Comparison of Self and Caregiver Reports of Antiretroviral Treatment Adherence among Children and Adolescents Living with HIV in Western Kenya.

BACKGROUND: Youth living with HIV with perinatal infection spend a lifetime taking antiretroviral treatment (ART) to suppress the virus, and face significant challenges to successfully maintaining ART adherence. Tools to measure adherence include self-report, medication event monitoring system (MEMS) pill bottle caps, pill counts, and plasma or hair drug levels; however, the inter-rater agreement between child and caregiver self-report has not been validated in an African setting. This study aims to assess inter-rater agreement between child and caregiver self-reports, compared to reporting from MEMS pill bottle caps. METHODS: This was a secondary analysis of a cluster-randomized trial to evaluate an intervention for children living with HIV, conducted at the Academic Model Providing Access to Healthcare in western Kenya. We analyzed data from 285 child-caregiver dyads to compare adherence self-reported by children and their caregivers, and subsequently compared all self-reports to adherence reported by MEMS pill bottle caps to determine whether child or caregiver self-reports aligned more closely with adherence measured by MEMS. RESULTS: Children and their caregivers reported similar levels of adherence and numbers of missed doses in the past month, and both reports were similarly associated with adherence reported by MEMS pill bottle caps. Children with a caregiver that was not a biological parent were significantly more likely to report more missed doses than their caregiver. The correlation coefficient for the relationship between the child and caregiver self-reports was 0.71; for the relationship between child report and MEMS was 0.23; and for the relationship between caregiver report and MEMS was 0.20. Both children and caregivers under-reported non-adherence compared to MEMS data. CONCLUSION: Children and caregiver self-reports were generally similar in reporting adherence and were not highly correlated with MEMS reports of adherence, with children and caregivers reporting higher level of adherence than the MEMS data. This may indicate that children and caregiver reports are similarly inaccurate or biased; however, further research with larger sample sizes is required to further understand the differences in these reports.

Comparison of self-reported ART adherence rates among children and adolescents living with HIV in western Kenya The study aims to compare adherence between children and caregivers of Youth Living with HIV (YLWH) with perinatal infection, comparing data from 285 child-caregiver dyads and MEMS pill bottle caps. Results showed similar levels of adherence and missed doses in the past month, with a correlation coefficient of 0.71. However, children and caregivers reported higher levels of adherence than MEMS data. The study highlights the importance of understanding the reliability between self-reports and MEMS data in promoting adherence among YLWH.

Ethical Considerations for Engaging Children and Adolescents Living with HIV in Research in African Countries: A Systematic Review.

Research engaging children and adolescents living with HIV (CALWH) is critical for youth-friendly services and HIV care, and researchers need to ensure that such engagement is ethical. We conducted a systematic review to identify key ethical considerations for the engagement of CALWH in research. The review focused on primary research articles conducted in African countries that examined ethical issues in CALWH engaged in research. Ten studies met the inclusion criteria; the following seven key domains were extracted: 1) justifications for engaging CALWH in research; 2) community involvement; 3) informed consent/assent; 4) caregiver involvement; 5) perceptions of benefits; 6) perception of the risks of involvement; and 7) confidentiality. These domains can inform the ethical engagement of CALWH in research.

Ethical Considerations for Engaging Youth Living with HIV in Research: Perspectives from Youth, Their Caregivers and Subject Matter Experts in Kenya.

Introduction: Engaging youth living with HIV (YLWH) in research is critical to improving HIV-related outcomes, but their involvement raises unaddressed bioethical questions. Methods: This study used qualitative inquiry with Kenyan YLWH, caregivers, and subject matter experts (SMEs) to evaluate ethical considerations and strategies for research involving YLWH. Results: Interviews were conducted with 99 participants: 40 YLWH (median age 17.5, 50% female), 20 caregivers (70% female), and 39 SMEs (44% female). All participant groups discussed the need for HIV disclosure status assessment, confidentiality, and engagement of caregivers. Youth participants discussed the importance of clear protocol explanations and developing good rapport. All participant groups perceived youth under 18 to be harder to recruit due to a number of identified barriers. Clinic settings were the most acceptable place for recruitment. Conclusion: Participants provided perspectives on engaging YLWH in research that can be incorporated into protocols and regulatory guidelines.

Gender differences in HIV knowledge among adolescents and young people in low-and middle-income countries: a systematic review.

Objectives: This review seeks to critically analyze studies assessing gender differences in HIV-related knowledge among adolescents and young people in low- and middle-income countries. Methods: Using PRISMA guidelines and searching Pubmed and Scopus online databases, the search strategy combined search keywords with Boolean operators: (HIV OR AIDS) AND (knowledge) AND (gender) AND (adolescents). AC and EG conducted the search and independently reviewed all articles in Covidence software; conflicts were resolved by GC. Articles were included if they evaluated differences in HIV knowledge in at least two groups ages 10-24 and were implemented in a low or middle-income country. Results: The search resulted in 4,901 articles, of which fifteen studies, implemented in 15 countries, met selection criteria. Twelve evaluated differences in HIV knowledge in school settings; three evaluated participants in clinic settings. Adolescent males consistently scored higher in composite knowledge scores, as well as knowledge of HIV transmission, prevention, attitudes and sexual decision-making. Conclusion: We found gender-based discrepancies between knowledge, perception of risk and HIV prevalence among youth globally, with boys consistently scoring higher in HIV knowledge. However, there is significant evidence that social and cultural contexts render girls at high risk of HIV infection, and the gaps in girls' knowledge and boys' roles in HIV risk must be addressed urgently. Future research should consider interventions that facilitate discussion and HIV knowledge building across genders.

HIV-Related Stigma Shapes Research Participation for Youth Living With HIV in Kenya.

Introduction: HIV stigma affects medication adherence, psychosocial outcomes, and clinical management for youth living with HIV (YLWH). We explored the impact of HIV stigma on research participation, to inform the ethical engagement of this vulnerable group. Methods: We interviewed 40 YLWH, 20 caregivers, and 39 subject matter experts (SMEs); transcripts were analyzed by HK and EG, with emerging themes confirmed by JA and AC. Results: All categories of participants identified the impacts of stigma on YLWH research participation, suggesting implementing privacy protections, considering recruitment locations carefully, and developing supportive relationships with YLWH. SMEs suggested that YLWH experience uniquely high risks from stigma due to the compounding effects of developmental challenges and transitionary life period. Accidental HIV disclosure and subsequent stigma were identified as a risk of research participation; some viewed the creation of community through research as a benefit. Conclusion: Participants provided insights into stigma-related considerations for research with YLWH, which may guide engagement protocols.

Associations between low Apgar scores and mortality by race in the United States: A cohort study of 6,809,653 infants.

BACKGROUND: Apgar scores measure newborn health and are strongly associated with infant outcomes, but their performance has largely been determined in primarily white populations. Given the majority of the global population is not white, we aim to assess whether the association between low Apgar score and mortality in infants varies across racial groups. METHODS AND FINDINGS: Population-based cohort study using 2016 to 2017 United States National Vital Statistics System data. The study included singleton infants born between 37+0 and 44+6 weeks to mothers over 15 years, without congenital abnormalities. We looked at 3 different mortality outcomes: (1) early neonatal mortality; (2) overall neonatal mortality; and (3) infant mortality. We used logistic regression to assess the association between Apgar score (categorized as low, intermediate, and normal) and each mortality outcome, and adjusted for gestational age, sex, maternal BMI, education, age, previous number of live births, and smoking status, and stratified these models by maternal race group (as self-reported on birth certificates). The cohort consisted of 6,809,653 infants (52.8% non-Hispanic white, 23.7% Hispanic, 13.8% non-Hispanic black, 6.6% non-Hispanic Asian, and 3.1% non-Hispanic other). A total of 6,728,829 (98.8%) infants had normal scores, 63,467 (0.9%) had intermediate scores, and 17,357 (0.3%) had low Apgar scores. Compared to infants with normal scores, low-scoring infants had increased odds of infant mortality. There was strong evidence that this association varied by race (p < 0.001) with adjusted odds ratios (AORs) of 54.4 (95% confidence interval [CI] 49.9 to 59.4) in non-Hispanic white, 70.02 (95% CI 60.8 to 80.7) in Hispanic, 23.3 (95% CI 20.3 to 26.8) in non-Hispanic black, 100.4 (95% CI 74.5 to 135.4) in non-Hispanic Asian, and 26.8 (95% CI 19.8 to 36.3) in non-Hispanic other infants. The main limitation was missing data for some variables, due to using routinely collected data. CONCLUSIONS: The association between Apgar scores and mortality varies across racial groups. Low Apgar scores are associated with mortality across racial groups captured by United States (US) records, but are worse at discriminating infants at risk of mortality for black and non-Hispanic non-Asian infants than for white infants. Apgar scores are useful clinical indicators and epidemiological tools; caution is required regarding racial differences in their applicability.

Nonoperative Management of Blunt Splenic Trauma in Patients with Traumatic Brain Injury: Feasibility and Outcomes.

INTRODUCTION: Preventing secondary insult to the brain is imperative following traumatic brain injury (TBI). Although TBI does not preclude nonoperative management (NOM) of splenic injuries, development of hypotension in this setting may be detrimental and could therefore lead trauma surgeons to a lower threshold for operative intervention and a potentially higher risk of failure of NOM (FNOM). We hypothesized that the presence of a TBI in patients with blunt splenic injury would lead to a higher risk of FNOM. METHODS: Patients with blunt splenic injury were selected from the National Trauma Data Bank research datasets from 2007 to 2011. TBI was defined as AIS head ≥ 3 and FNOM as patients who underwent a spleen-related operation after 2 h from admission. TBI patients were compared to those without head injury. The primary outcome was FNOM. RESULTS: Of 47,713 patients identified, 41,436 (86.8%) underwent a trial of NOM. FNOM was identical (10.6 vs. 10.8%, p = 0.601) among patients with and without TBI. TBI patients had lower adjusted odds for FNOM (AOR 0.66, p < 0.001), even among those with a high-grade splenic injury (AOR 0.68, p < 0.001). No difference in adjusted mortality was noted when comparing TBI patients with and without FNOM (AOR 1.01, p = 0.95). CONCLUSIONS: NOM of blunt splenic trauma in TBI patients has higher adjusted odds for success. This could be related to interventions targeting prevention of secondary brain injury. Further studies are required to identify those specific practices that lead to a higher success rate of NOM of splenic trauma in TBI patients.

Trauma patients with lower extremity and pelvic fractures: Should anti-factor Xa trough level guide prophylactic enoxaparin dose?

BACKGROUND: Adequate venous thromboembolism (VTE) prophylaxis is essential after trauma, especially in patients with lower extremity and/or pelvic fractures. We sought to investigate if prophylactic enoxaparin dosed by anti-Xa trough levels could reduce clinically evident VTE in trauma patients with lower extremity or pelvic injury. METHODS: Prospective data was collected on trauma patients admitted for at least two days with any lower extremity and/or pelvic fracture and who received enoxaparin for VTE prophylaxis between October 2013 and January 2016. Patients in the control cohort received enoxaparin at 30 mg twice daily. Patients in the adjustment cohort had anti-Xa trough levels measured after three or more consecutive doses of enoxaparin. Those with a trough level of 0.1 IU/mL or lower had their dosage increased by 10-mg increments. RESULTS: Of the 159 patients included, 58 (36.5%) were monitored with anti-Xa trough levels. The cohorts were similar in age, sex, regional AIS, ISS score, ICU and hospital length of stay, proportion of patients with diagnostic testing for VTE, and time to first enoxaparin dose. Initial enoxaparin dosing in the majority of patients (84.5%) who had anti-Xa trough levels measured was subprophylactic. Patients receiving enoxaparin dosed by anti-Xa trough level had a significantly lower VTE rate than those who did not (1.7% v. 13.9%, p = 0.03). CONCLUSIONS: Prophylactic enoxaparin adjusted by anti-factor Xa level may lead to a decreased rate of clinically evident VTE among trauma patients with lower extremity and/or pelvic fractures. Our findings indicate that the initial dose of enoxaparin was frequently too low.