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Introduction

HIV/AIDS remains a global public health issue, and young people are key target population for HIV/AIDS prevention and control.^1,2 According to the UNAIDS 2024 Global AIDS Progress Report, approximately 360,000 young people aged 15–24 years were newly infected with HIV in 2023, of whom 140,000 were aged 15–19 years.³ In China, between 2010 and 2019, a total of 141,557 HIV cases were reported among individuals aged 15–24 years, with more than 3000 new young people cases diagnosed annually.^4,5

For individuals living with HIV, lifelong HIV treatment is crucial to maintaining immune function, so keeping long-term adherence is a key determinant of treatment success.⁶ The U.S.A. National Institutes of Health (NIH) defines HIV treatment adherence as initiating ART immediately upon HIV diagnosis, maintaining regular follow-ups during treatment, and consistently adhering to prescribed ART medication regimens.⁷ However, existing studies have shown that the treatment adherence among YLWH is relatively poor. The World Health Organization (WHO) explicitly recommends immediate ART initiation upon diagnosis,⁸ while young people often experience greater delays in ART initiation than adults.^7,9 Research shows that only 57.0% of YLWH initiated ART within 30 days of diagnosis,¹⁰ and only 18.7% initiated ART within 7 days.¹¹ Furthermore, young people exhibit high rates of treatment disengagement, with a loss-to-follow-up rate of 20% to 40% within the first year, particularly during the transition from pediatric to adult HIV care.¹² Studies consistently reported that ART adherence among young people is lower than that of children and adults.^13,14 Macdonell KE et al¹⁵ found that 67% of adults achieved ≥90% medication adherence, only 21% of young people reached this threshold. Similarly, Boadu I et al¹⁶ reported that ART adherence of YLWH was approximately 66%, further emphasizing the need for targeted interventions. Therefore, it is imperative to conduct scientific, effective and comprehensive interventions to improve treatment adherence among YLWH.

The issue of treatment adherence among people living with HIV (PLHIV) persists throughout the entire treatment process, with long-term adherence remaining a major global challenge.^17,18 Implementing early intervention at the time of diagnosis could not only increase ART initiation rates but also optimize ART-related cognition of PLHIV.¹⁹ What’s more, PLHIV who received psychological intervention at diagnosis were more likely to accept antiretroviral treatment.²⁰ Campbell et al²¹ demonstrated that delivering targeted educational messages during the rapid ART initiation process, particularly at the time of diagnosis, could enhance the acceptance of ART, reduce internalized stigma, and foster long-term adherence. Similarly, Kumwenda et al²² found that healthcare workers emphasized the critical role of immediate counseling and education at the point of diagnosis ensured women’s sustained ART adherence. These findings suggest that systematic health education and adherence interventions at the time of diagnosis may facilitate timely ART initiation, improve treatment awareness, and reduce the risk of treatment discontinuation.

Therefore, it is necessary to advance the time of treatment adherence health education forward to the point of diagnosis, to reduce the time of starting treatment, improve follow-up and medication adherence, thereby helping YLWH maintain immune function and prolong survival. A structured checklist can serve as a standardized tool for healthcare professionals to deliver consistent and comprehensive health education, which may improve both the quality and effectiveness of adherence interventions. Grounded in the Protection Motivation Theory (PMT), this study developed an education checklist on treatment adherence for newly diagnosed YLWH through literature review and Delphi method, with the goal of providing scientific evidence and practical guidance for healthcare professionals in delivering adherence-focused health education to newly diagnosed YLWH.

Materials and Methods

Study Design

Firstly, this study included experts from the fields of HIV/AIDS clinical treatment, infectious disease prevention, infectious disease nursing and management, patient adherence education, epidemiology, and symptom management. Experts were invited based on their relevant professional background, practical experience, and familiarity with the subject matter. Subsequently, the preliminary draft of the expert questionnaire was developed through a literature review and an expert group discussion and then sent them to experts. Based on the results of the first round of responses from the expert panel, we revised the objectives and contents of the health education checklist and modified it to form the second round of expert questionnaires, which were sent out.²³ After that, we reached consensus and finalized the health education checklist.

Expert Selection

Purposive sampling augmented by snowball recruitment was employed to deliberately select Delphi panel members from different regions and organizations in China.²⁴ This study followed the principle of informed consent, and experts were selected from November to December 2024 based on the following inclusion and exclusion criteria: (a) bachelor’s degree or above; (b) professional title qualification of intermediate or above; (c) extensive experience in HIV/AIDS prevention and control, or HIV/AIDS research or health education; (d) work experience over 5 years. Exclusion criteria: (a) experts meeting the inclusion criteria but unable to continue participation due to limited availability, health conditions, or other personal reasons were excluded. Experts who meet the inclusion criteria were subsequently contacted via email, telephone, or text message and were provided with detailed information regarding the research objectives, content, and significance. Finally, a total of 17 experts with a high level of academic expertise in the field of HIV/AIDS agreed to participate in this Delphi study and a follow-up questionnaire was sent to them and then sent back by e-mail.

The experts came from seven provinces in China and represented different professions, including infectious disease clinicians, adherence educators, epidemiologists, nursing managers, and front-line nurses. The wide range of regions helped to show differences in health resources and access to ART, while the mix of professions brought views on clinical practice, health education, and patient support. These views were combined to revise the items and make the checklist completer and more practical for use in different settings.

Theoretical Framework

The development of the health education checklist was based on PMT, which is a behavior change theory based on individual motivation. It employs two mechanisms—threat appraisal and coping appraisal to stimulate protective motivation, ultimately promoting health behaviors.²⁵ In the context of treatment adherence among YLWH, threat appraisal includes severity, vulnerability, internal rewards, and external rewards, while coping appraisal encompasses response efficacy, self-efficacy, and response costs.²⁶ By strengthening these key elements of PMT, treatment adherence among young people can be effectively improved, fostering long-term health behavior adoption and maintenance. The theoretical framework based on PMT was presented as Figure 1.

Figure 1 The theoretical framework based on Protection Motivation Theory (PMT). This model illustrates how treatment adherence among young people living with HIV (YLWH) can be understood through two key cognitive processes: threat appraisal and coping appraisal. Threat appraisal includes severity, vulnerability, and perceived rewards (both external and internal), which influence the perception of risk. Coping appraisal includes response efficacy, self-efficacy, and response costs, which influence the individual’s confidence and perceived ability to manage HIV treatment. Arrows indicate the direction of influence, and annotated elements highlight motivational factors targeted in intervention design.

Preliminary Development of the Health Education Checklist

A systematic literature review was conducted by using databases such as Web of Science, PubMed, CINAHL, Cochrane Library, and Elsevier, China National Knowledge Infrastructure (CNKI), VIP Database, Wanfang Database. Relevant literature on HIV treatment adherence health education for YLWH was reviewed and analyzed. Based on PMT and practical experience, an initial item pool of health education checklist for the YLWH was developed. Through expert panel discussions, a preliminary face-to-face health education checklist for newly diagnosed YLWH was drafted, consisting of 5 first-level items, 12 second-level items, and 41 third-level items (Supplementary Table 1). The first-level indicators represented the core dimensions of the health education framework based on the PMT and served as the foundational structure for promoting treatment adherence among newly diagnosed YLHW. The second-level indicators were categorized and defined according to the motivational constructs embedded within each theoretical dimension. The third-level indicators are the concrete and operational items under each second-level indicator, designed to guide the development and implementation of practical health education content in clinical settings.

Questionnaire Design

The expert consultation questionnaire consisted of the following three sections: 1. Expert Information Form. 2. Health Education Checklist Consultation Form: this part was the main body of assessment in the expert questionnaire, the contents of the preliminary draft of health education checklist were shown in this section. Experts were required to evaluate the importance of each item by using a 5-point Likert scale, ranging from 1 to 5 point as “very unimportant” to “very important”. They were also required to evaluate the relevance of each item by using a 4-point Likert scale, ranging from 1 to 4 points as “not relevant at all” to “highly relevant”. In addition, this section provided suggestions and recommendations for revisions. The comment and revision section were included for each item. 3. Expert Authority Form: this section assessed the level of authority of experts, which included familiarity and judgment basis. Familiarity was assessed on a 5-point Likert scale, and the judgment basis included work experience, theoretical analysis, literature review, and direct observation. These factors were also used to calculate the authority coefficient of each expert. The checklist was designed to apply across the 15–24 years age range. Experts were instructed to consider the full developmental span during item evaluation. Items with potential age-specific implications were retained only if experts judged them appropriate for flexible application, depending on the patient’s age and cognitive ability.

Expert Consulting

The expert consultation was conducted through Email distribution and in-person delivery from December 2024 to February 2025, with a predetermined deadline for questionnaire retrieval. After the first round of consultation, items were modified or removed based on expert opinions, then leading to the development of a second-round questionnaire. Items were deleted if the mean of the importance of the item is less than 3.5 and the coefficient of variation is greater than 0.2.²⁷ The consultation ends when experts reach a consensus.

Data Analysis

Excel 2010 and SPSS 24.0 software were used for data analysis. Frequency and percentage were used to describe the personal information of experts. Experts’ concern for this study was reflected in the positive coefficient of the expert panel, ie, the rate of the return of a questionnaire.²⁸ It is generally believed that the positive coefficient above 85% indicates good feedback of the survey. The authority coefficient (Cr) of the expert was the mean value of the expert’s judgment basis (Ca) and degree of familiarity (Cs) with the research content, based on the formula Cr = (Ca+Cs)/2.²⁹ The degree of expert’s opinion dispersion was represented by the Kendall coefficient of concordance (Kendall’ W) and coefficient of variation (CV). The importance and relevance of each index was described by mean±standard deviation. P < 0.05 was considered to indicate statistical significance for the differences.

Quality Control

To ensure the results were representative and reliable, the criteria for selecting experts were strictly formulated. Zhao et al³⁰ noted that evaluations conducted by a homogeneous group of experts may be subject to bias. Therefore, this study purposefully involved experts from various research domains. Returned questionnaires were checked for completeness and clarity. Experts were contacted to confirm unclear or missing parts. Questionnaires with more than 10% of unanswered questions were excluded. All data were entered by two researchers using Excel 2010 software.

Ethical Consideration

The Delphi panel members were informed in the invitation Email and accompanying material that they were free to withdraw at any point. Consent to participate was implied by response to the expression of interest and subsequent return of questionnaires. This study was approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University (Approval No. KY2024067).

Results

Expert Sociodemographic Information

The present research enrolled panel of 17 experts from 7 provinces and cities including Beijing, Shanghai, Sichuan, Shandong, Jilin, Hebei, Hunan in China. The experts specialized in HIV/AIDS clinical treatment, infectious disease prevention, infectious disease nursing and management, patient adherence education, epidemiology, and symptom management. The average age of the experts was 41.76 (SD 6.12) years old, and their average working experience was 15.29 (SD 7.83) years. Seven experts (41.18%) hold a doctoral degree, five experts (29.41%) were with master’s degree, and five experts (29.41%) have bachelor’s degree (Table 1).

Table 1 The Socio-Demographic Information of the Experts

Enthusiasm and Authority Coefficient of Experts

Expert enthusiasm is reflected in the questionnaire response rate, which is generally considered high when it exceeds 70%.³¹ In the first round, all 17 distributed questionnaires were returned with valid responses, yielding a 100% response rate, and 9 experts (52.94%) provided suggestions for revision. In the second round, 17 questionnaires were distributed, and 16 valid responses were received, yielding a 94.12% response rate, and 3 experts (18.75%) provided suggestions for revision (Table 2). An authority coefficient (Cr) >0.70 is commonly regarded as a threshold for expert reliability.³² In this study, the authority coefficient (Cr) of two rounds were 0.867 and 0.905, indicating a high level of expert authority in this study.

Table 2 Positive Coefficient of Experts

Degree of Concentration and Coordination of Experts’ Opinions

In the first round of consultation, the importance scores of all items ranged from 3.59 to 5.00, while the relevance scores of all items ranged from 3.00 to 3.94, with a full mark rate of 34.08% to 100%. The coefficient of variation (CV) was less than 0.25, except for three indexes were 0.255, 0.297 and 0.318. The Kendall’s W was 0.621 (χ²= 854.749, P < 0.001). In the second round of consultation, the importance scores of all items ranged from 4.56 to 5.00, while the relevance scores of all items ranged from 3.56 to 3.94, with a full mark rate of 39.84% to 100%. The coefficient of variation (CV) was less than 0.25. The Kendall’s W was 0.716 (χ²= 721.970, P < 0.001) (Table 3).

Table 3 The Health Education Checklist for YLWH Based on the PMT (Second-Round)

The Formation Process of the Health Education Checklist

In this study, two rounds of consultation were conducted. According to the indicator screening criteria, expert opinions, and discussion of the research team, the indicators were adjusted until a consensus is reached.

In the first round of consultation, the experts did not make any comments on the first-level and second-level indicators, so they were all retained. However, a total of 61 expert comments on the third-level indicators were collected in this round, which were consolidated into 31 revision suggestions, 10 supplementary recommendations, and 6 deletion suggestions after merging identical feedback. The revision suggestions primarily focused on content enhancement, including refining HIV-related knowledge, detailing treatment adherence management, supplementing information on the side effects of ART and corresponding coping strategies, elaborating on the consequences of poor adherence, adding auxiliary examinations related to treatment, and optimizing safe sexual behavior management and adherence skills training. The supplementary recommendations included reinforcing treatment adherence education, incorporating high-risk behaviors assessments and successful adherence case studies. In the mental health management section, experts suggested adding emotion regulation strategies and psychological crisis interventions. In the social support section, experts proposed introducing guardian supervision mechanisms and optimizing guidance strategies for HIV disclosure. In the daily management section, experts recommended improving access to medications, adjusting lifestyle habits, and identifying barriers to treatment adherence. Based on the suggestions of the experts, the contents of health education checklist were supplemented considering the characteristics of YLWH, and the second round of questionnaire was developed.

In the second round of consultation, experts had relatively unified opinions on each indicator, so only a total of 11 expert comments were received in this round, which were consolidated into 2 revision suggestions and 6 supplementary recommendations. The revision suggestions included relocating the section on techniques and methods for maintaining treatment adherence among PLHIV to Section 3.1: Strengthening Self-Management; and moving the policies on the rights and privacy protection of PLHIV to Section 5.1: Lower the barriers and costs associated with adherence to treatment.³² Following group discussions, the research team incorporated expert feedback and an expert consensus on health education checklist for newly diagnosed YLWH was finally reached. The content system included 5 first-level items, 10 second-level items, and 32 third-level items as shown in Table 3.

After the first Delphi round, 26 items were retained, 6 items were modified through merging or refinement based on expert suggestions, and 9 items were deleted because of low scores, redundancy, or lack of consensus. In the second round, no further changes were made, and the process mainly served to confirm expert agreement on the final 32-item checklist.

Discussion

Content Analysis of the Health Education Checklist

HIV treatment adherence is not a simple concept and was influenced by a range of cognitive, behavioral and age-related determinants. This study developed a structured and context-specific checklist comprising 32 items across five domains—perceived threat, response efficacy, self-efficacy, perceived rewards, and response cost grounded in PMT—to guide healthcare professionals in promoting adherence among newly diagnosed YLWH.

Enhance YLWH’s Initiative and Active Engagement

Health education is one of the effective approaches to promoting patient health recovery through multidimensional interventions such as systematic knowledge dissemination, health behavior shaping, and collaborative patient-provider management, serves to prevent disease onset and progression.^33–35 PMT is founded on the Health Belief Model³⁶ and emphasizes cognitive regulatory processes, offering a more effective framework than traditional health education for explaining, predicting, and intervening in various health behaviors.³⁷ Interventions based on PMT focus on enhancing patients’ initiative and self-motivation, encouraging them to actively adopt and sustain positive health behaviors. The health education checklist developed in this study was closely aligned with the core variables of PMT. Through threat appraisal and coping appraisal, the checklist provides in-person, face-to-face health education for YLWH, reinforcing their awareness of susceptibility to and severity of HIV and ART-related knowledge while improving their self-efficacy and coping abilities.³⁸ Additionally, by leveraging internal and external regulatory factors alongside continuous support, the checklist stimulates patients’ self-motivation, enhances their protective motivation, and encourages proactive engagement in health management, ultimately fostering long-term health behaviors.³⁹ The health education checklist for YLWH employs structured and goal-oriented educational activities to cultivate health beliefs, enhance adherence to ART, and ultimately improve the quality of healthcare services. Furthermore, it plays a positive role in safeguarding public health security. Therefore, this study’s PMT-based health education checklist could provide a valuable reference for healthcare providers in conducting health guidance, thereby optimizing health education outcomes and enhancing treatment effectiveness.

Emphasize Specialization and Target Precision

Health education for YLWH is becoming increasingly diverse. However, a common issue is the failure to adequately address both internal and external factors influencing YLWH, leading to a disconnect between acquired knowledge and actual behaviors among this key population,⁴⁰ ultimately reducing the effectiveness of health education interventions. Similarly, international studies have highlighted that existing health education programs for YLWH often lack personalization and fail to adequately cater to the diverse needs of young people in different socio-cultural backgrounds.⁴⁰ Furthermore, most current health education programs prioritize short-term knowledge dissemination while neglecting long-term behavioral monitoring, which affects the sustainability of ART adherence improvements.⁴¹ To address these issues, this study conducted a comprehensive analysis of how YLWH interacts with the core variables of PMT and developed a tailored health education checklist with strong target specificity and applicability. This study explicitly defined the dissemination of fundamental HIV/AIDS knowledge, emphasized the importance of ART adherence, and included policies related to treatment, management of medication side effects, adherence strategies, and drug resistance prevention. It also strengthened patients’ belief in ART adherence by demonstrating the benefits of treatment, the consequences of non-adherence, and promoting the U=U concept. Moreover, the checklist enhances patients’ self-management skills, such as regular viral load monitoring, medication reminders, and access to treatment resources. It further mitigated the reinforcement effects of non-adherence by highlighting the long-term consequences of poor treatment adherence and providing psychological and social support strategies. Additionally, it reduces the perceived costs of adherence by helping patients overcome treatment barriers, alleviating HIV-related stigma, and optimizing daily life management. These components underscore the checklist’s comprehensiveness and high degree of targeting, making it a specialized and effective intervention reference for improving ART adherence among YLWH.

Reliability and Credibility of the Health Education Checklist

The health education checklist for healthcare professionals to ensure treatment adherence of newly diagnosed YLWH constructed in this study was scientific, comprehensive and diversified with the following characteristics. Firstly, the development of this health education checklist was theory-driven based on PMT—a well-established and widely used theory. In addition, the initial content of the checklist was informed by an extensive review of literature focusing on treatment adherence among YLWH, which ensured a strong theoretical and empirical foundation for the index system. Secondly, the checklist was reliable and authoritative due to the participation of qualified experts in the field. A total of 17 experts were invited from tertiary-level hospitals and universities across seven provinces and municipalities in China. Among them, five experts had over 20 years of experience, and eight had over 15 years of professional experience. This ensured a high level of expertise and reduced regional bias. Thirdly, the expert group had a high academic and professional profile. Seven experts held doctoral degrees, five held master’s degrees, and eleven held intermediate certificate or associate senior position titles. Their areas of specialization covered infectious disease research, HIV medical care, HIV nursing, psychological care, and public health, allowing for diverse and targeted feedback across multiple relevant domains. This helped enhance the relevance, comprehensiveness, and applicability of the checklist. Fourthly, the consultation process demonstrated a high level of engagement and consistency. The two rounds of Delphi consultation achieved effective response rates of 100% and 94.12%, respectively. In the first and second rounds, 52.94% and 18.75% of the experts provided constructive textual suggestions, reflecting their strong engagement with the research. Fifthly, the reliability of the checklist was supported by quantitative indicators. The authority coefficients of the two consultation rounds were 0.867 and 0.905, indicating high reliability and credibility of the expert input.²² The Kendall’s concordance coefficient of two rounds of consultation were 0.621 and 0.716, both statistically significant (P < 0.001), suggesting strong consistency and agreement among experts.⁴² Therefore, this health education checklist was well-founded, reliable, and scientifically robust, provided practical guidance for improving ART adherence in clinical settings.

Limitations

This study has some limitations. First, our panel did not include pediatricians or specialists in child psychology and psychiatry, though the clinicians and public health experts involved had long experience with young people living with HIV. Similar Delphi studies also showed that missing some specialists did not prevent key items from being judged appropriate. Second, the study focused on young people aged 15–24 years, a group often treated as one in HIV research. We recognize differences within this range, so the checklist allows flexible use for different ages. Third, although we reduced bias by selecting experts from various fields and calculating authority coefficients, some subjectivity may remain. Future studies should involve more experts and further validation.

Conclusion

Based on the Protection Motivation Theory, this study constructed a scientific and operational health education checklist for newly diagnosed YLWH through literature review, expert group discussion and Delphi method. This checklist provided healthcare providers with a clear and concise practical guidance to help improve adherence to antiretroviral treatment among newly diagnosed YLWH. Further empirical studies could be conducted to evaluate its practical effectiveness, applicability, and feasibility in real-world healthcare settings.

Abbreviations

HIV, Human Immunodeficiency Virus; AIDS, Acquired Immune Deficiency Syndrome; ART, Antiretroviral therapy; PMT, Protection Motivation Theory; YLWH, Young people living with HIV; PLHIV, People living with HIV; Kendall’s W, Kendall’s coefficient of concordance; CV, Coefficient of variation; SD, Standard deviation; AR, Approval rate.

Data Sharing Statement

The datasets generated and analyzed in this study are not publicly available due to the principle of confidentiality. They are available from the corresponding author upon reasonable request.

Ethics Approval and Consent to Participate

The study obtained the consent of the ethics committee of affiliated hospital of southwest medical university (Number: ky2024067), and verbal consent was obtained from each participant.

Funding

This research was supported by the National Natural Science Foundation of China (82304256).

Disclosure

The authors declare that they have no competing interests in this work.

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Patients with eosinophilic esophagitis (EoE) often describe the condition as painful, disruptive and frightening. The rare chronic disease causes inflammation of the esophagus, leading to abdominal pain, difficulty swallowing, vomiting and, in some cases, food getting stuck in the throat.

Now, a University of Cincinnati College of Medicine researcher has received new funding to expand her investigations into the underlying causes of EoE and potential new treatments.

Simin Zhang, MD, an allergist and research assistant professor in the Division of Rheumatology, Allergy and Immunology in the Department of Internal Medicine, has been awarded a three-year, $300,000 grant from the American Academy of Allergy, Asthma & Immunology. Her research focuses on the roles of mast cells – or allergic immune cells – and their interactions with fibroblasts, the structural cells which can both repair and damage tissue.

Mast cells are a key part of the allergic immune response, but we don’t fully understand their role in eosinophilic esophagitis. We are investigating how mast cells interact with fibroblasts in the esophagus and whether interrupting that interaction could prevent inflammation and tissue damage.”

Simin Zhang, MD, allergist and research assistant professor, Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, University of Cincinnati 

Understanding a complex disease

The esophagus is the muscular tube that carries food from the mouth to the stomach. In EoE, unusually high numbers of white blood cells called eosinophils build up in the esophageal tissue, causing irritation and injury. Over time, this can result in scarring and narrowing of the esophagus, a condition known as stricturing, which can make eating painful and increase the risk of food becoming lodged, sometimes requiring endoscopic removal or dilation of the esophagus.

Unlike some food allergies that trigger immediate, life-threatening anaphylaxis, EoE causes a slower, more prolonged immune response. Many patients with EoE also live with other allergic conditions such as anaphylactic food allergies, asthma, hay fever and eczema. Physicians often describe this pattern as part of the “atopic march” in which allergic diseases emerge and overlap throughout a patient’s life.

While the exact cause of EoE remains unknown, having a personal or family history of allergies appears to raise the risk. The condition affects both children and adults, often requiring lifelong management.

A collaborative approach

In addition to her role at UC, Zhang holds a dual appointment at Cincinnati Children’s Hospital Medical Center, where she conducts research and provides clinical care through the Cincinnati Center for Eosinophilic Disorders (CCED), a facility that is internationally recognized for advancing both treatment and research for EoE and related conditions.

Zhang’s work bridges laboratory discovery and patient care. “Our research has the potential to identify new ways of treating a disease that affects quality of life for both children and adults,” she said.

She added that she is motivated by the challenges her patients face every day. “Many people with EoE struggle just to eat a meal without fear,” said Zhang. “Our goal is to uncover the mechanisms driving the disease and ultimately improve therapies so that patients can live more comfortably.”

KINSHASA, Congo — The number of suspected Ebola cases in Congo’s southern Kasai province have more than doubled in a week since a new outbreak was confirmed there, Africa’s top public health agency said Thursday.

The suspected cases have increased from 28 to 68 in recent days, the Africa Centers for Disease Control and Prevention said at an online briefing. It has also spread from to two to four districts while the death toll currently stands at 16.

Local residents expressed concerns on Thursday over the outbreak, the first in Congo in three years and the province’s first in more than a decade.

The fighting in eastern Congo has complicated efforts to contain the disease, which can spread rapidly due to the proximity and density of villages and provinces, Dr. Ngashi Ngongo, a principal advisor with Africa CDC, said at the briefing.

“It was two (districts), now it is four,” Ngongo said.

The outbreak was announced a week ago after a pregnant woman was confirmed to have been infected in the locality of Boulapé.

The World Health Organization sent experts alongside Congo’s Rapid Response Team to Kasai to strengthen disease surveillance, offer treatment and monitor infection preventions and controls.

The Central African country has a history of Ebola since 1976. The latest outbreak is the 16th in the country and the 7th in the Kasai province. A previous outbreak between 2018 and 2020 in eastern Congo killed more than 1,000 people.

Local authorities in Kasai are trying to contain the outbreak. Public movements have been curtailed and checkpoints have been set up at the main entrances to Tshikapa, the capital of the province, authorities said.

Emmanuel Kalonji, 37, a resident of Tshikapa, told The Associated Press that some people had fled the villages before returning. “However, given the limited resources, survival is not guaranteed,” said Kalonji.

In Boulapé, people are concerned about the impact on their living conditions, said Ethienne Makashi, the local official in charge of water, hygiene and sanitation.

“However, we do have one case showing good progress, which gives a glimmer of hope for those receiving care,” said Makashi.

—-

Adetayo reported from Lagos, Nigeria

Dr. Rhonda Patrick, a prominent researcher with a Ph.D. in Biomedical Science from the University of Tennessee, recently appeared on The Diary of a CEO, the popular business podcast hosted by British entrepreneur Steven Bartlett. During the interview, Patrick championed what’s known as the “Norwegian 4×4 protocol” as the most effective exercise method for reversing age-related damage to the cardiovascular system.

The science behind Dr. Patrick’s claims

Patrick, who completed her postdoctoral fellowship at Children’s Hospital Oakland Research Institute and currently serves as founder of FoundMyFitness, has built her reputation on translating complex scientific research into actionable health insights. Her academic credentials include published research in journals such as Nature Cell Biology and FASEB Journal, with extensive work on aging, nutrition, and disease prevention.

The Norwegian 4×4 protocol, developed by researchers at the Norwegian University of Science and Technology (NTNU), involves four rounds of four-minute high-intensity intervals followed by three-minute recovery periods. Patrick described the routine as sustainable intensity exercise where “you’re not really having a conversation while you’re doing it,” but it’s “far from all-out” effort.

The exercise can be performed on various equipment including stationary bikes, rowing machines, or assault bikes, with participants maintaining approximately 75-80% of their maximum heart rate during the active intervals. The total workout, including warm-up and cool-down, takes roughly 30-40 minutes and needs to be performed only once or twice per week.

The protocol’s effectiveness stems from landmark research published in Circulation, one of the world’s leading cardiovascular journals. The study, led by Dr. Benjamin Levine at UT Southwestern Medical Center, followed 61 healthy but sedentary middle-aged adults (average age 53) for two years.

Participants who followed a structured exercise program that included the Norwegian 4×4 protocol once weekly showed remarkable improvements: an 18% increase in maximum oxygen uptake (VO2 max) and a more than 25% improvement in left ventricular compliance, effectively reversing structural heart changes by approximately 20 years.

“As we age, our hearts get smaller and stiffer,” Patrick said during her Diary of a CEO interview. “After those two years of 5 to 6 hours of physical exercise every single week, their hearts looked 20 years younger in terms of structure.”

Central to the protocol’s anti-aging effects is its impact on VO2 max, the maximum amount of oxygen your body can utilize during exercise. Research consistently shows VO2 max as one of the strongest predictors of longevity and cardiovascular health.

A major study published in JAMA involving over 122,000 participants found individuals with the lowest VO2 max values had a fourfold increased risk of mortality compared to those with the highest values. Simply moving from the bottom 25th percentile to the 25th-50th percentile was associated with a 50% reduction in all-cause mortality.

Performing the exercise safely

Patrick emphasized the Norweigan 4×4 protocol requires progressive implementation. “It’s not easy, you can’t just start doing it right out the gate,” she said. “You want to kind of work your way up to that… work your way up as you do it one week, two weeks, you know, a month later, two months later.”

For business professionals seeking efficient health optimization, the Norwegian 4×4 protocol offers significant advantages. Its time-efficient nature, requiring less than an hour total including warm-up and cool-down, makes it practical for busy schedules while delivering outsized returns on investment in terms of cardiovascular health and longevity. And the research suggests this minimal time commitment could provide protection against heart failure, particularly the type known as heart failure with preserved ejection fraction, which becomes increasingly common with age and sedentary lifestyle.

You can watch Dr. Patrick’s full interview below.

For this story, Fortune used generative AI to help with an initial draft. An editor verified the accuracy of the information before publishing.

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An investigational prescription digital therapeutic demonstrated in a phase 3 trial that it could reduce the negative symptoms of schizophrenia.

In the trial, CT-155, which is being developed by Boehringer Ingelheim and Click Therapeutics, is being used as an adjunct to standard-of-care antipsychotic therapy in people diagnosed and living with schizophrenia experiencing negative symptoms.

An estimated 24 million worldwide have schizophrenia, according to the World Health Organization. People with schizophrenia have persistent delusions and hallucinations. Up to 60% of people with schizophrenia have negative symptoms, which include an inability to feel pleasure, having a flat affect or other speech problems and often lacking motivation.

Current medications, however, are not approved to treat the negative symptoms, which lead to impairment in day-to-day functioning. CT-155 is a smartphone app developed by Click Therapeutics that aims to address the behavioral dimensions of conditions such as schizophrenia. It uses AI-based technology to engage patients and help them manage their symptoms. CT-155 was granted breakthrough device designation in January 2024.

“Although treatments are being used to help manage negative symptoms, there are no U.S. regulatory authority-approved treatments indicated for the negative symptoms of schizophrenia to date. This is one of the largest unmet needs for these patients and those who care for them,” Emmanuelle Clerisme-Beaty, M.D., medical director of US and senior vice president of medicine at Boehringer Ingelheim Pharmaceuticals, said in a news release.

In the CONVOKE study, CT-155 along with standard of care was compared with a digital control app as an adjunct to standard of care antipsychotic therapy to assess safety and efficacy. The trial enrolled 464 patients who were stable on antipsychotic medications.

CT-155 was well tolerated and demonstrated a favorable safety profile consistent with past studies. It met the primary endpoint of change in experiential negative symptoms from baseline to week 16 as measured by the Clinical Assessment Interview for Negative Symptoms, Motivation and Pleasure Scale. This scale is a semi-structured interview given by clinicians to assess motivation and pleasure in patients with schizophrenia. It has been demonstrated to be a reliable and valid rating scale for assessing negative symptoms.

Detailed results will be presented during the Novel Therapeutics Symposium on Monday, Oct. 13, 2025, at the 38th Annual European College of Neuropsychopharmacology (ECNP) Congress being held in Amsterdam, The Netherlands.

Click and Boehringer Ingelheim have worked together since 2020, when they first announced a worldwide collaboration around a potential therapy for schizophrenia. In late 2022, the companies announced an expansion of the partnership, agreeing to collaborate on a second schizophrenia therapy.

Click Therapeutics has received marketing authorization for several other prescription digital products.Earlier this year, Click received marketing authorization and has launched Rejoyn (formerly CT-152), used as an adjunct to the use of antidepressants, for patients with major depressive disorder. Rejoyn, available by prescription, is a six-week treatment program designed to help enhance cognitive control of emotion through cognitive emotional training exercises for the brain and brief therapeutic lessons. Rejoyn costs $200 for the full six weeks.

The company has also received marketing authorization for CT-132, the first digital therapeutic for the preventive treatment of episodic migraine in the United States, alongsideacute and/or other preventive treatments. The company has received marketing authorization for AspyreRx, which aims to aid behavioral change in patients with Type 2 diabetes. However, both these products have not yet launched.