Ruby Fayorsey

Background: Case identification remains a challenge to reaching the United Nations 95-95-95 targets for children with HIV. Although the World Health Organization approved oral mucosal HIV self-testing (HIVST) for children older than 2 years in 2019, there is little information on HIVST for pediatric case identification in Ethiopia. Setting: Nine health facilities across Ethiopia. Methods: We implemented a pilot program from November 2021 to April 2022 to assess acceptability and feasibility of using HIVST to screen children 2–14 years of adult index clients, (ie, parents/caregivers living with HIV and on antiretroviral therapy). HIV-positive adults who had children with unknown HIV status were given HIVST kits (OraQuick) to screen their children at home. Parents/caregivers were asked to report results telephonically and bring children screening positive to the health facility for confirmatory HIV testing. We defined HIVST acceptability as ≥50% of parents/caregivers accepting testing and ≥50% reporting results within 7 days of receiving a test kit. Feasibility was defined as ≥60% of children with a reactive HIVST receiving confirmatory testing and <5 serious social harms reported per 1000 kits distributed. Results: Overall, 1496 of 1651 (91%) parents/caregivers accepted HIVST kits to test their children at home and 1204 (71%) reported results within 7 days. Of 17 children (1%) with reactive results, 13 (76%) received confirmatory testing; of which 7 (54%) were confirmed to be HIV positive. One serious social harm was reported. Conclusions: Providing adult parents/caregivers with HIVST kits to screen their children at home is an acceptable and feasible strategy to reach untested children and improve pediatric case finding in a low prevalence setting.

The WHO recommends monitoring viral load (VL) to gauge ART efficacy among People Living with HIV (PLHIV). Low suppression rates persist in low- and middle-income countries due to poor adherence. Enhanced Adherence Counseling (EAC) aims to improve adherence and treatment outcomes. This study, part of the Reaching Impact Saturation and Epidemic Control (RISE) project in Nigeria, analyzes factors affecting viral re-suppression post-EAC. It aims to inform clinical decisions and improve PLHIV health outcomes in the country. This was a retrospective analysis of a de-identified client-level dataset of unsuppressed VL clients who were current on treatment at the end of June 2022 and subsequently enrolled in the EAC program. A log-binomial regression model was used to report crude and adjusted risk ratio with 95% Confidence Intervals (95% CI) and a p-value of 0.05 to determine the association between clinical characteristics and suppression of VL post-EAC in the RISE program (July 2021 to June 2022). A total of 1607 clients with initial high VL who completed EAC were included in this analysis out of which 1454 (91%) were virally suppressed. The median time to completion of EAC was 8 weeks and the median time for post EAC VL test was 8 weeks. Following EAC, PLHIV in the 10–19 years age band were 10% more likely to be re-suppressed (ARR: 1.10; 95% CI 1.01 to 1.19). In addition, there was a 50% reduced likelihood of viral re-suppression among PLHIV on second-line regimens compared to PLHIV on first-line regimens (ARR: 0.50; 95% CI 0.41 to 0.62). Findings show that Age and ART regimen were significant predictors of VLS. More targeted outreach of EAC amongst second-line regimens and ages 10 and above is necessary to ensure better VLS within these groups.

This study explores factors influencing viral re-suppression among 1,607 recipients of HIV care in Nigeria who completed Enhanced Adherence Counseling (EAC) between July 2021 and June 2022. The analysis, part of the Reaching Impact, Saturation, and Epidemic Control (RISE) project, utilized routine program data from 132 health facilities. Results showed a 91% re-suppression rate post-EAC, with age and ART regimen type identified as significant factors. Adolescents (10-19 years) had a higher likelihood of re-suppression, while ROC on second-line regimens exhibited lower resuppression rates. These findings inform programmatic decisions to enhance HIV treatment outcomes in Nigeria.

Background: Retention of mothers and infants across the prevention of mother-to-child HIV transmission (PMTCT) continuum remains challenging. We assessed the effectiveness of a lay worker administered combination intervention compared with the standard of care (SOC) on mother–infant attrition. Methods: HIV-positive pregnant women starting antenatal care at 10 facilities in western Kenya were randomized using simple randomization to receive individualized health education, retention/adherence support, appointment reminders, and missed visit tracking vs. routine care per guidelines. The primary endpoint was attrition of mother–infant pairs at 6 months postpartum. Attrition was defined as the proportion of mother–infant pairs not retained in the clinic at 6 months postpartum because of mother or infant death or lost to follow-up. Intent-to-treat analysis was used to assess the difference in attrition. This trial is registered with ClinicalTrials.gov; NCT01962220. Results: From September 2013 to June 2014, 361 HIV-positive pregnant women were screened, and 340 were randomized to the intervention (n = 170) or SOC (n = 170). Median age at enrollment was 26 years (interquartile range 22–30); median gestational age was 24 weeks (interquartile range 17–28). Overall attrition of mother–infant pairs was 23.5% at 6 months postpartum. Attrition was significantly lower in the intervention arm compared with SOC (18.8% vs. 28.2%, relative risk (RR) = 0.67, 95% confidence interval: 0.45 to 0.99, P = 0.04). Overall, the proportion of mothers who were retained and virally suppressed (<1000 copies/mL) at 6 months postpartum was 54.4%, with no difference between study arms. Conclusions: Provision of a combination intervention by lay counselors can decrease attrition along the PMTCT cascade in low-resource settings.

The recent scale-up of prevention of mother-to-child transmission of HIV (PMTCT) services has rapidly accelerated antiretroviral therapy (ART) uptake among pregnant and postpartum women in sub-Saharan Africa. The Mother and Infant Retention for Health (MIR4Health) study evaluates the impact of a combination intervention administered by trained lay health workers to decrease attrition among HIV-positive women initiating PMTCT services and their infants through 6 months postpartum. This was a qualitative study nested within the MIR4Health trial. MIR4Health was conducted at 10 health facilities in Nyanza, Kenya from September 2013 to September 2015. The trial intervention addressed behavioral, social, and structural barriers to PMTCT retention and included: appointment reminders via text and phone calls, follow-up and tracking for missed clinic visits, PMTCT health education at home visits and during clinic visits, and retention and adherence support and counseling. All interventions were administered by lay health workers. We describe results of a nested small qualitative inquiry which conducted two focus groups to assess the experiences and perceptions of lay health workers administering the interventions. Discussions were recorded and simultaneously transcribed and translated into English. Data were analyzed using framework analysis approach. Study findings show lay health workers played a critical role supporting mothers in PMTCT services across a range of behavioral, social, and structural domains, including improved communication and contact, health education, peer support, and patient advocacy and assistance. Findings also identified barriers to the uptake and implementation of the interventions, such as concerns about privacy and stigma, and the limitations of the healthcare system including healthcare worker attitudes. Overall, study findings indicate that lay health workers found the interventions to be feasible, acceptable, and well received by clients. Lay health workers played a fundamental role in supporting mothers engaged in PMTCT services and provided valuable feedback on the implementation of PMTCT interventions. Future interventions must include strategies to ensure client privacy, decrease stigma within communities, and address the practical limitations of health systems. This study adds important insight to the growing body of research on lay health worker experiences in HIV and PMTCT care. Clinicaltrials.gov NCT01962220 .

Objective: To describe pediatric ART scale‐up in Ethiopia, one of the 21 global priority countries for elimination of pediatric HIV infection.Methods: A descriptive analysis of routinely collected HIV care and treatment data on HIV‐infected children (P < 0.0001). Children with more advanced disease and those enrolled in rural settings were more likely to die. Children enrolled in more recent years were less likely to die but more likely to be LTF.Conclusions: Over the last decade large numbers of HIV‐infected children have been successfully enrolled in HIV care and initiated on ART in Ethiopia. Retention prior to and after ART initiation remains a major challenge.

Background: Effective retention of HIV-infected mothers and their infants is fraught with multiple challenges, resulting in loss across the continuum of prevention of mother-to-child HIV transmission (PMTCT) care and missed opportunities to offer life-saving HIV prevention and treatment. Methods: The Mother Infant Retention for Health study is an individual-randomized study evaluating the effectiveness of active patient follow-up compared with standard of care on the combined outcome of attrition of HIV-infected women and their infants at 6 months postpartum. Lay counselors administered the active patient follow-up package of interventions, including individualized health education, use of flip charts during clinic visits, and at home, phone and short message service appointment reminders, active phone and physical tracking of patients immediately after missed clinic visits, and individualized retention and adherence support. Results: Use of study visits to indicate participant progression along the PMTCT cascade highlights the nature of loss among women and infants in PMTCT care because of issues such as pregnancy complications, infant deaths, and transfer out. Delay in implementation of Option B+, unanticipated slow enrollment, a health-care worker strike, rapid HIV test kit shortages, and changes in national PMTCT guidelines necessitated several modifications to the protocol design and implementation to ensure successful completion of the study. Conclusions: Flexibility when operationalizing an implementation science study is critical in the context of the shifting landscape in a noncontrolled “real-world” setting. Trial Registration: Clinicaltrials.gov NCT01962220.

Background: The number of youth and adolescents (10–24 years) with HIV infection has increased substantially presenting unique challenges to effective health service delivery. Methods: We examined routinely collected patient-level data for antiretroviral treatment (ART)-naive HIV-infected patients, aged 10–24 years, enrolled in care during 2006–2011 at 109 ICAP-supported health facilities in three provinces in Kenya. Loss to follow-up (LTF) was defined as having no clinic visit for 12 months prior to ART initiation (pre-ART) and 6 months for ART patients. Competing risk and Kaplan–Meier estimators were used to calculate LTF and death rates. Sub-distributional and Cox proportional-hazards models were used to identify potential predictors of death and LTF. Results: Overall 22 832 patients were enrolled in care at 10–24 years of age, 69.5% were aged 20–24 years, and 82% were female. Median CD4⁺ cell count was 332 cells/μl (interquartile range 153–561); 70.8% were WHO stage I/II. Young adolescents (10–14 years) had more advanced WHO stage and lower median CD4⁺ cell count compared to youth (15–24 years) at enrollment (284 vs. 340 cells/μl; P < 0.0001). Cumulative incidence of LTF and death at 24 months for pre-ART patients was 46.1% [95% confidence interval (CI) 45.4–46.8%) and 2.1% (95% CI 1.9–2.3%), respectively. For those on ART, 32.2% (95% CI 31.1–33.3%) were LTF and 3.9% (95% CI 1.7–2.3%) died within 24 months. LTF among pre-ART and ART patients was twice as high among youth compared to young adolescents. Conclusion: LTF of young people with HIV in this Kenyan cohort was high and notably greater among youth compared to young adolescents. Novel strategies targeting these populations are urgently needed to improve retention.