Delivery of index-linked HIV testing for children: learnings from a qualitative process evaluation of the B-GAP study in Zimbabwe.

BACKGROUND: Index-linked HIV testing for children, whereby HIV testing is offered to children of individuals living with HIV, has the potential to identify children living with undiagnosed HIV. The "Bridging the Gap in HIV Testing and Care for Children in Zimbabwe" (B-GAP) study implemented and evaluated the provision of index-linked HIV testing for children aged 2-18 years in Zimbabwe. We conducted a process evaluation to understand the considerations for programmatic delivery and scale-up of this strategy. METHODS: We used implementation documentation to explore experiences of the field teams and project manager who delivered the index-linked testing program, and to describe barriers and facilitators to index-linked testing from their perspectives. Qualitative data were drawn from weekly logs maintained by the field teams, monthly project meeting minutes, the project coordinator's incident reports and WhatsApp group chats between the study team and the coordinator. Data from each of the sources was analysed thematically and synthesised to inform the scale-up of this intervention. RESULTS: Five main themes were identified related to the implementation of the intervention: (1) there was reduced clinic attendance of potentially eligible indexes due to community-based differentiated HIV care delivery and collection of HIV treatment by proxy individuals; (2) some indexes reported that they did not live in the same household as their children, reflecting the high levels of community mobility; (3) there were also thought to be some instances of 'soft refusal'; (4) further, delivery of HIV testing was limited by difficulties faced by indexes in attending health facilities with their children for clinic-based testing, stigma around community-based testing, and the lack of familiarity of indexes with caregiver provided oral HIV testing; (5) and finally, test kit stockouts and inadequate staffing also constrained delivery of index-linked HIV testing. CONCLUSIONS: There was attrition along the index-linked HIV testing cascade of children. While challenges remain at all levels of implementation, programmatic adaptations of index-linked HIV testing approaches to suit patterns of clinic attendance and household structures may strengthen implementation of this strategy. Our findings highlight the need to tailor index-linked HIV testing to subpopulations and contexts to maximise its effectiveness.

Origins of clustered frequency combs in Kerr microresonators.

Recent experiments have demonstrated the generation of widely spaced parametric sidebands that can evolve into "clustered" optical frequency combs in Kerr microresonators. Here we describe the physics that underpins the formation of such clustered comb states. In particular, we show that the phase matching required for the initial sideband generation is such that (at least) one of the sidebands experiences anomalous dispersion, enabling the sideband to drive frequency comb formation via degenerate and non-degenerate four-wave mixing. We validate our proposal through a combination of experimental observations made in a magnesium-fluoride microresonator and corresponding numerical simulations. We also investigate the coherence properties of the resulting clustered frequency combs. Our findings provide valuable insights on the generation and dynamics of widely spaced parametric sidebands and clustered frequency combs in Kerr microresonators.

Childhood fish oil supplementation modifies associations between traffic related air pollution and allergic sensitisation.

BACKGROUND: Studies of potential adverse effects of traffic related air pollution (TRAP) on allergic disease have had mixed findings. Nutritional studies to examine whether fish oil supplementation may protect against development of allergic disease through their anti-inflammatory actions have also had mixed findings. Extremely few studies to date have considered whether air pollution and dietary factors such as fish oil intake may interact, which was the rationale for this study. METHODS: We conducted a secondary analysis of the Childhood Asthma Prevention Study (CAPS) birth cohort, where children were randomised to fish oil supplementation or placebo from early life to age 5 years. We examined interactions between supplementation and TRAP (using weighted road density at place of residence as our measure of traffic related air pollution exposure) with allergic disease and lung function outcomes at age 5 and 8 years. RESULTS: Outcome information was available on approximately 400 children (~ 70% of the original birth cohort). Statistically significant interactions between fish oil supplementation and TRAP were seen for house dust mite (HDM), inhalant and all-allergen skin prick tests (SPTs) and for HDM-specific interleukin-5 response at age 5. Adjusting for relevant confounders, relative risks (RRs) for positive HDM SPT were RR 1.74 (95% CI 1.22-2.48) per 100 m local road or 33.3 m of motorway within 50 m of the home for those randomised to the control group and 1.03 (0.76-1.41) for those randomised to receive the fish oil supplement. The risk differential was highest in an analysis restricted to those who did not change address between ages 5 and 8 years. In this sub-group, supplementation also protected against the effect of traffic exposure on pre-bronchodilator FEV1/FVC ratio. CONCLUSIONS: Results suggest that fish oil supplementation may protect against pro-allergic sensitisation effects of TRAP exposure. Strengths of this analysis are that supplementation was randomised and independent of TRAP exposure, however, findings need to be confirmed in a larger experimental study with the interaction investigated as a primary hypothesis, potentially also exploring epigenetic mechanisms. More generally, studies of adverse health effects of air pollution may benefit from considering potential effect modification by diet and other factors. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry. www.anzctr.org.au Registration: ACTRN12605000042640 , Date: 26th July 2005. Retrospectively registered, trial commenced prior to registry availability.

Comparison of the NHANES dietary screener questionnaire to the Automated Self-Administered 24-Hour Recall for Children in the Healthy Communities Study.

BACKGROUND: A dietary screener questionnaire (DSQ) was used to assess dietary outcomes among children in the Healthy Communities Study (HCS), a study of the relationships between programs and policies to prevent child obesity and child diet, physical activity and weight outcomes. METHODS: To compare dietary intake estimates derived from the DSQ against those from the Automated Self-Administered 24-Hour Recalls for Children (ASA24-Kids) among children, a measurement error model, using structural equation modelling, was utilized to estimate slopes, deattenuated correlation coefficients, and attenuation factors by age and sex, ethnicity, and BMI status. PARTICIPANTS/SETTING: A randomly selected sub-sample of HCS participants aged 4-15 years in 130 communities throughout the U.S. who completed the DSQ and up to two ASA24-Kids recalls (n = 656;13% of HCS participants). RESULTS: For most nutrient/foods examined, the DSQ yielded larger mean intake estimates than the ASA24-Kids, and agreement between the two measures varied by food/nutrient, age and sex, ethnicity, and BMI category. Deattenuated correlation coefficients of 0.4 or greater were observed for added sugars from SSBs (0.54), fruits and vegetables (0.40), and dairy foods (0.50). Lower deattenuated correlation coefficients were seen for total added sugars (0.37), whole grains (0.34), and fiber (0.34). Attenuation factors were most severe for total added sugars intake among overweight children, and for several other dietary outcomes among children aged 9-11 years. CONCLUSIONS: The DSQ was found to be a tool with acceptable agreement with the ASA24-Kids for measuring multiple dietary outcomes of interest in the HCS, although there may be potential due to measurement error to underestimate results (bias towards the null). In future studies, measurement error modelling and regression calibration may be possible solutions to correct for bias due to measurement error in most food/nutrient intake estimates from the DSQ when used among children.

Widely tunable optical parametric oscillation in a Kerr microresonator.

We report on the first experimental demonstration of widely tunable parametric sideband generation in a Kerr microresonator. Specifically, by pumping a silica microsphere in the normal dispersion regime, we achieve the generation of phase-matched four-wave mixing sidebands at large frequency detunings from the pump. Thanks to the role of higher-order dispersion in enabling phase matching, small variations of the pump wavelength translate into very large and controllable changes in the wavelengths of the generated sidebands: we experimentally demonstrate over 720 nm of tunability using a low-power continuous-wave pump laser in the C-band. We also derive simple theoretical predictions for the phase-matched sideband frequencies and discuss the predictions in light of the discrete cavity resonance frequencies. Our experimentally measured sideband wavelengths are in very good agreement with theoretical predictions obtained from our simple phase-matching analysis.

Experimental observation of coherent cavity soliton frequency combs in silica microspheres.

We report on the experimental observation of coherent cavity soliton frequency combs in silica microspheres. Specifically, we demonstrate that careful alignment of the microsphere relative to the coupling fiber taper allows for the suppression of higher-order spatial modes, reducing mode interactions and enabling soliton formation. Our measurements show that the temporal cavity solitons have sub-100-fs durations, exhibit considerable Raman self-frequency shift, and generally come in groups of three or four, occasionally with equidistant spacing in the time domain. RF amplitude noise measurements and spectral interferometry confirm the high coherence of the observed soliton frequency combs, and numerical simulations show good agreement with experiments.

Facility-based delivery in the context of Zimbabwe's HIV epidemic--missed opportunities for improving engagement with care: a community-based serosurvey.

BACKGROUND: In developing countries, facility-based delivery is recommended for maternal and neonatal health, and for prevention of mother-to-child HIV transmission (PMTCT). However, little is known about whether or not learning one's HIV status affects one's decision to deliver in a health facility. We examined this association in Zimbabwe. METHODS: We analyzed data from a 2012 cross-sectional community-based serosurvey conducted to evaluate Zimbabwe's accelerated national PMTCT program. Eligible women (≥16 years old and mothers of infants born 9-18 months before the survey) were randomly sampled from the catchment areas of 157 health facilities in five of ten provinces. Participants were interviewed about where they delivered and provided blood samples for HIV testing. RESULTS: Overall 8796 (77 %) mothers reported facility-based delivery; uptake varied by community (30-100%). The likelihood of facility-based delivery was not associated with maternal HIV status. Women who self-reported being HIV-positive before delivery were as likely to deliver in a health facility as women who were HIV-negative, irrespective of when they learned their status - before (adjusted prevalence ratio (PRa) = 1.04, 95% confidence interval (CI) = 1.00-1.09) or during pregnancy (PRa = 1.05, 95% CI = 1.01-1.09). Mothers who had not accessed antenatal care or tested for HIV were most likely to deliver outside a health facility (69%). Overall, however 77% of home deliveries occurred among women who had accessed antenatal care and were HIV-tested. CONCLUSIONS: Uptake of facility-based delivery was similar among HIV-infected and HIV-uninfected mothers, which was somewhat unexpected given the substantial technical and financial investment aimed at retaining HIV-positive women in care in Zimbabwe.

"She's a Family Member": How Community Health Workers Impact Perinatal Mothers' Stress Through Social-Emotional Support and Connections to Programs and Resources.

Introduction: This study examines whether being a client in the Northwest Ohio Pathways HUB program reduces stress and improves mental wellbeing for perinatal mothers. The HUB works to improve health by connecting mothers to community health workers (CHWs) who assess mothers' risk factors and connect them to evidence-based care pathways to reduce known risks associated with adverse birth outcomes. Methods: A one-time survey of 119 mothers in the program and monthly semi-structured interviews with 41 mothers, totaling 220 interviews. Results: Almost all mothers reported significantly reduced stress after joining the program. The majority also reported an improved sense of safety, security, and hope. Interviews show additional moderate reductions in stress over time while being a program client. Interviews also indicate that mothers' relationship with their CHW is key to these improvements: CHW provide social-emotional support, access to tangible goods, and help navigating social service bureaucracies. Discussion: The results support the broader literature on the health benefits of community health workers and address identified gaps within the literature, which has infrequently studied CHWs in the perinatal context. Conclusion: CHWs may be one way to address racial inequity in birth outcomes linked to infant mortality, given research on the links between inequitable exposure to stressors, the impacts of racism-induced stress, and preterm and low birth weight babies. Further, the findings indicate the need to better support CHWs, and the programs that utilize them, with increased funding, insurance reimbursement, and certification.

Understanding the impact of the COVID-19 pandemic and its control measures on women and children: A Zimbabwe case study.

COVID-19 presented countries with unprecedented health policy challenges. For low-income countries in particular, policymakers had to contend with both the direct threats posed by COVID-19 as well as the social, educational, and economic harms associated with lockdown and other infection prevention and control measures. We present a holistic and contextualised case study of the direct and indirect impacts of COVID-19 on women and children, with some assessment of their uneven distribution across socio-economic, age and gender groups. We used different types of primary and secondary data from multiple sources to produce a holistic descriptive analysis. Primary data included: qualitative data obtained from 28 in-depth interviews of key informants, six focus group discussions; and 40 household interviews. We also extracted data from government reports and announcements, the District Health Information Software version 2 (DHIS2), newspaper articles and social media, as well as from published research articles. Our findings show that the direct and indirect adverse impacts of COVID-19 were compounded by many years of severe political economic challenges, and consequent deterioration of the healthcare system. The indirect effects of the pandemic had the most severe impacts on the poorest segment of society and widened age and gender inequalities. The pandemic and its accompanying infection prevention and control measures negatively affected health service delivery and uptake. The management of COVID-19 presented enormous challenges to policymakers and public health specialists. These included managing the greatest tension between direct and indirect harms; short-term and long-term effects; and the unequal distribution of harms across different segments of society.

Increasing the initiation of antiretroviral therapy through optimal placement of diagnostic technologies for pediatric HIV in Zimbabwe: A modeling analysis.

OBJECTIVES: Point-of-care (POC) devices for infant HIV testing provide timely result-return and increase antiretroviral (ART) initiation. We aimed to optimally locate POC devices to increase 30-day ART initiation in Matabeleland South, Zimbabwe. METHODS: We developed an optimization model to identify the locations for limited POC devices at health facilities, maximizing the number of infants who receive HIV test results and initiate ART within 30 days of testing. We compared location-optimization model results to non-model-based decision heuristics, which are more practical and less data-intensive. Heuristics assign POC devices based on demand, test positivity, laboratory result-return probability, and POC machine functionality. RESULTS: With the current placement of 11 existing POC machines, 37% of all tested infants with HIV were projected to receive results and 35% were projected to initiate ART within 30 days of testing. With optimal placement of existing machines, 46% were projected to receive results and 44% to initiate ART within 30 days, retaining three machines in current locations, moving eight to new facilities. Relocation based on the highest POC device functionality would be the best-performing heuristic decision (44% receiving results and 42% initiating ART withing 30 days); although, it still would not perform as well as the optimization-based approach. CONCLUSION: Optimal and ad hoc heuristic relocation of limited POC machines would increase timely result-return and ART initiation, without further, often costly, interventions. Location optimization can enhance decision-making regarding the placement of medical technologies for HIV care.

Dairy consumption and diet quality in a sample of Australian children.

OBJECTIVE: To examine the association between intake of dairy products and indicators of diet quality among a sample of Australian children. METHODS: Three 24-hour recalls were collected from 222 children aged 8-10 years living in western Sydney. Analysis of covariance was used to examine differences in mean intakes of foods and nutrients among 3 dairy consumption groups (<1 serve, 1-2 serves, ≥2 serves per day). The percentage of children meeting healthy eating guidelines for foods and estimated average requirements (EAR) for nutrients was also assessed. RESULTS: Higher dairy consumption was associated with higher intakes of energy, protein, calcium, phosphorus, magnesium, potassium, zinc, vitamin A, riboflavin, and niacin as well as foods from the bread and cereal group but lower intakes of mono- and polyunsaturated fats, foods from the meat and alternatives group, and energy-dense, nutrient-poor foods. Children who consumed ≥2 serves of dairy products per day (38%) were more likely to meet food and nutrient recommendations. Body mass index z-score and waist circumference were not associated with dairy consumption. Milk intake was inversely associated with the intake of sugar-sweetened beverages, and children who did not meet their minimum dairy serve recommendations consumed higher quantities of sugar-sweetened beverages than milk. CONCLUSIONS: Adequate dairy consumption was associated with diets of higher nutritional quality but also higher intakes of energy, suggesting a potential benefit from shifting consumption from regular-fat to reduced-fat dairy products in line with current national recommendations.

Breastfeeding, asthma, and allergy: a tale of two cities.

BACKGROUND: The effect of breastfeeding duration on subsequent asthma and allergy remains the subject of much controversy. OBJECTIVE: To investigate whether differences in study design or disease-related exposure modification were the cause of the differences in study findings. METHOD: The data from two cohorts, the Childhood Asthma Prevention Study (CAPS) from Australia and the Barn Allergi Miljo Stockholm cohort from Sweden, which had reported different findings on the association between breastfeeding and asthma, were combined. For this analysis, the definitions for breastfeeding, asthma, and allergy were harmonized. Subjects were included if they had at least one parent with wheeze or asthma and had a gestational age of more than 36 wks (combined n = 882). The risk of disease-related exposure modification was assessed using survival analysis. RESULTS: Breastfeeding reduced the risk of asthma at 4/5 and 8 yrs of age in children with a family history of asthma. The effect was stronger in the Swedish cohort. Breastfeeding had no effect on the prevalence of sensitization to inhaled allergens in this cohort with a family history of asthma but was a risk factor for sensitization to cow's milk, peanuts, and eggs in the CAPS cohort at 4/5 yrs and in the combined cohort at 8 yrs. There was no evidence to support the existence of disease-related exposure modification in either cohort. CONCLUSION: These findings point to the importance of harmonization of features of study design, including subject selection criteria and variable definitions, in resolving epidemiological controversies such as those surrounding the impact of breastfeeding on asthma and allergic sensitization.

Comparison of Fruit and Vegetable Prices between Farmers' Markets and Supermarkets: Implications for Fruit and Vegetable Incentive Programs for Food Assistance Program Participants.

This cross-sectional study was part of a larger evaluation of a fruit and vegetable (FV) incentive program for Supplemental Nutrition Assistance Program (SNAP) participants in California. We examined the price differences in FV to explore whether these could help explain a previously observed lack of effect of the incentive program on FV consumption. Differences by type (organic/no-spray or conventional), among a convenience sample of farmers' markets (n = 11) and nearby supermarkets (n = 7), were assessed using Wilcoxon rank-sum tests adjusting for clustering by market. We calculated the cost of market baskets comprising recommended FV servings for a household using median prices to consider the implications of FV price differences for SNAP shoppers who use financial incentives for FV. We found that farmers' markets primarily offered organic FV while supermarkets primarily offered conventionally grown FV. Farmers' market prices tended to be lower than supermarkets for organic FV but higher for conventional FV. Compared to supermarkets, the market basket composed only of organic FV cost USD 16.34 less at farmers' markets, whereas a basket comprised of a mix of conventionally and organically grown FV cost USD 3.68 more. These differences warrant further exploration; FV price and type should be considered in studies aimed at understanding the impact of SNAP financial incentive programs.

Engaging women and men in the gender-synchronised, community-based Mbereko+Men intervention to improve maternal mental health and perinatal care-seeking in Manicaland, Zimbabwe: A cluster-randomised controlled pragmatic trial.

Background: Maternal mental morbidity and low perinatal health service utilisation in resource-constrained settings contribute substantially to the global burden of poor maternal, newborn, and child health. The community-based Mbereko+Men program in rural Zimbabwe engaged women and men in complementary activities to improve men's support for women and babies, coparents' equitable, informed health decision-making, and ultimately, maternal mental health and care-seeking for maternal and newborn health services. The study aimed to test the effectiveness of the Mbereko+Men program on maternal mental health at 0-6 months after childbirth. Methods: We conducted a cluster-randomised controlled pragmatic trial using a two-arm parallel design with four clusters per arm. Data was data collected through cross-sectional surveys before and after the implementation of the intervention or standard care. Rural health facility catchments in Mutasa District, Zimbabwe, were randomised using a true random number sequence. Survey participants were women who had given birth within 0-6 months and their male coparents. The primary outcome was women's mean Edinburgh Postnatal Depression Scale (EPDS) score. Secondary outcomes captured care-seeking, men's supportive behaviours, and gender dynamics in coparent relationships. Masking was not used. All clusters were included in the analysis. The trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620001014943) in October 2020. Results: Between April 13 and May 20, 2016, 457 women and 242 men participated in the pre-intervention survey; between October 19 and November 30, 2017, 433 women and 273 men participated in the post-intervention survey. Women's mean EPDS scores declined in both arms. The decline was 34% greater in the intervention arm (adjusted risk ratio = 0.66; 95% confidence interval = 0.48, 0.90, P = 0.008). Improvements in care-seeking, men's support, and coparents' relationships were detected. Conclusions: A low-intensity gender-synchronised intervention engaged women and men to improve maternal mental health and care-seeking in a setting characterised by gender inequality and demand-side barriers to care.

'I was trying to get there, but I couldn't': social norms, vulnerability and lived experiences of home delivery in Mashonaland Central Province, Zimbabwe.

Increasing facility-based delivery rates is pivotal to reach Sustainable Development Goals to improve skilled attendance at birth and reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). The translation of global health initiatives into national policy and programmes has increased facility-based deliveries in LMICs, but little is known about the impact of such policies on social norms from the perspective of women who continue to deliver at home. This qualitative study explores the reasons for and experiences of home delivery among women living in rural Zimbabwe. We analysed qualitative data from 30 semi-structured interviews and 5 focus group discussions with women who had delivered at home in the previous 6 months in Mashonaland Central Province. We found evidence of strong community-level social norms in favour of facility-based delivery. However, despite their expressed intention to deliver at a facility, women described how multiple, interacting vulnerabilities resulted in delivery outside of a health facility. While identified as having delivered 'at home', narratives of birth experiences revealed the majority of women in our study delivered 'on the road', en route to the health facility. Strong norms for facility-based delivery created punishments and stigmatization for home delivery, which introduced additional risk to women at the time of delivery and in the postnatal period. These consequences for breaking social norms promoting facility-based delivery for all further increased the vulnerability of women who delivered at home or on the road. Our findings highlight that equitable public health policy and programme designs should include efforts to actively identify, mitigate and evaluate unintended consequences of social change created as a by-product of promoting positive health behaviours among those most vulnerable who are unable to comply.

Feasibility and Accuracy of HIV Testing of Children by Caregivers Using Oral Mucosal Transudate HIV Tests.

BACKGROUND: Children encounter multiple barriers in accessing facilities. HIV self-testing using oral mucosal transudate (OMT) tests has been shown to be effective in reaching hard-to-reach populations. We evaluated the feasibility and accuracy of caregivers conducting HIV testing using OMTs in children in Zimbabwe. METHODS: We offered OMTs to caregivers (>18 years) living with HIV to test children (2-18 years) living in their households. All caregivers were provided with manufacturer instructions. In Phase 1 (January-December 2018, 9 clinics), caregivers additionally received a demonstration by a provider using a test kit and video. In Phase 2 (January-May 2019, 3 clinics), caregivers did not receive a demonstration. We collected demographic data and assessed caregiver's ability to perform the test and interpret results. Caregiver performance was assessed by direct observation and scored using a predefined checklist. Factors associated with obtaining a full score were analyzed using logistic regression. RESULTS: Overall 400 caregivers (83.0% female, median age 38 years) who were observed tested 786 children (54.6% female, median age 8 years). For most tests, caregivers correctly collected oral fluid [87.1% without provider demonstrations (n = 629) and 96.8% with demonstrations (n = 157), P = 0.002]. The majority correctly used a timer (90.3% without demonstrations and 96.8% with demonstrations, P = 0.02). In multivariate logistic regression caregivers who obtained a full score for performance were more likely to have received a demonstration (odds ratio 4.14, 95% confidence interval: 2.01 to 8.50). CONCLUSIONS: Caregiver-provided testing using OMTs is a feasible and accurate HIV testing strategy for children. We recommend operational research to support implementation at scale.

Comparison of index-linked HIV testing for children and adolescents in health facility and community settings in Zimbabwe: findings from the interventional B-GAP study.

BACKGROUND: Index-linked HIV testing, whereby children of individuals with HIV are targeted for testing, increases HIV yield but relies on uptake. Community-based testing might address barriers to testing access. In the Bridging the Gap in HIV testing and care for children in Zimbabwe (B-GAP) study, we investigated the uptake and yield of index-linked testing in children and the uptake of community-based vs facility-based HIV testing in Zimbabwe. METHODS: B-GAP was an interventional study done in the city of Bulawayo and the province of Matabeleland South between Jan 29 and Dec 12, 2018. All HIV-positive attendees (index patients) at six urban and three rural primary health-care clinics were offered facility-based or community-based HIV testing for children (age 2-18 years) living in their households who had never been tested or had tested as HIV-negative more than 6 months ago. Community-based options involved testing in the home by either a trained lay worker with a blood-based rapid diagnostic test (used in facility-based testing), or by the child's caregiver with an oral HIV test. Among consenting individuals, the primary outcome was testing uptake in terms of the proportion of eligible children tested. Secondary outcomes were uptake of the different HIV testing methods, HIV yield (proportion of eligible children who tested positive), and HIV prevalence (proportion of HIV-positive children among those tested). Logistic regression adjusting for within-index clustering was used to investigate index patient and child characteristics associated with testing uptake, and the uptake of community-based versus facility-based testing. FINDINGS: Overall, 2870 index patients were linked with 6062 eligible children (3115 [51·4%] girls [sex unknown in seven], median age 8 years [IQR 5-13]). Testing was accepted by index patients for 5326 (87·9%) children, and 3638 were tested with a known test outcome, giving an overall testing uptake among 6062 eligible children of 60·0%. 39 children tested positive for HIV, giving an HIV prevalence among the 3638 children of 1·1% and an HIV yield among 6062 eligible children of 0·6%. Uptake was positively associated with female sex in the index patient (adjusted odds ratio [aOR] 1·56 [95% CI 1·38-1·77], p<0·0001) and child (aOR 1·10 [1·03-1·19], p=0·0080), and negatively associated with any financial cost of travel to a clinic (aOR 0·86 [0·83-0·88], p<0·0001), increased child age (6-9 years: aOR 0·99 (0·89-1·09); 10-15 years: aOR 0·91 [0·83-1·00]; and 16-18 years: aOR 0·75 [0·66-0·85]; p=0·0001 vs 2-5 years), and unknown HIV status of the mother (aOR 0·81 [0·68-0·98], p=0·027 vs HIV-positive status). Additionally, children had increased odds of being tested if community-based testing was chosen over facility-based testing at screening (1320 [73·9%] children tested of 1787 vs 2318 [65·5%] of 3539; aOR 1·49 [1·22-1·81], p=0·0001). INTERPRETATION: The HIV yield of index-linked testing was low compared with blanket testing approaches in similar settings. Index-linked HIV testing can improve testing uptake among children, although strategies that improve testing uptake in older children are needed. Community based testing by lay workers is a feasible strategy that can be used to improve uptake of HTS among children and adolescents. FUNDING: UK Medical Research Council, UK Department for International Development, Wellcome Trust.

Why be smoke-free? A qualitative study of smoke-free restaurant owner and manager opinions.

This qualitative study captured the opinions of the owners and managers of smoke-free restaurants. The purpose of this study, initiated by local citizens who were members of a group called Healthy Alamance, was to identify the motivations and experiences of restaurant owners and managers who had committed to smoke-free indoor environments. Telephone interviews were attempted with all 80 owners/managers of smoke-free restaurants in Alamance County, North Carolina, and 87.5% of these restaurant owners/managers completed the interview. The investigators isolated economic factors, customer demands and considerations, and environmental issues as the three principal categories describing smoke-free restaurant owners' and managers' motivations for becoming smoke free. The results from this study can be used to assist communities working toward the development of a smoke-free restaurant campaign.

Community-level obesity prevention is not associated with dieting behaviours and weight dissatisfaction in children: The Healthy Communities Study.

BACKGROUND: Within the context of high childhood obesity prevalence, there is a concern that community efforts intended to reduce childhood obesity may lead to unintended adverse outcomes. OBJECTIVE: This analysis examined relationships between community programs, policies, and environmental changes (CPPs) for obesity prevention with unhealthy dieting behaviours and body weight satisfaction in children. METHODS: Using the Healthy Communities Study 2013 to 2015 survey sample of 5138 US children aged 4 to 15 years old, multilevel models examined associations between standardized CPP intensity scores and child dieting behaviours and weight satisfaction, adjusting for community and child-level covariates and clustered study design. RESULTS: In fully adjusted models, higher total, physical activity, and nutrition CPP intensity scores were associated with lower odds of dissatisfaction with weight (1 year total CPP odds ratio [OR]: 0.41, 95% confidence interval [CI], 0.22-0.73; 6 year total CPP OR: 0.48, 0.29-0.80). Higher physical activity CPP intensity over the past year was associated with greater odds of weight satisfaction (OR: 1.77, 95% CI, 1.10-2.84). No associations were observed with dieting behaviours. CONCLUSIONS: Results suggest that community efforts focusing on nutrition and physical activity to prevent childhood obesity may be associated with weight satisfaction and not with unhealthy dieting behaviours.

Brief Report: Improving Early Infant Diagnosis Observations: Estimates of Timely HIV Testing and Mortality Among HIV-Exposed Infants.

BACKGROUND: Improving efforts toward elimination of mother-to-child transmission of HIV requires timely early infant diagnosis (EID) among all HIV-exposed infants, but the occurrence of timely EID and infant survival may be underascertained in routine, facility-bound program data. METHODS: From March 2015 to May 2015, we traced a random sample of HIV-positive mother and HIV-exposed infant pairs lost to follow-up for EID in facility registers in Zimbabwe. We incorporated updated information into weighted survival analyses to estimate incidence of EID and death. Reasons for no EID were surveyed from caregivers. RESULTS: Among 2651 HIV-positive women attending antenatal care, 1823 (68.8%) infants had no documented EID by 3 months of age. Among a random sample of 643 (35.3%) HIV-exposed infants lost to follow-up for EID, vital status was ascertained among 371 (57.7%) and updated care status obtained from 256 (39.8%) mothers traced. Among all HIV-infected mother-HIV-exposed infant pairs, weighted estimates found cumulative incidence of infant death by 90 days of 3.9% (95% confidence interval: 3.4% to 4.4%). Cumulative incidence of timely EID with death as a competing risk was 60%. The most frequently cited reasons for failure to uptake EID were "my child died" and "I didn't know I should have my child tested." CONCLUSIONS: Our findings indicate uptake of timely EID among HIV-exposed infants is underestimated in routine health information systems. High, early mortality among HIV-exposed infants underscores the need to more effectively identify HIV-positive mother-HIV exposed infant pairs at high risk of adverse outcomes and loss to follow-up for enhanced interventions.