gender, and household dynamics as a way to understand risk behavior. We propose this can be done through a framework of precarious hope which we put forward in this paper, in which hope, agency, sociocultural and political economic contexts situate risk as a gendered practice of hope amidst constraint.

The household is a ubiquitous unit of analysis across the social sciences. In policy, research and practice, households are often considered a link between individuals and the structures that they interact with on a daily basis. Yet, researchers often take the household for granted as something that means the same thing to everyone across contexts. As the household has never truly been a static unit of analysis, we need to revisit the household to ensure that we are still capturing what it means to be part of a household – especially if we are engaging in research where we aim to compare households across time and space. We analyse how the concept of the household has been used over time and identify areas, such as migration and urbanisation, where we need to ensure conceptual clarity. We use our field notes and ethnographic interviews to show the challenges of such an analysis.

Health and well-being have been historically uncommon areas of focus in studies of forced migration within the social sciences, where the focus has more often been focused broadly on identity, liminality, and social suffering. Urban refugees have also been largely excluded from the narrative. Yet, urban refugees represent the majority of the world’s refugees, which means we are effectively excluding the majority of the refugee experience from our research. Health is often a central marker of inequality and marginalization. Understanding the entanglement of forced migration to urban areas and health bears enormous potential for policy and practice. This paper will outline what we know, and set an agenda for the study of urban refugee health.