Improving Sexual Health in Pregnancy in Africa: a people-centred approach

I am a scientist and sexual and reproductive health (SRH) doctor, recently appointed as Chancellor's Fellow at the University of Edinburgh. I have been based full-time in Africa for most of my career, conducting research, training, and providing clinical care aiming to reduce mortality and morbidity from poor sexual health. Sexually transmitted infections (STIs), including HIV, cause a high morbidity and mortality burden in southern and eastern Africa. During pregnancy and post-partum, STIs have additional serious consequences. This is also a period when women are engaging with health services, presenting a window of opportunity for intervention, both to prevent immediate adverse consequences and to educate and empower for the future. Generating evidence-based guidance on sexual healthcare in pregnancy is a priority for the World Health Organization. To generate the evidence needed to inform sexual healthcare in pregnancy and post-partum, my Professorship will build on my well-established programme of research at the Botswana Sexual and Reproductive Health Initiative and a newer collaboration with the Malawi-Liverpool-Wellcome Trust Programme through 5 Specific Aims: 1: Public-patient involvement and engagement. A Community Engagement and Involvement Group and Community and Youth Advisory Boards will be appointed to map out the overall project priorities, goals, processes, review progress, and co-produce/co-design specific project activities and interventions. 2: Diagnostic-driven STI management. STI services are often unavailable, inaccessible or inappropriate to populations in Africa; rely on 'syndromic management' which has been shown to be ineffective in controlling STIs; are not routinely informed by surveillance data; and often do not include care for sexual partners. We will conduct a series of mixed-method studies to address these challenges, developing and evaluating a patient-centred, diagnostic STI intervention, with cost-effectiveness assessments and antimicrobial resistance surveillance. 3: Preventing HIV-infection. HIV incidence is high during pregnancy and post-partum. Pre-exposure prophylaxis for HIV (PrEP) is critical, yet implementation models remain undefined. We will assess preferences for PrEP and HIV self-testing among HIV-uninfected pregnant and post-partum women and their partners using discrete choice experiments and qualitative methodologies. We will then co-design and test an intervention to improve PrEP and HIV self-testing using integrated delivery models. 4: Intervention and cohort. From Aim 1-3 outputs, we will co-create a people-centred, evidence-based 'Better Sexual Health in Pregnancy' intervention and a cohort infrastructure embedded within routine services in Botswana to test it, and ultimately to determine programmatic outcomes when delivered at scale. 5: Policy and practice. To maximise sustainable impact, we will engage key stakeholders and develop relationships and resources to influence regional and international policy and build a well-equipped advocacy network to drive progress beyond this Professorship. Embedded across all aims are capacity building and training (I will support Malawian and Botswanan researchers and clinicians to develop their research careers and become the next generation of leading scientists); and public communication of science (I will communicate about our research throughout the project to raise the profile of SRH). This Professorship will lead to sustainable reductions in the morbidity and mortality associated with poor sexual health in pregnancy in Malawi and Botswana.