Identifying Adolescents at Highest Risk of ART Non-adherence, Using the World Health Organization-Endorsed HEADSS and HEADSS+ Checklists.

Brief tools are necessary to identify adolescents at greatest risk for ART non-adherence. From the WHO's HEADSS/HEADSS+ adolescent wellbeing checklists, we identify constructs strongly associated with non-adherence (validated with viral load). We conducted interviews and collected clinical records from a 3-year cohort of 1046 adolescents living with HIV from 52 South African government facilities. We used least absolute shrinkage and selection operator variable selection approach with a generalized linear mixed model. HEADSS constructs most predictive were: violence exposure (aOR 1.97, CI 1.61; 2.42, p < 0.001), depression (aOR 1.71, CI 1.42; 2.07, p < 0.001) and being sexually active (aOR 1.80, CI 1.41; 2.28, p < 0.001). Risk of non-adherence rose from 20.4% with none, to 55.6% with all three. HEADSS+ constructs were: medication side effects (aOR 2.27, CI 1.82; 2.81, p < 0.001), low social support (aOR 1.97, CI 1.60; 2.43, p < 0.001) and non-disclosure to parents (aOR 2.53, CI 1.91; 3.53, p < 0.001). Risk of non-adherence rose from 21.6% with none, to 71.8% with all three. Screening within established checklists can improve identification of adolescents needing increased support. Adolescent HIV services need to include side-effect management, violence prevention, mental health and sexual and reproductive health.

Influence of match status and possession status on the physical and technical characteristics of elite youth female soccer match-play.

This study compared the influence of match status (drawing, losing, or winning) and possession status (in-possession, out-of-possession, or ball-out-of-play) on the physical and technical characteristics of U14 and U16 elite youth female soccer match-play. Data were collected from 189 female academy players during 45 competitive matches, resulting in 387 match observations. Linear mixed models estimated relative; total distance, high-speed running (≥3.00 m·s-1), very high-speed running (≥4.83 m·s-1), and sprinting (≥5.76 m·s-1) distance according to match status and possession status, and 21 technical variables according to match status. Differences in physical and technical characteristics were observed between and within age-groups, dependent upon match status and possession status. Regardless of match status, both age-groups covered greater distances when the ball was in-play compared to ball-out-of-play (107-130 vs 58-68 m·min-1). U16s covered greater distances when out-of-possession than in-possession, regardless of match status. Whilst U14s covered greater distances out-of-possession when drawing or losing only. Differences in physical and technical characteristics when drawing, losing, or winning, suggest a change in playing style according to match status, likely in an attempt to influence or maintain the score-line. These findings have practical implications for coaching, talent identification and development practices within youth female soccer.

Whole and peak physical characteristics of elite youth female soccer match-play.

This study quantified whole and peak physical characteristics of Under (U)14 and U16 elite youth female soccer, and compared by position and age-group. Data was collected using 10 Hz GPS units from 431 match observations, during 50 matches involving 201 players (U14 n = 93; U16 n = 108) representing Regional Talent Centres in The Football Association's Girl's England Talent Pathway League. Whole match data were reported as absolute and relative; total (TD), high-speed running (HSR; ≥3.46 m·s-1), very high-speed running (VHSR; ≥5.29 m·s-1), and sprinting (SPR; ≥6.26 m·s-1) distance, and maximum velocity. Moving average analysis determined peak data (1-10 minute durations). Linear mixed models established position-specific differences. U16s covered greater; absolute distance at all speeds (small-moderate ESs; p < 0.001); relative VHSR and SPR m·min-1 (small-moderate ESs; p < 0.001); peak TD and HSR m·min-1 (small ESs) across several peak-durations, and VHSR m·min-1 (small ESs; p < 0.001) across all peak-durations compared to U14s. Position-specific differences were observed across all positions between and within both age-groups, identifying whole and peak physical characteristics are age- and position-dependent within elite youth female soccer match-play. Findings may facilitate informed coaching practices and training programme design, talent identification and development processes.

Effectiveness of community adolescent treatment supporters (CATS) interventions in improving linkage and retention in care, adherence to ART and psychosocial well-being: a randomised trial among adolescents living with HIV in rural Zimbabwe.

BACKGROUND: Engagement with community adolescent treatment supporters (CATS) improves adherence, psychosocial well-being, linkage and retention in care among adolescents living with HIV. However, there is an urgent need for empirical evidence of the effectiveness of this approach, in order to inform further programmatic development, national and international policy, guidelines and service delivery for adolescents living with HIV. This study set out to determine the effectiveness of CATS services on improving linkage to services and retention in care, adherence and psychosocial well-being among adolescents living with HIV in Zimbabwe. METHODS: A randomised trial was conducted in Gokwe South district, Zimbabwe over a period of 12 months. Ninety-four HIV-positive adolescents, 10-15 years old, on antiretroviral therapy were recruited to the study. 47 participants received standard of care from the Ministry of Health and Child Care and 47 received the same standard of care plus CATS services. Data collection involved a questionnaire which was administered at baseline then repeated at three, six, nine and twelve months for all participants. Survey questions on confidence, self-esteem and self-worth had a three-point Likert scale. Stigma, quality of life and the linkages to services and retention questions had a five-point Likert scale. RESULTS: Survey questionnaires were completed with response rates of 40 out of 47 (85%) for the intervention arm, and 28 out of 47 (60%) for the control arm, at end-line. The intervention group were 3.9 times more likely to adhere to treatment compared to the control group. Linkage to services and retention in care within the intervention group increased compared with a decrease in the control arm. The intervention group reported a statistically significant increase in confidence, self-esteem, self-worth (p < 0.001) and quality of life compared (p = 0.028) with a decrease in the control arm. CONCLUSIONS: This study found that adolescents receiving the CATS service had improved linkage to services and retention in care, improved adherence and improved psychosocial well-being compared to adolescents who did not have access to such services. TRIAL REGISTRATION: PACTR201711002755428 . Registered 11 November 2017. Retrospectively registered.

Viral suppression in adolescents on antiretroviral treatment: review of the literature and critical appraisal of methodological challenges.

OBJECTIVE: Medication adherence is often suboptimal for adolescents with HIV, and establishing correct weight-based antiretroviral therapy dosing is difficult, contributing to virological failure. This review aimed to determine the proportion of adolescents achieving virological suppression after initiating ART. METHODS: MEDLINE, EMBASE and Web of Science databases were searched. Studies published between January 2004 and September 2014 including ≥50 adolescents taking ART and reporting on the proportion of virological suppressed participants were included. RESULTS: From a total of 5316 potentially relevant citations, 20 studies were included. Only eight studies reported the proportion of adolescents that were virologically suppressed at a specified time point. The proportion of adolescents with virological suppression at 12 months ranged from 27 to 89%. CONCLUSION: Adolescent achievement of HIV virological suppression was highly variable. Improved reporting of virological outcomes from a wider range of settings is required to support efforts to improve HIV care and treatment for adolescents.

Service delivery interventions to improve adolescents' linkage, retention and adherence to antiretroviral therapy and HIV care.

OBJECTIVES: Adolescents living with HIV face substantial difficulties in accessing HIV care services and have worse treatment outcomes than other age groups. The objective of this review was to evaluate the effectiveness of service delivery interventions to improve adolescents' linkage from HIV diagnosis to antiretroviral therapy (ART) initiation, retention in HIV care and adherence to ART. METHODS: We systematically searched the Medline, SCOPUS and Web of Sciences databases and conference abstracts from the International AIDS Conference and International Conference on AIDS and STIs in Africa (ICASA). Studies published in English between 1st January 2001 and 9th June 2014 were included. Two authors independently evaluated reports for eligibility, extracted data and assessed methodological quality using the Cochrane risk of bias tool and Newcastle-Ottawa Scale. RESULTS: Eleven studies from nine countries were eligible for review. Three studies were randomised controlled trials. Interventions assessed included individual and group counselling and education; peer support; directly observed therapy; financial incentives; and interventions to improve the adolescent-friendliness of clinics. Most studies were of low to moderate methodological quality. CONCLUSIONS: This review identified limited evidence on the effectiveness of service delivery interventions to support adolescents' linkage from HIV diagnosis to ART initiation, retention on ART and adherence to ART. Although recommendations are qualified because of the small numbers of studies and limited methodological quality, offering individual and group education and counselling, financial incentives, increasing clinic accessibility and provision of specific adolescent-tailored services appear promising interventions and warrant further investigation.

Digital psychosocial interventions for individuals with spinal cord injury: a scoping review.

Objective: To provide an overview of the digital mental health care landscape for individuals with spinal cord injury (SCI). Methods: PubMed, PsycInfo, and PSYNDEX were searched for articles meeting the following criteria: (1) article written in English or German; (2) digital psychosocial intervention; (3) SCI only; (4) treatment of individuals with SCI and not their relatives or caregivers. Records were screened by title and abstract and records meeting the inclusion criteria were obtained for full text screening. The references of identified articles were screened to find further relevant articles. The literature search was updated before submission. Risk of Bias was assessed by using the Cochrane risk-of-bias tool for randomized trials (RoB 2) and a narrative synthesis was conducted. Results: Ten randomized-controlled trials (RCT) and ten non-randomized-controlled trials were identified and compared in this review, evaluating twelve internet- and mobile-based interventions, five smartphone apps, and three virtual reality applications. The interventions were primarily used as stand-alone aftercare programs. While some were not based on any theory, cognitive behavioral therapy mostly served as the theoretical basis for the online interventions. The extent of human support also varied greatly between the studies. The number of intervention modules ranged between 2 and 72. There were also major differences in outcome variables and effects. A meta-analytical evaluation of the data was not conducted due to heterogeneity of studies. Conclusion: Digital applications to promote the psychosocial health of individuals with SCI are an emerging field of research with many treatment approaches still to come. First high quality RCT studies report promising results. Unfortunately, not all studies are of high quality or the interventions have been insufficiently adapted to the needs of people with SCI. Therefore, more research is needed to further develop applications, and to generalize and test the effects found in the long term.

Healthcare provisions associated with multiple HIV-related outcomes among adolescent girls and young women living with HIV in South Africa: a cross-sectional study.

INTRODUCTION: Adolescent girls and young women (AGYW) living with HIV experience poor HIV outcomes and high rates of unintended pregnancy. Little is known about which healthcare provisions can optimize their HIV-related outcomes, particularly among AGYW mothers. METHODS: Eligible 12- to 24-year-old AGYW living with HIV from 61 health facilities in a South African district completed a survey in 2018-2019 (90% recruited). Analysing surveys and medical records from n = 774 participants, we investigated associations of multiple HIV-related outcomes (past-week adherence, consistent clinic attendance, uninterrupted treatment, no tuberculosis [TB] and viral suppression) with seven healthcare provisions: no antiretroviral therapy (ART) stockouts, kind and respectful providers, support groups, short travel time, short waiting time, confidentiality, and safe and affordable facilities. Further, we compared HIV-related outcomes and healthcare provisions between mothers (n = 336) and nulliparous participants (n = 438). Analyses used multivariable regression models, accounting for multiple outcomes. RESULTS: HIV-related outcomes were poor, especially among mothers. In multivariable analyses, two healthcare provisions were "accelerators," associated with multiple improved outcomes, with similar results among mothers. Safe and affordable facilities, and kind and respectful staff were associated with higher predicted probabilities of HIV-related outcomes (p<0.001): past-week adherence (62% when neither accelerator was reported to 87% with both accelerators reported), clinic attendance (71%-89%), uninterrupted ART treatment (57%-85%), no TB symptoms (49%-70%) and viral suppression (60%-77%). CONCLUSIONS: Accessible and adolescent-responsive healthcare is critical to improving HIV-related outcomes, reducing morbidity, mortality and onward HIV transmission among AGYW. Combining these provisions can maximize benefits, especially for AGYW mothers.

Associations of social media and health content use with sexual risk behaviours among adolescents in South Africa.

Increasing rates of mobile phone access present potential new opportunities and risks for adolescents' sexual and reproductive health in resource-poor settings. We investigated associations between mobile phone access/use and sexual risks in a cohort of 10-24-year-olds in South Africa. 1563 adolescents (69% living with HIV) were interviewed in three waves between 2014 and 2018. We assessed mobile phone access and use to search for health content and social media. Self-reported sexual risks included: sex after substance use, unprotected sex, multiple sexual partnerships and inequitable sexual partnerships in the past 12 months. We examined associations between mobile phone access/use and sexual risks using covariate-adjusted mixed-effects logistic regression models. Mobile phone access alone was not associated with any sexual risks. Social media use alone (vs. no mobile phone access) was associated with a significantly increased probability of unprotected sex (adjusted average marginal effects [AMEs] + 4.7 percentage points [ppts], 95% CI 1.6-7.8). However, health content use (vs. no mobile phone access) was associated with significantly decreased probabilities of sex after substance use (AMEs -5.3 ppts, 95% CI -7.4 to -3.2) and unprotected sex (AMEs -7.5 ppts, 95% CI -10.6 to -4.4). Moreover, mobile phone access and health content use were associated with increased risks of multiple sexual partnerships in boys. Health content use was associated with increased risks of inequitable sexual partnerships in adolescents not living with HIV. Results suggest an urgent need for strategies to harness mobile phone use for protection from growing risks due to social media exposure.

Determining age-specific velocity thresholds for elite youth female soccer players.

Purpose: This study aimed to establish age-specific velocity thresholds for Under (U)14 and U16 elite youth female soccer players. Methods: Data was collected using 10 Hz GPS units during 50 matches from 187 players (U14 n = 89; U16 n = 98). Spectral clustering identified velocity thresholds for high-speed running (HSR), very high-speed running (VHSR), and sprinting (SPR), for 699 half-match observations (U14 n = 369; U16 n = 330). Linear mixed modelling determined youth (U14 and U16) and age-group (U14 or U16) velocity thresholds, and compared distances covered between these and existing senior thresholds. The effect of playing position and playing half on velocity thresholds was also quantified. Results: Youth velocity thresholds of HSR (≥3.00 m·s-1), VHSR (≥4.83 m·s-1), and SPR (≥5.76 m·s-1) were estimated from the model. Age-group and playing position influenced velocity thresholds but playing half did not. Adoption of youth and age-group velocity thresholds resulted in greater distance covered at HSR, VHSR, and SPR (p < 0.001; moderate-large effect size [ES] = 0.86-1.97) compared to senior thresholds. Both age-groups covered similar distances (trivial-small ESs = 0.002-0.23) when adopting youth and age-group velocity thresholds. Conclusion: These youth thresholds provide an alternative to arbitrary velocity thresholds within the literature, and thresholds derived from senior players or other populations, to inform appropriate quantification and interpretation of physical data within this population.

A systematic review of match-play characteristics in women's soccer.

This review aimed to (1) systematically review the scientific literature evaluating the match-play characteristics of women's soccer, (2) determine the methods adopted to quantify match-play characteristics of women's soccer, and (3) present the physical, technical and tactical characteristics of women's soccer match-play across age-groups, playing standards and playing positions. A systematic search of electronic databases was conducted in May 2021; keywords relating to the population, soccer and match-play characteristics were used. Studies which quantified physical, technical or tactical performance of women's soccer players during match-play were included. Excluded studies included adapted match-play formats and training studies. Sixty-nine studies met the eligibility criteria. Studies predominantly quantified match-play characteristics of senior international (n = 27) and domestic (n = 30) women's soccer match-play, with only seven studies reporting youth match-play characteristics. Physical (n = 47), technical (n = 26) and tactical characteristics (n = 2) were reported as whole-match (n = 65), half-match (n = 21), segmental (n = 17) or peak (n = 8) characteristics. Beyond age-groups, playing standard, and playing position, fourteen studies quantified the impact of contextual factors, such as environment or match outcome, on match-play characteristics. Distance was the most commonly reported variable (n = 43), as outfield women's soccer players covered a total distance of 5480-11160 m during match-play. This systematic review highlights that physical match-performance increases between age-groups and playing standards, and differs between playing positions. However, further research is warranted to understand potential differences in technical and tactical match-performance. Coaches and practitioners can use the evidence presented within this review to inform population-specific practices, however, they should be mindful of important methodological limitations within the literature (e.g. inconsistent velocity and acceleration/deceleration thresholds). Future research should attempt to integrate physical, technical and tactical characteristics as opposed to quantifying characteristics in isolation, to gain a deeper and more holistic insight into match-performance.

Assessing the Vulnerability and Risks of Adolescent Girls and Young Women in East and Southern Africa: A Preliminary Review of the Tools in Use.

The sexual and reproductive health (SRH) needs of adolescent girls and young women (AGYW) aged 10-24 years remain a cause for concern in the countries of East and Southern Africa (ESA). High rates of adolescent pregnancy and HIV prevalence prevail, and prevention programmes are challenged to identify those at greatest risk. This review aimed to identify tools being used in ESA countries that support the recording of factors that make AGYW vulnerable to SRH risks and document their use. A mixed-methods approach was used to find available English language tools that had been designed to assess the vulnerability of AGYW SRH risks including literature reviews and key informant interviews with thirty-five stakeholders. Twenty-two tools were identified, and experiences of their use obtained through the interviews. All but one tool focused on HIV prevention, and most aimed at establishing eligibility for programmes, though not aligned with programme type. Analyses of the content of seventeen tools showed information collection related to behavioral, biological, and structural risk factors of HIV and other aspects of AGYWs' lives. There was considerable diversity in the ways in which these questions were framed. Aspects of the processes involved in undertaking the risk and vulnerability assessments are presented.

Bullying and ART Nonadherence Among South African ALHIV: Effects, Risks, and Protective Factors.

BACKGROUND: Identifying risk and protective factors for adolescent antiretroviral therapy (ART) adherence is a public health priority, given high HIV-related mortality in this population. An area that merits further investigation is the relationship between bullying victimization, mental health problems, and ART nonadherence among adolescents living with HIV (ALHIV). However, no known studies assess effects of bullying on adolescent nonadherence or risk and protective factors that could moderate this relationship. SETTING: This study investigates (1) the direct longitudinal relationship between bullying exposure and ART nonadherence, and the indirect relationship via psychological distress, and (2) potential risk and modifiable protective factors moderating these pathways, among vertically and horizontally infected ALHIV who initiated treatment across 53 public health care facilities in a South African health district. METHODS: Survey data were collected at 2 time points, between 2014 and 2017, with 1046 ALHIV (94% retention). Various mediation and moderated mediation models were run as part of a staged analysis approach. RESULTS: A significant longitudinal relationship was found between bullying victimization and nonadherence, operating indirectly through psychological distress [B = 0.07; 95% confidence interval (CI): (0.03 to 0.13)]. Moderation analyses indicated that older adolescents exposed to bullying are more at risk of nonadherence [B = 0.52; 95% CI: (0.07 to 0.97) P < 0.05], and parental monitoring is a potential protective factor buffering indirect effects of bullying on nonadherence [B = -0.22; 95% CI: (-0.42 to -0.02) P < 0.05]. CONCLUSIONS: These findings underscore the importance of interventions that address bullying and psychological distress, and strengthen parental monitoring, particularly among older ALHIV.

Clinic and care: associations with adolescent antiretroviral therapy adherence in a prospective cohort in South Africa.

OBJECTIVE: Adolescent antiretroviral treatment (ART) adherence remains critically low. We lack research testing protective factors across both clinic and care environments. DESIGN: A prospective cohort of adolescents living with HIV (sample n = 969, 55% girls, baseline mean age 13.6) in the Eastern Cape Province in South Africa were interviewed at baseline and 18-month follow-up (2014-2015, 2015-2016). We traced all adolescents ever initiated on treatment in 52 government health facilities (90% uptake, 93% 18-month retention, 1.2% mortality). METHODS: Clinical records were collected; standardized questionnaires were administered by trained data collectors in adolescents' language of choice. Probit within-between regressions and average adjusted probability calculations were used to examine associations of caregiving and clinic factors with adherence, controlling for household structure, socioeconomic and HIV factors. RESULTS: Past-week ART adherence was 66% (baseline), 65% (follow-up), validated against viral load in subsample. Within-individual changes in three factors were associated with improved adherence: no physical and emotional violence (12.1 percentage points increase in adjusted probability of adherence, P < 0.001), improvement in perceived healthcare confidentiality (7.1 percentage points, P < 0.04) and shorter travel time to the clinic (13.7 percentage points, P < 0.02). In combination, improvement in violence prevention, travel time and confidentiality were associated with 81% probability of ART adherence, compared with 47% with a worsening in all three. CONCLUSION: Adolescents living with HIV need to be safe at home and feel safe from stigma in an accessible clinic. This will require active collaboration between health and child protection systems, and utilization of effective violence prevention interventions.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis.

INTRODUCTION: Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV). METHODS: A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years. RESULTS AND DISCUSSION: Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19. CONCLUSIONS: This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

Nothing About Us Without RIGHTS-Meaningful Engagement of Children and Youth: From Research Prioritization to Clinical Trials, Implementation Science, and Policy.

This article presents a new agenda for the meaningful engagement of youth in guiding research and policy. It has been codeveloped with youth, adolescents, and children who are living with and affected by HIV. We set out 6 basic requirements (we call them RIGHTS) that hold across clinical trials, observational studies, implementation science, service delivery, and policy development. These requirements are based on a literature review and in-depth consultations with children, adolescents, and youth, which have taken place over a decade in the HIV/AIDS epidemic. Youth engagement must be adequately Resourced with time, training, technical support, and funds. It must be Impactful, with youth informed of how their inputs have been directly used in research, policy, and programming. It must be Genuine, with youth understanding the intentions of the project and choosing to take part. It is essential that we ensure that participation is Harmless, and that it is responsive to the emotional and mental health needs of youth. Processes of participation should be Teen friendly, designed to be enjoyable and relevant to youth priorities. Finally, regarding Skills building, participation should allow for the competencies and skills developed to be recognized in youth education and career experience (without advertising the HIV aspect if this is inappropriate for young people). We propose that these 6 basic requirements be endorsed by all research organizations, and that they become a core component of research in the HIV response.

Zvandiri-Bringing a Differentiated Service Delivery Program to Scale for Children, Adolescents, and Young People in Zimbabwe.

Since 2004, there has been a dramatic shift in the HIV response for children, adolescents, and young people in low resource settings. Previous programs and services were largely orientated to adults. This is now changing, but there is limited evidence on how to take services for children, adolescents, and young people living with HIV (CAYPLHIV) to scale. Zvandiri is a theoretically grounded, multicomponent-differentiated service delivery model for children, adolescents, and young people in Zimbabwe that integrates peer-led, community interventions within government health services. Africaid analyzed routine program and other data from November 2004 to October 2017 to document Zvandiri scale-up, framed by the World Health Organization framework for scaling up interventions. Since 2004, Zvandiri has evolved from one support group in Harare into a comprehensive model, combining community- and clinic-based health services and psychosocial support for CAYPLHIV. Zvandiri was scaled up across Zimbabwe through phased expansion into 51 of 63 districts, reaching 40,213 CAYPLHIV. Evidence indicates that this approach improved uptake of HIV testing services, adherence, and retention in care. The environment and strategic choices were critical when taking the model to scale, particularly nesting the program within existing services, and capacity strengthening of service providers working jointly with trained, mentored CAYPLHIV. The results provide a firm foundation for programming and from which to build evidence of sustainable impact. Formal impact evaluation is needed and underway. These program data contribute to the essential evidence base on strategic approaches to assist in planning services for this relatively neglected group.

Setting Global Research Priorities in Pediatric and Adolescent HIV Using the Child Health and Nutrition Research Initiative (CHNRI) Methodology.

BACKGROUND: WHO and the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) of the International AIDS Society (IAS) led a collaborative process to set global prioritized research agendas, aiming to focusing future research, funding, and stakeholder's efforts. This study describes the methodology used to establish the research agendas. METHODS: The Child Health and Nutrition Research Initiative methodology was adapted in parallel exercises on pediatric and adolescent HIV. After definition of scope by an expert working group, priority questions were collected from stakeholders through an online survey. Submitted questions were coded, analyzed, and collated. The same respondents were asked to score the collated lists through a second online survey. The top 10 ranked questions per thematic area (testing, treatment, and service delivery) were reviewed and priority themes developed with consideration of existing policy, systematic reviews, and planned, ongoing, and recently published research. RESULTS: A total of 375 respondents submitted 1735 priority research questions. The majority of respondents were from Africa; 55% self-identified as researchers. The final collated lists included 51 and 61 research questions for pediatric and adolescent HIV, respectively. The response rate for the second survey was 48%. The final research agendas include 5 priority research themes per area, discussed in 2 separate publications. CONCLUSIONS: To date, this is the largest example of the Child Health and Nutrition Research Initiative method in pediatric and adolescent HIV in terms of stakeholders reached, and the first to incorporate top thematic areas based on current evidence. Its impact on improving outcomes for these populations will require strong political and financial commitment.

A Global Research Agenda for Adolescents Living With HIV.

BACKGROUND: Despite growing interest in undertaking research in adolescent HIV, the current pace of interventional research in particular remains very low compared with the needs of adolescents living with HIV (ALHIV). More robust evidence is needed to inform innovative and targeted interventions that bridge research gaps, inform policy, and improve outcomes for adolescents. A global research prioritization exercise was undertaken by WHO and CIPHER to focus efforts on priority research in the context of diminishing resources. METHODS: The Child Health and Nutrition Research Initiative (CHNRI) methodology was adapted and used. Outcomes were reviewed by an expert group and 5 priority themes identified for testing, treatment, and service delivery, accounting for existing policies, published literature, and ongoing research. RESULTS: A total of 986 research questions were submitted by 323 individuals from 67 countries. For HIV testing, priority themes included strategies and interventions to improve access, uptake, and linkage to care, and self-testing, particularly for key populations. For treatment, priorities included strategies to monitor and improve adherence, novel drug delivery systems, preventions and management of coinfections, optimal drug sequencing, and short- and long-term outcomes. For service delivery, priorities included service delivery models across the cascade, strategies to improve retention in care and sexual and reproductive health, support for pregnant ALHIV, and the provision of psychosocial support. CONCLUSIONS: This prioritized research agenda assists in focusing future research in ALHIV and will help to fill critical knowledge gaps. Key stakeholders, donors, program managers, and researchers should all support these priority questions and themes to collaboratively drive the adolescent HIV research agenda forward.

Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic.

INTRODUCTION: With increasing survival of vertically HIV-infected children and ongoing new horizontal HIV infections, the population of adolescents (age 10-19 years) living with HIV is increasing. This review aims to describe the epidemiology of the adolescent HIV epidemic and the ability of national monitoring systems to measure outcomes in HIV-infected adolescents through the adolescent transition to adulthood. METHODS: Differences in global trends between younger (age 10-14 years) and older (age 15-19 years) adolescents in key epidemic indicators are interrogated using 2016 UNAIDS estimates. National population-based survey data in the 15 highest adolescent HIV burden countries are evaluated and examples of national case-based surveillance systems described. Finally, we consider the potential impact of adolescent-specific recommendations in the 2016 WHO Consolidated Guidelines on the Use of Antiretroviral Drugs for Treating and Preventing HIV Infection. DISCUSSION: UNAIDS estimates indicate the population of adolescents living with HIV is increasing, new HIV infections in older adolescents are declining, and while AIDS-related deaths are beginning to decline in younger adolescents, they are still increasing in older adolescents. National population-based surveys provide valuable estimates of HIV prevalence in older adolescents and recent surveys include data on younger adolescents. Only a few countries have nationwide electronic case-based HIV surveillance, with the ability to provide population-level data on key HIV outcomes in the diagnosed population living with HIV. However, in the 15 highest adolescent HIV burden countries, there are no systems tracking adolescent transition to adulthood or healthcare transition. The strength of the 2016 WHO adolescent-specific recommendations on antiretroviral therapy and provision of HIV services to adolescents was hampered by the lack of evidence specific to this age group. CONCLUSIONS: Progress is being made in national surveillance and global monitoring systems to specifically identify trends in adolescents living with HIV. However, HIV programmes responsive to the evolving HIV prevention and treatment needs of adolescents can be facilitated further by: data disaggregation to younger and older adolescents and mode of HIV infection where feasible; implementation of tools to achieve expanded national case-based surveillance; streamlining consent/assent procedures in younger adolescents and consensus on indicators of adolescent healthcare transition and transition to adulthood.