Awareness of and willingness to use oral pre-exposure prophylaxis (PrEP) for HIV prevention among sexually active adults in Malawi: results from the 2020 Malawi population-based HIV impact assessment.

BACKGROUND: The World Health Organization recommends Pre-Exposure Prophylaxis (PrEP) for all populations at substantial risk of HIV infection. Understanding PrEP awareness and interest is crucial for designing PrEP programs; however, data are lacking in sub-Saharan Africa. In Malawi, oral PrEP was introduced in 2018. We analyzed data from the 2020 Malawi Population-based HIV Impact Assessment (MPHIA) to assess PrEP awareness and factors associated with PrEP interest in Malawi. METHODS: MPHIA 2020 was a national cross-sectional household-based survey targeting adults aged 15 + years. Oral PrEP was first described to the survey participants as taking a daily pill to reduce the chance of getting HIV. To assess awareness, participants were asked if they had ever heard of PrEP and to assess interest, were asked if they would take PrEP to prevent HIV, regardless of previous PrEP knowledge. Only sexually active HIV-negative participants are included in this analysis. We used multivariable logistic regression to assess sociodemographic factors and behaviors associated with PrEP interest. All results were weighted. RESULTS: We included 13,995 HIV-negative sexually active participants; median age was 29 years old. Overall, 15.0%, 95% confidence interval (CI): 14.2-15.9% of participants were aware of PrEP. More males (adjusted odds ratio (aOR): 1.3, 95% CI: 1.2-1.5), those with secondary (aOR: 1.5, 95% CI: 1.2-2.0) or post-secondary (aOR: 3.4, 95% CI: 2.4-4.9) education and the wealthiest (aOR: 1.6, 95% CI: 1.2-2.0) were aware of PrEP than female, those without education and least wealthy participants, respectively. Overall, 73.0% (95% CI: 71.8-74.1%) of participants were willing to use PrEP. Being male (aOR: 1.2; 95% CI: 1.1-1.3) and having more than one sexual partner (aOR: 1.7 95% CI: 1.4-1.9), were associated higher willingness to use PrEP. CONCLUSIONS: In this survey, prior PrEP knowledge and use were low while PrEP interest was high. High risk sexual behavior was associated with willingness to use PrEP. Strategies to increase PrEP awareness and universal access, may reduce HIV transmission.

Comparison of COVID-19 Pandemic Waves in 10 Countries in Southern Africa, 2020-2021.

We used publicly available data to describe epidemiology, genomic surveillance, and public health and social measures from the first 3 COVID-19 pandemic waves in southern Africa during April 6, 2020-September 19, 2021. South Africa detected regional waves on average 7.2 weeks before other countries. Average testing volume 244 tests/million/day) increased across waves and was highest in upper-middle-income countries. Across the 3 waves, average reported regional incidence increased (17.4, 51.9, 123.3 cases/1 million population/day), as did positivity of diagnostic tests (8.8%, 12.2%, 14.5%); mortality (0.3, 1.5, 2.7 deaths/1 million populaiton/day); and case-fatality ratios (1.9%, 2.1%, 2.5%). Beta variant (B.1.351) drove the second wave and Delta (B.1.617.2) the third. Stringent implementation of safety measures declined across waves. As of September 19, 2021, completed vaccination coverage remained low (8.1% of total population). Our findings highlight opportunities for strengthening surveillance, health systems, and access to realistically available therapeutics, and scaling up risk-based vaccination.

Adapting strategies for effective and efficient pediatric HIV case finding in low prevalence countries: risk screening tool for testing children presenting at high-risk entry points in Ethiopia.

BACKGROUND: Implementing effective and efficient case-finding strategies is crucial to increasing pediatric antiretroviral therapy coverage. In Ethiopia, universal HIV testing is conducted for children presenting at high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC); however, low positivity rates observed at inpatient, malnutrition and OVC entry points warrant re-assessing current case-finding strategies. The aim of this study is to develop HIV risk screening tool applicable for testing children presenting at inpatient, malnutrition and OVC entry points in low-HIV prevalence settings. METHODS: The study was conducted from May 2017-March 2018 at 29 public health facilities in Amhara and Addis Ababa regions of Ethiopia. All children 2-14 years presenting to five high-risk entry points including malnutrition treatment, inpatient wards, tuberculosis (TB) clinics, index testing for children of positive adults, and referral of orphans and vulnerable children (OVC) were enrolled after consent. Data were collected from registers, medical records, and caregiver interviews. Screening tools were constructed using predictors of HIV positivity as screening items by applying both logistic regression and an unweighted method. Sensitivity, specificity and number needed to test (NNT) to identify one new child living with HIV (CLHIV) were estimated for each tool. RESULTS: The screening tools had similar sensitivity of 95%. However, the specificities of tools produced by logistic regression methods (61.4 and 65.6%) which are practically applicable were higher than those achieved by the unweighted method (53.6). Applying these tools could result in 58‒63% reduction in the NNT compared to universal testing approach while maintaining the overall number of CLHIV identified. CONCLUSION: The screening tools developed using logistic regression method could significantly improve HIV testing efficiency among children presenting to malnutrition, inpatient, and OVC entry points in Ethiopia while maintaining case identification. These tools are simplified to practically implement and can potentially be validated for use at various entry points. HIV programs in low-prevalence countries can also further investigate and optimize these tools in their settings.

Rates of confirmatory HIV testing, linkage to HIV services, and rapid initiation of antiretroviral treatment among newly diagnosed children living with HIV in Ethiopia: perspectives from caregivers and healthcare workers.

BACKGROUND: Successful linkage to HIV services and initiation of antiretroviral treatment (ART) for children living with HIV (CLHIV) is critical to improve pediatric ART coverage. We aimed to assess confirmatory testing, linkage, and rapid ART initiation among newly diagnosed CLHIV in Ethiopia from the perspectives of caregivers and healthcare workers (HCWs). METHODS: We conducted standardized surveys with HCWs and caregivers of children 2-14 years who were diagnosed with HIV but not yet on ART who had been identified during a cross-sectional study in Ethiopia from May 2017-March 2018. Eight health facilities based on their HIV caseload and testing volume and 21 extension sites were included. Forty-one children, 34 care givers and 40 healthcare workers were included in this study. Three months after study enrollment, caregivers were surveyed about timing and experiences with HIV service enrollment, confirmatory testing, and ART initiation. Data collected from HCWs included perceptions of confirmatory testing in CLHIV before ART initiation. SPSS was used to conduct descriptive statistics. RESULTS: The majority of the 41 CLHIV were enrolled to HIV services (n = 34, 83%) and initiated ART by three months (n = 32, 94%). Median time from diagnosis to ART initiation was 12 days (interquartile range 5-18). Five children died before the follow-up interview. Confirmatory HIV testing was conducted in 34 children and found no discordant results; the majority (n = 23, 68%) received it within one week of HIV diagnosis. Almost all HCWs (n = 39/40, 98%) and caregivers (n = 31/34, 91%) felt better/the same about test results after conducting confirmatory testing. CONCLUSION: Opportunities remain to strengthen linkage for newly diagnosed CLHIV in Ethiopia through intensifying early follow-up to ensure prompt confirmatory testing and rapid ART initiation. Additional services could help caregivers with decision-making around treatment initiation for their children.

Trends in Antiretroviral Therapy Eligibility and Coverage Among Children Aged <15 Years with HIV Infection - 20 PEPFAR-Supported Sub-Saharan African Countries, 2012-2016.

Rapid disease progression and associated opportunistic infections contribute to high mortality rates among children aged <15 years with human immunodeficiency virus (HIV) infection (1). Antiretroviral therapy (ART) has decreased childhood HIV-associated morbidity and mortality rates over the past decade (2). As accumulating evidence revealed lower HIV-associated mortality with early ART initiation, the World Health Organization (WHO) guidelines broadened ART eligibility for children with HIV infection (2). Age at ART initiation for children with HIV infection expanded sequentially in the 2010, 2013, and 2016 WHO guidelines to include children aged <2, <5, and <15 years, respectively, regardless of clinical or immunologic status (3-5). The United States President's Emergency Plan for AIDS Relief (PEPFAR) has supported ART for children with HIV infection since 2003 and, informed by the WHO guidelines and a growing evidence base, PEPFAR-supported countries have adjusted their national pediatric guidelines. To understand the lag between guideline development and implementation, as well as the ART coverage gap, CDC assessed national pediatric HIV guidelines and analyzed Joint United Nations Programme on HIV and AIDS (acquired immunodeficiency syndrome; UNAIDS) data on children aged <15 years with HIV infection and the numbers of these children on ART. Timeliness of WHO pediatric ART guideline adoption varied by country; >50% of children with HIV infection are not receiving ART, underscoring the importance of strengthening case finding and linkage to HIV treatment in pediatric ART programs.

Quality and uptake of antenatal and postnatal care in Haiti.

BACKGROUND: Despite improvement, maternal mortality in Haiti remains high at 359/100,000 live births. Improving access to high quality antenatal and postnatal care has been shown to reduce maternal mortality and improve newborn outcomes. Little is known regarding the quality and uptake of antenatal and postnatal care among Haitian women. METHODS: Exit interviews were conducted with all pregnant and postpartum women seeking care from large health facilities (n = 10) in the Nord and Nord-Est department and communes of St. Marc, Verrettes, and Petite Rivière in Haiti over the study period (March-April 2015; 3-4 days/facility). Standard questions related to demographics, previous pregnancies, current pregnancy, and services/satisfaction during the visit were asked. Total number of antenatal visits were abstracted from charts of recently delivered women (n = 1141). Provider knowledge assessments were completed by antenatal and postnatal care providers (n = 39). Frequencies were calculated for descriptive variables and multivariable logistic regression was used to explore predictors of receiving 5 out of 10 counseling messages among pregnant women. RESULTS: Among 894 pregnant women seeking antenatal care, most reported receiving standard clinical service components during their visit (97% were weighed, 80% had fetal heart tones checked), however fewer reported receiving recommended counseling messages (44% counselled on danger signs, 33% on postpartum family planning). Far fewer women were seeking postnatal care (n = 63) and similar service patterns were reported. Forty-three percent of pregnant women report receiving at least 5 out of 10 counseling messages. Pregnant women on a repeat visit and women with greater educational attainment had greater odds of reporting having received 5 out of 10 counseling messages (2nd visit: adjusted odds ratio [aOR] =1.70, 95% confidence interval [CI]: 1.09-2.66; 5+ visit: aOR = 5.44, 95% CI: 2.91-10.16; elementary school certificate: aOR = 2.06, 95% CI: 1.17-3.63; finished secondary school or more aOR = 1.97, 95% CI = 1.05-3.02). Chart reviews indicate 27% of women completed a single antenatal visit and 36% completed the recommended 4 visits. CONCLUSIONS: Antenatal and postnatal care uptake in Haiti is sub-optimal. Despite frequent reports of provision of standard service components, counseling messages are low. Consistent provision of standardized counseling messages with regular provider trainings is recommended to improve quality and uptake of care in Haiti.

Predictors of micronutrient powder intake adherence in a pilot programme in Nepal.

OBJECTIVE: Poor adherence to recommended intake protocols is common and a top challenge for micronutrient powder (MNP) programmes globally. Identifying modifiable predictors of intake adherence could inform the design and implementation of MNP projects. DESIGN: We assessed high MNP intake adherence among children who had received MNP ≥2 months ago and consumed ≥1 sachet (n 771). High MNP intake adherence was defined as maternal report of child intake ≥45 sachets. We used logistic regression to assess demographic, intervention components and perception-of-use factors associated with high MNP intake. SETTING: Four districts of Nepal piloting an integrated infant and young child feeding and MNP project. SUBJECTS: Children aged 6-23 months were eligible to receive sixty MNP sachets every 6 months with suggested intake of one sachet daily for 60 d. Cross-sectional surveys representative of children aged 6-23 months were conducted. RESULTS: Receiving a reminder card was associated with increased odds for high intake (OR=2·18, 95 % CI 1·14, 4·18); exposure to other programme components was not associated with high intake. Mothers perceiving ≥1 positive effects in their child after MNP use was also associated with high intake (OR=6·55, 95 % CI 4·29, 10·01). Perceiving negative affects was not associated; however, the child not liking the food with MNP was associated with lower odds of high intake (OR=0·12, 95 % CI 0·08, 0·20). CONCLUSIONS: Behaviour change intervention strategies tailored to address these modifiable predictors could potentially increase MNP intake adherence.

Paid Maternity Leave and Breastfeeding Outcomes.

BACKGROUND: Despite the benefits of breastfeeding, rates in the United States are low. Shorter maternity leave is associated with lower initiation and shorter durations of breastfeeding; however, little is known about how paid maternity leave may influence breastfeeding rates. METHODS: We used data from the 2006-2010 U.S. National Survey of Family Growth on the most recent birth to employed women who delivered a child within the previous 5 years. Separate multivariable logistic regression models were used to describe the associations between paid leave duration (0, 1-5, 6-11, ≥ 12 weeks, maternity leave not taken) and three outcomes: 1) breastfeeding initiation, 2) 6-month duration, and 3) 6-month duration among initiators. RESULTS: Twenty-eight percent of prenatally employed women received no paid leave. Women who received 12 or more weeks of paid leave were more likely to initiate breastfeeding compared to women with no paid leave (87.3% vs 66.7%, adjusted odds ratio [aOR] 2.83 [95% confidence interval {CI} 1.23-6.48]). Similarly, women with 12 or more weeks of paid leave were more likely to breastfeed at 6 months, compared to women with no paid leave (24.9% vs 50.1%, aOR 2.26 [95% CI 1.20-4.26]). Among women who initiated breastfeeding, having received 12 or more weeks' paid leave increased the odds of breastfeeding for 6 or more months; however, the association was not statistically significant in the adjusted model (aOR 1.81 [95% CI 0.93-3.52]). CONCLUSIONS: Employed women who received 12 or more weeks of paid maternity leave were more likely to initiate breastfeeding and be breastfeeding their child at 6 months than those without paid leave.

Structural elements in the Girk1 subunit that potentiate G protein-gated potassium channel activity.

G protein-gated inwardly rectifying K(+) (Girk/K(IR)3) channels mediate the inhibitory effect of many neurotransmitters on excitable cells. Girk channels are tetramers consisting of various combinations of four mammalian Girk subunits (Girk1 to -4). Although Girk1 is unable to form functional homomeric channels, its presence in cardiac and neuronal channel complexes correlates with robust channel activity. This study sought to better understand the potentiating influence of Girk1, using the GABA(B) receptor and Girk1/Girk2 heteromer as a model system. Girk1 did not increase the protein levels or alter the trafficking of Girk2-containing channels to the cell surface in transfected cells or hippocampal neurons, indicating that its potentiating influence involves enhancement of channel activity. Structural elements in both the distal carboxyl-terminal domain and channel core were identified as key determinants of robust channel activity. In the distal carboxyl-terminal domain, residue Q404 was identified as a key determinant of receptor-induced channel activity. In the Girk1 core, three unique residues in the pore (P) loop (F137, A142, Y150) were identified as a collective potentiating influence on both receptor-dependent and receptor-independent channel activity, exerting their influence, at least in part, by enhancing mean open time and single-channel conductance. Interestingly, the potentiating influence of the Girk1 P-loop is tempered by residue F162 in the second membrane-spanning domain. Thus, discontinuous and sometime opposing elements in Girk1 underlie the Girk1-dependent potentiation of receptor-dependent and receptor-independent heteromeric channel activity.

Predictors of micronutrient powder sachet coverage in Nepal.

Many countries implement micronutrient powder (MNP) programmes to improve the nutritional status of young children. Little is known about the predictors of MNP coverage for different delivery models. We describe MNP coverage of an infant and young child feeding and MNP intervention for children aged 6-23 months comparing two delivery models piloted in rural Nepal: distributing MNPs either by female community health volunteers (FCHVs) or at health facilities (HFs). Cross-sectional household cluster surveys were conducted in four pilot districts among mothers of children 6-23 months after starting MNP distribution. FCHVs in each cluster were also surveyed. We used logistic regression to describe predictors of initial coverage (obtaining a batch of 60 MNP sachets) at 3 months and repeat coverage (≥2 times coverage among eligible children) at 15 months after project launch. At 15 months, initial and repeat coverage were higher in the FCHV model, although no differences were observed at 3 months. Attending an FCHV-led mothers' group meeting where MNP was discussed increased odds of any coverage in both models at 3 months and of repeat coverage in the HF model at 15 months. Perceiving ≥1 positive effects in the child increased odds of repeat coverage in both delivery models. A greater portion of FCHV volunteers from the FCHV model vs. the HF model reported increased burden at 3 and 15 months (not statistically significant). Designing MNP programmes that maximise coverage without overburdening the system can be challenging and more than one delivery model may be needed.

Importation and containment of Ebola virus disease - Senegal, August-September 2014.

On August 29, 2014, Senegal confirmed its first case of Ebola virus disease (Ebola) in a Guinean man, aged 21 years, who had traveled from Guinea to Dakar, Senegal, in mid-August to visit family. Senegalese medical and public health personnel were alerted about this patient after public health staff in Guinea contacted his family in Senegal on August 27. The patient had been admitted to a referral hospital in Senegal on August 26. He was promptly isolated, and a blood sample was sent for laboratory confirmation; Ebola was confirmed by reverse transcriptase-polymerase chain reaction at Institut Pasteur Dakar on August 29. The patient's mother and sister had been admitted to an Ebola treatment unit in Guinea on August 26, where they had named the patient as a contact and reported his recent travel to Senegal. Ebola was likely transmitted to the family from the brother of the patient, who had traveled by land from Sierra Leone to Guinea in early August seeking treatment from a traditional healer. The brother died in Guinea on August 10; family members, including the patient, participated in preparing the body for burial.

Tuberculosis preventive treatment uptake among adults living with human immunodeficiency virus: Analysis of Zimbabwe population-based human immunodeficiency virus impact assessment 2020.

BACKGROUND: Tuberculosis remains the leading cause of death by an infectious disease among people living with HIV (PLHIV). TB Preventive Treatment (TPT) is a cost-effective intervention known to reduce morbidity and mortality. We used data from ZIMPHIA 2020 to assess TPT uptake and factors associated with its use. METHODOLOGY: ZIMPHIA a cross-sectional household survey, estimated HIV treatment outcomes among PLHIV aged ≥15 years. Randomly selected participants provided demographic and clinical information. We applied multivariable logistic regression models using survey weights. Variances were estimated via the Jackknife series to determine factors associated with TPT uptake. RESULTS: The sample of 2419 PLHIV ≥15 years had 65% females, 44% had no primary education, and 29% lived in urban centers. Overall, 38% had ever taken TPT, including 15% currently taking TPT. Controlling for other variables, those screened for TB at last HIV-related visit, those who visited a TB clinic in the previous 12 months, and those who had HIV viral load suppression were more likely to take TPT. CONCLUSION: The findings show suboptimal TPT coverage among PLHIV. There is a need for targeted interventions and policies to address the barriers to TPT uptake, to reduce TB morbidity and mortality among PLHIV.

Trends in HIV prevalence, incidence, and progress towards the UNAIDS 95-95-95 targets in Malawi among individuals aged 15-64 years: population-based HIV impact assessments, 2015-16 and 2020-21.

BACKGROUND: In 2014, UNAIDS set the goal of ending the AIDS epidemic by 2030 through the achievement of testing and treatment cascade targets. To evaluate progress achieved and highlight persisting gaps in HIV epidemic control in Malawi, we aimed to compare key indicators (prevalence, incidence, viral load suppression, and UNAIDS 95-95-95 targets) from the 2015-16 and 2020-21 Malawi Population-based HIV Impact Assessment (PHIA) survey results. METHODS: The Malawi PHIAs were nationally representative, cross-sectional surveys with a two-stage cluster sampling design. The first survey was conducted between Nov 27, 2015, and Aug 26, 2016; the second survey was conducted between Jan 15, 2020, and April 26, 2021. Our analysis included survey participants aged 15-64 years. Participants were interviewed and a 14 mL blood sample was collected and tested for HIV infection using the national rapid testing algorithm. For each survey, we estimated key HIV epidemic indicators and achievement of 95-95-95 targets. The risk ratio (RR) of the indicators between surveys were computed and considered significant at a confidence level of 0·05. All results were weighted, and self-reported awareness and treatment status were adjusted to account for detection of antiretrovirals. FINDINGS: Our analysis included 17 187 participants aged 15-64 years in 2015-16 and 21 208 in 2020-21 who participated in the surveys and blood draw. In the 2020-21 survey, 88·4% (95% CI 86·7-90·0) of people living with HIV were aware of their HIV-positive status; of those aware, 97·8% (97·1-98·5) were on antiretroviral therapy; and of those on treatment, 96·9% (95·9-97·7) were virally suppressed. Between surveys, the national HIV prevalence decreased significantly from 10·6% (10·0-11·2) to 8·9% (8·4-9·5) with RR 0·85 (95% CI 0·78-0·92; p<0·0001). The annual HIV incidence decreased from 0·37% (0·20-0·53) to 0·22% (0·11-0·34) with RR 0·61 (95% CI 0·31-1·20; p=0·15). The population viral load suppression increased from 68·3% (66·0-70·7) in 2015-16 to 87·0% (85·3-88·5) in 2020-21 (RR 1·27 [95% CI 1·22-1·32]; p<0·0001). INTERPRETATION: These results suggest that Malawi had already surpassed the UNAIDS viral load suppression target for 2030 (85·7%) by 2020-21. Through strategies and evidence-informed interventions implemented in the last half decade, especially scale-up of effective HIV treatment, Malawi has made tremendous progress, including decreasing HIV prevalence and incidence and achieving both the second and third 95 targets ahead of 2030. To address the first 95, efforts in HIV diagnosis should focus on males and younger age groups. There is a continued need for effective linkage to care, retention on antiretroviral therapy, and adherence support to maintain and build on progress. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention.

Acute cocaine exposure weakens GABA(B) receptor-dependent G-protein-gated inwardly rectifying K+ signaling in dopamine neurons of the ventral tegmental area.

Enhanced glutamatergic neurotransmission in dopamine (DA) neurons of the ventral tegmental area (VTA), triggered by a single cocaine injection, represents an early adaptation linked to the more enduring effects of abused drugs that characterize addiction. Here, we examined the impact of in vivo cocaine exposure on metabotropic inhibitory signaling involving G-protein-gated inwardly rectifying K(+) (Girk) channels in VTA DA neurons. Somatodendritic Girk currents evoked by the GABA(B) receptor (GABA(B)R) agonist baclofen were diminished in a dose-dependent manner in mice given a single cocaine injection. This adaptation persisted for 3-4 d, was specific for DA neurons of the VTA, and occurred in parallel with an increase in spontaneous glutamatergic neurotransmission. No additional suppression of GABA(B)R-Girk signaling was observed following repeated cocaine administration. While total Girk2 and GABA(B)R1 mRNA and protein levels were unaltered by cocaine exposure in VTA DA neurons, the cocaine-induced decrease in GABA(B)R-Girk signaling correlated with a reduction in Girk2-containing channels at the plasma membrane in VTA DA neurons. Systemic pretreatment with sulpiride, but not SCH23390 (7-chloro-3-methyl-1-phenyl-1,2,4,5-tetrahydro-3-benzazepin-8-ol), prevented the cocaine-induced suppression of GABA(B)R-Girk signaling, implicating D(2/3) DA receptor activation in this adaptation. The acute cocaine-induced weakening of somatodendritic Girk signaling complements the previously demonstrated cocaine-induced strengthening of glutamatergic neurotransmission, likely contributing to enhanced output of VTA DA neurons during the early stages of addiction.

Finding Children Living With HIV in Low-prevalence Countries: HIV Prevalence and Testing Yield From 5 Entry Points in Ethiopia.

BACKGROUND: Limited data in low HIV prevalence settings such as Ethiopia limit policy development and implementation of optimized pediatric testing approaches to close the treatment gap. This study aimed to determine HIV prevalence, testing yield and factors associated with HIV among children at 5 entry points. METHODS: We conducted a cross-sectional study from May 2017 to March 2018 in 29 public health facilities in Amhara and Addis Ababa regions in Ethiopia. Children 2-14 years were enrolled through 5 entry points. Data were obtained from registers, medical records and interviews with caregivers. HIV prevalence and testing yields were calculated for each entry point. Mixed-effects logistic regression analysis identified factors associated with undiagnosed HIV. RESULTS: The study enrolled 2166 children, of whom 94 were HIV positive (40 newly diagnosed). HIV prevalence and testing yield were the highest among children of HIV-positive adults (index testing; 8.2% and 8.2%, respectively) and children presenting to tuberculosis clinics (7.9% and 1.8%) or with severe malnutrition (6.5% and 1.4%). Factors associated with undiagnosed HIV included tuberculosis or index entry point [adjusted odds ratio (aOR), 11.97; 95% CI 5.06-28.36], deceased mother (aOR 4.55; 95% CI 1.30-15.92), recurrent skin problems (aOR 17.71; 95% CI 7.75-40.43), severe malnutrition (aOR 4.56; 95% CI 2.04-10.19) and urban residence (aOR 3.47; 95% CI 1.03-11.66). CONCLUSIONS: Index testing is a critical strategy for pediatric case finding in Ethiopia. Strategies and resources can prioritize minimizing missed opportunities in implementing universal testing for very sick children (tuberculosis, severe malnutrition) and implementing targeted testing in other entry points through use of factors associated with HIV.

Micronutrient powder use and infant and young child feeding practices in an integrated program.

Integrated infant and young child feeding (IYCF)/micronutrient powder (MNP) programs are increasingly used to address poor IYCF practices and micronutrient deficiencies in low-income settings; however, little is known about how MNP use may affect IYCF practices. We describe how MNP use was associated with IYCF practices in a pilot program in select districts of Nepal where free MNP for children 6-23 months were added to an existing IYCF platform. Representative cross-sectional surveys were conducted in pilot districts with mothers of eligible children at 3 months (plains ecozone, n=1054) or 15 months (hill ecozone, rural only, n=654) after implementation of an integrated MNP/IYCF program. We used logistic regression to assess how IYCF practices varied by MNP use (none, 1-30, 30-60 sachets). At both time points, consuming 30-60 MNP sachets vs. none was associated with achieving minimum dietary diversity and minimum acceptable diet. In the 3 month survey consuming 30- 60 MNP sachets vs none was also associated with achieving minimum meal frequency and continued breastfeeding at 2 years. In this setting, addition of MNP to an existing platform of IYCF messaging did not appear detrimental to IYCF practices.

Early Identification and Prevention of the Spread of Ebola in High-Risk African Countries.

In the late summer of 2014, it became apparent that improved preparedness was needed for Ebola virus disease (Ebola) in at-risk countries surrounding the three highly affected West African countries (Guinea, Sierra Leone, and Liberia). The World Health Organization (WHO) identified 14 nearby African countries as high priority to receive technical assistance for Ebola preparedness; two additional African countries were identified at high risk for Ebola introduction because of travel and trade connections. To enhance the capacity of these countries to rapidly detect and contain Ebola, CDC established the High-Risk Countries Team (HRCT) to work with ministries of health, CDC country offices, WHO, and other international organizations. From August 2014 until the team was deactivated in May 2015, a total of 128 team members supported 15 countries in Ebola response and preparedness. In four instances during 2014, Ebola was introduced from a heavily affected country to a previously unaffected country, and CDC rapidly deployed personnel to help contain Ebola. The first introduction, in Nigeria, resulted in 20 cases and was contained within three generations of transmission; the second and third introductions, in Senegal and Mali, respectively, resulted in no further transmission; the fourth, also in Mali, resulted in seven cases and was contained within two generations of transmission. Preparedness activities included training, developing guidelines, assessing Ebola preparedness, facilitating Emergency Operations Center establishment in seven countries, and developing a standardized protocol for contact tracing. CDC's Field Epidemiology Training Program Branch also partnered with the HRCT to provide surveillance training to 188 field epidemiologists in Côte d'Ivoire, Guinea-Bissau, Mali, and Senegal to support Ebola preparedness. Imported cases of Ebola were successfully contained, and all 15 priority countries now have a stronger capacity to rapidly detect and contain Ebola.The activities summarized in this report would not have been possible without collaboration with many U.S and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Addressing contact tracing challenges-critical to halting Ebola virus disease transmission.

BACKGROUND: Delayed and ineffective contact tracing contributed to the extensive transmission of Ebola virus disease (EVD) in the 2014-2015 West African outbreak. Understanding and addressing the challenges to implementing and managing contact tracing is essential to stopping EVD transmission and preventing large-scale EVD outbreaks in the future. METHODS: Interviews were conducted with United States Centers for Disease Control and Prevention staff members engaged in contact tracing activities in the affected West African countries of Sierra Leone, Guinea, Liberia, Senegal, Nigeria, and Mali from September through December 2014. Two staff members from each country were interviewed. The five most frequently cited contact tracing challenges were identified. RESULTS: Challenges have been evident in every step of the contact tracing process from implementation to management, including identifying, locating, and enrolling contact-persons, as well as managing personnel and ensuring contact tracing performance. Common themes observed in all of the affected West African countries have included fear, stigma, and community misperceptions regarding EVD. Countries that have overcome these challenges, ensuring immediate and comprehensive contact tracing, have been successful in halting EVD transmission. CONCLUSIONS: Addressing challenges to contact tracing implementation and management in the West African EVD outbreak is essential to stopping ongoing transmission.

Maternity leave duration and full-time/part-time work status are associated with US mothers' ability to meet breastfeeding intentions.

BACKGROUND: Breastfeeding provides numerous health benefits for infants and mothers; however, many infants are not breastfed as long as recommended or desired by mothers. Maternal employment is frequently cited as a barrier to breastfeeding. OBJECTIVE: This study aimed to assess whether maternity leave duration and return status (full-time [FT], part-time [PT]) were associated with not meeting a mother's intention to breastfeed at least 3 months. METHODS: We used data from the Infant Feeding Practices Study II, a cohort study. Analyses were limited to women employed prenatally who intended to breastfeed 3 months or longer (n = 1172). Multivariable logistic regression was used to assess the relationship between maternity leave duration and return-to-work status (< 6 weeks/FT, < 6 weeks/PT, 6 weeks-3 months/FT, 6 weeks-3 months/PT, not working by 3 months) and meeting a mother's intention to breastfeed at least 3 months. RESULTS: Overall, 28.8% of mothers did not meet their intention to breastfeed at least 3 months. Odds of not meeting intention to breastfeed at least 3 months were higher among mothers who returned to work FT before 3 months (< 6 weeks/FT: adjusted odds ratio = 2.25, 95% confidence interval, 1.23-4.12; 6 weeks-3 months/FT: adjusted odds ratio = 1.82, 95% confidence interval, 1.30-2.56), compared with mothers not working at 3 months. CONCLUSION: Returning to work full-time before 3 months may reduce a mother's ability to meet her intention to breastfeed at least 3 months. Employer support for flexible work scheduling may help more women achieve their breastfeeding goals.