This paper presents an improved solution for the airflow energy harvester based on the push–pull diamagnetic levitation structure. A four-notch rotor is adopted to eliminate the offset of the floating rotor and substantially increase the energy conversion rate. The new rotor is a centrally symmetrical-shaped magnet, which ensures that it is not subjected to cyclically varying unbalanced radial forces, thus avoiding the rotor’s offset. Considering the output voltage and power of several types of rotors, the four-notch rotor was found to be optimal. Furthermore, with the four-notch rotor, the overall average increase in axial magnetic spring stiffness is 9.666% and the average increase in maximum monostable levitation space is 1.67%, but the horizontal recovery force is reduced by 3.97%. The experimental results show that at an airflow rate of 3000 sccm, the peak voltage and rotation speed of the four-notch rotor are 2.709 V and 21,367 rpm, respectively, which are 40.80% and 5.99% higher compared to the three-notch rotor. The experimental results were consistent with the analytical simulation. Based on the improvement, the energy conversion factor of the airflow energy harvester increased to 0.127 mV/rpm, the output power increased to 138.47 mW and the energy conversion rate increased to 58.14%, while the trend of the levitation characteristics also matched the simulation results. In summary, the solution proposed in this paper significantly improves the performance of the airflow energy harvester. With the rapid development of wireless sensor networks , microelAirflow is a kind of widespread source of clean energy in nature, and it has many sources and the widest range of applications. Xin et al.  propose Diamagnetic levitation was first investigated experimentally by Cansiz and Hull  in 2004.This paper focuses on improving the airflow energy harvester based on the new diamagnetic levitation structure to enhance output performance and energy conversion rate. A centrosymmetric rotor is proposed to address the shortcomings of the three-notch rotor. Simulation models are built in COMSOL to compare and verify various floating rotors’ output performance and determine the optimum rotor parameters. A joint COMSOL and MATLAB simulation was carried out to compare the levitation characteristics of the new rotor with those of the three-notch rotor. Experimental prototypes and platforms have been built based on theoretical and simulated models, and the results show that the airflow energy harvester with the new rotor has higher output performance and better levitation characteristics.The three-dimensional model of the airflow energy harvester is shown in PusF and PulF. Diamagnetic force UpF and LowF are exerted on the floating rotor from the upper and lower HOPG sheets. In G represents the gravity of the floating rotor, and RF denotes the axial resultant force. The potential energy of the floating rotor can be expressed by Equation (2).M is the magnetic dipole moment of the floating rotor, PusB denotes the magnetic flux density of the pushing magnet, PulB shows the magnetic flux density of the pulling magnet, m shows the mass of the floating rotor, and z shows the distance from the ground. Equation (3) can be obtained by substituting the diamagnetic influence exponents [zC and rC into Equation (2).The push–pull diamagnetic levitation structure is shown in xponents  Cz and CThe formula for the stability of the floating rotor that can be derived from Equations (3)–(5) are the equations for vertical and horizontal stability.Compared with the old structure , the pusThe schematic diagram of the three-notch rotor is shown in dF1 and dF2, respectively.When the airflow collides with the floating rotor, the motion state of the airflow can be simplified as shown in θ represents the angle between the driving force and the line connecting the two. When θ is closer to 90°, the driving effect on the rotor is more prominent, while the radial force on the rotor is smaller. It can be seen from θ1 is greater than θ2, and the tangential component of the driving force dF1 is larger, while the radial component of the driving force dF2 is larger.Connecting the collision point of the airflow and the center of the floating rotor, α of the yellow and green areas is 32°, and the angle β of the red and cyan areas is 28°.According to the relative positions of the nozzle and itself, the floating rotor can be divided into three parts, red, green, and blue areas shown in RdF and LdF, respectively. The two forces are decomposed into two tangential forces RdtF and LdtF, and radial forces RdrF and LdrF. As can be seen from rF, which makes the floating rotor unbalanced in the horizontal plane and thus begins to offset. When the pushing magnet, the pulling magnet, and the floating rotor are not coaxial, the pushing magnet and pulling magnet exert a horizontal magnetic force on the floating rotor, and the sum of the two horizontal magnetic forces is the horizontal recovery force HF of the floating rotor. In HF also increases. As expressed in Equation (8), when it reaches O’, the value of the horizontal recovery force HF is equal to that of the radial force rF, the floating rotor reaches its equilibrium in the horizontal direction, and the offset also reaches the maximum value. O’ is denoted as the maximum right side offset point of the floating rotor, where the floating rotor continues to rotate and enters the next stage, as shown in The first stage is shown in RdF is significantly greater than the left driving force LdF. In the horizontal direction, the floating rotor will return to the original central O point under the combined action of the horizontal recovery force HF, the right-side radial force RdrF and the left radial force LdrF. In O, the left and right-side nozzles are at an equal distance from the floating rotor, the radial and tangential components of the left and right-side driving forces LdF and RdF are equal, as shown in Equation (9). The floating rotor enters the third stage after 30° rotation around O.In rF is exactly opposite to the horizontal resultant force in the first stage, the floating rotor will be offset to the left, finally reaching the maximum left offset point O”. The floating rotor will enter the fourth stage with another 30° rotation. The fourth stage is like the second one in that the floating rotor returns to the initial point O again under the action of the horizontal recovery force HF and the two radial forces. The entire period is the completion of the rotation of the floating rotor before entering the next rotation period.In the third stage, the airflow from the left nozzle blows toward the notch surface, while the right nozzle blows toward the circular surface, which corresponds to the rotation of the floating rotor by 180° relative to the first stage. At this time, the direction of the horizontal resultant force During one rotation cycle, the floating rotor is offset to the left and right in the horizontal plane in turn because radial forces cannot be fully counteracted. After reaching a maximum speed of 20,000 rpm, the floating rotor undergoes more than 900 periodic offsets per second. Such a high frequency of periodic offset consumes substantial energy, reducing the energy conversion rate. If the floating rotor deflection is to be eliminated, it must be ensured that the airflow from both nozzles is blowing simultaneously toward the circular surface or the notch surface. The three-notch rotor cannot eliminate the offset due to its structure. When the number of notches is even, the rotor has a centrosymmetric structure, as shown in ECFρ. The quotient of the peak voltage and the speed of the rotor is the value of the energy conversion factor. The peak voltage PE can, therefore, be expressed by Equation (10).In the airflow energy harvester, two factors influence the magnitude of the peak voltage. One is the rotation speed ω of the floating rotor. Higher speed led to higher induction electromotive force in the coil. The other one is the energy conversion factor 3. The simulation model shown in The energy conversion part of the energy harvester consists of two shaped coils made up of three circular coils connected in series, which are arranged above and below the floating rotor, as shown in TCE (BCE) in the top coils (bottom coils) is less than the sum of the voltages of the three coils, as expressed in Equation (11). Moreover, the value of TCE (BCE) is always zero when using the four-notch rotor. In contrast, as seen in TCE (BCE) of both the three-notch and six-notch rotors are three times the electromotive force in a single coil, as expressed in Equation (12). Furthermore, the total voltage of the three-notch rotor is significantly higher than that of the six-notch rotor by a factor of approximately two. The energy conversion factors ECFS2ρ, ECFS3ρ, ECFS4ρ and ECFS6ρ of the four rotors in a single coil are calculated from Equation (10), and the values of them are 0.0260 mV/rpm, 0.0263 mV/rpm, 0.0272 mV/rpm, and 0.0146 mV/rpm, respectively. According to Equation (13), the centrosymmetric rotors may have a higher output performance. The coil arrangement of the three-notch rotor is not suitable for the centrosymmetric rotors, which results in their low total voltage.As seen in SCE of the two-notch rotor, three-notch rotor, four-notch rotor, and six-notch rotor are 0.3392 V, 0.4344 V, 0.5415 V, and 0.2839 V, respectively. The output voltage E is calculated according to Equation (14), where N is the number of notches in each rotor. In With the centrosymmetric rotors, the existing coil arrangement must be changed to avoid the induction electromotive force canceling each other out. The improved coil arrangement is shown in The simulation gives a resistance of 2.42 Ω for a single circular coil. The power of four rotors was calculated from the total output voltage and resistance, as shown in The levitation characteristics of the three-notch and four-notch rotors were calculated using a joint MATLAB and COMSOL simulation. The magnetic and diamagnetic forces of the four-notch rotor are smaller compared to the three-notch rotor due to the lower magnetic induction strength, which makes the axial combined forces and the potential energy of the two types of floating rotor follow approximately the same trend, with slight differences, as shown in PusL values of 59 mm, 58.5 mm, 58 mm, 57.5 mm, and 57 mm, the axial magnetic spring stiffness increases by an average of 7.886%, 8.328%, 9.915%, 10.939%, and 11.263%, respectively. The overall average increase in axial magnetic spring stiffness is 9.666%.The axial magnetic spring stiffness of the floating rotor represents the ability of the energy harvester to cope with external axial excitation. The larger the axial spring stiffness, the higher the axial stability. As seen in PusL represents a levitation point, and at each levitation point, there is a maximum monostable levitation space HmaxL. When using the four-notch rotor, PusL takes on a larger range of values and more levitation equilibrium points can be selected. For the same value of PusL, the maximum monostable levitation space of the four-notch rotor is somewhat enhanced, with an overall average enhancement of 1.67%. Furthermore, the maximum monostable levitation space’s maximum value is increased from 4.88 mm to 5.14 mm. The larger maximum monostable levitation space facilitates observation of the levitation state of the floating rotor and reduces the possibility of friction between the floating rotor and the coil due to axial excitation.In As shown in The experimental platform of the improved airflow energy harvester is built according to PusL decreases, the rotor can be kept levitation by reducing PulL. When the value of PusL is reduced from 55.365 mm to 51.365 mm, the maximum monostable levitation space Hmax3L is reduced from 4.73 mm to 3.89 mm for the three-notch rotor and Hmax4L is reduced from 4.81 mm to 3.97 mm for the four-notch rotor. Meanwhile, Hmax4L is consistently greater than Hmax3L, with an average improvement of 2.05%, in line with the simulation results in Experiments were first carried out on the maximum monostable levitation space at multiple levitation equilibrium points for the three-notch rotor and the four-notch rotor. The axial positions of the pushing magnet, the pushing magnet, and the two HOPG sheets are changed so that the floating rotor is at different levitation equilibrium points. The thickness of each component and the axial distance between them and the base plate are measured using Vernier calipers. The distance between the upper and lower HOPG plates was calculated from the measured data to be the maximum monostable levitation space and recorded in PusL is 55.365 mm. The airflow from the nozzle is increased from 0 sccm to 3000 sccm in 200-sccm increments. The horizontal displacement of the floating rotor is measured by a laser displacement sensor ; the larger the horizontal displacement value, the smaller the horizontal recovery force. The data are further processed and plotted in Both rotors are tested for horizontal recovery force when In The experimental platform for testing the output performance is shown in In The four-notch rotor significantly increases the power output and energy conversion rate of the energy harvester, which means that more electronic devices can be loaded and the collected wind energy can be converted into electricity more efficiently. The energy harvester can harvest the wind energy in the environment more effectively and offer workable output with a limited airflow input.This paper investigates the airflow energy harvester using the push–pull diamagnetic levitation structure. Instead of using the three-notch rotor, a four-notch rotor was introduced into the energy harvester, and a corresponding comparison study was carried out to verify the improvement. The centrosymmetric rotors are required to eliminate the periodic offset. Simulations in COMSOL Multiphysics 5.6 of the output performance of multiple floating rotors, have determined that the four-notch rotor has the best output performance. After the improvement, the levitation characteristics of the four-notch rotor were changed due to its reduced magnetic induction strength and mass. The axial magnetic spring stiffness increased by an overall average of 9.666%, and the maximum monostable levitation space increased by an average of 1.67%. However, there is a reduction in horizontal response force of approximately 3.97%, which does not affect horizontal stability due to the elimination of the floating rotor horizontal offset. An experimental platform was set up to verify the output and levitation characteristics. According to the experimental results, when the airflow is 3000 sccm, the peak voltage of the four-notch rotor can reach 2.709 V, and the maximum speed can reach 21,360 rpm. The peak voltage, maximum rotation speed, output power, energy conversion factor, and energy conversion rate of the four-notch rotor are respectively increased by 40.80%, 5.99%, 41.40%, 32.68%, and 41.39%, compared to the three-notch rotor. At the same time, the variation in levitation characteristics is consistent with the simulation results. The use of the four-notch rotor also substantially improves output performance, particularly by increasing the energy conversion rate from 41.12% to 58.14%, while increasing the maximum monostable levitation space and axial magnetic spring stiffness, demonstrating that this is a proven improvement solution.


Why do some zoonotic diseases receive priority from health policy decision-makers and planners whereas others receive little attention? By leveraging Shiffman and Smith’s political prioritisation framework, our paper advances a political economy of disease prioritisation focusing on four key components: the strength of the actors involved in the prioritisation, the power of the ideas they use to portray the issue, the political contexts in which they operate, and the characteristics of the issue itself . These components afford a nuanced characterisation of how zoonotic diseases are prioritised for intervention and highlight the associated knowledge gaps affecting prioritisation outcomes. We apply this framework to the case of zoonoses management in India, specifically to identify the factors that shape disease prioritisation decision-making and outcomes.We conducted 26 semi-structured interviews with national, state and district level health policymakers, disease managers and technical experts involved in disease surveillance and control in India.Our results show pluralistic interpretation of risks, exemplified by a disconnect between state and district level actors on priority diseases. The main factors identified as shaping prioritisation outcomes were related to the nature of the zoonoses problem  as well as political, social, cultural and institutional environments , and challenges in organisation leadership for cross-sectoral engagement.The findings highlight a compartmentalised regulatory system for zoonoses where political, social, cultural, and media factors can influence disease management and prioritisation. A major policy window is the institutionalisation of One Health to increase the political priority for strengthening cross-sectoral engagement to address several challenges, including the creation of effective institutions to reconcile stakeholder priorities and prioritisation processes. Expanding human populations and sustained land-use change have brought humans into close proximity to wildlife, amplifying the risk of potential disease spillover from wildlife to livestock and humans , 2. At tAgainst this background, defining disease priorities for resource allocation and intervention is complex and deeply political –14 and aAddressing questions like these requires an integrated approach that provides the analytical lens or platform to reconcile different stakeholder priorities, available evidence and institutional processes that shape prioritisation outcomes. Recent prioritisation efforts have focussed on bridging the gap between animal and human health sectors through the agency of collaborative, cross-sectoral expert-driven prioritisations , 15. Altwhy do some zoonotic diseases receive priority from policy decision-makers and health planners (responsible for disease surveillance and control) whereas others receive little attention? Specifically, we address the following sub-questions: (i) how are zoonotic diseases prioritised for interventions and (ii) what are the knowledge gaps affecting disease prioritisation?In the face of limited resources for disease prevention activities  and control measures, a better understanding of the political, institutional, and socioeconomic factors that affect prioritisation decision-making and outcomes across different contexts remains paramount in guiding defensible resource allocation and optimising interventions. While some previous studies have identified factors that shape political prioritisation and responses to non-communicable diseases , 16, to 2.We conducted a qualitative study using semi-structured interviews with policy decision-makers, disease managers and technical experts involved in zoonoses management in India across national, state and district levels. The selection of key-informants was based on a prior One Health stakeholder mapping exercise conducted to identify different organisations involved in disease surveillance and control. Stakeholders in this context refer to individuals or actors whose interest (or mandate) significantly affect or are impinged by management decisions regarding zoonoses prevention and control. We purposively selected key-informants to cover the primary roles in the policy agenda setting and implementation of interventions across scale. Other actors and institutions were recruited through snowballing. Recruitment of key-informants for the in-depth interviews continued until data saturation was reached, stratified by sector  to capture population heterogeneity , 16. We We adopted Shiffman and Smith’s political prioritisation framework to organise interview data into themes for evaluating factors shaping the political prioritisation of zoonoses in India . The modThe anonymised interview transcripts were analysed thematically within NVIVO 12 using a combination of deductive and inductive analysis, with the individual as the unit of analysis . We firs3.3.1.n = 14) were affiliated to the human health sector, indicative of the dominance of human health actors in India’s health policy arena. Three informants were affiliated with the animal health and two with the wildlife sectors, respectively. The remaining six were experts and other informed actors, with extensive knowledge having spent their careers working on zoonoses in academic institutions  and civil society organisations focussed on disease interventions. In total, 26 interviews were conducted and categorised into four sectoral domains. The majority of informants were male and had over a decade of experience working in the field of zoonoses. Despite efforts to achieve a balanced representation of relevant sectors in zoonoses decision-making across levels, over half of informants .“We are able to prioritise ourselves as per the local need but common diseases are prioritised at national level. Local diseases are prioritised at local level. That liberty is given to the states. Some states have added diphtheria, others have added pertussis. Karnataka, for example, has added Kyasanur forest disease (KFD) as a priority disease.” .On the rationale for the state-centric prioritisation of diseases, another state-level informant explained that this was mainly to avert any potential dilution effect  and to foster strong state ownership of the process:“If it [prioritisation] is done at the national level, then dilution will be there. Suppose there are 5 diseases, I will make a plan for 5 diseases. My priority, now at present because of KFD outbreak and H1N1, my top priority is H1N1 and second is KFD. So I have to prioritise my action plan for the control of morbidity and mortality of these two diseases. So better to give at the state level …” .3.3.To the extent that guiding institutions, actor relationships and power shapes the disease system and prioritisation outcomes, it was important to assess the strength/authority and positionality of actors and organisations within the policy arenas responsible for zoonoses agenda-setting and interventions. From the interview data, three types of authority – institutional, delegated and expert authority – were identified as linked to zoonoses management . The anaThe key actors within the health system identified as wielding institutional authority regarding zoonoses control and prevention include the National Centre for Disease Control (NCDC), Indian Council for Medical Research (ICMR), Indian Council for Agricultural Research (ICAR), Department of Animal Husbandry and Dairying (AH&D) and state departments of animal, human health and wildlife . State-lConcerning the degree of collaboration between various actors involved in zoonoses prioritisation, national and state-level informants generally concurred that the disease prioritisation process is largely sectorally-driven, i.e., the emphasis of a focal zoonosis that is considered of prime importance for animal health may not be the same for human health. On the rationale for the siloed-approach to prioritisation decision-making, a national-level animal health actor said:“Glanders, for example, is a category B bioweapon which from my perspective is a priority disease. Okay you go to the human health side, the rate of transmission to human is very less. Now, how do you prioritise from that side?” .On the question over what opportunities exist for joint disease prioritisation, the interviews revealed mixed views as to the extent to which decision-making process was indeed collaborative. For instance, animal health actors particularly highlighted that existing collaborations were largely tokenistic as they often played second fiddle to their human health counterparts with respect to zoonoses prioritisation. Two critical views expressed by a state-level actor and an expert from the animal health sector about collaborative prioritisation in the current state of affairs are instructive:“They [human health actors] will not be at all ready to listen to you. If you go to them and you tell them this is what we need to do, they will not at all be willing to listen to you. Actually the policy matters have been directed towards protection of mankind. We are working to protect humankind, aren’t we [sic]? And the animal health side is completely side-lined. .“There is missing link between human health and animal health sectors [in respect to collaborative decision-making]. They will not take our ideas and we will not take theirs. It is recently only we came together …” .every sector remains overloaded. For example, if I talk to colleagues in the veterinary sector, I know that human resources is lesser than what is required. So that is a limiting factor. So people remain bounded with their own departmental work that they do not have time, energy and resources to engage other sectors, except during disease emergencies. It may not necessarily be only in India” . Nevertheless, other informants downplayed the contested authority of animal health actors in joint prioritisation commonly citing examples of successful cross-sectoral engagement  and sustained informal relationships which contributed significantly in circumventing otherwise ‘formal barriers’ to collaborations .From the human health perspective, some state-level informants concurred that their animal health counterparts had circumscribed authority with respect to zoonoses decision-making since the supposedly joint-prioritisation platform was largely human health centred. Interviewees contended that the power asymmetries shaping collaborative arrangements between animal and human health actors are reflective of a broader social stratification, in which human doctors exerted high societal influence relative to veterinarians . Besidesnobody is talking about these neglected disease (say KFD or scrub typhus) and there is no funding to incentivise related interventions. Unlike rabies or TB, national health control and civil society engagement has been weak for other diseases” . Correspondingly, a national-level bureaucrat  recounted how commercial livestock and dairy farms constituted a strong lobbying group that influenced the political prioritisation of brucellosis for eradication by 2030, culminating in the announcement of funding for the National Animal Disease Control Programme (NADCP) by the Prime minister’s office for 2019–2024 . As one bureaucrat lamented, ““I think because of the fact that the animal welfare lobby has usurped the agenda for dog population control. It is really to do with the animal welfare lobby … That’s why there has been no strong move to dog control by the health department to come up with any policy even though it is their mandate to reduce the burden of disease” .3.4.Underpinning the disease prioritisation context is the resonating set of ideas – i.e. framing of the issue publicly in ways that attracts political support – that determine the attention accorded to the candidate priority disease. In essence, how a disease is portrayed and understood by actors involved in zoonoses management matters for prioritisation and intervention . We thus3.4.1.A shared understanding of an issue and its solutions by a policy community is fundamental to its coalescence. Despite the lack of formally ratified disease prioritisation criteria, several interviewees highlighted morbidity, case fatality, mortality and economic impact as the common ‘internal framing’ used to characterise candidate diseases for prioritisation. Two typical observations by a state and national level official regarding the determinants of priority accorded to focal diseases are instructive:“The most prominent diseases are linked to high case fatality and mortality which informs their high priority status. Everywhere [in the country] importance will come to a [candidate] disease when any death happen from it, mortality is the primary criteria. Until then we do not take it seriously. Once the deaths happen State, national, international, and locally everyone will be alert” .“I guess in most part of the community it is very pathogen-focused but there are a lot of similarities between different kinds of zoonotic diseases. Obviously the kind of visibility they get in the policy agenda and the kind of responses depends on who gets affected in terms of population, types of animals, economic or political visibility and also how visible the diseases are.” .3.4.2.On the question of external framing of candidate priority diseases, a recurring theme across the interviews was that public attention and media publicity featured prominently in determining the political visibility or importance accorded to respective disease problems. Juxtaposing the case of two priority zoonoses (Anthrax and Brucellosis) in elucidating how public perception affects prioritisation outcomes, an expert informant and disease manager, respectively, said:Anthrax causing deaths causes human outcry whereas you know Brucellosis might not in the same way for example, despite having a much larger burden. Rabies having smaller cases is much more visible compared to other silent diseases with larger burden” .““If there is a huge number of animal deaths happening in the short span of time, for example the case of an anthrax outbreak people are bound to get incensed they are bound to inform their leadership so chances are that it will be high on the political ladder. But if a disease which is not causing huge deaths or is causing silent disability for a long time then people might or might not be aware about it even if the scientists are aware people might not be aware about it but it is a political issue” .per se but largely the political visibility shaped by narratives about diseases and their portrayal in the media space. In separate interviews, a disease manager and surveillance officer addressed the effect of public portrayals or disease narratives on eventual priority setting outcomes:A number of national and state level actors (responsible for disease surveillance and control) also corroborated the foregoing observations, implicitly suggesting that prioritisation of diseases is not necessarily based on epidemiological characteristics of diseases  Right now, the dengue positivity [for example] is more compared to that of COVID-19, but people are not much bothered about dengue. Also the health department is not giving that much importance, what COVID-19 is getting. The government prioritisation shifted based on how much news that disease is making or how much fear that is made in people’s minds” .““Most of the things are driven by the press also. Some press persons will magnify few diseases which are not so important. If highlighted in the media, once the world comes to know that is a very serious, these kind of people are really getting troubled then it is highlighted [within policy circles]. But unfortunately, the effort [political visibility] is sustained only initially that euphoria will be there …” .3.5.3.5.1.“so obviously you know the setup is bureaucratic … most senior people heading relevant committees are not the technical people [but political actors] so other members are going to defer to that person’s you know politics. So there’s only so much you can achieve in an environment like that …” .A general consensus across the interviews was the critical role the political environment – that is the overall institutional and cultural context in which actors operate  – plays Another informant had this to say:Whatever the activities that are implemented, the decision-maker should be a technical person. Not the bureaucrats as far as my knowledge is concerned … That is how we eradicated smallpox, polio and guinea worm because the technical persons were the heads of department in those days. That is the need of the hour!” .“they are not actually coming up with the truth! Some of the states are absolutely silent and saying like we do not have this disease although our informal surveillance networks suggest otherwise” . In juxtaposition, several state and district level informants disclosed some implicit assumptions that shaped the existing disease reporting regime as some interviewees cited fear of victimisation/scapegoating, punitive-transfers and/or overstretched technical manpower as some probable reasons for the supposed reticence in full disclosure of ‘actual’ disease outbreaks to higher-ups at the national and state levels. In fact, some informants particularly observed that the reticence/behaviour of under-reporting has consequences for degree to which they can rely on existing disease reporting systems like the IDSP and/or Integrated Health Information Portal (IHIP) for early warning and targeting interventions, understanding factors driving disease emergence, as well as for overall disease prioritisation. A typical perspective by a state-level surveillance officer is illustrative:A cross-section of interviewees also conceded that disease under-reporting or misreporting as a function of wider state-level politics significantly eroded the credibility of the existing prioritisation process. A state-level bureaucrat, in defence of the seemingly heavy political influence in disease prioritisation decision-making, argued that the notion of controlling the narrative was equally important as a disease itself. The said official further noted that the quest to safeguard the country’s reputation, avert unsolicited surveillance, economic losses and public outcry (as in the case of the 1994 plague outbreak) largely incentivised decision-makers’ attempts to control narratives by suppressing news of disease outbreaks. Relatedly, a national bureaucrat voiced out, “In outbreak situations, it is the state or district level officers whose necks are on the line if they are not able to [in the eyes of political actors] properly control the situation. Technical experts sitting at national level institutions like National Centre for Disease Control [NCDC], you know, they will come and do outbreak investigations but if something happens they really do not have to face that level of accountability because their job is to provide technical advice and the decision-making and the political fallout of that is going to be restricted to state level officers.” .“Reflecting on the current state of play, some state and district level informants believed technical officers in some government departments and ministries (responsible for zoonoses decision-making) become ‘pawns’ often providing seeming scientific justifications for otherwise political decisions . A case “Managing media and elected representatives that becomes a very big burden. In a way it is good but sometimes it is very detrimental [for disease management]. Their [political actors] pressure is always reflected in the eventual decisions we make in the area of our work …” .inter alia, that the high political visibility of brucellosis is largely a product of the religious and economic significance of the ‘cow’ in Indian society. This has meant that culling as an intervention is frowned upon in Indian political discourse and a silent policy of ‘non-identification of diseased cattle’ has been adopted, given the potential to trigger distress selling and stigmatisation. A typical view in this regard was given by a zoonoses expert:Aside from the political contexts, the cultural environment  impacted significantly on disease prioritisation process and outcomes. For example, a number of interviewees noted, The cow is a political icon in Indian political discourse so you cannot cull cows and if they are diseased and you cannot mark them as diseased as you end up spreading distress selling … So the policy of the government now from what I understand is not to identify individual animals but to do pooling of sampling at the farm-level and if they do identify individual animal they ask for quarantine measures and not for culling or not for selling because they do not want the farmer to be stigmatized or to resort in distress selling of the animal …” .“3.5.2.n = 17 key-informants, interviewed after the COVID-19 lockdowns in December 2021) were in agreement that the COVID-19 pandemic raised awareness about zoonoses and provided a good political window of opportunity for galvanising and sustaining cross-sectoral action. Indeed, contrasting the observations across interviews highlight a common refrain “COVID-19 has given impetus to the need of the hour” , suggesting the importance of leveraging joint technical and surveillance capacities as an avenue to bridge the long-standing gap between animal health and human health actors and decision-makers with respect to zoonoses management. Reflecting on their pandemic experiences, several informants recounted for example how the spontaneous collaboration of functionally disparate ICAR and ICMR institutional laboratories proved instrumental in the turnaround times for the processing of human COVID-19 samples and surveillance for speedy decision-making and intervention. The observations of national human health and state-level veterinarian during separate interviews are instructive:While discussing political moments that shifted policy and facilitated stronger engagement among key actors responsible for zoonoses decision-making, several informants .“Due to the [COVID-19] pandemic, the people [decision-makers] have become sensitized to the One Health agenda and they do give importance to One Health, but having an implementable One Health model with clear-cut guidelines and outcomes, uh still is difficult to develop and implement on the ground” .Some informants were unenthused or sceptical about the so-called ‘COVID-19 opportunity’ arguing that the seemingly spontaneous cross-sectoral engagement of animal and human health actors was not surprising as it was reflective of the often reactive approach to cross-sector collaborations during outbreak situations. Indeed, to buttress their argument some local-level informants noted the missed opportunity in capitalising the learnings and experiences of the 2008 Avian Influenza outbreak management  to inform a concrete and holistic policy on cross-sectoral collaboration for improved zoonoses management. Other informants noted that the focus on COVID-19 response relegated otherwise equally urgent zoonoses problems to the background due to overstretched personnel and surveillance infrastructure. Two typical views in this regard by a disease expert and surveillance officer are illustrative:“I definitely feel that there is traction in understanding [about cross-sectoral action for zoonoses control] but again at the national level, the picture is much more complicated because there are so many different players and they are pushing so many different kinds of agendas that is difficult to make sense of.” .“We were just about to take off in terms of Integrated Health Information Platform (IHIP) but when COVID-19 came, other diseases came into the background. So now that COVID-19 has come down to a tremendous extent, we want to bring this general disease surveillance to the forefront now” .3.6.per capita rate of infection, morbidity or mortality of candidate diseases) and effective interventions ranked highest across the interviews. Several interviewees cited the lack of credible indicators – clear measures that demonstrate the severity of candidate diseases impacted significantly on which candidate diseases gets prioritised – due to limited scientific evidence particularly on the multi-scale burdens, affected populations and socio-economic impacts of focal zoonoses. The foregoing observation further buttresses the earlier argument that politically induced reticence to record some problematic diseases within disease reporting systems and the state level prioritisation of which diseases are surveilled makes it difficult to judge overall burdens and compare data between states (see Section 3.5). As one interviewee, a state-level bureaucrat, openly admitted:Across the interviews, the biological, social, and economic characteristics of focal zoonoses were highlighted by participants as significant determinants of the degree of political visibility. Of the several disease-specific attributes identified, credible indicators , disease severity .per se constituted the key hurdle for prioritisation efforts as they often resorted to passive surveillance  to inform decision-making rather than active, systematic surveillance mechanisms . Nuancing this narrative, some experts and state-level respondents further iterated that data challenge was largely due to the limited technical and surveillance infrastructural capacity at the district levels. Reflecting on how the limited surveillance capacity on disease reporting  affects data quality and prioritisation, an expert informant said:Corroborating this assertion, other national and state level bureaucrats who were interviewed further clarified that the data quality rather than data availability “We still lack data in terms of animal diseases under surveillance because it’s just the veterinarians who whatever they detect without much of a laboratory base, they just report it. On the human side, we do have infrastructure and we do have some manpower which I think still lacks some of the skilled manpower to actually do a decent reporting.” .A district level surveillance officer also argued that the limited technical capacity of field officers hampered their effective use of collated data. The said official observed:Even if data is there, I am not able to make the right use of the data and I’m not analysing. Because there is a gap in the building capacity at the field functionary level as we have not inculcated the habit of analysing data to my field functionaries, so they never look at the data.” .“Corroborating observations about data limitations and quality, a top-level national bureaucrat  admitted that while the IDSP has been useful for collating data on disease incidence and outbreak occurrence, a major drawback is the periodicity issues stemming from delayed/ and or non-submission of data by field functionaries:“The integrated disease surveillance programme [IDSP] has been very useful in terms of data collection, but there are some kind of you know periodicity issues with data as some reporting units are not submitting timely data. Besides, data picked by IDSP is not appropriate because most of the times, the diagnostic facility itself is not available. So we cannot at all be assured of the data quality.” .“not in Karnataka! No challenges like that. Our staff and medical officers are well aware of these diseases …” . The conflicting view of top-level bureaucrats and district-level implementers on data considerations highlights a potential disconnect between policymakers and implementers on the ground. The deep-seated sensitivities around open communication about challenges and need to safeguard their positions has meant senior-level bureaucrats often play to the “politics of the game.” Alluding to this assertion in separate interviews, a state-level surveillance officer and district-level disease manager, respectively, stated:Yet some state-level informants, particularly from the health department did not perceive disease surveillance and data considerations to be a challenge. In fact, one interviewee, a senior state bureaucrat, in his explanation retorted You have to realise that whenever we talk about zoonoses management [in India] is much easier to talk when you are not [directly] involved, it’s very complicated …” .““People who are sitting at the state/national level and who are capable of taking these decisions, sometimes they are also more burdened. At the same time, they do not really know the practical difficulties that we [disease managers] face at the primary health sector. If they get tuned to this kind of situation that’s there, I think they might agree with us. At the same time, district- level officers who are there they need to keep on escalating these questions to the people [decision-makers] who are there at the state level” .“it’s mainly fatality! Otherwise even if a disease is causing any morbidity, it should cause a severe disability or mortality then only the district and state level actors start noticing” . Echoing similar sentiments, another expert informant argued: “Bird flu, for example, comes like an epidemic whereas rabies and brucellosis are endemic (day-to-day problem). Whereas bird flu, it strikes and a lot of birds die, there is a lot of news in the newspaper, on the TV and the scare that it can spread to humans … In that case you know very fast action is to be taken by animal husbandry department so they also become very active” . It therefore follows that existing prioritisation often tends to privilege exotic and more prominent diseases  at the expense of some high burden endemic diseases. Moreover, some local-level informants suggested that who a disease affects in terms of population and/or types of animals tended to significantly influence prioritisation outcomes. A case in point is KFD  which until 2019 had little visibility on the policy radar in Karnataka state. Citing the example of brucellosis, an expert informant observed different risk perception of the same disease by actors in the animal and human sectors leading to differential prioritisation:On the question of how the degree of disease severity affected prioritisation outcomes, several informants suggested that the framing and measurement of severity is often quite ambiguous (due to complexity of zoonoses), but generally acknowledged that disease burdens, case fatality and mortality are critical determinants of political visibility of candidate diseases. As a district-level disease manager summarily noted, “I would say it depends on the pathogen and disease involved. The same disease might affect different people differently. For example, if a disease affects cattle (say brucellosis) then the dairy producers might have a different take (interested in productivity) compared to veterinarians who might perceive differently based on the risk of getting the disease. So I think there is a tension at play here between productivity and risks. Sometimes it is easier to tease them apart …” .The above observation might explain the seeming neglect of human anthrax outbreaks  often reported amongst marginalised tribal populations and workers handling animal carcasses , 29. Fur4.inter alia, that the complex and compartmentalised regulatory regime for zoonoses creates a policy milieu where political, socio-cultural and media influences can dominate prioritisation and management decisions.Understanding the political economy of factors that shape zoonoses prioritisation for resource allocation and intervention necessitates a contextual characterisation of the complex web of actors and networks. This includes their different constraints, priorities, mandates, and sources of information , 23, 30.Our findings highlight a challenging paradox. Several national and state-level interviewees acknowledged some drawbacks of the existing prioritisation process, including the sectorally-driven approach and the over-emphasis on exotic diseases  at the expense of high burden of silent ones . At the same time, the same informants equally recognised that uncertainties of data , lack of sensitive/point of care diagnostics hindering reporting, and the fact that different zoonoses impact populations differently renders the prioritisation of silent zoonoses  difficult. Synonymous with observation in the wider literature , 30, ourWith respect to the characteristics of individual disease problems, the disease severity exemplified by mortality and case fatality significantly determined political prioritisation. The lack of standardised indices for measurement of severity given that different zoonoses affected populations differently and the unevenness in the evidence base for focal diseases renders collaborative-prioritisation  difficult to achieve. For instance, whereas the seroprevalence of brucellosis is very high in animals, the corresponding human risk is low. Moreover, the lack of standard metrics in the animal health system to estimate disease burden (like the disability-adjusted life years (DALY) for humans) makes it difficult to estimate burden for chronic zoonotic diseases. The foregoing observation is also reflected in the contest of authority with respect to avenues for collaborative prioritisation, as animal health actors generally felt short-changed by the current state of play. Thus in facilitating collaborative-prioritisation, improvement in the ways burdens are captured in existing information systems across endemic as well as exotic diseases cannot be overemphasised. In furtherance to this, the Integrated health Information Portal (IHIP) is being developed (as a replacement for the existing IDSP) to afford an enhanced, collaborative and timely disease reporting platform. Besides, further understanding, investigating and developing indicators for the nature and extent of non-clinical, wider societal impact of zoonotic diseases, particularly for marginalised communities, rather than relying on mortality and morbidity metric only is paramount. In any event, the design and implementation of cross-sector action plans for priority diseases  backed by strong political will at the highest decision-making strata remain critical in generating the requisite financial and non-financial incentives to foster and sustain collaboration of different actors in zoonotic disease management . Despite4.1.n = 17) were interviewed after the COVID-19 pandemic could have raised their awareness about zoonoses, and therefore potentially ‘skewed’ their observations. In any event, India’s federal character implies a need for caution in the generalisability of the findings to other states of India due to the inherent political and culturally and economic diversity that exist in the 29 Indian states and the fact that health is a state subject, with disease prioritisation operationalised at the state level.This study is not without limitations. We acknowledge that the use of a snowball sampling approach in the recruitment of key-informants could have potentially skewed the representation of interviewees in favour of a particular sub-group of interest in this study, noting that actors affiliated with the human health sector constituted the majority of our study sample. Nevertheless, our prior stakeholder analysis  and purp5.Looking ahead, the COVID-19 and One Health platforms could present a window of opportunity to galvanise political support for zoonoses. Proponents argue that One Health partnerships could alleviate information asymmetries and create opportunities for knowledge exchange on candidate zoonoses critical for effective prioritisation , 32. In fesasa@ceh.ac.uk).The datasets presented in this article are not readily available because of sensitive participant information. Request to access the datasets should be directed to UK Centre for Ecology and Hydrology Institutional Data Access contact via FA (email: The studies involving humans were approved by the Research Ethics Committees of the Ashoka Trust for Research in Ecology and the Environment (IRB/CBC/0003/ATV/07/2018), Institute of Public Health (IPH) Bangalore (IEC-FR/04/2017) in India, and the The Liverpool School of Tropical Medicine Research Ethics Committee  in the United Kingdom. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.FA developed the conceptual focus, reviewed the literature, synthesised its contents, analysed data, and wrote the manuscript. AS contributed to data gathering and curation, data analysis, and reviewed the manuscript. JY, SH, and BP contributed to the conceptual focus, data interpretation, and reviewed the manuscript. MC contributed to the data interpretation and reviewed the manuscript. All authors contributed to the article and approved the submitted version.The IndiaZooSystems project that led to these results is supported by the Medical Research Council (MRC), the Foreign, Commonwealth and Development Office (FCDO), the Economic and Social Research Council (ESRC) and Wellcome under the Health Systems Research Initiative (grant numbers MR/S012893/1 & MR/S012893/2) awarded to BP, MC, SH, and JY. Additional support was provided to FA and BP from the UK Research and Innovation Global Challenges Research Fund funded IndiaZooRisk project (grant number MR/T029846/1). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the study reported.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Herpes Simplex Virus Encephalitis (HSVE) can have lifelong sequelae. Presentation can be nonspecific in cancer patients. Cerebrospinal fluid testing may be falsely negative early in illness [1]. New immune-based or targeted radiation (RT) modalities may change risk, incidence of HSVE in cancer patients.Retrospective study at Memorial Sloan Kettering Cancer Center (MSK). Review of records of patients with CSF meningitis/encephalitis (ME) PCR panels from 8/1/2016 to 7/31/2022. All unique patients who received brain RT at MSK during those dates were used to calculate incidence rates.2749 patients had 5497 CSF analyses with ME panel. Of these, 12 tests from 10 patients showed HSV-1 or -2; 1 patient had relapsing HSVE and 3 positive HSV2 tests each done at least 6 months apart.Table 1 shows 10 patients with HSVE. 8 had solid tumors, 6 with receipt of chemo- or immunotherapy within 30 days. All solid tumor patients with HSVE had brain RT; 6 received steroids. 1 patient with relapsing HSVE was on immune checkpoint inhibitor (ICI). 4/8 patients with MRIs (Table 2) lacked typical findings; 4/8 patients with EEGs had focal temporal seizure activity. CSF pleocytosis was absent in 4/10 cases. 5 patients had residual deficits. 4 died due to progression of disease.Incidence of HSVE with brain radiation was 2.6/10,000 patient-years.General population incidence of HSVE ranges from 1-4 per million population per year [2]. Those receiving cancer treatment and brain RT have elevated HSVE risk. We found the risk after brain RT is much higher: 2.6/10,000 person-years. Only 1 of 10 patients in our series made a full recovery.Other key findings include:1) One patient with recurrent HSVE in the setting of nivolumab: ICI combined with brain RT may increase risk of HSV reactivation. Such patients should be considered for high dose antiviral prophylaxis after a first HSVE episode.2) Normal MR imaging and lack of CSF pleocytosis does not preclude HSVE diagnosis in clinically compatible illness.3) No cases occurred among solid tumor patients treated with chemo- and/or immunotherapy only.Limitations:1. Retrospective design.2. Inclusion of lab confirmed cases only.Mini Kamboj, MD , ASCO: speaker fee|Medscape: speaker fee|MJH life sciences: speaker fee|Regeneron: Advisor/Consultant|Web md: speaker fee


The use of non-occupational post-exposure prophylaxis (nPEP) to prevent HIV acquisition among those exposed as an approach to HIV prevention has expanded in Uganda. Although there are increased efforts to avail nPEP services among most at-risk populations, the usage of nPEP medicines remains low. Therefore, this study examined the risk perception and usage of non-occupational post-exposure prophylaxis (nPEP) among fisherfolk in the Ggulwe fishing parish, Bussi sub-county, Wakiso district.A cross-sectional study among adults was carried out from October 2020 to January 2021 in Ggulwe parish, Bussi sub-county, Wakiso district, to examine the usage of nPEP and factors influencing the usage. Data were collected using semi-structured questionnaires, and key informants' interviews were conducted among healthcare providers and the local leadership. The quantitative data were summarized using bivariate and multivariate logistic regression, while the qualitative data were analyzed thematically to enrich the quantitative results.p < 0.001), lack of knowledge of the existence of nPEP , the perception that nPEP can effectively prevent HIV infection after exposure , and the community's opinion affecting the willingness to take nPEP .Overall, 248 fisherfolk encountered an event that required the use of nPEP, and of these, 55/248 (22.2%) were able to use nPEP to prevent them from acquiring HIV. The usage of nPEP among adults in the Bussi sub-county, Wakiso district, was associated with not knowing that HIV can be prevented using nPEP medicines . The low usage of nPEP was associated with a lack of knowledge and awareness about nPEP. This effort to improve the usage of nPEP should include community sensitization and HIV infection prevention using nPEP to raise awareness about HIV infection exposures and the risk of HIV infection during non-occupational exposures. Globally, 76 million people have acquired HIV, and 33 million people have died of HIV/AIDS since the beginning of the HIV epidemic. In addition, 38.0 million (31.6–44.5 million) people were living with HIV at the end of 2019. An estimated 0.7% (0.6–0.9%) of adults aged 15–49 years worldwide are living with HIV, although the burden of the epidemic continues to vary considerably between countries and regions (HIV/AIDS is a leading cause of death in sub-Saharan Africa (SSA), accounting for 71% of the global burden of the infection . DiffereIn the Uganda Population-based HIV Impact Assessment 2016–2017), the prevalence of HIV infection is lowest (0.2%) among the 15–19-year-old age group and highest (13.6%) among the 50–54-year-old age group , the pre comparedThe fisherfolk community is one of the high HIV-risk groups due to their frequent mobility, transactional and commercial sex, multiple sexual partners, high consumption of alcohol, poor health infrastructure, and limited access to health services –15. In aHowever, there is limited information on the factors associated with the usage of PEP in this community. Therefore, the study aimed to describe factors influencing the usage of non-occupational PEP in a fisherfolk community located on the shores of Lake Victoria in central Uganda.This study used a cross-sectional study design employing both qualitative and quantitative methods of data collection . For theIn Uganda, HIV-PEP is provided to all eligible clients within 72 h of exposure. Non-occupational exposure is defined as non-occupational exposures including sexual assault (rape and defilement), road traffic accidents, unprotected sex with an HIV-infected person, and unprotected sex with a person of unknown HIV status . The MinA population of 5,011 spread across the five villages was used in the study based on the Uganda National Bureau of Statistics Population Census 2014. A cross-sectional mixed-method study was carried out among fisherfolk communities located along the shores of Lake Victoria in the Ggulwe parish, Wakiso district, from October 2020 to January 2021. To attain quantitative data, we included participants aged 15–49 years selected using purposive and simple random techniques, and for qualitative data, we used healthcare workers and local leaders due to their high level of knowledge on HIV prevention measures and interventions in the area. The sample size was determined using Krejcie and Morgan's  formula,Our outcome variable was the usage of non-occupational post-exposure prophylaxis, defined as receipt of the following: “Yes” for participants who had taken nPEP within 72 h of exposure and “No” for those who had not. The non-occupational exposure was measured by asking whether the participant had had sexual assault (rape and defilement), road traffic accidents, unprotected sex with an HIV-infected person, or unprotected sex with a person of unknown HIV status prior to the use of nPEP. The usage in this study was taken to be whether a participant utilized PEP obtained from either a government or private health facility after accidental or suspected exposure to HIV. The independent variables consisted of individual factors such as demographics, knowledge about PEP, risk perception, and knowledge of other HIV prevention measures; community-related factors including stigma, perceived effectiveness, and associated negative effects; and health facility-related factors consisting of attitude of health workers and availability of nPEP, and finally, nPEP knowledge among health workers and adherence to prescription guidelines.p < 0.02 at bivariate analysis were included in the final multivariable model. Factors specified as important based on previous literature were included in the final model. A two-sided significance p < 0.05 and a 95% confidence interval were considered statistically significant for the analysis. Measures of association were reported as crude odds ratios at bivariate analysis and adjusted odds ratios at multivariable analysis.Data were analyzed using STATA version 14.0. Frequencies and their corresponding percentages were used for categorical variables, and mean and standard deviation were used for continuous variables that were normally distributed. The dependent variable was modeled as a binary outcome. Bivariate and multivariable analyses were performed using logistic regression with odds ratios as a measure of association. All variables with a To enrich and triangulate the quantitative results, we conducted qualitative interviews with men and women in Ggulwe fishing village, Bussi sub-county, Wakiso district. In particular, we held three FGDs, each consisting of six to eight people who were selected randomly from among those community members while maintaining COVID-19 SOPs. The group consisted of both men and women who had encountered or not encountered a situation that exposed them to HIV in the 12 months prior to the study. The FGDs were held within the village meeting rounds in the local language, “Luganda,” by two research assistants (DH and MN), both students trained in qualitative research methods. One research assistant (DH) moderated all the FGDs, while the other (MN) audio-recorded the responses and probed where necessary. Each FGD lasted for ~45 min on average. The moderator encouraged all the group members to ask questions and to provide comments as much as possible on HIV-PEP, knowledge, and usage. For key informant interviews (KIIs), four healthcare providers engaged in the provision of PEP services were purposefully selected and interviewed to elicit their expert opinions on the usage of PEP for HIV prevention. Both FGDs and KIIs were held until saturation was reached. Codes, subthemes, and themes were developed using NVivo V12 Pro, where the transcripts were uploaded and exported to Excel, which helped develop results.The study obtained ethical approval from the research and ethics committee of Uganda Martyrs University. Administrative permission was sought from Ggulwe Parish. We obtained written informed consent from all the eligible participants who were above 18 years. Permission to include participants below the age of 18 was obtained from one or both of the parents/guardians depending on their accessibility. We then sought the child's assent to participate in the study. Those who declined to participate despite permission from their parents/guardians were not included in the study. The study obtained written informed consent from the adult participants. Participants under 18 years, who are considered emancipated minors, had to provide assent. Participation was voluntary and the study ensured maximum confidentiality considering the intricacy of the study topic. Furthermore, the team was mindful of the anticipated emotional discomfort from the survivors of rape and defilement. In such cases, psychosocial support in the form of confidential counseling and post-trauma support was offered by trained healthcare workers who were members of the study team, and further referrals where required were directed to the available community services.p = 0.044). Those with a single exposure are less likely to use PEP services. Being exposed multiple times to HIV infection was not statistically significant for nPEP usage.p < 0.001). Similarly, individuals who did not know about non-occupational PEP were 70% less likely to use the services . Furthermore, those individuals who did not know how non-occupational PEP was supposed to be used were less likely to use the services . The results are summarized in In the study, the assumption was that an individual who encountered a non-occupational event with an increased likelihood of HIV infection exposure used the non-occupational PEP. At multivariable analysis, the social demographic factors did not significantly influence the usage of non-occupational PEP. The study found that individuals who did not know that HIV infection could be prevented using nPEP were 90% less likely to use the nPEP services .“Another participant cited that there were sensitization campaigns conducted by several organizations to educate communities about PEP.UVRI did a lot of work to educate people but has never heard anyone say you can find that drug here or there. It is only UVRI that has done commendable work to educate the people about PEP in both Kava-enyanja and Kituufu sub islands but has since not heard of similar community awareness on the PEP. The awareness has not sufficiently sunk into the community. People don't know -how does it work; how does it help. There is a lot of awareness on HIV but it is lacking on PEP. People don't usually use it-I have never heard someone use it, yet as you see, this is an island with many prostitutes, so the awareness is lacking, it's not enough” KI Councilor, Ggulwe parish.“The various HIV/AIDS prevention methods cited were male circumcision, abstinence, the use of male condoms, avoiding multiple sexual partners, regular screening for HIV before having sex, being faithful to one sexual partner, and avoiding sharing sharp objects.The study findings also revealed that the fishing community was given information and supplied with condoms. The health workers also encourage young people to abstain until marriage, although it proves fruitless. One of the key informants explained as follows:The community knows other prevention but young girls are attracted by money to indulge in unprotected sex. We also give out free condoms but currently out of stock for 1 month. We can even spend 3 months without condoms, we tell clients to get condoms somewhere else or even from VHTs who usually have. On abstinence, people know – but it can't work here. Most of these people leave their families in Kampala and other areas, someone can't abstain from sex for a long period including the youths,” KI enrolled nurse/M&E officer.“Following HIV preventive measures is futile in fishing communities since people get easy money and are driven to engage in risky sexual behavior.Also, women in these communities are few and are shared among the available male. Again, there is a lot of alcoholism, a drunkard person can't easily have self-control on who to have or not to have sexual intercourse with, using barriers like condoms,” KI Councilor, Ggulwe parish.“The following explanations were obtained. One key informant explained the following:Even one lady I gave nPEP in August 2020 after the rape was not aware, she was supposed to receive PEP because she was not aware of it yet the rapist was on ART,” KI, ART in-charge Bussi S/C.“From the arguments above, the indications are that little dissemination of WHO guidelines on administering PEP to clients exists. Most of the KIs reported that the community education programs of PEP are few, and they must educate clients on ART. One of the participants explained the following:One may go to the health facility and find someone with no expertise in dealing with PEP, told to go back. The client may not go back for fear of being known by many people who may disclose one's status in public,” KI, VHT coordinator, Bussi S/C.“p = 0.025). Other factors hindering nPEP service usage, such as fear of social stigma, distance to the health facility, refusal by a partner or spouse, and lack of knowledge about nPEP, were found to influence the usage of nPEP. Although 10/55(14.9%) of the clients reported that they had been denied nPEP at the health facilities in the Bussi sub-county, health workers denying clients nPEP because they may not qualify to take it were found to affect its use, and at times it was out of stock.The time spent while waiting to receive nPEP was found to be significant. The odds of an adult waiting <30 min to take nPEP were 0.05 times more likely than their counterparts that had not  said he gave it to someone who tested negative at the end of 3 months. However, one of the key informants explained the following:Some say that once the health workers give you PEP medicine; you are already HIV positive. This is because it is HIV medicine. Differentiating between PEP and ARVs is a problem. This may be aggravated by disclosure to the partner about one's HIV status so that the negative partner can take PEP after sexual intercourse,” KI enrolled nurse.“However, despite the community myths, most of the respondents did not have adequate knowledge of the use of non-occupational PEP in the prevention of HIV infection after exposure.The study findings show that the level of knowledge on nPEP to prevent the acquisition of HIV was associated with the usage of nPEP. Conversely, while assessing the use of non-occupational PEP in MSM in the USA, Donnell et al.  found thThe gap in knowledge about nPEP in the study area is not a special case as compared to the cited areas of Nigeria, Boston, and San Francisco. Similar approaches to enhance the uptake of this preventive therapy could be applied.The perceived risk of acquiring HIV/AIDS was not significant in the non-occupational PEP. Similarly, in a study conducted in the USA among MSM, no association was found between the risk of HIV and nPEP use after exposure. Three seroconversions occurred at 384 visits (1.56 per 100 person-years) with nPEP use, compared to 210 seroconversions at 25,550 visits (1.64 per 100 person-years) with no nPEP use . The use of nPEP occurred more frequently in men with high-risk sexual behaviors. Those who had reported 10 or more partners had almost triple the adjusted odds of nPEP use  relative to those who had reported zero to one . Signifip = 0.06). A study on factors associated with the usage of nPEP among Thai men revealed that a higher proportion of them who intended to take nPEP answered “yes” when asked whether nPEP would reduce their concerns about becoming infected with HIV . There was no difference in the sense of stigmatization between those who did and those who did not intend to take nPEP  among fisherfolk in Ggulwe parish on the shores of Lake Victoria in central Uganda had several limitations that need to be noted.The LGBTQ concept was neither reported nor given the desired focus because there was no reference legal document with literature on the subject. This limited the extent to which this population was included and discussed in the study.The sample size of the study was relatively small, which may have limited the generalizability of the findings to a broader population of fisherfolk in different regions. The limited scope of participants might have led to an underrepresentation of diverse perspectives and experiences within the fishing community.The study heavily relied on self-reported data from the participants, introducing the potential for recall bias and social desirability bias. It is likely that participants provided responses that they believed were more socially acceptable, leading to an inaccurate representation of their actual risk perceptions and PEP usage.Relatedly, due to resource constraints and logistical challenges, the study was conducted over a relatively short period of time. This timeframe might not have captured seasonal variations or long-term trends in risk perception and PEP usage among the fisherfolk. A more extended study period could have provided a more comprehensive understanding of this interesting area of study.Furthermore, while efforts were made to ensure cultural sensitivity and local context adaptation, the study's design and data collection methods might not have fully captured the distinctions of the fisherfolk's beliefs, practices, and perceptions related to HIV prevention and PEP. Cultural factors that were not adequately accounted for could have influenced the results.Finally, the researchers faced challenges in accessing some sub-island villages with limited health facilities, potentially leading to an underrepresentation of these areas in the study. This limitation might have affected the comprehensiveness of the findings and recommendations, particularly in terms of equitable PEP access.In conclusion, the 22% nPEP usage study sheds light on the critical need for comprehensive strategies to enhance the adoption and effective utilization of PEP within the fisherfolk communities of Ggulwe parish. The low usage was associated with limited awareness and knowledge about the non-occupational PEP.There is a need to put together new strategies that publicize non-PEP in the general population, especially the sexually active age group.There is a need to develop a collaborative approach that involves government bodies, beach management units, community-based organizations (CBOs), development partners, fisherfolk associations, local leaders, and village health teams (VHTs). This can be complemented by conducting health education outreach and employing peer educators from within the fisherfolk community.Relatedly, the timely dissemination of consolidated guidelines for the prevention and treatment of HIV in Uganda is vital as a reliable resource for both healthcare providers and the fisherfolk. This information can immensely contribute to informed decision-making and reinforce the importance of PEP as an integral part of the overall strategy to combat HIV/AIDS.Equally crucial is the need for equitable distribution of PEP within fisherfolk communities, especially in remote sub-island villages where health facilities are scarce. By extending PEP availability to the last mile, PEP will not only be accessible but will also be effectively utilized. This approach aligns with the overarching goal of leaving no one behind in the fight against HIV/AIDS.Bottom-line, a community that understands the importance of PEP and its role in preventing HIV transmission is more likely to embrace the treatment and integrate it into their healthcare-seeking behaviors. By fostering a sense of ownership and empowerment within the fisherfolk community, the broader goal of eradicating AIDS becomes more achievable.dbahikire1990@gmail.com.The datasets presented in this article are not readily available because date sets are restricted to the authors. Requests to access the datasets should be directed to DB conceived and designed the research study, collected data, wrote the initial draft of the manuscript, and responded to reviewers' comments. MN validated the data collection tools, supervised the study, provided guidance and general oversight during the entire course of the study, and also provided input in the review process. CA supported report compilation and performed statistical analyses. CM and LN contributed to the review of the manuscript. MB provided guidance and critically reviewed and revised the manuscript for important intellectual content. All authors contributed to the article and approved the submitted version.