Global responses to the coronavirus disease 2019 (COVID19) pandemic are converging with pervasive, existing sexual and reproductive health and justice inequities to disproportionately impact the health, wellbeing, and economic stability of women, girls, and vulnerable populations. People whose human rights are least protected are likely to experience unique difficulties from COVID19. 1 Women, girls, and marginalised Centring sexual and reproductive health and justice in the global COVID-19 response unmonitored isolation, from the effects of COVID19, as well as loneliness and mental health deterioration. The risks of using CHWs in this way could be reduced by supervision, with independent monitoring and evaluative research to identify problems early and correct them. The CHWs could visit in pairs to reduce the risks.People might resist or be reluctant to be visited by CHWs, and they could opt out of home visits at any time, but experience with CHWs in Brazil in the past 30 years suggests this would happen rarely. 4 In Brazil, 250 000 CHWs provide a much needed and relied upon service. CHWs in Brazil have been established for many years, are well integrated into their communities, and provide a wide range of health and social care support activities to each of the 100-150 households that they are responsible for. Therefore, in Brazil, additional roles for preventing the spread of and supporting those infected with COVID19 or in selfisolation could be integrated into the work of CHWs. Much can be learned from countries with successful experiences of radical, largescale workforce interventions. 9 It could be argued that this is an unrealistic proposal and that adapting the existing system or training so many people is too challenging. However, current health and social care systems in the UK are under extreme pressure and could become overwhelmed. In a time of fear, isolation, and growing health inequalities, 10 use of CHWs for the COVID19 response would boost social coherence and fill gaps that have begun to emerge between health and social care and inperson and virtual access to health care. Our proposal for CHWs would produce a large cadre of people with an understanding of basic epidemiological and public health concepts 11 who could challenge scientific misinformation and explain the rationale for specific health policies and interventions to the public. This approach would also help build a new generation of leaders who can help tackle the complex challenges of our age.

SisterLove Inc., a community-based organization (CBO) in Atlanta, Georgia, evaluated the efficacy of its highly interactive, single-session HIV prevention intervention for black women, the Healthy Love Workshop (HLW). HLW is delivered to pre-existing groups of women (e.g., friends, sororities) in settings of their choosing. Eligible groups of women were randomly assigned to receive the intervention (15 groups; 161 women) or a comparison workshop (15 groups; 152 women). Behavioral assessments were conducted at baseline and at 3- and 6-month follow-ups. Among sexually active women at the 3-month follow-up, HLW participants were more likely than comparison participants to report having used condoms during vaginal sex with any male partner or with a primary male partner, and to have used condoms at last vaginal, anal or oral sex with any male partner. At the 6-month follow-up, HLW participants were more likely to report condom use at last vaginal, anal or oral sex with any male partner, and having an HIV test and receiving their test results. The study findings suggest that a single-session intervention delivered to pre-existing groups of black women is an efficacious approach to HIV prevention. This study also demonstrates that a CBO can develop and deliver a culturally appropriate, effective HIV prevention intervention for the population it serves and, with adequate resources and technical assistance, rigorously evaluate its intervention.

BackgroundWe sought to understand the multilevel syndemic factors that are concurrently contributing to the HIV epidemic among women living in the US. We specifically examined community, network, dyadic, and individual factors to explain HIV vulnerability within a socioecological framework.MethodsWe gathered qualitative data (120 interviews and 31 focus groups) from a subset of women ages 18–44 years (N = 2,099) enrolled in the HPTN 064 HIV seroincidence estimation study across 10 US communities. We analyzed data from 4 diverse locations: Atlanta, New York City (the Bronx), Raleigh, and Washington, DC. Data were thematically coded using grounded theory methodology. Intercoder reliability was assessed to evaluate consistency of team-based coding practices.ResultsThe following themes were identified at 4 levels including 1) exosystem (community): poverty prevalence, discrimination, gender imbalances, community violence, and housing challenges; 2) mesosystem (network): organizational social support and sexual concurrency; 3) microsystem (dyadic): sex exchange, interpersonal social support, intimate partner violence; and 4) individual: HIV/STI awareness, risk taking, and substance use. A strong theme emerged with over 80 % of responses linked to the fundamental role of financial insecurity underlying risk-taking behavioral pathways.ConclusionsMultilevel syndemic factors contribute to women’s vulnerability to HIV in the US. Financial insecurity is a predominant theme, suggesting the need for tailored programming for women to reduce HIV risk.Trial registrationClinicaltrials.gov, NCT00995176

Introduction While pregnant people have been an important focus for HIV research, critical evidence gaps remain regarding prevention, co‐infection, and safety and efficacy of new antiretroviral therapies in pregnancy. Such gaps can result in harm: without safety data, drugs used may carry unacceptable risks to the foetus or pregnant person; without pregnancy‐specific dosing data, pregnant people face risks of both toxicity and undertreatment; and delays in gathering evidence can limit access to beneficial next‐generation drugs. Despite recognition of the need, numerous barriers and ethical complexities have limited progress. We describe the process, ethical foundations, recommendations and applications of guidance for advancing responsible inclusion of pregnant people in HIV/co‐infections research. Discussion The 26‐member international and interdisciplinary Pregnancy and HIV/AIDS: Seeking Equitable Study (PHASES) Working Group was convened to develop ethics‐centred guidance for advancing timely, responsible HIV/co‐infections research with pregnant people. Deliberations over 3 years drew on extensive qualitative research, stakeholder engagement, expert consultation and a series of workshops. The guidance, initially issued in July 2020, highlights conceptual shifts needed in framing research with pregnant people, and articulates three ethical foundations to ground recommendations: equitable protection from drug‐related risks, timely access to biomedical advances and equitable respect for pregnant people's health interests. The guidance advances 12 specific recommendations, actionable within the current regulatory environment, addressing multiple stakeholders across drug development and post‐approval research, and organized around four themes: building capacity, supporting inclusion, achieving priority research and ensuring respect. The recommendations describe strategies towards ethically redressing the evidence gap for pregnant people around HIV and co‐infections. The guidance has informed key efforts of leading organizations working to advance needed research, and identifies further opportunities for impact by a range of stakeholder groups. Conclusions There are clear pathways towards ethical inclusion of pregnant people in the biomedical research agenda, and strong agreement across the HIV research community about the need for – and the promise of – advancing them. Those who fund, conduct, oversee and advocate for research can use the PHASES guidance to facilitate more, better and earlier evidence to optimize the health and wellbeing of pregnant people and their children.

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