Summary Background Low-income and middle-income countries (LMICs) face major challenges in achieving the UN's Sustainable Development Goals (SDGs) for vulnerable adolescents. We aimed to test the UN Development Programme's proposed approach of development accelerators—provisions that lead to progress across multiple SDGs—and synergies between accelerators on achieving SDG-aligned targets in a highly vulnerable group of adolescents in South Africa. Methods We did standardised interviews and extracted longitudinal data from clinical records at baseline (2014–15) and 18-month follow-up (2016–17) for adolescents aged 10–19 years living with HIV in the Eastern Cape province of South Africa. We used standardised tools to measure 11 SDG-aligned targets—antiretroviral therapy adherence, good mental health, no substance use, HIV care retention, school enrolment, school progression, no sexual abuse, no high-risk sex, no violence perpetration, no community violence, and no emotional or physical abuse. We also assessed receipt at both baseline and follow-up of six hypothesised development accelerators—government cash transfers to households, safe schools (ie, without teacher or student violence), free schools, parenting support, free school meals, and support groups. Associations of all provisions with SDG-aligned targets were assessed jointly in a multivariate path model, controlling for baseline outcomes and sociodemographic and HIV-related covariates, and adjusted for multiple outcome testing. Cumulative effects were tested by marginal effects modelling. Findings 1063 (90%) of 1176 eligible adolescents were interviewed. Three provisions were shown to be development accelerators. Parenting support was associated with good mental health (odds ratio 2·13, 95% CI 1·43–3·15, p<0·0001), no high-risk sex (2·44, 1·45–5·03, p=0·005), no violence perpetration (2·59, 1·63–4·59, p<0·0001), no community violence (2·43, 1·65–3·86, p<0·0001), and no emotional or physical abuse (2·38, 1·65–3·76; p<0·0001). Cash transfers were associated with HIV care retention (1·87, 1·15–3·02, p=0·010), school progression (2·05, 1·33–3·24, p=0·003), and no emotional or physical abuse (1·76, 1·12–3·02, p=0·025). Safe schools were associated with good mental health (1·74, 1·30–2·34, p<0·0001), school progression (1·57, 1·17–2·13, p=0·004), no violence perpetration (2·02, 1·45–2·91, p<0·0001), no community violence (1·81, 1·30–2·55, p<0·0001), and no emotional or physical abuse (2·20, 1·58–3·17, p<0·0001). For five of 11 SDG-aligned targets, a combination of two or more accelerators showed cumulative positive associations, suggesting accelerator synergies of combination provisions. For example, the fitted probability of adolescents reporting no emotional or physical abuse (SDG 16.2) with no safe schools, cash transfers, or parenting support was 0·25 (0·16–0·34). With cash transfer alone it was 0·37 (0·33–0·42), with safe school alone 0·42 (0·30–0·55), and with parenting...

Background The INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which ‘accelerator’ provisions can simultaneously reduce multiple types of violence against children. Methods and findings We pooled data from two prospective South African adolescent cohorts including Young Carers (2010–2012) and Mzantsi Wakho (2014–2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: −3.74% points, 95% CI −5.31 to −2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: −5.23% points, 95% CI −7.26 to −3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: −14.72% points, 95% CI −19.11 to −10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: −12.41% points, 95% CI −16.00 to −8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: −7.87% points, 95% CI −11.98 to −3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: −7.30% points, 95% CI −10.50 to −4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: −0.59% points, 95% CI −2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: −2.42% points, 95% CI −4.77 to −0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: −11.74% points, 95% CI −16.91 to −6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: −13.00% points, 95% CI −17.04 to −8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: −5.87% points, 95% CI −10.98 to −0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD −7.46% points, 95% CI −11.57 to −3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies. Conclusion In this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE.

ObjectivesWe assessed COVID-19 pandemic impacts on accessing needed sexual health services, and acceptability of alternative service delivery models, among sexual health service clients in British Columbia (BC), Canada.MethodsWe administered an online survey on 21 July–4 August 2020 to clients using a provincial STI clinic or internet-based testing service, GetCheckedOnline, in the year prior to March 2020. We used logistic regression to identify factors associated with having unmet sexual health needs (ie, not accessing needed services) during March–July 2020 and the likelihood of using various alternative service models, if available.ResultsOf 1198 survey respondents, 706 (59%) reported needing any sexual health service since March 2020; of these 706, 365 (52%) did not access needed services and 458 (66%) had avoided or delayed accessing services. GetCheckedOnline users (univariate OR (uOR)=0.62; 95% CI 0.43 to 0.88) or clients with more urgent needs (eg, treatment for new STI, uOR 0.40 (95% CI 0.21 to 0.7)) had lower odds of unmet sexual health needs. The most common factors reported for avoiding or delaying access were public messaging against seeking non-urgent healthcare (234/662, 35%), concern about getting COVID-19 while at (214/662, 32%) or travelling to (147/662, 22%) a clinic or lab and closure of usual place of accessing services (178/662, 27%). All factors were positively associated with having unmet sexual health needs, with public messaging showing the strongest effect (adjusted OR=4.27 (95% CI 2.88 to 6.42)). Likelihood of using alternative sexual health service models was high overall, with the most appealing options being home self-collection kits (634/706, 90%), receiving test kits or antibiotics at home (592/700, 85%) and express testing (565/706, 80%).ConclusionsOf BC sexual health service clients needing services during March–July 2020, many had unmet needs. Offering alternative service delivery methods may help to improve access during and beyond the COVID-19 pandemic.

BackgroundThe emergence and re-emergence of vector-borne and other infectious diseases of poverty pose a threat to the health of populations living in urban and low-income settings. A detailed understanding of intervention strategies, including effectiveness of past outbreak containment, is necessary to improve future practices. The objective was to determine what is known about the effectiveness of containment measures for emerging and re-emerging vector-borne and other infectious diseases of poverty in urban settings and identify research gaps and implications for public health practice.Main bodyWe conducted a scoping review and systematically searched peer-reviewed and grey literature published between 2000 and 2016. Different data extraction tools were used for data coding and extraction, and data on implementation process and transferability were extracted from all studies. A quality assessment was conducted for each included study.We screened 205 full-text articles and reports for a total of 31 articles included in the review. The quality of the studies was generally low to moderate. The largest body of evidence concerned control activities for Ebola virus and dengue fever. The majority of interventions (87%) relied on multiple types of measures, which were grouped into four categories: 1) healthcare provision; 2) epidemiological investigation and/or surveillance; 3) environmental or sanitary interventions; and 4) community-based interventions. The quality of the majority of studies (90%) was poor or moderate, and one-third of the studies did not provide a clear description of the outcomes and of the procedures and/or tools used for the intervention.ConclusionsOur results highlight the difficulty of establishing causation when assessing the effect of containment measures. Studies that extend beyond solely reporting on effectiveness and take into account the complexity of real-world settings are urgently needed. We recommend the allocation of research efforts to the evaluation of the implementation processes of interventions as well as their comprehensive and systematic description using validated checklists.Electronic supplementary materialThe online version of this article (10.1186/s40249-018-0478-4) contains supplementary material, which is available to authorized users.

Exposure to sexual risk in early adolescence strongly predicts HIV infection, yet evidence for prevention in young adolescents is limited. We pooled data from two longitudinal South African surveys, with adolescents unexposed to sexual risk at baseline (n = 3662). Multivariable logistic regression tested associations between intermittent/consistent access to eight provisions and reduced sexual risk exposure. Participants were on average 12.8 years, 56% female at baseline. Between baseline and follow-up, 8.6% reported sexual risk exposure. Consistent access to caregiver supervision (OR 0.53 95%CI 0.35-0.80 p = 0.002), abuse-free homes (OR 0.55 95%CI 0.37-0.81 p = 0.002), school feeding (OR 0.55 95%CI 0.35-0.88 p = 0.012), and HIV prevention knowledge (OR 0.43, 95%CI 0.21-0.88 p = 0.021) was strongly associated with preventing early sexual risk exposure. While individual factors reduced the odds of sexual risk exposure, a combination of all four resulted in a greater reduction, from 12.9% (95%CI 7.2-18.7) to 1.0% (95%CI 0.2-1.8). Consistent access to provisions in early adolescence may prevent sexual risk exposure among younger adolescents.

Background Human granulocytic anaplasmosis (HGA) is a potentially severe tick-borne infection caused by the bacterium Anaplasma phagocytophilum ( A. phagocytophilum ) of the genus Rickettsia. Here, we describe the epidemiological and clinical characteristics of an unusual cluster of HGA cases detected in the Estrie region in Québec, Canada, during the 2021 transmission season. Methods Confirmed cases of HGA were defined as individuals with typical clinical manifestations and a positive polymerase chain reaction assay. The cases were interviewed using a structured questionnaire and clinical data was obtained from medical records. Results A total of 25 confirmed cases were identified during the 2021 transmission season, thus constituting the largest known cluster of HGA in Canada. The most common symptoms reported were fever, fatigue and headaches. Laboratory investigations found that 20 (80%) of the patients had thrombocytopenia and 18 (72%) had leukopenia at presentation. Almost half of the patients required hospitalization (n=11, 44%), with a median duration of four days (interquartile range [IQR] 2.5–5 days), including one patient who required intensive care. No deaths were recorded during the study. Epidemiological investigation found that all cases were domestically acquired, and yard maintenance was the most prevalent at-risk activity identified. Only seven (28%) cases had been aware of a tick bite in the previous two weeks. Conclusion Detection of this unusual cluster of HGA cases provides further evidence that A. phagocytophilum may now be established along the southern border of Québec. Clinicians should consider HGA when assessing patients with typical symptoms and recent exposure to high-risk environments for tick bite.

Objectives Initial public health guidance related to sex and COVID-19 infection focused on reducing partner number. We characterized individuals having a higher partner number during the initial phases of the pandemic. Methods In British Columbia, the initial wave of COVID-19 cases was from March 14 to May 19, 2020, followed by gradual lifting of public health restrictions. We conducted an e-mail survey of existing sexual health service clients during the period of July 23 to August 4, 2020. We used bivariate logistic regression to examine the association between the reported number of sexual partners since the start of the pandemic and key variables (level of significance p < 0.01). Results Of the 1196 clients in our final sample, 42% reported 2+ partners since the start of the pandemic, with higher odds among participants who were men who have sex with men, and single or in open relationships prior to the pandemic. This group was more likely to perceive stigma associated with having sex during the pandemic, and had the highest use of strategies to reduce risk of COVID-19 infection during sexual encounters (mainly focused on reducing/avoiding partners, such as masturbation, limiting sex to a “bubble”, and not having sex). Conclusion Sexual health service clients in BC with 2+ partners during the initial phases of BC’s pandemic used strategies to reduce their risk of COVID-19 infection during sex. Our study provides support for a harm reduction approach to guidance on COVID-19 risk during sex, and highlights the need for further research on stigma related to having sex during the COVID-19 pandemic.

ObjectivesThe objectives of this study were: (1) to examine the correlates of HIV positivity among participants who injected drugs and engaged in sex work (PWID-SWs) in the SurvUDI network between 2004 and 2016, after stratification by sex, and (2) to compare these correlates with those of sexually active participants who did not engage in sex work (PWID non-SWs).Design and settingThis biobehavioural survey is an open cohort of services where participants who had injected in the past 6 months were recruited mainly through harm reduction programmes in Eastern Central Canada.ParticipantsData from 5476 participants (9223 visits in total; 785 not included in multivariate analyses due to missing values) were included.MethodsParticipants completed an interviewer-administered questionnaire and provided saliva samples for anti-HIV antibody testing. Generalised estimating equations taking into account multiple participations were used.ResultsBaseline HIV prevalence was higher among SWs compared with non-SWs (women: 13.0% vs 7.7%; P<0.001, and men: 17.4% vs 10.8%; P<0.001). PWID-SWs were particularly susceptible to HIV infection as a result of higher levels of vulnerability factors and injection risk behaviours. They also presented different risk-taking patterns than their non-SWs counterparts, as shown by differences in correlates of HIV positivity. Additionally, the importance of sex work for HIV infection varies according to gender, as suggested by a large proportion of injection risk behaviours associated with HIV among women and, conversely, a stronger association between sexual behaviours and HIV positivity observed among men.ConclusionThese results suggest that sex work has an impact on the risk of HIV acquisition and that risk behaviours vary according to gender. Public health practitioners should take those specificities into account when designing HIV prevention interventions aimed at PWIDs.