A trial of nurturing care among children who are HIV-exposed and uninfected in eSwatini.

INTRODUCTION: Children who are HIV-exposed and uninfected (CHEU) are a growing population at potential risk of poor neurocognitive development. We tested a nurturing care intervention on children's neurocognitive development and maternal depressive symptoms (primary) with mediation through caregiving activities (secondary). METHODS: This study was conducted among six intervention and nine comparison antenatal-care/prevention of vertical transmission (ANC/PVT) HIV clinics in eSwatini. We enrolled pregnant women and measured infant development at 9 and 18 months. mothers2mothers (m2m) designed and implemented the clinic-home-community-based intervention. We measured infants' neurodevelopment, maternal depressive symptoms and caregiving activities with the Mullen Scales of Early Learning (MSEL), Edinburgh Postnatal Depression Scale, HOME Inventory and Family Care Indicators. We fitted linear mixed effects regression models with clinic random effects to compare intervention versus comparison arms, and generalised structural equation models to evaluate mediation, adjusting for confounders. RESULTS: Mother-infant pairs (n = 429) participated between January 2016 through May 2018. Socio-demographic characteristics were balanced between arms except for higher rates of peri-urban versus rural residence and single versus married mothers in the comparison group. The 18 month retention was 82% (180/220) intervention, 79% (166/209) comparison arm, with 25 infant deaths. Intervention MSEL scores were significantly, and modestly, higher in receptive language (55.7 [95% CI 54.6, 56.9] vs. 53.7 [95% CI 52.6, 54.8]), expressive language (42.5 [95% CI 41.6, 39.8] vs. 40.8 [95% CI 39.8, 41.7]) and composite MSEL (85.4 [95% CI 83.7, 84.5] vs. 82.7 [95% CI 81.0, 84.5]), with no difference in maternal depressive symptoms or in observations of mother-child interactions. Intervention book-sharing scores were higher (0.63 vs. 0.41) and mediated the effect on MSEL scores (indirect effect, p-values ≤ 0.024). The direct effects on visual reception and expressive language scores were significantly higher in the intervention compared to the comparison arm (coefficients 1.93 [95% CI 0.26, 3.60] and 1.66 [95% CI 0.51, 2.79, respectively]). CONCLUSIONS: Nurturing care interventions can be integrated into ANC/PVT clinic-home-community programmes. The intervention, mediated through interactive caregiving activities, increased language development scores among CHEU. Partnering with a local team, m2m, to design and implement a culturally relevant intervention illustrates the ability to impact parent-child play and learning activities that are associated with children's neurodevelopment.

Stigma and outness about sexual behaviors among cisgender men who have sex with men and transgender women in Eswatini: a latent class analysis.

BACKGROUND: Men who have sex with men (MSM) and transgender women in Sub-Saharan Africa are subjected to high levels of sexual behavior-related stigma, which may affect mental health and sexual risk behaviors. MSM and transgender women who are open about, or have disclosed their sexual behaviors appear to be most affected by stigma. Characterizing the mechanism of action of stigma in potentiating HIV-risks among these key populations is important to support the development of interventions. METHODS: In this study, a total of 532 individuals were recruited across Eswatini (Swaziland) through chain-referral-sampling from October - December 2014, including 419 cisgender MSM and 109 transgender women. Participants were surveyed about demographics, stigma, outness of same-sex practices to family members and healthcare workers, and mental and sexual health. This study used latent class analysis (LCA) to determine latent constructs of stigma/outness, and used multinomial logistic regression to determine associations with underlying constructs and sexual risk behaviors. RESULTS: Three latent classes emerged: 1) Those who reported low probabilities of stigma (55%; 276/502); 2) Those who reported high probabilities of stigma including physical violence and fear/avoidance of healthcare, and were not "out" (11%; 54/502); and 3) Those who reported high probabilities of stigma including verbal harassment and stigma from family and friends, and were "out" (34%; 172/502). Relative to the "low stigma" class, participants from an urban area (adjusted odds ratio [AOR] = 2.78, 95% Confidence Interval [CI] = 1.53-5.07) and who engaged in condomless anal sex (AOR = 1.85, 95% CI = 1.17-2.91) were more likely to belong to the "high stigma, 'out'" class. In contrast, those who had a concurrent male or female partner were more likely to belong to the "high stigma, not 'out'" class AOR = 2.73, 95% CI = 1.05-7.07). Depression was associated with membership in both high-stigma classes (AOR = 3.14, 95% CI = 1.50-6.55 "not out", AOR = 2.42, 95% CI = 1.51-3.87 "out"). CONCLUSIONS: Sexual behavior stigma at a community level is associated with individual-level risk behaviors among MSM and transgender women, and these associations vary by level of outness about sexual practices. Achieving sufficient coverage of evidence-based stigma interventions may be key to realizing the potential impact of HIV prevention and treatment interventions for MSM and transgender women in Eswatini.

Authorship Correction: Sampling Key Populations for HIV Surveillance: Results From Eight Cross-Sectional Studies Using Respondent-Driven Sampling and Venue-Based Snowball Sampling.

[This corrects the article DOI: 10.2196/publichealth.8116.].

Sampling Key Populations for HIV Surveillance: Results From Eight Cross-Sectional Studies Using Respondent-Driven Sampling and Venue-Based Snowball Sampling.

BACKGROUND: In using regularly collected or existing surveillance data to characterize engagement in human immunodeficiency virus (HIV) services among marginalized populations, differences in sampling methods may produce different pictures of the target population and may therefore result in different priorities for response. OBJECTIVE: The objective of this study was to use existing data to evaluate the sample distribution of eight studies of female sex workers (FSW) and men who have sex with men (MSM), who were recruited using different sampling approaches in two locations within Sub-Saharan Africa: Manzini, Swaziland and Yaoundé, Cameroon. METHODS: MSM and FSW participants were recruited using either respondent-driven sampling (RDS) or venue-based snowball sampling. Recruitment took place between 2011 and 2016. Participants at each study site were administered a face-to-face survey to assess sociodemographics, along with the prevalence of self-reported HIV status, frequency of HIV testing, stigma, and other HIV-related characteristics. Crude and RDS-adjusted prevalence estimates were calculated. Crude prevalence estimates from the venue-based snowball samples were compared with the overlap of the RDS-adjusted prevalence estimates, between both FSW and MSM in Cameroon and Swaziland. RESULTS: RDS samples tended to be younger (MSM aged 18-21 years in Swaziland: 47.6% [139/310] in RDS vs 24.3% [42/173] in Snowball, in Cameroon: 47.9% [99/306] in RDS vs 20.1% [52/259] in Snowball; FSW aged 18-21 years in Swaziland 42.5% [82/325] in RDS vs 8.0% [20/249] in Snowball; in Cameroon 15.6% [75/576] in RDS vs 8.1% [25/306] in Snowball). They were less educated (MSM: primary school completed or less in Swaziland 42.6% [109/310] in RDS vs 4.0% [7/173] in Snowball, in Cameroon 46.2% [138/306] in RDS vs 14.3% [37/259] in Snowball; FSW: primary school completed or less in Swaziland 86.6% [281/325] in RDS vs 23.9% [59/247] in Snowball, in Cameroon 87.4% [520/576] in RDS vs 77.5% [238/307] in Snowball) than the snowball samples. In addition, RDS samples indicated lower exposure to HIV prevention information, less knowledge about HIV prevention, limited access to HIV prevention tools such as condoms, and less-reported frequency of sexually transmitted infections (STI) and HIV testing as compared with the venue-based samples. Findings pertaining to the level of disclosure of sexual practices and sexual practice-related stigma were mixed. CONCLUSIONS: Samples generated by RDS and venue-based snowball sampling produced significantly different prevalence estimates of several important characteristics. These findings are tempered by limitations to the application of both approaches in practice. Ultimately, these findings provide further context for understanding existing surveillance data and how differences in methods of sampling can influence both the type of individuals captured and whether or not these individuals are representative of the larger target population. These data highlight the need to consider how program coverage estimates of marginalized populations are determined when characterizing the level of unmet need.

Stevens-Johnson syndrome and HIV in children in Swaziland.

BACKGROUND: Stevens-Johnson syndrome (SJS) can be a severe and life-threatening reaction with many potential causes, including multiple medications used in HIV care and treatment. Specific risk factors, especially in children, are not currently well-understood. METHODS: We describe a series of cases of SJS that occurred from 2006 to 2010 in an HIV-focused clinic in Mbabane, Swaziland. The electronic medical and pharmacy records of all pediatric patients <20 years old were reviewed to identify cases of SJS. Patient demographic, immunosuppression and outcome data were also collected. RESULTS: A total of 19 cases of SJS were documented. Eighty-four percent of cases were attributed to nevirapine (NVP) exposure whereas the remaining cases were caused by cotrimoxazole (11%) and efavirenz (5%). Median symptom onset was 22 days after initiation of the offending medication (interquartile range = 14-25 days). At time of SJS, 84% had advanced or severe immunosuppression. Forty-two percent of patients required hospitalization, and no SJS-associated deaths were known to occur. Use of efavirenz was attempted in 8 NVP-associated cases after SJS resolution and was successful in all except 1. CONCLUSIONS: SJS occurrence was rare in this population, with the majority of cases being associated with NVP. All occurred within 32 days of medication initiation, providing a target window for intensified monitoring and anticipatory guidance. SJS can occur in children at any age, with any level of immunosuppression, and can occur during the lead-in dosing period of NVP.

Mortality and clinical outcomes in HIV-infected children on antiretroviral therapy in Malawi, Lesotho, and Swaziland.

OBJECTIVE: To determine mortality and immune status improvement in HIV-infected pediatric patients on antiretroviral treatment (ART) in Malawi, Lesotho, and Swaziland. METHODS: We conducted a retrospective cohort study of patients aged <12 years at ART initiation at 3 sites in sub-Saharan Africa between 2004 and 2009. Twelve-month and overall mortality were estimated, and factors associated with mortality and immune status improvement were evaluated. RESULTS: Included in the study were 2306 patients with an average follow-up time on ART of 2.3 years (interquartile range 1.5-3.1 years). One hundred four patients (4.5%) died, 9.0% were lost to follow-up, and 1.3% discontinued ART. Of the 104 deaths, 77.9% occurred in the first year of treatment with a 12-month mortality rate of 3.5%. The overall mortality rate was 2.25 deaths/100 person-years (95% confidence interval [CI] 1.84-2.71). Increased 12-month mortality was associated with younger age; <6 months (hazard ratio [HR] = 8.11, CI 4.51-14.58), 6 to <12 months (HR = 3.43, CI 1.96-6.02), and 12 to <36 months (HR = 1.92, CI 1.16-3.19), and World Health Organization stage IV (HR = 4.35, CI 2.19-8.67). Immune status improvement at 12 months was less likely in patients with advanced disease and age <12 months. CONCLUSIONS: Despite challenges associated with pediatric ART in developing countries, low mortality and good treatment outcomes can be achieved. However, outcomes are worse in younger patients and those with advanced disease at the time of ART initiation, highlighting the importance of early diagnosis and treatment.