A well-documented barrier to voluntary medical male circumcision (VMMC) is financial loss due to the missed opportunity to work while undergoing and recovering from VMMC. We implemented a 2-phased outcome evaluation to explore how enhanced demand creation and financial compensation equivalent to 3 days of missed work influence uptake of VMMC among men at high risk of HIV exposure in Zambia. In Phase 1, we implemented human-centered design-informed interpersonal communication. In Phase 2, financial compensation of ZMW 200 (~ US$17) was added. The proportion of men undergoing circumcision was significantly higher in Phase 2 compared to Phase 1 (38% vs 3%). The cost of demand creation and compensation per client circumcised was $151.54 in Phase 1 and $34.93 in Phase 2. Financial compensation is a cost-effective strategy for increasing VMMC uptake among high-risk men in Zambia, and VMMC programs may consider similar interventions suited to their context.

The accurate measurement of violence depends on high-quality data collected using methods that ensure participant confidentiality, privacy, and safety. To assess survey participants' emotional distress, discomfort, and self-perceived value of participating in the Honduras (2017), El Salvador (2017), Cote d'Ivoire (2018), and Lesotho (2018) Violence Against Children and Youth Surveys, which include sensitive topics such as sexual, physical, and emotional violence, we investigated individual self-reported distress and perceived value of participation by age, sex, and other demographic factors. We also examined the associations between past experiences of violence and both self-reported distress and perceived value of survey participation. Few individuals reported distress or concerns about disclosure. Across countries, 82.9% (Cote d'Ivoire) to 96.1% (Honduras) of participants indicated they were not afraid that someone might overhear their answers, 82.5% (Cote d'Ivoire) to 98.0% (El Salvador) said participation was not upsetting or stressful, and 93.3% (Cote d'Ivoire) to 98.6% (Honduras) said participation was worthwhile. The value of these interviews may exceed the negative feelings that some questions potentially elicit and can contribute to improved responses to victims.

BACKGROUND: The increase in cell phone ownership in low- and middle- income countries (LMIC) has created an opportunity for low-cost, rapid turnaround data collection by calling participants on their cell phones. Cell phones can be mobilized for myriad data collection purposes, including surveillance. In LMIC, cell phone-based surveillance has been used to track Ebola, measles, acute flaccid paralysis, and diarrheal disease, as well as non-communicable diseases. Phone-based surveillance in LMIC is a particularly pertinent, burgeoning approach in the context of the COVID-19 pandemic. Participatory surveillance via cell phone could allow governments to assess burden of disease and complements existing surveillance systems. OBJECTIVE: We describe the protocol for the LeCellPHIA project, a cell phone surveillance system that collects weekly population-based data on influenza-like illness (ILI) in Lesotho by calling a representative sample of a recent face-to-face survey. METHODS: We established a phone-based surveillance system to collect ILI symptoms from approximately 1700 participants who had participated in a recent face-to-face survey in Lesotho, the Population-based HIV Impact Assessment (PHIA) Survey. Of the 15,267 PHIA participants who were over 18, 11,975 (78.44%) consented to future research and provided a valid phone number. We followed the PHIA sample design and included 342 primary sampling units from 10 districts. We randomly selected 5 households from each primary sampling unit that had an eligible participant and sampled one person per household. We oversampled the elderly, as they are more likely to be affected by COVID-19. A three-day Zoom training was conducted in June 2020 to train LeCellPHIA interviewers. RESULTS: The surveillance system launched July 1, 2020, beginning with a two-week enrollment period followed by weekly calls that will continue until September 30, 2021. Of the 11,975 phone numbers that were in the sample frame, 3,020 were sampled and 1,778 were enrolled. CONCLUSIONS: The surveillance system will track COVID-19 in a resource-limited setting. The novel approach of a weekly cell phone-based surveillance system can be used to track other health outcomes and this protocol provides information about how to implement such a system.

This study aims to quantify the prevalence of forced sex, pressured sex, and related pregnancy among adolescent girls and young women in five low- and middle-income countries. Nationally representative, cross-sectional household surveys were conducted in Haiti, Malawi, Nigeria, Zambia, and Uganda among girls and young women aged 13 to 24 years. A stratified three-stage cluster sample design was used. Respondents were interviewed to assess prevalence of sexual violence, pregnancy related to the first or most recent experience of forced or pressured sex, relationship to perpetrator, mean age at sexual debut, mean age at pregnancy related to forced or pressured sex, and prevalence of forced/coerced sexual debut. Frequencies, weighted percentages, and weighted means are presented. The lifetime prevalence of forced or pressured sex ranged from 10.4% to 18.0%. Among these adolescent girls and young women, the percentage who experienced pregnancy related to their first or most recent experience of forced or pressured sex ranged from 13.2% to 36.6%. In three countries, the most common perpetrator associated with the first pregnancy related to forced or pressured sex was a current or previous intimate partner. Mean age at pregnancy related to forced or pressured sex was similar to mean age at sexual debut in all countries. Preventing sexual violence against girls and young women will prevent a significant proportion of adverse effects on health, including unintended pregnancy. Implementation of strategies to prevent and respond to sexual violence against adolescent girls and young women is urgently needed.

Violence is a major public health and human rights concern, claiming over 1.3 million lives globally each year (1). Despite the scope of this problem, population-based data on physical and sexual violence perpetration are scarce, particularly in low-income and middle-income countries (2,3). To better understand factors driving both children becoming victims of physical or sexual violence and subsequently (as adults) becoming perpetrators, CDC collaborated with four countries in sub-Saharan Africa (Malawi, Nigeria, Uganda, and Zambia) to conduct national household surveys of persons aged 13-24 years to measure experiences of violence victimization in childhood and subsequent perpetration of physical or sexual violence. Perpetration of physical or sexual violence was prevalent among both males and females, ranging among males from 29.5% in Nigeria to 51.5% in Malawi and among females from 15.3% in Zambia to 28.4% in Uganda. Experiencing physical, sexual, or emotional violence in childhood was the strongest predictor for perpetrating violence; a graded dose-response relationship emerged between the number of types of childhood violence experienced (i.e., physical, sexual, and emotional) and perpetration of violence. Efforts to prevent violence victimization need to begin early, requiring investment in the prevention of childhood violence and interventions to mitigate the negative effects of violence experienced by children.

HIV testing services (HTS) are an essential component of a national response to the HIV epidemic, and in lower and middle income countries, at least 150 million persons are tested annually. HIV testing is necessary to identify persons in need of antiretroviral treatment, which has been documented to be highly effective not only for treatment but also for prevention of HIV transmission to both adults and children. An assessment of the recent literature on sustainability of health and HIV services suggests that organizational performance, flexibility, and integration with other health interventions contribute to sustainability of HIV services and programs. This article describes the experiences of two HIV testing service providers in Uganda and Zambia as well as the track record of services to prevent mother-to-child HIV transmission to illustrate the factors of performance, flexibility, adaptability, and integration which are key to the sustainability of HIV testing services.

BACKGROUND: Verbal autopsy (VA) can be used to describe leading causes of death in countries like Zambia where vital events registration does not produce usable data. The objectives of this study were to assess the feasibility of using verbal autopsy to determine age-, sex-, and cause-specific mortality in a community-based setting in Zambia and to estimate overall age-, sex-, and cause-specific mortality in the four provinces sampled. METHODS: A dedicated census was conducted in regions of four provinces chosen by cluster-sampling methods in January 2010. Deaths in the 12-month period prior to the census were identified during the census. Subsequently, trained field staff conducted verbal autopsy interviews with caregivers or close relatives of the deceased using structured and unstructured questionnaires. Additional deaths were identified and respondents were interviewed during 12 months of fieldwork. After the interviews, two physicians independently reviewed each VA questionnaire to determine a probable cause of death. RESULTS: Among the four provinces (1,056 total deaths) assessed, all-cause mortality rate was 17.2 per 1,000 person-years (95% confidence interval [CI]: 12.4, 22). The seven leading causes of death were HIV/AIDS (287, 27%), malaria (111, 10%), injuries and accidents (81, 8%), diseases of the circulatory system (75, 7%), malnutrition (58, 6%), pneumonia (56, 5%), and tuberculosis (50, 5%). Those who died were more likely to be male, have less than or equal to a primary education, and be unmarried, widowed, or divorced compared to the baseline population. Nearly half (49%) of all reported deaths occurred at home. CONCLUSIONS: The 17.2 per 1,000 all-cause mortality rate is somewhat similar to modeled country estimates. The leading causes of death -- HIV/AIDS, malaria, injuries, circulatory diseases, and malnutrition -- reflected causes similar to those reported for the African region and by other countries in the region. Results can enable the targeting of interventions by region, disease, and population to reduce preventable death. Collecting vital statistics using standardized Sample Vital Registration with Verbal Autopsy (SAVVY) methods appears feasible in Zambia. If conducted regularly, these data can be used to evaluate trends in estimated causes of death over time.