Swedish International Development Cooperation Agency Research Articles

Sequential and parallel testing for microbiological confirmation of tuberculosis disease in children in five low-income and middle-income countries: a secondary analysis of the RaPaed-TB study

Despite causing high mortality worldwide, paediatric tuberculosis is often undiagnosed. We aimed to investigate optimal testing strategies for microbiological confirmation of tuberculosis in children younger than 15 years, including the yield in high-risk subgroups (eg, children younger than 5 years, with HIV, or with severe acute malnutrition [SAM]). For this secondary analysis, we used data from RaPaed-TB, a multicentre diagnostic accuracy study evaluating novel diagnostic assays and testing approaches for tuberculosis in children recruited from five health-care centres in Malawi, Mozambique, South Africa, Tanzania, and India conducted between Jan 21, 2019, and June 30, 2021. Children were included if they were younger than 15 years and had signs or symptoms of pulmonary or extrapulmonary tuberculosis; they were excluded if they weighed less than 2 kg, had received three or more doses of anti-tuberculosis medication at time of enrolment, were in a condition deemed critical by the local investigator, or if they did not have at least one valid microbiological result. We collected tuberculosis-reference specimens via spontaneous sputum, induced sputum, gastric aspirate, and nasopharyngeal aspirates. Microbiological tests were Xpert MTB/RIF Ultra (hereafter referred to as Ultra), liquid culture, and Löwenstein-Jensen solid culture, which were followed by confirmatory testing for positive cultures. The main outcome of this secondary analysis was categorising children as having confirmed tuberculosis if culture or Ultra positive on any sample, unconfirmed tuberculosis if clinically diagnosed, and unlikely tuberculosis if neither of these applied. Of 5313 children screened, 975 were enrolled, of whom 965 (99%) had at least one valid microbiological result. 444 (46%) of 965 had unlikely tuberculosis, 282 (29%) had unconfirmed tuberculosis, and 239 (25%) had confirmed tuberculosis. Median age was 5·0 years (IQR 1·8-9·0); 467 (48%) of 965 children were female and 498 (52%) were male. 155 (16%) of 965 children had HIV and 110 (11%) children had SAM. 196 (82%) of 239 children with microbiological detection tested positive on Ultra. 110 (46%) of 239 were confirmed by both Ultra and culture, 86 (36%) by Ultra alone, and 43 (18%) by culture alone. 'Trace' was the most common semiquantitative result (93 [40%] of 234). 481 (50%) of 965 children had only one specimen type collected, 99 (21%) of whom had M tuberculosis detected. 484 (50%) of 965 children had multiple specimens collected, 141 (29%) of whom were positive on at least one specimen type. Of the 102 children younger than 5 years with M tuberculosis detected, 80 (78%) tested positive on sputum. 64 (80%) of 80 children who tested positive on sputum were positive on sputum alone; 61 (95%) of 64 were positive on induced sputum, two (3%) of 64 were positive on spontaneous sputum, and one (2%) was positive on both. High rates of microbiological confirmation of tuberculosis in children can be achieved via parallel sampling and concurrent testing procedures. Sample types and choice of test to be used sequentially should be considered when applying to groups such as children younger than 5 years, living with HIV, or with SAM. European and Developing Countries Clinical Trials Partnership programme, supported by the EU, the UK Medical Research Council, Swedish International Development Cooperation Agency, Bundesministerium für Bildung und Forschung, the German Center for Infection Research, and Beckman Coulter.

230 Optimising Outdoor Recreational Activities in Bali, Indonesia: The Significance of the Cultural Landscape Subak as a Health-Enhancing Environment

Abstract Purpose Subak – the terraced rice landscapes of Bali – appears to be more protected and better preserved than the rest of the greenspaces in Indonesia. As one of the first studies of outdoor recreational activities in the cultural landscape subak, this study aims to describe the significance of this environment – which is also a UNESCO World Heritage Site – for the activities to promote and improve health and well-being. Methods The study compiled a quantitative questionnaire answered by fifty-eight respondents, five semi-structured in-depth interviews, and a series of participant observations. Results Based on mixed methods analyses, the results revealed: (1) outdoor recreational activities in the subak areas have yielded benefits, namely improved cognitive and social skills, as well as an enhanced state of health and well-being, (2) the role of the subak areas in facilitating outdoor recreational activities has shown cognitive, emotional, and behavioural changes in the study participants, and (3) outdoor recreational activities in the subak areas have fostered a more environmentally conscious mindset that helps improve human health and well-being. Conclusions This study elucidated possible implications that underlined the activities in the subak as a way to adopt pro-environmental behaviour (PEB) and thereby helped improve human health and well-being, protect the subak environment, and achieve the Sustainable Development Goals (SDGs) in the context of this study, particularly SDG 3 Good Health and Well-Being, SDG 11 Sustainable Cities and Communities, and SDG 12 Responsible Consumption and Production. Overall, the mixed methods analysis applied in the study provided new transcendent perspectives that in future research can form the starting point to emphasise the significance of the greenspaces, namely the cultural landscape subak, as a health-enhancing environment for outdoor recreational activities to promote and improve health and well-being. Funding The fieldwork was funded by the Swedish government Sida (Swedish International Development Cooperation Agency) through a scholarship of 27,000 SEK.

Effect of single-dose, live, attenuated dengue vaccine in children with or without previous dengue on risk of subsequent, virologically confirmed dengue in Cebu, the Philippines: a longitudinal, prospective, population-based cohort study

A three-dose dengue vaccine (CYD-TDV) was licensed for use in children aged 9 years and older starting in 2015 in several dengue-endemic countries. In 2016, the Philippine Department of Health implemented a dengue vaccination programme, which was discontinued because of safety concerns. We assessed the relative risk of developing virologically confirmed dengue among children who did or did not receive a single dose of CYD-TDV by previous dengue virus (DENV) infections at baseline classified as none, one, and two or more infections. In this longitudinal, prospective, population-based cohort study, we enrolled healthy children (aged 9-14 years) residing in Bogo or Balamban, Cebu, Philippines, between May 2, and June 2, 2017, before a mass dengue vaccination campaign, via the Rural Health Unit in Bogo and three Rural Health Units in Balamban. We collected demographic information and sera for baseline DENV serostatus and conducted active surveillance for acute febrile illness. Children who developed acute febrile illness were identified, clinical data were collected, and blood was drawn for confirmation of dengue by RT-PCR. The primary outcome was the relative risk of developing virologically confirmed dengue among children who received or did not receive a single dose of CYD-TDV by DENV serostatus at baseline. A single dose of CYD-TDV did not confer protection against virologically confirmed dengue in children who had none or one previous DENV infection at baseline. One dose conferred significant protection against hospital admission for virologically confirmed dengue among participants who had two or more previous DENV infections at baseline during the first 3 years (70%, 95% CI 20-88; p=0·017) and the entire follow-up period (67%, 19-87; p=0·016). The risk of developing virologically confirmed dengue after a single dose of CYD-TDV varied by baseline DENV serostatus. Since the study assessed the effect of only a single dose, the findings cannot inform decisions on vaccination by public health officers. However, the findings have implications for children who receive an incomplete vaccination regimen and these results should prompt more detailed analyses in future trials on dengue vaccines. The Philippine Department of Health, Hanako Foundation, WHO, Swedish International Development Cooperation Agency, International Vaccine Institute, University of North Carolina, and US National Institute of Allergy and Infectious Diseases.

Development and validation of quantitative PCR assays for HIV-associated cryptococcal meningitis in sub-Saharan Africa: a diagnostic accuracy study

HIV-associated cryptococcal meningitis is the second leading cause of AIDS-related deaths, with a 10-week mortality rate of 25-30%. Fungal load assessed by colony-forming unit (CFU) counts is used as a prognostic marker andto monitor response to treatment in research studies. PCR-based assessment of fungal load could be quicker andless labour-intensive. We sought to design, optimise, and validate quantitative PCR (qPCR) assays for the detection, identification, and quantification of Cryptococcus infections in patients with cryptococcal meningitis in sub-Saharan Africa. We developed and validated species-specific qPCR assays based on DNA amplification of QSP1 (QSP1A specific to Cryptococcus neoformans, QSP1B/C specific to Cryptococcus deneoformans, and QSP1D specific to Cryptococcus gattii species) and a pan-Cryptococcus assay based on a multicopy 28S rRNA gene. This was a longitudinal study that validated the designed assays on cerebrospinal fluid (CSF) of 209 patients with cryptococcal meningitis at baseline (day 0) and during anti-fungal therapy (day 7 and day 14), from the AMBITION-cm trial in Botswana and Malawi (2018-21). Eligible patients were aged 18 years or older and presenting with a first case of cryptococcal meningitis. When compared with quantitative cryptococcal culture as the reference, the sensitivity of the 28S rRNA was 98·2% (95% CI 95·1-99·5) and of the QSP1 assay was 90·4% (85·2-94·0) in CSF at day 0. Quantification of the fungal load with QSP1 and 28S rRNA qPCR correlated with quantitative cryptococcal culture (R2=0·73 and R2=0·78, respectively). Both Botswana and Malawi had a predominant C neoformans prevalence of 67% (95% CI 55-75) and 68% (57-73), respectively, and lower C gattii rates of 21% (14-31) and 8% (4-14), respectively. We identified ten patients that, after 14 days of treatment, harboured viable but non-culturable yeasts based on QSP1 RNA detection (without any positive CFU in CSF culture). QSP1 and 28S rRNA assays are useful in identifying Cryptococcus species. qPCR results correlate well with baseline quantitative cryptococcal culture and show a similar decline in fungal load during induction therapy. These assays could be a faster alternative to quantitative cryptococcal culture to determine fungal load clearance. The clinical implications of the possible detection of viable but non-culturable cells in CSF during induction therapy remain unclear. European and Developing Countries Clinical Trials Partnership; Swedish International Development Cooperation Agency; Wellcome Trust/UK Medical Research Council/UKAID Joint Global Health Trials; and UKNational Institute for Health Research.

Chemoprevention for malaria with monthly intermittent preventive treatment with dihydroartemisinin–piperaquine in pregnant women living with HIV on daily co-trimoxazole in Kenya and Malawi: a randomised, double-blind, placebo-controlled trial

The efficacy of daily co-trimoxazole, an antifolate used for malaria chemoprevention in pregnant women living with HIV, is threatened by cross-resistance of Plasmodium falciparum to the antifolate sulfadoxine-pyrimethamine. We assessed whether addition of monthly dihydroartemisinin-piperaquine to daily co-trimoxazole is more effective at preventing malaria infection than monthly placebo plus daily co-trimoxazole in pregnant women living with HIV. We did an individually randomised, two-arm, placebo-controlled trial in areas with high-grade sulfadoxine-pyrimethamine resistance in Kenya and Malawi. Pregnant women living with HIV on dolutegravir-based combination antiretroviral therapy (cART) who had singleton pregnancies between 16 weeks' and 28 weeks' gestation were randomly assigned (1:1) by computer-generated block randomisation, stratified by site and HIV status (known positive vs newly diagnosed), to daily co-trimoxazole plus monthly dihydroartemisinin-piperaquine (three tablets of 40 mg dihydroartemisinin and 320 mg piperaquine given daily for 3 days) or daily co-trimoxazole plus monthly placebo. Daily co-trimoxazole consisted of one tablet of 160 mg sulfamethoxazole and 800 mg trimethoprim. The primary endpoint was the incidence of Plasmodium infection detected in the peripheral (maternal) or placental (maternal) blood or tissue by PCR, microscopy, rapid diagnostic test, or placental histology (active infection) from 2 weeks after the first dose of dihydroartemisinin-piperaquine or placebo to delivery. Log-binomial regression was used for binary outcomes, and Poisson regression for count outcomes. The primary analysis was by modified intention to treat, consisting of all randomised eligible participants with primary endpoint data. The safety analysis included all women who received at least one dose of study drug. All investigators, laboratory staff, data analysts, and participants were masked to treatment assignment. This trial is registered with ClinicalTrials.gov, NCT04158713. From Nov 11, 2019, to Aug 3, 2021, 904 women were enrolled and randomly assigned to co-trimoxazole plus dihydroartemisinin-piperaquine (n=448) or co-trimoxazole plus placebo (n=456), of whom 895 (99%) contributed to the primary analysis (co-trimoxazole plus dihydroartemisinin-piperaquine, n=443; co-trimoxazole plus placebo, n=452). The cumulative risk of any malaria infection during pregnancy or delivery was lower in the co-trimoxazole plus dihydroartemisinin-piperaquine group than in the co-trimoxazole plus placebo group (31 [7%] of 443 women vs 70 [15%] of 452 women, risk ratio 0·45, 95% CI 0·30-0·67; p=0·0001). The incidence of any malaria infection during pregnancy or delivery was 25·4 per 100 person-years in the co-trimoxazole plus dihydroartemisinin-piperaquine group versus 77·3 per 100 person-years in the co-trimoxazole plus placebo group (incidence rate ratio 0·32, 95% CI 0·22-0·47, p<0·0001). The number needed to treat to avert one malaria infection per pregnancy was 7 (95% CI 5-10). The incidence of serious adverse events was similar between groups in mothers (17·7 per 100 person-years in the co-trimoxazole plus dihydroartemisinin-piperaquine group [23 events] vs 17·8 per 100 person-years in the co-trimoxazole group [25 events]) and infants (45·4 per 100 person-years [23 events] vs 40·2 per 100 person-years [21 events]). Nausea within the first 4 days after the start of treatment was reported by 29 (7%) of 446 women in the co-trimoxazole plus dihydroartemisinin-piperaquine group versus 12 (3%) of 445 women in the co-trimoxazole plus placebo group. The risk of adverse pregnancy outcomes did not differ between groups. Addition of monthly intermittent preventive treatment with dihydroartemisinin-piperaquine to the standard of care with daily unsupervised co-trimoxazole in areas of high antifolate resistance substantially improves malaria chemoprevention in pregnant women living with HIV on dolutegravir-based cART and should be considered for policy. European and Developing Countries Clinical Trials Partnership 2; UK Joint Global Health Trials Scheme (UK Foreign, Commonwealth and Development Office; Medical Research Council; National Institute for Health Research; Wellcome); and Swedish International Development Cooperation Agency.

Localized nature-based solutions for enhanced climate resilience and community wellbeing in urban informal settlements

ABSTRACT Nature-based Solutions (NbS) are considered to hold promise for addressing the pressing and multi-faceted challenges of climate resilience. Addressing this contemporary agenda, this research paper explores the potential value of NbS in urban contexts based on the experience of implementing four NbS pilots to address climate adaptation and disaster risk reduction in an informal settlement in Honiara, Solomon Islands. The project, funded by the Swedish International Development Cooperation Agency (SIDA), employed an inclusive co-production approach, with the project team engaging closely with community members and local stakeholders throughout the planning, design and implementation stages. Findings reinforce the importance of long-term engagement and trust-building with members of the community and also underscore the value of empowering local partners in project design and implementation in Pacific Island Nations. The paper details the local processes that were involved and highlights the key insights and lessons learned from the proof-of-concept project which can usefully inform the scaling up of NbS initiatives to achieve multiple benefits in other similar urban contexts in the Global South.

Diagnostic accuracy of a three-gene Mycobacterium tuberculosis host response cartridge using fingerstick blood for childhood tuberculosis: a multicentre prospective study in low-income and middle-income countries

Childhood tuberculosis remains a major cause of morbidity and mortality in part due to missed diagnosis. Diagnostic methods with enhanced sensitivity using easy-to-obtain specimens are needed. We aimed to assess the diagnostic accuracy of the Cepheid Mycobacterium tuberculosis Host Response prototype cartridge (MTB-HR), a candidate test measuring a three-gene transcriptomic signature from fingerstick blood, in children with presumptive tuberculosis disease. RaPaed-TB was a prospective diagnostic accuracy study conducted at four sites in African countries (Malawi, Mozambique, South Africa, and Tanzania) and one site in India. Children younger than 15 years with presumptive pulmonary or extrapulmonary tuberculosis were enrolled between Jan 21, 2019, and June 30, 2021. MTB-HR was performed at baseline and at 1 month in all children and was repeated at 3 months and 6 months in children on tuberculosis treatment. Accuracy was compared with tuberculosis status based on standardised microbiological, radiological, and clinical data. 5313 potentially eligible children were screened, of whom 975 were eligible. 784 children had MTB-HR test results, of whom 639 had a diagnostic classification and were included in the analysis. MTB-HR differentiated children with culture-confirmed tuberculosis from those with unlikely tuberculosis with a sensitivity of 59·8% (95% CI 50·8-68·4). Using any microbiological confirmation (culture, Xpert MTB/RIF Ultra, or both), sensitivity was 41·6% (34·7-48·7), and using a composite clinical reference standard, sensitivity was 29·6% (25·4-34·2). Specificity for all three reference standards was 90·3% (95% CI 85·5-94·0). Performance was similar in different age groups and by malnutrition status. Among children living with HIV, accuracy against the strict reference standard tended to be lower (sensitivity 50·0%, 15·7-84·3) compared with those without HIV (61·0%, 51·6-69·9), although the difference did not reach statistical significance. Combining baseline MTB-HR result with one Ultra result identified 71·2% of children with microbiologically confirmed tuberculosis. MTB-HR showed promising diagnostic accuracy for culture-confirmed tuberculosis in this large, geographically diverse, paediatric cohort and hard-to-diagnose subgroups. European and Developing Countries Clinical Trials Partnership, UK Medical Research Council, Swedish International Development Cooperation Agency, Bundesministerium für Bildung und Forschung; German Center for Infection Research (DZIF).

Doing ‘Us-Them’ differently: the identity work of frontline aid bureaucrats in translating aid effectiveness policy rhetoric into practice

ABSTRACT Bilateral aid agencies often face implementation challenges in internal efforts to address long-standing aid fragmentation and effectiveness issues. This article introduces the organizational identity concept to understand better these challenges by examining how Swedish International Development Cooperation Agency (Sida) frontline staff understand their role and organizational goals in light of shifting demands to coordinate and align Swedish government agencies’ (SGA) aid engagements. SGAs implement 10-15% of Swedish bilateral aid annually. A recent government strategy prioritizes strengthening partner countries’ public institutions and partnerships in line with the Agenda 2030 for sustainable development. Analysis of interviews and focus group data reveals a general shift among bureaucrats beyond the traditional us-them funder identity, to embrace a range of other identity orientations in the Sida-SGA relationship. The various orientations reflected Sida frontline bureaucrats’ diverse interpretations of their individual authority and socialized sense-making of ambivalent organizational changes, as they grapple with questions of ‘Who we should be?’ and ‘What we should do?’ on the frontline. The study provides a fine-grained view of the essential attitudes, skills and behavior on the frontline that influence aid relationships and the implementation of aid effectiveness principles, adding nuance to the existing aid effectiveness literature.

In-country availability of medical abortion medicines: a description of the framework and methodology of the WHO landscape assessments

BackgroundAvailability of quality-assured medical abortion medicines plays a crucial role in providing comprehensive abortion care. However, access to these medicines is still restricted for many abortion seekers. Increasing availability of affordable, quality-assured mifepristone and misoprostol is important to improve access to safe medical abortion services. Driven by the outcomes of a global consultation hosted by the World Health Organization and the Swedish International Development Cooperation Agency in 2018, we decided to holistically examine access to medical abortion medicines from supply to demand. The overarching principle of the national landscape assessments was to generate evidence to support policy dialog and policymaking that is contextual to the needs of the country. This paper aims to describe the framework and methodological approach used in the World Health Organization landscape assessments of medical abortion medicines at country-level.MethodsA country assessment protocol was developed to guide the methodology of the World Health Organization landscape assessments. The assessment protocol included adaptation of an existing availability framework, an online desk review and literature review for existing data available for the country of interest, country-level key informant interviews, and analysis of the data to identify barriers and opportunities to improve medical abortion availability.ConclusionThe availability framework and methodology will allow the identification of key barriers that limit readiness of medical abortion medicines, and the development of opportunities to overcome those barriers. The national landscape assessments will provide directions for future investments and offer guidance for policy and programming on medical abortion care.

Vertical HIV transmission within 18 months post partum among women on lifelong antiretroviral therapy for HIV in Dar es Salaam, Tanzania: a prospective cohort study

The UNAIDS estimate of vertical HIV transmission in Tanzania is high (11%), despite 84% uptake of antiretroviral therapy (ART) among pregnant women with HIV. We aimed to evaluate vertical transmission and its determinants by 18 months post partum among women on lifelong ART in routine health-care settings in Tanzania. We conducted a prospective cohort study in 226 health facitilies across Dar-es-Salaam, Tanzania. Eligible participants were pregnant women of any age with HIV, and later their infants, who enrolled in routine health-care services for the prevention of vertical transmission. We prospectively followed up mother-infant pairs at routine monthly visits until 18 months post partum and extracted data from the care and treatment clinic (CTC2) database, a national electronic database that stores patient-level HIV care and treatment clinic data. The primary outcome was time from birth to HIV diagnosis, defined as a positive infant HIV DNA PCR or antibody test from age 18 months. We used the Kaplan-Meier method to estimate cumulative risk of vertical transmission by 18 months post partum and Cox proportional hazards regression with shared frailties to account for potential clustering in health facilities to evaluate predictors of transmission. Between Jan 1, 2015, and Dec 31, 2017, 22 930 pregnant women with HIV (median age 30 years, IQR 25-34) enrolled on a care programme. After excluding 9140 (39·9%) women and 539 (2·4%) infants with missing outcome data, 13 251 (59·0%) mother-infant pairs were analysed, of whom 6072 (45·8%) women were already on ART before pregnancy. By 18 months post partum, 159 (1·2%) of 13 251 infants were diagnosed with HIV, equivalent to a risk of vertical transmission of 1·4% (95% CI 1·2-1·6). In the complete case analysis, the rates of vertical transmission were higher among women who enrolled in the third trimester of pregnancy than among those who enrolled in the first trimester (adjusted hazard ratio 3·01, 95% CI 1·59-5·70; p=0·0003), among women with advanced HIV disease than among those with early-stage disease (1·89, 1·22-2·93; p=0·0046), and among women who were on a second-line ART regimen than among those on a first-line regimen (3·58, 1·08-11·82; p=0·037). By contrast, the rate of vertical transmission was lower among women who were already on ART at enrolment than among those starting ART at enrolment (0·39, 0·25-0·60; p<0·0001) as well as among women in high-volume clinics than among those in low-volume clinics (0·46 (0·24-0·90; p<0·0097). Provision of ART for life (WHO's option B+ recommendation) has reduced the risk of vertical transmission to less than 2% among pregnant women with HIV in routine care settings in urban Tanzania. There is still a need to improve timely HIV diagnosis and ART uptake, and to optimise follow-up for the prevention of vertical transmission and the uptake of infant HIV testing. Swedish International Development Cooperation Agency.

Cost-effectiveness of single, high-dose, liposomal amphotericin regimen for HIV-associated cryptococcal meningitis in five countries in sub-Saharan Africa: an economic analysis of the AMBITION-cm trial

HIV-associated cryptococcal meningitis is a leading cause of AIDS-related mortality. The AMBITION-cm trial showed that a regimen based on a single high dose of liposomal amphotericin B deoxycholate (AmBisome group) was non-inferior to the WHO-recommended treatment of seven daily doses of amphotericin B deoxycholate (control group) and was associated with fewer adverse events. We present a five-country cost-effectiveness analysis. The AMBITION-cm trial enrolled patients with HIV-associated cryptococcal meningitis from eight hospitals in Botswana, Malawi, South Africa, Uganda, and Zimbabwe. Taking a health service perspective, we collected country-specific unit costs and individual resource-use data per participant over the 10-week trial period, calculating mean cost per participant by group, mean cost-difference between groups, and incremental cost-effectiveness ratio per life-year saved. Non-parametric bootstrapping and scenarios analyses were performed including hypothetical real-world resource use. The trial registration number is ISRCTN72509687, and the trial has been completed. The AMBITION-cm trial enrolled 844 participants, and 814 were included in the intention-to-treat analysis (327 from Uganda, 225 from Malawi, 107 from South Africa, 84 from Botswana, and 71 from Zimbabwe) with 407 in each group, between Jan 31, 2018, and Feb 17, 2021. Using Malawi as a representative example, mean total costs per participant were US$1369 (95% CI 1314-1424) in the AmBisome group and $1237 (1181-1293) in the control group. The incremental cost-effectiveness ratio was $128 (59-257) per life-year saved. Excluding study protocol-driven cost, using a real-world toxicity monitoring schedule, the cost per life-year saved reduced to $80 (15-275). Changes in the duration of the hospital stay and antifungal medication cost showed the greatest effect in sensitivity analyses. Results were similar across countries, with the cost per life-year saved in the real-world scenario ranging from $71 in Botswana to $121 in Uganda. The AmBisome regimen was cost-effective at a low incremental cost-effectiveness ratio. The regimen might be even less costly and potentially cost-saving in real-world implementation given the lower drug-related toxicity and the potential for shorter hospital stays. European Developing Countries Clinical Trials Partnership, Swedish International Development Cooperation Agency, Wellcome Trust and Medical Research Council, UKAID Joint Global Health Trials, and the National Institute for Health Research. For the Chichewa, Isixhosa, Luganda, Setswana and Shona translations of the abstract see Supplementary Materials section.

Connecting Water Access with Multidimensional Poverty: The Case of Tupiza River Basin in Bolivia

In developing countries, where economic expansion depends on extractive activities such as agriculture and mining, water quantity and quality considerations need to be examined in tandem with GDP growth and poverty reduction efforts. Poorest households in the Tupiza watershed in Bolivia are located in rural areas where water access for irrigation and safe drinking water is becoming increasingly scarce. Small-scale unregulated mining offers an alternative for revenue making in rural households, although wastewater from industry threatens water quality and new technologies to reduce water pollution are not implemented in this region yet. This study analyses water access and poverty linkages using the Multidimensional Poverty Analysis (MDPA) framework from the Swedish International Development Cooperation Agency (Sida) to guide a survey and to develop indicators using the Shapley-Owen decomposition method and multivariate regressions. A set of household-level policies were included to predict the influence of these policies on poverty reduction estimates. Results have shown that remote communities in rural areas have the lowest value of multidimensional poverty and for some of these communities mining activities represent an alternative that could be considered if their water access conditions worsen over time. While mining can bring better monetary benefits, it can cause the degradation of ecological flows from the produced wastewater. Under the current technologies and processes, it can pose negative impacts on water quality and threatens the public health of these communities.

Health of female agricultural workers in the Jordan Valley: an exploration of the effects of broader environmental transformations

BackgroundThe Jordan Valley, one of the main agricultural areas of the West Bank, has been subject to several structural challenges owing to political, economic, and ecological factors. Palestinians in the Jordan Valley live in poverty, in constant fear of home demolitions, and with constraints on their ability to maintain agricultural livelihoods. Several reports have described living conditions in the Jordan Valley, but none have focused on the situation of female agricultural workers. This study aimed to investigate the changes in agriculture in the Jordan Valley, and how these changes have affected the ways in which female agricultural workers carry out their work, and the effects on their living conditions and health. MethodsQualitative interviews with 30 women (aged ≥18 years) and two focus groups, each containing ten women, were carried out between June and December, 2019. The participants were agricultural workers in two communities in the Jordan Valley—Nweimeh-Dyouk and Jiftlik—that were selected as examples of different scenarios resulting from the classification of land after the Oslo Accords. Participants were selected using purposive and snowball sampling. Interviews and focus groups were recorded and transcribed verbatim. Transcripts were analysed thematically through repeated reading and re-reading until patterns and themes gradually appeared. Ethical approval was obtained from the Research Ethics Committee of the Institute of Community and Public Health. Informed verbal consent was obtained from all participants. FindingsThe role of female individuals in agriculture has changed with the introduction of agricultural technology. Although technology has decreased the effort required to prepare land, which is mainly done by male individuals, the increased production has required greater efforts in harvesting crops and loading boxes, which are tasks mainly done by women. Although agricultural work is the main occupation of women in the Jordan Valley, there has been a decline in its economic benefits, because of land confiscation and restrictions on water resources by Israeli occupation. This decrease has led to female individuals pursuing different routes to earn an income. Some women continue to work in agriculture on family land, whereas others have started to work on Palestinian or Israeli farms outside the family. Some women migrate, with their family, to other locations to work in agriculture. Women in the first category have better living conditions and social interactions with their community but have difficult economic conditions. Those in the second category have better economic conditions, and those in the third category have very poor living, social, and economic conditions compared with those in the other categories. In terms of the health effects of their work, most women reported that carrying heavy loads and continuous bending when harvesting affected their bones, muscles, and joints. There were several cases of asthma, and respiratory and skin allergies. Additional problems related to dehydration and poor nutrition, resulting from increased workloads and difficult living conditions, were reported. InterpretationChanges in the agricultural sector in the Jordan Valley have affected the way in which female agricultural workers carry out their work, as well as their living conditions and health status. Difficult living conditions, together with occupational exposure, and lack of awareness of safety measures and agronomic techniques and skills, have negatively affected the health status of female agricultural workers. Unless more attention is given to this group of female workers, they will continue to experience difficult living conditions, low levels of social interaction, lack of proper employment (without formal or stable salaries, contracts, or annual leave) and adverse effects on their health. FundingArab Council for the Social Sciences, Swedish International Development Cooperation Agency.

Transforming journalism in Vietnam: An exploration of two Swedish Media Aid projects

In this article, I examine the development of journalism in Vietnam by exploring documentation from two media aid projects carried out by the Swedish International Development Cooperation Agency (Sida) from 1993 until 2007. The project documents contain fieldnotes, evaluations and reflections from the trainers who were recruited from Swedish media houses to conduct training in Vietnam. A qualitative document analysis was used to examine the content with a conceptual framework built on notions of comparative media systems, global media ethics and the salience of social connections in Vietnam. The findings explore how the Swedish media aid intervened in the Vietnamese media by contributing to a technological transition of journalism although the training in newsroom management and media ethics were challenged by conflicting journalism ideology and social norms. The article contributes to the existing research on media development, reflections on media aid and the development of Vietnamese journalism by analysing project documents that provide first-hand information from a period when Vietnamese journalism underwent a dramatic transition towards the digitalized media system existing today.

An investigation into the livelihoods strategies of informal women traders in Zimbabwe

This article investigated varieties of livelihoods strategies employed by some informal women traders doing business at flea markets in the Harare Business Districts of the Harare Province. The study was informed by the Sustainable Livelihood Approach proffered by the Swedish International Development Cooperation Agency Division (SIDA 2001) for Policy and Socio-Economic Analysis. A quantitative and qualitative research design was developed and data was gathered through questionnaires, in-depth interviews, focus group discussions and direct observations during transect walks. The objectives of the study were to; identify micro-credit schemes used by the informal women traders doing business at flea markets, explore the livelihoods of microcredit schemes as pathways to poverty eradication and finally determine interventions and sustainable strategies that could be used for the informal women traders. The study discovered that women informal traders engaged in diverse activities for sustainable livelihoods strategies that eradicate poverty. The bulk of informal women traders face staid livelihoods challenges, resulting in them living in poverty. The study thus calls on Government and financing institutions to finance them for local empowerment, gain access and control of available livelihoods resources in a meaningful way. A range of policy interventions and sustainable strategies could be developed that enable informal women traders to eradicate poverty in Zimbabwe,

A Review of the integrated WEF nexus modeling platform in the NENA region: Morocco case study

Nowadays, the world is recognizing the water-food-energy (WEF) as a conceptual framework that aims to the implementation of the Sustainable Development Goals (SDGs). The WEF Nexus is being developed to support the integrity of national and more importantly local projects in the cross-sectoral partnerships and coordination to enhance the sustainable development outcomes from the different projects as well as avoiding the trade-offs. Most importantly, building a great synergy between the sectors is challenged by sectorial boundaries such as policy decisions, scaling investments, and cross-sectorial consequences, which leads to anticipation biases when it comes to social, economic, and environmental costs. This paper aims to review the latest integrated WEF Nexus modeling platform that has been developed in the NENA region during the project "Implementing the 2030 Agenda for Water Efficiency/Productivity and Water Sustainability in NENA Countries" (WEPS-NENA), led by the Food and Agriculture Organization of the United Nations (FAO) and supported by the Swedish International Development Cooperation Agency.

Results-Based Financing for Health: A Case Study of Knowledge and Perceptions Among Stakeholders in a Donor-Funded Program in Zambia.

In 2015, the Zambian government and the Swedish International Development Cooperation Agency (Sida) signed an agreement in which Sida committed to funding a program for Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition (RMNCAH). The program includes a results-based financing (RBF) model that aims to reward Zambian districts for improved district-wide results on relevant indicators with additional funding. We aimed to describe stakeholders' knowledge of the RBF model and perceptions of the incentive structure during the first 18 months of the program's implementation. This study illuminates the possible pitfalls of implementing an RBF scheme without giving attention to all necessary steps of the process. A qualitative case study was used and included a review of documents, in-depth interviews, and observations. From February-April 2017, we conducted 37 in-depth interviews, representing the views of 12 development partner agencies, government departments, and health facility staff throughout Zambia. We used a qualitative framework analysis. Findings show that the Zambian government and Sida had different perceptions on what levels of the health system RBF will incentivize and that most districts and hospital administrators interviewed were unaware of the indicators that the RBF was part of the RMNCAH program at all. The lack of knowledge about the RBF scheme among respondents suggests the possibility that the model did not ultimately have the necessary preconditions to create an effective incentive structure. These results demonstrate the need for improved communication between stakeholders and the importance of sufficiently planning an RBF model before implementation.

North-South collaboration: On the making of a Center for Comparative Education and Policy Studies at Addis Ababa University

The Ethiopian educational system has made promising advancements since the turn of the century. Despite this progress, education continues to grapple with a myriad of challenges, including differences in educational access and quality, insecure living conditions, and gender inequalities. Research can offer knowledge for tackling these challenges, but often it is knowledge from the global North that dominates, despite its questionable relevance to the global South. Therefore, this study analyses the evolvement of a Center for Comparative Education and Policy Studies, situated in an Ethiopian higher education context and supported by the Swedish International Development Cooperation Agency (SIDA), and how the Center has contributed to developing knowledge that is relevant to local contexts. An important outcome of the Center was the development of a doctoral program in International and Comparative Education and the knowledge produced in the doctoral theses that emerged. Our inquiry concerns how Southern theory contributes to an increased understanding of the development of the Center and the relevance of the doctoral theses. The findings underscore the importance of expanding Southern knowledge in education and the need for further reflection on the geopolitics of knowledge in research capacity development cooperation.

Incorporating oral PrEP into standard prevention services for South African women: a nested interrupted time-series study.

SummaryBackgroundAs oral pre-exposure prophylaxis (PrEP) becomes the standard of prevention globally, its potential effect on HIV incidence in clinical trials of new prevention interventions is unknown, particularly for trials among women. In a trial measuring HIV incidence in African women, oral PrEP was incorporated into the standard of prevention in the trial's last year. We assessed the effect of on-site access to PrEP on HIV incidence in this natural experiment.MethodsWe did a nested interrupted time-series study using data from the ECHO trial. At 12 sites in four countries (Eswatini, Kenya, South Africa, and Zambia), women (aged 16–35 years) were randomly assigned to receive one of three contraceptives between Dec 14, 2015, and Sept 12, 2017, and followed up quarterly for up to 18 months to determine the effect of contraceptive method on HIV acquisition. Women were eligible if they wanted long-acting contraception, were medically qualified to receive study contraceptives, and had not used any of the study contraceptives in the past 6 months. The present analyses are limited to nine South African sites where on-site access to oral PrEP was implemented between March 13 and June 12, 2018. Using an interrupted time-series design, we compared HIV incidence before versus after PrEP access, limited to quarterly study visits at which on-site PrEP access was available to at least some participants and, in a sensitivity analysis, to the 180 days before and after access. The outcome was incident HIV infection, detected using two rapid HIV tests done in parallel for each participant at every scheduled follow-up visit. This study is registered on ClinicalTrials.gov, NCT02550067.Findings2124 women were followed up after on-site PrEP access began, of whom 543 (26%) reported PrEP use. A total of 12 HIV seroconversions were observed in 556 person-years (incidence 2·16%) after on-site PrEP access, compared with 133 HIV seroconversions in 2860 person-years (4·65%) before PrEP access (adjusted incidence rate ratio [IRR] 0·45, 95% CI 0·25–0·82, p=0·0085). Similar results were also observed when limiting the analysis to 180 days before versus after PrEP access. A total of 46 HIV seroconversions were observed in 919 person-years within 180 days before PrEP access, compared with 11 seroconversions in 481 person-years in the 180 days following PrEP access (incidence 5·00 vs 2·29 per 100 person-years; IRR 0·43, 95% CI 0·22–0·88, p=0·012).InterpretationOn-site access to PrEP as part of standard of prevention in a clinical trial among women in South Africa was associated with halving HIV incidence, when approximately a quarter of women started PrEP. Providing access to on-site PrEP could decrease incidence in HIV prevention trials. These data are also among the first to show in any setting that access to PrEP is associated with decreased HIV acquisition among South African women.FundingBill & Melinda Gates Foundation, United States Agency for International Development, President's Emergency Plan for AIDS Relief, the Swedish International Development Cooperation Agency, South African Medical Research Council, and United Nations Population Fund.

Integration Conundrums: Framing and Responding to Climate Security Challenges in Development Cooperation

This paper contributes to the burgeoning research on the integration of climate-related security risks by organizations. Development organizations have an important preventive mandate and can mitigate climate security challenges in low- and lower-middle-income economies, but they have a complex task, contending with power asymmetries and a very wide set of policy-making processes occurring in tandem. We explore how climate security challenges are being addressed in development organizations through focusing on the Swedish International Development Cooperation Agency (Sida), which has worked with integration of cross-sectoral issues since the 1980s. We narrow in specifically on how the overlaps between two separate policy areas at Sida—climate and conflict—have been framed and responded to in recent years. The study finds that the integration of these two areas is prioritized on a general policy level but that there are obstacles when translating policy into practice. Challenges include conceptual diversity, tensions between expert and general knowledge and differing organizational preconditions. Despite this, integration does occur between the two policy areas on several levels, ranging from a macro-level general awareness of potential overlaps with a “do no harm” ambition, to micro levels of integration in which strategies and interventions are adjusted.