BMJ Global Health最新文献

Introduction: Integration of management of tuberculosis (TB) and HIV with prevention and treatment of non-communicable diseases (NCDs) is a global priority. However, delivering the full spectrum of HIV/TB and NCD services is hindered by a lack of evidence regarding effective models and strategies for integrating NCDs and HIV/TB care services in varying contexts and across interventions. We conducted a scoping review to describe service delivery models and strategies used to facilitate integration of NCD care in HIV and/or TB care settings in low- and middle-income countries (LMICs).

Methods: We searched eight electronic databases for studies published from 2010 to 2025 that evaluated methods to integrate evidence-based screening and/or treatment of NCDs (diabetes, cervical cancer, hypertension and depression) and NCD risk factors (alcohol and tobacco use) in the context of HIV and/or TB care in LMICs. We applied a framework for categorising integration models ranging from coordination to full integration and used implementation science taxonomies to define implementation strategies and outcomes.

Results: 72 articles were included; 62.5% evaluated implementation of NCD interventions in HIV care settings, 31.9% in TB care and 5.6% in both. Less than a third (27.8%) reported a fully integrated service delivery model (shared systems and services). Commonly described implementation strategies included training (81.9%), evaluation strategies (43.1%), interactive assistance for providers (40.3%) and infrastructure change (eg, changing record systems) (37.5%).

Conclusion: Studies in LMICs are evaluating a range of strategies and service models for integrating NCD interventions into HIV and TB care in LMICs. This reflects differences in health system capacity and priorities. Greater alignment with WHO systems-integration models and implementation science frameworks could strengthen the evidence base and support progress towards global NCD goals through more consistent reporting of frameworks, integration strategies and implementation outcomes.

During 2024, the number of pandemic-prone and epidemic-prone disease outbreaks worldwide was estimated at 301. The data highlight a shift in disease outbreak patterns, with a decline in the number of countries reporting public health events of concern linked to COVID-19 and a rise in those reporting outbreaks of viral diseases transmitted by vectors.About 90% of the outbreaks in 2024 were associated with COVID-19, dengue, yellow fever, Oropouche virus disease and influenza (linked to identified zoonotic or pandemic influenza virus). Although disease outbreaks can affect any country anywhere, they tend to disproportionately occur in countries facing many other socio-economic development, climatic and humanitarian challenges. In this regard, sub-Saharan Africa and the subregion of Latin America and the Caribbean-home to just 23.3% of the world's population-reported the highest number of disease outbreaks in 2024 with about 57% of the total. Particularly, the sub-Saharan Africa region has been the site of nearly 32% of recorded outbreaks since 1996. Future research should include efforts to improve the quality and availability of disease outbreaks data-particularly in the most exposed or vulnerable regions-and to promote the scientific use of such information for foresight purposes and for forecasting future health events of concern to support anticipatory action.

Background: A more nuanced understanding of behavioural responses to incentives over time, particularly after they are removed, could guide more effective interventions. In this study, we build on the primary trial evaluation to explore the dynamic effectiveness of small, short-term monthly financial incentives on HIV care-seeking behaviours during and after incentive removal.

Methods: We conducted a 32-site cluster-randomised controlled trial (NCT04201353) among adult antiretroviral therapy (ART) initiates (<30 days) in four regions of Lake Zone, Tanzania. HIV care and treatment clinics were randomly assigned 1:1 to the intervention (up to 6 monthly cash transfers of 22 500 TZS each (~US$10), conditional on appointment attendance) or standard of care. Using time-to-event analysis, we assess the effect of incentives on three HIV-care seeking behaviours: missed appointment by >4 days, <90% ART adherence and interruption in treatment of >28 days.

Results: Among 1990 participants, we found large significant reductions in rate of missed appointments (hazard ratio (HR), 95% CI: 0.51, 0.39 to 0.68), <90% ART adherence (HR, 95% CI: 0.58, 0.41 to 0.83) and interruption in treatment (>28 days without ART) (HR, 95% CI: 0.54, 0.35 to 0.83) during the 6 months of incentives, but no effects after their removal. HRs by month reveal similar findings, with dramatic and consistent reductions in risk concentrated in months 2-6 that disappear in month 7, immediately after incentives are discontinued.

Conclusions: These results highlight the value of short-term incentives for initiating new care-seeking behaviours and emphasise a need for innovative design choices, such as escalating rewards or incorporation of time- or context-based cues, that may help motivate sustained behaviour change after their removal.

Trial registration number: NCT04201353.

Maternal mortality remains disproportionately high in low-income and middle-income countries, where pyramidal health systems and inadequate referral processes often delay access to emergency obstetric care. The Three Delays Model has long been used to analyse delays in maternal care globally, but it fails to capture the full complexity of referral-related delays within pyramidal health systems. Drawing on the example of Madagascar, this paper reviews the limitations of the traditional model and proposes a revised 'Six Delays Model'. This model expands the traditional three delays to include the following six stages: 'delay in seeking initial care', 'delay in reaching initial care', 'delay in receiving initial care', 'delay in seeking referral care', 'delay in reaching referral care', 'delay in receiving referral care'.This revised model improves granularity, integrates patient-provider and inter-provider dynamics that influence referral decisions and reflects both individual and community-level factors that influence decision-making. By mapping delays accurately along the patient journey, the revised model provides a more actionable model for policymakers and implementers seeking to reduce maternal mortality. While more complex, the expanded model offers necessary nuance and adaptability for pyramidal health systems and supports targeted intervention design to address systemic barriers to timely and adequate obstetric care.

Background: People living with HIV (PLWH) face a significantly elevated risk of cardiovascular diseases (CVDs). This study aims to quantify temporal trends in HIV-attributable CVD burden at global, regional and national levels using a comparative risk assessment framework.

Methods: We systematically searched PubMed, Embase and MEDLINE for cohort studies from inception to 28 October 2024, assessing HIV infection and CVD risk. Pooled risk ratios (RRs) for total and subtype-specific CVDs were estimated using random-effects meta-analysis. Based on pooled RRs and HIV prevalence data from the Global Burden of Disease (GBD) 2021 study, we calculated population attributable fractions (PAFs) from 1990 to 2011. These PAFs were applied to GBD disability-adjusted life-years (DALYs) to estimate the age-standardised DALYs rate (ASDRs) of CVDs attributable to HIV by sex, region and year between 2000 and 2021.

Findings: 35 cohort studies with 199 effect estimates were included. HIV infection was associated with increased risk of total CVDs (RR=1.38), stroke (1.90), ischaemic stroke (1.31), haemorrhagic stroke (2.04), ischaemic heart disease (1.72), myocardial infarction (1.60), heart failure (1.71), peripheral vascular disease (1.19) and cardiac arrest (2.58). Subgroup analyses showed higher ischaemic stroke risk in females and increased CVD risk among PLWH with low CD4+ or high viral load. From 1990 to 2011, the global PAF for total CVDs attributable to HIV rose from 0.0814% to 0.2244%. Global ASDR attributable to HIV nearly tripled, increasing from 3.45 to 9.26 per 100 000 population between 2000 and 2021, with stroke and ischaemic heart disease contributing most. The burden was highest in low-Sociodemographic Index regions, particularly southern Africa; in 2021, Lesotho and Eswatini had the highest ASDRs.

Interpretation: HIV-attributable CVD burden has risen substantially over the past two decades, with marked concentration in the African Region. Integrating CVD screening and management into HIV care is urgently needed in high-prevalence settings.

Introduction: Health workers (HWs) set an example for vaccine recipients, convey vaccine benefits and risks and interface with patients at increased risk for complications in pandemic settings. We explored HWs' acceptance of and recommendation for COVID-19 vaccine with and without previous receipt of seasonal influenza vaccine (SIV) in nine countries.

Methods: In 2023-2024, cross-sectional surveys among HW were conducted in Bangladesh, Cote d'Ivoire, Ghana, Laos, Lebanon, Morocco, Philippines, Thailand and Tunisia. Country researchers used a standard protocol and questionnaire to assess beliefs, perceptions and acceptance around SIV and COVID-19 vaccine and likelihood of recommending these vaccines to patients. Pooled findings were stratified by the presence or absence of a national HW SIV recommendation. Generalised mixed effects models were used to characterise the relationship between receipt of SIV and COVID-19 vaccine acceptance and recommendation, adjusting for WHO region, sex and duration of employment.

Results: Our analysis included 12 296 HWs from nine countries representing four WHO regions: African, Eastern Mediterranean, Southeast Asian and Western Pacific. Five countries had a national HW SIV recommendation (61% of HWs surveyed) prior to COVID-19 vaccine introduction. More than 90% of HWs reported completing the COVID-19 vaccination series, whereas intention to continue receiving annual COVID-19 vaccine was lower (61%). HWs who received SIV in the last season compared with those who did not were more likely to have received one or more COVID-19 booster doses (adjusted OR (aOR) 2.63, 95% CI 2.27 to 3.04) and to have recommended COVID-19 vaccine to patients (aOR 1.53, 95% CI 1.29 to 1.82).

Conclusions: Prior experience with SIV was associated with HW behaviour and recommendations regarding COVID-19 vaccination. Intention to continue receiving COVID-19 vaccines remains a challenge; ongoing training and education for vaccination staff could be beneficial. HWs play a critical role in the successful delivery of new and existing vaccines, particularly in a pandemic setting.

Background: Community-based health insurance (CBHI) is crucial for strengthening primary healthcare (PHC) and progressing towards universal health coverage (UHC), especially in resource-constrained, war-affected settings. While previous studies have explored CBHI in various contexts, this study uniquely investigates household willingness to join (WTJ) CBHI and its determinants in post-war Tigray, Ethiopia, offering valuable insights into the specific challenges and opportunities in this under-researched setting.

Methods: We conducted a multistage community-based survey across 15 districts within 6 accessible administrative zones, 1 year after the cessation of hostilities, sampling 2289 households in 30 clusters. The primary outcome variable-household WTJ CBHI-was analysed in relation to sociodemographic factors, a wealth index, type of frequently accessed healthcare facility, knowledge on CBHI benefits and prior experience with CBHI. Weighted logistic regression identified significant predictors of WTJ with p<0.05.

Results: 2270 households participated (99.17% response rate). Respondents were 60.31% female, and median age 42.50 years (IQR 33-55). Pre-war CBHI enrolment of households was approximately 62.40% (95% CI 60.11% to 64.63%), while post-war WTJ reached about 87.57% (95% CI 85.99% to 88.99%) of households. Key WTJ predictors included younger age, marital status, host community status, farming occupation, belonging to the 'less poor' wealth quintile, hospital access, knowledge of CBHI benefits and previous CBHI membership.

Conclusions: This study reveals substantial interest in CBHI among households in post-war Tigray, highlighting its potential to strengthen the healthcare system. To ensure equitable access and achieve UHC-particularly in rural and war affected areas-revitalising CBHI and rebuilding PHC are essential. While longitudinal research is warranted to understand how war-driven contextual changes affect CBHI demand over time, policies should prioritise affordability, enhance awareness and strengthen hospital linkages. This supports the prioritisation of CBHI investment as a crucial strategy in this context and potentially in similar under-resourced and war-torn settings.

Objective: Despite rising prevalence, very limited evidence is available on the clustering of hypertension and clustering of diabetes at household level in India. This study examines the clustering of hypertension and clustering of diabetes at household level among members aged 15 years and above in India.

Methods: Clustering of hypertension is defined as two or more members of the household having hypertension. Clustering of diabetes is defined as two or more members of the household having diabetes. Clustering was examined in 636 699 households interviewed in the fifth round of the National Family Health Survey 2019-2021. The relationship dyads of clustering and awareness of the diseases within households were also examined.

Results: Two or more members suffered from hypertension in 14.9% households, which contributed to 49.8% of total hypertension cases in India. Diabetes was clustered in 7.7% of households which contributed to 39.3% of total diabetes cases in India. Among households with two diagnosed members, the most common relationship dyad was spouses (53.6% for hypertension and 53.8% diabetes), followed by parent-child (29.8% for hypertension and 28.8% for diabetes). In households with three diagnosed members, the most common dyad was parent-child (44.3% for hypertension and 42.5% for diabetes). Among households with clustering, all the members with disease were unaware in 42.5% of the households for hypertension and 55.5% for diabetes, and mixed awareness was seen in 37.9% and 31.4% households for hypertension and diabetes, respectively.

Conclusion: Given the disproportionate amount of India's total case burden of hypertension and diabetes concentrated within clustered households, our findings underscore the importance of targeting households for interventions of hypertension and diabetes management in addition to interventions targeting individuals. Our findings may equip health systems with information on patterns of concentrated pockets of undiagnosed disease burden within households and may help in designing intensified interventions for rapid progress towards Sustainable Development Goal V.3.4.

Introduction: Emerging evidence of durable immunogenicity from mono-dose human papillomavirus vaccination (HPVV) prompted the WHO to recommend a single-dose HPVV schedule in December 2022. There is, however, limited understanding of processes and considerations influencing country adoption of the updated HPVV dosing schedule recommendation.

Methods: We identified four archetypes characterising countries' progress along the HPVV introduction and single-dose adoption continua. From September 2023 to February 2024, we purposefully sampled and conducted semistructured interviews with immunisation stakeholders representing Ministries of Health, Gavi-funded technical assistance partners, civil society organisations and multilateral agencies from African and Asian low-income and middle-income countries. Using multicycle, iterative thematic analysis, we identified factors enabling the adoption of the HPVV single-dose recommendation, as well as constraints to rendering a decision on the HPVV dosing schedule.

Results: We interviewed 66 stakeholders across 19 countries with mature HPVV programmes (n=11) or forthcoming national HPVV introductions (n=8), as well as countries adopting (n=10) or undecided about (n=9) the single-dose schedule. Stakeholders conveyed enthusiasm for single-dose HPVV, citing the following anticipated benefits: higher HPVV schedule completion and coverage, especially in underimmunised populations; costs saved from operational reconfigurations and reduced vaccine procurement demands, particularly for countries transitioning out of Gavi co-financing in a vaccine supply-constrained environment; and optimised vaccine stock management capacity, importantly for countries pursuing new vaccine introductions for multiple antigens simultaneously. Factors demotivating HPVV single-dose schedule adoption or delaying decision-making included: limited localised evidence of long-term immunologic protection from single-dose HPVV; off-label product use liabilities; costs/resources required for retraining the health workforce in countries with mature HPVV programmes; and potential for widening HPVV coverage inequities, notably in countries with elevated HIV burdens.

Conclusions: Coupled with the WHO's endorsement, the perceived benefits of single-dose HPVV consistently outweighed the anticipated risks, even when these risks delayed country-level HPVV schedule-related decision-making.

Objective: To determine whether liquefied petroleum gas (LPG) can reduce perinatal mortality in a setting with high reliance on biomass fuels for cooking.

Design: Community-based two-arm parallel cluster randomised controlled trial, in Sherpur, Bangladesh.

Participants: 4944 pregnant women were recruited, with 2472 in each group. Eligible women were pregnant between 40 and 120 days, aged 15-49 years, permanent residents and planning to give birth in their cluster of residence.

Intervention: LPG stove and fuel to birth. Controls continued with usual cooking practices.

Main outcome: Primary outcome at the individual level: perinatal mortality.

Secondary outcomes: early neonatal mortality, neonatal mortality, preterm birth and personal exposure to particulate matter 2.5 (PM2.5).

Results: The final birth outcomes included 4592 participants. The perinatal mortality rate (PMR) was 50 per 1000 births in the intervention group compared with 61 per 1000 births in the control group (relative risk (RR) 0.83; 95% CI 0.65 to 1.06). PM2.5 concentrations were 47.2 µg/m³ in the intervention versus 60.3 µg/m³ in the control; mean difference -0.133 (95% CI -0.194 to -0.072). In late pregnancy, it was 62·7 µg/m³ in the intervention versus 88·7 µg/m³ in the control, mean difference -0.149 (-0.198 to -0.101). Early neonatal mortality was 22% in the intervention compared with 30% in the control (RR 0.73; 95% CI 0.50 to 1.05). Preterm birth rates were similar. In post hoc subgroup of small versus large households (HH), the PMR was lower in the smaller HH in the intervention group (67, rate 54 per 1000 births) than in the control group (102, 71 per 1000 births, adjusted RR 0.75; 95% CI 0.56 to 1.00; p=0.047).

Conclusions: Reductions in perinatal mortality favoured the intervention but were statistically non-significant. These findings demonstrate a reduction in mortality in smaller HH when cooking needs are adequately covered by clean fuel.

Trial registration number: ACTRN12618001214224; Australian and New Zealand Clinical Trials Registry.