Program implementation gaps and ethical issues in the prevention of HIV infection among infants, children, and adolescents in sub-Saharan Africa

Key normative, legal, and policy considerations for supporting pregnant and postpartum adolescents in high HIV-burden settings: a critical analysis

Rates of adolescent pregnancy within sub-Saharan Africa are increasing. Adolescent mothers ages 10-19 years face a distinct set of risks to their own and their children's health, compounded by many economic, social, and epidemiological challenges, such as living with HIV. In navigating this complex developmental period, many adolescent mothers face structural barriers impeding safe transitions to adulthood and motherhood. Drawing on existing literature and emerging data, we outline three normative, legal, and policy issues - violence and gender inequity, access to sexual and reproductive health services, and access to social and structural supports - which affect the health, wellbeing and development of adolescent mothers and their children. We also highlight emergent evidence about programming and policy changes that can better support adolescent mothers and their children. These key proposed responses include removing barriers to SRH and HIV service integration; ensuring implementation of return-to-school policies; and extending social protection systems to cater for adolescent mothers. Despite ongoing global crises and shifts in funding priorities, these normative, legal, and policy considerations remain critical to safeguard the health and wellbeing of adolescent mothers and their children.

Global, regional, and national HIV/AIDS disease burden levels and trends in 1990-2019: A systematic analysis for the global burden of disease 2019 study

Background

Since the first HIV/AIDS case appeared in 1980s, HIV/AIDS has been the focus of international attention. As a major public health problem, there are epidemiological uncertainties about the future of HIV/AIDS. It is important to monitor the global statistics of HIV/AIDS prevalence, deaths, disability adjusted life years (DALYs), and risk factors for adequate prevention and control.

Methods

The Global Burden of Disease Study 2019 database was used to analyze the burden of HIV/AIDS in 1990-2019. By extracting global, regional, and national data on HIV/AIDS prevalence, deaths, and DALYs, we described the distribution by age and sex, explored the risk factors, and analyzed the trends in HIV/AIDS.

Results

In 2019, there were 36.85 million HIV/AIDS cases (95% UI: 35.15-38.86 million), 863.84 thousand deaths (95% UI: 78.61-99.60 thousand), and 47.63 million (95% UI: 42.63-55.65 million) DALYs. The global age-standardized HIV/AIDS prevalence, death, and DALY rates were 454.32 (95% UI: 433.76-478.59), 10.72 (95% UI: 9.70-12.39), and 601.49 (95% UI: 536.16-703.92) per 100,000 cases, respectively. In 2019, the global age-standardized HIV/AIDS prevalence, death, and DALY rates increased by 307.26 (95% UI: 304.45-312.63), 4.34 (95% UI: 3.78-4.90), and 221.91 (95% UI: 204.36-239.47) per 100,000 cases, respectively, compared to 1990. Age-standardized prevalence, death, and DALY rates decreased in high sociodemographic index (SDI) areas. High age-standardized rates were observed in low sociodemographic index areas, while low age-standardized rates were observed in high sociodemographic index areas. In 2019, the high age-standardized prevalence, death, and DALY rates were predominant in Southern Sub-Saharan Africa, and global DALYs peaked in 2004 and subsequently decreased. The highest global HIV/AIDS DALYs were in the 40-44 age group. The main risk factors affecting HIV/AIDS DALY rates included behavioral risks, drug use, partner violence, and unsafe sex.

Conclusions

HIV/AIDS disease burden and risk factors vary by region, sex, and age. As access to health care increases across countries and treatment for HIV/AIDS infection improves, the HIV/AIDS disease burden is concentrated in areas with low SDIs, particularly in South Africa. Regional differences should be fully considered to target optimal prevention strategies and treatment options based on risk factors.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review

PURPOSE

Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice.

METHODS

We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work.

RESULTS

From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services).

DISCUSSION

A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Impact of COVID-19 on Well-Being and Physical Activity in Ugandan Children With and Without HIV

BACKGROUND

The present study aims to understand the socioeconomic and physical activity impact of the COVID-19 pandemic on children living with perinatally acquired HIV (PHIV) and without HIV (HIV-) in Kampala (Uganda).

METHODS

The authors included children aged 10-18 years who filled out questionnaires at baseline (2017-2018, prepandemic) and 2 years later (March 2020-January 2021, pandemic) in an observational cohort study at Joint Clinical Research Centre (Kampala). Physical activity energy expenditure was calculated using a youth compendium from the National Collaborative on Childhood Obesity Research. Descriptive and standard test statistics including Kruskal-Wallis were used.

RESULTS

One hundred and ninety-eight children from Kampala Uganda were included prepandemic (101 PHIV and 97 HIV-); 131 (71 PHIV and 60 HIV-) had information collected during the pandemic. At baseline, median and interquartile range age was 13 years (11; 15), and 52% were females. During the pandemic, overall weekly physical activity increased by a median of 854 minutes (interquartile range: 270-1890), and energy expenditures increased by 16% in both PHIV and in HIV- (P < .001 for groups overall prepandemic vs pandemic).

CONCLUSIONS

The authors found in this Ugandan cohort of children that children engaged in more physical activity. Further research is warranted to understand the long-term effects of the pandemic on children's well-being.

Health Equity in Pediatric Drug Development: Translating Aspiration into Operation

The concept of health equity—the attainment of the highest possible level of health for all members of society—requires equitable access to all aspects of healthcare, including pediatric drug development. However, many communities are under-represented in pediatric drug development programs. Barriers to participation include geographic, economic, racial/ethnic bias, legal, cultural, linguistic, and other factors. While there is no “one size fits all” approach to addressing these barriers, community engagement and collaboration is recognized by the Centers for Disease Control, the World Health Organization, and other global health organizations as a cornerstone for building a more equitable healthcare system. In this article, we will present case studies of stakeholder and community engagement in clinical research for rare diseases and other areas of healthcare, as examples of strategies and practices for actively involving under-represented communities and fostering their participation in pediatric drug development programs. These studies may serve as templates for facilitating equity in pediatric drug development from aspiration into operation.

The Impact of Armed Conflict on the Prevalence and Transmission Dynamics of HIV Infection in Libya

The interrelationships between HIV/AIDS and armed conflict are a complex phenomenon, and studies are rarely devoted to this area of research. Libya is the second-largest country in Africa that has been evoked with war since the NATO intervention in 2011. The country has also experienced one of the largest HIV outbreaks associated with the Bulgarian nurse's saga. The effect of the armed conflict on the dynamic spread of HIV is not yet well-known. The objectives of this study were to determine the impact of armed conflict on the epidemiological situation of HIV infection in Libya and to analyze the transmission dynamics of HIV strains during the conflict. We investigated the movement of people with HIV during the Libyan armed conflict, analyzed the HIV subtypes reported from 2011 to 2020, and followed up the infected cases all over the country. The patterns of HIV spread within the Libyan regions were traced, and the risk factors were determined during the conflict period. A total of 4,539 patients with HIV/AIDS were studied from the four regions during the Libyan conflict. Our data analysis indicated that Benghazi, the biggest city in the Eastern region, was the significant exporter of the virus to the rest of the country. The viral dissemination changes were observed within the country, particularly after 2015. A major virus flows from the Eastern region during the armed conflict associated with internally displaced people. This resulted in the dissemination of new HIV strains and accumulations of HIV cases in western and middle regions. Although, there were no significant changes in the national prevalence of HIV/AIDS. Our data highlight the factors that complicated the spread and dissemination of HIV during the armed conflict, which provide a better understanding of the interaction between them. This could be used to plan for effective preventive measures in tackling the spread of HIV in conflict and post-conflict settings.

Multilevel modelling and multiple group analysis of disparities in continuity of care and viral suppression among adolescents and youths living with HIV in Nigeria

INTRODUCTION

Substantial disparities in care outcomes exist between different subgroups of adolescents and youths living with HIV (AYLHIV). Understanding variation in individual and health facility characteristics could be key to identifying targets for interventions to reduce these disparities. We modelled variation in AYLHIV retention in care and viral suppression, and quantified the extent to which individual and facility characteristics account for observed variations.

METHODS

We included 1170 young adolescents (10-14 years), 3206 older adolescents (15-19 years) and 9151 young adults (20-24 years) who were initiated on antiretroviral therapy (ART) between January 2015 and December 2017 across 124 healthcare facilities in Nigeria. For each age group, we used multilevel modelling to partition observed variation of main outcomes (retention in care and viral suppression at 12 months after ART initiation) by individual (level one) and health facility (level two) characteristics. We used multiple group analysis to compare the effects of individual and facility characteristics across age groups.

RESULTS

Facility characteristics explained most of the observed variance in retention in care in all the age groups, with smaller contributions from individual-level characteristics (14%-22.22% vs 0%-3.84%). For viral suppression, facility characteristics accounted for a higher proportion of variance in young adolescents (15.79%), but not in older adolescents (0%) and young adults (3.45%). Males were more likely to not be retained in care (adjusted OR (aOR)=1.28; p<0.001 young adults) and less likely to achieve viral suppression (aOR=0.69; p<0.05 older adolescent). Increasing facility-level viral load testing reduced the likelihood of non-retention in care, while baseline regimen TDF/3TC/EFV or NVP increased the likelihood of viral suppression.

CONCLUSIONS

Differences in characteristics of healthcare facilities accounted for observed disparities in retention in care and, to a lesser extent, disparities in viral suppression. An optimal combination of individual and health services approaches is, therefore, necessary to reduce disparities in the health and well-being of AYLHIV.

Addressing gaps in adolescent tuberculosis programming and policy in Nigeria from a public health perspective

OBJECTIVES

Tuberculosis (TB) is a leading infectious cause of death globally. Of the estimated 10 million people who developed active TB in 2019, 1.8 million (18%) were adolescents and young adults aged 15-24 years. Adolescents have poorer rates of TB screening, treatment initiation and completion compared to adults. Unfortunately, there is relatively less programme, research and policy focus on TB for adolescents aged 10-19 years. This article reviews the scope of health services and the relevant policy landscape for TB case notification and care/treatment, TB/HIV management, and latent TB infection for adolescents in Nigeria. Additionally, it discusses considerations for TB vaccines in this population.

CONTENT

All Nigeria Federal Ministry of Health policy documents relevant to adolescent health services and TB, and published between 2000 and 2020 underwent narrative review. Findings were reported according to the service areas outlined in the Objectives.

SUMMARY AND OUTLOOK

Nine policy documents were identified and reviewed. While multiple policies acknowledge the needs of adolescents in public health and specifically in TB programming, these needs are often not addressed in policy, nor in program integration and implementation. The lack of age-specific epidemiologic and clinical outcomes data for adolescents contributes to these policy gaps. Poor outcomes are driven by factors such as HIV co-infection, lack of youth-friendly health services, and stigma and discrimination. Policy guidelines and innovations should include adaptations tailored to adolescent needs. However, these adaptations cannot be developed without robust epidemiological data on adolescents at risk of, and living with TB. Gaps in TB care integration into primary reproductive, maternal-child health and nutrition services should be addressed across multiple policies, and mechanisms for supervision, and monitoring and evaluation of integration be developed to guide comprehensive implementation. Youth-friendly TB services are recommended to improve access to quality care delivered in a patient-centered approach.

Things must not fall apart: the ripple effects of the COVID-19 pandemic on children in sub-Saharan Africa

Zero to 19 year-old children in sub-Saharan Africa bear a disproportionate proportion of the global burden of communicable and non-communicable diseases. Significant public health gains have been made in the fight against these diseases, however, factors such as underequipped health systems, disease outbreaks, conflict, and political instability continue to challenge prevention and control. The novel coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) introduces new challenges to public health programs in sub-Saharan Africa. Of particular concern are programs targeting major conditions among children, such as undernutrition, vaccine-preventable pneumonia and diarrhea, malaria, tuberculosis, HIV, and sickle cell disease. This article focuses on the impact of the COVID-19 pandemic on child health in sub-Saharan Africa. We review the epidemiology of major pediatric diseases and, referencing modeling projections, discuss the short- and long-term impact of the pandemic on major disease control. We deliberate on potential complications of SARS-CoV-2 co-infections/co-morbidities and identify critical social and ethical issues. Furthermore, we highlight the paucity of COVID-19 data and clinical trials in this region and the lack of child participants in ongoing studies. Lastly, approaches and interventions to mitigate the pandemic's impact on child health outcomes are discussed. IMPACT: Children in sub-Saharan Africa bear a disproportionate burden of communicable and non-communicable diseases globally; this remains true even as the COVID-19 pandemic persists. Amidst the fast-expanding COVID-19 literature, there is little comprehensive coverage of the pandemic's indirect impact on child health in sub-Saharan Africa. This article comprehensively outlines the threat that the pandemic poses to major disease prevention and control for children in sub-Saharan Africa. It discusses the potential impact of SARS-CoV-2 co-infections/co-morbidities, highlights research gaps, and advocates for data and action to mitigate the ripple effects of the pandemic on this population.

Pediatric Critical Care in Resource Limited Settings-Lessening the Gap Through Ongoing Collaboration, Advancement in Research and Technological Innovations

Pediatric critical care has continued to advance since our last article, "Pediatric Critical Care in Resource-Limited Settings-Overview and Lessons Learned" was written just 3 years ago. In that article, we reviewed the history, current state, and gaps in level of care between low- and middle-income countries (LMICs) and high-income countries (HICs). In this article, we have highlighted recent advancements in pediatric critical care in LMICs in the areas of research, training and education, and technology. We acknowledge how the COVID-19 pandemic has contributed to increasing the speed of some developments. We discuss the advancements, some lessons learned, as well as the ongoing gaps that need to be addressed in the coming decade. Continued understanding of the importance of equitable sustainable partnerships in the bidirectional exchange of knowledge and collaboration in all advancement efforts (research, technology, etc.) remains essential to guide all of us to new frontiers in pediatric critical care.

Adolescent participation in HIV research: consortium experience in low and middle-income countries and scoping review

Adolescents in low and middle-income countries (LMICs) have a high prevalence of HIV, therefore, it is important that they are included in HIV research. However, ethical challenges regarding consent can hinder adolescent research participation. We examined examples from the Prevention and Treatment Through a Comprehensive Care Continuum for HIV-affected Adolescents in Resource Constrained Settings (PATC3H) research consortium, which investigates adolescent HIV prevention and treatment in seven LMICs: Brazil, Kenya, Mozambique, Nigeria, South Africa, Uganda, and Zambia. PATC3H researchers were asked to identify ethical and practical challenges of adolescent consent to research participation in these countries. We also did a scoping review of strategies that could improve adolescent participation in LMIC HIV studies. Examples from PATC3H research highlighted many ethical challenges that affect adolescent participation, including inconsistent or absent consent guidance, guidelines that fail to account for the full array of adolescents' lives, and variation in how ethical review committees assess adolescent studies. Our scoping review identified three consent-related strategies to expand adolescent inclusion: waiving parental consent requirements, allowing adolescents to independently consent, and implementing surrogate decision making. Our analyses suggest that these strategies should be further explored and incorporated into ethical and legal research guidance to increase adolescent inclusion in LMIC HIV research.

Low coverage of HIV testing among adolescents and young adults in Nigeria: Implication for achieving the UNAIDS first 95

Background

Most studies on HIV testing among young people in Nigeria are not nationally representative. As such, recent nationally representative data, such as the Multiple Indicator Cluster Survey (MICS), could help assess the current level of HIV testing among young people, a key target population for HIV prevention in the country. In this study, we examined the coverage and factors associated with HIV testing among adolescents and young adults (AYA).

Methods

We used the data for 14,312 AYA that examined recent and lifetime HIV testing from the 2017 MCIS. Our outcomes of interest were ever tested for HIV and recently tested for HIV. We examined the association between socio-demographic factors (e.g., age, marital status, education attainment, wealth status), stigma belief, exposure to media and HIV knowledge, and uptake of HIV testing using adjusted and unadjusted logistic regression models.

Results

Less than a quarter of the AYA (23.7%) had ever tested for HIV, and an even lower proportion (12.4%) tested in the year preceding the survey. More females (25.4%) compared to males (20.8%) had ever tested for HIV. Young people who were aged 20–24 years (AOR 1.52, 95% CI 1.34–1.72), married (AOR 2.42, 95% CI 1.98–2.97), had higher educational attainment (AOR 5.85, 95% CI 4.39–7.81), and belonged to the wealthiest quintile (AOR 1.99, 95% CI 1.53–2.60), had higher odds of having ever tested for HIV compared to those aged 15–19 years, never married, had no formal education and belonged to the poorest wealth quintile. Also, those who had positive stigma belief towards people living with HIV (AOR 2.93, 95% CI 2.47–3.49), had higher HIV knowledge (AOR 1.62, 95% CI 1.24–2.11), and higher media exposure (AOR 1.64, 95% CI 1.36–1.97), had higher odds of having ever tested compared to those who had more negative stigma belief, had low knowledge of HIV and low media exposure.

Conclusion

The HIV testing coverage among AYA in Nigeria is well below the national target of 95% indicated in the national HIV/AIDS strategic framework (2017–2021). Also, the low rate of HIV testing found in this study means realising the UNAIDS first 95 will require interventions targeting AYA. These interventions should focus on improving young people's knowledge of HIV, reducing negative stigma belief through media campaigns and increasing access to HIV testing through home-based testing and "opt-out" strategy at the point of care.