Advancing Adolescent and Young Adult HIV Prevention and Care and Treatment Through Use of Multi-level Theories and Frameworks: A Scoping Review and Adapted HIV Ecological Framework.

While multi-level theories and frameworks have become a cornerstone in broader efforts to address HIV inequities, little is known regarding their application in adolescent and young adult (AYA) HIV research. To address this gap, we conducted a scoping review to assess the use and application of multi-level theories and frameworks in AYA HIV prevention and care and treatment empirical research. We systematically searched five databases for articles published between 2010 and May 2020, screened abstracts, and reviewed eligible full-text articles for inclusion. Of the 5890 citations identified, 1706 underwent full-text review and 88 met the inclusion criteria: 70 focused on HIV prevention, with only 14 on care and treatment, 2 on both HIV prevention and care and treatment, and 2 on HIV-affected AYA. Most authors described the theory-based multi-level framework as informing their data analysis, with only 12 describing it as informing/guiding an intervention. More than seventy different multi-level theories were described, with 38% utilizing socio-ecological models or the eco-developmental theory. Findings were used to inform the adaptation of an AYA World Health Organization multi-level framework specifically to guide AYA HIV research.

The Critical Role of Supply Chains in Preventing Human Immunodeficiency Virus Drug Resistance in Low- and Middle-Income Settings.

The functioning of the supply chain may be a driving factor behind the development of human immunodeficiency virus (HIV) drug resistance (HIVDR) in many low- and middle-income countries (LMICs). Additionally, the effectiveness of supply chains will likely impact the scale-up of both viral-load monitoring and HIVDR testing. This article describes the complexities of global supply chains relevant for LMICs and presents early data on stock-outs and drug substitutions in several countries supported by the US President's Emergency Plan for AIDS Relief. Supply chain systems will need to be strengthened to minimize interruptions as new antiretroviral therapy regimens are introduced and to facilitate adoption of new laboratory technologies.

Estimation of HIV prevalence and burden in Nigeria: a Bayesian predictive modelling study.

Background: The cost of population-based surveys is high and obtaining funding for a national population-based survey may take several years, with follow-up surveys taking up to five years. Survey-based prevalence estimates are prone to bias owing to survey non-participation, as not all individuals eligible to participate in a survey may be reached, and some of those who are contacted do not consent to HIV testing. This study describes how Bayesian statistical modeling may be used to estimate HIV prevalence at the state level in a reliable and timely manner. Methods: We analysed national HIV testing services (HTS) data for Nigeria from October 1, 2020, to September 30, 2021, to derive state-level HIV seropositivity rates. We used a Bayesian linear model with normal prior distribution and Markov Chain Monte Carlo approach to estimate HIV state-level prevalence for the 36 states +1 FCT in Nigeria. Our outcome variable was the HIV seropositivity rates and we adjusted for demographic, economic, biological, and societal covariates collected from the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS), 2018 Nigeria Demographic and Health Survey (NDHS) and 2016-17 Multiple Indicator Cluster Surveys (MICS). The estimated population of 15-49 years olds in each state was multiplied by estimates from the estimated prevalence to generate state-level HIV burden. Findings: Our estimated national HIV prevalence was 2.1% (95% CI: 1.5-2.7%) among adults aged 15-49 years in Nigeria, which corresponds to approximately 2 million people living with HIV, compared to previous national HIV prevalence estimates of 1.4% from the 2018 NAIIS and UNAIDS estimation and projection package PLHIV estimation of 1.8 million in 2022. Our modelled HIV prevalence in Nigeria varies by state, with Benue (5.7%, 95% CI: 5.0-6.3) having the highest prevalence, followed by Rivers (5.2%, 95% CI: 4.6-5.8%), Akwa Ibom (3.5%, 95% CI: 2.9-4.1%), Edo (3.4%, 95% CI: 2.9-4.0%) and Taraba (3.0%, 95% CI: 2.6-3.7%) placing fourth and fifth, respectively. Jigawa had the lowest HIV prevalence (0.3%), which was consistent with prior estimates. Interpretation: This model provides a comprehensive and flexible use of evidence to estimate state-level HIV seroprevalence for Nigeria using program data and adjusting for explanatory variables. Thus, investment in program data for HIV surveillance will provide reliable estimates for HIV sub-national monitoring and improve planning and interventions for epidemiologic control. Funding: This article was made possible by the support of the American people through the United States Agency for International Development (USAID) under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

The Status of Adolescent Testing and Treatment in PEPFAR-Supported Programs, October 2017 to September 2020.

BACKGROUND: Adolescents have poorer outcomes across the HIV cascade compared with adults. We aimed to assess progress in HIV case finding, antiretroviral treatment (ART), viral load coverage (VLC), and viral load suppression (VLS) among adolescents enrolled in the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported programs over a 3-year period that included the beginning of the COVID-19 pandemic. METHODS: We analyzed PEPFAR program data in 28 countries/regions for adolescents aged 10-19 years between year 1 (October 2017to September 2018), year 2 (October 2018 to September 2019), and year 3 (October 2019 to September 2020). We calculated the number and percent change for HIV tests, HIV-positive tests, and total number on ART. Calculated indicators included positivity, percent of positives newly initiated on ART (ART linkage), VLC (percent of ART patients on ART for ≥6 months with a documented viral load result within the past 12 months), and VLS (percent of viral load tests with <1000 copies/mL). RESULTS: Between years 1 and 3, the number of HIV tests conducted decreased by 44.2%, with a 29.1% decrease in the number of positive tests. Positivity increased from 1.3%-1.6%. The number of adolescents receiving ART increased by 10.4%. In addition, ART linkage increased (77.8%-86.7%) as did VLC (69.4%-79.4%) and VLS (72.8%-81.5%). CONCLUSIONS: Our findings demonstrate PEPFAR's success in increasing the adolescent treatment cohort. We identified ongoing gaps in adolescent case finding, linkage, VLC, and VLS that could be addressed with a strategic mix of testing strategies, optimal ART regimens, and adolescent-focused service delivery models.

Undetected cognitive impairment and decision-making capacity in patients receiving hospice care.

OBJECTIVE: : Cognitive dysfunction is common in patients with advanced, life-threatening illness and can be attributed to a variety of factors (e.g., advanced age, opiate medication). Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end-of-life approaches and patients face multiple choices regarding treatment, family, and estate planning. This study examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically apparent cognitive impairment (e.g., delirium, unresponsiveness). DESIGN: : A total of 110 participants receiving hospice services completed a 1-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews. RESULTS: : In general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairment. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43-2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity. CONCLUSION: : Despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. Assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision making may lead to effective interventions to improve decision making and honor the wishes of patients and families.

Media exposure and tobacco, illicit drugs, and alcohol use among children and adolescents: a systematic review.

The authors systematically reviewed 42 quantitative studies on the relationship between media exposure and tobacco, illicit drug, and alcohol use among children and adolescents. Overall, 83% of studies reported that media was associated with increased risk of smoking initiation, use of illicit drugs, and alcohol consumption. Of 30 studies examining media content, 95% found a statistically significant association between increased media exposure and negative outcomes. Similarly, of the 12 studies evaluating the quantity of media exposure, 67% reported an association with a negative outcome. Overall, all 17 of the identified longitudinal studies supported a causal association between media exposure and negative outcomes over time. The evidence was strongest for links between media exposure and tobacco use; it was moderate for illicit drug use and alcohol use. Substantial variability in methodological rigor across studies and expanding definitions of media exposure contribute to persistent gaps in the knowledge base.

PEPFAR's response to the convergence of the HIV and COVID-19 pandemics in Sub-Saharan Africa.

INTRODUCTION: The COVID-19 pandemic reached the African continent in less than three months from when the first cases were reported from mainland China. As COVID-19 preparedness and response plans were rapidly instituted across sub-Saharan Africa, many governments and donor organizations braced themselves for the unknown impact the COVID-19 pandemic would have in under-resourced settings with high burdens of PLHIV. The potential negative impact of COVID-19 in these countries is uncertain, but is estimated to contribute both directly and indirectly to the morbidity and mortality of PLHIV, requiring countries to leverage existing HIV care systems to propel COVID-19 responses, while safeguarding PLHIV and HIV programme gains. In anticipation of COVID-19-related disruptions, PEPFAR promptly established guidance to rapidly adapt HIV programmes to maintain essential HIV services while protecting recipients of care and staff from COVID-19. This commentary reviews PEPFAR's COVID-19 technical guidance and provides country-specific examples of programme adaptions in sub-Saharan Africa. DISCUSSION: The COVID-19 pandemic may pose significant risks to the continuity of HIV services, especially in countries with high HIV prevalence and weak and over-burdened health systems. Although there is currently limited understanding of how COVID-19 affects PLHIV, it is imperative that public health systems and academic centres monitor the impact of COVID-19 on PLHIV. The general principles of the HIV programme adaptation guidance from PEPFAR prioritize protecting the gains in the HIV response while minimizing in-person home and facility visits and other direct contact when COVID-19 control measures are in effect. PEPFAR-supported clinical, laboratory, supply chain, community and data reporting systems can play an important role in mitigating the impact of COVID-19 in sub-Saharan Africa. CONCLUSIONS: As community transmission of COVID-19 continues and the number of country cases rise, fragile health systems may be strained. Utilizing the adaptive, data-driven programme approaches in facilities and communities established and supported by PEPFAR provides the opportunity to strengthen the COVID-19 response while protecting the immense gains spanning HIV prevention, testing and treatment reached thus far.

In Situ Atmospheric Deposition of Ultrasmooth Nickel Oxide for Efficient Perovskite Solar Cells.

Organic-inorganic perovskite solar cells have attracted significant attention due to their remarkable performance. The use of alternative metal-oxide charge-transport layers is a strategy to improving device reliability for large-scale fabrication and long-term applications. Here, we report solution-processed perovskite solar cells employing nickel oxide hole-extraction layers produced in situ using an atmospheric pressure spatial atomic-layer deposition system, which is compatible with high-throughput processing of electronic devices from solution. Our sub-nanometer smooth (average roughness of ≤0.6 nm) oxide films enable the efficient collection of holes and the formation of perovskite absorbers with high electronic quality. Initial solar-cell experiments show a power-conversion efficiency of 17.1%, near-unity ideality factors, and a fill factor of >80% with negligible hysteresis. Transient measurements reveal that a key contributor to this performance is the reduced luminescence quenching trap density in the perovskite/nickel oxide structure.

Strongly Enhanced Photovoltaic Performance and Defect Physics of Air-Stable Bismuth Oxyiodide (BiOI).

Bismuth-based compounds have recently gained increasing attention as potentially nontoxic and defect-tolerant solar absorbers. However, many of the new materials recently investigated show limited photovoltaic performance. Herein, one such compound is explored in detail through theory and experiment: bismuth oxyiodide (BiOI). BiOI thin films are grown by chemical vapor transport and found to maintain the same tetragonal phase in ambient air for at least 197 d. The computations suggest BiOI to be tolerant to antisite and vacancy defects. All-inorganic solar cells (ITO|NiOx |BiOI|ZnO|Al) with negligible hysteresis and up to 80% external quantum efficiency under select monochromatic excitation are demonstrated. The short-circuit current densities and power conversion efficiencies under AM 1.5G illumination are nearly double those of previously reported BiOI solar cells, as well as other bismuth halide and chalcohalide photovoltaics recently explored by many groups. Through a detailed loss analysis using optical characterization, photoemission spectroscopy, and device modeling, direction for future improvements in efficiency is provided. This work demonstrates that BiOI, previously considered to be a poor photocatalyst, is promising for photovoltaics.

A direct, continuous, sensitive assay for protein disulphide-isomerase based on fluorescence self-quenching.

PDI (protein disulphide-isomerase) activity is generally monitored by insulin turbidity assay or scrambled RNase assay, both of which are performed by UV-visible spectroscopy. In this paper, we present a sensitive fluorimetric assay for continuous determination of disulphide reduction activity of PDI. This assay utilizes the pseudo-substrate diabz-GSSG [where diabz stands for di-(o-aminobenzoyl)], which is formed by the reaction of isatoic anhydride with the two free N-terminal amino groups of GSSG. The proximity of two benzoyl groups leads to quenching of the diabz-GSSG fluorescence by approx. 50% in comparison with its non-disulphide-linked form, abz-GSH (where abz stands for o-aminobenzoyl). Therefore the PDI-dependent disulphide reduction can be monitored by the increase in fluorescence accompanying the loss of proximity-quenching upon conversion of diabz-GSSG into abz-GSH. The apparent K(m) of PDI for diabz-GSSG was estimated to be approx. 15 muM. Unlike the insulin turbidity assay and scrambled RNase assay, the diabz-GSSG-based assay was shown to be effective in determining a single turnover of enzyme in the absence of reducing agents with no appreciable blank rates. The assay is simple to perform and very sensitive, with an estimated detection limit of approx. 2.5 nM PDI, enabling its use for the determination of platelet surface PDI activity in crude sample preparations.

The status of adolescent medicine: building a global adolescent workforce.

Remarkable public health achievements to reduce infant and child mortality as well as improve the health and well-being of children worldwide have successfully resulted in increased survival and a growing population of young people aged 10-24 years. Population trends indicate that the current generation of 1.8 billion young people is the largest in history. However, there is a scarcity of dedicated resources available to effectively meet the health needs of adolescents and young adults worldwide. Growing recognition of the pivotal roles young people play in the cultures, societies, and countries in which they live has spurred an expanding global movement to address the needs of this special population. Building an effective global workforce of highly-skilled adolescent health professionals who understand the unique biological, psychological, behavioral, social, and environmental factors that affect the health of adolescents is a critical step in addressing the health needs of the growing cohort of young people. In this review, we aim to: 1) define a global assessment of the health needs for adolescents around the world; 2) describe examples of current training programs and requirements in adolescent medicine; 3) identify existing gaps and barriers to develop an effective adolescent health workforce; and 4) develop a call for targeted actions to build capacity of the adolescent health workforce, broaden culturally relevant research and evidence-based intervention strategies, and reinforce existing interdisciplinary global networks of youth advocates and adolescent health professionals to maximize the opportunities for training, research, and care delivery.

The Impact of Youth-Friendly Structures of Care on Retention Among HIV-Infected Youth.

Limited data exist on how structures of care impact retention among youth living with HIV (YLHIV). We describe the availability of youth-friendly structures of care within HIV Research Network (HIVRN) clinics and examine their association with retention in HIV care. Data from 680 15- to 24-year-old YLHIV receiving care at 7 adult and 5 pediatric clinics in 2011 were included in the analysis. The primary outcome was retention in care, defined as completing ≥2 primary HIV care visits ≥90 days apart in a 12-month period. Sites were surveyed to assess the availability of clinic structures defined a priori as 'youth-friendly'. Univariate and multivariable logistic regression models assessed structures associated with retention in care. Among 680 YLHIV, 85% were retained. Nearly half (48%) of the 680 YLHIV attended clinics with youth-friendly waiting areas, 36% attended clinics with evening hours, 73% attended clinics with adolescent health-trained providers, 87% could email or text message providers, and 73% could schedule a routine appointment within 2 weeks. Adjusting for demographic and clinical factors, YLHIV were more likely to be retained in care at clinics with a youth-friendly waiting area (AOR 2.47, 95% CI [1.11-5.52]), evening clinic hours (AOR 1.94; 95% CI [1.13-3.33]), and providers with adolescent health training (AOR 1.98; 95% CI [1.01-3.86]). Youth-friendly structures of care impact retention in care among YLHIV. Further investigations are needed to determine how to effectively implement youth-friendly strategies across clinical settings where YLHIV receive care.

Aging and loss to follow-up among youth living with human immunodeficiency virus in the HIV Research Network.

PURPOSE: In the United States, 21 years is a critical age of legal and social transition, with changes in social programs such as public insurance coverage. Human immunodeficiency virus (HIV)-infected youth have lower adherence to care and medications and may be at risk of loss to follow-up (LTFU) at this benchmark age. We evaluated LTFU after the 22nd birthday for HIV-infected youth engaged in care. LTFU was defined as having no primary HIV visits in the year after the 22nd birthday. METHODS: All HIV-infected 21-year-olds engaged in care (2002-2011) at the HIV Research Network clinics were included. We assessed the proportion LTFU and used multivariable logistic regression to evaluate demographic and clinical characteristics associated with LTFU after the 22nd birthday. We compared LTFU at other age transitions during the adolescent/young adult years. RESULTS: Six hundred forty-seven 21-year-olds were engaged in care; 91 (19.8%) were LTFU in the year after turning 22 years. Receiving care at an adult versus pediatric HIV clinic (adjusted odds ratio [AOR], 2.91; 95% confidence interval [CI], 1.42-5.93), having fewer than four primary HIV visits/year (AOR, 2.72; 95% CI, 1.67-4.42), and antiretroviral therapy prescription (AOR, .50; 95% CI, .41-.60) were independently associated with LTFU. LTFU was prevalent at each age transition, with factors associated with LTFU similar to that identified for 21-year-olds. CONCLUSIONS: Although 19.8% of 21-year-olds at the HIV Research Network sites were LTFU after their 22nd birthday, significant proportions of youth of all ages were LTFU. Fewer than four primary HIV care visits/year, receiving care at adult clinics and not prescribed antiretroviral therapy, were associated with LTFU and may inform targeted interventions to reduce LTFU for these vulnerable patients.

Factors informing HIV providers' decisions to start antiretroviral therapy for young people living with behaviorally acquired HIV.

PURPOSE: Young people with behaviorally acquired HIV (BHIV) are less likely than adults to initiate antiretroviral therapy (ART) despite meeting treatment criteria. We explored critical factors involved in healthcare providers' decision making regarding ART initiation for young people with BHIV (aged 12-24 years). METHODS: Semistructured interviews were conducted with 23 HIV providers from diverse training backgrounds caring for youth with BHIV at four adult clinics and one pediatric clinic in a high prevalence urban city. Interview domains probed clinical and nonclinical patient characteristics, the role of adherence, and provider attitudes working with youth to establish decision-making priorities for ART initiation. The constant comparative approach was used to develop grounded theory on providers' decision making on ART initiation. RESULTS: Clinical criteria, particularly the CD4 count, and the public health implications of HIV transmission determined the urgency for ART initiation. However, patient-related concerns regarding treatment readiness and adherence hampered the decision to initiate, especially at higher CD4 counts. Providers who acknowledged developmental characteristics of youth (e.g., evolving adult identity and self-efficacy around health management) appeared more cautious in assessing future ART adherence and responded with intensive clinical support. Extensive involvement of multidisciplinary teams was identified as an important strategy to retain youth in care, whereas strengthening youth-targeted approaches may be an unmet need in adult clinics. CONCLUSION: Evaluation of providers' awareness of the developmental features of youth and characteristics of youth-targeted approaches in clinics caring for youth with BHIV may inform interventions to increase youth engagement in care and subsequent decisions to successfully initiate ART.

The role of HIV serostatus disclosure on sexual risk behaviours among people living with HIV in steady partnerships in Rio de Janeiro, Brazil.

Understanding partnership dynamics is a crucial step in the process of HIV serostatus disclosure to partners. This study examines the relational characteristics associated with HIV serostatus disclosure and the role of disclosure on sexual behaviours within steady partnerships among people living with HIV (PLHIV) in Rio de Janeiro, Brazil. The overall study surveyed 900 participants from six large public health facilities to investigate psychosocial and structural factors associated with sexual health and well-being. This analysis focuses on 489 individuals reporting being in steady partnerships, 86% of whom reported HIV serostatus disclosure to steady partners. After adjusting for demographic variables, attitudes towards disclosure, having an HIV-positive partner, living with partner and longer relationships were significantly associated with reported disclosure in multivariable logistic regression. Living with partner was negatively associated with partner concurrency. However, having an HIV-positive partner, sex under the influence of drugs or alcohol and experiencing physical aggression by a steady partner were negatively associated with consistent condom use. Interventions supporting PLHIV to safely and voluntarily disclose to partners may be an effective prevention approach between steady partners; however, partner violence and substance use should be addressed in future work.

Severe Primary HSV-2 in a Perinatal HIV-Infected Woman with Advanced Immunosuppression.

Herpes simplex virus type 2 (HSV-2) is most commonly associated with mucocutaneous manifestations; however, coinfections with HIV may be associated with atypical and more severe presentations of clinical disease. We present a case of a young woman with advanced perinatally acquired AIDS presenting with severe purulent pharyngitis, fevers, and toxic appearance with a subsequent diagnosis of disseminated primary HSV-2 infection in multiple noncontiguous mucocutaneous sites. This case highlights an unusual presentation of the protean nature of primary HSV infection and the potential severity of illness in patients with advanced immunosuppression.

Parenting and mental illness: a pilot group programme for parents.

OBJECTIVE: To describe a pilot group programme for parents with a mental illness that was developed and implemented on the NSW Central Coast. CONCLUSIONS: The Parenting and Mental Illness Group Program is a 6-week group programme that is followed by four weekly, individual home visits. Data from the Eyberg Child Behaviour Inventory and Parenting Scale suggest the programme produced positive outcomes in children's behaviour and parenting practices; the programme was also viewed favourably by participants. While encouraging, these findings require replication, using larger numbers and evaluation of the programme in other sites. Supported by an evidence base, programmes such as this will be important to implement if mental health services are to improve outcomes for parents with mental health problems and their children.