Severe Features of Systemic Juvenile Idiopathic Arthritis in Patients with Congenital Heart Disease.

OBJECTIVE: To describe the clinical features of patients with congenital heart disease (CHD) who subsequently developed systemic juvenile idiopathic arthritis (sJIA). METHODS: We conducted a retrospective review of patients diagnosed with CHD and sJIA at our institution. Detailed clinical, laboratory and radiographic data were collected from the medical record and reviewed with each patient's primary medical team. RESULTS: Five patients with sJIA and CHD were identified. Each child had a unique cardiac anatomy but all of the patients required surgical repair during the first year of life. Four children had thymectomies at the time of cardiac surgery. Classic signs of sJIA such as fever (n=5), rash (n=5), and arthritis (n=4) developed after surgical intervention in all of the patients. The individuals in this cohort displayed risk factors associated with severe sJIA, including disease onset before 2 years of age (n=5), elevated IL-18 levels (n=5), baseline eosinophilia prior to initiation of biologic disease modifying anti-rheumatic drugs (bDMARDs) (n=4), and positivity for HLA-DRB1*15:01 alleles (n=4). Macrophage activation syndrome (MAS) occurred in 3 patients and sJIA-associated lung disease (sJIA-LD) was identified in 4 patients. Two children died from complications of their cardiac and/or pulmonary disease. CONCLUSION: We identified an association between CHD and severe forms of sJIA. While these findings will need to be confirmed in larger, multi-center cohorts, the results highlight the importance of considering a diagnosis of sJIA in children with CHD and remaining vigilant for complications such as MAS and sJIA-LD.

Fidelity of implementation of national guidelines on malaria diagnosis for children under-five years in Rivers State, Nigeria.

BACKGROUND: Malaria is still a disease of global public health importance and children under-five years of age are the most vulnerable to the disease. Nigeria adopted the "test and treat" strategy in the national malaria guidelines as one of the ways to control malaria transmission. The level of adherence to the guidelines is an important indicator for the success or failure of the country's roadmap to malaria elimination by 2030. This study aimed to assess the fidelity of implementation of the national guidelines on malaria diagnosis for children under-five years and examine its associated moderating factors in health care facilities in Rivers State, Nigeria. METHODS: This was a descriptive, cross-sectional study conducted in Port Harcourt metropolis. Data were collected from 147 public, formal private and informal private health care facilities. The study used a questionnaire developed based on Carroll's Conceptual Framework for Implementation Fidelity. Frequency, mean and median scores for implementation fidelity and its associated factors were calculated. Associations between fidelity and the measured predictors were examined using Mann Whitney U test, Kruskal Wallis test, and multiple linear regression modelling using robust estimation of errors. Regression results are presented in adjusted coefficient (ß) and 95% confidence intervals. RESULTS: The median (IQR) score fidelity score for all participants was 65% (43.3, 85). Informal private facilities (proprietary patent medicine vendors) had the lowest fidelity scores (47%) compared to formal private (69%) and public health facilities (79%). Intervention complexity had a statistically significant inverse relationship to implementation fidelity (ß = - 1.89 [- 3.42, - 0.34]). Increase in participant responsiveness (ß = 8.57 [4.83, 12.32]) and the type of malaria test offered at the facility (e.g., RDT vs. no test, ß = 16.90 [6.78, 27.03]; microscopy vs. no test, ß = 21.88 [13.60, 30.16]) were positively associated with fidelity score. CONCLUSIONS: This study showed that core elements of the "test and treat" strategy, such as testing all suspected cases with approved diagnostic methods before treatment, are still not fully implemented by health facilities. There is a need for strategies to increase fidelity, especially in the informal private health sector, for malaria elimination programme outcomes to be achieved.

Discharge Practices for Infants with Bronchopulmonary Dysplasia: A Survey of National Experts.

OBJECTIVE: To establish consensus practices among a panel of national experts for the discharge of premature infants with bronchopulmonary dysplasia (BPD) from the hospital to home. STUDY DESIGN: We conducted a Delphi study that included US neonatologists and pediatric pulmonologists from the Bronchopulmonary Dysplasia Collaborative to establish consensus practices-defined as recommendations with at least 80% agreement-for infants with BPD being discharged from the hospital. Specifically, we evaluated recommendations for diagnostic tests to be completed around discharge, follow-up respiratory care, and family education. RESULTS: Thirty-one expert participants completed 3 rounds of surveys, with a 99% response rate (92 of 93). Consensus was established that infants with moderate-severe BPD (ie, those who remain on respiratory support at 36 weeks) and those discharged on oxygen should be targeted for in-person pulmonary follow-up within 1 month of hospital discharge. Specialized neonatal follow-up is an alternative for infants with mild BPD. Infants with moderate or severe BPD should have an echocardiogram performed after 36 weeks to screen for pulmonary hypertension. Infants with BPD warrant additional evaluations if they have growth restriction or poor growth, pulmonary hypertension, or tachypnea and if they are discharged to home on oxygen, diuretics, or nonoral feeds. CONCLUSIONS: This Delphi survey establishes expert consensus around best practices for follow-up respiratory management and routine evaluation for infants with BPD surrounding neonatal discharge. Areas of disagreement for which consensus was not established are discussed.

The effect of a roving nurse mentor on household coverage and quality of care provided by community health worker teams in South Africa: a longitudinal study with a before, after and 6 months post design.

OBJECTIVE: Community health workers (CHW) are undertaking more complex tasks as part of the move towards universal health coverage in many low- and middle-income settings. They are expected to provide promotive and preventative care, make referrals to the local clinic, and follow up on non-attendees for a range of health conditions. CHW programmes can improve access to care for vulnerable communities, but many such programmes struggle due to inadequate supervision, low levels of CHW literacy, and the marginalized status of CHW in the health system. In this paper, we assess the effect of a roving nurse mentor on the coverage and quality of care of the CHW service in two vulnerable communities in South Africa. PARTICIPANTS: CHW, their supervisors, household members. INTERVENTION: Roving professional nurse mentor to build skills of supervisors and CHW teams. METHODS: Three household surveys to assess household coverage of the CHW service (baseline, end of the intervention, and 6 months after end of intervention); structured observations of CHW working in households to assess quality of care. RESULTS: The intervention led to a sustained 50% increase in the number of households visited by a CHW in the last year. While the proportion of appropriate health messages given to household members by CHW remained constant at approximately 50%, CHW performed a greater range of more complex tasks. They were more likely to visit new households to assess health needs and register the household in the programme, to provide care to pregnant women, children and people who had withdrawn from care. CHW were more likely to discuss with clients the barriers they were facing in accessing care and take notes during a visit. CONCLUSION: A nurse mentor can have a significant effect both on the quantity and quality of CHW work, allowing them to achieve their potential despite their marginalised status in the health system and their limited prior educational achievement. Supportive supervision is important in enabling the benefit of having a health cadre embedded in marginalised communities to be realised.

Factors associated with access to condoms and HIV services among women in high migration communities in six Southern African countries.

Despite the documented importance of sexual and reproductive health in women's life, access to sexual and reproductive health (SRH) services by migrant women remains low leading to negative sexual and reproductive health outcomes. This study investigated the factors associated with access to condoms and Human immunodeficiency virus (HIV) testing services among 2070 women aged 15-49 years residing in high migration communities. Logistic regression models were fitted and migration status was found to be an important factor in women's access to HIV testing services. In addition to migration status, age, educational level, marital status, religion, comprehensive knowledge about SRH, comprehensive knowledge about HIV, partner's age, and partner's educational level were significantly associated with access to condoms and HIV testing services. Programmes aimed at increasing access to condoms and HIV services should collaborate with adult basic education programmes in order to increase women's education and involve all women regardless of migration status, age and marital status. In addition, the involvement of male partners and religious leaders in disseminating and imparting accurate information and knowledge regarding SRH and HIV services to ensure women's access to both condoms and HIV testing services is required.

Daycare Attendance is Linked to Increased Risk of Respiratory Morbidities in Children Born Preterm with Bronchopulmonary Dysplasia.

OBJECTIVES: To test the hypothesis that daycare attendance among children with bronchopulmonary dysplasia (BPD) is associated with increased chronic respiratory symptoms and/or greater health care use for respiratory illnesses during the first 3 years of life. STUDY DESIGN: Daycare attendance and clinical outcomes were obtained via standardized instruments for 341 subjects recruited from 9 BPD specialty clinics in the US. All subjects were former infants born preterm (<34 weeks) with BPD (71% severe) requiring outpatient follow-up between 0 and 3 years of age. Mixed logistic regression models were used to test for associations. RESULTS: Children with BPD attending daycare were more likely to have emergency department visits and systemic steroid usage. Children in daycare up to 3 years of age also were more likely to report trouble breathing, having activity limitations, and using rescue medications when compared with children not in daycare. More severe manifestations were found in children attending daycare between 6 and 12 months of chronological age. CONCLUSIONS: In this study, children born preterm with BPD who attend daycare were more likely to visit the emergency department, use systemic steroids, and have chronic respiratory symptoms compared with children not in daycare, indicating that daycare may be a potential modifiable risk factor to minimize respiratory morbidities in children with BPD during the preschool years.

Ventilatory Strategies in Infants with Established Severe Bronchopulmonary Dysplasia: A Multicenter Point Prevalence Study.

We performed a point prevalence study on infants with severe bronchopulmonary dysplasia (BPD), collecting data on type and settings of ventilatory support; 187 infants, 51% of whom were on invasive positive-pressure ventilation (IPPV), from 15 centers were included. We found a significant center-specific variation in ventilator modes.

Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline.

Background: Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods: A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions: The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.

Factors associated with sexual and reproductive health service utilisation in high migration communities in six Southern African countries.

BACKGROUND: Migration among women has significant health consequences on their access to and utilisation of health services, particularly sexual and reproductive health services. Despite the large quantity of research on migrant health, there is a paucity of research on the factors associated with utilization of modern methods of contraception, intimate partner violence services and sexual and reproductive health (SRH) referral services among non-migrants, internal and international migrant women. Consequently, understanding the factors associated with utilisation of SRH services among women in Southern Africa motivates this study. METHODS: The study uses secondary data from a cross sectional survey conducted in 2018. Logistic regression models were fitted to investigate the factors associated with utilisation of sexual and reproductive health services among 2070 women aged 15-49 years in high migrant communities in six Southern African countries. RESULTS: Factors found to be associated with current non-use of modern contraceptive methods were country, employment status, educational level, comprehensive knowledge about SRH, comprehensive knowledge about HIV, desire for another child, partner's age and partner's educational level. Regarding utilisation of SRH services, important factors were ever denied access to a public healthcare facility, country, marital status and comprehensive knowledge about HIV. Factors associated with utilising IPV services were migration status, age and attitude towards wife beating. CONCLUSION: The findings highlight that migration status is associated with utilisation of IPV services. Comprehensive knowledge about SRH and partner characteristic variables were associated with current non-use of modern contraceptive methods. There is a need for SRH programs that can disseminate accurate information about SRH and encourage male involvement in SRH related issues. In addition, the SRH programs should target all women regardless of their migration status, age, educational level and marital status.

Treatment initiation among tuberculosis patients: the role of short message service (SMS) technology and Ward-based outreach teams (WBOTs).

BACKGROUND: In South Africa, tuberculosis (TB) is a public health problem with treatment initiation failure rates varying between 14.9 and 25%. Lack of proper provider/patient communication on next steps after testing, not being aware that results are ready; and other competing priorities are some of the reasons for this failure. We aimed to assess the effectiveness of Short Message Service (SMS) technology and ward-based outreach teams (WBOTs) in improving TB treatment initiation. A 3-arm randomized controlled trial (Standard of care-SOC, SMS technology or WBOTs) was conducted between September 2018 and April 2020. Newly diagnosed TB patients randomly allocated to SMS and WBOTs groups were sent reminder messages (text message or paper slip respectively) that results were ready. Due to unforeseen challenges (financial and impact of the COVID 19 pandemic), implementation was only in two of the eight clinics planned. RESULTS: 314 TB patients were assigned to one of three groups (SOC = 104, WBOTs = 105, and SMS = 105). Chi-square tests were used to compare proportions starting treatment (primary outcome). More patients in the SMS group (92/105; 88%) initiated treatment than in the SOC group (81/104; 78%), although this difference did not reach statistical significance (P = 0.062). The time to treatment initiation was significantly shorter in the SMS group than in the SOC group (P < 0.001). The proportions of patients initiated on treatment in the WBOTs group (45/62; 73%) and in the SOC group (44/61; 72%) were similar (P = 0.956). The times to treatment initiation for these two groups were also similar. The 3 group analysis yielded similar proportions initiated on treatment (P = 0.048 for SMS/SOC comparison and P = 0.956 for WBOTs/SOC comparison) but analysis of times to treatment initiation yielded some variations. CONCLUSION: Reminder SMS messages sent to newly diagnosed TB patients improved the time to treatment initiation. Further research is required to show effect of the WBOTs intervention. TRIAL REGISTRATION: Retrospectively registered with the Pan African Clinical Trial Registry ( PACTR202101914895981 ). The trial was registered with the Pan African Clinical Trial Registry on 25 January, 2021 (ref: PACTR202101914895981 ; https://pactr.samrc.ac.za ). The registration was retrospective due to an oversight. Nevertheless, the protocol details outlined in our ethics application were strictly adhered to.

Cost Savings Without Increased Risk of Respiratory Hospitalization for Preterm Children after the 2014 Palivizumab Policy Update.

OBJECTIVE: Our objective was to compare rates of hospitalizations for respiratory illnesses in preterm and full-term (FT) children for 4 years before and after the 2014 update to the American Academy of Pediatrics (AAP) respiratory syncytial virus (RSV) immunoprophylaxis guidance, which restricted eligibility among infants born at 29 to 34 weeks in the first winter and all preterm infants in the second winter after neonatal discharge. STUDY DESIGN: We conducted pre-post and interrupted time series analyses on claims data from a commercial national managed care plan. We compared the number of RSV and all respiratory hospital admissions in the first and second RSV seasons after neonatal discharge among a cohort of preterm children, regardless of palivizumab status, in the 4 years before and after the implementation of the 2014 palivizumab eligibility change. A FT group was included for reference. RESULTS: The cohort included 821 early preterm (EP, <29 weeks), 4,790 moderate preterm (MP, 29-34 weeks), and 130,782 FT children. Palivizumab use after the policy update decreased among MP children in the first and second RSV seasons after neonatal discharge, without any change in the odds of hospitalization with RSV or respiratory illness. For the EP group, there was no change in the rate of palivizumab or the odds of hospitalization with RSV or respiratory illness after the policy update. For the FT group, there was a slight decrease in odds of hospitalization post-2014 after the policy update. The interrupted time series did not reveal any secular trends over time in hospitalization rates among preterm children. Following the policy change, there were cost savings for MP children in the first and second RSV seasons, when accounting for the cost of hospitalizations and the cost of palivizumab. CONCLUSION: Hospitalizations for RSV or respiratory illness did not increase, and cost savings were obtained after the implementation of the 2014 AAP palivizumab prophylaxis policy. KEY POINTS: · Palivizumab use decreased among children born moderate preterm (29 to34 weeks) after the 2014 palivizuamb policy update.. · There was no change in odds of hospitalization with respiratory syncitial virus or respiratory illness among preterm infants after the policy update when compared to before.. · There were cost savings, when accounting for the cost of hospitalizations and the cost of palivizumab, after the policy update among children born moderate preterm..

Sociodemographic differences in quality of treatment to Medicaid enrollees receiving buprenorphine.

Background: Buprenorphine is a key medication to treat opioid use disorder, but little is known about how treatment quality varies across sociodemographic groups. Objective: We examined measures of treatment quality and explored variation by sociodemographic factors. Methods: We used Medicaid MAX data from 50 states from 2006 to 2014 to identify buprenorphine treatment episodes (N = 317,494). We used multivariable logistic regression to examine the quality of buprenorphine treatment along four dimensions: (1) sufficient duration, (2) effective dosage, and concurrent prescribing of (3) opioid analgesics and (4) benzodiazepines. We explored how quality varied by race/ethnicity, age, sex, and urbanicity. Results: In adjusted models, compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic individuals had lower odds of receiving effective dosage (aORs = 0.79 and 0.89, respectively) and sufficient duration (aORs = 0.64 and 0.71, respectively), and lower odds of concurrent prescribing of opioid analgesics (aORs = 0.86 and 0.85, respectively) and benzodiazepines (aORs = 0.51 and 0.59, respectively). Older individuals had higher odds of sufficient duration (aORs from 1.21-1.33), but also had higher odds of concurrent opioid analgesics prescribing (aORs from 1.29-1.56) and benzodiazepines (aORs from 1.44-1.99). Females had higher odds of sufficient duration (aOR = 1.12), but lower odds of effective dosage (aOR = 0.77) and higher odds of concurrent prescribing of opioid analgesics (aOR = 1.25) and benzodiazepines (aOR = 1.16). Compared to individuals living in metropolitan areas, individuals living in non-metropolitan areas had higher odds of sufficient duration (aORs = 1.11 and 1.24) and effective dosage (aORs = 1.06 and 1.33), and lower odds of concurrent prescribing (aORs from 0.81-0.98). Conclusions: Black and Hispanic individuals were less likely to receive effective buprenorphine dosage and sufficient duration. Quality results were mixed for older and female individuals; although these individuals were more likely to receive treatment of sufficient duration, they were also more likely to be concurrently prescribed potentially contraindicated medications, and females were less likely to receive effective dosage. Findings raise concerns about adequacy of care for minority and other at-risk populations.

Analysis of multivariate longitudinal immuno-epidemiological data using a pairwise joint modelling approach.

BACKGROUND: Immuno-epidemiologists are often faced with multivariate outcomes, measured repeatedly over time. Such data are characterised by complex inter- and intra-outcome relationships which must be accounted for during analysis. Scientific questions of interest might include determining the effect of a treatment on the evolution of all outcomes together, or grouping outcomes that change in the same way. Modelling the different outcomes separately may not be appropriate because it ignores the underlying relationships between outcomes. In such situations, a joint modelling strategy is necessary. This paper describes a pairwise joint modelling approach and discusses its benefits over more simple statistical analysis approaches, with application to data from a study of the response to BCG vaccination in the first year of life, conducted in Entebbe, Uganda. METHODS: The study aimed to determine the effect of maternal latent Mycobacterium tuberculosis infection (LTBI) on infant immune response (TNF, IFN-γ, IL-13, IL-10, IL-5, IL-17A and IL-2 responses to PPD), following immunisation with BCG. A simple analysis ignoring the correlation structure of multivariate longitudinal data is first shown. Univariate linear mixed models are then used to describe longitudinal profiles of each outcome, and are then combined into a multivariate mixed model, specifying a joint distribution for the random effects to account for correlations between the multiple outcomes. A pairwise joint modelling approach, where all possible pairs of bivariate mixed models are fitted, is then used to obtain parameter estimates. RESULTS: Univariate and pairwise longitudinal analysis approaches are consistent in finding that LTBI had no impact on the evolution of cytokine responses to PPD. Estimates from the pairwise joint modelling approach were more precise. Major advantages of the pairwise approach include the opportunity to test for the effect of LTBI on the joint evolution of all, or groups of, outcomes and the ability to estimate association structures of the outcomes. CONCLUSIONS: The pairwise joint modelling approach reduces the complexity of analysis of high-dimensional multivariate repeated measures, allows for proper accounting for association structures and can improve our understanding and interpretation of longitudinal immuno-epidemiological data.

Lung function trajectories in children with post-prematurity respiratory disease: identifying risk factors for abnormal growth.

BACKGROUND: Survivors of prematurity are at risk for abnormal childhood lung function. Few studies have addressed trajectories of lung function and risk factors for abnormal growth in childhood. This study aims to describe changes in lung function in a contemporary cohort of children born preterm followed longitudinally in pulmonary clinic for post-prematurity respiratory disease and to assess maternal and neonatal risk factors associated with decreased lung function trajectories. METHODS: Observational cohort of 164 children born preterm ≤ 32 weeks gestation followed in pulmonary clinic at Boston Children's Hospital with pulmonary function testing. We collected demographics and neonatal history. We used multivariable linear regression to identify the impact of neonatal and maternal risk factors on lung function trajectories in childhood. RESULTS: We identified 264 studies from 82 subjects with acceptable longitudinal FEV1 data and 138 studies from 47 subjects with acceptable longitudinal FVC and FEV1/FVC data. FEV1% predicted and FEV1/FVC were reduced compared to childhood norms. Growth in FVC outpaced FEV1, resulting in an FEV1/FVC that declined over time. In multivariable analyses, longer duration of mechanical ventilation was associated with a lower rate of rise in FEV1% predicted and greater decline in FEV1/FVC, and postnatal steroid exposure in the NICU was associated with a lower rate of rise in FEV1 and FVC % predicted. Maternal atopy and asthma were associated with a lower rate of rise in FEV1% predicted. CONCLUSIONS: Children with post-prematurity respiratory disease demonstrate worsening obstruction in lung function throughout childhood. Neonatal risk factors including exposure to mechanical ventilation and postnatal steroids, as well as maternal atopy and asthma, were associated with diminished rate of rise in lung function. These results may have implications for lung function trajectories into adulthood.

Difference in HIV prevalence by testing venue: results from population level survey in Uganda.

Growing demand for use of Health Facility (HF) HIV testing data, in addition to other testing data to obtain district level HIV prevalence requires understanding the comparability of these various sources. We analysed the 2011 Uganda AIDS indicator survey data to assess: the proportion of people tested for HIV across Uganda by venue of testing; HIV prevalence ratio for those tested in a HF compared to those tested in community setting; [Katz, D., Baptista, J., Azen, S. P., & Pike, M. C. (1978). Obtaining confidence intervals for the risk ratio in cohort studies. International Biometric Society, 34(3), 469-474. https://doi.org/10.2307/2530610] and factors associated with HIV positivity in each subgroup. Of the 11,685 individuals, 8978 (77.1%) had ever tested for HIV in a HF. Fifty nine per cent tested in a HF in the 12 months preceding the survey (female: 5507, 72.7% versus male: 1413, 34.9%). HIV prevalence ratio was 1.8 times among those tested in a HF compared to those tested at community setting (10.9% [95% CI: 10.0-11.7] versus 6.2% [95% CI: 5.4-7.0]). Among HF testers, older age group, previously married and having no sexual partner was associated with significantly higher HIV prevalence. Using facility testing data for planning and decisions should take into consideration the elevated and varying HIV prevalence among individuals accessing HIV testing services at HFs as well as differences in their social-demographic characteristics.

Consolidation of primary care physicians and its impact on healthcare utilization.

We use administrative data from Medicare to document the massive consolidation of primary care physicians over the last decade and its impact on patient healthcare utilization. We first document that primary care organizations have consolidated all over the United States between 2008 and 2014. We then show that regions that experienced greater consolidation are associated with greater decline in overall healthcare spending. Finally, in our primary exercise, we exploit transitions of patients across organizations that are driven by changes in the organizational affiliations of their primary care physicians to study the impact of organizational size on overall spending. Our preferred specification suggests that patients switching from small to large physician organizations reduce their overall healthcare spending by 16%, and that this reduction is primarily driven by a 13% reduction in primary care visits and 0.09 (21%) fewer inpatient admissions per year.

Comprehensive sexuality education in six Southern African Countries: Perspectives from learners and teachers.

Comprehensive sexuality education (CSE) promotes young people's healthy sexual decisions. This study assessed the level of provision of CSE in schools in ten sites in six Southern African countries from the perspectives of learners and teachers. The data was from a needs assessment preceding the baseline evaluation of the SRHR-HIV Knows no Borders Project conducted in ten sites in six Southern African countries. A total of 161 learners from 10 schools and 96 teachers from 96 schools were interviewed. Among the teachers, 82.3% reported CSE was part of the school curriculum. Although basic education policies in Southern African countries are in tandem with international, regional and national policies, complete implementation of the policies remains unfulfilled owing to conflicting policies and socio-cultural values of diverse stakeholders. Awareness campaigns and trainings may help to promote positive perceptions among stakeholders about sensitive CSE topics and the distribution of SRH commodities in schools.

Effect of Stopping Cotrimoxazole Preventive Therapy on Microbial Translocation and Inflammatory Markers Among Human Immunodeficiency Virus-Infected Ugandan Adults on Antiretroviral Therapy: The COSTOP Trial Immunology Substudy.

BACKGROUND: Cotrimoxazole preventive therapy (CPT) in human immunodeficiency virus (HIV) infection is a World Health Organization-recommended standard of care in resource-limited settings, but the mechanism of CPT's beneficial effects is unclear. The COSTOP trial (ISRCTN44723643) evaluated the noninferiority of discontinuing CPT in stabilized patients on antiretroviral therapy. The COSTOP immunology substudy was conducted on a subset of COSTOP participants randomized to continue CPT (n = 86) or discontinue CPT (placebo, n = 86) as daily treatment for 1 year. METHODS: We evaluated whether CPT reduces microbial translocation, indicated by the presence of bacterial lipopolysaccharide (LPS) and LPS control factors such as soluble CD14 (sCD14) and endotoxin core antibody (EndoCAb immunoglobulin M [IgM]) in plasma. Intestinal barrier damage as indicated by plasma intestinal fatty acid binding protein (IFABP), T-cell activation, and the inflammatory markers C-reactive protein (CRP), interleukin 6 (IL-6), and tumor necrosis factor α (TNF-α) were also evaluated. RESULTS: We found no significant change in markers of microbial translocation (LPS, IFABP, sCD14, and T-cell activation), with decreased EndoCAb IgM. There was significant increase in inflammation markers (CRP and IL-6) after stopping CPT compared to those who continued CPT. CONCLUSIONS: These results add to the evidence of immunological benefits of CPT among HIV-infected populations in resource-limited settings. However, no evidence of reducing microbial translocation was observed.

Major Depressive Disorder Among HIV Infected Youth in Uganda: Incidence, Persistence and Their Predictors.

Incidence and persistence of major depressive disorder (MDD) in children and adolescents with HIV (CA-HIV) in Uganda is described. 1339 CA-HIV attending care were enrolled and followed up for 12 months. MDD was assessed using the DSM-5 referenced Child and Adolescent Symptom Inventory-5 (CASI-5), with a prevalence for MDD at baseline of 5% (95% CI 3.3-7.3). Kaplan-Meir method was used to estimate incidence of MDD and Cox models were fitted to investigate predictors of incident MDD. Cumulative incidence of MDD over 12 months was 7.6 per 100 person-years 95% CI (6.2-9.4) and a rate of persistent MDD of 10/105 (9.5% CI 3.9-15.1). Significant independent predictors of incident MDD were: highest educational level of CA-HIV (protective), increasing depressive scores and decreasing CD4 Nadir. These finding have implications for what should constitute components of a mental health integration model in HIV youth services and for the future development of individualised mental health care.

Clinical correlates and adverse outcomes of ADHD, disruptive behavior disorder and their co-occurrence among children and adolescents with HIV in Uganda.

Attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) are important mental health concerns among children and adolescents living with HIV (CA-HIV). This study examines clinical correlates and adverse outcomes associated with ADHD, ODD/CD and ADHD + ODD/CD among (N = 1,336) CA-HIV living in Uganda. Being male, higher socio-economic status, emotional disorder, greater caregiver distress and youth-caregiver conflict were associated with a greater risk of behavioral disorders, particularly ADHD + ODD/CD. This group was also five-times more likely to have engaged in sex than their peers and report greater disciplinary problems at school than those without a behavioral disorder. These findings highlight the distinct clinical presentation and adverse outcomes associated with ADHD + ODD/CD among CA-HIV. As more CA-HIV are surviving into adulthood, screening and treatment of mental disorders is needed to ensure they are given the chance to thrive. In addition to youth, interventions should target caregivers due to their impact on youth outcomes.