HIV status disclosure, facility-based delivery and postpartum retention of mothers in a prevention clinical trial in rural Nigeria.

Background: Within the context of a cluster randomized prevention of mother-to-child HIV transmission (PMTCT) trial, we evaluated the impact of disclosure on selected PMTCT continuum of care measures. Methods: In 12 rural matched-pair clinics randomly assigned to an intervention package versus standard-of-care, we enrolled 372 HIV-infected pregnant women from April 2013 to March 2014. This secondary analysis included 327 (87.9%) women with unknown HIV status or who were treatment naïve at presentation to antenatal care. We employed mixed effects logistic regression to estimate impact of disclosure on facility delivery and postpartum retention in HIV care at 6 and 12 weeks. Results: Fully 86.5% (283/327) of women disclosed their HIV status to their partner, more in the trial intervention arm (OR 3.17, 95% CI 1.39-7.23). Adjusting for intervention arm, maternal age, education and employment, women who disclosed were more likely to deliver at a health facility (OR 2.73, 95%CI 1.11-6.72). Participants who disclosed also had a trend towards being retained in care at 6 and 12 weeks' postpartum (OR 2.72, 95% CI 0.79-9.41 and 2.46, 95% CI 0.70-8.63, respectively). Conclusions: HIV status disclosure at 6 weeks' postpartum was positively associated with facility-based delivery, but not with early postpartum retention. Facilitating HIV status disclosure to partners can increase utilization of facility obstetric services.

Nonacademic Attributes Predict Medical and Nursing Student Intentions to Emigrate or to Work Rurally: An Eight-Country Survey in Asia and Africa.

AbstractWe sought to identify independent, nonacademic predictors of medical and nursing student intent to migrate abroad or from rural to urban areas after graduation in low- and middle-income countries (LMIC). This was a cross-sectional survey of 3,199 first- and final-year medical and nursing students at 16 training institutions in eight LMIC. Questionnaires assessed demographics, career intentions, and preferences regarding selected career, location, and work-related attributes. Using principal component analysis, student preferences were reduced into four discrete categories of priorities: 1) work environment resources, 2) location livability, 3) altruistic job values, and 4) individualistic job values. Students' preferences were scored in each category. Using students' characteristics and priority scores, multivariable proportional odds models were used to derive independent predictors of intentions to emigrate for work outside the country, or to work in a rural area in their native country. Students prioritizing individualistic values more often planned international careers (adjusted odds ratio [aOR] = 1.44, 95% confidence interval [CI] = 1.16-1.78), whereas those prioritizing altruistic values preferred rural careers (aOR = 1.82, 95% CI = 1.50-2.21). Trainees prioritizing high-resource environments preferentially planned careers abroad (aOR = 1.38, 95% CI = 1.12-1.69) and were unlikely to seek rural work (aOR = 0.60, 95% CI = 0.49-0.73). Independent of their priorities, students with prolonged prior rural residence were unlikely to plan emigration (aOR = 0.67, 95% CI = 0.50-0.90) and were more likely to plan a rural career (aOR = 1.53, 95% CI = 1.16-2.03). We conclude that use of nonacademic attributes in medical and nursing admissions processes would likely increase retention in high-need rural areas and reduce emigration "brain drain" in LMIC.

Comprehensiveness of HIV care provided at global HIV treatment sites in the IeDEA consortium: 2009 and 2014.

INTRODUCTION: An important determinant of the effectiveness of HIV treatment programs is the capacity of sites to implement recommended services and identify systematic changes needed to ensure that invested resources translate into improved patient outcomes. We conducted a survey in 2014 of HIV care and treatment sites in the seven regions of the International epidemiologic Database to Evaluate AIDS (IeDEA) Consortium to evaluate facility characteristics, HIV prevention, care and treatment services provided, laboratory capacity, and trends in the comprehensiveness of care compared to data obtained in the 2009 baseline survey. METHODS: Clinical staff from 262 treatment sites in 45 countries in IeDEA completed a site survey from September 2014 to January 2015, including Asia-Pacific with Australia (n = 50), Latin America and the Caribbean (n = 11), North America (n = 45), Central Africa (n = 17), East Africa (n = 36), Southern Africa (n = 87), and West Africa (n = 16). For the 55 sites with complete data from both the 2009 and 2014 survey, we evaluated change in comprehensiveness of care. RESULTS: The majority of the 262 sites (61%) offered seven essential services (ART adherence, nutritional support, PMTCT, CD4+ cell count testing, tuberculosis screening, HIV prevention, and outreach). Sites that were publicly funded (64%), cared for adults and children (68%), low or middle Human Development Index (HDI) rank (68%, 68%), and received PEPFAR support (71%) were most often fully comprehensive. CD4+ cell count testing was universally available (98%) but only 62% of clinics offered it onsite. Approximately two-thirds (69%) of sites reported routine viral load testing (44-100%), with 39% having it onsite. Laboratory capacity to monitor antiretroviral-related toxicity and diagnose opportunistic infections varied widely by testing modality and region. In the subgroup of 55 sites with two surveys, comprehensiveness of services provided significantly increased across all regions from 2009 to 2014 (5.7 to 6.5, p < 0.001). CONCLUSION: The availability of viral load monitoring remains suboptimal and should be a focus for site capacity, particularly in East and Southern Africa, where the majority of those initiating on ART reside. However, the comprehensiveness of care provided increased over the past 5 years and was related to type of funding received (publicly funded and PEPFAR supported).

Low implementation of Xpert MTB/RIF among HIV/TB co-infected adults in the International epidemiologic Databases to Evaluate AIDS (IeDEA) program.

OBJECTIVE: Xpert MTB/RIF is recommended by the World Health Organization (WHO) as the initial tuberculosis (TB) diagnostic test in individuals suspected of HIV-associated TB. We sought to evaluate field implementation of Xpert among a cohort of HIV/TB co-infected individuals, including availability, utilization and outcomes. DESIGN: Observational cohort study (patient-level data) and cross-sectional study (site-level Xpert availability data). METHODS: Data were collected at 30 participating International epidemiologic Databases to Evaluate AIDS (IeDEA) sites in 18 countries from January 2012-January 2016. All patients were HIV-infected and diagnosed with TB, either bacteriologically or clinically, and followed until a determination of TB treatment outcome. We used multivariable modified Poisson regression to estimate adjusted relative risk (RR) and 95% confidence intervals for unfavorable TB treatment outcomes. RESULTS: Most sites (63%) had access to Xpert, either in the clinic (13%), in the same facility (20%) or offsite (30%). Among 2722 HIV/TB patients included, median age was 35.4 years and 41% were female; BMI and CD4 count were low. Overall, most patients (76%) received at least one TB test; 45% were positive. Only 4% of all patients were tested using Xpert: 64% were Xpert-positive, 13% showed rifampicin (RIF) resistance and 30% were extrapulmonary (EPTB) or both pulmonary-EPTB. Treatment outcomes were mostly favorable (77%) and we found little association between Xpert use and an unfavorable TB treatment outcome (RR 1.25, 95%CI: 0.83, 1.90). CONCLUSIONS: In this cohort, Xpert utilization was low even though the majority of sites had access to the test. Our findings show the need for expanded implementation and further research exploring barriers to use in low-resource settings.

Understanding intra-vaginal and labia minora elongation practices among women heads-of-households in Zambézia Province, Mozambique.

Intra-vaginal drying and tightening and labia minora elongation are commonly practised in some parts of southern Africa. We sought to capture data on these practices among women living in Zambézia province, Mozambique. Information was gathered from 3543 female heads of household on > 500 variables, including vaginal practices, in 2014. Women who planned to use intra-vaginal tightening substances had 1.84 times higher odds of ever receiving an HIV test (p < 0.001) and 1.40 times higher odds of at least one antenatal care visit attended during last pregnancy (p = 0.015). Women who had or planned to undergo labia minora elongation had 2.61 times higher odds of receiving an HIV test in the past (p < 0.001) and 1.60 times higher odds of attending at least one antenatal care visit during their last pregnancy (p < 0.001). There was little evidence for a relationship between self-reported HIV status and anticipated use of intra-vaginal tightening substances (p = 0.21). Current or anticipated participation in labia elongation showed a protective effect on HIV infection (p = 0.028). Given documented associations between intra-vaginal substance use, vaginal infections and HIV acquisition, understanding the prevalence of vaginal practices is an essential component to addressing the epidemic.

Predictors of Health-Care Utilization Among Children 6-59 Months of Age in Zambézia Province, Mozambique.

Globally, approximately 5.9 million children under 5 years of age died in 2015, a reduction of over 50% since 1990. Millennium Development Goal 4 established the goal of reducing child mortality by two-thirds by 2015. Multiple countries have surpassed this goal; however, regional and within-country inequities exist. We sought to study determinants of health-care utilization among children 6-59 months of age with fever, diarrhea, and respiratory symptoms in Zambézia Province, Mozambique. We conducted a population-based cross-sectional survey of female heads of household between April and May 2014. Mobile teams conducted interviews in 262 enumeration areas, with three distinct districts being oversampled for improved precision. Descriptive statistics and logistic regression using Stata 13.1 and R 3.2.2 were used to examine factors associated with health-care utilization. A total of 2,317 children were evaluated in this study. Mothers' median age was 26 years, whereas child median age was 24 months. The proportion of children reporting fever, diarrhea, or respiratory illness in the prior 30 days was 44%, 22%, and 22%, respectively. Health-care utilization varied with 65% seeking health care for fever, compared with 57% for diarrhea and 25% for respiratory illness. In multivariable logistic regression, the characteristics most associated with health-care utilization across illnesses were delivery of last child at a facility, higher maternal education, and household ownership of a radio. The decision or ability to use health care is a multifaceted behavior swayed by societal norms, values, socioeconomics, and perceived need. Recognizing the predictors of a particular population may offer useful information to increase uptake in health-care services.

Occupational hazards of traditional healers: repeated unprotected blood exposures risk infectious disease transmission.

OBJECTIVE: Healers provide support for acute and chronic illnesses in rural Mozambique, such as socially acceptable traditional 'vaccinations' (subcutaneous cuts in the skin to rub herbs directly into the bloody lesion). We aimed to document the frequency of blood exposure by traditional practitioners in Mozambique. METHODS: We conducted surveys with a simple random sample of 236 traditional healers in Zambézia province. Chi-square and Wilcoxon rank-sum tests were used to compare 'injection' behaviours across districts. RESULTS: Healers treated a median of eight patients in the past month (IQR: 4-15). About 75% conducted 'injections'. These healers 'injected' a median of four patients (IQR: 1-8), used a new razor a median of three times (IQR: 1-8), and almost never used gloves. Lifetime blood exposures among those who provided 'injections' during treatments were estimated to be 1758 over a healer's career. CONCLUSION: The majority of healers are exposed repeatedly to patient blood. Given the high prevalence of HIV, hepatitis B and C virus, and other blood-borne agents, specific healer practices are an occupational hazard and reuse of razors is risky for their clients.

Patient and Provider Satisfaction With a Comprehensive Strategy to Improve Prevention of Mother-to-Child HIV Transmission Services in Rural Nigeria.

BACKGROUND: High mother-to-child HIV transmission rates in Nigeria are coupled with a critical shortage of trained health personnel, dearth of infrastructure, and low levels of male involvement in HIV care. This study evaluated maternal and provider satisfaction with services for prevention of mother-to-child transmission within the context of an implementation science cluster-randomized trial that included task shifting to lower-cadre workers, male engagement, point-of-care CD4 cell counts, and integrated mother-infant care. METHODS: Patient and clinician satisfaction were measured at 6 control and 6 intervention sites using a 5-point Likert scale. Patient satisfaction was assessed at 6 weeks postpartum through a 22-item scale about the provider's ability to explain the health problem, time spent with the clinician, and motivation to follow prescribed treatment. Provider satisfaction was assessed through a 12-item scale about motivation, compensation, and training, with 4 additional questions about the impact of task shifting on job satisfaction to intervention arm providers. RESULTS: We measured satisfaction among 340 mothers (intervention n = 160; control n = 180) and 60 providers (intervention n = 36; control n = 24). Total patient satisfaction (maximum 5) was higher in the intervention than control arm [median (interquartile range) = 4.61 (4.22-4.79) vs. 3.84 (3.22-4.22), respectively; P < 0.001]. Provider satisfaction was generally high, and was similar between the intervention and the control arms [median (interquartile range) = 3.60 (3.37-3.91) vs. 3.50 (3.08-4.25), respectively; P = 0.69]. Provider satisfaction dropped when questions on newly acquired provider roles were included [3.47 (3.25-3.72)]. Patient and provider satisfaction were not associated with uptake of antiretroviral therapy or mother-infant retention at 6 and 12 weeks postpartum. CONCLUSIONS: Satisfaction was higher among patients at intervention sites, and provider satisfaction decreased when newly assigned roles were factored in. Task shifting should include training and supportive oversight to ensure comfort with assigned tasks.

Implementation of Tuberculosis Intensive Case Finding, Isoniazid Preventive Therapy, and Infection Control ("Three I's") and HIV-Tuberculosis Service Integration in Lower Income Countries.

SETTING: World Health Organization advocates for integration of HIV-tuberculosis (TB) services and recommends intensive case finding (ICF), isoniazid preventive therapy (IPT), and infection control ("Three I's") for TB prevention and control among persons living with HIV. OBJECTIVE: To assess the implementation of the "Three I's" of TB-control at HIV treatment sites in lower income countries. DESIGN: Survey conducted between March-July, 2012 at 47 sites in 26 countries: 6 (13%) Asia Pacific, 7 (15%), Caribbean, Central and South America, 5 (10%) Central Africa, 8 (17%) East Africa, 14 (30%) Southern Africa, and 7 (15%) West Africa. RESULTS: ICF using symptom-based screening was performed at 38% of sites; 45% of sites used symptom-screening plus additional diagnostics. IPT at enrollment or ART initiation was implemented in only 17% of sites, with 9% of sites providing IPT to tuberculin-skin-test positive patients. Infection control measures varied: 62% of sites separated smear-positive patients, and healthcare workers used masks at 57% of sites. Only 12 (26%) sites integrated HIV-TB services. Integration was not associated with implementation of TB prevention measures except for IPT provision at enrollment (42% integrated vs. 9% non-integrated; p = 0.03). CONCLUSIONS: Implementation of TB screening, IPT provision, and infection control measures was low and variable across regional HIV treatment sites, regardless of integration status.

Factors associated with the use of mosquito bed nets: results from two cross-sectional household surveys in Zambézia Province, Mozambique.

BACKGROUND: Malaria remains a major threat to some 3.2 billion persons globally. Malaria contributes heavily to the overall disease burden in Mozambique and is considered endemic. A cornerstone of Mozambique's vector control strategy has been to strive for universal coverage of insecticide-treated nets (ITN). METHODS: The study is a population-based cross-sectional survey of female heads-of-household in Zambézia Province, Mozambique conducted during August-September, 2010 and April-May, 2014. Analyses accounted for a stratified two-stage cluster sample design. Outcomes of interest included sleeping under a mosquito net during the previous night. Descriptive statistics were calculated for three oversampled districts and for the entire province. Multivariable logistic regression analysis was used to estimate factors associated with both changes over time and increased mosquito bed net usage. RESULTS: Of the 3916 households interviewed in 2010 and 3906 households in 2014, 64.3% were in possession of at least one mosquito bed net. A higher proportion of households in Namacurra (90%) reported possession of a mosquito net, compared to Alto Molócuè (77%) and Morrumbala (34%), respectively in 2014. Of pregnant respondents, 58.6% reported sleeping under a mosquito net the previous night in 2010 compared to 68.4% in 2014. Fifty percent of children 0-59 months slept under a mosquito net the previous night in 2010 compared to 60% in 2014. Factors associated with use of a mosquito net for female head-of-household respondents were higher education, understanding Portuguese, larger household size, having electricity in the household, and larger household monthly income. As travel time to a health facility increased (per 1 h), respondents had 13% lower odds of sleeping under a mosquito net (OR 0.87; 95% CI 0.74-1.01, p = 0.07). Pregnant women in 2014 had a 2.4 times higher odds of sleeping under a bed net if they lived in Namacurra compared to Alto Molócuè (95% CI 0.91-6.32, p = 0.002 for district). Higher maternal education, living in Namacurra, and acquisition of mosquito bed nets were associated with a child 0-59 months reporting sleeping under the net in the previous night in 2014. CONCLUSIONS: Intensified focus on the poorest, least educated, and most distant from health services is needed to improve equity of ITN availability and usage. Additionally, while some districts have already surpassed goals in terms of coverage and utilization of ITN, renewed emphasis should be placed on bringing all geographic regions of the province closer to meeting these targets.

Integrated prevention of mother-to-child HIV transmission services, antiretroviral therapy initiation, and maternal and infant retention in care in rural north-central Nigeria: a cluster-randomised controlled trial.

BACKGROUND: Antiretroviral therapy (ART) and retention in care are essential for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to assess the effect of a family-focused, integrated PMTCT care package. METHODS: In this parallel, cluster-randomised controlled trial, we pair-matched 12 primary and secondary level health-care facilities located in rural north-central Nigeria. Clinic pairs were randomly assigned to intervention or standard of care (control) by computer-generated sequence. HIV-infected women (and their infants) presenting for antenatal care or delivery were included if they had unknown HIV status at presentation (there was no age limit for the study, but the youngest participant was 16 years old); history of antiretroviral prophylaxis or treatment, but not receiving these at presentation; or known HIV status but had never received treatment. Standard of care included health information, opt-out HIV testing, infant feeding counselling, referral for CD4 cell counts and treatment, home-based services, antiretroviral prophylaxis, and early infant diagnosis. The intervention package added task shifting, point-of-care CD4 testing, integrated mother and infant service provision, and male partner and community engagement. The primary outcomes were the proportion of eligible women who initiated ART and the proportion of women and their infants retained in care at 6 weeks and 12 weeks post partum (assessed by generalised linear mixed effects model with random effects for matched clinic pairs). The trial is registered with ClinicalTrials.gov, number NCT01805752. FINDINGS: Between April 1, 2013, and March 31, 2014, we enrolled 369 eligible women (172 intervention, 197 control), similar across groups for marital status, duration of HIV diagnosis, and distance to facility. Median CD4 count was 424 cells per µL (IQR 268-606) in the intervention group and 314 cells per µL (245-406) in the control group (p<0·0001). Of the 369 women included in the study, 363 (98%) had WHO clinical stage 1 disease, 364 (99%) had high functional status, and 353 (96%) delivered vaginally. Mothers in the intervention group were more likely to initiate ART (166 [97%] vs 77 [39%]; adjusted relative risk 3·3, 95% CI 1·4-7·8). Mother and infant pairs in the intervention group were more likely to be retained in care at 6 weeks (125 [83%] of 150 vs 15 [9%] of 170; adjusted relative risk 9·1, 5·2-15·9) and 12 weeks (112 [75%] of 150 vs 11 [7%] of 168 pairs; 10·3, 5·4-19·7) post partum. INTERPRETATION: This integrated, family-focused PMTCT service package improved maternal ART initiation and mother and infant retention in care. An effective approach to improve the quality of PMTCT service delivery will positively affect global goals for the elimination of mother-to-child HIV transmission. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development and US National Institutes of Health.

Interactive Data Visualization for HIV Cohorts: Leveraging Data Exchange Standards to Share and Reuse Research Tools.

OBJECTIVE: To develop and disseminate tools for interactive visualization of HIV cohort data. DESIGN AND METHODS: If a picture is worth a thousand words, then an interactive video, composed of a long string of pictures, can produce an even richer presentation of HIV population dynamics. We developed an HIV cohort data visualization tool using open-source software (R statistical language). The tool requires that the data structure conform to the HIV Cohort Data Exchange Protocol (HICDEP), and our implementation utilized Caribbean, Central and South America network (CCASAnet) data. RESULTS: This tool currently presents patient-level data in three classes of plots: (1) Longitudinal plots showing changes in measurements viewed alongside event probability curves allowing for simultaneous inspection of outcomes by relevant patient classes. (2) Bubble plots showing changes in indicators over time allowing for observation of group level dynamics. (3) Heat maps of levels of indicators changing over time allowing for observation of spatial-temporal dynamics. Examples of each class of plot are given using CCASAnet data investigating trends in CD4 count and AIDS at antiretroviral therapy (ART) initiation, CD4 trajectories after ART initiation, and mortality. CONCLUSIONS: We invite researchers interested in this data visualization effort to use these tools and to suggest new classes of data visualization. We aim to contribute additional shareable tools in the spirit of open scientific collaboration and hope that these tools further the participation in open data standards like HICDEP by the HIV research community.

Risk Factors for Loss to Follow-Up among People Who Inject Drugs in a Risk Reduction Program at Karachi, Pakistan. A Case-Cohort Study.

INTRODUCTION: Retention of male people who inject drugs (PWIDs) is a major challenge for harm reduction programs that include sterile needle/syringe exchange in resource-limited settings like Pakistan. We assessed the risk factors for loss to follow-up among male PWIDs enrolled in a risk reduction program in Karachi, Pakistan. METHODS: We conducted a prospective cohort study among 636 HIV-uninfected male PWIDs enrolled during March-June 2009 in a harm reduction program for the estimation of incidence rate. At 24 months post-enrollment, clients who had dropped out of the program were defined as lost to follow-up and included as cases for case-cohort study. RESULTS: The median age of the participants was 29 years (interquartile range: 23-36). Active outreach accounted for 76% (483/636) of cohort recruits. Loss to follow-up at 24 months was 25.5% (162/636). In multivariable logistic regression, younger age (AOR: 0.97, 95% CI: 0.92-0.99, p = 0.028), clients from other provinces than Sindh (AOR: 1.49, 95% CI: 1.01-2.22, p = 0.046), having no formal education (AOR: 3.44, 95% CI: 2.35-4.90, p<0.001), a history of incarceration (AOR: 1.68, 95% CI: 1.14-2.46, p<0.008), and being homeless (AOR: 1.47, 95% CI: 1.00-2.19, p<0.049) were associated with loss to follow-up. CONCLUSIONS: Our cohort retained 74.5% of male PWIDs in Karachi for 24 months. Its loss to follow up rate suggested substantial ongoing programmatic challenges. Programmatic enhancements are needed for the highest risk male PWIDs, i.e., younger men, men not from Sindh Province, men who are poorly educated, formerly incarcerated, and/or homeless.

Engagement of Men in Antenatal Care Services: Increased HIV Testing and Treatment Uptake in a Community Participatory Action Program in Mozambique.

Uptake of HIV testing and antiretroviral therapy (ART) services during antenatal care (ANC) in rural Mozambique is disappointing. To nurture supportive male engagement in ANC services, we partnered with traditional birth attendants and trained a new type of male-to-male community health agent, "Male Champions", who focused on counseling male partners to create new, male-friendly community norms around engagement in spousal/partner pregnancies. We assessed ANC service uptake using a pre-post intervention design. The intervention was associated with increases in: (1) uptake of provider-initiated counseling and testing among pregnant woman (81 vs. 92 %; p < 0.001); (2) male engagement in ANC (5 vs. 34 %; p < 0.001); and (3) uptake of ART (8 vs. 19 %; p < 0.001). When men accepted HIV testing, rates of testing rose markedly among pregnant women. With the challenges in scale-up of Option B+ in sub-Saharan Africa, similar interventions may increase testing and treatment acceptability during pregnancy.

Factors associated with declining under-five mortality rates from 2000 to 2013: an ecological analysis of 46 African countries.

OBJECTIVE: Inadequate overall progress has been made towards the 4th Millennium Development Goal of reducing under-five mortality rates by two-thirds between 1990 and 2015. Progress has been variable across African countries. We examined health, economic and social factors potentially associated with reductions in under-five mortality (U5M) from 2000 to 2013. SETTING: Ecological analysis using publicly available data from the 46 nations within the WHO African Region. OUTCOME MEASURES: We assessed the annual rate of change (ARC) of 70 different factors and their association with the annual rate of reduction (ARR) of U5M rates using robust linear regression models. RESULTS: Most factors improved over the study period for most countries, with the largest increases seen for economic or technological development and external financing factors. The median (IQR) U5M ARR was 3.6% (2.8 to 5.1%). Only 4 of 70 factors demonstrated a strong and significant association with U5M ARRs, adjusting for potential confounders. Higher ARRs were associated with more rapidly increasing coverage of seeking treatment for acute respiratory infection (ß=0.22 (ie, a 1% increase in the ARC was associated with a 0.22% increase in ARR); 90% CI 0.09 to 0.35; p=0.01), increasing health expenditure relative to gross domestic product (ß=0.26; 95% CI 0.11 to 0.41; p=0.02), increasing fertility rate (ß=0.54; 95% CI 0.07 to 1.02; p=0.07) and decreasing maternal mortality ratio (ß=-0.47; 95% CI -0.69 to -0.24; p<0.01). The majority of factors showed no association or raised validity concerns due to missing data from a large number of countries. CONCLUSIONS: Improvements in sociodemographic, maternal health and governance and financing factors were more likely associated with U5M ARR. These underscore the essential role of contextual factors facilitating child health interventions and services. Surveillance of these factors could help monitor which countries need additional support in reducing U5M.

Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia.

BACKGROUND: Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited. METHODS: We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women. RESULTS: Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women. CONCLUSIONS: HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.

Impact of Global Health Research Training on Scholarly Productivity: The Fogarty International Clinical Research Scholars and Fellows Program.

In the Fogarty International Clinical Research Scholars and Fellows (FICRS-F) Program, 536 U.S. and international doctoral and postdoctoral health profession students and trainees completed 1-year research training at research centers in low- and middle-income countries. To evaluate the Program's impact, we analyzed data gathered prospectively during the Program, from PubMed, and from a representative survey of alumni. Of 100 randomly selected respondents, 94 returned the survey. Reflecting the sources of funding, human immunodeficiency virus/acquired immunodeficiency syndrome was the focus of 47% of the projects, but research in noncommunicable diseases (NCDs) and dual infection/NCD-related topics increased over time. Among the first 1,617 alumni publications, output was associated positively with being an international versus U.S. trainee, a postdoctoral Fellow versus predoctoral Scholar, and accumulation of more years post-training (all P < 0.001). Fellows were first author on a higher proportion of their articles than were Scholars (P < 0.001), and U.S. trainees were more often first author than international trainees (P = 0.04). Survey respondents had submitted 117 grant applications, and 79 (67.5%) had been funded. The FICRS-F Program yielded substantial research productivity in the early post-training years. Research outputs and impact will increase over time as alumni careers mature and they gain research independence and assume leadership positions.

CD4 Response Up to 5 Years After Combination Antiretroviral Therapy in Human Immunodeficiency Virus-Infected Patients in Latin America and the Caribbean.

We describe CD4 counts at 6-month intervals for 5 years after combination antiretroviral therapy initiation among 12 879 antiretroviral-naive human immunodeficiency virus-infected adults from Latin America and the Caribbean. Median CD4 counts increased from 154 cells/mm(3) at baseline (interquartile range [IQR], 60-251) to 413 cells/mm(3) (IQR, 234-598) by year 5.

Mortality and loss to follow-up among HIV-infected persons on long-term antiretroviral therapy in Latin America and the Caribbean.

INTRODUCTION: Long-term survival of HIV patients after initiating highly active antiretroviral therapy (ART) has not been sufficiently described in Latin America and the Caribbean, as compared to other regions. The aim of this study was to describe the incidence of mortality, loss to follow-up (LTFU) and associated risk factors for patients enrolled in the Caribbean, Central and South America Network (CCASAnet). METHODS: We assessed time from ART initiation (baseline) to death or LTFU between 2000 and 2014 among ART-naïve adults (≥18 years) from sites in seven countries included in CCASAnet: Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru. Kaplan-Meier techniques were used to estimate the probability of mortality over time. Risk factors for death were assessed using Cox regression models stratified by site and adjusted for sex, baseline age, nadir pre-ART CD4 count, calendar year of ART initiation, clinical AIDS at baseline and type of ART regimen. RESULTS: A total of 16,996 ART initiators were followed for a median of 3.5 years (interquartile range (IQR): 1.6-6.2). The median age at ART initiation was 36 years (IQR: 30-44), subjects were predominantly male (63%), median CD4 count was 156 cells/µL (IQR: 60-251) and 26% of subjects had clinical AIDS prior to starting ART. Initial ART regimens were predominantly non-nucleoside reverse transcriptase inhibitor based (86%). The cumulative incidence of LTFU five years after ART initiation was 18.2% (95% confidence interval (CI) 17.5-18.8%). A total of 1582 (9.3%) subjects died; the estimated probability of death one, three and five years after ART initiation was 5.4, 8.3 and 10.3%, respectively. The estimated five-year mortality probability varied substantially across sites, from 3.5 to 14.0%. Risk factors for death were clinical AIDS at baseline (adjusted hazard ratio (HR)=1.65 (95% CI 1.47-1.87); p<0.001), lower baseline CD4 (HR=1.95 (95% CI 1.63-2.32) for 50 vs. 350 cells/µL; p<0.001) and older age (HR=1.47 (95% CI 1.29-1.69) for 50 vs. 30 years at ART initiation; p<0.001). CONCLUSIONS: In this large, long-term study of mortality among HIV-positive adults initiating ART in Latin America and the Caribbean, overall estimates of mortality were heterogeneous, generally falling between those reported in high-income countries and sub-Saharan Africa.

Impact of Global Health Research Training on Career Trajectories: The Fogarty International Clinical Research Scholars and Fellows Program.

From 2004 to 2012, the Fogarty International Clinical Research Scholars/Fellows Program (FICRS-F) provided 1-year research training opportunities for U.S. and international doctoral "Scholars" and postdoctoral "Fellows" at low- and middle-income country (LMIC) centers. We collected data prospectively and then surveyed a representative sample of 100 alumni (94% response), assessing Program impacts on their careers and collaborations. Frequently, collaborations continued beyond the formal training period with U.S.- (63%) and site-based mentors (66%). U.S. Fellows reported the highest post-training focus on research (88 on a 100-point scale), and the highest Program impact on competitiveness for career or training positions and choices of post-training topics and institutions (95 points). Interest in global health research increased markedly during the training period, especially for LMIC trainees, and was sustained post-training. LMIC alumni reported a significantly higher focus on global health and research than did U.S. alumni. Alumni reported that their mentored research training had a substantial impact on their career trajectories.