Mortality Among Children Aged <5 Years Living with HIV Who Are Receiving Antiretroviral Treatment - U.S. President's Emergency Plan for AIDS Relief, 28 Supported Countries and Regions, October 2020-September 2022.

Globally, children aged <5 years, including those living with HIV who are not receiving antiretroviral treatment (ART), experience disproportionately high mortality. Global mortality among children living with HIV aged <5 years receiving ART is not well described. This report compares mortality and related clinical measures among infants aged <1 year and children aged 1-4 years living with HIV with those among older persons aged 5-14, 15-49, and ≥50 years living with HIV receiving ART services at all clinical sites supported by the U.S. President's Emergency Plan for AIDS Relief. During October 2020-September 2022, an average of 11,980 infants aged <1 year and 105,510 children aged 1-4 years were receiving ART each quarter; among these infants and children receiving ART, 586 (4.9%) and 2,684 (2.5%), respectively, were reported to have died annually. These proportions of infants and children who died ranged from four to nine times higher in infants aged <1 year, and two to five times higher in children aged 1-4 years, than the proportions of older persons aged ≥5 years receiving ART. Compared with persons aged ≥5 years living with HIV, the proportions of children aged <5 years living with HIV who experienced interruptions in treatment were also higher, and the proportions who had a documented HIV viral load result or a suppressed viral load were lower. Prioritizing and optimizing HIV and general health services for children aged <5 years living with HIV receiving ART, including those recommended in the WHO STOP AIDS Package, might help address these disproportionately poorer outcomes.

Considerations to Improve Pediatric HIV Testing and Close the Treatment Gap in 16 African Countries.

BACKGROUND: In 2019, South Africa, Nigeria, Tanzania, Democratic Republic of Congo, Uganda, Mozambique, Zambia, Angola, Cameroon, Zimbabwe, Ghana, Ethiopia, Malawi, Kenya, South Sudan and Côte d'Ivoire accounted for 80% of children living with HIV (CLHIV) not receiving HIV treatment. This manuscript describes pediatric HIV testing to inform case-finding strategies. METHODS: We analyzed US President's Emergency Plan for AIDS Relief monitoring, evaluation, and reporting data (October 1, 2018 to September 30, 2019) for these 16 countries. Number of HIV tests and positive results were reported by age band, country, treatment coverage and testing modality. The number needed to test (NNT) to identify 1 new CLHIV 1-14 years was measured by testing modality and country. The pediatric testing gap was estimated by multiplying the estimated number of CLHIV unaware of their status by NNT per country. RESULTS: Among children, 6,961,225 HIV tests were conducted, and 101,762 CLHIV were identified (NNT 68), meeting 17.6% of the pediatric testing need. Index testing accounted for 13.0% of HIV tests (29.7% of positive results, NNT 30), provider-initiated testing and counseling 65.9% of tests (43.6% of positives, NNT 103), and universal testing at sick entry points 5.3% of tests (6.5% of positives, NNT 58). CONCLUSIONS: As countries near HIV epidemic control for adults, the need to increase pediatric testing continues. Each testing modality - PITC, universal testing at sick entry points, and index testing - offers unique benefits. These results illustrate the comparative advantages of including a strategic mix of testing modalities in national programs to increase pediatric HIV case finding.

The Status of Adolescent Testing and Treatment in PEPFAR-Supported Programs, October 2017 to September 2020.

BACKGROUND: Adolescents have poorer outcomes across the HIV cascade compared with adults. We aimed to assess progress in HIV case finding, antiretroviral treatment (ART), viral load coverage (VLC), and viral load suppression (VLS) among adolescents enrolled in the US President's Emergency Plan for AIDS Relief (PEPFAR)-supported programs over a 3-year period that included the beginning of the COVID-19 pandemic. METHODS: We analyzed PEPFAR program data in 28 countries/regions for adolescents aged 10-19 years between year 1 (October 2017to September 2018), year 2 (October 2018 to September 2019), and year 3 (October 2019 to September 2020). We calculated the number and percent change for HIV tests, HIV-positive tests, and total number on ART. Calculated indicators included positivity, percent of positives newly initiated on ART (ART linkage), VLC (percent of ART patients on ART for ≥6 months with a documented viral load result within the past 12 months), and VLS (percent of viral load tests with <1000 copies/mL). RESULTS: Between years 1 and 3, the number of HIV tests conducted decreased by 44.2%, with a 29.1% decrease in the number of positive tests. Positivity increased from 1.3%-1.6%. The number of adolescents receiving ART increased by 10.4%. In addition, ART linkage increased (77.8%-86.7%) as did VLC (69.4%-79.4%) and VLS (72.8%-81.5%). CONCLUSIONS: Our findings demonstrate PEPFAR's success in increasing the adolescent treatment cohort. We identified ongoing gaps in adolescent case finding, linkage, VLC, and VLS that could be addressed with a strategic mix of testing strategies, optimal ART regimens, and adolescent-focused service delivery models.

Pediatric HIV Case Identification Across 22 PEPFAR-Supported Countries During the COVID-19 Pandemic, October 2019-September 2020.

During 2020, an estimated 150,000 persons aged 0-14 years acquired HIV globally (1). Case identification is the first step to ensure children living with HIV are linked to life-saving treatment, achieve viral suppression, and live long, healthy lives. Successful interventions to optimize pediatric HIV testing during the COVID-19 pandemic are needed to sustain progress toward achieving Joint United Nations Programme on HIV/AIDS (UNAIDS) 95-95-95 targets.* Changes in HIV testing and diagnoses among persons aged 1-14 years (children) were assessed in 22 U.S. President's Emergency Plan for AIDS Relief (PEPFAR)-supported countries during October 1, 2019-September 30, 2020. This period corresponds to the two fiscal quarters before the COVID-19 pandemic (i.e., Q1 and Q2) and the two quarters after the pandemic began (i.e., Q3 and Q4). Testing was disaggregated by age group, testing strategy, and fiscal year quarter. During October 2019-September 2020, PEPFAR supported 4,312,343 HIV tests and identified 74,658 children living with HIV (CLHIV). The number of HIV tests performed was similar during Q1 and Q2, decreased 40.1% from Q2 to Q3, and increased 19.7% from Q3 to Q4. The number of HIV cases identified among children aged 1-14 years (cases identified) increased 7.4% from Q1 to Q2, decreased 29.4% from Q2 to Q3, and increased 3.3% from Q3 to Q4. Although testing in outpatient departments decreased 21% from Q1 to Q4, testing from other strategies increased during the same period, including mobile testing by 38%, facility-based index testing (offering an HIV test to partners and biological children of persons living with HIV) by 8%, and testing children with signs or symptoms of malnutrition within health facilities by 7%. In addition, most tests (61.3%) and cases identified (60.9%) were among children aged 5-14 years (school-aged children), highlighting the need to continue offering HIV testing to older children. These findings provide important information on the most effective strategies for identifying CLHIV during the COVID-19 pandemic. HIV testing programs should continue to use programmatic, surveillance, and financial data at both national and subnational levels to determine the optimal mix of testing strategies to minimize disruptions in pediatric case identification during the COVID-19 pandemic.

Adapting HIV services for pregnant and breastfeeding women, infants, children, adolescents and families in resource-constrained settings during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has impacted global health service delivery, including provision of HIV services. Countries with high HIV burden are balancing the need to minimize interactions with health facilities to reduce the risk of COVID-19 transmission, while delivering uninterrupted essential HIV prevention, testing and treatment services. Many of these adaptations in resource-constrained settings have not adequately accounted for the needs of pregnant and breastfeeding women, infants, children and adolescents. We propose whole-family, tailored programme adaptations along the HIV clinical continuum to protect the programmatic gains made in services. DISCUSSION: Essential HIV case-finding services for pregnant and breastfeeding women and children should be maintained and include maternal testing, diagnostic testing for infants exposed to HIV, index testing for children whose biological parents or siblings are living with HIV, as well as for children/adolescents presenting with symptoms concerning for HIV and comorbidities. HIV self-testing for children two years of age and older should be supported with caregiver and provider education. Adaptations include bundling services in the same visit and providing testing outside of facilities to the extent possible to reduce exposure risk to COVID-19. Virtual platforms can be used to identify vulnerable children at risk of HIV infection, abuse, harm or violence, and link them to necessary clinical and psychosocial support services. HIV treatment service adaptations for families should focus on family based differentiated service delivery models, including community-based ART initiation and multi-month ART dispensing. Viral load monitoring should not be a barrier to transitioning children and adolescents experiencing treatment failure to more effective ART regimens, and viral load monitoring for pregnant and breastfeeding women and children should be prioritized and bundled with other essential services. CONCLUSIONS: Protecting pregnant and breastfeeding women, infants, children and adolescents from acquiring SARS-CoV-2 while sustaining essential HIV services is an immense global health challenge. Tailored, family friendly programme adaptations for case-finding, ART delivery and viral load monitoring for these populations have the potential to limit SARS-CoV-2 transmission while ensuring the continuity of life-saving HIV case identification and treatment efforts.

Chain Peer Referral Approach for HIV Testing Among Adolescents in Kisumu County, Kenya.

New HIV infections among adolescents continues to be a large public health burden in sub-Saharan Africa, with few adolescents accessing HIV testing and counseling (HTC) services. We evaluated the effect of a peer referral program among adolescents in Kisumu county, Kenya in accessing HTC. Female adolescents aged 15 to 19 years were recruited from three health clinics in Kisumu County. They, in turn, recruited their peers for HTC by handing out referral cards. Referrals would then recruit their peers and this peer-referral repeated for approximately 5 months. The 252 female index seeds showed a relatively higher-risk profile for HIV compared to the 792 referral participants. The referral system yielded an increased proportion of first-time adolescent testers from 13.1% among index seeds to 42.7% among the second wave of referrals. However, the peer referral system ultimately did not increase the absolute number of adolescents Queryaccessing HTC. Future strategies should consider these findings to better target those with undiagnosed HIV infection.

Health Care Experiences of Youth Living With HIV Who Were Lost to Follow-up in Western Kenya.

HIV is the leading cause of mortality for youth in sub-Saharan Africa. Youth are more likely than any other age group to be lost to follow-up (LTFU) from care. We investigated the health care-related experiences of youth living with HIV (YLWH) who were LTFU (i.e., had not returned to care for at least 4 months), as well as the perceptions of the community health workers who supported them. Data were collected from two focus group discussions with community health workers (n = 18) who worked with YLWH and 27 semistructured interviews with YLWH (ages 15-21 years) who were LTFU. Attitudes toward health care were presented in the context of a social-ecological model. Respondents highlighted the need for improved youth-oriented services, including youth-friendly clinics and training for care providers about specific needs of YLWH. Researchers should develop and test the impact of these interventions to improve retention of YLWH in care.

Forming a Kanyakla: A qualitative study to develop a novel social support intervention for adolescents living with HIV.

INTRODUCTION: HIV is a leading cause of morbidity and mortality among youth in sub Saharan Africa. This study explores the adaptation of an adult social network intervention for adolescents, entitled Kanyakla. METHODS: The study was conducted in Kisumu, Kenya from July to November 2016. Data was collected from: (1) semi-structured interviews (n = 32) with adolescents living with HIV aged 15-19; and (2) two focus group discussions (n = 21). Transcripts were coded using thematic analysis through the lens of an Adolescent Development Model. RESULTS: Participants were interested in joining a Kanyakla to build social support, learn new skills, and partake in recreational activities. Many participants feared inadvertent disclosure related to stigma. Certain dichotomous themes emerged including the need for privacy versus the need for social support; and the desire for inclusion of elders versus preference for same-aged peers in the Kanyaklas. CONCLUSIONS: With this study, we have key information that can be applied to developing the Kanyakla intervention for adolescents. Further study is needed to reconcile the dichotomies that emerged.

Adolescent pregnancy at antiretroviral therapy (ART) initiation: a critical barrier to retention on ART.

INTRODUCTION: Adolescence and pregnancy are potential risk factors for loss to follow-up (LTFU) while on antiretroviral therapy (ART). We compared adolescent and adult LTFU after ART initiation to quantify the impact of age, pregnancy, and site-level factors on LTFU. METHODS: We used routine clinical data for patients initiating ART as young adolescents (YA; 10 to 14 years), older adolescents (OA; 15 to 19 years) and adults (≥20 years) from 2000 to 2014 at 52 health facilities affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) East Africa collaboration. We estimated cumulative incidence (95% confidence interval, CI) of LTFU (no clinic visit for ≥6 months after ART initiation) and identified patient and site-level correlates of LTFU, using multivariable Cox proportional hazards models for all patients as well as individual age groups. RESULTS: A total of 138,387 patients initiated ART, including 2496 YA, 2955 OA and 132,936 adults. Of these, 55%, 78% and 66%, respectively, were female and 0.7% of YA, 22.3% of OA and 8.3% of adults were pregnant at ART initiation. Cumulative incidence of LTFU at five years was 26.6% (24.6 to 28.6) among YA, 44.1% (41.8 to 46.3) among OA and 29.3% (29.1 to 29.6) among adults. Overall, compared to adults, the adjusted hazard ratio, aHR, (95% CI) of LTFU for OA was 1.54 (1.41 to 1.68) and 0.77 (0.69 to 0.86) for YA. Compared to males, pregnant females had higher hazard of LTFU, aHR 1.20 (1.14 to 1.27), and nonpregnant women had lower hazard aHR 0.90 (0.88 to 0.93). LTFU hazard among the OA was primarily driven by both pregnant and nonpregnant females, aHR 2.42 (1.98 to 2.95) and 1.51 (1.27 to 1.80), respectively, compared to men. The LTFU hazard ratio varied by IeDEA program. Site-level factors associated with overall lower LTFU hazard included receiving care in tertiary versus primary-care clinics aHR 0.61 (0.56 to 0.67), integrated adult and adolescent services and food ration provision aHR 0.93 (0.89 to 0.97) versus nonintegrated clinics with food ration provision, having patient support groups aHR 0.77 (0.66 to 0.90) and group adherence counselling aHR 0.61 (0.57 to 0.67). CONCLUSIONS: Older adolescents experienced higher risk of LTFU compared to YA and adults. Interventions to prevent LTFU among older adolescents are critically needed, particularly for female and/or pregnant adolescents.

The effects of framed messages for engaging adolescents with online smoking prevention interventions.

Messages emphasizing the harms of smoking (loss-framed) or the benefits of not smoking (gain-framed) may be effective for engaging adolescents with tobacco prevention resources. This novel approach could help to close a gap in tobacco prevention intervention delivery in the pediatric primary care setting. To examine the effects of framed messages for engaging adolescents with an evidence-based smoking prevention website, adolescents ages 12 to 17 presenting for primary care well-visits were recruited for a three-arm experiment. Participants completed baseline measures including demographics, smoking behavior, and smoking susceptibility and were randomized to view 1 of 3 messages introducing an evidence-based smoking prevention website: (1) gain-framed communicating the benefits of avoiding smoking, (2) loss-framed communicating the harms of smoking, or (3) neutral. Self-reported website engagement was assessed at 1-month follow-up. Participants (279) (87% of those enrolled) completed a follow-up (M age 14.9 years, 66% female, 32% non-white race, 47% non-susceptible never smokers, 53% susceptible never smokers/ever smokers). Overall, 26% of participants reported website engagement. After adjusting for baseline intentions to visit the website, engagement was significantly greater in response to the loss-framed message than the gain-framed (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.51, 6.15) and neutral (OR 2.31, 95% CI 1.15, 4.63) messages. The message framing effects did not differ by baseline smoking risk. Loss-framed messages emphasizing the harms of smoking may be effective for engaging adolescents with smoking prevention resources.

The effectiveness of an adolescent reproductive health education intervention in Uganda.

Ugandan adolescents lack sufficient reproductive health knowledge, which accounts in part for the staggering rates of teen pregnancies and sexually transmitted (STI) infections in this population. This study aimed to (1) examine Ugandan adolescents' baseline STI and contraceptive knowledge; (2) determine whether this knowledge varies by demographic factors, prior sexual experience or school grade; and (3) evaluate the effectiveness of an educational program to increase and retain STI and contraceptive knowledge among Ugandan adolescents. This study surveyed 129 adolescents (ages 15-19) regarding knowledge of STIs and contraceptive methods at schools and community non-governmental organizations at three time points. Findings demonstrated that at baseline the mean test scores for contraceptive knowledge and STI knowledge were 44% and 72%, respectively. Participants in higher secondary school grade-levels had greater odds of having prior STI knowledge (OR=19.6, 95% CI 2.0-187.6); participants who had previously engaged in sex had greater odds of having prior contraceptive knowledge (OR=4.62, 95% CI 1.45-14.72). A higher grade level was not associated with better knowledge of contraception; and being sexually active was not associated with better knowledge of STI information. Participants' knowledge of STIs and contraceptives improved after the education session (p<0.001), and knowledge was retained 3-weeks later (p<0.001). Findings suggest that Ugandan adolescents do not have adequate education regarding contraceptive methods and that implementation of reproductive health modules by an outside party can be effective in improving knowledge.

"It is all about the fear of being discriminated [against] the person suffering from HIV will not be accepted": a qualitative study exploring the reasons for loss to follow-up among HIV-positive youth in Kisumu, Kenya.

BACKGROUND: Youth represent 40% of all new HIV infections in the world, 80% of which live in sub-Saharan Africa. Youth living with HIV (YLWH) are more likely to become lost to follow-up (LTFU) from care compared to all other age groups. This study explored the reasons for LTFU among YLWH in Kenya. METHODS: Data was collected from: (1) Focus group Discussions (n = 18) with community health workers who work with LTFU youth. (2) Semi-structured interviews (n = 27) with HIV + youth (15-21 years old) that had not received HIV care for at least four months. (3) Semi-structured interviews (n = 10) with educators selected from schools attended by LTFU interview participants. Transcripts were coded and analyzed employing grounded theory. RESULTS: HIV-related stigma was the overarching factor that led to LTFU among HIV + youth. Stigma operated on multiple levels to influence LTFU, including in the home/family, at school, and at the clinic. In all three settings, participants' fear of stigma due to disclosure of their HIV status contributed to LTFU. Likewise, in the three settings, the dependent relationships between youth and the key adult figures in their lives were also adversely impacted by stigma and resultant lack of disclosure. Thus, at all three settings stigma influenced fear of disclosure, which in turn impacted negatively on dependent relationships with adults on whom they rely (i.e. parents, teachers and clinicians) leading to LTFU. CONCLUSIONS: Interventions focusing on reduction of stigma, increasing safe disclosure of HIV status, and improved dependent relationships may improve retention in care of YLWH.

Identification and characterization of adolescents' sexual boundaries.

PURPOSE: Adolescents' decisions to have sex may be based on a priori boundaries placed on sex. This study addresses: (1) to what extent adolescents set vaginal sexual boundaries; (2) the types of sexual boundaries most and least likely to be endorsed; and (3) to what extent sexual boundaries vary by sex, race/ethnicity, and sexual experience. METHODS: A cross-sectional study of 518 students attending 10th grade. Survey measures queried about demographics, ever having sex, and existence of sexual boundaries (e.g., being in love, having an attractive partner) that must be in place before having vaginal sex. RESULTS: The most frequently endorsed boundaries were maturity, commitment, trust, love, and marriage. These boundaries were more frequently endorsed than having a safer-sex method. Compared with females, males were more likely to choose boundaries based on partner attractiveness (p < .001) and avoiding trouble (p < .04). Compared with Asians and Pacific Islanders, whites were more likely to endorse wanting to be a certain age to have sex (p < .01 and p < .05, respectively); Asians and Pacific Islanders were more likely to choose sexual boundaries based on marriage (p's < .05). Adolescents who were sexually experienced were more likely than inexperienced adolescents to endorse boundaries related to relationship characteristics and partner attractiveness (OR = 2.5), and less likely to endorse boundaries related to feeling mature (OR = .34) and waiting until marriage (OR = .34). CONCLUSIONS: Identifying adolescents' sexual boundaries should help healthcare professionals better understand under what circumstances adolescents are more or less likely to have sex; and this information should ultimately inform the development of new interventions.

Diagnosis of pediatric pulmonary tuberculosis by stool PCR.

Pediatric pulmonary tuberculosis diagnosis is difficult because young children are unable to expectorate sputum samples. Testing stool for tuberculosis DNA from swallowed sputum may diagnose pulmonary tuberculosis. Hospitalized children with suspected tuberculosis had stool, nasopharyngeal, and gastric aspirates cultured that confirmed pulmonary tuberculosis in 16/236 patients. Twenty-eight stored stools from these 16 children were used to evaluate stool polymerase chain reaction (PCR) for tuberculosis diagnosis compared with 28 stool samples from 23 healthy control children. Two DNA extraction techniques were used: fast-DNA mechanical homogenization and Chelex-resin chemical extraction. DNA was tested for tuberculosis DNA with a hemi-nested IS6110 PCR. PCR after Fast-DNA processing was positive for 6/16 culture-proven tuberculosis patients versus 5/16 after Chelex extraction (sensitivity 38% and 31%, respectively). All controls were negative (specificity 100%). If sensitivity can be increased, stool PCR would be a rapid, non-invasive, and relatively bio-secure initial test for children with suspected pulmonary tuberculosis.