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Self-injurious thoughts and behaviors (SITBs) are a growing concern among youth in sub-Saharan Africa, but their prevalence and correlates in this region are poorly understood. We therefore examined self-reported SITBs in a population-representative sample of youth in rural Burkina Faso. We used interviews from 1,538 adolescents aged 12 to 20 years living in 10 villages and 1 town in northwestern Burkina Faso. Adolescents were asked about their experiences with suicidal and nonsuicidal SITBs, adverse environmental factors, psychiatric symptoms, and interpersonal-social experiences. SITBs included lifetime prevalence of life is not worth living, passive suicide ideation, active suicide ideation, and nonsuicidal self-injury (NSSI). After describing SITB prevalence, we ran logistic and negative binomial regression models to predict SITBs. Weighted lifetime SITB prevalence estimates were: 15.6% (95% confidence interval [CI]: 13.7–18.0) for NSSI; 15.1% (95% CI: [13.2, 17.0]) for life is not worth living; 5.0% (95% CI [3.9, 6.0]) for passive suicide ideation; and 2.3% (95% CI [1.6, 3.0]) for active suicide ideation. Prevalence of life is not worth living increased with age. All four SITBs were significantly positively associated with mental health symptoms (depression symptoms, probable posttraumatic stress disorder) and interpersonal-social experiences (peer and social connectedness, physical assault, sexual assault and unwanted sexual experiences). Females were significantly more likely to report that their life was not worth living compared to males (aOR = 0.68; 95% CI [0.48, 0.96]). There is a high prevalence of SITBs among youth in rural Burkina Faso, most notably NSSI and life is not worth living, with interpersonal-social factors being the strongest predictors. Our results highlight the need for longitudinal SITB assessment to understand how risk for SITBs operates in resource-constrained settings, and to design interventions to mitigate risk. Given low school enrollment in rural Burkina Faso, it will be important to consider youth suicide prevention and mental health initiatives that are not school-based. [ABSTRACT FROM AUTHOR]

Pre-Exposure Prophylaxis (PrEP) is a potential game-changer for HIV. We used PrEP introduction for Young Women Who Sell Sex (YWSS) in a rural South Africa district to understand community norms and PrEP coverage in YWSS. Between 2017 and 2018, we measured awareness and uptake of PrEP in a representative cohort of 2184 Adolescent Girls and Young Women (AGYW) aged 13–22. We conducted group discussions with young people and community members (19); key informant interviews (9), in-depth interviews with 15–24 year-olds (58) and providers (33). Interviews were analysed using thematic analysis. PrEP awareness increased from 2% to 9%. Among 965 AGYW sexually-active by 2018, 13.4% (95%CI: 11.4%–15.7%) reported transactional sex and 10.6% (95%CI: 8.85–12.7%) sex for money. Of the 194 YWSS, 21 were aware of PrEP, but none had used it. Youth were enthusiastic about PrEP as tool for HIV prevention; whilst older community members were cautious about a technology they had limited experience with but could benefit select groups. Teachers and healthcare providers were concerned that PrEP would lower personal responsibility for sexual health. In conclusion, the narrow and limited introduction of PrEP to YWSS reduced the accessibility and reach. Introducing PrEP as part of sexual healthcare may improve demand and access for YWSS. [ABSTRACT FROM AUTHOR]

Objectives Previous research on subjective age (SA), that is, how young or old a person feels relative to their chronological age, has shown that older adults tend to feel younger than they are (by about 15%–20%), but the extent of this effect depends, in part, on their health. However, as most of the studies have been conducted in Western countries, it is unclear how well these results generalize to culturally different samples. Objectives, therefore, were to examine SA in middle-aged and older adults from a very low-income setting in rural Burkina Faso, to examine associations between SA and health/quality of life-related measures, and to compare findings with Western studies. Methods Representative, cross-sectional sample of N = 3,028 adults (≥40 years, recruited in 2018) from north-western Burkina Faso. Data included questionnaires on depression (Patient Health Questionnaire-9) and quality of life (World Health Organization Quality of Life scale, including subjective health) as well as performance-based and objective health-related measures (Community Screening Instrument for Dementia as cognitive screening, walking speed). Results Respondents felt on average 3% younger (SD = 0.13) than their chronological age, with 48% (95% confidence interval: 0.46–0.50) feeling younger—27 percentage points lower than seen in representative Western studies. Lower depression, better walking speed, cognition, and quality of life were all associated with younger SA. Discussion Middle-aged and older adults in Nouna felt less young than similar age groups in Western studies. One of the reasons may be that youthfulness is less of a value outside Western cultures. As in Western studies, parts of the variation in SA can be explained by health parameters. [ABSTRACT FROM AUTHOR]

Objectives The importance of impairment in performing activities of daily living (ADL) is likely to increase in sub-Saharan Africa because few care options for affected people exist. This study investigated the prevalence of ADL impairment, the extent to which care need was met, and described characteristics of people with ADL impairment and unmet need in Burkina Faso. Methods This study used data from the Centre de Recherche en Santé de Nouna Heidelberg Aging Study, a population-based study among 3,026 adults aged older than 40 years conducted in rural Burkina Faso. Information on 6 basic ADL items was sought, with a follow-up question asking whether care need was not met, partially met, or met. Bivariable correlations and multivariable logistic regression were used to determine sociodemographic and health characteristics associated with ADL impairment and unmet need. Results ADL impairment of any kind was reported by 1,202 (39.7%) respondents and was associated with older age (adjusted odds ratio: 1.05 [95% CI: 1.04–1.06]), being a woman (1.33 [1.06–1.60]), and reporting depressive symptoms (1.90 [1.65–2.18]). Among those with ADL impairment, 67.8% had at least one unmet need. Severe ADL impairment was found in 202 (6.7%) respondents, who reported a lower prevalence of unmet need (43.1%). Severe ADL impairment was associated with depressive symptoms (2.55 [2.11–3.07]) to a stronger degree than any ADL impairment. Discussion Prevalence of ADL impairment and unmet need was high in this setting. Variation in impairment across the population highlighted key groups for future interventions. Unmet need for care was highest in middle-aged adults, indicating a gap in care provision. [ABSTRACT FROM AUTHOR]

Background Weeks after issuing social distancing orders to suppress severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and reduce growth in cases of severe coronavirus disease 2019 (COVID-19), all US states and the District of Columbia partially or fully relaxed these measures. Methods We identified all statewide social distancing measures that were implemented and/or relaxed in the United States between 10 March and 15 July 2020, triangulating data from state government and third-party sources. Using segmented linear regression, we estimated the extent to which relaxation of social distancing affected epidemic control, as indicated by the time-varying, state-specific effective reproduction number (R t ). Results In the 8 weeks prior to relaxation, mean R t declined by 0.012 units per day (95% confidence interval [CI], −.013 to −.012), and 46/51 jurisdictions achieved R t  < 1.0 by the date of relaxation. After relaxation of social distancing, R t reversed course and began increasing by 0.007 units per day (95% CI,.006–.007), reaching a mean R t of 1.16. Eight weeks later, the mean R t was 1.16 and only 9/51 jurisdictions were maintaining an R t < 1.0. Parallel models showed similar reversals in the growth of COVID-19 cases and deaths. Indicators often used to motivate relaxation at the time of relaxation (eg, test positivity rate <5%) predicted greater postrelaxation epidemic growth. Conclusions We detected an immediate and significant reversal in SARS-CoV-2 epidemic suppression after relaxation of social distancing measures across the United States. Premature relaxation of social distancing measures undermined the country's ability to control the disease burden associated with COVID-19. [ABSTRACT FROM AUTHOR]

Background: Smartphones have rapidly become an important marker of wealth in low- and middle-income countries, but international household surveys do not regularly gather data on smartphone ownership and these data are rarely used to calculate wealth indices. Methods: We developed a cross-sectional survey module delivered to 3028 households in rural northwest Burkina Faso to measure the effects of this absence. Wealth indices were calculated using both principal components analysis (PCA) and polychoric PCA for a base model using only ownership of any cell phone, and a full model using data on smartphone ownership, the number of cell phones, and the purchase of mobile data. Four outcomes (household expenditure, education level, and prevalence of frailty and diabetes) were used to evaluate changes in the composition of wealth index quintiles using ordinary least squares and logistic regressions and Wald tests. Results: Households that own smartphones have higher monthly expenditures and own a greater quantity and quality of household assets. Expenditure and education levels are significantly higher at the fifth (richest) socioeconomic status (SES) quintile of full model wealth indices as compared to base models. Similarly, diabetes prevalence is significantly higher at the fifth SES quintile using PCA wealth index full models, but this is not observed for frailty prevalence, which is more prevalent among lower SES households. These effects are not present when using polychoric PCA, suggesting that this method provides additional robustness to missing asset data to measure underlying latent SES by proxy. Conclusions: The lack of smartphone data can skew PCA-based wealth index performance in a low-income context for the top of the socioeconomic spectrum. While some PCA variants may be robust to the omission of smartphone ownership, eliciting smartphone ownership data in household surveys is likely to substantially improve the validity and utility of wealth estimates. [ABSTRACT FROM AUTHOR]

In sub-Saharan Africa, female bar workers (FBWs) often serve as informal sex workers. Little is known about the prevalence of HIV and HIV-related risk factors among FBWs in Dar es Salaam (DSM), Tanzania. Using an adapted Structural HIV Determinants Framework, we identified structural, interpersonal, psychosocial, and behavioral risk factors for HIV acquisition. We compared the prevalence of HIV and HIV-related risk factors among a random sample of 66 FBWs from DSM to an age-standardized, representative sample of female DSM-residents from the 2016 Demographic and Health and 2011–2012 AIDS Indicator Surveys. Compared to other women in DSM, FBWs had elevated prevalence of all four groups of risk factors. Key risk factors included gender and economic inequalities (structural); sexual violence and challenges negotiating condom use (interpersonal); depression, post-traumatic stress disorder, and low social support (psychosocial); and history of unprotected sex, multiple sex partners, and high alcohol consumption (behavioral). HIV prevalence did not differ between FBWs (7.1%, 95% CI 3.7-13.3%) and survey respondents (7.7%, 95% CI: 5.3-11.1%), perhaps due to FBWs' higher – though sub-optimal – engagement with HIV prevention strategies. Elevated exposure to HIV-related risk factors but low HIV prevalence suggests economic, psychosocial, and biomedical interventions may prevent HIV among FBWs in DSM. [ABSTRACT FROM AUTHOR]

There is increasing interest in home based testing and treatment of HIV to expand access to treatment in sub-Saharan Africa. Such programs rely on self-reported HIV history and use of antiretroviral therapy (ART). However, the accuracy of self-reported ART use in community settings is not well described. In this study, we compared self-reported ART (SR-ART) use in a home based survey against biological exposure to ART (BE-ART), in a population study of older adults in South Africa. Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa (HAALSI) is a cohort of adults aged 40 +. The baseline home-based interview included self-reported HIV status and ART use. All participants also underwent biological testing for HIV antibodies, viral load and exposure to emtricitabine (FTC) or lamivudine (3TC), which are included in all first-line and second-line ART regimens in the public-sector South African HIV program. We calculated the performance characteristics for SR-ART compared to BE-ART and fit multivariable logistic regression models to identify correlates of invalid SR-ART responses. Of 4560 HAALSI participants with a valid HIV test result available, 1048 (23%) were HIV-positive and 734 [70% of people living with HIV (PLWH)] were biologically validated ART users (BE-ART). The sensitivity of SR-ART use was 64% (95% CI 61–68%) and the specificity was 94% (95% CI 91–96%); the positive predictive value (PPV) was 96% (95% CI 94–98%) and negative predictive value (NPV) was 52% (95% CI 48–56%). We found no sociodemographic predictors of accurate SR-ART use. Over one in three individuals with detectable ART in their blood denied current ART use during a home-based interview. These results demonstrate ongoing stigma related to HIV and its treatment, and have important implications for community health worker programs, clinical programs, and research studies planning community-based ART initiation in the region. [ABSTRACT FROM AUTHOR]

Background Investing in offspring's human capital has been suggested as an effective strategy for parents to improve their living conditions at older ages. A few studies have assessed the role of children's schooling in parental survival in high-income countries, but none have considered lower-resource settings with limited public wealth transfers and high adult mortality. Methods We followed 17,789 parents between January 2003 and August 2015 in a large population-based open cohort in rural KwaZulu-Natal, South Africa. We used Cox proportional hazards models to investigate the association between offspring's schooling and time to parental death. We assessed the association separately by parental sex and for four cause of death groups. Results A one year increase in offspring's schooling attainment was associated with a 5% decline in the hazard of maternal death (adjusted Hazard Ratio [aHR]: 0.95, 95%CI: 0.94–0.97) and a 6% decline in the hazard of paternal death (aHR: 0.94, 95%CI: 0.92–0.96), adjusting for a wide range of demographic and socio-economic variables of the parent and their children. Among mothers, the association was strongest for communicable, maternal, perinatal and nutritional conditions (aHR: 0.87, 95%CI: 0.82–0.92) and AIDS and tuberculosis (aHR: 0.92, 95%CI: 0.89–0.96), and weakest for injuries. Among fathers, the association was strongest for injuries (aHR: 0.87, 95%CI: 0.79–0.95) and AIDS and tuberculosis (aHR: 0.92, 95%CI: 0.89–0.96), and weakest for non-communicable diseases. Conclusion Higher levels of schooling in offspring are associated with increased parental survival in rural South Africa, particularly for mothers at risk of communicable disease mortality and fathers at risk of injury mortality. Offspring's human capital may be an important factor for health disparities, particularly in lower-resource settings. [ABSTRACT FROM AUTHOR]

Background. Antiretroviral therapy (ART) was highly efficacious in preventing human immunodeficiency virus (HIV) transmission in stable serodiscordant couples in the HPTN-052 study, a resource-intensive randomized controlled trial with near-perfect ART adherence and mutual HIV status disclosure among all participating couples. However, minimal evidence exists of the effectiveness of ART in preventing HIV acquisition in stable serodiscordant couples in "real-life" population-based settings in hyperendemic communities of sub-Saharan Africa, where health systems are typically resource-poor and overburdened, adherence to ART is often low, and partners commonly do not disclose their HIV status to each other. Methods. Data arose from a population-based open cohort in KwaZulu-Natal, South Africa. A total of 17 016 HIV-uninfected individuals present between January 2005 and December 2013 were included. Interval-censored time-updated proportional hazards regression was used to assess how the ART status affected HIV transmission risk in stable serodiscordant relationships. Results. We observed 1619 HIV seroconversions in 17 016 individuals, over 60 349 person-years follow-up time. During the follow-up period, 1846 individuals had an HIV-uninfected and 196 had an HIV-infected stable partner HIV incidence was 3.8/ 100 person-years (PY) among individuals with an HIV-infected partner (95% confidence interval [CI], 2.3-5.6), 1.4/100 PY (.4- 3.5) among those with HIV-infected partners receiving ART, and 5.6/100 PY (3.5-8.4) among those with HIV-infected partners not receiving ART. Use of ART was associated with a 77% decrease in HIV acquisition risk among serodiscordant couples (adjusted hazard ratio, 0.23; 95% CI, .07-.80). Conclusions. ART initiation was associated with a very large reduction in HIV acquisition in serodiscordant couples in rural KwaZulu-Natal. However, this "real-life" effect was substantially lower than the effect observed in the HPTN-052 trial. To eliminate HIV transmission in serodiscordant couples, additional prevention interventions are probably needed. [ABSTRACT FROM AUTHOR]

While sexual partner age disparity is frequently considered as a potential risk factor for HIV among young women in Africa, no research has addressed this question among older women. Our aim was thus to determine whether sex partner age disparity was associated with subsequent HIV acquisition in women over 30 years of age. To achieve this aim we conducted a quantitative analysis of a population-based, open cohort of women in rural KwaZulu-Natal, South Africa (n = 1,737) using Cox proportional hazards models. As partner age rose, HIV acquisition risk fell significantly: compared to a same-aged partner, a 5-year older partner was associated with a one-third reduction [hazard ratio (HR) 0.63, 95 % CI 0.52-0.76] and a 10-year older partner with a one-half reduction (HR 0.48, 95 % CI 0.35-0.67) in acquisition risk. This result was neither confounded nor effect-modified by women's age or socio-demographic factors. These findings suggest that existing HIV risk-reduction campaigns warning young women about partnering with older men may be inappropriate for older women. HIV prevention strategies interventions specifically tailored to older women are needed. [ABSTRACT FROM AUTHOR]

To characterize adherence to post-exposure prophylaxis after non-forcible sexual exposure to HIV, we conducted a review of the literature and meta-analysis. Articles were considered if they contained primary adherence data following non-forcible sexual exposure. Random-effects meta-analysis was used to create pooled point estimates for adherence. Of 1,257 abstracts identified through our search algorithm, 17 were eligible for inclusion in this review, representing 3,634 patients enrolled in 3 randomized controlled trials (RCTs), 9 prospective and 5 retrospective observational studies. Pooled adherence, primarily assessed by self-report, was 77 % [95 % confidence interval (CI) 68-87] in prospective observational studies, 81 % (95 % CI 65-96) in retrospective studies, 78 % (95 % CI 65-91) in RCTs, and 78 % (95 % CI 72-85) overall. Overall adherence was moderately high, with high variability between studies. Assessment of adherence could be enhanced by the use of objective measurements. [ABSTRACT FROM AUTHOR]