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Aim This study aims to investigate associations of formal childcare with maternal and child outcomes in a large sample of adolescent mothers. Background Forty percent of adolescent girls in Africa are mothers. Increasing evidence shows positive impacts of formal childcare use for adult women, but no known studies in the Global South examine associations for adolescent mothers and their children. Methods We interviewed 1046 adolescent mothers and completed developmental assessments with their children (n = 1139) in South Africa's Eastern Cape between 2017 and 2019. Questionnaires measured childcare use, maternal and child outcomes and socio-demographic background variables. Using cross-sectional data, associations between formal childcare use and outcomes were estimated in multivariate multi-level analyses that accounted for individual-level and family-level clustering. Results Childcare use was associated with higher odds of being in education or employment (AOR: 4.01, 95% CIs: 2.59–6.21, p Conclusions Adolescent mothers might benefit substantially from formal childcare, but causal links need to be explored further. Childcare use was also associated with improved parenting and better child development over time, suggesting positive pathways for children. At an average of $9 per month, childcare provisions for adolescent mothers may offer low-cost opportunities to achieve high returns on health and human capital outcomes in Sub-Saharan African contexts.

Background: The COVID-19 pandemic priorities have focused on prevention, detection, and response. Beyond morbidity and mortality, pandemics carry secondary impacts, such as children orphaned or bereft of their caregivers. Such children often face adverse consequences, including poverty, abuse, and institutionalisation. We provide estimates for the magnitude of this problem resulting from COVID-19 and describe the need for resource allocation. Methods: We used mortality and fertility data to model minimum estimates and rates of COVID-19-associated deaths of primary or secondary caregivers for children younger than 18 years in 21 countries. We considered parents and custodial grandparents as primary caregivers, and co-residing grandparents or older kin (aged 60–84 years) as secondary caregivers. To avoid overcounting, we adjusted for possible clustering of deaths using an estimated secondary attack rate and age-specific infection–fatality ratios for SARS-CoV-2. We used these estimates to model global extrapolations for the number of children who have experienced COVID-19-associated deaths of primary and secondary caregivers. Findings: Globally, from March 1, 2020, to April 30, 2021, we estimate 1 134 000 children (95% credible interval 884 000–1 185 000) experienced the death of primary caregivers, including at least one parent or custodial grandparent. 1 562 000 children (1 299 000–1 683 000) experienced the death of at least one primary or secondary caregiver. Countries in our study set with primary caregiver death rates of at least one per 1000 children included Peru (10·2 per 1000 children), South Africa (5·1), Mexico (3·5), Brazil (2·4), Colombia (2·3), Iran (1·7), the USA (1·5), Argentina (1·1), and Russia (1·0). Numbers of children orphaned exceeded numbers of deaths among those aged 15–50 years. Between two and five times more children had deceased fathers than deceased mothers. Interpretation: Orphanhood and caregiver deaths are a hidden pandemic resulting from COVID-19-associated deaths. Accelerating equitable vaccine delivery is key to prevention. Psychosocial and economic support can help families to nurture children bereft of caregivers and help to ensure that institutionalisation is avoided. These data show the need for an additional pillar of our response: prevent, detect, respond, and care for children. Funding: UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, Medical Research Council), UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

BACKGROUND: There is little information on the prevalence of recreational drug use among UK heterosexual men and women, in particular on use of drugs associated with 'chemsex' within gay communities. The aim of this study was to examine among HIV-negative and HIV-positive heterosexual men and women in England: (i) the prevalence of recreational drug use (including use of drugs associated with chemsex), (ii) socio-economic/lifestyle correlates of drug use, and (iii) the association of drug use with sexual behavior measures and mental health symptoms. METHODS: Data are from the AURAH study of HIV-negative individuals attending sexual health clinics across England (2013-2014) and the ASTRA study of HIV-positive individuals attending HIV outpatient clinics in England (2011-2012). Prevalence of recreational drug use (past three months) and associations are presented separately among the four sample groups: HIV-negative (N = 470) and HIV-positive (N = 373) heterosexual men and HIV-negative (N = 676) and HIV-positive (N = 637) women. RESULTS: The age standardized prevalence of any drug use was 22.9%, 17.1%, 15.3%, and 7.1% in the four sample groups respectively. In all groups, cannabis was the drug most commonly used (range from 4.7% to 17.9%) followed by cocaine (1.6% to 8.5%). The prevalence of use of drugs associated with chemsex was very low among HIV-negative participants (1.0% heterosexual men, 0.2% women) and zero among HIV-positive men and women. In age-adjusted analysis, factors linked to drug use overall and/or to cannabis and cocaine use specifically in the four sample groups included Black/mixed Caribbean and white (vs. Black/mixed African) ethnicity, lower level of education , cigarette smoking, and higher risk alcohol consumption. Associations of recreational drug use with measures of condomless sex, depression, and anxiety were observed in the four groups, but were particularly strong/apparent among women. CONCLUSION: Providers need to be aware of cannabis and cocaine use and its potential link with sexual risk behavior and symptoms of depression and anxiety among heterosexual men and women attending sexual health and HIV clinics.

This report summarises the study findings and impact of a research project implemented jointly by the Universities of Oxford and Cape Town: Pathways to survival: identifying psychosocial, family and service mechanisms to improve anti-retroviral adherence amongst HIV-positive adolescents in Southern Africa (hereafter: Mzantsi Wakho – Your South Africa – its locally used name). The core source of funding for this high-impact and successful study came from the Nuffield Foundation. This study was also supported by supplementary co-funding. This study was the first to systematically examine potential causes of ART non-adherence and non-retention in HIV care amongst adolescents (10-19 years old) in Sub-Saharan Africa. Through additional funding awarded to the research team, additional research aims were also examined. The research project was implemented by a team of more than 50 researchers, including capacity-building for early-career academics and students in South Africa and the UK. In July 2015 – March 2018, this multi-disciplinary, mixed-methods team engaged with over 1,600 adolescents, 100 caregivers, and 120 healthcare providers through participatory workshops, in-depth interviews, ethnographic research, and three waves of quantitative surveys. In parallel, a clinic team engaged with over 79 public health facilities collecting data from clinic managers, healthcare providers, and patient files (with appropriate consent). With the essential support of the Nuffield Foundation, this study became the world’s largest longitudinal cohort of adolescents living with HIV. Mzantsi Wakho’s research team successfully followed up and maintained high retention rates across three time points, as research participants transitioned from early adolescence into youth. The study has already had major impact on policy, UN guidelines and programming for adolescents living with HIV.

ObjectiveTo assess the association of symptoms of depression and anxiety with sexual risk behaviour and history, among women and heterosexual men attending genitourinary medicine (GUM) clinics.MethodsAttitudes to and Understanding of Risk of Acquisition of HIV (AURAH) was a cross-sectional, self-administered questionnaire study recruited from 20 GUM clinics in England, 2013–2014. This analysis included women and heterosexual men. The prevalence of depression and anxiety symptoms was assessed. Modified Poisson regression was used to produce adjusted prevalence ratios (aPR) for the association of t demographic, socioeconomic and lifestyle factors with depression and anxiety, adjusted for gender, age, ethnicity, education level and study region. Among individuals reporting sex in the past 3 months, associations of depression and anxiety with sexual risk behaviour and history were assessed separately by gender, adjusted for age, ethnicity, study region, education and relationship status.ResultsQuestionnaires were completed by 676 women and 470 heterosexual men. Depression symptoms were reported by 100 (14.8%) women and 33 men (7.0%). Anxiety symptoms were reported by 79 women (11.7%) and 21 men (4.5%). Among women reporting recent sex, those with depression symptoms were more likely to report condomless sex with a non-regular partner, aPR 1.38 (1.07–1.77) and recent condomless sex with two or more partners, 1.80 (1.25–2.59). Women with anxiety symptoms more likely to report recent condomless sex with two or more partners, 1.68 (1.13–2.50), low self-efficacy for condom use, 1.54 (1.02–2.31) and STI diagnosis in the last year 1.51 (1.04–2.20). Among heterosexual men reporting recent sex, depression and anxiety symptoms were associated with low self-efficacy with condom use, 2.32 (1.29–4.19) for depression and 2.23 (1.26–3.94) for anxiety, but not with measures of condomless sex.DiscussionThe associations between psychological symptoms and sexual risk behaviours highlight the importance of holistic assessment of need by both general and sexual health clinicians. We highlight the challenge in delivering holistic care associated with fragmentation of sexual health services.

Adolescent HIV-risk behaviors are increased by family violence, low parental supervision, substance use and poverty. ‘Cash + care’ structural approaches can reduce adolescent HIV-risks, but parenting a teenager is complex and challenging. WHO, UNICEF, USAIDPEPFAR and academics developed and tested a parenting support and violence reduction program for low-resource settings, to be used as part of structural prevention programs.

Background: HIV infection in a family may affect optimum child development. Our hypothesis is that child\ud development outcomes among HIV-exposed infants will be improved through a complex early childhood\ud stimulation (ECS) programme, and income and loans saving programme for HIV positive parents.\ud Methods: The study was a cluster-randomized controlled trial in 30 clinic sites in two districts in Zimbabwe.\ud Clinics were randomised in a 1:1 allocation ratio to the Child Health Intervention for Development Outcomes\ud (CHIDO) intervention or Ministry of Health standard care. The CHIDO intervention comprises three elements: a\ud group ECS parenting programme, an internal savings and lending scheme (ISALS) and case-management home visits\ud by village health workers. The intervention was aimed at caregiver-child dyads (child aged 0–24 months) where the\ud infant was HIV exposed or infected. The primary outcomes were cognitive development (assessed by the Mullen Scales\ud of Early Learning) and retention of the child in HIV care, at 12 months after enrolment. A comprehensive process\ud evaluation was conducted.\ud Discussion: The results of this cluster-randomised trial will provide important information regarding the effects of\ud multi-component interventions in mitigating developmental delays in HIV-exposed infants living in resource-limited\ud environments.\ud Trial registration: This trial is registered with the Pan African Clinical Trials Registry (www.pactr.org), registration\ud number PACTR201701001387209; the trial was registered on 16th January 2017 (retrospectively registered).\ud Keywords: Early childhood stimulation, Internal savings and lending scheme, Case management, HIV exposed infants,\ud Zimbabwe

This study examines the cognitive profiles of infants born to HIV positive mothers in Zimbabwe. Caregivers with HIV exposed infants delivered in 30 clinics in two areas of Zimbabwe were recruited to the study. Of the 574 study participants, 562 caregiver-infant dyads with a biological HIV +ve mother and infant aged 0-24 months were interviewed. All infants were tested by a trained administrator for cognitive development on the Mullen Scales of Early Learning (MSEL). The Edinburgh Postnatal Depression Scale and Parental Stress Index-Short Form were completed by the mothers together with infant and caregiver socioeconomic characteristics. Linear regression models were used to relate cognitive development scores to maternal stress scores, maternal depression scores and infant HIV status adjusting for infant and caregiver characteristics, as well as socioeconomic factors. Higher maternal depression scores were associated with lower overall infant cognitive scores (adjusted mean difference (aMD) = -0.28; CI 95%:-0.50 to -0.06; p = 0.01) and in the expressive language (aMD = -0.14; CI 95%:-0.27 to -0.01; p = 0.04), fine motor skills (aMD = -0.17; CI 95%: -0.33 to -0.01; p = 0.03), gross motor (aMD = -0.22; CI 95%:-0.40 to -0.04; p = 0.02), and visual reception (aMD = -0.22; CI 95%:-0.40 to -0.05; p = 0.01) domains. Higher maternal stress was associated with poorer overall infant cognitive scores (aMD = -0.11; CI 95%:-0.20 to -0.02; p = 0.02) and in the specific domains of expressive language (aMD = -0.07; CI 95%:-0.12 to -0.01; p = 0.01), gross motor skills (aMD = -0.12; CI 95%:-0.18 to -0.05; p

Child development is negatively impacted by HIV with children that are infected and affected by HIV performing worse than their peers in cognitive assessments.We conducted a descriptive follow-up comparison study (n=989) in South Africa and Malawi. We tracked child development in 135 HIV-positive children compared to 854 uninfected children aged 4-13 years attending community-based organizations at baseline and again 12-15 months later.Children with HIV were more often stunted (58.8% vs. 27.4%) and underweight (18.7% vs. 7.1%). They also had significantly poorer general physical functioning (M=93.37 vs. M=97.00). HIV-positive children scored significantly lower on digit span and the draw-a-person task.These data clearly show that HIV infection poses a serious risk for child development and that there is a need for scaled up interventions. Community-based services may be ideally placed to accommodate such provision and deliver urgently needed support to these children.

Purpose: The Manicaland cohort was established to provide robust scientific data on HIV prevalence and incidence, patterns of sexual risk behaviour and the demographic impact of HIV in a sub-Saharan African population subject to a generalised HIV epidemic. The aims were later broadened to include provision of data on the coverage and effectiveness of national HIV control programmes including antiretroviral therapy (ART).Participants: General population open cohort located in 12 sites in Manicaland, east Zimbabwe, representing 4 major socioeconomic strata (small towns, agricultural estates, roadside settlements and subsistence farming areas). 9,109 of 11,453 (79.5%) eligible adults (men 17-54 years; women 15–44 years) were recruited in a phased household census between July 1998 and January 2000. Five rounds of follow-up of the prospective household census and the open cohort were conducted at 2-year or 3-year intervals between July 2001 and November 2013. Follow-up rates among surviving residents ranged between 77.0% (over 3 years) and 96.4% (2 years).Findings to date: HIV prevalence was 25.1% at baseline and had a substantial demographic impact with 10-fold higher mortality in HIV-infected adults than in uninfected adults and a reduction in the growth rate in the worst affected areas (towns) from 2.9% to 1.0%pa. HIV infection rates have been highest in young adults with earlier commencement of sexual activity and in those with older sexual partners and larger numbers of lifetime partners. HIV prevalence has since fallen to 15.8% and HIV incidence has also declined from 2.1% (1998-2003) to 0.63% (2009-2013) largely due to reduced sexual risk behaviour. HIV-associated mortality fell substantially after 2009 with increased availability of ART.Future plans: We plan to extend the cohort to measure the effects on the epidemic of current and future HIV prevention and treatment programmes. Proposals for access to these data and for collaboration are welcome.

Depression is intricately bound with HIV. Depression may elevate risks of HIV acquisition and be triggered by an HIV diagnosis, in people living with HIV or in people receiving treatment. Depression is a key comorbidity in HIV. Mental health is often underserved especially in adult care, and more so for children and adolescents – despite the elevated infection rates, nonadherence and mortality in these age groups.

Objective: Many studies that document child outcomes in the context of parental HIV – which has been established as a risk factor for child development – focus on older children/adolescents. Studies also concentrate on the status of the primary caregiver, not other household members who might be infected. Design: This study examined the effects of caregiver and household HIV on child development (4–13 years) in South Africa and Malawi (2011–2014). Methods: Data were gathered from 989 children and their primary caregivers at baseline and repeated at 12–15 months follow-up (86.5% follow-up rate). Only caregivers of a single child and caregiver/child dyads without missing data were included, providing a sample of 808 dyads for analysis. Children were divided into three groups according to caregiver-reported HIV burden: having an HIV-positive primary caregiver (19.8%), having HIV in the household (14.2%) or no HIV (66%). Results: The HIV burden was positively associated with an array of negative child outcomes, often mediated by caregiver depression levels. Family HIV burden at baseline affected child behavioural problems at follow-up indirectly through carer depression (B = 0.02; CI = 0.003, 0.06). Internalizing (B = 0.02; CI = 0.002, 0.05) and externalizing problems at follow-up (B = 0.01; CI = 0.0002, 0.03) were also indirectly affected by family HIV burden through caregiver depression. Conclusions: The data suggest that family HIV can affect child development, emphasizing the important role of depression in the pathway to such an effect. Community-based interventions directed at alleviating parental depression in the presence of HIV may help to interrupt the cycle of family HIV and adverse child outcomes.