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HIV infection and in utero exposure, common in Sub-Saharan Africa, are associated with pediatric neurocognitive impairment. Cognitive screening can identify impairments, but it is rarely used in this setting. The Penn Computerized Neurocognitive Battery (PennCNB), an evidence-based cognitive screening tool, was adapted for use in Botswana. To facilitate future implementation, 20 semi-structured interviews were conducted to elicit key stakeholders' perspectives on factors likely to be related to successful uptake of the PennCNB in clinical settings. An integrated analytic approach combining constructs from the Consolidated Framework for Implementation Research and modified grounded theory was used. Results underscore the need for cognitive screening in Botswana and the acceptability of the PennCNB. Implementation barriers include limited time and resources, whereas facilitators include standard procedures for introducing new tools into medical settings and for training implementers. Recommended implementation strategies include integrating screening into the existing workflow, implementing the tool in the medical and educational sectors, and targeting selection of children for assessment. This research addresses the research-to-practice gap by engaging in pre-implementation inquiry and designing for implementation. Results will inform the development of strategies to maximize the likelihood of successful implementation of the PennCNB to identify neurocognitive impairment in children in this high-need setting.

Adolescents with suboptimal medication taking may deceive caregivers about non-adherence. We conducted a 5-year longitudinal study of adolescents monitored simultaneously with both easily manipulated (e.g., self-report) and hard to manipulate (e.g., microelectronic data) strategies. Adolescents with repeatedly high adherence on the former and low adherence on the latter were invited along with their parental figures ("parents") to participate. We conducted focus groups and semi-structured interviews, separately for adolescents and parents, to elucidate drivers of discordant measures. Forty-seven adolescents and 26 parents participated in focus groups and 4 adolescents were interviewed. Adolescents described hiding pills, discarding pills, and lying. Their motivations included fear of disappointing those who care about them, desire to avoid admonishment by parents and clinic staff, and desire to avoid remedial adherence counseling. Both adolescents and parents considered negative feedback for prior poor adherence to be key motivation to hide current poor adherence from clinic staff. Providing positive feedback for truth-telling, rather than for "evidence" of excellent adherence, might help adolescent patients and their parents to develop stronger treatment alliances with each other and with clinic staff. Such alliances would allow adherence interventions to be better targeted and more fruitful in increasing adherence.

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.

Human immunodeficiency virus (HIV) infection is prevalent among children and adolescents in Botswana, but standardized neurocognitive testing is limited. The Penn Computerized Neurocognitive Battery (PennCNB) attempts to streamline evaluation of neurocognitive functioning and has been culturally adapted for use among youth in this high-burden, low-resource setting. However, its reliability across measurements (i.e., test–retest reliability) is unknown. This study examined the test–retest reliability of the culturally adapted PennCNB in 65 school-age children (age 7–17) living with HIV in Botswana. Intraclass correlation coefficients (ICCs) for PennCNB summary scores (ICCs > 0.80) and domain scores (ICCs = 0.66–0.88) were higher than those for individual tests, which exhibited more variability (ICCs = 0.50–0.82), with the lowest reliability on memory tests. Practice effects were apparent on some measures, especially within memory and complex cognition domains. Taken together, the adapted PennCNB exhibited adequate test–retest reliability at the domain level but variable reliability for individual tests. Differences in reliability should be considered in implementation of these tests.

Children living with HIV (HIV+) experience increased risk of neurocognitive deficits, but standardized cognitive testing is limited in low-resource, high-prevalence settings. The Penn Computerized Neurocognitive Battery (PennCNB) was adapted for use in Botswana. This study evaluated the criterion validity of a locally adapted version of the PennCNB among a cohort of HIV+ individuals aged 10-17 years in Botswana. Participants completed the PennCNB and a comprehensive professional consensus assessment consisting of pencil-and-paper psychological assessments, clinical interview, and review of academic performance. Seventy-two participants were classified as cases (i.e., with cognitive impairment; N = 48) or controls (i.e., without cognitive impairment; N = 24). Sensitivity, specificity, positive predictive value, negative predictive value, and the area under receiver operating characteristic curves were calculated. Discrimination was acceptable, and prediction improved as the threshold for PennCNB impairment was less conservative. This research contributes to the validation of the PennCNB for use among children affected by HIV in Botswana.

Children born to mothers infected with the human immunodeficiency virus (HIV) during pregnancy experience increased risk of neurocognitive impairment. In Botswana, HIV infection is common among youth, but standardized cognitive screening is limited. The Penn Computerized Neurocognitive Battery (PennCNB), a tool that streamlines evaluation of neurocognitive functioning, was culturally adapted for use among youth in this high-burden, low-resource setting. The present study examined the structural validity of the culturally adapted PennCNB. A cohort of 7-17-year-old children living with HIV (HIV +) and HIV-exposed-uninfected (HEU) children were enrolled from the Botswana-Baylor Children's Clinical Centre of Excellence in Gaborone, Botswana. Confirmatory and exploratory factor analyses were performed on speed, accuracy, and efficiency measures for 13 PennCNB tests. Fit of the confirmatory factor analysis was acceptable, which supports the design of the battery measuring four neurocognitive domains: Executive functioning, episodic memory, complex cognition, and sensorimotor/processing speed. However, the model revealed high interfactor correlation. Exploratory factor analysis suggested that tests assessing executive functioning and sensorimotor/processing speed clustered together rather than forming differentiable factors. Overall, this research provides valuable insight into the structural validity of a neurocognitive battery adapted for use in a non-Western setting, suggesting that the PennCNB could serve as a useful tool for the assessment of neurocognitive function in Botswana and, potentially, other resource-limited settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Human immunodeficiency virus (HIV) infection and in utero exposure increase the risk of neurocognitive deficits, but comprehensive neurocognitive screening is unavailable in settings with high HIV prevalence (e.g., Sub-Saharan Africa). The Penn Computerized Neurocognitive Battery (PennCNB) was culturally adapted and translated for use among children and adolescents in Botswana. To prepare for the implementation process, this study assessed perceptions of acceptability, a leading indicator of implementation success, of the adapted PennCNB among a cohort of HIV+ and HIV-exposed-uninfected (HEU) young people (N = 155, aged 7–17 years) in Gaborone, Botswana. Immediately following completion of the PennCNB, participants completed a three-point Likert scale survey eliciting perspectives of acceptability of the overall PennCNB and the 13 individual subtests and provided open-ended responses to elaborate upon acceptability ratings. Descriptive statistics were calculated, and predictors (age, sex, and PennCNB performance) of unacceptable response were evaluated using logistic regressions. A content analysis was completed on the open-ended responses. Participants reported high acceptability of the overall PennCNB (98%). Of the subtests, the Penn Trailmaking Test, Part A (measuring sensorimotor/processing speed) received the highest acceptability rating (82%), while the Penn Face Memory test (measuring episodic memory) was the least acceptable (40% unacceptable). Age and performance on the PennCNB were associated with an unacceptable response for Fractal N-Back (OR 0.873) and the Penn Line Orientation Test (OR 0.620), respectively. Themes about the content of the cognitive assessment, features of the tests, and participant characteristics were articulated as reasons for reporting the PennCNB subtests as acceptable or unacceptable. Overall, this research offers promise for successful implementation of the PennCNB for use among pediatric populations in Botswana.

Despite access to nationally supplied antiretroviral treatment, viral load suppression rates remain suboptimal in the Dominican Republic. Counseling and support services are available but mainly targeted to those identified as having the most need. At Clínica de Familia La Romana (CFLR) in La Romana, all patients undergo a structured baseline interview including exploration of expected barriers to care. We conducted a retrospective cohort study of a random sample of patients at CFLR with treatment initiation between 1 January 2015 and 1 December 2017 to determine if self-identified barriers to HIV care predict viral load suppression. Viral load suppression occurred in 63% of the 203 patients evaluated. Lack of food ( n = 19) was significantly associated with lack of viral suppression (OR 3.0, 95% CI 1.14–7.87). Nondisclosure of HIV status ( n = 24) showed evidence for a protective effect (OR 0.33; 95% CI 0.11–1.0). Further steps should be taken to address food insecurity as well as to understand associated barriers to care among individuals with food insecurity.

Psychological reactance is an aversive response to perceived threats against personal agency. For adolescents receiving HIV treatment in Botswana, we utilized a two-question, medication-specific reactance tool to assess whether: (1) verbal reminders to take medicines made adolescents want to avoid taking them, and, (2) whether adolescents felt anger when reminded to take medicines. Reactant adolescents had 2.05-fold (95% CI 1.23, 3.41) greater odds of treatment failure than non-reactant adolescents (p = 0.03). Adjusted risk of treatment failure was 14% (95% CI 3%, 28%) greater for each point elevation in reactance score (p = 0.016). Autonomy over medication-taking did not modify the association between reactance and treatment failure. Psychological reactance may be a useful interventional target for improving adolescent adherence.

SETTING: Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana.OBJECTIVE: To evaluate the challenges encountered, healthcare worker (HCW) approaches, and supported interventions in TB and TB-HIV (human immunodeficiency virus) care for adolescents and young adults (AYA, aged 10–24 years).DESIGN: Semi-structured interviews with HCW in TB clinics, analyzed using thematic analysis.RESULTS: Sixteen HCWs were interviewed. AYA developmental needs included reliance on family support for care, increasing autonomy, attending school or work, building trust in HCWs, and intensive TB education and adherence support. Stigma strongly influenced care engagement, including clinic attendance and HIV testing. Health system barriers to optimal AYA TB care included limited staffing and resources to follow-up or support. HCWs utilized intensive education and counseling, and transitioned AYA to community-based directly observed therapy whenever feasible. HCWs supported implementation of youth-friendly services, such as AYA-friendly spaces or clinic days, training in AYA care, use of mobile applications, and peer support interventions, in addition to health system strengthening.CONCLUSION: HCWs utilize dedicated approaches for AYA with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment. Further work is needed to study interventions to improve AYA TB care and outcomes.

Introduction: Youth living with HIV (YLWH) experience higher rates of mental illness than their peers. Holistic care for YLWH may involve adopting mental health screening programs into comprehensive HIV care to help identify and address mental health concerns in young people. We explored various contexts, procedures, and safety measures throughout the integration and maintenance of a mental health screening program for adolescents attending an HIV referral clinic in Gaborone, Botswana. Methods: Implementation goals included a safety goal of 100% appropriate referral rate for emergency cases, and a screening goal of 70% of the approximately 1100 adolescent and young adults who were clients of the clinic at least once in the one year review period. Frequent meetings with the behavioral health team and relevant clinic staff were conducted to determine when, where and how to screen the clients. Referral procedures and an emergency protocol for certain “red flag” behaviors was developed to facilitate a warm handing off to trained mental health professionals along with a backup for non-mental health clinicians to assist in the absence of the PSS team. Every other week severe score case reports were produced by the screening team to prevent loss to follow up of suicidal ideation, hallucination or very high scores. Mild to moderate cases were referred to clinicians trained in brief intervention therapy. Results: Of the 846 clients screened, 191 (19.2%) had severe scores. Eight (4.1%) of these 191 severe case scores were either not immediately reported, or were inappropriately referred. Two of those eight had suicidal ideation and were not immediately referred but were appropriately followed up after being identified during bimonthly implementation team meetings. Identifying a specific trained person tasked with facilitating the screening was found to be most helpful. As was training the clinicians in methods to respond to mild to moderate results, particularly during unavailability of PSS team members. A clear and detailed protocol for severe cases was also noted as a key element in keeping the screening program safe. Conclusions: Establishing a universal screening program in an LMIC is possible with the consideration of various contextual factors.

This retrospective study investigated outcomes among lost to follow-up (LTFU) adolescents and young adults (AYAs: 10-24 years of age) with tuberculosis (TB) registered from 2008 to 2014 in Gaborone, using surveillance data. Of 68 LTFU AYAs, 16 repeated treatment; 8 completed and 6 were again LTFU. Of 4 confirmed deaths, 3 had TB/HIV coinfection. Approaches to improve AYA retention in TB care are needed.

Background. The World Health Organization recommends biannual deworming with single-dose albendazole for all children over 1 year in regions where soil-transmitted helminths (STH) are endemic. There are limited data from the Dominican Republic (DR) on the effectiveness of deworming programs. Methods. Between January and June 2019, we enrolled 63 preschool-aged children at a community clinic in the DR. Participants received albendazole at enrollment. Stool samples were collected and examined for parasites at enrollment, 2 to 4 and 12 to 16 weeks post-albendazole. Caregivers were surveyed on home hygiene practices and children’s symptoms. Findings. At enrollment, 1 or more parasites were noted in 89% of samples. Ascaris lumbricoides (68%) was the most common species, followed by Entamoeba histolytica (35%) and Giardia intestinalis (8%). Two-to-four weeks post-albendazole, fewer than half of those with A. lumbricoides infections at baseline had cleared the infection. STH symptoms significantly improved between enrollment and 2 to 4 weeks. By 12 to 16 weeks after treatment, A. lumbricoides infections were as high as baseline. Interpretation. Although limited by size and available technology, our study contributes data on STH in the DR. Single-dose deworming with albendazole did not reduce Ascaris lumbricoides infections in our sample. As STH are the most common neglected tropical diseases and negatively impact children’s health globally, further studies on both effective deworming programs and interventions to prevent STH are needed.

A safe and healthy natural and built environment is fundamental to children’s health and represents a significant determinant of community well-being. We aimed to identify and prioritize environmental health concerns within resource-poor neighborhoods in the Dominican Republic using free-listing and semi-structured focus groups composed of parents and caregivers in the perirural community of Consuelo, Dominican Republic. Transcripts were coded and relevant themes identified using qualitative content analysis. Demographic data and information regarding trash disposal practices were also collected. Participants described common health concerns, including respiratory infections, asthma, vector-borne illnesses, and diarrheal diseases and linked them to environmental hazards in their communities, such as air quality and sanitation. Interventional priorities that emerged included reduction of trash accumulation and trash burning as well as improvement of sanitation facilities.

Many children and adolescents around the world suffer from neurocognitive deficits due to chronic disorders, such as Human Immunodeficiency Virus (HIV) and malaria. Resource-limited settings exacerbate the risk of negative cognitive outcomes due to high prevalence of associated disorders, poverty, and limited access to interventions. Current literature does not provide consensus regarding the efficacy of interventions to support children with cognitive impairments in low-resource settings. This research aimed to identify and evaluate interventions for youth with neurocognitive deficits in resource-limited settings. A systematic review of peer-reviewed literature was conducted within five databases (PubMed, Web of Science, CINAHL, PsycInfo, and WHO Index Medicus). Cognitive impairment was broadly defined to be inclusive of aspects of intellectual and cognitive functioning (e.g., working memory, attention, executive function). The income status of the country or countries in which each study was located was determined according to World Bank Income Status. Studies conducted in countries classified as low- or middle-income were included. Since low-resource areas exist within high-income countries, the resource availability within study settings in high-income countries was systematically evaluated for inclusion. The search yielded 19 articles that met all inclusion criteria. Interventions included strategies involving caregiver training, computerized and non-computerized cognitive training, physical activity, and nutritional supplementation. Interventions were administered in medical facilities, educational facilities, or the home. The majority of the interventions targeted the domains of memory and attention. Overall, the efficacy of interventions was inconsistent. Further, results indicated that the relationship between cognitive improvement and intervention types was not consistent across cognitive domains. However, when evaluating studies on an individual basis, some strategies demonstrated clinically- and statistically-significant improvement in cognitive function among specific groups of children. The low article yield highlights that few researchers have evaluated pediatric cognitive support interventions in low-resource contexts. This review suggests support strategies that should be considered for future studies as neurocognitive screening capacity improves in resource-limited settings.

IntroductionNeurodevelopmental delays and cognitive impairments are common in youth living with HIV. Unfortunately, in resource-limited settings, where HIV infection impacts millions of children, cognitive and neurodevelopmental disorders commonly go undetected because of a lack of appropriate assessment instruments and local expertise. Here, we present a protocol to culturally adapt and validate the Penn Computerized Neurocognitive Battery (PennCNB) and examine its validity for detecting both advanced and subtle neurodevelopmental problems among school-aged children affected by HIV in resource-limited settings.Methods and analysisThis is a prospective, observational cohort study. The venue for this study is Gaborone, Botswana, a resource-limited setting with high rates of perinatal exposure to HIV and limited neurocognitive assessment tools and expertise. We aim to validate the PennCNB in this setting by culturally adapting and then administering the adapted version of the battery to 200 HIV-infected, 200 HIV-exposed uninfected and 240 HIV-unexposed uninfected children. A series of analyses will be conducted to examine the reliability and construct validity of the PennCNB in these populations.Ethics and disseminationThis project received ethical approval from local and university Institutional Review Boards and involved extensive input from local stakeholders. If successful, the proposed tools will provide practical screening and streamlined, comprehensive assessments that could be implemented in resource-limited settings to identify children with cognitive deficits within programmes focused on the care and treatment of children affected by HIV. The utility of such assessments could also extend beyond children affected by HIV, increasing general access to paediatric cognitive assessments in resource-limited settings.

BACKGROUND Despite growing interest in the use of technology to improve health outcomes in low- and middle-income countries (LMICs), local attitudes toward mobile health (mHealth) use in these settings are minimally understood. This is especially true in the Dominican Republic, where mHealth interventions are starting to emerge. This information is critical for developing effective mHealth interventions to address public health issues, such as low exclusive breastfeeding (EBF) rates, which can lead to poor outcomes. With an EBF rate of 5% in the first 6 months of life, the Dominican Republic has one of the lowest EBF rates worldwide. OBJECTIVE This study aims to describe the current use of information and communication technology (ICT) and to analyze the attitudes and perceptions related to using mHealth interventions among caregivers of children aged ≤5 years and health promoters in the Dominican Republic. Findings can inform mHealth strategies aimed at improving EBF in this, and other, LMICs. METHODS Participants were recruited from 3 outpatient sites: the Niños Primeros en Salud program at Centro de Salud Divina Providencia in Consuelo (rural setting) and Clínica de Familia La Romana and its program Módulo de Adolescentes Materno Infantil in La Romana (urban setting). Focus groups were conducted with caregivers and community health promoters to identify the use, attitudes, perceptions, and acceptability of mHealth as well as barriers to EBF. Discussions were conducted in Spanish, guided by semistructured interview guides. All sessions were audio-recorded and later transcribed. Thematic content analysis was conducted in Spanish by two bilingual researchers and was structured around a hybrid behavioral theory framework to identify salient themes. RESULTS All participants (N=35) reported having a mobile phone, and 29 (83%) participants had a smartphone. Sources for obtaining health information included the internet, physicians and clinic, family and friends, health promoters, and television. Barriers to mHealth use included the cost of internet service, privacy concerns, and perceived credibility of information sources. Participants indicated the desire for, and willingness to use, an mHealth intervention to support breastfeeding. The desired features of a possible mHealth intervention included offering diverse methods of information delivery such as images and video content, text messages, and person-to-person interaction as well as notifications for appointments, vaccines, and feeding schedules. Other important considerations were internet-free access and content that included maternal and child health self-management topics beyond breastfeeding. CONCLUSIONS There is a high level of acceptance of ICT tools for breastfeeding promotion among caregivers in urban and rural areas of the Dominican Republic. As mHealth tools can contribute to increased breastfeeding self-efficacy, identifying desirable features of such a tool is necessary to create an effective intervention. Participants wanted to receive trusted and reliable information through various formats and were interested in information beyond breastfeeding.

This study aimed to determine if disclosure of HIV status to adolescents impacted their medication adherence and how medication autonomy might explain observed effects.Three hundred adolescents on HIV treatment using electronic medication monitors were followed for 24 months while undergoing routine care. One hundred six of the adolescents were HIV disclosure-naïve and HIV status disclosure in this group was assessed quarterly. Analyses included data from the 75 adolescents who experienced disclosure during the study providing adherence and autonomy data both predisclosure and postdisclosure. Segmented generalized estimating equations were used to examine the trend of adherence and autonomy predisclosure and postdisclosure. Covariates assessed include age at disclosure, sex, and orphan status.Median age at study entry was 12.2 years (interquartile range 11.6-12.9). Incident disclosure occurred in 75 (71%) of the adolescents at a median age of 13.1 years (interquartile range 12.5-13.9). Adherence decreased by 11% (95% confidence interval [CI] 7-15, p.001) during the predisclosure period and by 22% (95% CI 9-36, p = .001) during the postdisclosure period. Adolescents' autonomy over their medication-taking increased over time, but disclosure did not impact the rate of increase in measured medication-taking autonomy. On a scale of 1-4 assessing autonomy (1 = receiving directly observed therapy and 4 = taking medicines mostly without supervision), autonomy increased by an average of .03 units/month (95% CI .02-.03, p.001) predisclosure and by .05 units/month (95% CI -.01 to .11, p = .42) postdisclosure.The findings suggest that, among perinatally HIV infected adolescents, HIV status disclosure may adversely impact treatment adherence. Postdisclosure support to HIV infected adolescents should be intensified.

Background: Increased rates of alcohol and drugs abuse has been noted among secondary school students in Botswana. Objectives : We conducted nine student focus groups to elicit motivations for substance use as well as risk and mitigating factors. Methods: Participants were purposely sampled from among 2,227 secondary school students surveyed regarding drug/alcohol use in secondary schools. Students were selected for focus group participation based on their scores on the alcohol use and dependency inventory tool (AUDIT) and self-reported risk factors for alcohol/drug use. Results: Students reported that alcohol/drugs are readily available at school and at home. A prominent theme among substance users was inadequate support from parents, who they describe as uncomfortable and unwilling to talk about common issues faced during adolescence, including alcohol/drug use. Conclusions: We identified opportunities to improve the current situation such as renewing efforts to restrict alcohol availability and focusing on parent-child communication interventions.

* Abbreviations: GCH — : global child health HIC — : high-income country LMIC — : low- and middle-income countries Opportunities in global child health (GCH), the study and practice of improving child health globally, are expanding and increasingly formalized. In education, more postgraduate pediatric training programs offer specialized GCH training, preparing graduates to provide health care to children worldwide.1 Training in clinical areas such as neonatal resuscitation for health care workers in low- and middle-income countries (LMIC) are increasing,2 as are short courses for pediatricians from high-income countries (HICs) planning to practice in LMIC.3 In clinical practice, there are growing numbers of LMIC-HIC clinical partnerships, which provide clinical care and support mutual professional development.4 There are also expanding opportunities for HIC clinicians to participate in short-term medical trips.5 In research, there are increasing partnerships and networks supporting collaborative transnational GCH research.4 As GCH programs and partnerships expand and formalize, robust evaluation is needed to inform best practices and program improvement, provide accountability to communities served through GCH initiatives, and influence decision-making related to GCH priorities and funding. Our aim in this article is to (1) highlight current evaluation strengths; (2) identify evaluation needs and key evaluation questions (Table 1); and (3) suggest possible approaches to addressing evaluation needs in GCH education, clinical practice, research and partnerships. View this table: TABLE 1 Evaluation Needs, Key Evaluation Questions, and Existing Resources To Guide Evaluation Development for GCH Education and Clinical and Research Programs ### Current Evaluation Strengths Evaluations of the impact of GCH residency training … Address correspondence to Sophia P. Gladding, PhD, Departments of Medicine and Pediatrics, University of Minnesota, 141 VCRC, 410 E River Parkway, Minneapolis, MN 55455. E-mail: gladd001{at}umn.edu

BackgroundIron deficiency and iron deficiency anemia affect billions of people worldwide. Infants and young children are the most vulnerable. The Niños Primeros en Salud pediatric clinic aims to follow the American Academy of Pediatrics (AAP) recommendation to screen all children at 12 months of age, a vital period for development and the time of greatest risk.ObjectivesTo evaluate the clinic's performance screening for, diagnosing, and treating iron deficiency anemia; and to describe the prevalence and severity of anemia in infants and children attending a perirural clinic in the Dominican Republic.MethodsA total of 293 charts were reviewed for hemoglobin tests performed between 9 and 15 months of age. If a hemoglobin screening was performed, then sociodemographic characteristics, medical history, and laboratory data were collected. If blood tests revealed anemia, then the presence or absence of documented anemia diagnosis as well as the presence or absence of documented provision of iron therapy were recorded.FindingsLess than one-third (87, 29.7%) of patients had a documented hemoglobin test performed in this age range. Of these, 89.6% indicated anemia and nearly half (48.6%) revealed moderate anemia. One-third (34%) of hemoglobin results revealing anemia were not accompanied by a documented diagnosis. The vast majority (86.5%) of results indicated microcytosis, yet just more than half (50.8%) of anemic patients received iron therapy.ConclusionsMany children at the clinic were not screened for iron deficiency anemia during the period of highest risk. In the participants screened, iron deficiency anemia was underdiagnosed and often untreated. Anemia is a significant burden in this community—one demanding reliable screening and universal supplementation.

Youth living with HIV (YLWH) are less likely than older adults to achieve and sustain viral suppression. While treatment guidelines recommend decreased viral load (VL) monitoring in individuals with well-controlled HIV, the appropriateness of this strategy for adolescents is unknown. We conducted a retrospective cohort study to describe longitudinal viral suppression and identify incidence of, and risk factors for, virologic failure among YLWH at a US adolescent HIV clinic from 2002 to 2015. We utilized Cox proportional hazards modeling to compare hazard ratios (HRs) for virologic failure stratified by baseline characteristics. Study participants (n = 365) were predominately African American (87%) and cisgender men and transgender women who have sex with men (80%) and the majority (79%) entered care from 2002 to 2012. Of antiretroviral therapy (ART)-treated participants (n = 201), 88% achieved viral suppression, with 29% subsequently developing virologic failure at a median 12.0 months [interquartile range (IQR) 6.9–22.4] after suppression. The cohort incidence rate of virologic failure was 200 (confidence interval [95% CI]: 151–264) per 1000 person years (PY), with a rate after ≥2 years sustained suppression of 113 (95% CI: 57–227) per 1000 PY. After adjusting for time to ART initiation, initial regimen class, and year of cohort entry, cisgender women had increased hazards of virologic failure (HR 3.2 95% CI: 1.3–7.9, p = 0.01). In conclusion, youth remained at high risk of virologic failure throughout their treatment course, with higher hazards of virologic failure among cisgender women compared with other youth. Maintaining frequent VL monitoring in YLWH may be warranted, even after prolonged viral suppression.

Summary Background: Adherence to antiretroviral medication leads to HIV suppression and decreased morbidity and mortality. In resource- limited settings, the dependence on paper medical charts and unstable electronic health records creates a challenge to monitoring medication adherence. A pharmacy-based strategy that utilizes existing cellular phone infrastructure may lead to a more stable system to monitor adherence. Objectives: To develop and evaluate the usability of a smartphone-based software application (app) for tracking antiretroviral medication refill data in a resource-limited setting. Methods: A pharmacy-based smartphone app for tracking HIV medication adherence was developed through a multi-step rapid prototyping process. The usability of the app was assessed during the daily activities of pharmacy dispensers at HIV clinics in and around Gaborone, Botswana using a validated computer usability survey. Results: The study demonstrated the effective development of and favorable end-user responses to a pharmacy-based HIV medication adherence app. End users had suggestions for minor changes to improve the app’s functionality. Conclusions: In resource-limited settings where electronic health record support is limited, such a system was feasible and appealing. In the future, this system may allow for improved HIV medication adherence tracking and be applied to medications beyond antiretrovirals.

Background. Parents’ beliefs about and engagement in reading aloud to young children and other positive parenting practices have been associated with early childhood development (ECD) and later achievement. Aim. This exploratory study sought to assess parental attitudes and self-reported practices regarding ECD in a rural, low-income community in the Dominican Republic with many risk factors for ECD delays, including high rates of poverty, iron-deficiency anemia, and malnutrition. Methods. We used the Parent Reading Belief Inventory and open-ended questions to evaluate parental beliefs regarding reading, self-efficacy in promoting child development, current positive parenting practices, and parents’ concerns about the development of their 0- to 5-year-old children in Consuelo, Dominican Republic. We explored associations between demographic factors and strength of positive parenting beliefs and practices. Results. Overall participants had positive attitudes toward reading and their own importance in promoting their children’s development. Participants with at least some high school education had significantly higher Parent Reading Belief Inventory scores ( P = .03) than those with less formal education. Participants reported frequently singing, talking, and playing with their children, but less frequently reading with them. Few participants had access to reading materials for young children. Parental interest in programs to support ECD was high. Parents raised concerns about their children’s behavior, personal and educational attainment, and early literacy. Conclusion. Children whose parents have less formal education may benefit most from interventions to promote beliefs and practices likely to improve ECD. In this community, there is high interest in learning more about ECD.

Aims When implementing interventions for adolescents, specific adolescent friendly adaptation from adult interventions is vital. The Friendship Bench is a lay counselor community therapy model that has been shown to have high efficacy in adult populations with adult lay counselors in Zimbabwe and other communities. Our objective was to understand the overall mental health needs and necessary adaptations for lay counselor based work for adolescents in Botswana. Methods We used theory of change activities during stakeholder meetings to discuss necessary elements of the Friendship Bench for use with adolescents. We held four groups sessions with stakeholders who were youth, parents, members of youth serving non-governmental organizations, members of government, and HIV clinic clinicians, and social workers. The meetings addressed root causes of poor mental health in youth in Botswana, overall structure of mental health services, ultimate outcomes we would hope to achieve with a youth mental health intervention, and action steps and assumptions necessary to implement a lay counselor intervention. Results Root causes of mental health in youth included lack of knowledge about these issues, family problems like abuse/neglect, and poor communication, low self-esteem, rapid growth of technology, and biology/genetics. Structurally barriers included: the stigma against mental illness, lack of psychosocial support, poor follow-up for mental health services, cultural beliefs about mental illness, and fragmented mental health services available. The stakeholders seek a program that empowers adolescents and youth counselors to address mental health concerns in order to create a healthier community. The group identified several major elements of an effective lay counselor intervention including age appropriate (youth) lay counselors, broad education and screening of youth at risk, creative and fun ways of engaging and maintaining them into the intervention, flexibility with schedules, and strong lay counselors with adequate training and personalities that support thoughtful interpersonal engagement. Lay counselor pre-training qualifications were defined and included a preference for youth with similar diagnoses, a minimum of secondary school training, age of 18 to 35 and agreement to attend mandatory counseling. Conclusion Stakeholders from multiple segments of the community can illustrate key elements of interventions being expanded to new populations and environments.

Background Iron deficiency anemia affects millions of children worldwide. Iron intake assessments can inform targeted interventions. Methods This cross-sectional study describes diet and hemoglobin levels of children 1–5 y of age in a resource-limited setting in the Dominican Republic. The study team performed meal observations and measurements, dietary questionnaires, and point-of-care hemoglobin testing. Results Iron intake and bioavailability were low, with liberal estimates indicating that not more than 40% of subjects consumed the recommended daily allowance for iron. Forty of 80 children had anemia, with 23% demonstrating moderate or severe anemia. Conclusions Poor observed iron intake likely contributes to the high prevalence of anemia in this population.

BackgroundSub-Saharan Africa has high under-5 mortality and low childhood immunisation rates. Vaccine-preventable diseases cause one-third of under-5 deaths. Text messaging reminders improve immunisation completion in urban but not rural settings in sub-Saharan Africa. Low adult literacy may account for this difference. The feasibility and impact of combined automated voice and text reminders on immunisation completion in rural sub-Saharan Africa is unknown.MethodsWe randomised parturient women at the Mother and Child Hospitals Ondo State, Nigeria, owning a mobile phone and planning for child immunisation at these study sites to receive automated call and text immunisation reminders or standard care. We assessed the completion of the third pentavalent vaccine (Penta-3) at 18 weeks of age, immunisation completion at 12 months and within 1 week of recommended dates. We assessed selected demographic characteristics associated with completing immunisations at 12 months using a generalised binomial linear model with ‘log’ link function. Feasibility was assessed as proportion of reminders received.ResultsEach group had 300 mother−baby dyads with similar demographic characteristics. At 18 weeks, 257 (86%) and 244 (81%) (risk ratio (RR) 1.05, 95% CI 0.98 to 1.13; p=0.15) in the intervention and control groups received Penta-3 vaccine. At 12 months, 220 (74%) and 196 (66%) (RR 1.12, 95% CI 1.01 to 1.25; p=0.04) in the intervention and control groups received the measles vaccine. Infants in the intervention group were more likely to receive Penta-3 (84% vs 78%, RR 1.09, 95% CI 1.01 to 1.17; p=0.04), measles (73% vs 65%, RR 1.13, 95% CI 1.02 to 1.26; p=0.02) and all scheduled immunisations collectively (57% vs 47%, RR 1.13, 95% CI 1.02 to 1.26; p=0.01) within 1 week of the recommended date. No demographic character predicted immunisation completion. In the intervention group, 92% and 86% reported receiving a verification reminder and at least one reminder during the study period, respectively.ConclusionPaired automated call and text reminders significantly improved immunisation completion and timeliness.Trial registration numberNCT02819895.

Pill counts with calculated adherence percentages are used in many settings to monitor adherence, but can be undermined by patients discarding pills to hide nonadherence. Pill counts suggesting that >100% of prescribed doses were taken can signal "pill dumping." We defined "overadherence" among a cohort of 300 HIV-infected adolescents as having greater than one-third of pill counts with >100% adherence during a year of follow-up. Apparent overadherence was more common in those with virologic failure than in those with suppressed viral loads (33% vs 13%, χ(2) P = 0.001). Pill count adherence repeatedly >100% may identify HIV-infected adolescents at increased risk of treatment failure.

Background Despite growing interest in the use of technology to improve health outcomes in low- and middle-income countries (LMICs), local attitudes toward mobile health (mHealth) use in these settings are minimally understood. This is especially true in the Dominican Republic, where mHealth interventions are starting to emerge. This information is critical for developing effective mHealth interventions to address public health issues, such as low exclusive breastfeeding (EBF) rates, which can lead to poor outcomes. With an EBF rate of 5% in the first 6 months of life, the Dominican Republic has one of the lowest EBF rates worldwide. Objective This study aims to describe the current use of information and communication technology (ICT) and to analyze the attitudes and perceptions related to using mHealth interventions among caregivers of children aged ≤5 years and health promoters in the Dominican Republic. Findings can inform mHealth strategies aimed at improving EBF in this, and other, LMICs. Methods Participants were recruited from 3 outpatient sites: the Niños Primeros en Salud program at Centro de Salud Divina Providencia in Consuelo (rural setting) and Clínica de Familia La Romana and its program Módulo de Adolescentes Materno Infantil in La Romana (urban setting). Focus groups were conducted with caregivers and community health promoters to identify the use, attitudes, perceptions, and acceptability of mHealth as well as barriers to EBF. Discussions were conducted in Spanish, guided by semistructured interview guides. All sessions were audio-recorded and later transcribed. Thematic content analysis was conducted in Spanish by two bilingual researchers and was structured around a hybrid behavioral theory framework to identify salient themes. Results All participants (N=35) reported having a mobile phone, and 29 (83%) participants had a smartphone. Sources for obtaining health information included the internet, physicians and clinic, family and friends, health promoters, and television. Barriers to mHealth use included the cost of internet service, privacy concerns, and perceived credibility of information sources. Participants indicated the desire for, and willingness to use, an mHealth intervention to support breastfeeding. The desired features of a possible mHealth intervention included offering diverse methods of information delivery such as images and video content, text messages, and person-to-person interaction as well as notifications for appointments, vaccines, and feeding schedules. Other important considerations were internet-free access and content that included maternal and child health self-management topics beyond breastfeeding. Conclusions There is a high level of acceptance of ICT tools for breastfeeding promotion among caregivers in urban and rural areas of the Dominican Republic. As mHealth tools can contribute to increased breastfeeding self-efficacy, identifying desirable features of such a tool is necessary to create an effective intervention. Participants wanted to receive trusted and reliable information through various formats and were interested in information beyond breastfeeding.

In adults living with HIV, pharmacy refill data are good predictors of virologic failure (VF). The utility of pharmacy refill data for predicting VF in adolescents has not been reported. We evaluated data from 291 adolescents on antiretroviral therapy. The main outcome measure was VF, defined as two consecutive HIV viral load measurements ≥ 400 copies/mL during 24-months of follow-up. Pharmacy refill non-adherence was defined as two consecutive refill adherence measurements

Background Alcohol and illicit drug use has been recognized as a growing problem among adolescents in Botswana. Little is known about factors affecting alcohol and drug use among Botswana’s secondary school students. To aid the design and implementation of effective public health interventions, we sought to determine the prevalence of alcohol and drug use in secondary school students in urban and peri-urban areas of Botswana, and to evaluate risk and protective factors for substance use. Methods We performed a 72-item cross-sectional survey of students in 17 public secondary schools in Gaborone, Lobatse, Molepolole and Mochudi, Botswana. The World Health Organization’s (WHO) Alcohol Use Disorder Identification Test (AUDIT) was used to define hazardous drinking behavior. Using Jessor’s Problem Behavior Theory (PBT) as our conceptual framework, we culturally-adapted items from previously validated tools to measure risk and protective factors for alcohol and drug use. Between-group differences of risk and protective factors were compared using univariate binomial and multinomial-ordinal logit analysis. Relative risks of alcohol and drug use by demographic, high risks and low protections were calculated. Multivariate ordinal-multinomial cumulative logit analysis, multivariate nominal-multinomial logit analysis, and binominal logit analysis were used to build models illustrating the relationship between risk and protective factors and student alcohol and illicit drug use. Clustered data was adjusted for in all analyses using Generalized Estimating Equations (GEE) methods. Results Of the 1936 students surveyed, 816 (42.1%) reported alcohol use, and 434 (22.4%) met criteria for hazardous alcohol use. Illicit drug use was reported by 324 students (16.7%), with motokwane (marijuana) being the most commonly used drug. Risk factors more strongly associated with alcohol and drug use were reported alcohol availability, individual and social vulnerability factors, and poor peer modeling. Individual and social controls protections appear to mitigate risk of student alcohol and drug use. Conclusions Alcohol and illicit drug use is prevalent among secondary school students in Botswana. Our data suggest that interventions that reduce the availability of alcohol and drugs and that build greater support networks for adolescents may be most helpful in decreasing alcohol and drug use among secondary school students in Botswana. Electronic supplementary material The online version of this article (10.1186/s12889-018-6263-2) contains supplementary material, which is available to authorized users.

Purpose The purpose of this study was to determine whether diary-driven adjustment of Medication Event Monitoring System (MEMS) data based on Supporting Information strengthens the relationship between measured antiretroviral medication adherence and plasma HIV viral load (VL). Methods HIV+ adolescents on antiretroviral treatment were monitored with MEMS for 30 days preceding a VL measurement. The primary outcome was VL ≥ 400 copies/mL. Handwritten diaries were used to comprehensively record deviations from recommended use (bottle opened but dose not taken or bottle not opened and dose taken). Data were adjusted (“cleaned”) based on diary events. Data were “capped” at the prescribed number of doses/day. Receiver operator characteristic analysis compared the relationships between (i) raw MEMS data, (ii) diary-cleaned, (iii) capped, or (iv) cleaned and capped MEMS data and VL. Results Over 30 days preceding VL measurements, 273 adolescents had 465 diary events. Capping resulted in fewer patients classified as 95% adherent (65.2%) compared with raw data (71.4%), p

BACKGROUND Seizures are common among patients with HIV/AIDS in the developing world and are associated with significant morbidity and mortality. Early treatment with combination antiretroviral therapy (cART) may reduce this risk by decreasing rates of central nervous system infections and HIV encephalopathy. METHODS A case-control study of new-onset epilepsy among children aged 0-18 years with perinatally acquired HIV/AIDS followed in Gaborone, Botswana, during the period 2003-2009 was conducted. Children with epilepsy were identified and compared with age- and sex-matched controls without epilepsy with respect to timing of cART initiation. Early treatment was defined as treatment with cART before the age of 12 months, at a CD4% of greater than 25 in children aged 1-5 years, or at an absolute CD4 count of >350 cell per cubic millimeter in children aged 5 years and older. RESULTS We identified 29 cases of new-onset epilepsy and 58 age- and sex-matched controls. The most common identified etiologies for epilepsy were central nervous system infections and direct HIV neurotoxicity. Only 8 (28%) of the children who developed epilepsy received early treatment compared with 31 (53%) controls (odds ratio: 0.36, 95% confidence interval: 0.14 to 0.92, P = 0.03). This effect was primarily driven by differences in rates of epilepsy among children who initiated treatment with cART between the ages of 1 and 5 years (11% vs. 53%, odds ratio: 0.11, 95% confidence interval: 0.01 to 1.1, P = 0.06). CONCLUSIONS Earlier initiation of cART may be protective against epilepsy in children with HIV.

Objectives Although cognitive outcomes among perinatally infected youth have improved with highly active antiretroviral therapy (HAART), the impact of the age of initiation of treatment and the central nervous system (CNS) penetration effectiveness (CPE) of the regimen on cognitive outcomes is unknown. We aimed to describe the association between initiation age/regimen CPE score and cognitive outcomes in perinatally HIV-infected youth. Methods Linear regression was used to retrospectively assess the association between full-scale IQ score (FSIQ) and age of initiation of HAART, regimen CPE, and the presence/absence of an AIDS diagnosis before initiation of HAART in an urban US cohort. Results A total of 88 of 181 subjects (48.6%) had an AIDS diagnosis. In 69, AIDS preceded the start of HAART. Mean FSIQ (mean age 155.4 months) was 86.3 [standard deviation (SD) 15.6]. Neither age of initiation of HAART (P = 0.45) nor regimen CPE score (P = 0.33) was associated with FSIQ. Mean FSIQ for patients with an AIDS diagnosis before HAART initiation [82 (SD 17.0)] was significantly lower than for patients initiating HAART before an AIDS diagnosis [90 (SD 13)] (P = 0.001). Of the 129 subjects without AIDS by age 5 years, 41 (31.8%) initiated HAART before age 5 years; four of 41 later developed AIDS, compared with 32 of 88 of those who did not initiate HAART before age 5 years. The relative risk of AIDS if HAART was initiated before age 5 years was 0.19 (95% confidence interval 0.05-0.60). Conclusions Earlier age at HAART initiation and higher CPE score of a regimen did not improve cognitive outcomes. However, initiating HAART prior to AIDS protected against AIDS and was associated with a significantly higher FSIQ.

Levels of adherence to HIV treatment are lower among adolescents compared with older and younger individuals receiving similar therapies. We purposely sampled the most and least adherent adolescents from a 300-adolescent longitudinal HIV treatment adherence study in Gaborone, Botswana. Multiple objective and subjective measures of adherence were available and study participants were selected based on sustained patterns of either excellent or poor adherence over a one-year period. Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with the adolescents and a subset of their caregivers with the goal of revealing barriers and facilitators of adherence. Focus groups were segregated by adherence classification of the participants. Following coding of transcripts, matrices were developed based on participants' adherence classifications in order to clarify differences in themes generated by individuals with different adherence characteristics. 47 adolescents and 25 adults were included. The non-adherent adolescents were older than the adherent adolescents (median age 18 years (IQR 16-19) vs. 14 years (IQR 12-15 years)), with median time on treatment near 10 years in both groups. Interference with daily activities, concerns about stigma and discrimination, side effects, denial of HIV status, and food insecurity arose as challenges to adherence among both those who were consistently adherent and those who were poorly-adherent to their medications. Low outcome expectancy, treatment fatigue, mental health and substance use problems, and mismatches between desired and received social support were discussed only among poorly adherent adolescents and their caregivers. Challenges raised only among adolescents and caregivers in the non-adherent groups are hypothesis-generating, identifying areas that may have a greater contribution to poor outcomes than challenges faced by both adherent and non-adherent adolescents. The contribution of these factors to poor outcomes should be explored in future studies.

High mortality among adolescents with HIV reflects delays and failures in the care cascade. We sought to elucidate critical missed opportunities and barriers to care among adolescents hospitalized with HIV at Botswana's tertiary referral hospital. We enrolled all HIV-infected adolescents (aged 10-19 years) hospitalized with any diagnosis other than pregnancy from July 2015 to January 2016. Medical records were reviewed for clinical variables and past engagement in care. Semi-structured interviews of the adolescents (when feasible) and their caregivers explored delays and barriers to care. Twenty-one eligible adolescents were identified and 15 were enrolled. All but one were WHO Clinical Stage 3 or 4. Barriers to diagnosis included lack of awareness about perinatal HIV infection, illness or death of the mother, and fear of discrimination. Barriers to adherence to antiretroviral therapy included nondisclosure, isolation, and mental health concerns. The number of hospitalized HIV-infected adolescents was lower than expected. However, among those hospitalized, the lack of timely diagnosis and subsequent gaps in the care cascade elucidated opportunities to improve outcomes and quality of life for this vulnerable group.

Purpose The recommended first-line treatment for young children infected with HIV includes the liquid formulation of the co-formulated protease inhibitors lopinavir/ritonavir (Kaletra ® [Abbott Laboratories, Chicago, Illinois]). Clinical reports indicate that some children readily accept the taste of Kaletra, whereas others strongly reject it, which can deter therapeutic adherence and outcomes. Methods As a proof-of-concept approach, a sensory panel of genotyped adults was used to document the range of individual differences in the taste and palatability (hedonics) of the liquid formulation of Kaletra and other taste stimuli, including common excipients. Panelists rated taste sensations using generalized labeled magnitude scales to determine genotype–phenotype relationships. Several months later, the panelists were retested to assess response reliability. Findings Not all panelists had the same sensory experience when tasting Kaletra. Palatability ratings varied widely, from moderate like to strongest imaginable dislike, and were reliable over time. The more irritating and bitter Kaletra tasted, the more disliked by the panelist. The more they disliked the taste of Kaletra, the more they disliked the taste of its excipient ethanol and the bitter stimulus denatonium. Those who experienced less bitter and sweeter taste sensations had a different genetic signature than the other panelists. Bitterness and irritation ratings of Kaletra varied by the orphaned bitter receptor gene ( TAS2R60 ), whereas sweetness ratings of Kaletra varied according to the cold receptor gene ( TRPM8 ), which is activated by menthol, an excipient of Kaletra. Neither genotype related to ratings for ethanol or denatonium, however. Implications The use of a sensory panel holds promise as a first step in determining the nature of individual differences in the palatability of existing pediatric drug formulations and sources of variation. In this era of personalized medicine, the need is great to develop psychophysical tools to determine which drugs will show variation in acceptance by children and whether patterns of individual variation in taste as assessed by adults mirror those of young patients. ClinicalTrials.gov identifier: NCT01841710.