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Highlights •Ecosystem services help itemise how we value natural places, but the concept is not robust.• A more robust framework should focus on aspects of human appreciation of places.• We propose an ecosystem valuing framework with 12 universal aspects of appreciation.• This can be unambiguously complemented by ecological analyses where necessary. AbstractThe ecosystem services framework (ESF) is advantageous and widely used for itemising and quantifying ways in which humans benefit from natural places. However, it suffers from two important problems: (i) incoherence of definitions and (ii) a narrow approach to valuation, inadequate to represent the full range of human motives for conservation and the diverse interests of different stakeholders. These shortcomings can lead to a range of problems including doublecounting, blind spots and unintended consequencest. Here we propose an ecosystem valuing framework (EVF) as a broader and more rigorous way to deliver the benefits currently sought from the ESF, without the conceptual problems. The flawed genius of ecosystem servicesThe ecosystem services framework (ESF) is a very popular approach to incentivising nature conservation, increasingly used by conservation campaigners and policy makers around the world as well as by scientists contributing to this cause. Its genius is to facilitate a multi-dimensional analysis of the benefits that humans may derive from natural places, allowing a wide range of interests and conservation concerns to be considered and integrated with a broad view of sustainable development 3 and human wellbeing. As such it supports a consequentialist ethic that can be more successful than deontological approaches (see Glossary) in securing consensus and motivating action [1]. However, criticisms of the ESF as a tool for conservation raise doubts about its effectiveness and legitimacy [2,3]. The most controversial issue is probably that of monetisation, as laid out recently by Silvertown [4]. One set of responses to such problems would continue using the ESF as a general tool for assessing habitats while recognising its multilayered structure [5], supervising it to avoid unintended consequences [6], perhaps discouraging monetisation [7], and even attempting to subjugate intrinsic value under the category of services [8]. Yet there are more profound problems with the ESF that call for a radical shift if we wish to contribute to conservation as part of a sustainable development agenda. Two outstanding issues are sufficient, in our opinion, to demand an overhaul of the ESF so radical as to require a new name. First, the definitions do not work. The fact that definitions of 'ecosystem services' (ES) and of specific categories are often vague, tautologous and/or at variance with the concepts actually employed is symptomatic of deep-seated problems, as we shall explain.Second, collapsing multiple human value judgments into one or a few numerical values is a form of devaluation. We unpack this claim by exploring the inescapably cultural foundation of ...

BackgroundChildbirth at health facilities is an important strategy to reduce maternal morbidity and mortality, improve fetal outcomes, and reduce mother-to-child transmission of HIV. Although access to antenatal care in Kenya is high (>90%), less than half of births occur at health facilities. This analysis aims to assess correlates of facility delivery among recently pregnant HIV-infected women participating in a community-based survey, and to determine whether these correlates were unique when compared to HIV-uninfected women from the same region.MethodsWomen residing in the Kenya Medical Research Institute/Centers for Disease Control and Prevention Health and Demographic Surveillance System, and who had delivered an infant in the previous year were visited at home in 2011. Consenting mothers answered a questionnaire assessing demographics, place of delivery, utilization of prevention of mother-to-child HIV transmission (PMTCT) services, and stigma indicators. Known HIV-positive women were purposively oversampled. Chi-square tests of proportions and multivariate logistic regression, stratified by HIV status, were performed to assess correlates of facility delivery.ResultsOverall, 101 (46.8%) HIV-infected and 127 (39.9%) HIV-uninfected women delivered at health facilities. Among HIV-infected women, cost (42.8%), distance (18.8%) and fear of harsh treatment (15.2%) were primary disincentives for facility delivery; 2.9% noted fear of HIV testing was a disincentive. HIV-infected women who delivered at facilities had higher education (p = 0.04) and socioeconomic status (p < 0.005), initiated antenatal care (ANC) earlier (4.9 vs. 5.4 months, p = 0.016), were more likely to know partner’s HIV status (p = 0.016), report satisfaction with delivery care (p = 0.001) and use antiretrovirals (87.1% vs. 77.4%, p = 0.063) compared to those with non-facility delivery. Stigma indicators were not associated with delivery location. Similar cofactors of facility delivery were noted among uninfected women.ConclusionsUtilization of facility delivery remains low in Kenya and poses a challenge to elimination of infant HIV and reduction of peripartum mortality. Cost, distance, and harsh treatment were cited as barriers and these need to be addressed programmatically. HIV-infected women with lower socioeconomic status and those who present late to ANC should be prioritized for interventions to increase facility delivery. Partner involvement may increase use of maternity services and could be enhanced by couples counseling.

We conducted an exploratory analysis of former HIV Prevention Trials Network 052 (HPTN 052) clinical trial participants in 2016 to assess their (1) satisfaction with the HPTN 052 clinical trial care and treatment, and reasons for joining the trial; and (2) perspectives about the post-trial transition to public HIV care centers. Quantitative data showed that, of the 70 survey participants, 94.3% (n = 66) reported being very satisfied with the care and treatment they received while participating in the clinical trial and 51.4% (n = 36) reported they joined the study because they would receive information to improve their own or their partner's health. Qualitative data (five in-depth interviews and two focus group discussions) analysis revealed the following themes: transition experiences; perceived superior clinical trial care; study benefits not offered at public HIV care centers; and the public HIV care centers' indifference to the uninfected partner. For some HPTN 052 participants, transition to HIV care clinics was disappointing. Clinical trial investigators and local Institutional Review Boards should consider the need for safeguards and oversight of post-trial health care for trial participants after the trial ends, especially in resource-constrained settings, to avoid negative health outcomes.

Background Despite the effective scale-up of HIV testing and treatment programs, only 75% of people living with HIV (PLWH) globally know their status, and this rate is lower among men. This highlights the importance of implementing HIV testing and linkage interventions with a high uptake in this population. In a cluster randomized controlled trial conducted in Kenya between 2013 and 2015, we found that assisted partner services (APS) for HIV-exposed partners of newly diagnosed PLWH safely reached more HIV-exposed individuals with HIV testing compared with client referral alone. However, more data are needed to evaluate APS implementation in a real-world setting. Objective This study aims to evaluate the effectiveness, acceptability, fidelity, and cost of APS when integrated into existing HIV testing services (HTS) in Western Kenya. Methods Our study team from the University of Washington and PATH is integrating APS into 31 health facilities in Western Kenya. We are enrolling females newly diagnosed with HIV (index clients) who consent to receiving APS, their male sexual partners, and female sexual partners of male sexual partners who tested HIV positive. Female index clients and sexual partners testing HIV positive will be followed up at 6 weeks, 6 months, and 12 months postenrollment to assess linkage to care, antiretroviral therapy initiation, and HIV viral load suppression. We will evaluate the acceptability, fidelity, and cost of real-world implementation of APS via in-depth interviews conducted with national, county, and subcounty-level policy makers responsible for HTS. Facility health staff providing HTS and APS, in addition to staff working with the study project team, will also be interviewed. We will also conduct direct observations of facility infrastructure and clinical procedures and extract data from the facilities and county and national databases. Results As of March 2020, we have recruited 1724 female index clients, 3201 male partners, and 1585 female partners. We have completed study recruitment as well as 6-week (2936/2973, 98.75%), 6-month (1596/1641, 97.25%), and 12-month (725/797, 90.9%) follow-up visits. Preliminary analyses show that facilities scaling up APS identify approximately 12-18 new HIV-positive males for every 100 men contacted and tested. We are currently completing the remaining follow-up interviews and incorporating an HIV self-testing component into the study in response to the COVID-19 pandemic. Conclusions The results will help bridge the gap between clinical research findings and real-world practice and provide guidance regarding optimal strategies for APS integration into routine HIV service delivery. International Registered Report Identifier (IRRID) DERR1-10.2196/27262