A peer-facilitated psychological group intervention for perinatal women living with HIV and depression in Tanzania-Healthy Options: A cluster-randomized controlled trial.

BACKGROUND: Perinatal women living with HIV (PWLH) have a greater risk of depression compared to other women; however, there are limited specialized mental health services available to them. We aimed to determine whether a stepped-care intervention facilitated by trained lay providers can improve mental health outcomes postpartum for PWLH. METHODS AND FINDINGS: Healthy Options is a cluster-randomized controlled study conducted in 16 government-managed antenatal care clinics that provided HIV care for pregnant women in urban Tanzania. Recruitment occurred from May 2015 through April 2016, with the final round of data collection completed in October 2017. Participants included a consecutive sample of pregnant women under 30 weeks of gestation, living with HIV and depression, and attending the study clinics. Control sites received enhanced usual care for depression (EUDC). Intervention sites received EUDC plus the Healthy Options intervention, which includes prenatal group sessions of problem-solving therapy (PST) plus cognitive behavioral therapy (CBT) sessions for individuals showing depressive symptoms at 6 weeks postdelivery. We assessed depressive symptoms comparable to major depressive disorder (MDD) using the Patient Health Questionnaire-9 (PHQ-9) with a locally validated cutoff at 9 months and 6 weeks postpartum. The primary time point is 9 months postpartum. We examined differences in outcomes using an intent-to-treat analysis with a complete case approach, meaning those with data at the relevant time point were included in the analysis. We used generalized estimating equations accounting for clustering. Of 818 women screened using the PHQ-9, 742 were determined eligible and enrolled (395 intervention; 347 control); 649 women (87.5%) participated in the first follow-up and 641 women (86.4%) in the second. A majority (270, 74.6%) of women in the intervention arm attended 5 or more PST sessions. Women enrolled in Healthy Options demonstrated a 67% (RR 0.33; 95% CI: 0.22, 0.51; p-value: <0.001; corresponding to a 25.7% difference in absolute risk) lower likelihood of depressive symptoms than women in control clusters at 6 weeks postpartum. At 9 months postpartum, women enrolled in Healthy Options demonstrated a nonsignificant 26% (RR 0.74; 95% CI: 0.42, 1.3; p-value: 0.281; corresponding to a 3.2% difference in absolute risk) lower likelihood of depressive symptoms than women in control clusters. Study limitations include not using diagnostic interviews to measure depression and not blinding data collectors to intervention status during follow-up. CONCLUSIONS: The Healthy Options intervention did not demonstrate reduction in depressive symptoms at 9 months postpartum, the primary outcome. Significant reductions were seen in depression symptoms at 6 weeks postpartum, the secondary outcome. Stepped-care interventions may be relevant for improving outcomes in the critical early postpartum window. TRIAL REGISTRATION: Clinical Trial registration number (closed to new participants) NCT02039973.

Depression and Viral Suppression Among Adults Living with HIV in Tanzania.

Limited information is available on the association between depression and viral suppression among people living with HIV (PLH) in sub-Saharan Africa. We conducted a prospective cohort study of 3996 adults initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania. Log-binomial models were used to assess the association between depression and the risk of an unsuppressed viral load (> 400 copies/mL) after 6 months of ART. Women who had depression at both initiation and after 6 months of treatment had 1.94 times (95% CI 1.22, 3.09; z = 2.78, p < 0.01) the risk of an unsuppressed viral load after 6 months of treatment as compared to women who did not have depression at either time point. Men with the top tertile of depressive symptoms after 6 months of treatment had 1.58 times the risk of an unsuppressed viral load (95% CI 1.04, 2.38; z = 2.15, p = 0.03) as compared to the lowest tertile. Research should be pursued on interventions to prevent and address depression among adults initiating ART to potentially support achievement of viral suppression.

Prevalence and factors associated with intimate partner violence after HIV status disclosure among pregnant women with depression in Tanzania.

Intimate partner violence (IPV) exacts a heavy burden on women, resulting in poor health outcomes. This study had the following aims: (1) estimate the prevalence of IPV post-disclosure of HIV status among pregnant women living with HIV and depression; and (2) evaluate risk and protective factors for IPV post-disclosure. Participants were women accessing PMTCT services at 16 health facilities in Dar es Salaam and screened at the threshold of 9 on the PHQ-9. Generalized linear equations with a log link and standard errors clustered at the facility level were used to calculate associations between predictors and IPV post-disclosure. Among 659 women who were in an intimate relationship, 10.2% had experienced physical violence and 11.6% had reported sexual violence from their partner in the past six months; 327 had disclosed their HIV status to their partners. After disclosure to their partners 279 women (85.3%) experienced IPV. HIV-related stigma was associated with increased risk of IPV following disclosure and appreciative relationships with partners and higher hope were associated with reduced risk of IPV. There is a need to identify and advance approaches to HIV disclosure that prevent IPV. Interventions should be developed based on known risk and protective factors for IPV following HIV disclosure in Tanzania and similar settings.

Barriers and Facilitators to Effective Implementation of the NAMWEZA Intervention in Dar es Salaam, Tanzania.

The NAMWEZA intervention was implemented, using a ten-session group format, to build skills targeting psychosocial vulnerabilities and enhancing HIV prevention among people living with HIV (PLH) and their social networks. The overall goal of this intervention is to improve psychological wellbeing and reduce HIV risk behaviours. These analyses aim to describe the barriers and facilitators of implementing the NAMWEZA intervention from the perspective of participants and trained peer group facilitators. Twenty-four in-depth interviews were conducted with NAMWEZA participants, and 50 pooled peer facilitator self-assessment reports were obtained from 16 trained peers. Participants identified personal and structural barriers, including fear of inadvertent HIV status disclosure, time constraints, level of participant reimbursements, and limited space available for group sessions. Factors facilitating effective implementation included perceived benefits of the program, such as reduction in HIV-related risk behaviours, increased self-esteem, and improvement in confidence in HIV prevention communications. Scaling up the NAMWEZA intervention to other areas of Tanzania or regionally should take into account these facilitators and barriers to implementation.

Validating the Children's Depression Inventory in the context of Rwanda.

BACKGROUND: Depression is often co-morbid with chronic conditions, and when combined with HIV it can increase progression and reduce survival. A brief and accurate screening tool for depression among children living with HIV is necessary to increase access to mental health care and improve HIV-related outcomes in the long-term. METHODS: A validation study was conducted, comparing the Children's Depression Inventory (CDI) with a structured clinical assessment as the gold standard among children living with HIV ages 7-14 years in Rwanda. The response rate was 87 % and the analysis was performed among 100 study participants. RESULTS: Twenty-five percent of children had a diagnosis of depression based on the clinical interview. Sensitivity of the CDI ranged from 44 to 76 % and specificity was 92 to 100 % for cut-off scores from 5 to 9. The area under the curve (AUC) for receiver operating characteristic analysis, an estimate of overall accuracy, was 0.87 (95 % confidence interval: 0.77 - 0.97). CONCLUSIONS: The significant prevalence of depression among children living with HIV in Rwanda reflects a critical need to advance mental health care in this population. Although overall accuracy of the CDI is reasonable in this context, further research needs to be done to develop a more sensitive measure of depression in this vulnerable population. Development of a highly sensitive screening measure will be a fundamental step towards improving access to mental health care among children living with HIV, potentially improving health outcomes and quality of life in the long-term as this vulnerable population transitions into adulthood.

Risk and protective factors for suicidal ideation and behaviour in Rwandan children.

BACKGROUND: Suicide is a leading cause of death for young people. Children living in sub-Saharan Africa, where HIV rates are disproportionately high, may be at increased risk. AIMS: To identify predictors, including HIV status, of suicidal ideation and behaviour in Rwandan children aged 10-17. METHOD: Matched case-control study of 683 HIV-positive, HIV-affected (seronegative children with an HIV-positive caregiver), and unaffected children and their caregivers. RESULTS: Over 20% of HIV-positive and affected children engaged in suicidal behaviour in the previous 6 months, compared with 13% of unaffected children. Children were at increased risk if they met criteria for depression, were at high-risk for conduct disorder, reported poor parenting or had caregivers with mental health problems. CONCLUSIONS: Policies and programmes that address mental health concerns and support positive parenting may prevent suicidal ideation and behaviour in children at increased risk related to HIV.

Feasibility of a school-based mental health program implementation to improve the status of depression and quality of life of mothers of children with autism spectrum disorders in urban Bangladesh: MENTHOL study.

Background: We assessed the feasibility of implementing psychological counseling services (PCS) for mothers of children with autism spectrum disorders (ASD) integrated within special education settings in urban Bangladesh. Method: In two special education schools for ASD in Dhaka City, trained female psychologists screened mothers using the Patient Health Questionnaire (PHQ-9). PCS was administered to all the mothers irrespective of a diagnosis of depression. Mothers with a PHQ-9 score >4 who met criteria for a major depressive episode (MDE) based on the DSM-IV Structured Interview Axis I Disorders (SCID-I) were also administered skill-building training through monthly home visits to support ASD care. The level of depression was assessed by the Depression Measurement Scale (DMS), and quality of life (QoL) was measured by Visual Analogue Scale (VAS) of EQ5D5L scale before and after PCS. Result: Among 188 mothers enrolled in the study, 81 (43%) received PCS, and 27.1% (22) had MDE. In the first month, 73 sessions were scheduled and 60 completed (85%). In the last month, 53 sessions were scheduled and 52 completed (98%). The mean DMS score decreased from 79.5 ± 23 to 60 ± 20 (p = 0.004), and DMS scores were significantly higher among mothers with MDE (97.8 ± 12.1 v. 69.9 ± 22.1; p < 0.001) compared to those without MDE (72.7 ± 22.6 v. 56.1 ± 18.1; p = 0.003). The mean VAS score improved from 70.3 ± 14.1 to 80.2 ± 13.3 (p = 0.001) between the first and the last session. Changes in DMS were negatively correlated with changes in VAS scores (ß: -0.213, 95% CI 0.370 to -0.056). Conclusion: Within special education schools for ASD in urban Bangladesh, it was feasible to administer an integrated program of PCS for mothers of children with ASD by trained psychologists who were able to screen and intervene to reduce their level of depression and improve their quality of life.

Evaluating spillover of HIV knowledge from study participants to their network members in a stepped-wedge behavioural intervention in Tanzania.

OBJECTIVES: We aim to describe the social network members of participants of a behavioural intervention, and examine how the effects of the intervention may spillover among network members. DESIGN: Secondary analysis of a step-wedge randomised controlled trial. SETTING: Change agents (CAs) were recruited from waiting rooms of HIV treatment facilities in Dar es Salaam, Tanzania, and their network members (NMs) were recruited directly by CAs. PARTICIPANTS: We enrolled 662 CAs in an HIV behavioural intervention. They, along with 710 of their NMs, completed baseline and follow-up interviews from 2011 to 2013. PRIMARY AND SECONDARY OUTCOMES: The primary outcome of this study was change in NMs' HIV knowledge, and the secondary outcome was whether the NM was lost to follow-up. RESULTS: At baseline, many characteristics were different between NMs and CAs. We found a number of NM characteristics significantly associated with follow-up of NMs, particularly female gender (OR=1.64, 95% CI: 1.02 to 2.63) and HIV knowledge (OR=20.0, 95% CI: 3.70 to 125); only one CA variable was significantly associated with NM follow-up: having a private source of water (OR=2.17, 95% CI: 1.33 to 3.57). The 14.2% increase in NMs' HIV knowledge was largely due to CAs feeling empowered to pass on prior knowledge, rather than transmitting new knowledge to their NMs. CONCLUSIONS: Characteristics of social network members of persons living with HIV persons living with HIV may play a role in study retention. Additionally, the HIV knowledge of these NMs increased largely as a function of CA participation in the intervention, suggesting that intervening among highly-connected individuals may maximise benefits to the potential population for whom spillover can occur. TRIAL REGISTRATION NUMBER: Clinical Trial: NCT01693458; Post-results.

Depression and post-traumatic stress disorder among Haitian immigrant students: implications for access to mental health services and educational programming.

BACKGROUND: Previous studies of Haitian immigrant and refugee youth have emphasized "externalizing" behaviors, such as substance use, high risk sexual behavior, and delinquency, with very little information available on "internalizing" symptoms, such as depression and anxiety. Analyzing stressors and "internalizing" symptoms offers a more balanced picture of the type of social and mental health services that may be needed for this population. The present study aims to: 1) estimate the prevalence of depression and post-traumatic stress disorder (PTSD) among Haitian immigrant students; and 2) examine factors associated with depression and PTSD to identify potential areas of intervention that may enhance psychosocial health outcomes among immigrant youth from Haiti in the U.S. METHODS: A stratified random sample of Haitian immigrant students enrolled in Boston public high schools was selected for participation; 84% agreed to be interviewed with a standardized questionnaire. Diagnosis of depression and PTSD was ascertained using the best estimate diagnosis method. RESULTS: The prevalence estimates of depression and PTSD were 14.0% and 11.6%; 7.9% suffered from comorbid PTSD and depression. Multivariate logistic regression demonstrated factors most strongly associated with depression (history of father's death, self-report of schoolwork not going well, not spending time with friends) and PTSD (concern for physical safety, having many arguments with parents, history of physical abuse, and lack of safety of neighborhood). CONCLUSIONS: A significant level of depression and PTSD was observed. Stressors subsequent to immigration, such as living in an unsafe neighborhood and concern for physical safety, were associated with an increased risk of PTSD and should be considered when developing programs to assist this population. Reducing exposure to these stressors and enhancing access to social support and appropriate school-based and mental health services may improve educational attainment and psychosocial health outcomes among Haitian immigrant youth.

Early life risk factors of motor, cognitive and language development: a pooled analysis of studies from low/middle-income countries.

OBJECTIVE: To determine the magnitude of relationships of early life factors with child development in low/middle-income countries (LMICs). DESIGN: Meta-analyses of standardised mean differences (SMDs) estimated from published and unpublished data. DATA SOURCES: We searched Medline, bibliographies of key articles and reviews, and grey literature to identify studies from LMICs that collected data on early life exposures and child development. The most recent search was done on 4 November 2014. We then invited the first authors of the publications and investigators of unpublished studies to participate in the study. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies that assessed at least one domain of child development in at least 100 children under 7 years of age and collected at least one early life factor of interest were included in the study. ANALYSES: Linear regression models were used to assess SMDs in child development by parental and child factors within each study. We then produced pooled estimates across studies using random effects meta-analyses. RESULTS: We retrieved data from 21 studies including 20 882 children across 13 LMICs, to assess the associations of exposure to 14 major risk factors with child development. Children of mothers with secondary schooling had 0.14 SD (95% CI 0.05 to 0.25) higher cognitive scores compared with children whose mothers had primary education. Preterm birth was associated with 0.14 SD (-0.24 to -0.05) and 0.23 SD (-0.42 to -0.03) reductions in cognitive and motor scores, respectively. Maternal short stature, anaemia in infancy and lack of access to clean water and sanitation had significant negative associations with cognitive and motor development with effects ranging from -0.18 to -0.10 SDs. CONCLUSIONS: Differential parental, environmental and nutritional factors contribute to disparities in child development across LMICs. Targeting these factors from prepregnancy through childhood may improve health and development of children.

Wòch nan Soley: the denial of the right to water in Haiti.

This article combines health and water research results, evidence from confidential documents released under the Freedom of Information Act, legal analysis, and discussion of historical context to demonstrate that actions taken by the international community through the Inter-American Development Bank are directly related to a lack of access to clean water in Haiti. The article demonstrates that these actions constitute a clear violation of Haitians' right to water under both domestic and international law. The article exposes the United States governments role in blocking the disbursal of millions of dollars in international bank loans that would have had life-saving consequences for the Haitian people. The loans were derailed in 2001 by politically-motivated interventions on behalf of the US and other members of the international community in direct violation of the Inter-American Development Bank charter. To demonstrate the impact of these interventions, the article presents data gathered in a study that employed human rights and public health methodologies to assess the right to water in Haiti. The data reveal that Haitians experience obstacles concerning every aspect of the right to water: diffculties with water availability, limited physical and economic accessibility, and poor water quality. The article provides a framework of concrete duties and obligations that should be followed by all actors involved in Haiti in order to realize Haitians' human right to water. In response to the undeniable link between the international community's political interference and the intolerably poor state of potable water in Haiti, the article concludes with a recommendation that all actors in Haiti follow a rights-based approach to the development and implementation of water projects in Haiti. The full report of Wòch nan Soley: The Denial of the Right to Water in Haiti is available online at http://www.pih.org/inforesources/Reports/Hait_Report_FINAL.pdf.

Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru.

BACKGROUND: Despite the prevalence of multidrug-resistant tuberculosis in nearly all low-income countries surveyed, effective therapy has been deemed too expensive and considered not to be feasible outside referral centers. We evaluated the results of community-based therapy for multidrug-resistant tuberculosis in a poor section of Lima, Peru. METHODS: We describe the first 75 patients to receive ambulatory treatment with individualized regimens for chronic multidrug-resistant tuberculosis in northern Lima. We conducted a retrospective review of the charts of all patients enrolled in the program between August 1, 1996, and February 1, 1999, and identified predictors of poor outcomes. RESULTS: The infecting strains of Mycobacterium tuberculosis were resistant to a median of six drugs. Among the 66 patients who completed four or more months of therapy, 83 percent (55) were probably cured at the completion of treatment. Five of these 66 patients (8 percent) died while receiving therapy. Only one patient continued to have positive cultures after six months of treatment. All patients in whom treatment failed or who died had extensive bilateral pulmonary disease. In a multiple Cox proportional-hazards regression model, the predictors of the time to treatment failure or death were a low hematocrit (hazard ratio, 4.09; 95 percent confidence interval, 1.35 to 12.36) and a low body-mass index (hazard ratio, 3.23; 95 percent confidence interval, 0.90 to 11.53). Inclusion of pyrazinamide and ethambutol in the regimen (when susceptibility was confirmed) was associated with a favorable outcome (hazard ratio for treatment failure or death, 0.30; 95 percent confidence interval, 0.11 to 0.83). CONCLUSIONS: Community-based outpatient treatment of multidrug-resistant tuberculosis can yield high cure rates even in resource-poor settings. Early initiation of appropriate therapy can preserve susceptibility to first-line drugs and improve treatment outcomes.

Hopefulness Fosters Affective and Cognitive Constructs for Actions to Cope and Enhance Quality of Life among People Living with HIV in Dar Es Salaam, Tanzania.

The aims of this study were to describe how people living with HIV (PLWH) perceive hope and illustrate implications for HIV care and treatment. This is a qualitative study done to explore perceptions and meanings of hope among PLWH attending care and treatment clinics in Dar es Salaam, Tanzania. In all, 10 focus group discussions and 9 in-depth interviews were conducted. People living with HIV described the following 3 dimensions of hope: cognitive, positive emotions, and normalization. Being cognizant of the effectiveness of antiretroviral treatment (ART) often led to positive emotions, such as feeling comforted or strengthened, which in turn was related to positive actions toward normalizing life. Improved treatment outcomes facilitated hope, while persistent health problems, such as ART side effects, were sources of negative emotions contributing to loss of hope among PLWH. Hope motivated positive health-seeking behaviors, including adherence to ART, and this may guide interventions to help PLWH cope and live positively with HIV.

An assessment of the Francois-Xavier Bagnoud poverty alleviation program in Rwanda and Uganda.

OBJECTIVES: We evaluate the three-year community-based FXBVillage poverty-alleviation model, which provides extremely poor families with sustained social support and graduated material support for education, healthcare, housing, nutrition, and income-generation. METHODS: We combine a pre/post analysis of participant households in Rwanda (n = 912) and Uganda (n = 628) with construction and assessment of a combined multivariable household wealth index comparing FXBVillage data with national Demographic Health Surveys. RESULTS: Many FXBVillage households shifted to higher household wealth quintiles. This shift was particularly strong in Rwanda. Increases among relevant household characteristics included (in Rwanda/Uganda): ≥3 meals/day (5-88%)/(44-86%), school attendance 5-17 years (79-97%)/(64-89%), adequate school supplies (7-97%)/(4-71%), and communal financial support if needed (27-98%)/(29-87%). Universal bednet ownership and water treatment was nearly attained; vaccine coverage was not, especially in Uganda. CONCLUSIONS: The model likely supports poverty-alleviation among participants. The variability of improvements, across indicators and countries, highlights the need for better understanding of interactions within programs and between programs and implementation settings, as well as how these interactions matter to poverty-reduction strategies.

Casualties: narrative and images of the war on Iraq.

The Iraqi people have endured an excess burden of morbidity and mortality during the past 15 years due to war and sanctions, with the March 2003 Anglo-American assault on and subsequent occupation of Iraq representing the most recent chapter. Children have been disproportionately affected; many have died from infectious disease, malnutrition, and lack of access to health care. There have been significant differences in the availability of narrative accounts and images of this suffering, reflective of the need of those who wage wars and impose sanctions to keep the public uninformed. This article suggests that public health and medical practitioners have a responsibility to seek out such accounts and images. The authors explore possible responses to narrative and images of this suffering, and outline the sorts of responses engendered by three perspectives-charity, development, and social justice. The suffering of the people of Iraq should spur a response from the health community to alleviate the situation and prevent unnecessary suffering.

Stunting risk of orphans by caregiver and living arrangement in low-income and middle-income countries.

BACKGROUND: An estimated 151 million children worldwide have lost one or both parents (UNICEF). Although a considerable literature has documented the impact of parental loss on children's emotional development, to date there are mixed findings regarding the potential effect of orphanhood on children's physical growth. The aim of the study is to examine the association between orphanhood (maternal, paternal or both) on childhood stunting status, accounting for living arrangement. METHODS: We combine nationally representative data from 84 Demographic Health Surveys for 49 low-income and middle-income countries (LMICs). Data from 222 690 children aged 0-23 months were included in the analytical sample. We show pooled estimates from multiple analysis models, as well as models examining the role of the surviving parent's residence and household structure. RESULTS: In fully adjusted models, maternal orphans were found to have an increased risk of stunting (RR 1.3, 95% CI 1.2 to 1.4) compared to children with two living parents. The stratified models demonstrated that the greatest risk was observed for maternal orphans whose surviving fathers did not live with the child (RR 1.4, 95% CI 1.3 to 1.6). CONCLUSIONS: Early orphanhood constitutes a major risk for children's physical development in LMICs. However, the results suggest that the adverse effects of a parental loss can be mitigated if appropriate support is provided, indicating the potential benefits of the surviving parents staying with their children. The benefits of targeted social policies aimed at single fathers and grandparents supporting orphans may be significant.

HIV and child mental health: a case-control study in Rwanda.

BACKGROUND: The global HIV/AIDS response has advanced in addressing the health and well-being of HIV-positive children. Although attention has been paid to children orphaned by parental AIDS, children who live with HIV-positive caregivers have received less attention. This study compares mental health problems and risk and protective factors in HIV-positive, HIV-affected (due to caregiver HIV), and HIV-unaffected children in Rwanda. METHODS: A case-control design assessed mental health, risk, and protective factors among 683 children aged 10 to 17 years at different levels of HIV exposure. A stratified random sampling strategy based on electronic medical records identified all known HIV-positive children in this age range in 2 districts in Rwanda. Lists of all same-age children in villages with an HIV-positive child were then collected and split by HIV status (HIV-positive, HIV-affected, and HIV-unaffected). One child was randomly sampled from the latter 2 groups to compare with each HIV-positive child per village. RESULTS: HIV-affected and HIV-positive children demonstrated higher levels of depression, anxiety, conduct problems, and functional impairment compared with HIV-unaffected children. HIV-affected children had significantly higher odds of depression (1.68: 95% confidence interval [CI] 1.15-2.44), anxiety (1.77: 95% CI 1.14-2.75), and conduct problems (1.59: 95% CI 1.04-2.45) compared with HIV-unaffected children, and rates of these mental health conditions were similar to HIV-positive children. These results remained significant after controlling for contextual variables, there were no significant differences on mental health outcomes groups, reflecting a potential explanatory role of factors such as daily hardships, caregiver depression, and HIV-related stigma [corrected]. CONCLUSIONS: The mental health of HIV-affected children requires policy and programmatic responses comparable to HIV-positive children.

Scaling up early infant diagnosis of HIV in Rwanda, 2008-2010.

More than 390,000 children are newly infected with HIV each year, only 28 per cent of whom benefit from early infant diagnosis (EID). Rwanda's Ministry of Health identified several major challenges hindering EID scale-up in care of HIV-positive infants. It found poor counseling and follow-up by caregivers of HIV-exposed infants, lack of coordination with maternal and child health-care programs, and long delays between the collection of samples and return of results to the health facility and caregiver. By increasing geographic access, integrating EID with vaccination programs, and investing in a robust mobile phone reporting system, Rwanda increased population coverage of EID from approximately 28 to 72.4 per cent (and to 90.3 per cent within the prevention of mother to child transmission program) between 2008 and 2011. Turnaround time from sample collection to receipt of results at the originating health facility was reduced from 144 to 20 days. Rwanda rapidly scaled up and improved its EID program, but challenges persist for linking infected infants to care.

Closing the implementation gap in services for children affected by HIV/AIDS: from assisting orphans and vulnerable children (OVC) to providing long-term opportunities for economic growth.

While delivering innovative care for over 17 million children living with and affected by HIV/AIDS is a priority for today's global health community, most of these children's health needs remain unmet. Concerns about funding, implementation, and transparency continue to obstruct quality care for all. This paper discusses why services supported by macro-level funding, local initiatives, innovative financing, and enhanced long-term development strategies, are imperative. Concurrent advocacy and preventive measures, such as universal access to education, can sustain this investment in human capital. Such efforts may enhance economic growth, expand local capacity, and improve the quality of life in communities currently burdened by the HIV epidemic.