Availability and Quality of Surveillance and Survey Data on HIV Prevalence Among Sex Workers, Men Who Have Sex With Men, People Who Inject Drugs, and Transgender Women in Low- and Middle-Income Countries: Review of Available Data (2001-2017).

BACKGROUND: In 2019, 62% of new HIV infections occurred among key populations (KPs) and their sexual partners. The World Health Organization (WHO) recommends implementation of bio-behavioral surveys every 2-3 years to obtain HIV prevalence data for all KPs. However, the collection of these data is often less frequent and geographically limited. OBJECTIVE: This study intended to assess the availability and quality of HIV prevalence data among sex workers (SWs), men who have sex with men (MSM), people who inject drugs, and transgender women (transwomen) in low- and middle-income countries. METHODS: Data were obtained from survey reports, national reports, journal articles, and other grey literature available to the Global Fund, Joint United Nations Programme on HIV/AIDS, and WHO or from other open sources. Elements reviewed included names of subnational units, HIV prevalence, sampling method, and size. Based on geographical coverage, availability of trends over time, and recency of estimates, data were categorized by country and grouped as follows: nationally adequate, locally adequate but nationally inadequate, no recent data, no trends available, and no data. RESULTS: Among the 123 countries assessed, 91.9% (113/123) presented at least 1 HIV prevalence data point for any KP; 78.0% (96/123) presented data for at least 2 groups; and 51.2% (63/123), for at least 3 groups. Data on all 4 groups were available for only 14.6% (18/123) of the countries. HIV prevalence data for SWs, MSM, people who inject drugs, and transwomen were available in 86.2% (106/123), 80.5% (99/123), 45.5% (56/123), and 23.6% (29/123) of the countries, respectively. Only 10.6% (13/123) of the countries presented nationally adequate data for any KP between 2001 and 2017; 6 for SWs; 2 for MSM; and 5 for people who inject drugs. Moreover, 26.8% (33/123) of the countries were categorized as locally adequate but nationally inadequate, mostly for SWs and MSM. No trend data on SWs and MSM were available for 38.2% (47/123) and 43.9% (54/123) of the countries, respectively, while no data on people who inject drugs and transwomen were available for 76.4% (94/123) and 54.5% (67/123) of the countries, respectively. An increase in the number of data points was observed for MSM and transwomen. Overall increases were noted in the number and proportions of data points, especially for MSM, people who inject drugs, and transwomen, with sample sizes exceeding 100. CONCLUSIONS: Despite general improvements in health data availability and quality, the availability of HIV prevalence data among the most vulnerable populations in low- and middle-income countries remains insufficient. Data collection should be expanded to include behavioral, clinical, and epidemiologic data through context-specific differentiated survey approaches while emphasizing data use for program improvements. Ending the HIV epidemic by 2030 is possible only if the epidemic is controlled among KPs.

Are monitoring and evaluation systems adequate to report the programmatic coverage of HIV services among key populations in countries?

There was no global guidance or agreement regarding when a country has an adequate system to report on the service packages among human immunodeficiency virus (HIV) key populations. This article describes an approach to categorizing the system in a country for reporting the service package among HIV key populations. The approach consists of four dimensions, namely the epidemiological significance, comprehensiveness of the service packages, geographic coverage of services, and adequacy of the monitoring system. The proposed categorization approach utilizes available information and can inform the improvement of the service delivery and monitoring systems among HIV key populations.

Impact of maternal characteristics on the effect of maternal influenza vaccination on fetal outcomes.

BACKGROUND: Maternal infections during pregnancy have been associated with adverse fetal and infant health outcomes, and vaccination against influenza is the most effective tool to prevent morbidity and mortality due to seasonal and pandemic influenza. We evaluated the association between receipt of the inactivated seasonal influenza vaccine on preterm and small for gestational age (SGA) births, with the aim to assess racial and socioeconomic variations in vaccine effect. METHODS: We conducted a retrospective analysis of state-wide surveillance data from Georgia for the most recent four years available at the beginning of the study, a total of 8393 live births in Georgia from January 1, 2005 through December 31, 2008. We constructed multivariable logistic regression models and calculated odds ratios (OR) estimates with corresponding 95% confidence intervals (CI) to evaluate the effect of maternal influenza vaccination on SGA (birth weight <10th percentile for gestational age) and preterm (gestational age at birth <37 weeks) births while controlling for potential confounders. RESULTS: Among all women, we found significant strong associations between maternal influenza vaccination and reduced odds of a preterm birth during the widespread influenza activity period [OR=0.39, 95% CI: 0.18, 0.83]. In this period, vaccination was protective against SGA births among women at higher risk for influenza related morbidity - women enrolled in the Women, Infant and Child (WIC) program [OR=0.20, 95% CI: 0.04, 0.98] and Black women [OR=0.15 95% CI: 0.02, 0.94]; maternal influenza vaccination was associated with reduced odds of a preterm birth among white women [OR=0.34, 95% CI: 0.12, 0.91] and women of higher socio-economic status [OR=0.30, 95% CI: 0.12, 0.74]. CONCLUSION: Influenza vaccination during pregnancy was significantly associated with reduced odds of small for gestational age and preterm births during the widespread influenza activity period. Vaccination effects varied by socio-demographic characteristics.

Timely access to quality health care among Georgia children ages 4 to 17 years.

We examined factors associated with children's access to quality health care, a major concern in Georgia, identified through the 2010 Title V Needs Assessment. Data from the 2007 National Survey of Children's Health were merged with the 2008 Area Resource File and Health Resources and Services Administration medically underserved area variable, and restricted to Georgia children ages 4-17 years (N = 1,397). The study outcome, access to quality health care was derived from access to care (timely utilization of preventive medical care in the previous 12 months) and quality of care (compassionate/culturally effective/family-centered care). Andersen's behavioral model of health services utilization guided independent variable selection. Analyses included Chi-square tests and multinomial logit regressions. In our study population, 32.8 % reported access to higher quality care, 24.8 % reported access to moderate quality care, 22.8 % reported access to lower quality care, and 19.6 % reported having no access. Factors positively associated with having access to higher/moderate versus lower quality care include having a usual source of care (USC) (adjusted odds ratio, AOR:3.27; 95 % confidence interval, 95 % CI 1.15-9.26), and special health care needs (AOR:2.68; 95 % CI 1.42-5.05). Lower odds of access to higher/moderate versus lower quality care were observed for non-Hispanic Black (AOR:0.31; 95 % CI 0.18-0.53) and Hispanic (AOR:0.20; 95 % CI 0.08-0.50) children compared with non-Hispanic White children and for children with all other forms of insurance coverage compared with children with continuous-adequate-private insurance. Ensuring that children have continuous, adequate insurance coverage and a USC may positively affect their access to quality health care in Georgia.

Factors associated with parent report of access to care and the quality of care received by children 4 to 17 years of age in Georgia.

We examined factors associated with health care access and quality, among children in Georgia. Data from the 2007 National Survey of Children's Health were merged with the 2008 Area Resource File. The medically underserved area variable was appended to the merged file, restricting to Georgia children ages 4-17 years (N = 1,397). Study outcomes were past-year access to care, defined as utilization of preventive medical care and no occasion of delay or denial of needed care; and quality of care received, defined as compassionate, culturally-effective, and family-centered care which was categorized as higher, moderate, or lower. Analysis included binary and multinomial logit modeling. In our study population, 80.8 % were reported to have access to care. The quality of care distribution was: higher (39.4 %), moderate (30.6 %), and lower (30.0 %). Younger age (4-9 years) was positively associated with having access to care. Compared to children who had continuous and adequate private insurance, children who were never/intermittently insured or who had continuous and inadequate private insurance were less likely to have access. Compared to children who had continuous and adequate private insurance, there were lower odds of perceiving received care as higher/moderate versus lower quality among children who were never/intermittently insured or who had continuous and inadequate/adequate public insurance. Being in excellent/very good health and living in safe/supportive neighborhoods were positively associated with quality; non-white race/ethnicity and federal poverty level were negatively associated with quality. Assuring continuous, adequate insurance may positively impact health care access and quality.

Preexposure prophylaxis for HIV infection: healthcare providers' knowledge, perception, and willingness to adopt future implementation in the southern US.

BACKGROUND: Understanding providers' perspective on preexposure prophylaxis (PrEP) would facilitate planning for future implementation. METHODS: A survey of care providers from sexually transmitted disease and family planning clinics in South Carolina and Mississippi was conducted to assess their knowledge, perception, and willingness to adopt PrEP. Multivariable logistic and general linear regression with inverse propensity score treatment weights were used for analyses. RESULTS: Survey response rate was 360/480 (75%). Median age was 46.9 years and a majority were women (279 [78%]), non-Hispanic white (277 [78%]), nonphysicians (254 [71%]), and public health care providers (223 [62%]). Knowledge about PrEP was higher among physicians compared with nonphysicians (P = 0.001); nonpublic health care providers compared with public health care providers (P = 0.023), and non-Hispanic whites compared with non-Hispanic blacks (P = 0.034). The majority of the providers were concerned about the safety, efficacy, and cost of PrEP. Providers' perceptions about PrEP were significantly associated with their sociodemographic and occupational characteristics. The willingness to prescribe PrEP was more likely with higher PrEP knowledge scores (adjusted odds ratio [aOR] 14.94; 95% confidence interval [CI] 3.21-69.61), older age (aOR 1.14; 95% CI 1.01-1.29), and in those who agreed that "PrEP would empower women" (aOR 2.90; 95% CI 1.28-6.61); and was less likely for "other" race/ethnicity versus white (aOR 0.23; 95% CI 0.07-0.76) and in those who agreed that "PrEP, if not effective, could lead to higher HIV transmission" (aOR 0.45; 95% CI 0.27-0.75). CONCLUSIONS: To improve the acceptance of PrEP among providers, there is a need to develop tailored education/training programs to alleviate their concerns about the safety and efficacy of PrEP.

The effect of maternity leave length and time of return to work on breastfeeding.

OBJECTIVE: We investigated the effect of maternity leave length and time of first return to work on breastfeeding. METHODS: Data were from the Early Childhood Longitudinal Study-Birth Cohort. Restricting our sample to singletons whose biological mothers were the respondents at the 9-month interview and worked in the 12 months before delivery (N = 6150), we classified the length of total maternity leave (weeks) as 1 to 6, 7 to 12, ≥ 13, and did not take; paid maternity leave (weeks) as 0, 1 to 6, ≥ 7, and did not take; and time of return to work postpartum (weeks) as 1 to 6, 7 to 12, ≥ 13, and not yet returned. Analyses included χ(2) tests and multiple logistic regressions. RESULTS: In our study population, 69.4% initiated breastfeeding with positive variation by both total and paid maternity leave length, and time of return to work. In adjusted analyses, neither total nor paid maternity leave length had any impact on breastfeeding initiation or duration. Compared with those returning to work within 1 to 6 weeks, women who had not yet returned to work had a greater odds of initiating breastfeeding (odds ratio [OR]: 1.46 [1.08-1.97]; risk ratios [RR]: 1.13 [1.03-1.22]), continuing any breastfeeding beyond 6 months (OR: 1.41 [0.87-2.27]; RR: 1.25 [0.91-1.61]), and predominant breastfeeding beyond 3 months (OR: 2.01 [1.06-3.80]; RR: 1.70 [1.05-2.53]). Women who returned to work at or after 13 weeks postpartum had higher odds of predominantly breastfeeding beyond 3 months (OR: 2.54 [1.51-4.27]; RR: 1.99 [1.38-2.69]). CONCLUSION: If new mothers delay their time of return to work, then duration of breastfeeding among US mothers may lengthen.

Balancing work and family: effect of employment characteristics on breastfeeding.

This article describes an investigation of the effect of postpartum employment and occupational type on breastfeeding initiation and duration. Data were from the Early Childhood Longitudinal Study-Birth Cohort. Postpartum employment status was classified as full-time, part-time, and not employed. Among postpartum workers, occupational type was classified as management, professional, service, sales, administrative, and "other." In adjusted analysis, professional women had a 20% greater likelihood of initiating breastfeeding than administrative workers (risk ratio [RR] 1.20; 95% confidence interval [CI], 1.06-1.30). Full-time workers had a 10% lower likelihood of initiating breastfeeding than those not employed (RR 0.90; 95% CI, 0.82-0.97). Among breastfeeding initiators, full-time workers had a 19% lower likelihood of any breastfeeding beyond 6 months than those not employed (RR 0.81; 95% CI, 0.65-0.99). To improve breastfeeding initiation and duration in the United States, part-time options may be an effective solution for working mothers.

Reasons why women do not initiate breastfeeding: A southeastern state study.

PURPOSE: Despite the increase in breastfeeding initiation and duration in the United States, only five states have met the three Healthy People 2010 breastfeeding objectives. Our objectives are to study women's self-reported reasons for not initiating breastfeeding and to determine whether these reasons vary by race/ethnicity, and other maternal and hospital support characteristics. METHODS: Data are from the 2000-2003 Arkansas Pregnancy Risk Assessment Monitoring System, restricting the sample to women who did not initiate breastfeeding (unweighted n=2,917). Reasons for not initiating breastfeeding are characterized as individual reasons, household responsibilities, and circumstances. Analyses include the chi(2) test and multiple logistic regression. RESULTS: About 38% of Arkansas mothers of live singletons did not initiate breastfeeding. There was a greater representation of non-Hispanic Blacks among those who did not initiate breastfeeding (32%) than among those who initiated breastfeeding (9.9%). Among those who never breastfed, individual reasons were most frequently cited for noninitiation (63.0%). After adjusting for covariates, Hispanics had three times the odds of citing circumstances than Whites (odds ratio [OR], 3.07; 95% confidence interval [CI], 1.31-7.18). Women who indicated that the hospital staff did not teach them how to breastfeed had more than two times greater odds of citing individual reasons (OR, 2.25; 95% CI, 1.30-3.91) or reasons related to household responsibilities (OR, 2.27; 95% CI, 1.19-4.36) as compared with women who indicated they were taught. CONCLUSIONS: Findings suggest the need for targeting breastfeeding interventions to different subgroups of women. In addition, there are implications for policy particularly regarding breastfeeding support in hospitals.

A program evaluation of postpartum/newborn home visitation services in aiken county, South Carolina.

OBJECTIVE: Home visiting programs for very young children seek to promote their health and development. We conducted a process and outcome evaluation of the Postpartum/Newborn Home Visit (PPNBHV) service in 1 county. DESIGN: A retrospective study of Aiken County Health records of live infant births in 2004 was conducted. SAMPLE: A random sample of 176 infants who were born in 2004 and enrolled in the women, infants, and children's (WIC) program in the same year was selected. MEASURES: Process measures include timeliness of the home visit, and appropriateness of revisits. Outcome measures include age at WIC enrollment and immunization status at 6/9 months. RESULTS: Of the 176 infants, 76 (43%) received a home visit. Of these, 13 (17%) received the visit within the stipulated time frame. After controlling for potential confounders, infants who received a home visit were 4 times (95% CI 1.92-8.36) as likely to enroll early in the WIC program compared with those who did not. CONCLUSION: The PPNBHV service may contribute to early enrollment in the WIC program. Improvement in the timeliness of the visits is needed. Program monitoring and evaluation are necessary to ensure adherence, measure outcomes, and provide feedback for continuous quality improvement.