The World Health Organization recommends exclusive breastfeeding for the first six months, along with maternal antiretroviral treatment, to reduce the risk of HIV transmission to infants and promote their health and survival. However, globally, this practice is not as widespread as it should be, especially in sub-Saharan Africa, as shown by several studies among HIV-infected mothers. However, no comprehensive review has examined the overall prevalence and the factors influencing it. This systematic review and meta-analysis aimed to determine the overall prevalence of exclusive breastfeeding and associated factors among HIV-infected mothers in sub-Saharan Africa. International electronic databases including PubMed, Embase, Scopus, Cochrane, and Web of Science were systematically searched for observational studies on exclusive breastfeeding among HIV-infected mothers in sub-Saharan Africa published after 2010. Citation tracking revealed additional references. Two authors extracted the necessary data independently in a standardized format, which was analyzed with STATA version 17. The Joanna Briggs Institute (JBI) critical appraisal tool was used to assess the study quality. Heterogeneity was evaluated using the Cochran Q test and quantified with the I2 statistic. Publication bias was assessed using funnel plots and Egger's test. Sensitivity analyses, subgroup analyses, and meta-regression were conducted to assess sources of heterogeneity. Finally, a random effects meta-analysis model was computed to estimate the pooled prevalence of exclusive breastfeeding. Associations between factors and exclusive breastfeeding were also examined via a random effects model. After 5305 studies were reviewed, 32 studies involving 9319 study participants fulfilled the inclusion criteria and were included in this meta-analysis. The findings of these 32 studies revealed a pooled prevalence of 55.9% (95% CI: 45.93, 68.23%), with substantial heterogeneity (I2 = 99.68%). Breastfeeding counseling (AOR: 3.69, 95% CI: 2.41, 5.64), adequate antenatal care visits (AOR: 2, 95% CI: 1.49, 2.67), positive maternal attitudes toward infant feeding practices (AOR: 4.29, 95% CI: 2.32, 7.95) and good knowledge about infant feeding practices (AOR: 4.88, 95% CI: 3.3, 7.21) were associated with exclusive breastfeeding among HIV infected mothers. This study revealed that slightly over half of HIV-infected mothers in sub-Saharan Africa engage in exclusive breastfeeding. The findings highlight the need for support for HIV-infected mothers to enhance exclusive breastfeeding and minimize transmission risks, recommending better breastfeeding counseling, antenatal care, maternal education on feeding, and consideration of sociocultural factors for tailored strategies.
Awareness of cancer risk factors and perceptions about cancer is necessary to identify appropriate targets for cancer prevention interventions. To date, studies examining these factors among Black individuals- a population that experiences disparities in cancer-related incidence, outcomes, and survivorship - have not explored differences within ethnic subgroups. This study examined the awareness of cancer risk factors and cancer perceptions among African Americans and Sub-Saharan African immigrant adults and their associations with sociodemographics. This was a cross-sectional study that sampled African Americans and Sub-Saharan African immigrant adults aged 18-75 years between November 2020 and April 2022. Participants were recruited from the community using approved flyers and snowballing. We analyzed a self-administered survey that included measures of awareness of cancer risk factors, cancer perceptions, and sociodemographics. Descriptive statistics and logistic regression evaluated associations of sociodemographics with awareness of cancer risk factors and cancer risk perceptions variables. A total of 197 adults completed the surveys, including 109 African Americans and 88 Sub-Saharan African Immigrants (mean age = 41.5; SD = 12.9) and 59.4% female. The mean score of participants' awareness of cancer risk factors was 6.5 (SD = 3.3) on a scale range 0 to 13 and the cancer perceptions mean score was 13.8 (SD = 2.8) on a scale range 5 to 25. Educational attainment was associated with higher cancer risk factors awareness among African Americans but had no association among Sub-Saharan African immigrants. Every one-level increase in educational attainment among African Americans was associated with a 1.0-point increase in cancer risk awareness (b = 1.048, SE = 0.320, p = .001). The reported association is from a covariate adjusted model. Interventions should target individuals at higher risk of limited awareness of cancer risk factors and cancer misconceptions by implementing culturally tailored, community-based educational programs that leverage trusted community settings and provide accessible, relevant cancer prevention information.
Adolescent girls and young women (AGYW) aged 15 to 24 years continue to bear a disproportionate burden of HIV infections in sub-Saharan Africa. Although substantial research has examined behavioral risk factors, evidence on how individual, interpersonal, and structural determinants interact to shape HIV vulnerability remains fragmented. A clearer synthesis of these intersecting determinants is essential for informing integrated HIV prevention strategies and guiding the implementation of emerging biomedical interventions such as long-acting pre-exposure prophylaxis. A systematic review was conducted in accordance with PRISMA 2020 guidelines. Five electronic databases, namely PubMed, Scopus, Web of Science, Embase, and CINAHL, were searched for peer reviewed studies examining determinants of HIV vulnerability among AGYW in sub-Saharan Africa. Eligible studies included quantitative, qualitative, and mixed methods designs reporting empirical evidence on factors associated with HIV vulnerability. Findings were synthesized using a social ecological framework. Meta analysis was conducted for determinants with comparable quantitative effect estimates. A total of 49 studies conducted across 18 countries were included. Of these, 12 studies contributed to quantitative synthesis, while the remaining studies contributed to narrative synthesis. Meta analysis showed that age discordant partnerships, transactional sex, and intimate partner violence were significantly associated with increased HIV vulnerability among AGYW, with pooled estimates indicating consistent elevated risk across studies. Across studies not included in meta-analysis, poverty, food insecurity, school dropout, and migration were consistently identified as structural drivers of vulnerability. At the individual level, low perceived susceptibility to HIV and inconsistent condom use were frequently reported risk behaviors, often influenced by gender power imbalance, partner control, and economic dependence. HIV vulnerability among AGYW in sub-Saharan Africa is driven by interacting behavioral, relational, and structural determinants. These findings highlight the need for integrated HIV prevention strategies that combine behavioral interventions with structural responses addressing poverty, gender inequality, and access to youth friendly health services. At the policy level, national HIV response frameworks should strengthen cross sector collaboration across health, education, and social protection systems to address the broader conditions that sustain vulnerability. Future research should prioritize longitudinal and implementation studies to better understand causal pathways and evaluate multilevel interventions across diverse contexts.
ObjectivesPeople with disabilities have worse health outcomes than people without disabilities, leading to a 10-20-year life expectancy gap. Health workers' attitudes and lack of training are barriers to health care for people with disabilities, yet current training initiatives are unsystematic and limited to specific cadres or institutions. Countries that have adopted the UN Convention on the Rights of Persons with Disabilities likely have legal obligations to train health workers on disability. We sought to explore how this obligation is included in disability laws and policies in sub-Saharan Africa, as this is an important indication of activities to close the health gap for people with disabilities.MethodsWe searched the two available databases on disability laws: WHO MiNDBANK and UN websites for disability laws and policies for each country to systemically extract information across 11 domains.Results57 documents in English, French, and Portuguese from 31 countries were included. No relevant documents were found for 18 countries. Of the most recent document for each country, nearly half (n = 16, 52%) had no mention of disability training, while the remaining countries required or mandated it (n = 15; 49%, respectively). Most laws and policies had limited details, though more robust ones had information on budget allocation, competencies, and cadres included.ConclusionsTherefore, several countries in sub-Saharan Africa include health worker training in disability laws, but more detailed policies could improve disability training initiatives.
Digital pathology and artificial intelligence (AI) are transforming cancer diagnostics worldwide, yet their implementation in sub-Saharan Africa remains largely undocumented. The region faces a critical shortage of pathologists while bearing an increasing cancer burden, making AI-assisted diagnostics particularly relevant. However, practical deployment in resource-constrained environments raises unique technical, logistical, and educational challenges that differ substantially from those encountered in high-income settings. To systematically document the technical, logistical, and practical challenges encountered during the implementation of QuPath, an open-source digital pathology platform, for breast cancer immunohistochemical (IHC) biomarker assessment at a reference pathology lab in Cameroon, and to propose actionable solutions for similar resource-limited settings. We conducted a prospective implementation study at the Centre Pasteur du Cameroun, Yaoundé, involving 39 cases of invasive breast carcinoma with IHC for estrogen receptor, progesterone receptor, Ki67, and HER2. We documented all phases of the digital pathology workflow: pre-analytical slide preparation, slide digitization (performed remotely at Erasme University Hospital, Brussels), image transfer and storage, QuPath algorithm training, and automated analysis on a consumer-grade laptop (4 GB RAM, 500 GB storage). Challenges were categorized into four domains: hardware and infrastructure constraints, pre-analytical and scanning issues, software training and optimization, and human factors including the learning curve. Of 130 IHC slides, 18 (13.8%) required re-scanning due to detection failures or blurred images despite pre-scanning quality control. The absence of a local scanner necessitated international slide shipment, adding 8-12 weeks of delay and logistical complexity. Processing on a 4 GB RAM consumer laptop averaged 20 min per case (range: 5-60 min), with frequent application freezes on large tissue sections. Image files averaged 1.5 GB each at ×40 magnification, rapidly exhausting the 500 GB local storage capacity. The QuPath random tree classifier required manual annotation of representative tumor, stromal, and lymphoid regions on all 39 hematoxylin and eosin-stained cases before deployment on IHC slides, representing approximately 15-20 h of pathologist time. Exploratory concordance analysis suggested clinically meaningful agreement with expert pathologist scoring for three of the four biomarkers assessed, with detailed analytical validation reported separately. Implementing open-source digital pathology in sub-Saharan Africa is feasible but requires strategic planning around infrastructure, logistics, and training. We propose a practical framework addressing minimum hardware requirements, quality control protocols adapted to tropical environments, and a structured training program for pathologists. Our experience demonstrates that despite significant constraints, AI-assisted biomarker assessment can be successfully deployed in resource-limited settings, offering a pathway to improved diagnostic standardization where it is most needed.
The purpose of this study was to evaluate current practices in the management of epithelial ovarian cancer (OC) in sub-Saharan Africa (SSA). A 27-question survey was distributed to SSA-based physicians who managed OC and were members of the African Organisation for Research and Training in Cancer (AORTIC) via Research Electronic Data Capture. Questions evaluated diagnostics, imaging, surgical capacity, guideline adherence, access and barriers to systemic therapies, genetic testing and palliative care. Survey responses from 58 providers in 25 SSA countries were analysed. Clinical/medical oncologists and gynaecologic oncologists made up 52% and 36% of the respondents, respectively. Harmonised guidelines for SSA and the European Society of Medical Oncology guidelines were the most commonly used guidelines among respondents. Surgeries were performed by gynaecologic oncologists (53%) and general gynaecologists (38%). Complete cytoreductive surgery was the primary surgical goal for 38% of the respondents. Lymphadenectomy was routinely performed in 34% of patients with early-stage disease. The majority of systemic therapies were prescribed by clinical/medical oncologists (76%). Platinum/taxane doublet chemotherapy was the prevalent choice for adjuvant (90%) and neoadjuvant indications (83%). Single-agent gemcitabine was preferred for treating platinum-resistant disease (55%). Bevacizumab was prescribed by 33% of the providers. BRCA testing was limited. Drugs that target BRCA-positive tumours were prescribed by 12% of the respondents. Referral to routine palliative care services for advanced disease was performed by 41% of the respondents. The survey results demonstrate areas of guideline-concordant care for OC in SSA despite several challenges, including limited subspecialty surgical capacity and highlight important remaining gaps. To improve OC outcomes in SSA, increasing gynaecologic oncology capacity, promoting and adopting context-specific guidelines and supporting implementation-focused research require prioritisation.
Grid expansion remains a key strategy for increasing electricity access across Sub-Saharan Africa (SSA). However, whether utilities can generate sufficient revenue under current tariffs to support capital investment is unclear. We compile a comprehensive dataset of residential electricity tariffs for 48 SSA countries and develop a standardized model to estimate electricity bills using the Multi-Tier Framework (MTF). Affordability is assessed across income percentiles using simulated income distributions. Under current tariffs, around 608 million people (50%) may not afford Tier 4 electricity, rising to 1.05 billion (85%) for Tier 5 under a 10% energy-poverty threshold. Sensitivity analyses using 5% and 15% thresholds confirm the robustness of these findings. Even where higher-tier electricity is affordable, usage remains low. Combining affordability estimates with utility financial performance, we identify where grid expansion could be viable and where affordability constraints and utility deficits can create electrification traps. In many countries, off-grid solutions may be the only feasible pathway to achieving SDG7.
Community-led programs have expanded sexual and reproductive health services for female sex workers (FSW) across sub-Saharan Africa. However, substantial heterogeneity in HIV risk and engagement with prevention services remains, underscoring the need for differentiated approaches to identify FSW who remain underserved by HIV programs. We pooled 2013-2019 bio-behavioral survey data from nine countries in Sub-Sahara Africa. Latent class analysis defined underlying risk indicated by sexual behavior, client type, alcohol use, and violence. We profiled characteristics of classes and used mixture models to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for associations of class membership with prior HIV testing and biologically-confirmed HIV status. Among 5548 FSW (median age: 27, IQR 23-34), four classes were identified: Alcohol and Violence (16.8%), High Client Turnover (38.4%), Lower Client Volume (31.8%), and Limited Condoms and Lubricant Use (13.0%). Relative to other groups, FSW in Lower Client Volume were older and less likely to experience sex work interruptions or share earnings. Prior HIV testing was lower among the Limited Condoms and Lubricant Use class relative to others: Alcohol and Violence (aOR 4.99, 95%CI 3.44-7.24), High Client Turnover (aOR 4.09, 95%CI 3.19-5.24), and Lower Client Volume (aOR 3.58, 95%CI 2.80-4.59). Pooled analyses demonstrated heterogeneous individual and structural influences on HIV prevention among FSW. Increased specificity in implementation of HIV services for FSW may increase efficiency to achieve more with less in the HIV response.
We present the application of particle-shape parameters for silt grains in the 4-8 µm, 8-15 µm, and 15-31 µm fractions obtained using automatic particle-shape image analysis (Morphologi G3SE). Four shape parameters (HS Circularity, Convexity, Solidity, and Aspect Ratio), supported by scanning electron microscopy (SEM) investigations and multivariate statistical analyses, were used to aid interpretation of processes and formulation of hypotheses regarding possible sedimentary environments responsible for grain shape. The analysis examined dust particles collected during four Saharan dust intrusions into Europe: Greece (2016, 2018) and Poland (2021, 2024). The results suggest that the Convexity parameter is the most useful for distinguishing individual dust events (2016, 2018, 2021, and 2024), identifying similarities between them (particularly between 2021 and 2024), and demonstrating internal variability within a single dust plume between different deposition sites during the 2021 event. In contrast, HS Circularity and Solidity exhibited lower discriminatory and interpretative potential. Grain-size fractions below 10 µm showed the strongest ability to differentiate between dust events and deposition sites. This analysis may provide a basis for linking particle shapes with environments that may have contributed to the formation of the final shape of dust particles and may reflect a long, multi-stage pathway (MSteP). More than 75% of the analyzed dust particles were classified as subrounded, rounded or well rounded, and exhibited more isometric shapes with shallow or absent microdepressions. The predominance/presence of subrounded and rounded grains may suggest processes characteristic of subaqueous (fluvial or beach) environments.
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Temporal bone cancers are associated with high morbidity and poor prognosis. However, no established treatment guidelines currently exist. Information on temporal bone carcinomas in sub-Saharan Africa is almost non-existent in the literature. The aim of the study was to look at the outcomes of temporal bone malignancies in a developing-world setting. A retrospective chart review was conducted at a tertiary-care hospital in Cape Town, South Africa, of all patients with newly diagnosed temporal bone malignancies from 2008 to 2023. Distant metastases to the temporal bone were excluded. In total, 20 patients were identified, with a mean age of 60.7 years. From the study sample, 40% of the patients were male, and 60% were female. The most common histological diagnosis was squamous cell carcinoma (70%), followed by adenoid cystic carcinoma (15%). Seventy per cent of patients were treated with curative intent; 65% with primary surgery and 5% with primary radiotherapy, respectively. The remaining patients were offered palliative radiotherapy (25%) and best supportive care (5%). Disease recurrence occurred in 25% of patients, with the mean time to recurrence being 5.6 months. The mean overall survival for the cohort was 1.52 ± 1.23 years, while the mean disease-specific survival was 1.68 ± 1.67 years. Early diagnosis of temporal bone cancers is fundamental, and aggressive resection is essential, if indicated, to obtain negative margins and minimise recurrence. This study provides valuable insights into temporal cancers in sub-Saharan Africa and paves the way for larger studies on the continent.
Cancer mortality in sub-Saharan Africa is projected to double by 2030. African populations exhibit the highest genetic diversity worldwide, impacting cancer susceptibility, tumor biology, and therapeutic response, yet remain critically underrepresented in biomedical research. This narrative review examines biobanking and genomic research infrastructure in sub-Saharan Africa and its implications for precision oncology, highlighting that locally governed, sustainable biobanks and equitable international partnerships are fundamental prerequisites for Precision Oncology Without Borders.
Emergence of antimicrobial resistance (AMR) is a critical public health issue. The unregulated use of antibiotics in some regions of Sub-Saharan Africa make AMR emergence a prominent problem. Complex human-animal interfaces in these regions are hypothesized to create opportunities to transmit AMR, both in the form of resistant bacteria and mobile genetic elements carrying antibiotic resistance genes (ARGs). However, assessing the spread of ARGs into wildlife populations is complicated by naturally occurring resistance. Here, we use a longitudinal approach to explore whether the widespread use of antimicrobial compounds in West Africa was accompanied by an increase of ARGs in wild chimpanzees (Pan troglodytes verus) in Taï National Park (TNP), Côte d'Ivoire, the largest remaining piece of primary rainforest in West Africa. We analyzed 410 fecal samples from three groups collected over 17 years using hybridization capture and high-throughput sequencing to screen for over 2,000 ARGs. Both ARG abundance and the diversity of AMR classes increased. Results provide clear evidence of an increase of ARGs in this remote wild chimpanzee population during a period when ARGs increased regionally and across the globe.
As a priority contaminant regulated by environmental agencies, antimony (Sb) poses significant threats to both human health and marine ecosystems. However, the global long-term trends of particle-bound Sb concentrations and deposition fluxes remain poorly understood. To address this knowledge gap, we developed a 20-year global atmospheric Sb emission inventory (2000-2019) and, for the first time, simulated particle-bound Sb concentrations and deposition fluxes during this period. Our results revealed pronounced spatial variations in ambient Sb concentrations with the highest and lowest ones in China (1.49 ± 0.65 ng/m3) and Sub-Saharan Africa (SS: 0.007 ± 0.003 ng/m3), respectively. Regarding long-term trends, Sb concentrations in China increased steadily from 2000 to 2011 but declined sharply after 2013, likely due to the implementation of clean air policies. In contrast, India experienced a continuous rise in Sb levels since 2000, with no significant reduction in recent years. North America (NA) exhibited a persistent decline from 2000 to 2019, attributable to stable economic conditions and widespread adoption of advanced air pollution control technologies. Marine Sb deposition trends mirrored continental anthropogenic emission. For instance, deposition fluxes in the East China Sea (ECS) and North Atlantic Ocean (NAO) followed trends observed in China and Western Europe, respectively. Notably, total Sb depositions in remote oceans such as the Arctic Ocean (AO: +28%) and Southern Ocean (SO: +162%) increased markedly, underscoring the enduring influence of anthropogenic emissions on Sb deposition in even the most remote marine environments.
Despite rapid growth in oral microbiome research, it remains unclear how well publicly available data reflect the diversity of the global human population. This study systematically evaluated the geographic and sampling-type representativeness of publicly available human oral microbiome data. A global meta-research analysis of publicly available human oral microbiome records in the NCBI BioSample database released up to December 31, 2025, was conducted. Records were retrieved, harmonized, and analyzed across 4 dimensions: geographic origin, oral sampling type, temporal trends, and population-adjusted representation using a derived representation index (RI). A total of 222,454 BioSamples from 1,600 studies were identified, spanning 92 countries and 4 major oral sampling-type groups: oral fluids, oral mucosa and surfaces, dental plaque and calculus, and special or lesion-associated sites. Geographic distribution was highly concentrated; nearly half of all geographically annotated samples originated from the United States and China, while 61% of countries worldwide contributed no samples. Low- and middle-income regions, including Central and Southern Asia (RI = -12.76) and Sub-Saharan Africa (RI = -11.21), were underrepresented relative to their population sizes. Sampling-type distribution was similarly uneven, with saliva samples comprising more than half of all samples. In contrast, disease-relevant sites, including carious lesions, periapical lesions, and the dental pulp, each represented less than 0.2% of the dataset. Together, these findings underscore that publicly available human oral microbiome data remain unevenly distributed across geographic origin and sampling types, reflecting structural and practical factors that have persisted over time. Deliberate efforts to improve global representation, sampling diversity, and metadata standardization are needed to build a more scientifically robust oral microbiome evidence base.
Stomach cancer remains a major global health burden, and high sodium intake and smoking are key modifiable risk factors, yet their long-term and future contributions to global mortality and disability remain unclear. (1) assess the global burden of stomach cancer linked to high sodium intake and smoking from 1990 to 2021; (2) forecast the burden from 2021 to 2040. We used Global Burden of Disease 2021 data to calculate age- and sex-specific death and DALYs rates, percentage changes, and population attributable fractions for high sodium intake and smoking. In 2021, 7.9% and 11.2% of global age-standardized stomach cancer deaths were attributed to high sodium intake and smoking, respectively, with men and older adults most affected. East Asia had the highest death and DALY rates, and High-income North America and Western Sub-Saharan Africa the lowest; Mongolia and Bolivia topped sodium-related rates, while Morocco and Nigeria were lowest. From 1990 to 2021, sodium-related mortality rose most in Egypt and fell most in South Korea; smoking-related deaths rose in Egypt and Lesotho but fell in Singapore. High-middle SDI regions bore the greatest burden, and projections to 2040 predict global declines in death and DALY rates for both risks. Our findings highlight the need for targeted, region- and gender-specific policies to curb stomach cancer risk from high sodium intake and smoking, providing policymakers with vital data for effective public health interventions.
The incidence of maternal deaths from preventable pregnancy-related conditions remains alarmingly high at 303,000 annually, with over 800 women dying daily from avoidable causes. Ethiopia is one of eight sub-Saharan African countries that are identified as global hot spots for maternal mortality. Thus, this study aimed to model predictors of incomplete ANC utilization among reproductive-aged women in Ethiopia using explainable machine learning algorithms. This study employed the 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) dataset. Data preparation techniques such as feature engineering, data splitting, handling missing values, resolving imbalanced categories, and outlier removal were used to clean the data. Six popular machine learning classifiers were implemented in R 4.4.2 and Python 3.11.5 via Jupyter Notebook through the Scikit-learn and XGBoost packages and evaluated using multiple permanence matrices. Finally, Shapley Additive exPlanations (SHAP) analysis was used to clarify the impact of the most important predictors on the model's output. This study included 3979 women who had given birth during the five years prior to the survey out of the 8,885 interviewed women. Random forest (RF) was found to be the best model for modeling predictors of incomplete ANC utilization in Ethiopia, with 73% accuracy and 79% area under the ROC curve. Older age (25 and 34), residence area, being in the Benishangul-Gumuz, Tigray region, Harari region and wealth indices were top predictors of incomplete ANC utilization among reproductive-age women in Ethiopia. This study found that young women in rural areas, having low-income indices and low levels of education, as well as those living in the Somali and Harari regions, are more likely to experience incomplete ANC utilization. Policymakers and stakeholders should prioritize these vulnerable groups when designing policies and maternal health services to improve ANC utilization and reduce maternal mortality in Ethiopia.
Men in sub-Saharan Africa experience disproportionately poor HIV outcomes, yet their engagement with HIV prevention services remains limited. Although oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, relatively little research has examined the factors that support men's sustained use of PrEP after initiation. We conducted a qualitative sub-study among men who initiated PrEP through a community-based HIV prevention program in Buffalo City Metro, South Africa. Men who returned for their three-month PrEP refill were invited to complete an in-depth interview. Thematic analysis was guided by the Network-Individual-Resource Model. Twelve of 22 men who initiated PrEP returned for their three-month follow-up visit and participated in interviews. Men described several interconnected factors supporting continued PrEP use. Awareness of sexual risk and confidence in PrEP's protective benefits motivated continued use, while encouragement from partners and trusted male peers reinforced adherence. Participants also described developing daily routines that helped integrate PrEP into their lives. Structural conditions further shaped engagement: men preferred convenient community-based PrEP services, while anxiety surrounding routine HIV testing was described as discouraging for men more broadly, although many participants reported that their own concerns diminished with repeated testing. Men's sustained PrEP use was shaped by networked mental and tangible resources, including risk awareness, social support, adherence routines, and accessible service delivery environments. Community-based PrEP delivery models that leverage men's social networks may help improve sustained PrEP engagement among men in high HIV burden settings.