Pediatric HIV Case Identification Across 22 PEPFAR-Supported Countries During the COVID-19 Pandemic, October 2019-September 2020.

During 2020, an estimated 150,000 persons aged 0-14 years acquired HIV globally (1). Case identification is the first step to ensure children living with HIV are linked to life-saving treatment, achieve viral suppression, and live long, healthy lives. Successful interventions to optimize pediatric HIV testing during the COVID-19 pandemic are needed to sustain progress toward achieving Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets.* Changes in HIV testing and diagnoses among persons aged 1-14 years (children) were assessed in 22 U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries during October 1, 2019-September 30, 2020. This period corresponds to the two fiscal quarters before the COVID-19 pandemic (i.e., Q1 and Q2) and the two quarters after the pandemic began (i.e., Q3 and Q4). Testing was disaggregated by age group, testing strategy, and fiscal year quarter. During October 2019-September 2020, PEPFAR supported 4,312,343 HIV tests and identified 74,658 children living with HIV (CLHIV). The number of HIV tests performed was similar during Q1 and Q2, decreased 40.1% from Q2 to Q3, and increased 19.7% from Q3 to Q4. The number of HIV cases identified among children aged 1-14 years (cases identified) increased 7.4% from Q1 to Q2, decreased 29.4% from Q2 to Q3, and increased 3.3% from Q3 to Q4. Although testing in outpatient departments decreased 21% from Q1 to Q4, testing from other strategies increased during the same period, including mobile testing by 38%, facility-based index testing (offering an HIV test to partners and biological children of persons living with HIV) by 8%, and testing children with signs or symptoms of malnutrition within health facilities by 7%. In addition, most tests (61.3%) and cases identified (60.9%) were among children aged 5-14 years (school-aged children), highlighting the need to continue offering HIV testing to older children. These findings provide important information on the most effective strategies for identifying CLHIV during the COVID-19 pandemic. HIV testing programs should continue to use programmatic, surveillance, and financial data at both national and subnational levels to determine the optimal mix of testing strategies to minimize disruptions in pediatric case identification during the COVID-19 pandemic.

Importance of support groups to the health and well-being of vulnerable children and young people living with HIV: a case study of the Kids Clubs program in Haiti.

BACKGROUND: Although access to antiretroviral therapy (ART) among children and young people living with HIV has increased in recent years, adherence to medication and viral suppression remain challenges. Evidence of benefits of support groups is growing and reflects a range of models and approaches. Since 2014, hospital-linked psychosocial support groups for children and young people living with HIV, known as Kids Clubs, have been established throughout Haiti. The program provides safe spaces for them to meet with peers, supports medication adherence, delivers health and life skills education, and facilitates linkages with clinic visits and social services. This study describes program enrollment and participant engagement, ART adherence and viral suppression among participants, and other outcomes attributed to the program by participants, caregivers, and program implementers. METHODS: Our mixed methods study included quantitative analysis of program monitoring data on rollout and attendance, and medication adherence and viral load results extracted from medical records. We collected qualitative data from club members, caregivers, and implementers about their experiences with the clubs and the impact of participation. RESULTS: From January 2014-December 2018, 1330 individuals aged 8-29 were enrolled in the program; over three-quarters participated for at least 12 months. In 2018, 1038 members attended at least one club meeting; more than half missed three or fewer monthly meetings. Three-quarters of ever-enrolled members reported consistent medication use at their most recent clinic visit; 64.2% (600/935) of those with a recent viral load test were virally suppressed. Level of club attendance was positively associated with ART adherence (p < 0.01) and viral suppression (p < 0.05). Club members, caregivers, and implementers noted the value of the clubs to participants' retention in care and medication adherence, health knowledge, and capacity to deal with peer pressure, stigma, shyness, and depression. CONCLUSIONS: The Kids Club program has been successful in scaling HIV support services to highly vulnerable children and young people through peer-based groups, and program participation has led to a range of benefits. Efforts to innovate, evaluate, and scale support strategies for vulnerable young populations must be accelerated in order to ensure that they survive, thrive, and reach their full potential.

High Levels of HIV-1 Drug Resistance in Children Who Acquired HIV Infection Through Mother to Child Transmission in the Era of Option B+, Haiti, 2013 to 2014.

BACKGROUND: The main objective of this study was to determine the frequency and patterns of HIV drug resistance-associated mutations among children under 18 months of age born to HIV-1-positive mothers enrolled in the prevention of mother-to-child transmission services in Haiti. METHODS: Between January 1, 2013 and December 31, 2014, HIV-positive remnant dried blood spots collected from children under 18 months of age for Early Infant Diagnosis at the National Public Health Laboratory were used for HIV-1 genotyping. HIV drug resistance mutations were analyzed using the Stanford Drug Resistance HIVdb program. RESULTS: Of the 3555 dried blood spots collected for Early Infant Diagnosis, 360 (10.1%) were HIV-positive and 355 were available for genotyping. Of these, 304 (85.6%) were successfully genotyped and 217 (71.4%) had ≥1 drug resistance mutation. Mutations conferring resistance to nucleoside reverse transcriptase inhibitor (NRTIs) and non-NRTIs were present in 40.5% (123) and 69.1% (210), respectively. The most frequent mutations were K103N/S (48.0%), M184V (37.5%), G190A/S (15.1%), and Y181C/G/V (14.1%). Predicted drug resistance analysis revealed that 68.8% of the children had high-level resistance to non-NRTIs and 11.5% had intermediate to high-level resistance to abacavir. CONCLUSIONS: This study showed high rates of resistance to NRTIs and non-NRTIs among newly HIV-diagnosed children in Haiti, suggesting that in the era of "Option B+" (initiation of lifelong combination antiretroviral therapy to pregnant women with HIV), the majority of children who acquire HIV infection through mother-to-child transmission of HIV have resistant HIV. These results have led the National HIV Program to revise the pediatric guidelines to include protease inhibitors in first-line regimens for all HIV-positive newborns.

Early Diagnosis of HIV Infection in Infants - One Caribbean and Six Sub-Saharan African Countries, 2011-2015.

Pediatric human immunodeficiency virus (HIV) infection remains an important public health issue in resource-limited settings. In 2015, 1.4 million children aged <15 years were estimated to be living with HIV (including 170,000 infants born in 2015), with the vast majority living in sub-Saharan Africa (1). In 2014, 150,000 children died from HIV-related causes worldwide (2). Access to timely HIV diagnosis and treatment for HIV-infected infants reduces HIV-associated mortality, which is approximately 50% by age 2 years without treatment (3). Since 2011, the annual number of HIV-infected children has declined by 50%. Despite this gain, in 2014, only 42% of HIV-exposed infants received a diagnostic test for HIV (2), and in 2015, only 51% of children living with HIV received antiretroviral therapy (1). Access to services for early infant diagnosis of HIV (which includes access to testing for HIV-exposed infants and clinical diagnosis of HIV-infected infants) is critical for reducing HIV-associated mortality in children aged <15 years. Using data collected from seven countries supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), progress in the provision of HIV testing services for early infant diagnosis was assessed. During 2011-2015, the total number of HIV diagnostic tests performed among HIV-exposed infants within 6 weeks after birth (tests for early infant diagnosis of HIV), as recommended by the World Health Organization (WHO) increased in all seven countries (Cote d'Ivoire, the Democratic Republic of the Congo, Haiti, Malawi, South Africa, Uganda, and Zambia); however, in 2015, the rate of testing for early infant diagnosis among HIV-exposed infants was <50% in five countries. HIV positivity among those tested declined in all seven countries, with three countries (Cote d'Ivoire, the Democratic Republic of the Congo, and Uganda) reporting >50% decline. The most common challenges for access to testing for early infant diagnosis included difficulties in specimen transport, long turnaround time between specimen collection and receipt of results, and limitations in supply chain management. Further reductions in HIV mortality in children can be achieved through continued expansion and improvement of services for early infant diagnosis in PEPFAR-supported countries, including initiatives targeted to reach HIV-exposed infants, ensure access to programs for early infant diagnosis of HIV, and facilitate prompt linkage to treatment for children diagnosed with HIV infection.

Chloroquine-resistant haplotype Plasmodium falciparum parasites, Haiti.

Plasmodium falciparum parasites have been endemic to Haiti for >40 years without evidence of chloroquine (CQ) resistance. In 2006 and 2007, we obtained blood smears for rapid diagnostic tests (RDTs) and filter paper blots of blood from 821 persons by passive and active case detection. P. falciparum infections diagnosed for 79 persons by blood smear or RDT were confirmed by PCR for the small subunit rRNA gene of P. falciparum. Amplification of the P. falciparum CQ resistance transporter (pfcrt) gene yielded 10 samples with amplicons resistant to cleavage by ApoI. A total of 5 of 9 samples had threonine at position 76 of pfcrt, which is consistent with CQ resistance (haplotypes at positions 72-76 were CVIET [n = 4] and CVMNT [n = 1]); 4 had only the wild-type haplotype associated with CQ susceptibility (CVMNK). These results indicate that CQ-resistant haplotype P. falciparum malaria parasites are present in Haiti.

Seroprevalence of antibodies against rubella virus in pregnant women in Haiti.

OBJECTIVE: To assess the seroprevalence of immunity to the rubella virus in pregnant women in Haiti attending the Obstetrics and Gynecology Department of the State University Hospital, in the capital city of Port-au-Prince, in order to help with the introduction of the rubella vaccine for the population and provide protection for women of reproductive age in the country. METHODS: This cross-sectional study was done between February 2002 and May 2002. A total of 503 pregnant women were tested for rubella-specific immunoglobulin G antibodies, using enzyme immunoassay; 8 of those women were later excluded because they did not know their age, leaving 495 women in the analysis. RESULTS: Of the 495 participants included in our analysis, 471 of them (95.2%) were seropositive; only 24 of them (4.8%) were seronegative (susceptible). A statistically significant difference (P = 0.02) was found in the rate of seronegativity for rubella virus between the pregnant women living in the Port-au-Prince area (17 of 426 women, or 4.0%) and those living in rural areas (7 of 69 women, or 10.1%). In terms of age, 81 of the 495 (16.4%) women were under 21 years ld. CONCLUSIONS: This study is an important first step in addressing the issue of prevalence of rubella virus infection among Haitian women and in dealing with the still-underrecognized public health problem of congenital rubella syndrome in Haiti. We recommend additional research that uses randomized sampling and includes a significant proportion of women from rural areas of the country.

Seroprevalence of antibodies against rubella virus in pregnant women in Haiti / Seroprevalencia de anticuerpos contra el virus de la rubéola en mujeres embarazadas de Haití

OBJETIVO: Determinar la seroprevalencia de la inmunidad al virus de la rubéola en mujeres embarazadas que se atienden al Departamento de Obstetricia y Ginecología del Hospital de la Universidad Estatal, en Puerto Príncipe, capital de Haití, a fin de contribuir a introducir la vacunación de la población contra la rubéola y proteger a las mujeres en edad reproductiva en el país. MÉTODOS: Este estudio transversal se realizó entre febrero y mayo de 2002. Se evaluó la presencia de anticuerpos de tipo IgG específicos contra la rubéola en 503 embarazadas mediante un inmunoensayo enzimático. Posteriormente se excluyó a 8 mujeres debido a que no sabían su edad. RESULTADOS: De las 495 participantes estudiadas, 471 (95,2%) tenían seropositividad; solo 24 de ellas (4,8%) mostraron seronegatividad (susceptibilidad). Se encontraron menos mujeres seronegativas entre las residentes de Puerto Príncipe (17 de 426, 4,0%) que entre las residentes de zonas rurales (7 de 69, 10,1%) (P = 0,02). En relación con la edad, 81 (16,4%) de las 495 mujeres embarazadas estudiadas eran menores de 21 años. CONCLUSIONES: Con este estudio se da el primer paso hacia evaluar la prevalencia de la infección por el virus de la rubéola en mujeres haitianas y hacia el enfrentamiento de un problema de salud que todavía no ha sido reconocido en toda su magnitud: el síndrome de la rubéola congénita en Haití. Se recomienda emprender estudios adicionales con muestreos aleatorios que abarquen una fracción significativa de mujeres provenientes de zonas rurales.

Objective. To assess the seroprevalence of immunity to the rubella virus in pregnant women in Haiti attending the Obstetrics and Gynecology Department of the State University Hospital, in the capital city of Port-au-Prince, in order to help with the introduction of the rubella vaccine for the population and provide protection for women of reproductive age in the country. Methods. This cross-sectional study was done between February 2002 and May 2002. A total of 503 pregnant women were tested for rubella-specific immunoglobulin G antibodies, using enzyme immunoassay; 8 of those women were later excluded because they did not know their age, leaving 495 women in the analysis. Results. Of the 495 participants included in our analysis, 471 of them (95.2%) were seropositive; only 24 of them (4.8%) were seronegative (susceptible). A statistically significant difference (P = 0.02) was found in the rate of seronegativity for rubella virus between the pregnant women living in the Port-au-Prince area (17 of 426 women, or 4.0%) and those living in rural areas (7 of 69 women, or 10.1%). In terms of age, 81 of the 495 (16.4%) women were under 21 years old. Conclusions. This study is an important first step in addressing the issue of prevalence of rubella virus infection among Haitian women and in dealing with the still-underrecognized public health problem of congenital rubella syndrome in Haiti. We recommend additional research that uses randomized sampling and includes a significant proportion of women from rural areas of the country.

Neonatal sepsis and meningitis in Haiti.

The aim of the study was to determine the etiology of meningitis and sepsis in the newborn at the State University Hospital of Haiti and evaluate the susceptibility 'in vitro' of the pathogens to the antibiotics commonly used. This was a prospective case series study over a 10-month period (May 1997-February 1998) of 42 newborns with sepsis and/or meningitis. Besides the clinical signs, a positive blood culture and/or a positive culture of cerebrospinal fluid was present in each case. Gram-negative bacteria were most commonly found as a cause of early onset sepsis, with Enterobacter aerogenes as the most common agent. There were no such difference between gram-negative and gram-positive in late onset sepsis. Group B Streptococcus was associated with neonatal meningitis (44 per cent of cases) which was more related to gram-positive bacteria (66 per cent). Risk factors were vaginal discharge and dysuria in mothers, and low apgar score in newborns. Thirty-three per cent of the pathogens found, among them Klebsiella pneumoniae, were resistant 'in vitro' to ampicillin and gentamycin. All were susceptible to amikacin. Enterobacter aerogenes is an important pathogen in the etiology of early onset sepsis in the newborn at the State University Hospital of Haiti, while Group B Streptococcus is the leading cause of meningitis in that age group. Resistance to gentamycin should be taken into consideration for the treatment of sepsis and meningitis in the newborn.