Pediatric HIV+ Kaposi sarcoma exhibits clinical, virological, and molecular features different from the adult disease.

BACKGROUNDKaposi sarcoma (KS) is among the most common childhood cancers in Eastern and Central Africa. Pediatric KS has a distinctive clinical presentation compared with adult KS, which includes a tendency for primary lymph node involvement, a considerable proportion of patients lacking cutaneous lesions, and a potential for fulminant disease. The molecular mechanisms or correlates for these disease features are unknown.METHODSThis was a cross-sectional study. All cases were confirmed by IHC for KS-associated herpesvirus (KSHV) LANA protein. Baseline blood samples were profiled for HIV and KSHV genome copy numbers by qPCR and secreted cytokines by ELISA. Biopsies were characterized for viral and human transcription, and KSHV genomes were determined when possible.RESULTSSeventy participants with pediatric KS were enrolled between June 2013 and August 2019 in Malawi and compared with adult patients with KS. They exhibited high KSHV genome copy numbers and IL-6/IL-10 levels. Four biopsies (16%) had a viral transcription pattern consistent with lytic viral replication.CONCLUSIONThe unique features of pediatric KS may contribute to the specific clinical manifestations and may direct future treatment options.FUNDINGUS National Institutes of Health U54-CA-254569, PO1-CA019014, U54-CA254564, RO1-CA23958.

Long-term outcomes for children and adolescents with Kaposi sarcoma.

OBJECTIVES: Kaposi sarcoma (KS) is one of the most common childhood cancers in eastern and central Africa. It has become a treatable disease with increasing availability of antiretroviral therapy (ART) and chemotherapy. We aimed to fill the data gap in establishing whether long-term survival is achievable for children in low-income countries. METHODS: We retrospectively analysed data for children and adolescents aged ≤ 18.9 years diagnosed with HIV-related or endemic KS from 2006 to 2015 who received standardized institutional treatment regimens utilizing chemotherapy plus ART (if HIV-positive) at a tertiary care public hospital in Lilongwe, Malawi. Long-term survival was analysed and mortality was associated with KS for those with refractory/progressive disease at the time of death. RESULTS: There were 207 children/adolescents with KS (90.8% HIV-related); 36.7% were alive, 54.6% had died, and 8.7% had been lost to follow-up. The median follow-up time for survivors was 6.9 years (range 4.2-13.9 years). Death occurred at a median of 5.3 months after KS diagnosis (range 0.1-123 months). KS progression was associated with mortality for most (61%) early deaths (survival time of < 6 months); conversely, KS was associated with a minority (31%) of late-onset deaths (after 24 months). The 7-year overall survival was 37% [95% confidence interval (CI) 30-44%] and was higher for those diagnosed between 2011 and 2015 compared to 2006-2010: 42% (95% CI 33-51%) versus 29% (95% CI 20-39%), respectively (P = 0.01). Among the 66 HIV-positive survivors, 58% were still on first-line ART. CONCLUSIONS: Long-term survival is possible for pediatric KS in low-resource settings. Despite better survival in more recent years, there remains room for improvement.

Where there is no local author: a network bibliometric analysis of authorship parasitism among research conducted in sub-Saharan Africa.

INTRODUCTION: Authorship parasitism (ie, no authors affiliated with the country in which the study took place) occurs frequently in research conducted in low-income and middle-income countries, despite published recommendations defining authorship criteria. The objective was to compare characteristics of articles exhibiting authorship parasitism in sub-Saharan Africa to articles with author representation from sub-Saharan African countries. METHODS: A bibliometric review of articles indexed in PubMed published from January 2014 through December 2018 reporting research conducted in sub-Saharan Africa was performed. Author affiliations were assigned to countries based on regular expression algorithms. Choropleth maps and network diagrams were created to determine where authorship parasitism occurred, and multivariable logistic regression was used to determine associated factors. RESULTS: Of 32 061 articles, 14.8% (n=4754) demonstrated authorship parasitism, which was most common among studies from Somalia (n=175/233, 75.1%) and Sao Tome and Principe (n=20/28, 71.4%). Authors affiliated with USA and UK institutions were most commonly involved in articles exhibiting authorship parasitism. Authorship parasitism was more common in articles: published in North American journals (adjusted OR (aOR) 1.26, 95% CI 1.07 to 1.50) than in sub-Saharan African journals, reporting work from multiple sub-Saharan African countries (aOR 8.41, 95% CI 7.30 to 9.68) compared with work from upper-middle income sub-Saharan African countries, with <5 authors (aOR 14.46, 95% CI 12.81 to 16.35) than >10 authors, and was less common in articles published in French (aOR 0.60, 95% CI 0.41 to 0.85) than English. CONCLUSIONS: Authorship parasitism was common in articles reporting research conducted in sub-Saharan Africa. There were reliable predictors of authorship parasitism. Investigators and institutions in high-income countries, as well as funding agencies and journals should promote research from sub-Saharan Africa, including its publication, in a collaborative and equitable manner.

Outcomes of Echocardiography-Detected Rheumatic Heart Disease: Validating a Simplified Score in Cohorts From Different Countries.

Background The natural history of latent rheumatic heart disease (RHD) detected by echocardiography remains unclear. We aimed to assess the accuracy of a simplified score based on the 2012 World Heart Federation criteria in predicting mid-term RHD echocardiography outcomes in children from 4 different countries. Methods and Results Patient-level baseline and follow-up data of children with latent RHD from 4 countries (Australia, n=62; Brazil, n=197; Malawi, n=40; New Zealand, n=94) were combined. A simplified echocardiographic scoring system previously developed from Brazilian and Ugandan cohorts, consisting of 5 point-based variables with respective weights, was applied: mitral valveanterior leaflet thickening (weight=3), excessive leaflettip motion (3), regurgitation jet length ≥2 cm (6), aortic valvefocal thickening (4), and any regurgitation (5). Unfavorable outcome was defined as worsening diagnostic category, persistent definite RHD or development/worsening of valve regurgitation/stenosis. The score model was updated using methods for recalibration. 393 patients (314 borderline, 79 definite RHD) with median follow-up of 36 (interquartile range, 25-48) months were included. Median age was 14 (interquartile range, 11-16) years and secondary prophylaxis was prescribed to 16%. The echocardiographic score model applied to this external population showed significant association with unfavorable outcome (hazard ratio, 1.10; 95% CI, 1.04-1.16; P=0.001). Unfavorable outcome rates in low (≤5 points), intermediate (6-9), and high-risk (≥10) children at 3-year follow-up were 14.3%, 20.8%, and 38.5% respectively (P<0.001). The updated score model showed good performance in predicting unfavorable outcome. Conclusions The echocardiographic score model for predicting RHD outcome was updated and validated for different latent RHD populations. It has potential utility in the clinical and screening setting for risk stratification of latent RHD.

Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi.

BACKGROUND: Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood. METHODS: Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression. RESULTS: Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27-20.78], shock (aOR 18.54, 95% CI 3.87-88.90), HIV-positive (aOR 5.32, 95% CI 1.76-16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11-5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90-8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16-8.44). CONCLUSION: HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.

Population-Based Estimation of the Preterm Birth Rate in Lilongwe, Malawi: Making Every Birth Count.

Objective The objective of this study was to perform a population-based estimation of the preterm birth (PTB) rate in regions surrounding Lilongwe, Malawi. Study Design We partnered with obstetrician specialists, community health workers, local midwives, and clinicians in a 50 km region surrounding Lilongwe, Malawi, to perform a population-based estimation of the PTB rate during the study period from December 1, 2012 to May 19, 2015. Results Of the 14,792 births captured, 19.3% of births were preterm, including preterm early neonatal deaths. Additional PTB risk factors were similarly prevalent including domestic violence, HIV, malaria, anemia, and malnutrition. Conclusion When performing a population-based estimation of the rate of PTB, including women without antenatal care and women delivering at home, the 19.3% rate of PTB is among the highest recorded globally. This is accompanied by a high rate of risk factors and comorbid conditions.

The Video intervention to Inspire Treatment Adherence for Life (VITAL Start): protocol for a multisite randomized controlled trial of a brief video-based intervention to improve antiretroviral adherence and retention among HIV-infected pregnant women in Malawi.

BACKGROUND: Improving maternal antiretroviral therapy (ART) retention and adherence is a critical challenge facing prevention of mother-to-child transmission (PMTCT) of HIV programs. There is an urgent need for evidence-based, cost-effective, and scalable interventions to improve maternal adherence and retention that can be feasibly implemented in overburdened health systems. Brief video-based interventions are a promising but underutilized approach to this crisis. We describe a trial protocol to evaluate the effectiveness and implementation of a standardized educational video-based intervention targeting HIV-infected pregnant women that seeks to optimize their ART retention and adherence by providing a VITAL Start (Video intervention to Inspire Treatment Adherence for Life) before committing to lifelong ART. METHODS: This study is a multisite parallel group, randomized controlled trial assessing the effectiveness of a brief facility-based video intervention to optimize retention and adherence to ART among pregnant women living with HIV in Malawi. A total of 892 pregnant women living with HIV and not yet on ART will be randomized to standard-of-care pre-ART counseling or VITAL Start. The primary outcome is a composite of retention and adherence (viral load < 1000 copies/ml) 12 months after starting ART. Secondary outcomes include assessments of behavioral adherence (self-reported adherence, pharmacy refill, and tenofovir diphosphate concentration), psychosocial impact, and resource utilization. We will also examine the implementation of VITAL Start via surveys and qualitative interviews with patients, partners, and health care workers and conduct cost-effectiveness analyses. DISCUSSION: This is a robust evaluation of an innovative facility-based video intervention for pregnant women living with HIV, with the potential to improve maternal and infant outcomes. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03654898. Registered on 31 August 2018.

Improving Pediatric Academic Global Health Collaborative Research and Agenda Setting: A Mixed-Methods Study.

Academic global health collaborations have the potential to improve joint understanding of health issues in low- and middle-income countries (LMICs). Our objective was to elucidate perceptions of benefits and challenges of academic global health collaborations as well as areas for improving collaborative research conducted in LMICs. This cross-sectional, mixed-methods study surveyed investigators' perceptions of benefits and challenges of pediatric academic global health collaborations. Authors of articles from four pediatric journals reporting pediatric research conducted in LMICs published between 2006 and 2015 were surveyed. Responses of LMIC investigators were compared with those of investigators in high-income countries (HICs). Responses to open-ended questions were analyzed using a combined thematic and content analysis approach. Of 1,420 potential respondents, 252 (17.7%) responded to the survey. Collaborative research with investigators from other countries was perceived as beneficial by 88.5% of respondents (n = 223), although this perception was more common among HIC respondents (n = 110, 94.0%) than LMIC respondents (n = 113, 83.7%) (p = 0.014). Sixty-seven percent (n = 170) of respondents perceived that HIC investigators had set the research agenda in work conducted in a LMIC. Respondents identified several critical factors to improve academic global health collaborations, including research capacity building, communication, and early involvement of LMIC investigators with shared decision-making during study conception and grant writing. Pediatric academic global health collaboration was widely perceived as positive. However, despite calls for capacity building and locally generated research ideas, many respondents felt that HIC investigators set the research agenda for work conducted in LMICs. This study provides suggestions for improving collaboration among pediatric academicians globally.

Infection or drug toxicity? Acute ataxia and encephalopathy after uncomplicated falciparum malaria and efavirenz dose adjustment.

Acute ataxia in children is a rare clinical syndrome usually caused by an infectious, post-infectious, or toxin-related aetiology. Although infrequent, acute ataxia can be related to more common diseases and treatments in Southern African countries including side effects of efavirenz-based anti-retroviral therapy (ART) for HIV or the post-malaria neurologic syndrome (PMNS) after infection with falciparum malaria. We describe a case from Lilongwe, Malawi of a 16-year-old HIV-positive patient with viral load suppression who presented with acute ataxia, confusion, and diplopia. Although he was on efavirenz-based ART for many years, his dose was increased 6 weeks prior, and he was treated for uncomplicated falciparum malaria 5 weeks prior with resolution of symptoms. Studies including cerebrospinal fluid analyses were normal, and he had rapid improvement of symptoms following discontinuation of efavirenz-based ART. Several case series have described supratherapeutic levels of efavirenz leading to acute ataxia as well as the self-limiting PMNS after non-complicated falciparum malaria. Though rare, recognition of efavirenz and PMNS as causes of ataxia is important to inform prompt treatment for HIV patients with acute ataxia in Malawi and other similar settings.

Factors associated with burnout amongst healthcare workers providing HIV care in Malawi.

CONTEXT: High rates of burnout have been reported in low and medium income countries and can detrimentally impact healthcare delivery. Understanding factors associated with burnout amongst health care workers providing HIV care may help develop interventions to prevent/treat burnout. OBJECTIVES: We sought to understand factors associated with burnout amongst health care workers providing HIV care in Malawi. METHODS: This was a sub-study of a larger cross-sectional study measuring burnout prevalence amongst a convenience sample of healthcare workers providing HIV care in 89 health facilities in eight districts in Malawi. Burnout was measured using the Maslach Burnout Inventory. Anonymously administered surveys included questions about sociodemographics, work characteristics (work load, supervisor support, team interactions), depression, life stressors, assessment of type D personality, and career satisfaction. We performed univariable and multivariable regression analyses to explore associations between variables and burnout. RESULTS: We received 535 responses (response rate 99%). Factors associated with higher rates of burnout on multivariable regression analyses included individual level factors: male gender (OR 1.75 [CI 1.17, 2.63]; p = 0.007), marital status (widowed or divorced) (OR 3.24 [CI 1.32, 7.98]; p = 0.011), depression (OR 3.32 [CI 1.21, 9.10]; p = 0.020), type D personality type (OR 2.77 [CI 1.50, 5.12]; p = 0.001) as well as work related factors: working at a health center vs. a rural hospital (OR 2.02 [CI 1.19, 3.40]; p = 0.009); lack of a very supportive supervisor (OR 2.38 [CI 1.32, 4.29]; p = 0.004), dissatisfaction with work/team interaction (OR 1.76 [CI 1.17, 2.66]; p = 0.007), and career dissatisfaction (OR 0.76 [CI 0.60, 0.96]; p = 0.020). CONCLUSION: This study identified several individual level vulnerabilities as well as work related modifiable factors. Improving the supervisory capacity of health facility managers and creating conditions for improved team dynamics may help reduce burnout amongst healthcare workers proving HIV care in Malawi.

VITAL Start: Video-Based Intervention to Inspire Treatment Adherence for Life-Pilot of a Novel Video-Based Approach to HIV Counseling for Pregnant Women Living with HIV.

We developed and piloted a video-based intervention targeting HIV-positive pregnant women to optimize antiretroviral therapy (ART) retention and adherence by providing a VITAL Start (Video-intervention to Inspire Treatment Adherence for Life) before ART. VITAL Start (VS) was grounded in behavior-determinant models and developed through an iterative multi-stakeholder process. Of 306 pregnant women eligible for ART, 160 were randomized to standard of care (SOC), 146 to VS and followed for one-month. Of those assigned to VS, 100% completed video-viewing; 96.5% reported they would recommend VS. Of 11 health workers interviewed, 82% preferred VS over SOC; 91% found VS more time-efficient. Compared to SOC, VS group had greater change in HIV/ART knowledge (p < 0.01), trend towards being more likely to start ART (p = 0.07), and better self-reported adherence (p = 0.02). There were no significant group differences in 1-month retention and pharmacy pill count. VITAL Start was highly acceptable, feasible, with promising benefits to ART adherence.

Importance of authorship and inappropriate authorship assignment in paediatric research in low- and middle-income countries.

OBJECTIVE: To understand the importance of authorship and authorship position, and gauge perceptions of inappropriate authorship assignment, among authors publishing paediatric research conducted in low- and middle-income countries (LMICs). METHODS: We conducted a cross-sectional, mixed-methods study using an online survey of both corresponding and randomly selected, non-corresponding authors who published research conducted in LMICs from 2006 to 2015 in the top four paediatric journals by Eigenfactor score. We used chi-square tests to compare responses by authors living in LMICs to authors living in high-income countries (HICs). We analysed qualitative responses using thematic analysis. RESULTS: Of 1420 potential respondents, 19.6% (n = 279) completed the survey. 57% (n = 159) lived in LMICs and 43% (n = 120) in HICs. LMIC authors more commonly perceived first authorship as most important for their academic advancement than HIC authors (74.2% vs. 60.8%, P = 0.017), while HIC authors reported last authorship as most important (25.1% vs. 38.3%, P = 0.018). 65% (n = 181) of respondents believed that their collaborators had been inappropriately assigned authorship positions (no difference in LMIC and HIC responses) and 32.6% (n = 91) reported personally accepting inappropriate authorship positions (more common in HIC respondents, P = 0.005). In qualitative data, respondents questioned the applicability of standard authorship guidelines for collaborative research conducted in LMICs. CONCLUSIONS: LMIC and HIC authors held different perceptions about the importance of authorship position. Reported inappropriate authorship assignment was common among both LMIC and HIC respondents. Alternatives to standard authorship criteria for research conducted in LMICs merit further studies.

OBJECTIF: Comprendre l'importance de la paternité d'auteur et de la position de l'auteur, et évaluer les perceptions de l'attribution inappropriée de la paternité d'auteur parmi les auteurs qui publient des recherches pédiatriques menées dans des pays à revenu faible ou intermédiaire (PRFI). MÉTHODES: Nous avons mené une étude transversale à méthodes mixtes avec un sondage en ligne auprès d'auteurs de correspondance et sélectionnés au hasard, d'auteurs not de correspondance, ayant publié des recherches menées dans des PRFIde 2006 à 2015 dans les quatre revues pédiatriques les mieux classées par le score d'Eigenfactor. Nous avons utilisé des tests de chi carré pour comparer les réponses des auteurs des PRFI à ceux des aux auteurs des pays à revenu élevé (PRE). Nous avons analysé les réponses qualitatives à l'aide d'une analyse thématique. RÉSULTATS: Sur 1.420 répondants potentiels, 19,6% (n = 279) ont répondu au sondage. 57% (n = 159) vivaient dans des PRFI et 43% (n = 120) dans des PRE. Les auteurs des PRFI estimaient plus souvent que la position de premier auteur était le plus important pour leur avancement universitaire que les auteurs des PRE (74,2% contre 60,8%, P = 0,017), tandis que les auteurs desPRE ont déclaré que le dernier auteur était le plus important (25,1% contre 38,3%, P = 0,018). 65% (n = 181) des répondants estimaient que des positions d'auteur avaient été attribués de manière inappropriée à leurs collaborateurs (aucune différence entre les réponses des PRFI et des PRE) et 32,6% (n = 91) ont déclaré avoir personnellement accepté des positions d'auteurs inappropriées (plus fréquents chez les répondants desPRE, P = 0,005). En ce qui concerne les données qualitatives, les répondants se sont interrogés sur l'applicabilité des directives standards en matière de paternité d'auteur pour la recherche collaborative menée dans les PRFI. CONCLUSIONS: Les auteurs des PRFI et desPREont des perceptions différentes sur l'importance de la position de l'auteur. L'attribution inappropriée de laposition d'auteur signalée était fréquente chez les répondants des PRFI et des PRE. Les alternatives aux critères standards de la paternité d'auteur pour les recherches menées dans les PRFI méritent d'être approfondies.

Population-Based Estimation of Dental Caries and Periodontal Disease Rates of Gravid and Recently Postpartum Women in Lilongwe, Malawi.

Objectives The objective of this study was to determine the rate of dental caries and periodontal disease among gravid and recently postpartum women at five delivery centers within and surrounding Lilongwe, Malawi. Study Design We partnered with obstetric specialists, community health workers, and dentists to perform dental history interviews and dental examinations during the study period from December 2012 to May 2014. Dental examinations were performed according to World Health Organization standards to assess periodontal and oral health status. Results Among the 387 gravid and recently postpartum women, the rate of dental caries was 69.3% and the rate of composite dental disease (caries and periodontal disease) was 76.7%. The majority (69.5%) of women examined had a decayed-missing-filled (DMF) index greater than or equal to one; the average DMF Index was 2.48. The majority of women had never seen a dentist (62.8%). However, most did perform oral hygiene, two or more times per day (90.2%); most women reported brushing with toothpaste (88.1%). Conclusion When assessing this population for dental caries and periodontal disease, the rate of dental disease was high. Therefore, this may be an ideal setting to test for impactful interventions aimed at reducing caries and periodontal disease.

Enhancing an HIV index case testing passive referral model through a behavioural skills-building training for healthcare providers: a pre-/post-assessment in Mangochi District, Malawi.

INTRODUCTION: Although knowledge of HIV positivity is a necessary step towards engagement in HIV care, more than one quarter of HIV-positive Malawians remain unaware of their HIV status. Testing the sexual partners, guardians and children of HIV-positive persons (index case finding or ICF) is a promising way of identifying HIV-positive persons unaware of their HIV status. ICF can be passive where the HIV-positive individual (index) invites a partner (or contact) for HIV testing or active where a health provider assists the index with partner notification and offers HIV testing to the partner. Strategies to improve passive ICF have not been thoroughly studied. We describe the impact of a behavioural skills-building training to enhance healthcare workers' (HCWs) implementation of Malawi's passive ICF programme. METHODS: In June 2017, HCWs from 36 health facilities in Mangochi were oriented to Malawi's ICF programme and began implementation. In February and April 2018, a total of 573 HCWs from these facilities received further training from the Tingathe Programme. The training focused on eliciting more untested sexual contacts from indexes and better equipping indexes on issuing "family referral slips" to contacts. Monthly programmatic data were abstracted from clinical registers from October 2017 to July 2018. Monthly programmatic indicators were collected from the Index Case Testing Register and the HIV Counselling and Testing Register and were entered into a data set with one record per facility per month. T-tests were used to compare the means of these indicators. RESULTS: During the ten-month study period, there were 200 facility-months observed before and 124 facility-months observed after training. The mean number of indexes identified per facility-month remained stable after training (pre = 18.9, post = 21.2, p = 0.74), but the mean number of sexual partners listed per facility-month (pre = 6.3, post = 10.6, p < 0.001) increased. The mean number of contacts who received HIV testing (pre = 11.1, post = 24.8, p < 0.001) and the mean number of HIV-positive contacts identified per facility-month (pre = 1.3, post = 2.3, p < 0.001) also increased. CONCLUSIONS: A brief behavioural skills-building training impacted a range of meaningful outcomes, including identification of HIV-positive individuals in a passive ICF programme. Such approaches could facilitate the identification of HIV-positive persons unaware of their HIV status, a necessary step for engagement in HIV care.

The HIV diagnostic assistant: early findings from a novel HIV testing cadre in Malawi.

OBJECTIVES: In 2015, Malawi piloted the HIV diagnostic assistant (HDA), a cadre of lay health workers focused primarily on HIV testing services. Our objective is to measure the effect of HDA deployment on country-level HIV testing measures. DESIGN: Interrupted time series analysis of routinely collected data to assess immediate change in absolute numbers and longitudinal changes in trends. METHODS: Data from all HDA sites were divided into two periods: predeployment (October 2013 to June 2015) and postdeployment (July 2015 to December 2017). Monthly rates of several key HIV testing measures were evaluated: HIV testing, including all tests done, new positives, and confirmatory testing. Syphilis testing at antenatal clinic (ANC) and early infant diagnosis were also assessed. FINDINGS: The number of patients tested for HIV per month increased after HDA deployment across all sex, age, and testing subgroups. The number of tests immediately increased by 35 588 (P = 0.031), and the postintervention trend was significantly greater than the preintervention slope (+3442 per month, P = 0.001). Of 7.4 million patients tested for HIV in the postdeployment period, 2.6 million (34%) were attributable to the intervention. The proportion of new positives receiving confirmatory tests increased from 28% preintervention to 98% postintervention (P < 0.0001). Syphilis testing rates at ANC improved, with 98% of all tests attributable to HDA deployment. The number and proportion of infants receiving DNA-PCR testing at 2 months experienced significant trend increases (P < 0.0001). INTERPRETATION: HDA deployment is associated with significant increases in total HIV testing, identification of new positives, confirmatory testing, syphilis testing at ANC, and early infant diagnosis testing.

Kaposi Sarcoma Herpesvirus Inflammatory Cytokine Syndrome-like Clinical Presentation in Human Immunodeficiency Virus-infected Children in Malawi.

We describe 7 human immunodeficiency virus-infected Malawian children with Kaposi sarcoma who met criteria for Kaposi sarcoma herpesvirus (KSHV) inflammatory cytokine syndrome. Each presented with persistent fevers, bulky lymphadenopathy, massive hepatosplenomegaly, and severe cytopenias. Plasma analyses were performed in 2 patients, both demonstrating extreme elevations of KSHV viral load and interleukin 6.

Reciprocity? International Preceptors' Perceptions of Global Health Elective Learners at African Sites.

BACKGROUND: Short-term global health electives (STGHEs) have become increasingly common, with evidence showing educational and clinical benefits for short-term learners (STLs). Despite increased recognition that STGHEs should be mutually beneficial for host sites and STLs, evidence demonstrating the impact on international host preceptors is lacking. OBJECTIVES: To understand international host preceptors' perceptions regarding benefits and burdens of hosting STLs. METHODS: Focus group discussions with a convenience sample of 10 of 18 eligible preceptors were conducted at pediatric STGHE sites in Malawi and Lesotho. Qualitative content analysis was performed to identify themes using a deductive-inductive approach. FINDINGS: Common themes regarding benefits to preceptors included increased knowledge and resources for learning from STLs, broadened differential diagnoses, and the satisfaction of teaching. Regarding burdens, preceptors perceived that supervising STLs decreases efficiency. Preceptors identified the burden of having to intervene in instances that could lead to patient harm. Some preceptors perceived that STLs under-valued preceptors' clinical decision-making in resource-limited contexts. CONCLUSIONS: Our findings emphasize the need for institutions to identify mutuality of benefits between STLs and host sites when developing STGHEs. Host preceptors identified robust pre-departure training for STLs, lengthened duration of STGHEs, and formal preceptor orientation as ways to enhance mutuality of benefits.

Global Disparities Between Pediatric Publications and Disease Burden From 2006 to 2015.

There is a disproportionate burden of pediatric disease in low- and middle-income countries (LMICs); however, the proportion and relation of published articles to childhood disease burden in LMICs have not been assessed previously. This study aimed to determine whether published articles and disease topics from research conducted in LMICs in the most widely cited pediatric journals reflected the global burden of childhood disease. We reviewed all articles published from 2006 to 2015 in the 3 pediatric journals with the highest Eigenfactor scores to identify studies conducted in the World Bank-designated LMICs. We abstracted study topic, design, purpose, country, and funding sources. We derived descriptive statistics, Fisher's exact χ2 test, Monte Carlo estimates, and Spearman's rank order coefficients. Of the 19 676 articles reviewed, 10 494 were original research articles. Of those, 965 (9.2%) were conducted in LMICs. Over the study period, the proportion of published articles originating from LMICs increased (r 2 = 0.77). Disease topics did not reflect the underlying burden of disease as measured in disability-adjusted life years (Spearman's rank order coefficient = 0.25). Despite bearing the majority of the world's burden of disease, articles from LMICs made up a small proportion of all published articles in the 3 pediatric journals with the highest Eigenfactor scores. The number of published articles from LMICs increased over the study period; nevertheless, the topics did not coincide with the burden of disease in LMICs. These discrepancies highlight the need for development of a research agenda to address the diseases that are the greatest threat to the majority of children worldwide.

Two-year evolution of latent rheumatic heart disease in Malawi.

BACKGROUND: In asymptomatic children, screening echocardiography has been used to attempt to diagnose rheumatic heart disease (RHD) at an early stage (latent RHD). World Heart Federation guidelines have standardized categorization of "definite," "borderline," or no RHD by echo findings. The progression of RHD diagnosed through echo screening is not known. In 2014, we screened 1450 schoolchildren in Malawi. OBJECTIVE: Our objective was to evaluate 2-year RHD evolution among those diagnosed through screening. METHODS: Two-year follow-up echocardiograms of those diagnosed with latent RHD were read by a primary, secondary, then third reader if there was disagreement. Progression or regression of both definite and borderline groups were tabulated. Penicillin adherence, age, gender, number in home, and household income were compared between those with definite RHD who regressed to borderline and those that stayed definite. We utilized the local system used to track HIV defaulters in order to bring participants back into care. Comparisons were made using Fisher's exact and Wilcoxon rank-sum tests. RESULTS: Of the 39 with borderline RHD, 1 was lost to follow-up (2.6%), 1 progressed to definite (2.6%), 19 remained borderline (48.7%), 17 (43.6%) regressed to normal, and 1 was reclassified as mitral valve prolapse (2.6%). Of the 11 with definite RHD, 6 (54.5%) remained definite, 4 regressed to borderline (36.4%), and 1 regressed to normal (9.1%). Two of 11 with definite RHD had penicillin adherence above 80% for the 2-year follow-up period. There were no differences in adherence, gender, age, household income, or number in household between those with definite RHD that regressed to borderline and those who did not (P > .19). CONCLUSIONS: Borderlines had a very low progression rate to definite RHD. A strength of our study was a high retention rate (98%). Longer follow-up is needed to determine expected disease evolution.