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ImportanceCommon mental disorders (CMD) are prevalent in people living with HIV and associated with suboptimal antiretroviral therapy (ART) adherence.ObjectiveTo assess the effect of a lay health worker-led psychological intervention on adherence to ART, virologic suppression and mental health symptoms.DesignPragmatic cluster trial with block randomization of health facilities. Treatment assignment was known to participants, providers, evaluators, and data analysts. Recruitment started in October 2018 and the last follow-up visit was done in December 2020. Participants were followed up for 12 months.SettingSixteen public health care facilities in Bikita, a rural district in Masvingo Province, about 300 km south of Harare.ParticipantsMen and non-pregnant women aged 18 years or older who spoke English or Shona, screened positive for CMD (Shona Symptoms Questionnaire [SSQ]-14 score ≥9), had received first-line ART for at least six months, had no WHO clinical stage 4 disease, no psychotic symptoms, and gave informed consent.InterventionThe Friendship Bench, a lay health worker-led intervention consisting of six weekly individual counselling sessions of problem-solving therapy and optional peer-led group support.Main Outcomes and MeasuresThe primary outcome was Medication Event Monitoring System (MEMS) mean adherence between 2-6 months of follow-up. Secondary outcomes included mean adherence between 1-12 months, change from baseline SSQ-14 and Patient Health Questionnaire (PHQ-9) score at 3, 6, 9, and 12 months and change in viral load suppression (viral load ResultsWe recruited 516 participants, 244 in Friendship bench and 272 in standard care facilities. The mean age was 45.6 years (SD 10.9), and most participants were women (84.9%). In the Friendship Bench group, 88.1% of participants attended all six individual counselling sessions. Rates of adherence (>85%) and virologic suppression (>90%) were high in both groups. The intervention had no statistically significant effect on adherence or viral suppression. Declines in SSQ-14 scores from baseline to 3 months (-1.65, 95% CI -3.07 to -0.24), 6 months (-1.57, 95% CI -2.98 to -0.15), and 9 months (-1.63, 95% CI -3.05 to -0.22) were greater in the Friendship Bench than the standard care group (pConclusions and RelevanceThe Friendship Bench intervention is a feasible and acceptable approach to closing the treatment gap in mental health care in rural Zimbabwe. The intervention improved CMD symptoms but the intervention effect was smaller than previously shown in an urban setting. The intervention had no effect on adherence and viral suppression, possibly due to the absence of skill-based adherence training and ceiling effect.Trial registrationClinicalTrials.govIdentifier:NCT03704805Key pointsQuestionDoes the Friendship Bench intervention improve antiretroviral therapy (ART) adherence, viral suppression and mental health symptoms in people living with HIV in rural Zimbabwe?FindingsIn this cluster-randomized trial, participants in the intervention group had a significantly greater decrease in symptoms of common mental disorders than those in the control group, but the intervention showed no significant effect on antiretroviral therapy (ART) adherence or viral suppression.MeaningThe intervention did not affect adherence and viral suppression and the effect of the intervention on mental health symptoms was smaller than previously shown.

OBJECTIVES: To examine the proportion of people living with HIV who screen positive for common mental disorders (CMD) and the associations between CMD and self-reported adherence to antiretroviral therapy (ART). SETTING: Sixteen government-funded health facilities in the rural Bikita district of Zimbabwe. DESIGN: Cross-sectional study. PARTICIPANTS: HIV-positive non-pregnant adults, aged 18 years or older, who lived in Bikita district and had received ART for at least 6 months. OUTCOME MEASURES: The primary outcome was the proportion of participants screening positive for CMD defined as a Shona Symptoms Questionnaire score of 9 or greater. Secondary outcomes were the proportion of participants reporting suicidal ideation, perceptual symptoms and suboptimal ART adherence and adjusted prevalence ratios (aPR) for factors associated with CMD, suicidal ideation, perceptual symptoms and suboptimal ART adherence. RESULTS: Out of 3480 adults, 18.8% (95% CI 14.8% to 23.7%) screened positive for CMD, 2.7% (95% CI 1.5% to 4.7%) reported suicidal ideations, and 1.5% (95% CI 0.9% to 2.6%) reported perceptual symptoms. Positive CMD screens were more common in women (aPR 1.67, 95% CI 1.19 to 2.35) than in men and were more common in adults aged 40-49 years (aPR 1.47, 95% CI 1.16 to 1.85) or aged 50-59 years (aPR 1.51, 95% CI 1.05 to 2.17) than in those 60 years or older. Positive CMD screen was associated with suboptimal adherence (aPR 1.53; 95% CI 1.37 to 1.70). CONCLUSIONS: A substantial proportion of people living with HIV in rural Zimbabwe are affected by CMD. There is a need to integrate mental health services and HIV programmes in rural Zimbabwe. TRIAL REGISTRATION NUMBER: NCT03704805.

Early mortality of HIV/HBV-coinfected individuals on ART is very high in SSA, especially in rural settings, where access to care and treatment adherence may be reduced. Tracing of patients LTFU is needed if precise mortality estimates are to be obtained in rural SSA clinics

Supplemental Digital Content is available in the text, The World Health Organization (WHO) guidelines on antiretroviral therapy (ART) define treatment failure as 2 consecutive viral loads (VLs) ≥1000 copies/mL. There is, however, little evidence supporting 1000 copies as an optimal threshold to define treatment failure. Objective of this study was to assess the correlation of the WHO definition with the presence of drug-resistance mutations in patients who present with 2 consecutive unsuppressed VL in a resource-limited setting. In 10 nurse-led clinics in rural Lesotho children and adults on first-line ART for ≥6 months received a first routine VL. Those with plasma VL ≥80 copies/mL were enrolled in a prospective study, receiving enhanced adherence counseling (EAC) and a follow-up VL after 3 months. After a second unsuppressed VL genotypic resistance testing was performed. Viruses with major mutations against ≥2 drugs of the current regimen were classified as “resistant”. A total of 1563 adults and 191 children received a first routine VL. Of the 138 adults and 53 children with unsuppressed VL (≥80 copies/mL), 165 (116 adults; 49 children) had a follow-up VL after EAC; 108 (74 adults; 34 children) remained unsuppressed and resistance testing was successful. Ninety of them fulfilled the WHO definition of treatment failure (both VL ≥1000 copies/mL); for another 18 both VL were unsuppressed but with

Diarrhoeal diseases constitute a significant illness burden for children living in lowincome countries. Children under the age of five years suffer about four billion diarrhoea episodes per year, 90% of which occur in developing countries. Diarrhoeal illness accounts for more than four percent of the “disability adjusted life years" lost to the worldwide illness burden. ‘Unsafe water, sanitation and hygiene’ are the main global risk factors for diarrhoeal diseases. Current strategies for providing safe water to more than one billion people are being reshaped. Since the formulation of the seventh Millennium Development Goal (MDG), the focus is on large-scale and sustainable approaches. Target 10 of the MDGs includes halving the number of people without access to safe water and sanitation facilities by 2015. Solar water disinfection (SODIS) is a home-based – or ‘point-of-use’ – water purification and safe storage method that could support the achievement of this goal, by providing safe drinking water to populations in need. The method consists of exposing water-filled, transparent PET bottles to full sunlight for about one day. Our main objective of this project was to measure the effectiveness of solar water disinfection on the health of children under the age of five years. Based on a Latin American dissemination programme and further pilot studies in Bolivia (2001) and Bangladesh (1999/2000) on need assessment approaches in the domain of household water management, we decided to carry out the research in 10 rural Bolivian communities situated in the district of Mizque (Department of Cochabamba) from 2001 until 2003. A case-control study was embedded in a morbidity surveillance scheme and complemented with cross-sectional surveys, in order to comprehensively describe the outcome: the impact of the SODIS method on the frequency of childhood diarrhoea. We developed three SODIS promotion strategies that used various communication channels to reach the target population: i) monthly community-based workshops; ii) monthly household visits; and iii) a school campaign in 11 school centres of the district. During four months of weekly diarrhoea monitoring we interviewed 100 cases, as well as 171 controls; the latter were randomly selected from the entire population. One-hour semistructured interviews with mothers of selected study children were carried out to assess relevant risk factors for child diarrhoea. We then compared the diarrhoea incidence rates in study children between families who applied the SODIS method with different intensities, and adjusted the results for major known confounding factors (e.g. age, sex, hand washing). In addition, the quality of household drinking water was analysed repeatedly, which enabled us to calculate the efficacy of the SODIS method under natural conditions representing daily Bolivian life in rural areas. We also repeatedly examined stool samples from community children for the presence of protozoa and helminths, to identify the main transmission pathways of these potentially diarrhoea-causing parasites. The implementation of the SODIS method was challenging, as the target population did not immediately recognise benefits of using the new method. About 20% drank SODIS purified water on more than five days per week, and about 40% consumed the SODIS water less frequently. The individual promotion strategies affected the population in different ways: e.g. household visits increased adoption of the SODIS method and the school campaign enhanced awareness about germs and diseases. Such extensive promotion strategies may not be suitable for large-scale promotion of the SODIS method. The assessment of motivational messages directed towards tangible benefits for the population may prove essential to increase compliance. Once the population was introduced to the SODIS method, we assessed its effect on the study childrens’ health. The use of the SODIS method averted up to 75% of the diarrhoea episodes in a rural Bolivian child under five years of age. The impact was less, when families used the method less frequently (60%), indicating a dose-response relationship between the intensity of use (or compliance to the SODIS method) and reduction in diarrhoeal illness. In order to translate individual risk reductions to an impact measure at population level, we employed population-attributable fraction estimates using an uptake rate of the SODIS method of 20% in the community. Those calculations indicated that 15% of all child diarrhoeal illnesses in the population could be averted if the SODIS method would be consistently used. The high diarrhoea incidences in children under the age of five (about 6 episodes per year) were not reflected in the infection data. It may therefore be assumed that bacteria and viruses (which we did not investigate in this study) caused most diarrhoea episodes in this setting. We found that children would be re-infected rapidly after treatment for protozoa or helminth infection – 50% of the children were re-infected in the elapse of two month, mainly through Giardia lamblia and Entamoeba hist/disp. The age of the child, socioeconomic status and hygiene indicators in the household were main risk factors for reinfection. Water-borne transmission of these protozoa was not dominant in this setting. The high efficacy of the SODIS method in producing pathogen-free drinking water in the field is the foundation for a high effectiveness on people’s health. SODIS-purified drinking water contained 90% less faecal coliform contamination than untreated drinking water. Families that left their water exposed for at least two days, achieved a significantly better purification effect, almost reaching the WHO recommendations of zero-tolerance of indicator bacteria in drinking water. These results support our findings of a high effectiveness of the SODIS method on child health due to the purification of their drinking water. Increased purification efficacy of SODIS due to prolonged exposure time further indicates that SODIS user instructions could be further revised to guarantee best efficacy under field conditions. In rural Bangladesh, people were forced to switch from arsenic- to microbiologically contaminated drinking water sources. Diarrhoea rates were similar between intervention families that switched water sources, with people drinking groundwater, indicating that the SODIS method was efficacious enough to maintain water quality. We also learnt important aspects on the use (e.g. bottle scarcity in rural areas) and determinants for uptake and possible sustainable use of the method (e.g. acceptable alternative water source). Specific community selection criteria, including normative and perceived needs, were formulated for a subsequent need assessment in the Bolivian setting. Since the start of our activities, we were challenged with developing and validating indicators to classify families according to their use of the SODIS method, as no standards existed. In Bolivia, the combination of three indicators for the uptake of SODIS may best estimate the use of the method in families during a one-time evaluation visit: reported use (sensitivity: 73%), observed use (specificity: 82%) and frequency of drinking SODIS water in the last week (positive predictive value: 85%). The indicators can be measured rapidly and easily through especially appointed staff during programme evaluation. The most precise indicator is the repeated observation of SODIS purified water at the home during unannounced visits. The finding of a significant impact of the SODIS method on child health is consistent with our other findings of a dose-response relationship, high efficacy under field conditions and the efficacious protection from diarrhoeal diseases in Bangladesh. Future research should confirm these findings under a multitude of environmental, geographical and cultural settings and study designs, to produce reliable evidence of the methods’ effectiveness in improving the health of populations. The current research raised issues regarding the implementation of and compliance of the population to the SODIS method in combination with the possibility to guarantee its water-purification ability. This also raised questions on the costs in relation to the benefits of the SODIS method from the individual to the programme – and planners’ level; and the likelihood that the planner may no longer perceive the method as an intermediate but rather as a permanent solution to provide safe drinking water. In the future, investigations should: (i) define tangible benefits for target populations, that can later also be applied in social marketing strategies for the broader promotion and higher acceptance of the method in the population. In this context, user instructions should be adapted to guarantee water quality during large-scale promotion activities, (ii) assess the costs of the SODIS method at individual-, programme- and planners’ level. This will allow decision making at regional level, and comparison with other point-of-use methods at policy level, (iii) consider in the planning process with the local people that the SODIS method should not replace future permanent and durable solutions for drinking water (“SODIS is only a valuable means to the end”). This is the first research that evaluated various levels of the solar disinfection method (efficacy, promotion, compliance, use, health effect) in different settings. Also, this study estimated the effectiveness of the method on the health of young children at population level applying an innovative population-based approach. It demonstrated with confidence that the method is efficacious in reducing the diarrhoea burden in a child population. Due to its simplicity and almost ubiquitous applicability, solar disinfection is applicable in various settings, but the long-term use of the method also depends on the political will and the availability of subsidies (e.g. for motivational campaigns, or bottle provision). This project, with its multiplicity of findings served to inform and support a randomised control trial on the effectiveness of solar water disinfection in a rural area of Bolivia, and current endeavours in the national SODIS dissemination programme. At regional level, we mostly increased awareness about the application of the SODIS method that we hope will stimulate regional development. The ultimate decision-maker will always be the consumer and potential beneficiary.

24th annual AGU hydrology days was held at Colorado State University on March 10-12, 2004., Includes bibliographical references., Our aim is to develop a long-term, high resolution net radiation data set that accounts for the effects of local topography that confound simpler analyses of the shortwave radiative balance in rugged terrain; such a dataset may then be used in direct observations of the effects of long-term change and variability in the solar radiation input to the land surface-atmosphere interface, particularly with reference to the estimation of evaporation. Direct and diffuse horizontal solar radiation data are gathered from all reporting stations across the conterminous United States for the period of 1950-1994 and integrated at a monthly time-step. Twelve years of diffuse horizontal radiation data missing from the data sources are replicated based on their historical relationships to coincident and contemporaneous observed direct normal and global radiation. A topographic correction factor is derived to account for the incidence of direct solar radiation on arbitrarily oriented surfaces at any latitude at any moment in any day of the year, and combined with slope and aspect surfaces for the conterminous U.S. derived from a 5-km digital elevation mode. This factor takes into account the solar geometry throughout the seasonal and diurnal cycles by incorporating an hourly weighting in proportion to the diffuse horizontal radiation recorded during the middle day of the month, and is then applied to spatially interpolated surfaces of direct solar radiation and combined with spatially interpolated surfaces of diffuse radiation. Summed, these provide the total incident solar radiation input to an existing energy budget analysis to yield the net surface radiation that may then be applied in models of evaporation. As preliminary uses of this dataset, mean annual and long-term trend surfaces of net surface radiation over the conterminous U.S. for the period WY 1953-1994 are presented.