Assessment of a screening tool to aid home-based identification of adolescents (aged 10-14) living with HIV in Zambia and South Africa: HPTN 071 (PopART) study.

INTRODUCTION: The HPTN071 (PopART) for Youth (P-ART-Y) study evaluated the acceptability and uptake of a community-level combination HIV prevention package including universal testing and treatment (UTT) among young people in Zambia and South Africa. We determined whether a four-question primary care level screening tool, validated for use in clinical settings, could enhance community (door-to-door) identification of undiagnosed HIV-positive younger adolescents (aged 10-14) who are frequently left out of HIV interventions. METHOD: Community HIV-care Providers (CHiPs) contacted and consented adolescents in their homes and offered them participation in the PopART intervention. CHiPs used a four question-screening tool, which included: history of hospital admission; recurring skin problems; poor health in last 3 months; and death of at least one parent. A "yes" response to one or more questions was classified as being "at risk" of being HIV-positive. Rapid HIV tests were offered to all children. Data were captured through an electronic data capture device from August 2016 to December 2017. The sensitivity, specificity, positive predictive value and negative predictive value were estimated for the screening tool, using the rapid HIV test result as the gold standard. RESULTS: In our 14 study sites, 33,710 adolescents aged 10-14 in Zambia and 8,610 in South Africa participated in the study. About 1.3% (427/33,710) and 1.2% (106/8,610) self-reported to be HIV positive. Excluding the self-reported HIV-positive, we classified 11.3% (3,746/33,283) of adolescents in Zambia and 17.5% (1,491/8,504) in South Africa as "at risk". In Zambia the estimated sensitivity was 35.3% (95% CI 27.3%-44.2%) and estimated specificity was 88.9% (88.5%-89.2%). In South Africa the sensitivity was 72.3% (26.8%-94.9%) and specificity was 82.5% (81.6-83.4%). CONCLUSION: The sensitivity of the screening tool in a community setting in Zambia was low, so this tool should not be considered a substitute for universal testing where that is possible. In South Africa the sensitivity was higher, but with a wide confidence interval. Where universal testing is not possible the tool may help direct resources to adolescents more likely to be living with undiagnosed HIV. TRIAL REGISTRATION: Clinical Trial Number: NCT01900977.

Household Food Insecurity and Demographic Factors, Low Birth Weight and Stunting in Early Childhood: Findings from a Longitudinal Study in South Africa.

BACKGROUND: Low birthweight (LBW) as well as early childhood stunting are risk factors for increased childhood morbidity in low-and middle-income countries (LMIC). The Covid 19 pandemic has exacerbated food insecurity and unemployment globally, prompting concerns for maternal and child health. OBJECTIVES: We used data from the great recession of 2008 to examine the relationship between household food security and other risk factors with LBW and stunting using a longitudinal sample of South African women and their offspring. METHODS: Food security indicators, alcohol use, blood pressure and other characteristics were examined in relation to LBW (≤ 2500 g), stunting (height for age ≤ 2SD) and severe stunting (height for age ≤ 3SD). Regression modelling with clustering at maternal ID level were employed to adjust for maternal characteristics and women who gave birth more than once during the reference period. RESULTS: Birthweight data were available for 1173 children and height for age 1216 children. The prevalence of LBW was 14.7% while stunting and severe stunting was 17.8% and 14.5%. Child hunger in the household, maternal hypertension and alcohol use were associated with low birthweight. Food expenditure below the Stats SA poverty line and low dietary diversity was associated with stunting and severe stunting respectively. Maternal height and low birthweight were associated with both stunting and severe stunting. CONCLUSIONS FOR PRACTICE: Interventions that can improve household food security and nutritional status during the periconceptional and antenatal period may reduce the prevalence of low birthweight and subsequent stunting in low- and middle-income countries.

Dietary diversity, food insecurity and the double burden of malnutrition among children, adolescents and adults in South Africa: Findings from a national survey.

Childhood stunting remains a global public health problem. Many stunted children live in the same household as overweight or obese adults (the so-called double burden of malnutrition), evidence that quality as well as quantity of food is important. In recent years, food security measurement has shifted away from anthropometry (e.g., stunting) to experiential measures (e.g., self-reported hunger). However, given the continued problem of stunting, it is important that national surveys identify malnutrition. Objectives: To examine the associations between a variety of food security indicators, including dietary diversity, with adult, child (0-4 years) (5-9 years) and adolescent (10-17 years) anthropometry. To estimate the prevalence of double burden households. Methods: The study utilized cross-sectional data from the South African National Income Dynamics Survey NIDS (2008). We examined the associations between five food security indicators and anthropometry outcomes. The indicators were adult and child hunger in the household, self-reported household food sufficiency, food expenditure>60% of monthly expenditure and household dietary diversity. Multinomial and logistic regression models were employed to examine the associations with adult BMI categories and children's stunting and BMI. Results: The prevalence of stunting was 18.4% and the prevalence of wasting and overweight was 6.8 and 10.4%, respectively. Children <5 and adolescents with medium dietary diversity were significantly more likely to be stunted than children with high dietary diversity. Among children <5, child hunger and medium dietary diversity were significantly associated with wasting. None of the food security indicators were associated with stunting in children aged 5-9. Among stunted children, 70.2% lived with an overweight or obese adult. Among adults, increased dietary diversity increased the risk of overweight and obesity. Conclusion: Dietary diversity can be used as a proxy for poor nutritional status among children <5 years and adolescents but the relationship between dietary diversity and adult obesity is more complex. Given the double burden of malnutrition in many low- and middle-income countries, indicators of dietary quality remain important. These tools can be further refined to include an extra category for processed foods. Given the relative simplicity to collect this data, national surveys would be improved by its inclusion.

Cost and cost-effectiveness of a universal HIV testing and treatment intervention in Zambia and South Africa: evidence and projections from the HPTN 071 (PopART) trial.

BACKGROUND: The HPTN 071 (PopART) trial showed that a combination HIV prevention package including universal HIV testing and treatment (UTT) reduced population-level incidence of HIV compared with standard care. However, evidence is scarce on the costs and cost-effectiveness of such an intervention. METHODS: Using an individual-based model, we simulated the PopART intervention and standard care with antiretroviral therapy (ART) provided according to national guidelines for the 21 trial communities in Zambia and South Africa (for all individuals aged >14 years), with model parameters and primary cost data collected during the PopART trial and from published sources. Two intervention scenarios were modelled: annual rounds of PopART from 2014 to 2030 (PopART 2014-30; as the UNAIDS Fast-Track target year) and three rounds of PopART throughout the trial intervention period (PopART 2014-17). For each country, we calculated incremental cost-effectiveness ratios (ICERs) as the cost per disability-adjusted life-year (DALY) and cost per HIV infection averted. Cost-effectiveness acceptability curves were used to indicate the probability of PopART being cost-effective compared with standard care at different thresholds of cost per DALY averted. We also assessed budget impact by projecting undiscounted costs of the intervention compared with standard care up to 2030. FINDINGS: During 2014-17, the mean cost per person per year of delivering home-based HIV counselling and testing, linkage to care, promotion of ART adherence, and voluntary medical male circumcision via community HIV care providers for the simulated population was US$6·53 (SD 0·29) in Zambia and US$7·93 (0·16) in South Africa. In the PopART 2014-30 scenario, median ICERs for PopART delivered annually until 2030 were $2111 (95% credible interval [CrI] 1827-2462) per HIV infection averted in Zambia and $3248 (2472-3963) per HIV infection averted in South Africa; and $593 (95% CrI 526-674) per DALY averted in Zambia and $645 (538-757) per DALY averted in South Africa. In the PopART 2014-17 scenario, PopART averted one infection at a cost of $1318 (1098-1591) in Zambia and $2236 (1601-2916) in South Africa, and averted one DALY at $258 (225-298) in Zambia and $326 (266-391) in South Africa, when outcomes were projected until 2030. The intervention had almost 100% probability of being cost-effective at thresholds greater than $700 per DALY averted in Zambia, and greater than $800 per DALY averted in South Africa, in the PopART 2014-30 scenario. Incremental programme costs for annual rounds until 2030 were $46·12 million (for a mean of 341 323 people) in Zambia and $30·24 million (for a mean of 165 852 people) in South Africa. INTERPRETATION: Combination prevention with universal home-based testing can be delivered at low annual cost per person but accumulates to a considerable amount when scaled for a growing population. Combination prevention including UTT is cost-effective at thresholds greater than $800 per DALY averted and can be an efficient strategy to reduce HIV incidence in high-prevalence settings. FUNDING: US National Institutes of Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, Bill & Melinda Gates Foundation.

Lockdown-Associated Hunger May Be Affecting Breastfeeding: Findings from a Large SMS Survey in South Africa.

The impact that the COVID-19 pandemic has had, and will continue to have, on food security and child health is especially concerning. A rapid, Short Message Service (SMS) Maternal and Child Health survey was conducted in South Africa in June 2020 (n = 3140), with a follow-up in July 2020 (n = 2287). This was a national cross-sectional survey conducted among pregnant women and mothers registered with the MomConnect mhealth platform. Logistic regression was conducted to explore the associations between breastfeeding, maternal depressive symptoms, and hunger in the household. High breastfeeding initiation rates and the early introduction of other foods or mixed milk feeding were found. The prevalence of depressive symptoms in this survey sample was 26.95%, but there was no association between breastfeeding behaviour and depressive symptom scores (OR = 0.89; 95% CI: 0.63, 1.27). A positive correlation was found between not breastfeeding and not going to the health clinic. The odds of hungry mothers breastfeeding were significantly lower (OR = 0.66; p = 0.045). This result also holds in a multivariate framework, including covariates such as depressive symptoms, attendance of a PHC facility, and whether the infant was older than 3 months. Support for breastfeeding must include support, such as economic support, for breastfeeding mothers, to enable them to access nutritious diets. Mothers also need reassurance on the quality of their breastmilk and their ability to breastfeed and should be encouraged to continue to attend the health clinic regularly.

Work and home productivity of people living with HIV in Zambia and South Africa.

OBJECTIVE: To compare number of days lost to illness or accessing healthcare for HIV-positive and HIV-negative individuals working in the informal and formal sectors in South Africa and Zambia. DESIGN: As part of the HPTN 071 (PopART) study, data on adults aged 18-44 years were gathered from cross-sectional surveys of random general population samples in 21 communities in Zambia and South Africa. Data on the number of productive days lost in the last 3 months, laboratory-confirmed HIV status, labour force status, age, ethnicity, education, and recreational drug use was collected. METHODS: Differences in productive days lost between HIV-negative and HIV-positive individuals ('excess productive days lost') were estimated with negative binomial models, and results disaggregated for HIV-positive individuals after various durations on antiretroviral treatment (ART). RESULTS: From samples of 19 330 respondents in Zambia and 18 004 respondents in South Africa, HIV-positive individuals lost more productive days to illness than HIV-negative individuals in both countries. HIV-positive individuals in Zambia lost 0.74 excess productive days [95% confidence interval (CI) 0.48-1.01; P < 0.001] to illness over a 3-month period. HIV-positive in South Africa lost 0.13 excess days (95% CI 0.04-0.23; P = 0.007). In Zambia, those on ART for less than 1 year lost most days, and those not on ART lost fewest days. In South Africa, results disaggregated by treatment duration were not statistically significant. CONCLUSION: There is a loss of work and home productivity associated with HIV, but it is lower than existing estimates for HIV-positive formal sector workers. The findings support policy makers in building an accurate investment case for HIV interventions.

Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trial.

BACKGROUND: The life expectancy of HIV-positive individuals receiving antiretroviral therapy (ART) is approaching that of HIV-negative people. However, little is known about how these populations compare in terms of health-related quality of life (HRQoL). We aimed to compare HRQoL between HIV-positive and HIV-negative people in Zambia and South Africa. METHODS: As part of the HPTN 071 (PopART) study, data from adults aged 18-44 years were gathered between Nov 28, 2013, and March 31, 2015, in large cross-sectional surveys of random samples of the general population in 21 communities in Zambia and South Africa. HRQoL data were collected with a standardised generic measure of health across five domains. We used ß-distributed multivariable models to analyse differences in HRQoL scores between HIV-negative and HIV-positive individuals who were unaware of their status; aware, but not in HIV care; in HIV care, but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more. We included controls for sociodemographic variables, herpes simplex virus type-2 status, and recreational drug use. FINDINGS: We obtained data for 19 750 respondents in Zambia and 18 941 respondents in South Africa. Laboratory-confirmed HIV status was available for 19 330 respondents in Zambia and 18 004 respondents in South Africa; 4128 (21%) of these 19 330 respondents in Zambia and 4012 (22%) of 18 004 respondents in South Africa had laboratory-confirmed HIV. We obtained complete HRQoL information for 19 637 respondents in Zambia and 18 429 respondents in South Africa. HRQoL scores did not differ significantly between individuals who had initiated ART more than 5 years previously and HIV-negative individuals, neither in Zambia (change in mean score -0·002, 95% CI -0·01 to 0·001; p=0·219) nor in South Africa (0·000, -0·002 to 0·003; p=0·939). However, scores did differ between HIV-positive individuals who had initiated ART less than 5 years previously and HIV-negative individuals in Zambia (-0·006, 95% CI -0·008 to -0·003; p<0·0001). A large proportion of people with clinically confirmed HIV were unaware of being HIV-positive (1768 [43%] of 4128 people in Zambia and 2026 [50%] of 4012 people in South Africa) and reported good HRQoL, with no significant differences from that of HIV-negative people (change in mean HRQoL score -0·001, 95% CI -0·003 to 0·001, p=0·216; and 0·001, -0·001 to 0·001, p=0·997, respectively). In South Africa, HRQoL scores were lower in HIV-positive individuals who were aware of their status but not enrolled in HIV care (change in mean HRQoL -0·004, 95% CI -0·01 to -0·001; p=0·010) and those in HIV care but not on ART (-0·008, -0·01 to -0·004; p=0·001) than in HIV-negative people, but the magnitudes of difference were small. INTERPRETATION: ART is successful in helping to reduce inequalities in HRQoL between HIV-positive and HIV-negative individuals in this general population sample. These findings highlight the importance of improving awareness of HIV status and expanding ART to prevent losses in HRQoL that occur with untreated HIV progression. The gains in HRQoL after individuals initiate ART could be substantial when scaled up to the population level. FUNDING: National Institute of Allergy and Infectious Diseases, National Institute on Drug Abuse, National Institute of Mental Health, President's Emergency Plan for AIDS Relief, International Initiative for Impact Evaluation, the Bill & Melinda Gates Foundation.

Scope and quality of Cochrane reviews of nutrition interventions: a cross-sectional study.

BACKGROUND: All countries face significant challenges from complex manifestations of malnutrition, which affects one in three people globally. Systematic reviews provide ready-to-use syntheses of quality-appraised evidence to inform decision-making for actions. To enhance the utility and quality of future Cochrane nutrition evidence, we described the scope and quality of all nutrition systematic reviews in the Cochrane Database of Systematic Reviews (CDSR). METHODS: We screened all active CDSR records (31 July 2015) to identify reviews and protocols using pre-specified eligibility criteria and definitions. Duplicate, independent data extraction included criteria for inclusion of studies in completed reviews (PICOS). We assessed methodological quality (AMSTAR), use of GRADE, mapped reviews against 2013 Global Burden of Disease data, and categorised the paradigm (medical, lifestyle and socio-ecological) of the review question. We analysed our results using descriptive statistics. RESULTS: We screened 8484 records, and included 470 (8%) completed reviews (in 45 Cochrane Review Groups (CRGs)) and 169 (7%) protocols (in 41 CRGs) published by 47 of 53 CRGs with reviews. Most completed reviews were produced by the Pregnancy and Childbirth (n = 73), Neonatal (n = 64), Metabolic and Endocrine Disorders (n = 33), Developmental, Psychosocial and Learning Problems (n = 26), Kidney and Transplant (n = 18) and Heart (n = 18) CRGs. Only 27% (n = 129) of reviews had searches for new studies in 2013 or thereafter. Supplementation/supplement interventions were most common (50%; n = 235; majority with micronutrients; 73%, n = 173), followed by food interventions (20%; n = 95). All reviews included randomised controlled trials; about 5% included other designs; 25% used GRADE; the median AMSTAR score was 9 (interquartile range: 7 to 10), 51% were high (AMSTAR 9-11) and 49% moderate (AMSTAR 5-8) quality. More than 80% framed questions using a medical paradigm. For top causes of years-of-life-lost, most reviews addressed preterm birth, diabetes and ischaemic heart disease; for leading risk factors for disability-adjusted-life-years, most targeted childhood undernutrition and high body mass index. CONCLUSIONS: Nutrition reviews comprised 8% of active CDSR records, were widely distributed across nearly all CRGs and reflected the double nutrition burden. This analysis presents a comprehensive description of the scope and quality of Cochrane nutrition reviews, and identifies gaps for future activities to support actions to address the nutrition burden, in line with the current nutrition agenda and impetus.

Outpatient advance care planning for patients with metastatic cancer: a pilot quality improvement initiative.

BACKGROUND: Despite American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommending that oncologists discuss advance care planning (ACP) with patients with stage IV cancer early in treatment, in standard practice ACP remains a late step of a terminal illness. ACP preserves comfort and dignity at the end of life, ensuring patients receive the care that they desire. METHODS AND MATERIALS: A feasibility study in patients with stage IV cancer was developed to test whether incorporating ACP immediately after a stage IV cancer diagnosis is feasible. Inclusion criteria were consecutive new gastrointestinal and thoracic oncology patients treated by one of two oncologists. The project included creation of new workflow; development of an ACP patient education guidebook; training seminars for oncology staff; and enhancements to the electronic health record (EHR) to improve ACP documentation. RESULTS: The oncologists recorded 33 of 48 (69%) advance directive notes (ADNs) and 22 of 48 (46%) code status orders (CSOs) in the EHR of patients newly diagnosed with stage IV cancer by following ACP protocol during the 6-month trial period. Twenty-one of 33 ADNs were entered within 7 days of first consultation. The median time to ADN placement was 1 day after consultation. Twenty-two of 33 patients with ADNs had CSOs placed, of which 16 were do-not-resuscitate (DNR) and 6 were full code. One year prior to the feasibility study, only 1 of 75 deceased patients of the two oncologists had outpatient ADNs and CSOs. CONCLUSIONS: Outpatient ACP is feasible early in the care of patients with stage IV cancer through systematic improvement in workflow and motivated providers. Education and infrastructure were pivotal to routine development of advance care plans.

Incidence and management of arthralgias in breast cancer patients treated with aromatase inhibitors in an outpatient oncology clinic.

PURPOSE: Aromatase inhibitors (AIs) are routinely used as first-line adjuvant treatment of breast cancer in postmenopausal women with hormone receptor positive tumors. The current recommended length of treatment with an AI is 5 years. Arthralgias have been frequently cited as the primary reason for discontinuation of AI therapy. Various treatment strategies are proposed in literature, but a standardized treatment algorithm has not been established. The initial purpose of this study was to describe the incidence and management of AI-induced arthralgias in patients treated at Kellogg Cancer Center (KCC). Further evaluation led to the development and the implementation of a treatment algorithm and electronic medical record (EMR) documentation tools. METHODS: The retrospective chart review included 206 adult patients with hormone receptor positive breast cancer who were receiving adjuvant therapy with an AI. A multidisciplinary treatment team consisting of pharmacists, collaborative practice nurses, and physicians met to develop a standardized treatment algorithm and corresponding EMR documentation tool. The treatment algorithm and documentation tool were developed after the study to better monitor and proactively treat patients with AI-induced arthralgias. RESULTS/ CONCLUSIONS: The overall incidence of arthralgias at KCC was 48% (n = 98/206). Of these patients, 32% were documented as having arthralgias within the first 6 months of therapy initiation. Patients who reported AI-induced arthralgias were younger than patients who did not report AI-induced arthralgias (61 vs. 65 years, p = 0.002). There was no statistical difference in the incidence of arthralgias in patients with a history of chemotherapy (including taxane therapy) compared to those who did not receive chemotherapy (p = 0.352). Of patients presenting with AI-induced arthralgias, 41% did not have physician-managed treatment documented in the EMR. A standardized treatment algorithm and electronic chart documentation tools were then developed by the multidisciplinary team.

Outcomes of computerized physician order entry in an electronic health record after implementation in an outpatient oncology setting.

PURPOSE: Computerized physician order entry (CPOE) in electronic health records (EHR) has been recognized as an important tool in optimal health care provision that can reduce errors and improve safety. The objective of this study is to describe documentation completeness and user satisfaction of medical charts before and after implementation of an outpatient oncology EHR/ CPOE system in a hospital-based outpatient cancer center within three treatment sites. METHODS: This study is a retrospective chart review of 90 patients who received one of the following regimens between 1999 and 2006: FOLFOX, AC, carboplatin + paclitaxel, ABVD, cisplatin + etoposide, R-CHOP, and clinical trials. Documentation completeness scores were assigned to each chart based on the number of documented data points found out of the total data points assessed. EHR/CPOE documentation completeness was compared with completeness of paper charts orders of the same regimens. A user satisfaction survey of the paper chart and EHR/CPOE system was conducted among the physicians, nurses, and pharmacists who worked with both systems. RESULTS: The mean percentage of identified data points successfully found in the EHR/CPOE charts was 93% versus 67% in the paper charts (P < .001). Regimen complexity did not alter the number of data points found. The survey response rate was 64%, and the results showed that satisfaction was statistically significant in favor of the EHR/CPOE system. CONCLUSION: Using EHR/CPOE systems improves completeness of medical record and chemotherapy order documentation and improves user satisfaction with the medical record system. EHR/CPOE requires constant vigilance and maintenance to optimize patient safety.